Dr. Jose Barrera, MD, a Clinical Professor of the Uniform Services University in Washington DC and a Clinical Associate Professor at the University of Texas Health Sciences Center talks about the LATERA implant.
Interview conducted by Ivanhoe Broadcast News in January 2018.
Why did you get on this LATERA as opposed to a surgical procedure that might do the same thing or reasonably the same thing?
Dr. Barrera: I’m glad you asked. The LATERA implant is one option for patients with nasal airway obstruction, due to nasal valve collapse. There are many options for nasal airway obstruction. If the major cause of obstruction is due to weak sidewalls – when you breathe in and your sidewalls collapse – LATERA may be an option, but so can reconstructive rhinoplasty (an operation which opens up the skin of the nose and restructures the cartilages to support collapsibility; we often use rhinoplasty for aesthetic purposes). LATERA is an implant made out of polylactic acid, it’s absorbable and is a bio active stimulator collagen. LATERA will support the weak sidewalls and then once it absorbs, it will dissolve over two years and leaves behind a little collagen track which supports the sidewall. So consider it like an internal Breath Right strip.
It dissolves after a couple of years; it builds up the sidewalls. Are you talking about the sides of the nose and not the middle portion or is that included as well?
Dr. Barrera: Correct. The sidewall of the nose, which is anything from the nasal bones down to the tip. Any collapsibility when you breathe in, LATERA will help to alleviate.
I assume that most people who have this disorder realize that they have it but I’ve read if you take your fingers and do that, breathe like that you can breathe better?
Dr. Barrera: Correct. That’s called the Cottle maneuver, taking your fingers and simply pulling your cheek to hold your nostril to the side while taking a breath in, you’ll probably breathe better if you do that. But many folks, millions, hundreds of millions of Americans every year use Breathe Right Strips. So, if a Breath Right Strip helps you breathe, a LATERA implant may also help you breathe, except a LATERA implant is something that is a onetime procedure. You don’t have to keep purchasing Breathe Right Strips to breathe.
And glue them on at night as well.
Dr. Barrera: Exactly. Many patients complain about just that. They have a sore nose, or it peels the skin. But if a Breath Right Strip works for you – by all means, it may be an alternative. So what you’re really talking about are non-surgical alternatives to treating nasal airway obstruction. The LATERA implant is a minimally invasive alternative. More invasive surgical alternatives would be fixing a deviated septum or reducing the lining of the nose (turbinates), which can swell up from allergies. Additionally, for folks that can’t use a CPAP machine at night, because they have too much nasal obstruction, alleviating this nasal obstruction may be a benefit.
So with the CPAP which is forcing air, forcing room air in to your mouth and nose if they’re obstructed nasally then, unless they open their mouth, it’s not going to do the job right?
Dr. Barrera: Correct, the most common cause of CPAP intolerance or the inability to use CPAP at night is nasal obstruction. There is also claustrophobia and early arousal or frequent arousals due to the foreign body sensation. Lastly, your spouse may not like the hissing sound of the CPAP machine. But, if you can’t tolerate the CPAP machine and you want to try it, you want to use it, and make every effort to have your nose evaluated to see if we can improve things. We know that if we improve nasal airway breathing we can drop the pressure of the CPAP at least by three points, by three M bars. If you’re at a CP pressure twelve, you can drop it to nine, just simply by having nasal surgery.
Common sense tells me that going back to this, anybody who does that and opens up their nasal passage is going to be able to breathe better. How does one tell if they really are in need of this?
Dr. Barrera: If you feel during the daytime that you have nasal obstruction – you feel congested, you feel blocked, you feel like you can’t breathe out of one side compared to the other, then it’s time for an evaluation. If you’re on maximal medical therapy, meaning, you’re using saline sprays, using nasal steroid like Flonase or Nasonex, Nasacort and you’re still not better and feeling congested, it’s time to come in and get evaluated.
So there must be a lot of people out there who are trying that methodology and they’re not getting any better and are wondering? I don’t think it would dawn on me that it could be something that could be surgically corrected. So address that if you will number one. Number two, if they are doing that is there kind of a reverse attack method where you over use it and it swells the passages?
Dr. Barrera: Yes a lot of folks go out and they use Afrin for example. They buy Afrin over the counter and it provides some relief, but what ends up happening is that the lining of the nose gets conditioned to the Afrin. The Afrin works to decrease the swelling of the internal lining of the nose. But guess what? When you stop using Afrin you have a rebound effect. You get into this cycle of needing to use Afrin all the time. So we advise as otolaryngologists, only to use Afrin for no more than three days, if necessary. For the most part it’s not necessary; we want you off of Afrin and want you on a nasal steroid. We want you to do your allergy testing and see what’s causing the swelling to the internal lining of the nose. But other people have blockage, they have a deviated septum, they’ve had trauma or they’ve had a previous rhinoplasty that did not support the nose. This means they have collapsibility, they have obstruction because the rhinoplasty did not support the external structure of the nose. We’re speaking about doing a revision rhinoplasty, especially if the aesthetic quality of the nose isn’t to your liking. If you have a deviation or an asymmetry, or there’s a trauma, then we’re going to talk about rhinoplasty surgery. That’s going to alleviate the nasal airway obstruction and we can also have the additional benefit of improving the cosmetics. That’s very important for most people. But patients who don’t want to see a change in the aesthetic appearance of their nose, but yet want to breathe better, we can address that with minimally invasive and surgical methods, and LATERA is one of those methods.
LATERA is a surgical method or non-surgical?
