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.

So?

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.

May I Help You?

After rhinoplasty, many patients have a situation in which they are not sure if they should phone their surgeon. They don’t want to be a pest and phone for nothing, but what if something serious is going on?

Our own personal policy is to give patients our home and cell phones with instructions to call anytime questions pop up after surgery. Better to make a call for nothing than take a chance!

If you’ve selected a board-certified cosmetic plastic surgeon, don’t worry. He or she has seen every post-surgical complication you can imagine, including some in which patients resumed their intimate lives too soon, raising their blood pressure too much and causing some otherwise unnecessary bleeding.

In cosmetic surgery, the usual, typical complications besides bleeding include:

• Infections
• A solid swelling of clotted blood just under the skin (medically, a Hematoma)
• A small pool of watery blood right under the skin, medically known as a Seroma
• Very, very rarely, an allergic response to anesthesia

The bleeding we mention above is not a spurting or gushing, but usually just a little trickle seeping under the bandages.

Virtually all plastic surgeons provide a handout sheet on signs to watch for after surgery. Be sure and read them all.

As for infections: that is the reason your surgeon wants to see the morning after surgery. Best to jump on infections ASAP. The red warning flag – and an excellent reason to call your surgeon — is red or sore skin near an incision.

Some face lift, neck lift or other patients may notice some numbness in the treatment area. That happens when minor nerve endings just under the skin are severed. But sensation returns to normal in several to four months.

For rhinoplasty, most of the motivation for patients phoning their surgeon is nose bleeds. We’ve complied a list of seven handy tips for handling post-rhinoplasty or internal nose surgery nosebleeds, if any.

Protective guards come off nose job patients in four to six days.

If you have had what nose surgeons call functional nose surgery, that is, surgery for a deviated septum or turbinate reduction surgery you will be back in the office four to six days to take out the Kotler Nasal Airway and the medication-laced tampon which helps your nose heal immensely.

It’s a painless, easy procedure.

Watch a video in which a Kotler Nasal Airway is removed from a patient’s nose.

Starting a Face Lift

The last thing any plastic surgeon wants to see is some complication like infection that complicates the healing process.

Any cosmetic plastic surgeon fully realizes that everybody has busy lives and that returning to work and customary activities as soon as humanly possible is very important.

Thus, our operating room is as sterile as science can make it and we take no chances with infections; even a nose pimple discovered on the morning of surgery can cancel a rhinoplasty.

One of the latest biotechnology advances is a method to make healing take place quicker and better. Known as platelet-rich plasma, the technique helps lifted skin reattach to its underlying tissues after, say, a face or neck lift and with as little bruising and swelling as possible.

Here’s how it works: when the patient has been put under and is asleep, we take some of his or her blood and process it into a solution very rich in the natural substances that minimize bruises and swelling.

That processed extract is loaded with Mother Nature’s factors that speed the rejoining of the skin layer that has been lifted up from its natural bed.

Just before an incision is closed with final stitches, we spray the underside of the lifted skin and the deeper tissues from which that skin has been separated.

Results: Quicker healing, faster return to work, family, sports and life in general.

Also, according to the Wall Street Journal, a major effort against infections has started with Project Joints, to cut the infection rate for people undergoing joint transplants.

But the techniques could be used for anybody undergoing surgery. Tips include:

• A nose swab to test for the presence of Staph bacteria
• Using clippers – and not razors which might nick the skin — to remove hair
• Special anti-bacteria soap for showering for two weeks before surgery to inhibit infections
• Taking antibiotics before surgery

We use some of the same precautions in functional surgery which takes place inside the nose. That includes surgery on deviated septums and turbinate reduction surgery.

(Read more about the before surgery infection initiatives for patients.)

Bride, groom, fathers and mothers-in-law

June — that magical time of fairy tale weddings rushes at us.

While The Knot.com estimates the average cost of a June wedding with all the trimmings at a staggering $28,427, wedding planners are suggesting additional budgets for cosmetic plastic surgery.

