Episode 217: Functional Nasal Breathing with Dr. Melyssa Hancock, MD

Hi and welcome to episode 217 of the Ontether podcast. Today we have Dr. Melissa Hancock joining us. Dr. Hancock is a double board certified facial plastic and reconstructive surgeon in Boca Raton. She practices the full spectrum facial, cosmetic and reconstructive surgery with emphasis on rhinoplasty and revision rhinoplasty as well as facial rejuvenation procedures and skin cancer reconstruction. She's an active staff member at Boca Raton Regional Hospital and the Boca Raton Outpatient Laser and Surgery center and is also a clinical instructor at the Florida Atlantic University School of Medicine. She currently serves as President of the Florida Society of Facial Plastic and reconstructive surgery. Dr. Hancock received her undergraduate education at James Madison University in Virginia prior to attending medical school at the University of Maryland School of Medicine. She then completed a comprehensive five year surgical residency in Otolaryngology Head and Neck Surgery at Georgetown University hospital in Washington, DC. Following the completion of her surgical residency, Dr. Hancock completed a fellowship in Facial plastic and Reconstructive surgery. During this year long period of advanced training, she gained experience in the most innovative non surgical and surgical techniques. She also served as a clinical instructor for facial plastic and Reconstructive surgery at the Virginia Commonwealth University Hospital as well as the Richmond Veterans Affair Medical center where she participated in teaching, resident training and research. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified health care provider. Welcome to the Untouched Podcast. I am your host, Halle Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, Dural tissue and pediatric Feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest Posture tongue up, lips closed, teeth apart, heart breathe through your nose. Let's get started. Melissa, welcome to the podcast.

Hi. Thanks for having me.

I'm excited that you're here and so is everybody else because they've been hearing about me, you know, talk pretty much now. For the past year and a month about my experience with my own nasal surgery and just your office and you and how phenomenal it was compared to experiences I've had elsewhere. So, yeah, I'm just excited to dive into that today. So will you start and just tell us first a little bit about you, like, who you are, what you do, just so we can kind of lay the groundwork for everybody.

Okay, so I won't. I could start from the beginning, but that would take a really long time, and I don't think everybody wants to hear all those details. But. But I am. The short background is that I am from Connecticut. I went to Virginia for undergrad, Maryland for med school, and then I did my residency in ear, nose, and throat, and head and neck surgery at Georgetown in Washington, D.C. and then actually did a fellowship, which is an extra year of training just in facial plastics and reconstructive surgery in Virginia. After that, I moved to Florida for a job, and it's kind of just been all awesome since I moved. Keep moving further south. I joined Dr. Nathan Naklis, who's been in practice for 35, probably close to 40 years now. And really, the niche that he has is the nose and sinus or the nose and sinuses. He did it. He was the same way with as me, where he did a fellowship in facial plastics. So he also had that rhinoplasty component. And he's the one that really developed the idea of the total nose approach to correcting the sinus and nasal functional issues at the same time as addressing any cosmetic concerns. So I was really brought on to kind of take over that, which is what I've been doing. So my main. My practice is really composed of functional and aesthetic nose and sinus issues. There's not really an aesthetic component to the sinuses, but it's part of just the entire upper airway. So anything, whether it's medical, surgical, functional, esthetic, nose and sinus stuff is what I do.

I love that. And I love how you kept using the word functional, because that's something that comes up a lot on this podcast, is looking at the functional side of things. And that's really the reason why I feel like a lot of patients come to you in the first place. Now, when I came to you, I was like, okay, I know I have a deviated septum. I know I have turbulence that need to be addressed. I never heard of nasal small bodies. And, you know, you did such a beautiful job of explaining to me, like, showing me, like, what those were. I love that you had visuals. You know, the whole process you know, everything from, like, checking in to being like, you know, you guys sent me for the CT scan, and I met with, I think, your PA first, and she took all my history and everything. Just felt very thorough and documented so that by the time, you know, you came into the room, you sat with me for a while and you were like, okay, hey, this is what I'm seeing. Here's all the different options that you could do. Open, you know, closed this, that, and the other. And I didn't say anything about the rhinoplasty because I was like, I kind of just want to know, like, functionally first, like, how do I fix my ability to breathe? And then, hey, like, what happens if we want to add a rhinoplasty into this? Because I'm already going to be, you know, anesthesia, so why not let's just do the whole kitten caboodle. But also just with your. Your facial plastics background, I also felt comfortable doing that because I knew that you could get an esthetic that looked very natural and that wasn't, you know, like, oh, we're already under, so let's just do this procedure. It was sort of like, well, let's do it. Because you are highly skilled at this. And that's. You're like, okay, let's look, talk rhinoplasty. And that became a really fun conversation. So do you get a lot of people who come to you, like, for one versus the other or.

And.

Or both?

