Functional Surgery: Most Patients Rue Waiting

"A young woman is shown in her office burying her head in her hands"

Why Did I Wait so Long?

Some of the most common remarks made after nose surgery by “functional” surgery patients are: “Why-oh-why did I ever wait so long!” or “I wish I had this done years ago!”

(“Functional Surgery refers to nose surgery procedures that makes the nose better able to perform its basic function – breathing.)

Some waited for a long while because they were born with a breathing blockage and knew no other way. So for them it was not a question of getting older and more decrepit.

Suffering the effects of bad breathing for many years is fairly common among patients who have:

  • A deviated septum
  • An uncorrected broken nose
  • Allergy-enlarged turbinates

Along the way, the usual suspects show up: snoring and irate bedmates, frequent sinus infections, sleep apnea and perhaps use of a CPAP (Continuous, positive air pressure) machine.

(Read more about the relationship between the need for functional surgery and CPAP machines.)

Part of the problem rests with the so-called “gatekeeper” doctors who are family practitioners or internists in charge of referring their patients on to specialists, if needed.

Those “gatekeepers” should be able to recognize a deviated septum, a twisted nose or enlarged turbinates in the upper nose and see that a blockage of healthy breathing is possibly present.

Simply put: it’s not normal to have lousy breathing.

The next step would be referring that patient to an expert nasal surgeon who would know what to do.

Some patients who have bemoaned a long period of extended bad breathing then become the happiest patients on earth when:

  • The deviated septum is corrected
  • Enlarged turbinates are trimmed
  • A crooked nose is straightened
  • A rhinoplasty is also done

All the above only takes a single, two-hour session to better the person’s quality of life for the rest of his or her days. Plus, the patient’s facial appearance is vastly improved.

One patient actually explained why he had waited so long to have functional surgery to improve his breathing.

He heard from other rhinoplasty patients that the nasal packing inserted into the nose after nose surgery was pure misery, causing mouth breathing for five days.

After seeing many patients turn away from surgery due to nasal packing (which is great for holding everything in place and delivering medicines that help the nose heal better) we invented a slim airway known as the Kotler Nasal Airway.

Nasal packing is now wrapped around the airway, allowing the best of both worlds – breathing and healing.

Plastic Surgery’s Only Real Plastic

"A woman lifts her head to show a septum leaning into and blocking a nostril"

Deviated septum, left. After surgery, right.

Plastic surgery articles almost always carefully point out that the “plastic” in plastic surgery comes from the Greek word plastikos which means, “to mold or take form.”

Nonetheless, many blog authors use the word plastic in the sense of artificial.

But there is one place in reconstructive plastic surgery  (as opposed to cosmetic plastic surgery) where actual plastic is used – in nose surgery to restore healthy breathing.

Your nose is divided into two breathing channels we know as the nostrils. The septum, a thin wall of cartilage and bone separating the nostrils, is often found to be warped, twisted or otherwise bent like in the before and after picture above.

Nose surgeons then refer to it as a deviated septum and dislike it intensely because it interferes with healthy breathing by limiting the air you breathe through at least one nostril.

And because the nose is a three-dimensional structure, the septum also acts to support the nose.

Some people are just born with a deviated septum while blows to the nose in accidents and sports create many more.

So where does the real plastic part come in?

When doctors repair a deviated septum in nose surgery, they often use stitches to restore the septum to the midline of the nose. To hold everything in place during healing, nose surgeons use plastic splints, a type of rigid implant made of soft silicone plastic. But the splints don’t stay in the nose forever; they are usually removed in one to three weeks.

Yet another condition known as nasal valve collapse also uses real plastic. In some cases, too much of the septum has been previously used as a building material during previous cosmetic nose surgery.

(Read more about deviated septum revision and nasal valve collapse.)

In other cases, the nose has been hit especially hard and collapses into a so-called “boxer’s nose” or a “pug nose.”

In both cases, breathing troubles are usually present. Besides, it looks bad.

Some surgeons take cartilage from patents’ ears or from between the ribs to use as supports in the nose. But that creates more surgical wounds.

Other nose surgeons now use polyethylene plastic inserts to repair a nasal valve collapse. The inserts are measured for each patient’s nose and then stitched to the septum for extra support.

In a 36-month Veteran’s Hospital study of 18 patients who had noses repaired using the technique, 15 had excellent results according to a recent article in The Archives of Facial Plastic Surgery. In one patient, the plastic graft poked through the nose skin and two were removed.

