Dr. Torkian 0:01
This is Dr. Behrooz Torkian and I'm a board-certified facial plastic surgeon in Beverly Hills. Join me as I share the secrets in plastic surgeons and beauty professionals alike on achieving beauty for your face.
Dr. Torkian 0:13
Hey everybody, it’s Dr. Torkian in again on beauty and progress. Today is Friday. And I'm kind of chilling at my desk right now having a cup of coffee reflecting upon what issues came up this week that we had to kind of get through and sort of dive into and discuss with patients this week in our practice. And so one of the things that comes up all the time, because I see a lot of patients for rhinoplasty, I see a lot of patients for nose jobs. And this comes up a lot when I asked them the first thing I say is Hey, how's your breathing? And they say, Oh, I think it's fine, but I never really had a problem with my breathing. And so of course I took a look in there and I examined the nose and I'll tell you a lot of times people who think they have good breathing have deviated septum. And so that kind of explains the question. What does it feel like to have an airway obstruction? What does a deviated septum feel like? How do you know if you have a deviated septum? Do you have to have a special examination? Do you have to have a camera put into your nose to know if you have a deviated septum? Or do you have to have a CT scan or an MRI? All these questions come up a lot in my practice with patients that I see and sometimes people will come in and they'll say I think my breathing is fine. But someone told me I have a deviated septum. So here's how it really works The nose is divided into two halves First we have the left half and the right half and two sides are separated by the septum which is really just straight down the middle part of the septum is made out of cartilage part of the septum is made out of bone. Generally speaking, the back part which is made out of bone makes up roughly 50%, sometimes more, sometimes less. And the front part which is made out of cartilage makes up about the other 50 to 60% or so on. In some populations. In some ethnicities specifically like in the Asian and the African populations, especially those with flatter or smaller noses. Usually the cartilage part is a little bit smaller than bone part. So that kind of determines like what the composition of the septum is. Sometimes it's the projection from the face. Sometimes, sometimes you can be fooled, where you might have a Middle Eastern patient with a very large nose or a very projected nose. And then during surgery, you expect to find this like massive piece of cartilage And walk, walk walk. It's a small, teeny, tiny piece of cartilage. So how do we determine this not any easy way really, you can determine it sometimes in a CT scan. But it requires a lot of 3d spatial understanding of the anatomy when you're looking at it. And I'll be honest with you that some doctors may not have the experience to be able to tell that in a CT scan. Sometimes there'll be CT scans that are even read by radiologists, no offense to my colleagues out there where they may not even comment on a deviated septum or they'll see a deviated septum. And they'll call it something way worse than it is or way less than it is. But really, the important thing is how much airway obstruction is a septum that might be somehow shifted or twisted or bent between one side and the other causing airway obstruction on one side or the other. So technically speaking, if the airway is or if the septum is shifted towards the left side, then the left side will have a little bit less room and therefore feel obstructed and the right side will feel a little bit more open and vice versa. Sometimes there could be zigzag or s-shaped septums. And those septums on occasion will cause obstruction on the both sides. Now let's make it a little bit more complicated. What's on the sidewalls of the nose, there are inferior turbinates, and there are middle terminates and there are something called superior turbinates. The middle and superior we don't need to discuss right now they're a little bit more important in sinus anatomy and sinus drainage than they are in airway anatomy and airway pathways. But the inferior Terminus are these two little bumps that hang out on the side of the nose. They are basically on each side kind of acting like little puffy valve mechanisms for the notes, what they do is they get congested, they're made out of an erectile tissue that has a lot of blood vessels in it. And it responds and reacts to environmental stimuli, and sometimes even internal stimuli. So for example, if you have an allergy, let's say you have a peanut or something that you might be allergic to that you ate that internally would cause an allergic reaction release of histamine and that is swelling or a congestion or growth of these little tiny things inside the nose. And they cause obstruction. The way that they cause obstruction is that they're sitting on either side of the septum. And so when they grow and when they swell, they encroach upon the space between the septum and the sidewall, therefore blocking part of the airway. Now if you have a deviated septum and your inferior turbinates are swollen, then possibly both sides will be blocked but more likely, if they're only a little bit swollen, then the side that has the septum deviation going towards it will be blocked first before the side that's more open Naturally Speaking right now, what's interesting about the inferior German it's is that they do react to other things like medications and sometimes antihistamines and sometimes even sterile. Right injections or steroid sprays inside the nose, and they can shrink and they can decongest as well. Sometimes with internal stimuli