Yeah, I think, you know, by the time a lot of patients reach us, they already have been to other doctors with. Whether it's their primary care doctors or another ENT, or they had some. Maybe a workup. Usually not, though, in the past, and things have started to bother them to the point that it's affecting their quality of life. And I always tell patients, you know, I'm in the business of quality of life. I'm not, you know, this isn't going to be life or death here. This is really just about making everything in your life better from an ENT standpoint, or at least a nose and sinus standpoint. And people really underestimate the importance of nasal breathing. Everything from when you're just sitting there watching TV to sleeping, to what do you do when you're in an anxiety or an anxious state? Breathe in through your nose, out through your mouth? There's so much that is critical about nasal breathing. And when your sleep is affected, then you're tired, you don't feel motivated to work out, your work productivity is affected, your family life is affected. Those are usually the things that drive people to come in and say, I need to make a change. So yes, we get a lot, I get a lot of that functional stuff. Patients who, they just want to breathe better. And that's, that's the truth and that's really what they want out of this. And sometimes it can be a frustrating process because they might have been told things before, they might have had workups before, been mismanaged before. So what I like, and that's the, that's what I love about the setup that we have here, is we're kind of a one stop shop. You come, we look inside your nose in a way that nobody else can. We get those CT scans, which is really just more information for you. And it helps, I think patients understand kind of what's going on. And then of course we have allergy testing, we do home sleep tests or, you know, further workups for sleep disorders. And then, you know, there's also the cosmetics, which is always fun. And I always find it interesting because patients who come in for functional, if they have this, they've been thinking about cosmetics for a while. They're not quite straightforward about the cosmetics. They kind of want to see if I'm a good fit and they kind of like, like to surprise it on me. But that's. I can, I kind of already, I do this enough that I kind of know where it's going. So I. That's the fun part, right? That's the exciting part of thing about my face. And I'm just going to leave it up to this woman in a coat to do that for me. And so there's a lot of. It's really all about the rapport in the room. And I think that's important to have. As I've gotten further along in my career, there's certainly a lot more patients. I mean, social media plays a huge role as, you know, in just the aesthetics that business in general. So sort of as I've become busier, kind of been marketing more, getting more word of mouth stuff, become, you know, kind of more on a national level at this point, I am seeing a lot of patients coming in just for cosmetics. The kind of, the caveat with that is that at the same time that I see a lot of cosmetics, I also see patients who've had cosmetics before and now come in because they can't breathe. They had a rhinoplasty before. Functional issues weren't the reason they initially went in for surgery, but now they have them. And that's a whole other Separate niche that is just. It's a really. There's not a lot of surgeons that will take on those revision cases.

Yeah, that seems to be my go to whenever I can find a surgeon. Whether it's an oral surgeon or it's like you who basically gets the cases and fixes those cases that have either been botched elsewhere. I don't know. That seems to be the people that I trust from the, from the get go. It just takes me a while to find you. Yeah, no, so moving down here, it was funny because we were having dinner with somebody and somebody recommended your office. And I called and I think that they had actually had the procedure with Dr. Naklis. And so I was, you know, and they were like, no, no, you want Dr. Hancock. And I was like, okay. And so I came in and the consult was great. But I really do appreciate that whole like functional approach in combination with the esthetic approach. Because, you know, I was that patient who at the end I was like, okay, hey, I want a rhinoplasty too. Like, let's, let's talk rhinoplasty. Kind of sprung it on you at the end. You get, oh, we kind of froze.

For a second there.

But it's funny that you get a lot of those patients that, you know, that you're kind of like, yeah, I know, I know where you're headed. I know you're going to ask me about a rhinoplasty at the end. Let's get through the functional stuff so we can have that conversation too. It's, you know, it's almost mind boggling to me because one of the conversations we also have on here a lot is just how hard it is to find and T's throughout the United States who take a functional approach and who really are looking at how important nasal breathing is. And you know, I had like my own kid. She's sitting there, she's got like almost kissing tonsils at the age of. I think she was three or four at the time, maybe she was two. That may have been 24 months. We go to an entity and she's sitting there with her mouth closed because of who I am and because she knows she's supposed to have her mouth closed. But that's not her typical demeanor. And the auntie is like, her mouth is closed, she's nasal breathing. And I'm like, did you see her tonsils? Because that's clearly not going to hold true. Especially when she's like supine. When she's laying down sleeping, we know her mouth is going to be open. We know she's going to be noisy breathing if not snoring, she's constantly sick. And it was just, there was no follow up. There were no suggestions of medications or nasal rinses or sprays or anything. And I was just like, man, like, this is what my patients are experiencing that we send through ENT and we finally actually just found somebody. Finally, after nine years of me having a practice that we can refer to in the DMV, the D.C. metro area. Because this ENT's child went through treatment in my practice and his eyes were like massively opened and he treats kids and adults right now. So I'm like, please don't change that. When you become super busy with all people. We've referred to you, but it's hard to find. And so like, from your perspective, because you talked about how important nasal breathing is, you know, on the flip side, like, what do you as an ENT see as being problematic when you get a patient who is mouth breathing? Like, I know you talked about some of like the symptoms and impact on daily life. Is there, you know, anatomically, physiologically, are there other things that are concerning too?

So if you're breathing through your mouth all the time, there's a lot of sequela of just that alone. Bad breath, tooth decay, hoarseness, you know, throat irritation, worse reflux. But it also puts, it activates a different part of your nervous system, which leads to stress on the heart and the blood vessels and the lungs. And it's not just, oh, it's mouth breathing. It's all these other downstream effects that happen over years and years and years of doing that and it becomes the only way, you know. So I get a lot of patients that don't understand how bad they are breathing or how bad their anatomy is and why it's so important to fix this. And so there's sort of fine line where you're telling me you don't have certain symptoms, but it's impossible that you don't, or at least near impossible. I just think you're used to, you're used to this way of living that you don't really know what normal is anymore. You don't know what you're supposed to feel like. And that's. That is one of the two most common things that patients will say to me after surgery other than, I wish I did this sooner, is, wow, I had no idea that this is how it's supposed to be. Like, is air that cold? Like, why don't my nostrils, are they both supposed to Work. They're both working. Like, wow. And, you know, then you also have. You know, there's. When I talk to patients and when I do my evaluation, I try to explain very clearly that when we talk about nasal obstruction and sinonasal pathology, there's really two categories of causes, the structural stuff and your inflammatory stuff. And they have different treatments, and you may not get the relief you want unless you address both. And that's also something that, you know, people will come in, they've had treatment before, they were feeling good, and now, you know, their symptoms are back. Well, what medications are you on? Nothing. Okay. You mean I was supposed to be on that the rest of my life? Well, yeah. It's kind of like anything else, right? Like high blood pressure, diabetes. If you go off your medication, your symptoms are going to come back. So, you know, again, it's. When I talk to patients, it's more about, you know, oh, my wife says I snore, or my wife says I choke on my own tongue all night. Like, it's always more than that. And trying to get them to understand or appreciate kind of what's going on is always the most important part to me. And really what I tried to convey in that first or second or whatever visit.