We’ll leave the math to you but The Wedding Report Inc. says there were 2.2 million June weddings in 2012.

The trend even reaches across the pond to England where about 10 percent of brides-to-be have some form of cosmetic rejuvenation.

It’s the wedding pictures handed down for generations, explain wedding planners. (Or not, depending on how seriously you consider the U.S. 50 percent divorce rate.)

Nonetheless, brides and mothers of the brides with grooms and fathers of the bride running a close second are springing for rejuvenation surgery to look as good as possible at the wedding.

But how far out must one plan cosmetic surgery in time to be photographed for the Big Day?

After rhinoplasty, the bare minimum for presentation in public is about ten days. Given a month, the nose should shine; guests with a new nose job should try to be seen in profile. A rejuvenated nose is newly balanced and flattering to the face.

After a full face and neck lift, the average patient needs a minimum of 14 days recovery. But after 21 or so days, you should look fine.

An upper or lower eyelid lift provides a lot bang for the buck.  Baggy lower eyelids make a person look haggard and tired, while drooping upper eyelids create a sleepy appearance and can interfere with vision.

Patients require five to seven days for bruising and swelling, if any, to abate. The incisions are placed in natural folds and creases but are visible for four weeks.

After six weeks, those incisions are virtually impossible to see.

Mothers and fathers of the bride are often interested in a neck lift alone. Two weeks after the surgery, you can start exercising, but bruising may be present for six to eight weeks.

If time is running short, some facial fillers provide instant-to-very-short appearance results.

Juvederm, Restylane and Artefille can plump up deep lines, creases and facial folds on the day of injection.

Botox and Dysport can smooth forehead wrinkles and frown lines in three to seven days.

Informative, Pleasant Consultation

You’ve searched the Internet long and hard for an excellent rhinoplasty surgeon, perhaps read some books about cosmetic plastic surgery (including “Secrets of a Beverly Hills Cosmetic Surgery”) and have seen more before and after nose job pictures than Carter has liver pills.

You’re about ready to go in for a chat (medically, a consultation) to find out:

• If the changes you want are possible
• “ your health allows surgery
• “ you like and feel safe with the surgeon

Some surgeons charge a nominal amount for the consultation, although they usually apply the charge to the cost of plastic surgery if you go ahead.

The object in point is teaching, not selling.  Some fly-by-night practices may set you up with a salesperson for your first visit.

Make sure you discuss your surgery with the person who will operate; you’re there for a doctor’s exam, the first clue to which is filling out a medical history and other questionnaires.  If you want a rhinoplasty revision or a functional nose surgery like septoplasty (the correction of a deviated septum), the surgeon will know how to better explain your case.

To make the appointment worthwhile, be sure to bring:

• The education materials you have on hand
• A friend who can listen and advise
• “ notebook for jotting down questions, answers and other info

If you’ve selected an excellent cosmetic plastic surgeon, the consultation may also include photo imaging, a process in which an existing picture is fed into a special computer. Then, you, the surgeon and a computer artist make the changes on the screen that will show the almost certain result of your surgery, after healing. In many cases, the actual after-surgery picture looks better than the computer-predicted picture. (Continued below.)

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The patient below had computer imaging, showing, left to right, her actual before surgery picture, then her computer-predicted after surgery pictured followed by her actual after surgery photo.(Robert Kotler, M.D. photo)

Computer imaging and seeing what you will look like after surgery puts surgeon and patient on the same page about the expected surgical results.

(Look at more computer imaging cosmetic surgery before and after pictures.)

If it looks like you’re going ahead with the surgery, high-quality still medical before pictures of you will be taken. The surgeon needs those pictures for study before and during the procedure.

In the best of all words, the consultation should be relaxed, friendly and informative. Because your surgeon is first a physician, sometimes the best answer is…no plastic surgery at all!

Beauty: Its own Reward?

Is there a magazine, website or T.V. station anywhere who has not done a feature on cosmetic plastic surgery and the workplace? Or those who are fervently working to be in one?