Dr. Torkian 5:07
such as exercise, or sometimes during exertion, like during sex, of course, we have to talk about sex a little bit, otherwise, it wouldn't be fun, you get an opening of the airway. And therefore, you can imagine that these little inferior turbinates have decongested. And they've shrunken down, so you get a little bit more pathway for air, therefore, you're able to have a little bit of an easier air exchange, and you're able to breathe a little bit easier through the nose. Cool, right? Sometimes, if you're in elevation, it'll change. Sometimes, if you're in a dry environment, it'll change. But either way, these things act in conjunction with the remainder of the airway to do something for you. And they're not always acting unfavorably, meaning they're not always causing problems, they are something that is necessary. They are of course, a problem and a nuisance when you're congested. And when you have allergies, and you have to use steroids sprays, and Zyrtec and Claritin, and stuff, but what they do is cause a little bit of a slowing down of the airflow through the nose. Why is this important? Number one, the air that you're breathing in through your nose has to be humidified, and it has to have all the particles trapped out of it before it gets down into your vocal cords and through your cords into your lungs, it's just more comfortable. Number one, number two, there's less junk and particle in the air that your lungs have to deal with, you don't have to clear your throat as much. And you don't have to use your mucociliary functions inside your lungs to clear that junk out as much. Number two, they have a valve mechanism, they slow down the airflow through the nose. That means when you're taking a deep, deep breath in through the nose, you actually have a slower expansion of the lungs, that slowness of the expansion of the lungs improves the opening and the full function and use of the lungs. Meaning if you're not taking a very slow and deep breath, and you're just taking very shallow and fast breaths, you're not even using your whole lung capacity, there is some air that stays in there that gets stuck in there that's not moving in and out. And so therefore the carbon dioxide doesn't come out and the oxygen doesn't go in. And there's parts of the lung that don't even really fully expand. So you're not even really using all the gas exchange capacity of your lungs. So, therefore, the inferior turbinates are really important. This is why it has been long known for decades now that removing the inferior turbinates or completely annihilating and getting rid of the inferior turbinates, although they get in the way of your airway can be problematic for people because it just doesn't give them the right kind of breathing. The other things that happen with removal or complete annihilation or just really shrink in the inferior turbinates down too much is that they can sometimes cause dryness inside the nose. And that's a really, really serious problem sometimes called Oh, Xena, when there's some kind of a bacterial overgrowth in there kind of get stinky, and there's a lot of crusting and that dryness results in crusts and basically like a film on the mucous membrane that doesn't even allow you to feel when you've taken a breath. And so sometimes people will come in, they have a huge airway that's open that I can stick my four-color pen through and tickle the back of their throat, you know how thick those things are, or imagine a highlighter, but they don't feel like they're breathing. And the reason is, they're just too open. And so they need some kind of resistance a little bit to feel a satisfactory breath that cools down and mucous membranes and their nose by causing the air exchange to happen or the drying to kind of come out of the air and the warming of the air to happen. And that results in the feeling or the sensation of the breath. But it's like imagine if you were wearing a shirt, but you had no sensation in your skin. So you didn't really know if you were wearing a shirt, it would be kind of weird, right? That's kind of what I usually compare it to. So the inferior turbinates can be reduced, but they cannot be completely removed. The septum can be straightened, but even it cannot be completely removed. And many of us have heard of septal perforations. This is something that happens a lot of times in trauma, sometimes after surgeries and most often, probably, hopefully, it will be less and less common, but I think it's probably on the rise now with inhaled drug use. And so when when there are vezo constricting drugs, such as cocaine that may be used in the nose or anything else that might cause any kind of irritation in the nose. Eventually, the blood flow through the septum mucosa gets compromised somehow. And then the cartilage can basically just die off because it doesn't get the blood flow and the support nutritionally that it needs. So the septum is also quite important. So to optimize the airway, you got to take care of the septum and the inferior turbinates. Okay, now let's make it even a little bit more complicated. Some of you may have heard about vestibular stenosis or valve collapse, people sometimes come in and they say I don't want my nose to collapse, they're probably talking about something totally different that relates to the bridge, not having enough structure or strength in very aggressive septum surgeries. But in my world, when I'm talking about collapsing, I'm talking about the sidewalls of the nose meaning the nostrils and the sidewall that attaches to your cheek to the front part of your cheek now being strong enough to withstand the airflow that's going through the nose.