Yeah, yeah. No, and we've heard that from patients, too, in terms of, like, I had no idea what I was missing out on until I knew what I was missing out on. And it's. You know, I almost had to, like, laugh at myself because even with my own nose surgery, I had no idea how badly deviated the back part of my septum was. It was almost blocking my entire left, you know, nurse. And like, I. I'm in the world of myofunctional therapy. I teach other people how to breathe through their nose. And I'm here going, like, why? It's like, how did I miss this on myself? Like, I knew I was congested. I knew that, like, I was definitely in need of surgery. But again, like, you don't truly. Even when you're highly educated in this space, you don't truly know what you're missing out on until you live it firsthand and experience it. Because after the procedure, everyone was like, well, isn't it miserable to have, you know, all that stuff up your nose? Like, after the procedure, I was like, no, I can breathe. I mean, it's. I'm like, I hear it's going to swell, and I'm going to not be able to breathe well for, you know, maybe the next week while things start to really Swell up and heal. After day, like two or three or so, I was like. But in the first couple days, I was like, I can breathe so clearly that if this is, like, what we're working towards, after all the swelling calms down, like, this is life. Like, I am good. And I mean, I was also, like, hopped up on a bunch of stuff at that point. But, you know, it was glorious. It was all good, all good.

It was great.

And then, you know, and then now, a year and a month afterwards, you know, to be able to breathe through both sides of my nose, even if I have, like, some allergies or, like, congestion or something, it's completely different than my experience pre op, and it's impacted my sleep. Like, my sleep is better. I. My body just, like, dropped 15 pounds. It just fell off. I changed absolutely nothing about my lifestyle, and I'm like, oh, well, all that weight I wanted to lose after having kids just decided to peace out after my nose surgery because, oh, I could breathe. And I know from a home sleep test that I. Before I came into your office, that I was never going into that REM sleep. As soon as my body would hit rem, it would jolt itself back into an arousal level, and I wasn't fully waking up, and so I wasn't aware, but my body, I was basically energizer bunny, just going and going and going and going on absolutely low battery at all times. So, like, it's no wonder how much better I feel after being able to breathe and sleep.

Yep. And it is. And it's hard to sometimes, you know, when you've been a certain way your whole life, you know, it's kind of hard to take that leap sometimes. And it can be scary because the reality is not every patient does as well as you did so fast. Some people's recovery is a little bit slower sometimes, you know, they're more symptomatic, longer, and it takes a little bit more time to figure out the right medications or the right kind of, you know, what else needs to be done. And then there's always surprises and things like that. You know, things like Covid and weight gain and all these, you know, all these other random things that come into your life and now at a new dimension to just your quality of life in general. But again, it's. It's. It's important that wherever you do go, you do feel heard and you feel like you understand the process. You're not going to understand the surgical terms and all that. You know, I can't even pronounce Half the medications. But, you know, if you can, if you can at least have that relationship with who is going to be taking care of you, then it just, it works better. It just works better. And no matter what bumps or whatever happen, you're. You both are going to get through it and you're going to come out on the other side a better person and feeling better about yourself. And then the good surprises like weight loss and just better sleep and, you know, that other stuff do eventually come.

Yeah, well. And I have to plug your office because they were incredible, like in the pre op with any questions I had, really prepping me. You guys are so thorough and everything that you give, like, pre op wise. And I've seen it compared to other offices, even locally with a family member who had a procedure in another office and got like one piece of paper front and back. And I was like, where, where is all the pre op? Like, well, what do you. When you start nasal rinses and are you supposed to clean, like inside your nose? Like, because I had already done mine. And so I basically took everything I knew and basically told this person, like, hey, here's what you do. Let me help you. Like, and they were like, I don't know what I would have done otherwise because nobody gave me any of this information. So, you know, just to have that, all the information upfront ahead of time, you know, your office, like, literally walked me through it and then gave me the handout with everything written down. And it was very easy to like, I mean, I'm like anal type A when it comes to, like, this stuff. So I was like, make. I literally made charts and was like checking off like, okay, I took my meds in the morning and I did my nose rinse and I cleaned inside my nose and okay, we're good. And I've got to do this midday and I'm going to do this again in the evening. I pop my Arctica and all that stuff.

But.

But I loved the protocol. I think it worked so beautifully. And you know, even post op, you know, I had some situations like my dog basically jumping up and butting me, like, with his head up my nose. And I was like, my nose just went into my brain and I, at that point I still had the cast on. So I did come in and see you all and you're like, you're fine. But I was like, oh, my God, this is the one thing that I was not supposed to let happen.

I know. Well, you know, it's funny, like, you know, I get patients like, you Were like, oh my God, you're so thorough. You gave me all this information. And other people are like, I need so many freaking pieces of paper. I didn't know what I was reading. I got so confused. What drugs do I take? Oh, I didn't pick up any of my scripts. You didn't give me anything. You never told me that. And I'm like, oh my God. Like, I'm sorry, I don't, I don't know what to say. Like, I gave you too much paper, you know, and so it's just always interesting because I have both of those patients, the very like type A that want to know everything and want to know what to expect and want to be prepared. And the other ones who are like, when's my surgery again? Like, you know, we're like, oh, no, the family calendar.

