Speaker 1 (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person. Why? Because you're making a life-changing decision and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There is no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Shea, and you're listening to Beat the Doctor. This episode originally aired on the before and after Stories podcast. Welcome Dr. Bronny to the before and after Stories podcast. 

Speaker 2 (00:43):
Thank you. Eva. 

Speaker 1 (00:44):
Will you just tell us a little bit about your background and your training specific to being able to work on noses in particular? 

Speaker 3 (00:52):
Yes, I'd be happy to. I'm a facial plastic surgeon and my training, I was originally in otolaryngology head and neck surgery or ear, nose and throat surgery. That's where I did my residency, which was a six year training program at the University of Washington. That also included a year of just full-time research and within otolaryngology, one has the opportunity to go out after you graduate and practice in the community and do the whole spectrum of otolaryngology or ENT procedures. But I chose to focus on a few different specialties, primarily head and neck oncology or head and neck cancer surgery and facial plastic and reconstructive surgery. So I followed my residency with a one year fellowship in New Zealand at the University of Auckland that focused on major head and neck cancer removal and the reconstruction of the head and neck after that was something called microvascular reconstruction. 

Speaker 3 (01:47):
And then I also did another year of subspecialty fellowship after that was completed at the University of Washington that focused primarily on facial plastic and reconstructive surgery, the full spectrum but not as major head and neck reconstruction. The fellowship focused a lot on septal rhinoplasty, which is a part of what I did for Morgan surgery. So my practice currently focuses primarily on facial platy reconstructive surgery with I'd say about 50% of it being nasal and rhinoplasty surgery and significant portion being skin cancer surgery with the reconstruction of the head and neck or face after skin cancer, as well as aesthetic procedures such as like face lips and eyelid lips and Botox, et cetera. 

Speaker 1 (02:27):
That raises a lot of questions for me. Let's work backwards a little bit. So would this be the kind of surgery you'd need for skin cancer if your dermatologist was above and beyond what a dermatologist who takes care of skin cancer can handle? Is there some crossover there? 

Speaker 3 (02:45):
Yes, and so a significant portion of what I do with regard to skin cancer is the reconstruction of the face after someone has undergone MO'S surgery, which is a specific type of skin cancer type removal that a dermatologist who is specially trained in the MOS surgery technique will perform and they'll ask me to assist with the reconstruction for a few different reasons. Typically, one would be if the patient specifically asks for a plastic surgeon marks to repair their facial wound after the mo's dermatologist removes it, two of the MO'S dermatologist feels as if the wound is a little bit too large or complex for what they feel capable of reconstructing. And three, if the patient wants an additional anesthesia such as sedation or general anesthesia that may not be available in the dermatologist's office for the reconstruction. Those are the primary reasons why a skin cancer patient would come to someone like me just for the reconstruction itself. There are times where I do remove skin cancers that are much larger for the dermatologist to remove in their office just because it is a significant type of reconstruction and repair or sorry, removal and 

Speaker 2 (03:53):
Repair. 

Speaker 1 (03:55):
Those are really scary surgeries for people. I think it's a little bit unusual for us as the patient audience to think about skin cancer and rhinoplasty being done by the same surgeon, but it makes sense that you would cover both of those things, especially for things that are more severe. What I hear you saying is that you're extremely overqualified to do things like Botox. Would that be an accurate statement? 

Speaker 3 (04:21):
I never want to sound that I'm overqualified to do anything, but there's a wide spectrum of people who deliver Botox to patients and I do feel I'm very well qualified to do it. 

Speaker 1 (04:31):
And it was actually Botox which led Morgan to find you as his surgeon. So he's been coming to you. I know he told us earlier in this podcast that he's been coming to you for that for a long time. Do you find that a lot of your patients come in that way and then get a better sense of what else you're able to do as they go through that? 