Dr. Torkian 10:02
So think about a straw. Let's say you went to Jamba Juice and your Jamba Juice came out just now. And they put a big straw in there. But when you're sucking through your straw is basically collapsing on itself. It's like flopping, and it gets flat, and you're not able to suck through the straw. What happens when this happens to your nose. So now let's go back to the septum deviation, let's imagine that the septum has deviated to the left, and the better airways on the right, but patient comes in and says, Hey, Doc, I do have nasal airway problems, when I breathe in really deep, I can't breathe through my right side, it just gets completely blocked. And I say, Okay, take a big snare fan. And when they do, the right nostril just completely shuts down. And that's happening just the same way that the straw is shutting down and collapsing because there's a negative pressure from your lungs the same way that you're sucking in through the straw, your lungs are sucking in through the trachea and through the remainder of the airway. And the nose is a big part of that. And then it sucks down and it closes up. So that's called a vestibular stenosis or a valve collapse, there are two parts of the valve internal and external kind of requires a little bit of visual, so we won't talk about it on the podcast, but just know that that's what's there. So pretty much a huge part of the airway, and a huge part of the function of the nose, some, some patients will come in, and they'll say, when I'm sleeping in bed, I can't sleep on my right side unless I use my fist or my hand to pull my cheek open. So I can breathe through that side. And so it can be a real big problem for people, if they can't sleep on this side or the other and they're trying to flip flop back and forth, or they're trying to use their hands to, you know, prop up their nose or prop up the sidewall of their nose so that they can breathe, it can be a big problem. So in every rhinoplasty In my opinion, and every pretty much airway surgery, even if I'm not doing a cosmetic rhinoplasty, I address at least to some extent, the internal valve and the external valve. I need to know what's going on in these things and I need to at least preemptively fix them. Well, one of the reasons for this is a lot of the failures of septoplasty ease. But a patient comes in and says Hey, Doc, I had a septoplasty about five years ago and got better for a little while, but it's not really working anymore. Sometimes I look in and there's a read deviation of the nasal septum or growth of the inferior turbidites. But also very commonly, there is airway collapse or vestibular stenosis or vestibular valve collapse that hasn't been noticed or wasn't treated. So what do I have to do? Usually speaking, we have to strengthen that Valve area, we have to strengthen the vestibular area and it requires grafts and these are basically for lack of a better way of putting it tissue moved from one place to another. That's it. It's not an implant, meaning it doesn't come from somewhere else. But it's tissue of some sort move from one place to another. This tissue in this scenario needs to be the cartilage because you kind of need to replace the like with like right so we get cartilage from somewhere generally speaking, we can get cartilage from the septum. But if Dr. Smith or Dr. Joe down the street has done a septoplasty on the patient, then how much cartilage is there going to be in the septum we don't really know sometimes septoplasty these are done with a discarding of cartilage or sometimes a smashing or breaking up of cartilage or a cutting of cartilage. And sometimes it's put back sometimes it's not. And in those cases, we don't know what the condition or the or the even availability of the cartilage is for repair of the vestibular stenosis. So in cases like that, we may sometimes have to borrows from somewhere else, maybe the ear, maybe the red, maybe a cat a very complex topic we'll get into with a different podcast, but it has to come from somewhere. So when we get this cartilage and we put it into the right spots, we can strengthen the sidewall of the nose. Now if the septum doesn't have it, then I have to go to the ear. If the ear is too curved or too small and I have to go to the rib, then it's a huge process for the patient. Right. Would it be great if when you had your septoplasty that cartilage was already moved into position into the right place to prevent the vestibular stenosis to begin with. And even if it didn't make any difference in vestibular stenosis, at least it's banked there, at least it is alive there and it's saved for future use if you need it, as long as it doesn't cause any problems like blockage which can happen in the improper positioning of those types of grafts or cause a problem with cosmesis meaning show from the outside or cause a widening of the nose or something like that, then it's okay for us to save it in there. Now if these grafts are placed into the right place, they don't show through the skin. This is a really important topic that comes up all the time people say I don't want to grasp because you can see it's become less and less common for people to say that because tip grafts which were the general use of the term graft in rhinoplasty are really very uncommon right now. In fact, I don't believe I've used a tip raft for probably the past eight years in in the same capacity that used to be used. Of course sometimes when you're doing a revision and there's nothing In the tip, you have to do it but the tip of graft