Everybody knew when the surgery was and when I would need help through and who was doing carpools, when and who was going to stand in for me and my kids schools. I was like, I am not. Because also like wearing a mask with the, with the, you know, afterwards. Because I'm also very sensitive to certain medications. Like, I was kind of dizzy and I, I don't know if it was like the cephalexin or which one it was because as soon as I stopped it, like, I was no longer dizzy. But I was on that for a little longer, I think, because like some, I had some like red or the skin was a little bit discolored. We wanted to make sure that it healed properly. So I was like, that's important. So we're just going to stay in bed a little bit longer and make sure the heal, you know, we heal okay. But I was like, type A. Having kids has made me very type B in my business, in my life in general. But like, when it comes to like this thing in the middle of my face, I was like, this has got to heal correctly and if it doesn't, that's on me. So let's like, let's be a little type A about this. And I thought your team was like, hey, we need a chart like that. And I was like, I'll send you mine. I never did. So, you know, you guys want. And I'm happy to send it, but.

Well, you know, and it's, it's like, I love the post op journey for patients because I know they're going to get where they, where they want to be at some point. It just, some, some are very different, some are a little bit more difficult, and that's okay. And again, I think that's where it comes down to, you know, a. That you have to have a good relationship. Wherever somebody's cutting your face, like, don't take that lightly. And if they take it lightly, or you feel like they're taking it lightly and they're not listening to you, then it's just not the right person for you. It's the same with anything, right? It doesn't matter, like, whether it's food, restaurants, like doctors. It's all the same. You have to have that relationship, and you have to feel like, okay, we've got this. I know that no matter what happens, you know, we'll get through it. And no doctor. Doctor's office are perfect. And if, you know, if we. If I could make every patient happy faster, of course I would do that. But I don't have control over that. You know, I mean, that's something. And it's just, you know, it takes time. And I think what you. What you made, what you just said about, you know, staying in bed an extra day, you know, you have to give your body permission to heal. You have to take that time so that your body can really focus on, you know, a certain area of the body that needs to heal without putting it through more stress or anything else. And again, doing stuff too soon or trying to rush the process just. It backfires at some point for the most part. But, you know, again, it's. It's. There's a lot of different options. I mean, healthcare in general has become so difficult to navigate, right? You've got ent. You've got facial plastics, You've got allergists who aren't surgeons, and they're doctors. You've got family medicine, who dabbles in all of it. You know, I mean, it's like you don't really know sometimes where to go or who to go to or how to even know what somebody actually does. And that's, I think, what's made medicine very difficult for people to kind of get the. To really get the treatment that they need. Sometimes patients are so frustrated by the time they get to me that they. They're, like, already mad at me. And I'm like, I. You just filled us your demographic paperwork. Like, I don't know why we're so upset already.

Like, I haven't even met you yet.

I don't even actually know your name. Like, oh, my gosh. But, you know, it is. It can be really frustrating. And so I think having, you know, good. Being in a good state of mind, knowing that things might happen. Giving your body and yourself permission to be like, okay, I'm gonna. I'm gonna just not be type as. As type A about everything. I'm gonna focus on my energy in one respect or on one thing. And then also having a good support system, too. It helps, you know, having people who can help you and support you and kind of be there for you because, you know, let's face it, there's lots of times where I'm sure patients wanted to be. Yell at me, you know, oh, swelling's not going down fast enough, or I don't feel as good as I should, or, you know, and that's okay. And I always tell patients, you can come and yell at me all day long. There's a line, I'm sure. But, you know, having that support system to vent to, kind of get through it is also really important.

Yeah, no, for sure. And it's. You know, I always tell everyone. I'm like, look, my. My experience may not be your experience. It probably won't be because I have a very high pain tolerance when it comes to, like, big pain. So, like, I fell down once, cut my knee, needed 27 sutures. Searching on the inside. I. I mean, my body was also in shock, but I felt very little. And then once they, like, basically continued to give me Novocaine shots around my knee as they were, like, you know, cleaning it out and all that, I still, like, I just felt nothing because I. My body just kind of shuts down the pain receptors. I. So, like, after the procedure, you know, yes, I did take some of the.

But, yeah, men and women have just very different pain tolerances. So, you know, people ask me, is it painful? Is it. Is it. You know, how bad is it going to be? Most people describe it as uncomfortable. If you ask maybe a male, it's going to be very different. It's just the way it is. It's. It's kind of harder for, you know, that's just my observation. I don't know that there's any truth to that, but it's just, you know, kind of. It's just something to keep in mind, you know, if it's your child, if it's your husband, mother, brother, whoever it is, you know, just kind of want to gauge a group, not just one person, too. Can sometimes be hard, but can be really important when you're kind of making some big decisions.

Yeah. So, I mean, I think for me, I. I didn't feel any, like, pain. Now, as I mentioned, I did take some medications to help with that, especially at night. Like one of my friends was like, take the meds at night because it's going to be hard to sleep because you're not used to. I mean, I was mouth breathing before. That's part of into the surgery. But you're going to have to mouth breathe and there's also just going to be that inflammation like everywhere, right? Like you're just. Everything's inflamed post op, so it's hard to breathe, it's uncomfortable. Plus you're on your back, you're on an incline, you know, you're kind of trying to sleep in an unnatural way. And they were like, the best advice I can give you, having gone through it, is like, take the meds to help you sleep at night if you feel so inclined. And so I did, and that was probably some of the best advice because it was hard. It was hard to, you know, breathe to sleep and like stay asleep. And you know, plus then I was waking up intentionally to ice and you know, just take any meds or whatever because my sleep schedule was not just nighttime, it was off and you know, off and on throughout the day. But I never really truly had any pain that I felt like I needed the medication for. But yeah, there was like the discomfort for me more surrounding the breathing. And that's the biggest thing. Like anyone who has come to me and talked to me about it, I've said, look, I don't know what your pain levels are like, I don't know what they're going to be like. I had no pain. You may have pain, but just know go into it fully expecting you're going to have to mouth breathe for like a week or two where you're just not going to be able to breathe through your nose. And I think if you're just like prep yourself with that, then for me I was like able to stay out of that whole big like fight or flight of like, oh my gosh, I can't breathe.

