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Steven J. Pearlman, MD, FACS Dual Board Certified in Facial Plastic Surgery

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October: Breast Cancer and Domestic Violence Awareness Month

This month marks two very special observances that seek to both protect and empower women

National Breast Cancer Awareness Month is celebrating 25 years of awareness, dedication and empowerment. Even many pro football players are wearing pink shoes, socks and towels to heighten awareness for this devastating disease.  Breast cancer affects women young and old. While Breast cancer isn’t something that I come across as a treating physician since I confine my practice to the face and neck, this subject still holds dear to my heart. I know excellent physicians who dedicate their skills to helping victims. 

I dedicate my expertise to another dreadful cause for human suffering that is also being recognized this month – Domestic Violence.  Every 9 seconds a woman is battered in the U.S. by her partner. Over 500,000 cases of domestic violence are reported each year; however experts say that the incidence may be as high as three times that number. This applies to teenage relationships as well.

We are doing our part by participating in the Face to Face program of the American Academy of Facial Plastic and Reconstructive Surgery. The organization offers complimentary consultations, surgery, counseling and support to shattered victims of domestic abuse who otherwise would not be able to afford reconstructive or facial plastic surgery. My office is taking action against domestic violence and offering pro-bono reconstructive surgery through Face to Face. Facial trauma is a visual reminder that can never be hidden. The brave lady below met with me last spring through the Face to Face program. She had reconstructive surgery of her nose and a deviated septum. Her new nose means so much more to her than just ‘a new nose’. She no longer sees her past while glancing into the mirror each morning. She now has a new career, a beautiful family, and a new reflection on life.

If you know someone who is being abused, you must get them help and out of the relationship. It’s been documented that abuse is most likely to escalate. If you know someone who has been or might be subject to domestic violence, have them call the Women in Distress 24 – Hour hot line at 954-761-1122 or visit http://www.womenindistress.org/.

This is the month to protect and empower women who fall victim to two devastating conditions: Breast cancer and domestic violence. There are many ways that you can take a stand and spread awareness on both issues. You can walk a marathon, contribute to charities, or, like many teams on the NFL, show your support by wearing pink! Steven J. Pearlman, MD, FACS

Revision Rhinoplasty and Septoplasty in New York

The new Flexible PDS Plate is a great tool for difficult revision rhinoplasty, septoplasty and even for children with smashed noses

In November, I blogged about my initial experience with the newly approved flexible PDS plate for a difficult revision nasal septoplasty. That patient is now three months post op and doing very well. He is breathing much better after I performed his third (my first for him) septoplasty.

Last month I operated on the 6 year old I talked about in that blog; I will call him “N.” N is a cute, energetic little boy who just can’t stop smiling. He smashed his nose at Yankee stadium last summer. He had severe swelling inside his nose that looked like a hematoma. Nasal septal hematoma is one of the very few emergencies you can have that accompanies a broken nose. Blood collects and swells the inside of the nose. If the blood is not removed quickly, the nose can collapse. So, a colleague brought N to the operating room under the assumption N had a hematoma. What the surgeon found was that the cartilage was so damaged that it was zigzag with portions lying horizontally instead of vertically, mimicking a hematoma. However, due to severe alteration of his nasal septum his nose collapsed anyway, despite the rapid care he received. This doctor subsequently referred N to me for revision surgery.

After allowing the nasal cartilage to heal, I operated on N in early December. Externally his nose had collapsed and what we call a “saddle” nose. This may be subtle I the photos but would get exaggerated as he grows. When I opened up his nose, I found pieces of septal cartilage pointing in every direction and parts overlapping. I used the flexible PDS plate to rebuild his nasal septum and restore a natural nasal profile. That was accomplished by actually removing the entire nasal septum and rebuilding it on a back table using the flexible PDS plate as a template hold the fragments straight. Because the cartilage was partially destroyed, I also used some cartilage from the flat part of his ear (so it would not show any deformity whatsoever after healing) to fill in missing pieces.