Dr. Torkian 15:01
the way that it used to be placed. And the way that it used to be taught in the textbooks of the past is really kind of old school right now and not used very much. So aside from that they don't show they are not part of the external facade of the nose, meaning the cartilage and bone that's just underneath the skin, in general. And so you can't really see them, if they're placed properly, they don't hinder or worsen the outcome of the cosmetic appearance of the nose, but they actually improve it. And one of the ways that this happens is when there is a bridge reduction done in rhinoplasty. So let's say someone comes in and says I broke my nose, then I developed the hump, my septum got deviated cambree to the right side, so on and so forth. Everybody gets the idea. So we're tempted basically to shave down the bridge. And to straighten the septum, right? That is the ideal time for of course, the vestibular stenosis to be addressed, at least to know about it, and at least to preemptively try to treat it. But it's also a really important time to get the cosmetic dimensions of the nose, right, so let's talk about the bridge reduction, when the bridge of the nose is reduced, typically, and without a visual, I can't really show you why this happens, but the nose will narrow regardless of what you do. So as soon as you shave down the bridge, you have the bones along the arc of the bridge of the nose opened up, you have to push them in. So that requires osteotomy, sometimes called quote unquote breaking of the bones or breaking of the bridge, which really is a pet peeve of mine, I don't like to use those words. And mainly because it sounds like it's so random, and it cracks in multiple pieces. But it's really not it is very precise, but it requires to push those side walls in. And when they get pushed in the hole nose narrows and you have to limit that to some way or another the cartilage part, which is really important in the internal and external valves of the nose closes even more, it narrows even more. And it's really important to address those things. So that some of the issues and problems related to the older school techniques that were focused mainly just on removal, and not on reconstruction after the removal of cartilage and bone. those problems were really common way back when and they're not very common anymore. And that's mainly because we do spreader grafts or certain grafts that repair and restore the anatomy so that both function and cosmesis can be better. One of the things that you can actually look up and see online is something called an inverted v deformity in the nose. And that's one of the things that sometimes patients will complain about after a rhinoplasty that does not use any grafts to repair their middle vaults or the middle portion of their nose. And so the cartilaginous portion of the bridge gets narrower than the bone portion of the bridge. And then when you look at it from the front, there's a little shadow in some pictures with certain lighting that looks like an inverted or upside down V or you this probably is a little bit less common and now the digital age, mainly because these grafts are being used more but also people use the lighting tricks and people are really good at using filters and so on to be able to really light up the face, the more light there is. And the less centrally the light is coming from the less you actually will see those inverted deformities, but got to prevent them anyway. And it's better for the airway. So putting it all together in septum deviation is not always just a septum deviation, it doesn't always just cause one type of issue meaning a blockage on one side or the other. But sometimes it can be a little bit more complicated. The blockages can be dynamic, meaning when you breathe in real deep, you can sometimes have blockage of the opposite side where the septum is deviated to meaning blockage of the better side. And occasionally speaking, you can have paradoxical feelings in your nose, meaning because your airway on one side may be so open, you don't even feel like you're breathing through there, you just feel the air going through the side that's more closed because the air is causing a little bit more turbulence in that area. So it's kind of a weird thing. So I would say the way to know if you have a septum deviation is if for some reason or another when you're having mild congestion, you feel a difference between the two sides. One way to test this is to just block one nostril breathe in, that's my left side doesn't sound like much air is going through. And then I'll block my left nostril Breathe in. Now you can hear that huge breath going through my right side. Maybe I have a septum deviation. Maybe I'm just congested on the left side, not on the right right now. Who knows, right? That's one way you can check for yourself. If it's consistent and it consistently is just one side being blocked versus the other. Then you may have a septum deviation. The other way to know is just visit your facial plastic surgeon. Now, why facial plastic surgeon. Not all plastic surgeons are created equal.
