1. Rhinoplasty

One of the most common procedures that’s performed today is your routine nose job, or rhinoplasty. In most cases a hump is taken down, or the tip is made more narrow. In the process, certain support structures are weakened, with flimsy nostrils resulting many years later. In the 1950, the Goldman tip was one of the more popular styles, where the tip of the nose was made very narrow and lifted up slightly. With any procedure that narrows the tip, a portion of the lower lateral cartilages have to be either removed or weakened. This cartilage is one of the main support structures that keeps your nostril from collapsing inwards.

Initially after the procedure, patients can breathe well, but years or decades later, with constant inspiration and vacuum forces from routine breathing, the nostrils slowly cave inwards, worsening nasal congestion.

We know that nasal congestion can aggravate or cause obstructive sleep apnea. This is why nasal packing after any surgery is a miserable experience, and why you’ll toss and turn whenever you have a cold (from a stuffy nose). If your jaws are already narrowed, you’re more likely to have a nasal hump and narrowed nasal cavity, so worsening nasal congestion can only aggravate breathing problems downstream. Underdevelopment of the midface pulls the upper lip and the lower cartilaginous nose down, creating the classic nasal hump.

Even with contemporary rhinoplasty techniques, it’s important to prevent this from happening using proper technique and by minimizing removal of excessive cartilage.

2. Orthodontics / Headgear

I’m sure you’ve seen children wear headgear in past years, with a brace around the head and wires pushing or pulling teeth. Children with overjets (overbite) were managed by pushing the upper teeth back, thus creating the illusion of a proper bite. The fact is that in these children, the lower jaw is underformed, and the best thing to do is to pull the lower jaw or teeth forward to match the upper teeth.

Additionally, some orthodontists still extract teeth to make room for the remaining teeth. Your smile may be nice, but in the process, your jaw just became smaller. Any amount of narrowing of your jaws creates less room for your tongue, and with muscle relaxation in deep sleep, you’ll stop breathing much more often. It’s bad enough that modern human’s jaws are shrinking more and more (due to a radical change in our diets and with bottle-feeding), but when you start to extract multiple teeth, you’re definitely going to have problems breathing. The back molars also act to support the soft tissues of your throat. So removing your molars can destabilize the soft palate, aggravating more soft tissue collapse, especially later in life.

3. Jaw Surgery

Once in a while, I’ll see patients that underwent lower jaw surgery to push back a prominent lower jaw. In this situation, the upper jaw should  have be pulled forward. Since the base of your tongue attaches to you back of your mandible, any backward movement of your jaw can push your tongue back, aggravating breathing problems while you sleep.

4. Thyroglossal Duct Cyst

The thyroid gland starts at the back of your tongue and migrates down your neck in front of your voice box, and then divides into your right and left thyroid lobes with a small connection between the two over the top of the windpipe. Sometimes, a remnant of that tract from your tongue to the voice box can remain, with cysts or tracts or even thyroid tissue along this pathway. When a cyst develops, you’ll have a midline ball or swelling that won’t go away. The treatment for this condition, called thyroglossal duct cyst, it surgical removal.

The procedure is classically called the Sistrunk procedure, named after the surgeon that originally described it. The critical part of this procedure involves removed the midline 1/3 of the hyoid bone, which is a c-shaped bone that sits on top of your voice box. Unfortunately, you’re also weakening and destabilizing the attachments to the tongue and voice box. Upon questioning the handful of patients that have undergone this procedure in past years (some by me and some by other surgeons), most have said that their sleep quality worsened. If you’re ever going to undergo this procedure, it’s important to reattached or reconstruct the tissues that help to support your tongue and voice box.

5. Hysterectomy

Total hysterectomy with or without removal of the ovaries is a common procedure for many women. We know that especially when the ovaries are removed, this creates a state of surgical menopause. I’ve described in past articles that as progesterone naturally drops in normal menopause, sleep quality can diminish, mainly due to the effects of progesterone on tongue and upper airway muscle tone. As the tongue muscle tone slowly drops, obstructions and arousals become more frequent, and you won’t sleep well.