The new septum was stitched back into place and the remaining middle third cartilage (called the upper laterals) and the tip cartilages were elevated and sewn to the newly repaired septum at the restored height. This has been commonly used by rhinoplasty specialists in Europe for many years but is still very new in the U.S. since flexible PDS plate use was only FDA approved in September 2010.

N is doing extremely well. He and his parents report much better breathing and he is no longer snoring at night. N also says that he can smell everything better.

I feel strongly that the new Flexible PDS Plate is an excellent tool that will improve results in difficult revision rhinoplasty and septoplasty and for correcting very crooked noses, even for pediatric cases.

Rhinoplasty and Facial Fillers in New York

What I learned at the Annual AAFPRS (American Academy of Facial Plastic and Reconstrutive Surgery) meeting last month

First and foremost, it’s nice to see that most of what the “experts” are teaching isn’t much different than what I am already doing in my practice. There were two rhinoplasty seminars with excellent talks by Drs. Bahman Guyron, Dean Toriumi, Ira Papel, Pietro Palma, Jack Gunter, Norman Pastorek and Peter Adamson to name a few. A few of the take-home messages that I got were tips on reducing pain for the patient in rib cartilage harvesting and techniques for straightening out a crooked nose, which is the most difficult skill for perfecting a rhinoplasty.

Facial fillers have always been a hot topic at recent meetings and still were in Boston. Of course, everyone has their favorite fillers. The fillers change with the volume and applications. For smaller volumes, hyaluronic acid fillers such as Juvederm and Restylane still rule. For fine lines, Prevelle Silk. As we get to larger volumes, Radisse takes over and for the most volume and longest lasting results, Sculptra is likely best. Dr. Rebecca Fitzgerald gave a 1 hour breakfast seminar on Sculptra that actually lasted for two hours. Sculptra is now injected deeper under the facial tissues, just on top of the bones in most areas of the face.

What new products did I discover? Finally PDS foil is FDA approved for use. This has been used very successfully for years in Europe for nasal support in very crooked deviated septum repairs, revision rhinoplasty and other areas of the nose as well. I was invited to attend a special meeting in St. Louis in early November to learn the nuances of this new product. I was fortunate to have received a sample, which I used to help repair a much deviated septum. This particular patient had two prior attempts at correction, but the nose was still very crooked. I will discuss this procedure next week.

As much as I have learned in my past 22 years of medical practice and teaching Facial Plastic Surgery, it’s still important to keep on learning and modifying my patient care techniques.

Deviated Septum New York

Septoplasty Part II

Fixing a Deviated Septum

New York, NY – Fixing a deviated septum is usually performed from inside the nose by a closed or endonasal approach. Crooked bone and cartilage is moved, removed and/or straightened. There should NOT be any changes to the way the nose looks or any “black and blue” whatsoever. As I tell my septoplasty patients, your mother couldn’t tell that you had surgery 3 days later.  On the other hand, if you have a deviated septum it might be the ideal time to have a rhinoplasty if you have been thinking about it. Your surgeon will be operating in the neighborhood. Also, with modern rhinoplasty, often cartilage from the septum is used to strengthen the nose as we re-model it. Because of this, I suggest that if you are considering rhinoplasty and have a deviated septum, they should be performed at the same time. Other than the convenience of going through only one operation and one recover period, the fact that I often use cartilage from your septum to strengthen the nose during rhinoplasty is reason to do them together.

Please make sure that your surgeon looks inside your nose and checks for any causes of nasal obstruction; those that exist and those that may inadvertently occur during rhinoplasty. Based on Bernoulli’s Law of air flowing through a column, a minor asymptomatic deviation or other cause for obstruction can become more significant if the nose is narrowed. A rhinoplasty surgeon should be well versed in sinus surgery and all the associated consequences of functional nasal surgery.