I can't breathe.

I can't breathe because I fully anticipated and expected that I would have to mouth breathe. And I think it's also, it's funny, not funny, but I'm like, most of these people going into this are already mouth breather and that's part of why, you know, they're not nasal breathing. So then to not be able to nasal breathe and to be like totally uncomfortable and freaked out by that is like, it's sort of like, oh, well, that's kind of interesting that now you're realizing the impact and now you're upset that you can't nasal breathe, but you really weren't nasal breathing before the procedure either. So it's. Yeah, it's an interesting conversation.

Yeah.

So I guess. Okay. So then the next thing we kind of touched on a little bit was that horror whole, like, with the rhinoplasties, like form versus function. You had mentioned that you get people who have had rhinoplasties, and they didn't go into it from a functional standpoint. They went into it really for cosmetic. But now they may be coming to you because something happened. So what's happening? Is there nasal valve collapse? What leads to somebody coming to you for a reconstruction of the rhinoplasty?

So I actually was just writing, so this will be on my Instagram. But there's four main causes of nasal obstruction after rhinoplasty, the most common being nasal valve collapse. So, you know, people want smaller noses in general. Nobody, most people aren't coming in and saying, make my nose massive. Put more stuff in my nose. So they're trying to make it smaller. And the nuances of how that nose is put together and how it functions, there's a lot of them, and it's not easy. It doesn't sometimes make sense. So, you know, rhinoplasty, just by the nature of the procedure, the surgical maneuvers that you're doing are disrupting a lot of those relationships between the different cartilages and the soft. The skin and the muscles and the two little holes that are there. And if you first don't assess a patient before then, you don't really know what you're working with in surgery. Right. If they. If you don't assess their breathing before then, you're not even able to recognize what might. What you might have compromised in the process. So you're just making it worse for them on the other end. But at the same time, if you do have nasal obstruction, it's important to identify what it's. Why do you have that in the first place before you go into the procedure so that you can make sure that you do address it. But a lot of time, I mean, most of the time it has to do with the nasal valves. You. You cut ligaments and attachments, and those cartilages are kind of splayed apart and have to be put back together. And if you don't put them back together the right way, you get abnormal scarring. You get tissues that are too. Sufficient or too weak to support the nose and to support your breathing. It's a terrible feeling, and it's you know, a lot of times those patients too are really difficult. Not difficult in a sense of like personality wise, just difficult. They're in a difficult position because they went in for something, they may or may not be happy with how it looks, but now they can't breathe. They, that's new and scary and anxiety producing. So now they're going to go back to that person to fix something that they, you know, that they kind of messed up and look at the same time. Rhinoplasty doesn't always heal perfectly, but you got to try. I hope that my patients trust me, that little things happen. I'll fix it. I'll get you there. But in patients who I didn't do the original rhinoplasty come to me, you know, it's, it's a little scary. There's a lot of hesitation, there's a lot of, you know, concerns and you know, sometimes they actually like how the nose looks. So then when they hear that this isn't covered by insurance, it's not, you know, you can't get insurance coverage for a procedure that was caused by a cosmetic procedure. So they're like, well, I like how my nose looks. Nasal obstruction is the problem. Like, how come I have to pay this? And it's. It, I mean it. That can be a really. I prefer to stay out of those conversations, to be honest. But it's, you know, those, those. How do you, how do you not end up in that position? Right? If you're a patient, you want a rhinoplasty, how do you not end up there? It can be hard. You know, you go see a world renowned plastic surgeon. Kind of funny, but not. But do you trust the boob? God, do your nose, you know, or, you know, they're very different body parts. And you know, at the same time, what if that plastic surgeon is bringing in an ENT to do your septoplasty and your turbinates and some of these other functional procedures and they do the cosmetic. Like, what is that? Why, why aren't they all. If they're working on my nose, why aren't they just working on all of it? You know, that's also something that people don't, you know, the average patient may not understand or even know or even know to ask. You know, it's not like the plastic surgeon is sitting there advertising that he's got somebody that does the septum. You find that out when you, you know, made a mental decision and you've kind of committed. And some people can be afraid to take Back that commitment. And some people are like, all right, well, I'm glad somebody that knows what they're doing is going to be doing it, so. Sure. But again, I think it's. It's, you know, you. You really have to do your own due diligence and. And get more than one consult. You know, don't go for the cheapest because. But don't go for the more expensive either. You know, it kind of works both ways. And just, you got to have a good relationship. You know, you got to feel like you trust that person again. It's. It's your face. Like, you know, if you cut your foot and you got to suture that up or you have gallbladder surgery, yes, there's consequences, but, like, you can cover up that stuff, you know, and that's why there's this whole other element of, you know, just. That makes just everything a little bit more heightened. The anxiety, the fear, the. The anticipate, just all that, because there's no hiding it. You know, you're in the waiting room with everybody else who has a cast on their face. Like, you kind of see everybody and you're all checking each other out like, oh, boy, you know, what's going on with them? What's going on with me? Am I normal? Are they normal? Why are they bleeding? Why do they look so good? And then you have social media, which is complicated everything.

Yeah, well, and so how. I mean, it's not easy, I don't think, because I had a hard time finding this. But, like, how frequently do you find an ENT that also has the facial plastic credentials to be able to do all of this?