This is also one of the main reasons why hormone replacement therapy (HRT) helps many women sleep better. However, with the recent finding that HRT can increase rates of cancer, it’s not generally recommended anymore. If you’re thinking about undergoing a hysterectomy, be prepared not to sleep as well.

6. Breast Implants

If you’re a woman and like to sleep on your stomach, then getting breast implants can definitely worsen your sleep quality. For a few weeks after this procedure, most surgeons will ask you to sleep on your back. The problem is that when on your back, your tongue will fall back more often, leading to more frequent breathing obstructions and arousals. Until you’re able to go back to stomach sleeping, be prepared to lose a lot of sleep. Unfortunately, some women are never able to sleep on their stomachs again, being forced to sleep on their sides or back.

7. Any Type of Surgery

No matter what type of surgical procedure you undergo, if you’re forced to sleep on your back, then your sleep apnea will be worse. If you never had sleep apnea or sleep-breathing problems, then being on your back may bring on your first experience, especially if you’re a natural side or stomach sleeper.

As you can see, millions of people undergo these procedures every year. Sometimes, the effect on sleep occurs immediately, whereas in others, it can take months or years to surface. If you’re planning any of the above procedures, or if you’ve undergone any in the past, think about how it can potentially affect your quality of sleep. It’s something you should definitely sleep on.

The septoplasty operation is one of the most misunderstood surgical procedures that lay people, and even many physicians have. Some people even equate septoplasty with having a nose job, which is not true. Although, some people use having a crooked septum as 

an excuse to undergo a rhinoplasty, septoplasty, done correctly, can help patients breathe better, and more importantly, sleep better.

Understanding the Anatomy

In order to fully appreciate if septoplasty is the right procedure for you, you must understand the anatomy of how it’s done.

The nasal septum is the midline cartilaginous structure that divides the two halves of your nasal cavity. The part in the back of the septum is made of bone. Whenever the septum is crooked to a significant degree, your nose can be stuffy, and a septoplasty can be offered if medical therapy doesn't work.

However, having a crooked septum doesn't mean that you'll have a stuffy nose, or that you'll need a septoplasty. No one has a perfectly straight septum. There are other parts of your nasal anatomy that contributes to your ability to breathe, which includes your nasal turbinates and your nostrils. The turbinates are wing-like structures that jut in from the side-walls of your nose that look like wings. They normally warm, filter, smooth and humidify the air that you breathe. Inside this structure is the bone and the outside is a mucous membrane lining. The middle part is made of very vascular tissues that can swell tremendously when filled with blood. This is regulated by your involuntary nervous system. This nervous system normally swells and shrinks the turbinates, alternating from side to side, every few hours (called the nasal cycle).

Do You Have Flimsy Nostrils?

The other structure that is often overlooked is your nostrils. For most people, breathing in causes a mild vacuum effect that causes a mild collapse and a constriction of the nostrils. But in some people with either flimsy or weakened nostrils (from a prior rhinoplasty), they collapse very easily, even with a slight bit of inspiration. If you are one of these people, you may benefit from nasal dilator strips (Breathe-rite is one brand). Sometimes these strips are not strong enough, or it can irritate the skin. Another option is to use internal nasal dilators which work much better. Some of the more common brands are Breathewitheez, Nasal Cones, and Nozovent.

What's Involved with Septal Surgery? 

The septoplasty procedure can be done in conjunction with a turbinate procedure. There are many ways to perform a septoplasty, but the most important point is that it should be done well. The septum is covered on both sides by a mucous membrane. After an incision is made inside the nose on the mucous membrane, this layer is peeled away from the septal cartilage. The other side is also entered, which creates two tunnels on either side of the septal cartilage. The crooked part of the septal cartilage is next removed. Some surgeons either soften the cartilage or flatten it out and place it back, and others leave it out completely. In many cases, a small portion of bony spur that juts out at the base of the septal cartilage is also removed. The last part of the operation is where different surgeons use different techniques. Traditionally, thin plastic sheets with or without soft sponge-like packs are placed against the septum on both sides to keep the mucous membrane together for proper healing. If a large clot of blood forms between the two mucous membrane layers, the remaining cartilage may lose it's blood supply and literally melt away. 