Often headed by clever and double-entrée titles like “Career Lifts”, the reality is that more people are having some sort of rejuvenation surgery so they will not look tired, haggard or without energy in the workplace or on the job hunt.

That rejuvenation can include smaller, non-surgical procedures like Botox to erase wrinkles or facial fillers like Juvederm or Restylane to pump up deep facial creases and folds.

Skin refreshing treatments like chemical skin peeling are even more popular — and effective — than laser treatments.

Even permanent, non-surgical rhinoplasty if you’ve got the time might be your ticket. Also known as injection rhinoplasty, that treatment can take several months or more. The payoff? It costs 80 less than surgery. (Continued below.)

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The patient below and left wanted only a chin augmentation. After surgery, the right hand photo shows how that slight addition created a near-perfect profile. (Robert Kotler, M.D. photo.

Before and After Chin Augmentation

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(Continued.) Major improvements for job hunters or workplace risers usually include neck surgery, eyelid and forehead lifts along with face lifts.

The link between appearance and success is not just rumor. Declares the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) on its website after a national survey: “7.8 million working people believe that looking older on the job is a disadvantage, so most say they will consider facial plastic surgery.”

Gordon Patzer, PhD., spent three decades rounding up studies on attractive people for his book, Looks: Why They Matter More than You Ever Imagined.

His findings in a nutshell: physical beauty in both men and women comes with power and benefits. More attractive people get better grades in school, are more popular and earn about 10 percent more than average looking people.

It may be an ugly truth about beauty, but better-looking people are hired and promoted quicker. Dr. Patzer’s book includes many psychological tests showing that – fairly or unfairly – our more attractive brothers and sisters seem to do better in life from cradle to grave.

Which is not to say cosmetic plastic surgeons have the only answer. Certainly, diet, grooming, controlling one’s weight and regular exercise count for something on your own attractiveness quotient.

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.”

Is My Septum Straight?

Many nose job patients are surprised to discover the very middle of their noses – the septum – can present problems in how your nose looks and how it passes air on to the lungs.

You may already know the septum, a thin wall of bone and cartilage, divides the two nostrils, sitting in the middle of the nose. But knock the septum one way or another a tad too much and you may problems like constant nasal congestion, frequent sinus trouble and more.

Q: What are the signs of a perforated septum?

A: Signs of a perforation, or hole, in the septum may be obstruction in the upper nose, scabs or bleeding. Hearing whistling while breathing is a sure sign of a septum hole. For only nasal congestion, try a nasal saline spray and bedroom vaporizer.

Q: What if I do have a hole in my septum?

A: You may not hear whistling from a small hole. But a medium-size perforation causes bleeding and crusting while larger holes can block the breathing channel through the nose.  When ignored, the bigger holes can lead to collapse of the nasal bridge, a condition known as saddle nose.

(Read more about saddle nose.)

Q: Can I push my deviated septum back on my own to where it should be?

A: Just after a fracture of the septum, you could, but it would hurt tremendously. Plus, the risk of bleeding and bruising are present. After a few days, the septum heals in its broken position, meaning you can’t move it back by any method except surgery. Whatever the case, if your ability to breathe and function well are important, let an experienced nasal surgeon handle new and old septum fractures. Surgery to restore a septum to the middle of the nose is known as septoplasty.

Q:  What causes a hole in the septum besides cocaine?

A: The typical causes of septum perforation include intranasal cocaine abuse (“snorting”), blows to the nose in contact sports, fistfights, past nasal surgery, including nose jobs (rhinoplasty) not done well, auto wrecks and other trauma. Some people are just born with bent, twisted or crooked septums. A hole in the septum is repaired with a small plug made of silicone during nose surgery.

If you suffer from allergies, a nasal spray or antihistamines may help. Plus, the surgical repair of a deviated septum may – or may not – improve snoring.

Q: What is deviated septum surgery?

A: Read about deviated septum surgery including what happens before, after and during surgery.

“Is my nose tip swollen?”