Dr. Barrera: LATERA is something we can do in the clinic with anesthesia and also in the operating room. So being that it’s a procedure we classify it as a surgical procedure.
Describe to me what you do during that procedure.
Dr. Barrera: What we do is we numb the nose, in the clinic, with the patient awake. We use a little nasal spray that numbs the internal lining of nose. Sometimes we use gel that also numbs the lining of the nose. Then we use a little numbing medicine on the sidewall of the nose, and deploy the LATERA implant. The LATERA implant is a very small device, about the size of an ear bud, which we deploy in the sidewall of the nose and it supports the sidewall. When we deploy the LATERA implant it is deployed through a small cannula, the same type of cannula that we would use to put an IV in. It goes through the cannula and the design of the implant prevents it from backing out. And it gets deployed to sit right above the nasal bone, on the sidewall and you can’t see it. In fact, ninety percent of the ENT surgeons who deploy the LATERA implant report that there is no aesthetic change. And ninety five percent of patients also report that they’re happy with the implant themselves.
Do you do both sides of it?
Dr. Barrera: Yes, we do both sides.
So then that polymer you said eventually that goes away and then it builds it up.
Dr. Barrera: That’s right. The polymer that the LATERA implant is made out of is polylactic acid. Polylactic acid or PLLA is the same polymer that’s in sculptra. We use sculptra as a facial filler for aesthetic patients. And what it does it bio-stimulates collagen production.
Let’s go in to some tips for people with problems but can’t really identify or diagnose. What do they need to do? If they come to see someone like you, it sounds like your field of specialty is fairly broad. What tips or advice would you give for people, who should they go see, what questions should they ask?
Dr. Barrera: As a facial plastic surgeon and an otolaryngologist I’m triple board certified in head and neck surgery and facial plastic surgery and sleep medicine. My practice is unique in that capacity. I advise my patients that our practice provides a multidisciplinary approach. In our practice, we combine the tools and training from all these disciplines to help you breathe better. So if certain patients need reconstructive surgery we offer them a surgical maneuver using cartilage techniques like rhinoplasty to fix the problem. Other patients may have allergies which are causing congestion, so we’re going to try medical therapies like a Flonase, other nasal steroids or antihistamines. Allergy testing and allergy therapy may be needed to treat their nasal obstruction. Then you have other patients that just have weak cartilage or they’ve had previous surgery and still can’t breathe – we’re going to consider other modalities including the LATERA implant, especially for a patient that does not want any aesthetic change. If a patient says, I’m happy with the way my nose looks, but my nose collapses when I breathe, they may be a good candidate for the LATERA implant.
How do you decide when they come in, how do you make that distinct between whether they need the full surgical procedure?
Dr. Barrera: We start off with some validated questionnaires to try figure out what the patient symptoms are and we’re very academic in our practice in doing this. We’re running three different research studies currently on the LATERA implant. First, we look at these validated questionnaires. Second, we put a little tiny scope that looks and records a video of how the patient is breathing. I show the video to the patient, to show what is happening when they breathe in. I show them the level of obstruction they have from a deviated septum or from their sinuses, and show them what’s happening with the internal lining of your nose. Third, we put together an entire treatment plan. In the certain patients, they may need treatment for the lining of the nose, they may need treatment for a deviated septum, they may need treatment for collapsibility of their nose or they may just need one of those areas addressed.
What is the recovery time after you’ve had the LATERA versus full surgery?
Dr. Barrera: A patient that undergoes a LATERA implant preformed under local anesthesia, awake in the clinic, takes approximately twenty or thirty minutes. We can also do that in the operating room, my operating room is here at Texas Center for Facial Plastic and Laser Surgery. We have an operative suite here, so we can do it under anesthesia or under sedation. Really it is the patient’s preference and we discuss the advantages and disadvantages of all those options. But let’s say the patient decides to have the implant done in the clinic and that’s all they need, they can recover within a week. They can actually resume normal activity the next day. No splints, no packing, they can breathe better right away. They can go home just using normal medications like ibuprofen and Tylenol. It doesn’t really require narcotics or it doesn’t require a surgery at a hospital, something that can be done in clinical facility.
About the price of the procedure roughly?
Dr. Barrera: It is new technology and with every new technology the insurance qualifications are all dependent upon a patient’s plan.
I can imagine Breath Right I don’t know how much it is fifteen or twenty dollars a box and you’re going to go through in a year probably.
Dr. Barrera: That’s right, that’s true.
Any other thing you can think of to tell people out there about what they should look out for, who is a good candidate, any tips?
Dr. Barrera: If you’re frustrated because you can’t breathe through your nose, you can’t use your CPAP machine at night, your wife tells you you’re snoring, you feel that you’re congested in the allergy season, you feel blocked even after using saline spray, antihistamines or a nasal steroid, you can do a test yourself at home. You can use a Breath Right strip for three days and record how severe the symptoms were before the Breathe Right strip and how much improvement you received on a scale of one to ten. That will tell you whether or not you have collapsibility obstruction of the sidewall of your nose. If you use a medication, like a nasal steroid like fluticasone and you use it for a week, ideally a month, and you record symptom relief on a scale of one to ten. That tells us that there’s a problem with the lining of the nose or maybe allergy. These are just two simple tests you can do at home and if at the end of both of these you find that it’s—you have a collapsible nose or you have swelling of the lining of your nose or you just feel blocked you just can’t breathe regardless of whatever treatment you try. Then it’s time to come and visit an otolaryngologist who specializes in this area.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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José Barrera, MD
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