The remainder said their breathing was significantly better.

(Read the nose surgery report.)

Nose Surgery & the 5-Day Afrin Test

"A lovely woman is shown holding her nose due to stufiness"

                Constant Stuffy Nose

Many patients come into the office for a cosmetic rhinoplasty appraisal and are surprised to learn they have conditions inside their noses impairing healthy, normal breathing.

While getting the patient’s medical history some clues emerge: Usually the patient (along with the bedmate!) is plagued with loud snoring and sleep apnea. Maybe a CPAP is used.

Many are sensitive to allergies that cause upper nose structures known as turbinates to swell and again block breathing.

(Turbinates: bony structures in the upper nose that warm and filter your air. The turbinates are covered by a unique type of skin that can swell many times its normal size.)

Some patients have suffered a broken nose that’s healed in the broken position, again blocking good breathing.

But which is it, deviated septum, sensitive turbinates or a twisted or crooked nose? And who wants to undergo internal nose surgery for only slight relief?

A simple at-home test helps pinpoint the bugbear: the five-day Afrin test. For a short while, that test mimics the results of surgical enlargement of the nasal passages.

The demonstration could use any decongestant although Afrin, the most popular and common, along with its generic cousins, shrink the nose skin of the turbinates and the septum.

Watch for the following signs: if the patient:

  • Sleeps better
  • Has less daytime fatigue
  • Snores less or none

an inner nose procedure to improve breathing will most likely go well and be effective.

Here’s how the five-day Afrin test is done:

  1. Assign somebody at home to report on snoring
  2. Patient starts by sniffing five sprays into each nostril
  3. Watch a clock and let five minutes pass
  4. Repeat step 2.
  5. Do that for five days
  6. Separate the spraying episodes by eight to 12 hours

If, after five days, the in-house observer reports less snoring while the patient has more daytime energy, less nasal blockage, fewer headaches and a halt or reduction in sleep apnea, the Afrin has worked.

It’s because the decongestant reduces all the tissues lining the nose’s inside. However, Afrin has proportionally more effect on the lowest turbinate, the one that is usually surgically reduced in size for airway improvement.


Surgical correction of the deviated septum and trimming of the lower turbinates is almost assured to improve all the energy-draining symptoms of bad breathing listed above.

Of course, the 5-day test won’t do anything for the appearance of the nose; rhinoplasty is required for nose shaping.

Nose Surgery: Snoring & Nose Woes

"A wife is wide awake and angry over her husband's snoring"

Before Rhinoplasty?

Hopefully, female eyes will find this post — women are usually the sleep-deprived victims of a loudly snoring man.

Because we concentrate on reconstructive and cosmetic nasal surgery, we see many guys who come in for a rhinoplasty consultation. About half mention their snoring and ask if anything can be done during a nose job procedure to stifle the snoring.

Actually, a handful of conditions cause snoring but allow us to mention what happens just in the nose to cause the nighty log sawing.

The most common situation is a blockage in the upper nose caused by:

  • A once broken nose
  • Being born with a twisted nose
  •     “     sensitive to allergies
  • A bent, twisted or deviated septum

(The septum is the eggshell-thin partition of bone and cartilage between the nostrils.)

Because insufficient air travels through the nose and into the lungs while sleeping on the back, a patient must breathe through his mouth. The racket of snoring comes from tissues in the mouth flopping around with the airflow, sometimes stopping it.

The basic concept: “Healthy breathing is quiet; abnormal breathing is noisy.”

The mouth breathing of snoring also defeats three important nasal functions: warming, filtering and humidifying the air you breathe.

Snoring not only deprives care-worn mates of rest, it also deprives the snorer’s organs of healthy oxygen levels. Results? Daytime sleepiness, grogginess, low alert levels and, usually, falling asleep early in front of the TV.

Two other things can also stifle quiet healthy breathing: nasal polyps and enlarged turbinates, structures higher up in the nose that perform the warming, filtering and humidifying tasks.

Often, the turbinates react badly to allergies and swell, again blocking one or both breathing channels.

However, the news is far from all bad. Whatever the cause of the nasal blockage, an outpatient surgery can usually cure or greatly improve the condition, silencing the snoring.

To start, an exam of the nose, sinuses, throat and neck by a specialist in head and neck surgery is required.

In our practice, about half of cosmetic patients have breathing woes. Happily (and economically!) that functional surgery can be done in the same surgical session as a rhinoplasty.