Because the entire procedure in done inside the nose (or endoscopically), there is no swelling, bruising or changes to the outside of the nose or face (unless a rhinoplasty is done simultaneously).

What to Expect After Surgery

Nasal packing, if placed, are removed anywhere from 1-3 days after the procedure. Many patients report that this is one of the most uncomfortable parts of undergoing this procedure. Some surgeons, like myself, don't use any packs or splints using the following method: compressing the two mucous membrane layers by sewing the two layers together using an absorbable suture, like a quilting stitch. This way, nothing needs to be removed, and you're breathing much better right after the surgery. It's expected with this procedure that your nose will get clogged up after a day or two with accumulation of blood, mucous and debris.

This operation is usually performed as an outpatient procedure, so you'll go home a few hours after surgery. It's usually performed under general anesthesia, but can also de done under local anesthesia with sedation for certain situations. Most people can go back to work after a day or two. Heavy straining or lifting should be restricted for about one week. In my practice, I see the patients about 2 days after the surgery, when the nose is cleaned of all the accumulated debris. Some people need a second cleaning 1-2 weeks later.

Typically, it may take a few weeks to months to feel the full benefits of this operation. During the first few weeks, crusts will build up and fall out as wounds heal. This is also the time when the swelling from the surgery goes away. Afterwards, scarring and tightening of the soft tissues can take weeks to months. You may have your ups and downs in the first few weeks, but you should see consistent improvement by 3-4 weeks. 

Most people don't use any pain medications, but one is prescribed just in case. You'll probably be more bothered by the sore throat from having a breathing tube placed during intubation.

What Are The Risks?

Complications are rare, but with any surgical procedure, there is a small chance of infection or bleeding. There is also a small risk any time someone undergoes general anesthesia, which includes, allergic or medication reactions or airway problems. In terms of overall risk, it's riskier when you cross the street. Other very rare complications such as smell loss or a hole in your septum have been reported. 

A septoplasty, if done properly, is one of the most gratifying procedures for both the patient and the surgeon. Success rates are very high. However, there are a few percent of patients where nasal congestion still persists, or it comes back after a few weeks to months. In this situation, there are two main possible reasons: there is persistent turbinate swelling due to inflammation, or you have flimsy nostrils. There are treatment options for both theses conditions.

Think about your facial skeleton as the walls of a house. The soft tissues are the furniture. As you move the walls inward, there's less space for the furniture and less space for you to walk through the room. To improve the situation, you either have to widen the walls or remove some furniture. This is what's done with the various sleep apnea treatment options that involve surgery. With CPAP, picture yourself navigating through the crowded furniture a bit faster to get to the other side.

A very important concept that many forward-thinking physicians and dentists point out is that the soft tissues (your facial skin, and internal structures like your tongue or septal cartilage) grow to its' genetically predetermined size. If you have smaller jaws, then you'll have crowding in your mouth, with partial obstruction of the breathing passageways behind the tongue. This is why many modern humans can't sleep on our backs. With gravity, the tongue falls back, and when you add deep sleep with additional muscle relaxation, you'll stop breathing and keep waking up.

The same process applies with the nasal septum. If your jaws are more narrow, the roof of your mouth gets pushed up into your nasal cavity. Then one of two things can occur: the septum (which sits on the floor of your nose, which is also the roof of your mouth), buckles to one side or the other, of the septum stays in place, but causes the maxillary bone underneath to splay apart, leading to the symmetric right and left maxillary bone spurs that you'll often see. Sometimes, due to the constant stimulation of the septum on the roof of your mouth, a midline bony bulge can occur in your mouth (called a torus palatini). 