One of the areas that many rhinoplasty patients are hugely concern about is the nasal tip.

Sometimes after a nose job procedure, the nasal tip is unbalanced, pinched or even shows that too much surgery was done. And that quickly suggests to others the current nose is not the one born to the patient.

Some patients then ask to have rejuvenation surgery only on the nasal tip.

As in all other things nasal, the nose should look natural and not draw any attention to itself.

Some of the leading complaints include a particular nasal tip looking:

• Bulb-like or just too fat
• Bulky
• Too round
• Turned up (medically, a rotated tip,) often leading to the moniker “Miss Piggy”

(Read a patient letter  from a woman who had a nasal tip repaired in rhinoplasty,

signing herself,“ex-Miss Piggy.”)

It all matters because a small change in a nose can have a major impact on the rest of the face.

Some patients complain that for some months after a rhinoplasty, the nasal tip does not look natural. Usually, a skilled, experienced rhinoplasty surgeon will let the nose heal for a year before operating again. Why? The tip is the last part of the nose to take its final shape after nose surgery.

When a nasal tip has too much bulk, the rhinoplasty surgeon can make an incision inside a nostril and remove a tiny part of the cartilage while leaving its lining skin attached. Over time, that allows the tip to narrow.

But if the patient has thick skin, the surgeon performs what is medically known as a delivery technique which is a type of surgical bench surgery. Two incisions next to each other are made inside the nose and the cartilage brought forth, still attached to the tissues inside the nose.

Then, the surgeon makes the cartilage thinner and with less spring. Finally, the surgeon returns the now-smaller cartilage back to its former position inside the nose and closes the incisions.

Other nose surgeons use a technique known as “morselizing” which crushes the cartilage.

But the key to it all: the choice of nasal surgeon. He or she should be highly skilled and experienced with at least 10 years experience. You may be able to tell that from the surgeon’s website if the site has hundreds of before and after nasal surgery pictures of all types.

Sometimes, Mother Nature is at fault and the nose doesn’t heal as expected. In some cases, the surgery was done by a young, unqualified or inexperienced surgeon. In other cases, the really difficult part of the surgery like – refinement of the nasal tip — is lackluster.

Whatever the reason, as many as one-fifth to one-quarter of first rhinoplasty patients start the process over, looking for a Master rhinoplasty surgeon to make the nose look attractive and fit the patient’s face and profile via a rhinoplasty revision.

But why come to Beverly Hills? Sure, it’s known as the globe’s Mecca for all cosmetic plastic surgery  procedures, but that must make it unaffordable, right? Not necessarily. A skill set exists in Beverly Hills not found in other U.S. locations.

So what are the top five reasons for journeying to Beverly Hills for a second rhinoplasty?

1. Unhappy experiences with first nose jobs. Beverly Hills surgeons specialize in certain procedures – like revision rhinoplasty – and do the same few procedures for decades. Yet the costs of plastic surgery are affordable, thanks to competition among many, many specialists in one place.
2. Unhappy nose job patients now know nose surgery is far more difficult and want surgeons who concentrate on the nose. You could do pre-surgery consultations in one Beverly Hills building for a week.
3. Beverly Hills is a dedicated travel location, with a wide selection of hotels and even professional plastic surgery recovery hide-a-ways with nursing staff and rides to and from a surgeon’s office. (Learn more about cosmetic plastic surgery for patients in states other than California and abroad.)
4. Beverly Hills is only 20 minutes away from the Los Angeles airport (LAX.) Some patients include the kids on the trip, making it a short vacation. After several days, virtually all patients are able to be out and about to world-class museums, hitting top spots like the Norton Simon Museum, world-class beaches, fine restaurants and top theaters offerings.
5. Consider permanent, non-surgical rhinoplasty. While many cosmetic plastic surgeons offer the procedure, the vast majority use facial fillers that dissolve within about one year. But only in Beverly Hills can you often repair a botched nose job permanently without surgery.(Read more about permanent, non-surgical rhinoplasty.)