Some find relief in deviated septum surgery.

Quipped a happy patient: “Doctor, you took my nose from a country lane to a four-lane super highway.”

Nose Surgery Can Mean Better CPAP Breathing

"Two medical professionals give a lovely young woman a nasal exam"

Nasal Exam

Regular readers of our blog posts already know a CPAP is a face mask and machine for people who snore, often due to problems inside the nose that block healthy breathing.

But, as a curious cosmetic plastic surgeon, we also scan forums and bulletin boards for news about CPAP (which stands for “continuous positive air pressure,” a fancy way of saying “forcing air into your lungs through your nose”.)

So we note some users have found that nasal surgery makes their CPAP work even better.

The basic start of all this is raw snoring….ear-splitting, freight train decibel, nocturnal snoring that makes the bedroom curtains flap in the breeze and can be heard downstairs, if not the next house.  Pity the sleep-robbed mates of snorers.

Snoring can have many causes but some of the most common are:

  • A deviated septum
  • Swollen turbinates, structures higher up in the nose

A septum is the thin wall of cartilage that separates your two nostrils. When bent, twisted or otherwise deformed, they can block the breathing channels in the nose.

Turbinates warm and humidify the air you breathe. But they often react to allergies and other conditions by swelling, again blocking healthy, quiet breathing.

Curious about the numbers of healthy and blocked breathers, The University of Washington’s Sleep Disorders Center studied 306 CPAP users for two years. They wanted to find why some did not wear the CPAP mask regularly. (Read more about nose surgery and CPAP use.)

After exams, 108 patients showed abnormal nasal exams and were also the same group who did not use the mask correctly, if at all. The study authors concluded patients with abnormal nasal exams had decreased CPAP use and tolerance.

Concluded the authors: why not treat nasal conditions before prescribing a CPAP?

Yet another study at the Stanford Sleep Disorders and Research Center in Palo Alto, California, found that turbinate treatments, when appropriate, appear to benefit nasal obstruction and ease the breathing of CPAP users.

But before you say “yes” to a CPAP, ask yourself if any medical professional has actually looked up into your nose to see and diagnose the state of your nose and if its internal architecture allows for easy, quiet breathing.

Perhaps that would be the best first step possible!

Septoplasty & Turbinate Reduction Patients Speak

"A  beautiful woman shows only her nose and lips"

The function of the nose: to breathe

If you read plastic surgery bulletin boards and forums dedicated to people who have trouble breathing, you’ll discover that the real cause of their breathing woe is usually a surprise.

For instance, Kilgore T. writes: “I just had too many episodes of Afrin addiction due to swollen turbinates.”

(Background: turbinates are bony, flesh-covered structures high inside the nose. Turbinates often react to allergies and other “insults” by swelling and blocking healthy breathing.)

Afrin shrinks nasal tissues but has bothersome side effects like keeping you up all night because it’s an upper and causing mens’ sensitive tissues to swell.

The proposed solution to bugbear breathing: turbinate reduction surgery. Kilgore asks fellow bad breathing sufferers to:

Kilgore’s headline was: “Nose Surgery – CPAP usage and effect on apneas?” He’s asking if he would breathe well.

(Yet more background: CPAP, short for Continuous Positive Air Pressure is a machine that forces air through the nose and into the lungs; a CPAP is worn in bed at night.

Read more about CPAP and nose surgery.

Squid13 tossed in his two cents worth: “I had the surgery…they packed my nose with gauze for a couple of days and then removed it…in four to six weeks (the nose) good as new and boy did my breathing improve…make sure you go to a doctor who knows what he is doing, as too much turbinate reduction can lead to very deleterious results, i.e. empty nose syndrome.”

Added SleepingUgly: “I had septoplasty and turbinate reduction. It had great benefits to me (sic) in terms of being able to breathe through my nose…I have even gotten less sinus infections since the surgery.”

Commented Kitatonic: “(my doctor) stated nasal surgery should be done if the goal is to improve your daytime breathing.”

But Dale92 put a nice cap on Kilgore T.’s question: Pens Dale: “I had turbinate reduction on my right side and my deviated septum fixed in 2004. Before this, I was unable to breathe through my nose for most of my life except for periods of Afrin use which caused even more problems. Finally, I was able to breathe!…Like I said, it was the best thing I had ever done to improve my health…I would gladly do the surgery again.”