You know, I think it's not as hard to find an ENT who specializes in facial plastics. I think the harder part is finding an ENT that appreciates the functional side of things and, you know, really treats that just as aggressively and with as much diligence as they do the cosmetic. Right. It's. It's sometimes people. That's really why this is a niche that we have. You know, there's plenty of other facial plastic surgeons in this area, but not all of them actually do the functional work and care about it, you know, and that, I think, is the harder thing to find, you know, because you can go on the websites and you can find facial plastic surgeons, but again, finding one that can really, you know, appropriately treat, diagnose, and treat both things and kind of make you happy in both ways, have the best of both worlds. I think that's the hard part.

Yeah, I Mean, that's why I was, like, instantly sold. I was like, oh, my gosh. Like, I mean, I'd heard this office was good. I didn't come in, Like, I wasn't coming in ready to, like, basically hand over my credit card and be like, let's do this thing. Let the date. Like, I was coming in for a consult because someone said the office was great, you know, and coming from the work that I do, going back to function. When I started to see that, like, you were looking. Looking at the functional side of breathing and really, truly getting the nose, you know, that upper airway open so that I could function right by getting the septum, you know, fixed and by reducing my nasal turbinates and nasal swell bodies. And, you know, that was the bigger part of the conversation initially. I was like, okay, yeah. I mean, that is truly why I'm here. And now I've got this little inkling about the whole cosmetic side, which I know you're really good at, too. So now we're gonna have.

Have.

Like I said, I don't have that conversation. But that was really the driving force was the functional side of things, because I was like, I fully trust that you're going to get me breathing. And then in addition to breathing, I also know that, like, you know, from everything I've seen, you also understand how to make the nose look pretty, you know, And I remember you asking me, you were like, well, how. Like, how do you want your nose? Small? Do you want your nose, like, you know, like, what's your goal? And I was like, I don't really have a goal. All I know is I want it to look natural. And I developed a bump in childhood, you know, when I was basically carrying my children, which got worse with each pregnancy, because I know I had probably obstructive sleep apnea. As a pregnant woman, I have, like, you know, more of an upper airway resistance syndrome prior to having this surgery. But with. With childbirth, I'm like, I developed a nice little bump. I'd like to get rid of the bump. And I just kind of want the nose to appear, you know, straight, but I don't. It doesn't need to be made, like, smaller, per se. And I remember even, like, looking at the images you sent me because you were like, you know, the software is not going to be exactly like what the nose will look like, per se. It's just going to kind of give you the right idea. And I kind of. I took a look at it, and I was like, all right. I mean, I Trust you. And it's so funny to me because I'm very, like, picky about certain things in my life. So for me to, like, go into this full force, like, not even being like, hey, send me more renditions. What else could the nose look like? Could we do this? Could we do that? Just being like, all right, full trust. Like, full trust in you. I, you know, there's something in my gut. You get it?

Well, there's an aesthetics, right? Like, an aesthetic that different surgeons have. Like, and social media highlights this. Like, if you want a Barbie nose, there are surgeons that you go to for that. You know, if you want the Beverly Hills looking nose that looks like a Kardashians, not just a Beverly Hills. You know, if you want the. The other common one I get all the time is Bella Hadid. Like, I don't get it. I don't know if I can even. I'm not talking badly about her, but, like, I send patients back the frontal photo and I tell them, I will never do that to you. No, absolutely not. Like, it may look from the side, but that woman is not nasal breathing.

Yeah, I mean, so that was the whole thing was, you know, I don't want to say the name of the person, but there was, like, this surgeon that everybody went to in Virginia. Like, all my friends in Maryland growing up went to this one surgeon, and they called it the so and so nose. And I mean, you could just look at the nose and see that that tip was, like, pointed up at the very end. And I was like, I don't want the tip of my nose pointed up. I want it to, like, look. I don't. Or at least not, like, in an unnatural way. Like, I want the tip to be, like, where a tip of the nose should be. And I was like, I don't really know what that should be, but I remember in the beginning you even telling me, okay, it actually is going to look more, like, pointed upward while it's healing because it's going to drop a little bit as the swelling goes down, and we don't want it to go too far down. And I was like, okay, full trust. Like, I don't know anything about this, but I remember in the early days looking at my nose and be like, like, oh, that's so weird. It looks so. It was like, you know, and you said, you're like, some days it's gonna look phenomenal, and other days you'd be like, what is this blob on my face? Like? And that's exactly what happened. So I love that you prepped me for that.

And I think that's. That's part of it, you know, is just kind of setting the expectation right away, you know, I'm not. You are not gonna, you know, feel like your nose looks good for several months, you know, and if all you do is sit around and take pictures and selfies, you will drive yourself absolutely bananas. And you'll drive me bananas because you're going to come in every week telling me something new about the nose that I'm going to tell you the same thing is, give it time, chill out, it will all get better. And you got, you know, 11 months and 29 days until we, you know, until we're kind of there.

Well, and I did that. I did take daily photos, but I did it because I wanted to document it for people in my space. And then I did a training in December, which basically I shared with, like, my membership.

My.

My own membership. I shared with them, like, my journey. And I was like, this is basically from surgery, like, pre surgery. And then every single day, like, you can see the progression through at least the first month. And then I kind of, like, think went, like, more week by week or like, after I came in for visits, I would do, like, updated videos or pictures. And I was like, because this is like the three month, you know, six months, you know, that. That whole journey of where you start and, like, how far you have to go. And I think that also kind of gives people a little bit more information out. Obviously, I had a rhinoplasty. It's maybe different than someone just going in for, like, a septoplasty or terminate reduction or some combination of that. So they all kind of had that information. But I was like, look, like, I feel like this is actually becoming a big conversation in the MYO space because there's a lot of patients and even providers who are like, well, hey, if I'm going to go under, maybe I should just do the rhinoplasty too. So it was a pretty great way to force me to document because normally I would not have done that. And I think it was also just very helpful to see that journey for myself, otherwise I would have forgotten so much of it. But, like, going back and reading the notes and the things that I said and watching myself talk on video when I was on, like, certain medications is absolutely entertaining.