Dr. Torkian 19:57
Some don't get as much training in the anatomy or For the function of the airway, and they believe that that's something that is best left to the ENTs. Now, as I just discussed in great detail, this particular anatomic location in the in the body, particularly the anatomic structure is really intertwined. In terms of function and form. Its cosmetic, and appearance aspects are very, very closely related to its structural aspects which affect the airway. And so every rhinoplasty surgeon, meaning every surgeon that operates on the nose needs to have good training in both the anatomy of the inside of the nose and the anatomy of the outside of the nose and the function that comes with both of these changes, or anatomies. So, generally speaking, those are doctors that are trained both in ENT and plastic surgery. Sometimes there are those who are trained in plastic surgery with the right kind of training and experience. But in general, the facial plastic surgeons who are trained in ENT first and then trained in plastic surgery of the face after are more highly specialized in this. And so we are able to handle all these aspects together at the same time and ensure that there's no problems down the line and in the future. So it's very, very easy to tell if you have a septum deviation in my hands or in any of my colleagues in the facial plastic surgery or ENT World, we look inside the nose, and with a little light that we can shine in the nose and a little speculum that we use to open the nostril were able to actually identify septum deviations for easily. Occasionally, if you're really congested, we need to spray a decongestant, like Alfred and neo synephrine into the nose. And that helps to decongested open up some of the tissues so that we can see the septum a little bit more clearly, very, very rarely do we need to use a camera to see the deviation. It's nice to use a camera to see the deviation is nice for the practice, because sometimes insurance companies will pay a little bit extra for you to put the camera in to see the deviation. Although I think that that's ridiculous because most self-respecting doctors who look inside the nose and I know that I may offend some people out there and I'm sorry, but this is my opinion, you don't have to agree or like it, most of us should be able to look inside of a nose and tell someone if they have a septum deviation period. Okay, and if we can't, then we try harder, I guess. CT scans are not required to identify or diagnose septum deviations. But because insurance companies want proof where they want more information before they will approve certain surgeries. Because PPO insurances can cover part of these operations when airway obstructions and septum deviations are present. Sometimes they'll want to see a CT scan so that the CT scan can show them some kind of proof that there is a septum deviation. Occasionally I'll use a camera in the operating room and take pictures so that after the fact after I've corrected the septum, I can show them proof that yes, the septum was deviated. And here's the pictures to prove it. This is the left side of this the right side. And this is how much more obstructive one side is versus the header. And so these these things, although they are kind of costly, and sometimes, you know, seem to be a little frivolous, when you can just look in there and identify it 99% of the time, sometimes insurance companies just want proof. And so that's the way it goes. So hopefully this helps you all understand septum deviations, airway obstructions. And I'll assure you when we do surgery on noses, these are all very, very important and very tied into each other, you can't really separate the cosmetic from the airway, you can't separate the airway from the cosmetic sometimes, most of the time, you can if you want to, in my practice is almost never that way because people come in really more for a cosmetic issue. And they have a breathing issue as well. Or they know that they're going to someone that can handle both of them. So that's the way we usually see it, at least in my practice. And of course, if anybody has any questions about any kind of setup and deviation, any kind of airway obstruction, or anything that they may have, please don't hesitate to call us come in for a consultation. Another note I just wanted to make the issue always comes up about exercise, sometimes we open up the airway, and we fix the nose. And you know the airway, when you're inspecting it and looking at it looks really good. And one patient sitting in the chair, they function really well. But they say when I exercise, I still have to breathe through my mouth Doc, and it's not comfortable. And I have to remind people, and this is kind of on the last last note that I want to make the last comment that I want to make about this, you're not really supposed to be breathing through your nose the whole time during exercise. If you are you're probably not working out hard enough. If you can breathe through your nose and workout as hard as you should the entire time, then you've probably trained yourself to do that, right? It's not easy. This is why Yoga is difficult for some people because you have to train yourself to fight through the exertion and the desire to just open your mouth and take that deep breath that you need for the oxygen exchange. When you're doing intense yoga. Of course,
Dr. Torkian 24:55
you're have to train yourself and that's what makes it difficult but when you're running and I'm a runner I do a lot of HIIT exercises, and I like to do stairs, exercises and so on. If you're reaching that full cardiovascular capacity where you're like at your target heart rate, you're not supposed to be breathing through your nose the entire time, you have enough need for oxygen exchange, that you've got to get a breath fast and fast out, you've got to get carbon dioxide out really quick and get oxygen in really quick. When you slow down a little bit in between your hidden sessions, then you can breathe through your nose a little bit and feel comfortable with that. But when you're ramping up, breathe through your nose. Don't expect to continue breathing through your nose through the entire exercise, otherwise, you're probably doing it wrong somewhere or another. And if there's any issues with that, of course, I always encourage my patients to come back in and I offer them any kind of help that I can in order to kind of improve their airway or really just improve their style of breathing through exercise. Exercise is really important to me. So this is a topic that really comes up very often. Okay, again, if there's any questions about this, or if you're concerned that you may have an airway obstruction or septum deviation that you didn't know about, don't hesitate to call come in for a consultation. consultations do have a fee, but occasionally insurance can be applied to that fee. And we can take a look inside your nose and see what you've gotten give you some advice on how to treat it, how to manage it. Generally speaking, insurance companies will want to see about six months I think of over-the-counter or prescription antihistamine and nasal steroids spray use. Kind of interesting that they would make you go through those hoops when a qualified doctor has given you a diagnosis. But either way, they want to make sure that those things don't work for you before they qualify you for a payment on a septum surgery or an airway surgery. So sometimes we'll get people on medications and kind of put them through that whole pathway before we operate on them.
Dr. Torkian 26:47
Anyways, give us a call. Have a great weekend. Thanks again for joining me on beauty in progress. This is Dr. Torkian for beauty in progress signing off.
Dr. Torkian 26:56
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