A common misconception is that if you have or your doctor finds a deviated septum then you get a free or discounted nosejob. This might have been the case years ago. Insurance companies paid well and freely for nasal surgery. Doctors would call it a deviated septum and old nasal fracture or other creative names. Insurance companies got wise to this. Rhinoplasty is a cosmetic procedure and really isn’t the responsibility of your medical insurance company. Unless you broke your nose within the past year or so and have good documentation of a significant new deformity, don’t even think about it. There are some doctors who still add inappropriate codes to get higher reimbursement and others who will “throw in” a rhinoplasty if you have a deviated septum, but they aren’t necessarily the best surgeons. Be careful, you may get what you paid for: discount surgery.

There usually is some cost savings from doing a Septorhinoplasty together. Part of the operating room and anesthesia fees may be covered for the functional aspects of surgery. The functional portion of the Septorhinoplasty may also be covered by your medical insurance and may mean no or little additional cost beyond a cosmetic rhinoplasty for the functional (septoplasty) procedure. This depends on your insurance coverage.

 This is the nose that you will have for the rest of your life. You want it done once and done right. You should find the best surgeon you can, one who specializes in noses and does what is necessary to get a great nose. Steven J. Pearlman, MD, FACS

Septoplasty New York

Septoplasty – Deviated Septum Part I

New York, NY

What exactly is a deviated septum? How do I know if I have one? How did it happen? Will it change the way my nose looks if I have my deviated septum fixed, even if I don’t want to? Maybe I have one and no one knows? Will it get me a “free” or discounted nosejob?

These are just a few of the many questions patients and non-patients alike have when it comes to the elusive deviated septum. I will attempt to answer the above questions and more. My answers just kept on going and going so I am going to divide this into two parts.

The definition of a septum is a dividing wall. The nasal septum divides the two sides of the nose. The front 2/3 is made of cartilage and the back portion derived from two different thin bones. The septum sits in a groove of the bone that is above the palate of the mouth. When any or all portions of this structure are crooked, it is a deviated septum. We usually don’t even know when it became crooked. Maybe from falling on your face as a child, during sports or maybe even while you were being born; unless you can pinpoint a specific episode when you got hit in the nose followed by bleeding and a subsequently reduced airway.

Many people have crooked nasal septums and don’t know it. If there is no blockage of breathing or exacerbation of sinus and allergies then there is no need to worry or ever treat it. Many people have asymptomatic mildly deviated septums. The most common problem a deviated septum can cause is nasal blockage. If one side of your nose tends to be more blocked than the other, it is a high probability that you have a deviated septum. Other structures in the nose that can also contribute to blockage are called turbinates. These are curly bones that are covered with skin (mucosa) and tissue that swell with blood to warm and humidify the air we breathe. By the time air gets to your lungs it is 98% humidity and body temperature; most of this occurs in the nose. The turbinates work by swelling alternately, one side than the other. So, if one side is blocked then it alternates but you get good air through both together there really is no problem, just a normal nasal cycle. This cycle is even more evident at night, the “downhill” nostril swells. This is obvious when you turn over and the open nostril switches sides. If one side is almost always blocked, that means there is a fixed obstruction; a deviated septum or other abnormal structure such as a nasal polyp. Allergies, colds and other conditions that cause the inside of the nose to swell will also cause obstruction. This obstruction can be worse if there is also a deviated septum.  A deviated septum is diagnosed by a careful examination of the inside of the nose. Sometimes a CT scan helps delineate the back of the septum and can demonstrate possible associated sinusitis. Deviated septums can even be a cause of chronic headaches.

Sometimes a deviated septum may be asymptomatic. However a mild deviation can become a problem if the nose is made narrower in cosmetic rhinoplasty. This is why every rhinoplasty candidate should have the inside of their nose examined. If you see a doctor for a rhinoplasty and they don’t look inside your nose, it can lead to breathing difficulties after. Cosmetic rhinoplasty should go hand in hand with functional nasal surgery. It might not be necessary to address the septum, but it is important to make sure that it is not crooked; otherwise rhinoplasty may cause breathing difficulties. It amazes me that when I see patients for revision rhinoplasty with breathing issues how often they report that their prior surgeon never even looked inside their nose!

Steven J. Pearlman, MD, FACS

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