Best videos.

The best.

It's funny because social media does change so much of this, right? We, you know, of how we view ourselves and how we. What we think is normal. And that's all conversation really, for a totally different day. But social media can, can kind of wreak havoc on your expectations and that can be really hard, especially if other people are posting. And even as like a surgeon, like, I try to prepare people and I'm fully prepared that at some point somebody may post a video of where they're at and it doesn't look good or they're not happy and that's okay. And. But that is, you know, it can be very discerning for maybe somebody who sees that. Right. Maybe they're. Now it puts a new fear because it's not the context, isn't there like, no, I'm only at two, you know, three weeks and I just went, you know, worked out my nose. Yeah, it swells, you know, and it's one of the reasons I also really don't do cast reveals like on social media. That's like a huge thing and I do not get why, to be honest. Because it is such a personal moment. It's like the first time you're really seeing your whole new nose and it can be very anticlimactic. It doesn't. It's not. Everybody's like happy tears, like some people like, thanks. And I'm like, it looks great. It looks great. It's. But it's just so different. You know, you're not used to seeing your face that way and it's just like, you know, you've edited your photos a million times already, right? You've already done Photoshop them. So it's not, it shouldn't be a surprise, but it is. It's like real. And so, you know, I would say it's like a mix of 50, 50 some people have, you know, I get my occasional tick tocker and somebody's crying and you know, I'm going to change their life. And I'm like, okay, like, that's a bit much for this. But yes, okay, you know, I'll take the credit. And then, you know, you have the others that are like just kind of, you know, it's not as fun of a cast reveal as I would like. I would love everybody to be crying happy tears, but that's just not the reality of it. And you know, I think social media has changed a lot of just not just the way that information gets disseminated, but also the expectations and, you know, what you can expect to go through throughout that journey.

So, yeah, no, I mean, it's. Social media is both a blessing and a curse. It's like, so don't know what information to believe anymore because, you know, and especially with the future where we're headed with AI, anybody can upload any information. And now that's the truth. That's just how things exist. I'm like, so fun to see where this goes in the next like three to five years. We're already like way past where we should be. But hey, so I have a question for you. So I've seen these like, you know, nose jobs, not really nose jobs where people like inject Botox into the nose. Like, any thoughts on that? Or any like, not, you know, other. I would never do it personally, but I'm like, this just doesn't seem like it could. It's a good idea, but I don't have any reason to believe why or why not.

So, you know, it's usually a filler that's put in the nose to reshape the nose. You can certainly use Botox around certain areas of the nose to, to affect the way the muscles pull and, and how they interact with the nose shape and everything. But it's usually fillers and there's even threads. I can tell you that, like, I'm not an advocate for either of those. Like, the nose is such precious real estate. It's a very vascular organ. It is the center of your face. Anything that can go wrong, even if it's a 5% chance, like, why would you risk that on your face? It's just, it's, it's not the cheek, it's not the chin. Yes, there's risks with that, but the nose is just different. And it's not like it only this is the other part is like if people say, oh, I just did it because I wanted to see what a nose job would look like, well, it's only changing your side profile. That's all it's doing. It's not changing your frontal profile, it's not changing the oblique view, it's not changing, you know, anything else. And what it is doing is putting a foreign body in, under the skin and the tissue on top of cartilage and it's causing an inflammatory reaction. It may not be like this big blown out, you know, allergic looking reaction, but it's causing inflammation in the nose. So then if that's what you decide to do, is that you want to now get a real nose job, that, that there's already kind of damage or, or there's already that underlying inflammation. It's so delicate. So like you add a foreign body. I just, I am not a fan. There's not a lot of Data out there yet saying if it's bad or good. Like there's some papers out there that say, oh, the risk is low in the right hands and it's only filler. You can dissolve it, but you're still causing damage in some way. Not a lot, but you still cause inflammation, which as a surgeon, you can see at the tissue level when you're in there and it's harder to dissect or the tissues just aren't as robust as they should be. And it also changes how you heal. You know, you've. You've changed the vascular pattern to accommodate this foreign body. You've changed the drainage pathway. And I mean, even when the functional and the cosmetic surgeries are combined, I tell patients, let's get you started on things, it may not work that well, like the rinses with an anti inflammatory, but let's just do something to try to minimize the inflammation as best we can before we get to surgery. You know, anything that we can do to optimize the situation before we get there is always a good thing. So, you know, I, trust me, I love Botox fillers. I have at least six syringes of stuff in my face at any given time. I've tried it all. You know, some of it's great, some of it's not. Some of it is just meh. Some of it's overpriced, some of it's not worth it. But in the nose, you only got one of them, you know, and it's just, you just, you just never know. I don't know.

Yeah, I mean, I guess for me too, like, I see the before and after is even. And I'm like, I don't get it. Because I'm like, you're actually making the nose like taller and bigger and filling in the space oftentimes between the tip and your forehead. And so I'm like, I just, I don't get the appeal. I get. Like, some people love it, but that's. I was like, like on the backside. Just from a functional standpoint. I was like, something about this doesn't sit right with me. But I'm obviously not the ent. Like, I don't. So the whole impact on inflammation and then the vascular, you know, you even mentioned the drainage pathways. Like, that's huge. I mean, I think everything that we do and that we recommend or that we try to refer to other providers, you know, when things are out of scope for us to possibly recommend is always pointing in the direction of opening drainage pathways and reducing inflammation and Opening the ability to nasal. Allowing for the ability to nasal breathe. So, you know, I think that's, that's super helpful. And then my last question is in terms of like different types of nasal sprays, is that something that you'll often recommend for somebody, like before surgery regardless, or to try and see if we can prevent surgery if it's like more of a adenoid tissue versus like actual bone structure that we're, you know, considering for surgical removal or reduction?