You can also have a cosmetic nose job during the same procedure.

(Read the internal nose surgery comments in full.)

A Cosmetic Plastic Surgeon: What We’re Thankful for

"A thankful man crosses the fingers on both hands in thankfullness"


At this time of year, when we’ve set aside a single day to acknowledge things for which we are thankful, some special ones come to mind.

Of course, everybody is thankful for engaging careers, interesting work, good health, solid family connections and the often mixed blessings of living in a wonderful nation.

But a few special things stand out.

While the anesthetic propofol got some bad press in the Michael Jackson death trial, the substance — in the right hands and in the right location — is a blessing for countless numbers of cosmetic plastic surgery patients who wake after surgery with clear minds and calm bodies.

We are also thankful for some space program spin-offs that make surgery safer for the patient while giving surgeons extra information and peace of mind.

Occupying only desk space, surgeons and anesthesiologists have information about the condition of a patient on the table they could only dream about 15 years ago. With a glance at the high-tech monitoring equipment, we can see:

  • The patient’s body temperature
  • Blood pressure
  • The amount of oxygen in the blood
  • EKG read-outs on cardiac health
  • Many, many more health metrics.

All that makes anesthesia in an accredited outpatient surgery center or hospital less risky than driving your car to the surgery!

We are also thankful for one particular patient, Todd, who agreed to a revision rhinoplasty. But before leaving, Todd asked if nasal packing would be placed in his nose after the procedure.

When we said yes, nasal packing is part of the surgery, he replied “Forget it!” and left.

Many patients say that nasal packing – cotton or other medical materials laced with medicine to hold everything in place inside the nose, prevent infections and staunch bleeding, if any – is like having a clothes pin on your nose for a couple days.

Some say nasal packing prevents them from sleeping; others report a feeling of claustrophobia. It means you must breathe only through your mouth and that leads to a dry mouth.

That started us thinking about nasal packing and patient comfort after a:

The result? The Kotler Nasal Airway (KNA) an FDA-cleared tube that allows patients to breathe normally and still have the nasal packing that promotes healing. (Read more about the Kotler Nasal Airway, pictured below.)

O.K. – your turn. What are YOU thankful for?

"Kotler Nasal Airway is show on a table and inserted in a patient's nose"

Kotler Nasal Airway -- in and out of a patient

Cosmetic Surgery Discounts

"A stethoscope is seen laying on a stack of medical bills"

Cosmetic Surgery Costs

While Fox Business is reporting on the top 10 ways to pay for cosmetic surgery, they don’t mention any ways to trim the total costs of plastic surgery. (Read the top 10 ways to pony up for cosmetic surgery.)

If you know the natural up and down business cycles of rejuvenation surgery, you can arrange the procedure you want when cosmetic plastic surgeons will be very glad to hear from you and may consider trimming not only some sagging flesh, but the tab for it as well.

Some insurance-covered procedures produce a better function and a more pleasing appearance, including:

  • Nasal procedures inside the nose for people complaining of sinus-like symptoms. (Read more about breathing woe due to internal nasal structures.)

From November through the New Year, most facial surgeons are booked solid for patients requesting:

  • Eyelid lifts
  • Face lifts or rejuvenation by facial fillers like Restylane
  • Wrinkle removal

But the first two months of the New Year see fewer patients. Arrange your surgery then and ask about a discount of 20 percent.

Summer, however, is not a time to seek bargains, with many high school grads, before heading off to college, booking:

  • Rhinoplasty
  • Other facial procedures like ear pinning, or otoplasty

College grads are also in the mix, wanting an improved appearance before a serious job hunt.

Another excellent – and financially sound – way to spring for cosmetic surgery is to save up and pay by check or cash. Credit card companies charge the surgeon anywhere from three to five percent of the procedure.  Likewise a three to five percent discount from the surgeon is reasonable for full cash payment.

Smart consumers can also ask for surgery on a standby basis, with seven to 14 days notice before surgery.

Plastic surgeons arrange their surgery dates in advance. And the staff in an operating room must be paid, even if a patient cancels the surgery. But if a patient on the standby list can replace the cancellation, the operating room remains busy. A 20 to 25 percent discount for standby surgery has been granted by some surgeons.

A word about shopping for plastic surgery bargains: confine price comparisons to board-certified cosmetic plastic surgeons.


If a lesser-trained surgeon botches the job, your costs to repair the damage can be two to four times greater than the price of the first surgery!