If you upper jaw is underdeveloped from a front and back perspective, then your upper lip and lower nose will be pulled down and in, leading to the appearance of a nasal hump. This is one of the most common reasons for a traditional rhinoplasty. Furthermore, underdevelopment of the lower jaw creates the classic weak chin, which is traditionally treated with chin implants. Cheek bones are also underdeveloped, leading to a lowering of the lower eyelid and flattening of the face under the eyes. Since the facial skeleton is smaller, the skin that drapes the bony structures are more lax, and with aging, tends to sag and wrinkle easier. An excellent, more thorough review of these concepts can be found here.

When I first read about this process, my eyes were opened as to why there's so many sinus problems, nasal congestion, headaches, TMJ, and various sleep-breathing problems. This is also why when one specialty treats one particular problem (ENTs treating the sinus problem, dentists treating the TMJ problem, the neurologist treating the headache, and the dermatologist treating the wrinkles, etc.), these problems always tend to come back.

What do you think about what I'm describing? Is it academic hype, or should we be afraid of our very future? Please enter your comments in the comments box below.

There are two procedures that are still being routinely performed that have negative consequences years, if not decades later, and these are rhinoplasty, and dental extractions for orthodontic work. I see at least 4-5 patients a week that come to see me for routine problems, only to find that their "routine" procedure 10 to 25 years ago probably aggravated their current condition.

During routine rhinoplasty, especially when you're trying to narrow a wide tip, surgeons by definition have to weaken or remove a portion of the support structures (or cartilages) that keep the nostrils open. Current surgical methods take this into consideration to compensate for this fact, but many surgeons are still weakening the lower lateral cartilages without strengthening the remaining structures. This leads to flimsy nostrils that cave in with every inspiration.

As a result of this weakening, patients will have stuffy noses, unrelieved by allergy medications or decongestants. Medicines won't work for structural problems. Sometimes, someone with this condition accidentally tries a Breathe Rite nasal dilator strip, and swears by how wonderful it is.

Dental extractions are still being performed as part of routine orthodontic treatment. If there's too little space for the teeth, then it's logical that removing a few teeth can create enough space for the remaining teeth, right? What's missed entirely is that the jaw's too small. The teeth, especially the molars, act as support structures for the soft tissues of the throat. Once removed, the space behind the tongue collapses, leading to significantly lessened quality of sleep. Even simple orthodontic adjustments can have a major impact on sleep quality, since the space that that the tongue is contained in can change dramatically.

Fortunately, forward-thinking dentists are recognizing the fact that the position of your teeth and size of your jaws have a major impact on your breathing, and your health. Some of these dentists have leapfrogged ahead of the medical profession in terms of understanding the holistic implications of proper facial form and function.

Did you have rhinoplasty years ago, only to have continued nasal congestion, or did you undergo dental extractions before undergoing braces? If so, please describe your experience below.

Before I discuss the various ways to breathe better, a short anatomy course in in order. The nasal septum is a thin piece of cartilage and bone that splits your nasal cavity right down the middle. No one has a perfectly straight septum; everyone’s septum is slightly curved. Sometimes, nasal trauma can shift or move the septum away from its’ midline position. The nasal turbinates are wing-like structures that line the sidewalls of your nose. It’s covered with a mucous membrane, and normally it helps to smooth, warm and humidify air. The turbinates and sinuses also produce about 2 pints of mucous every day. The turbinates swell and shrink, alternating from side to side every few hours. This is called the nasal cycle. 

The front side walls make up your nostrils, which are soft cartilages covered on the inside and outside with skin. The back of your nose is one big cavity (called the nasopharynx), and the passageway turns down 90 degrees into the back of your throat. The nasopharynx is also where your ears connect via the Eustachian tubes. 

If any part of the anatomy that I described becomes obstructed partially or completely, you’ll feel stuffy in your nose. Usually it’s not one thing, but usually due to a combination of different reasons. For example, if you have a mildly deviated septum, suffering from mild allergies will swell up your nasal turbinates, narrowing you nasal passageways. This may not be enough to clog up your nose, but if you have flimsy nostrils or had rhinoplasty in the past that weakened the nostrils, then breathing in with a stuffy nose may trigger your nostrils to collapse. 