Yeah, I mean, very rarely is it is the pathology in the nose and sinus is just one thing, right? It's not just one. You have one valve that's collapsed or one. Or you're. It's just your turbine. It's usually a combination of things. In patients who truly just have structural issues, you know, even doing over the counter stuff isn't necessarily benign. Right. If your septums deviated and you're spraying and this flonase at your septum instead of into your nose because, you know it's blocked by the septum, then all you're doing is irritating that that tissue. You can cause nosebleeds. And then they don't feel like it's effective. And then it's like, why would the doctor tell me to do this? It doesn't even work. Does she even know what she's talking about? But also it's, you know, so I think it really, that's why you've really got to kind of approach it from a comprehensive standpoint and see what are your problems? What are we actually treating? What are your real diagnoses? I mean, how many patients say they have allergies but have never been allergy tested? You know, I mean, it's the idea. Why would you want to keep taking meds unless you really know what's going on? Are there, you know, is. Are there serious consequences for taking, you know, meds you don't need every day? Probably, you know, yes and no. Right. But I think that there are some nasal sprays that are more benign. Like you're over, you know, your flonase, your sensimus, nasal cords, you know, Nason X, they're over the counter. You know, they don't work right away. I don't know. You know, it takes a while for them to work, at least a couple of weeks. And, you know, if you're not really doing rinsing before, are you truly benefiting from it? Because now you're just spraying nasal sprays on boogers and snot. Is it really like doing what it could do? You Know, I tell patients, like, are you really going to wax your car before you walk without washing it? No. You're gonna wash it first. Yeah. You know, so. But, you know, even for some things, like for sinus surgery, you need to have tried medical management and failed because surgery isn't going. It's not changing your biology. I'm just giving you a new baseline. That's up to you to maintain that. Again, it's. It's. Sometimes medical management is a criteria for surgery, and sometimes it makes sense, and sometimes it doesn't.

Yeah, no, that's. That's helpful. Thank you. So I know we get a ton of questions with that, and, you know, there's a big movement towards using things like xlear or clear or whatever you want to call it. And, you know, my family, like, we've tried that. My husband loves it. But, like, for me and my kids, I just. I didn't. I felt like at a certain point I was like, I don't think this is doing anything. But we also were not nasal rinsing beforehand, so that probably was a part of it. Now my kids do a nasal rinse at least once a day. They use a little, you know, kids, Neil medications every morning. If they're congested or they've been outside a lot, I might have them do it at night, too. And, like, they are little pros. Like, they.

We.

We prep the bottle for them, and they 100% do the rest themselves at age 5 and 7. So I'm like. They are, like, more on it than I am myself.

But isn't that incredible that we can. That we can use salt water to help people feel better? I mean, that's what's the incredible part about this. You know, it's that fine line of, you know, homeopathic stuff. Right? You have a lot. That stuff's not regulated. You don't necessarily know what you're getting. You don't know what's in it. It's got all these other additives and stuff, but salt water literally cures and makes people feel better. And if that's the way that we can improve people's quality of life is by literally doing the equivalent of jumping in the pool without plugging your nose, then good for us. But it's great that they learn that early, too. You know, having those, you know, skills and even the knowledge to know, okay, you know, I don't need to go and buy Afrin. You know, I mean, that it just carries over. I'm going to jump first to the saltwater rinses Those don't help, then maybe I. It's just a better thought process and it's a better way to approach medicine and health issues rather than just, yeah, jumping to a medication or. Or just completely ignoring it and there's no hope. But I think that's all. Including my husband. That would be awesome because he still can't manage to make those rinses work. I don't know.

Neither can mine. But, hey, you know, goes in one side and doesn't seem to come out the other.

So I don't know, it just goes. Just gets stuck in the head somewhere and explain everything.

It must be.

I don't know. Oh, totally is. It totally is.

This has been amazing. Is there anything else that you want to add before we wrap up, other than where they can find you?

I don't know. I don't think so. But, you know, feel free to reach out. I mean, you kind of. You know, I've really got not much of a filter, and I'm happy to be very honest with people. So if people have questions or. Or, you know, want more information or whatever, I'm happy to help however I can.

That's why I love you. Awesome. All right, so if they want to find you, though, what's a good website for them to go to?

So they can go to www.nsibr.com? more people are checking my Instagram and Facebook. So going to Instagram and kind of messaging that way it's just a little bit more responsive, but. But either way it's fine. And then I do have a direct line here. I don't know if that was in place when you had first started, but that's also. It's 561-717-3486. And that's also on social media and stuff in case people want to get in. Sometimes the front desk doesn't always answer, so we have a back line.

All right, so I will put all of that information in the little, you know, area with all the notes, the show notes underneath the episode so that they can find you. But the website, the phone number, all the things your Instagram, Facebook. So people, you know, if you're driving, don't drive off the road. And that way if they want to find you, because people are like, is it worth traveling? And I'm like, yes, yes, it is. I don't know the nuances of that, but you can talk to, you know, they can talk to your office about traveling and all that surrounding a procedure like this. But yeah, thank you so much. For joining me on the podcast and we'll talk soon.

Yes, thanks so much and I will see you. Talk to you soon.

All right, Sounds good. All right, thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halliebalkin.com or pop over to Hollybalken on Instagram to get all the latest updates.