Starting from the tip of your nose, the first thing you must do is to find out if you have flimsy nostrils. If you have a very narrow nose, or if your nostril openings are very narrow and slit-like, then you may be prone to having flimsy nostrils. Try this experiment: Take both index fingers and press them just besides your nostrils on your cheek. While firmly pressing on your cheeks, lift the cheek skin upwards and sideways, pointing towards the outer corners of your eyes. Take a deep breath in. Can you breathe much better through your nose? Let go and try it again. If this maneuver works for you, you may benefit from using nasal dilator strips at night (one brand is called Breathe-Rite). Sometimes, the adhesives on these devices are not strong enough, or end up irritating the skin. Another way of treating this condition are various internal dilators (such as Nozovent, Breathewitheez, Nasal cones) that you can find over the counter or over the internet. 

Second, try using nasal saline sprays. You can use the simple spray bottles that put out a fine mist, to more sophisticated methods such as aerosol cans or even using a Water-pik machine (there’s a nasal adaptor that you can buy for this). Another popular variation is something called a Nedi-pot, which uses gravity to pour salt water into your nose and sinuses. You can either use prepared saline packages, or mix your own recipe (one cup of lukewarm water and 1/2 teaspoon of sea salt or Kosher salt with a pinch of baking soda). Whatever method you use, you’ll have to do it frequently to get maximum results. Besides cleansing out mucous, pollutants and allergens, saline also acts as a mild decongestant. 

Third, try not to eat anything within three hours of going to bed. If you still have food or juices lingering in your stomach when you go to bed, it can leak up passively into your throat and not only prevent a good night’s sleep, but these same juices can also leak up into your nose, causing swelling and inflammation. In addition, many people will also stop breathing once in a while, which creates a vacuum effect in the throat which actively suctions up your stomach juices into your throat and nose. 

Fourth, try to avoid drinking alcohol close to bedtime. Not only does alcohol irritate the stomach, it also relaxes your throat muscles as you sleep, which aggravates the process described in the previous paragraph. 

Fifth, if you have any known allergies, especially if it’s something in your bedroom, try to either remove it or or lessen your exposure to it. For example, many people are allergic to dust or molds, and if you have carpeting, or an area rug, it can harbor these allergens. Frequently washing your bed sheets in very hot water also helps. Investing in a quality HEPA filter should help even more. If you have any pets, consider keeping them out of your bedroom. If conservative measure to control allergies is not good enough, consider seeing an allergist for a more formal evaluation. 

Sixth, get regular exercise, especially outdoors. Not only are you exercising your heart and your muscles, you’re also exercising the nervous system in your nose. Vigorous physical activity activates your sympathetic nervous system, which constricts the blood vessels that supply your nasal turbinates. This allows you to breathe better through your nose, with all the added benefits described in my previous article. 

Lastly, slow down and relax. Modern society has removed all the natural built-in breaks throughout the day. Along with all the information overload and constant stimulation, going nonstop all day only adds to the increased stress levels that everyone experiences. In between major activities, take a minute or so to stop what you’re doing and stretch, get up and move around, and do some deep-breathing exercises. Stress can tense up the muscles, causing you to breathe shallower, which causes physiologic changes that can ultimately aggravate nasal congestion. 

These simple 7 steps won’t help everyone, but If you can go down the list and apply all the steps, many if not most of you should feel some improvement in your ability to breathe through your nose. If you’ve tried all these steps and still can’t breathe through your nose, then seek medial help. An otolaryngologist (an ear, nose and throat doctor) is the best doctor to take care of this condition. 

If you are a chronic mouth breather, in addition to what I described above, your jaw is probably more narrow than normal, with some degree of dental crowding. Chronic mouth breathers also tend not to sleep well at night due to various degrees of breathing difficulty. I discuss these issues in my other articles (sleep apnea and upper airway resistance syndrome).