Speaker 3 (04:52):
I would say some of our patients do. I'd say for my practice, the majority of my patients come through a referral by mouth either from other providers for specific reasons like what Morgan underwent for breathing difficulty or like we talked about the skin cancer reconstruction. But there are a subset of patients who do come into the office such as Morgan coming in for Botox or whatever reason it may be. And I think he may have seen we have internal sort of marketing in our office that looks at rhinoplasty and so forth and seen that we do that. Or one of the other things that may have came up with him specifically is that I do a full head neck examination on every patient, whether I'm just doing Botox or not, just because that's my role. I'm a physician and I want to make sure that I look at everything and just have a baseline set of what the patient exists like when I first meet them. And I noticed that he had a pretty severe septal deviation on examination when I first met him. And then I just asked him about, oh, do you have any difficulties breathing? There are patients who have the type of anatomy that Morgan had that was quite abnormal and are not really bothered by it. He had mentioned that he was, and so we talked a little bit more about that and that wasn't the focus of that appointment. And he said, at some point I'd like to talk more about that. And then that's how it evolved. 

Speaker 1 (06:06):
I would expect that a lot of people don't know that there's even a fix for that. Morgan knew he needed help because he fell on the dishwasher and I know my sister needs it because when she was a kid, she had a swimming accident where she hit the bottom of a lake. It wasn't hard, but it was hard enough that she ended up with some damage. She knows she needed it. But do you see people who don't even know that they have a problem 

Speaker 3 (06:32):
That is common because I think people do get used to breathing the way that they are through their nose throughout their life and may not know any other way that they breathe. They may not know otherwise. And so I had patients of mind that just felt like, oh, I always thought I remember just breathe that way or just that's just how people breathe. And it wasn't until they noticed a change for some reason or someone asked them about it, they feel like, oh, there other options on how you can read through your nose. 

Speaker 1 (07:01):
I noticed while I was researching septoplasty that there were actually, strangely enough, there were before and after photos out there that were tagged septoplasty and it seemed strange to me. I thought that that surgery was one that you could not see on the outside. You could never walk up to someone and say, oh, I can tell that you had a septoplasty done. Boy, you breathe really well. It sounds like you had a great septoplasty. 

Speaker 3 (07:28):
You are correct. Typically septoplasty or the traditional sense of repairing the septum often or more commonly does not result in any change in the shape of the nose. If you're seeing things on the internet, there are times where I've done it just a cosmetic rhinoplasty on somebody and they've just labeled a septoplasty too if they label it themselves. Sometimes patients don't have an understanding that might be maybe one of the reason why you saw it there, but there are times where people have such severe septal deviation that it does result in an external deformity that if you do change the position of the septum does make the nose itself look straighter and more symmetric. I have a number of patients like that too where typically it's just not a septoplasty alone though at that point it's more like a septal rhinoplasty. And even with Morgan, we did more than just a septoplasty. We did an endo nasal septoplasty, which means just doing the repair within the nose, no external incisions or made to look at the nose from the external sepal rhinoplasty approach. But he also underwent what we call turbinate reduction. Again, that you would never see the change of that on the outside. But he did undergo a nasal valve repair. They called a functional rhinoplasty. And so technically he has undergone a functional septal rhinoplasty. It's probably not what one would consider to be a cosmetic rhinoplasty where you obviously do see a change in shape on 

Speaker 2 (08:52):
The outside 

Speaker 1 (08:54):
For the nonmedical folks out there, can you just briefly describe the difference between what you do in a septoplasty and what you would do in a rhinoplasty and how they're different? 

Speaker 3 (09:04):
Yeah, so the septum is a part of B knows that separates the right and left nasal cavities. And so the septum is primarily on what you would see on the inside of the nose as you described, or there's the soft piece of tissue between your nostrils if you just touch the tip of your nose and go down called the columella just right in this area. And if you push onto that, that's the edge of the septum or we call the coddle edge of the septum and the septum is made of a cartilage in bone and the septoplasty specifically refers to changing the shape of that septum typically to remove any crooked aspects of it or deviated portions of it so that you can make the nasal airways on each side or specifically one side more open than they were. Rhinoplasty prefers specifically to changing the shape of the outside of the nose because the nose is composed of the nasal bones on the outside, the cartilage on the outside, but also the nasal septum, which forms kind of the central pillar of the nose. So even if you change that central pillar of the nose just by doing a septoplasty, you can technically change the shape of the nose on the outside as well, or you may see that translate to change on the outside of the nose even though they may not be one of the specific goals. 

Speaker 1 (10:31):
So Morgan's signature nose that he referred to earlier in our episode, he did not lose any of that. He 

Speaker 2 (10:37):
Did not, no. 

Speaker 1 (10:38):
He still has his magical signature nose. Okay. 

Speaker 2 (10:40):
Magical nose. 

Speaker 1 (10:43):
I think one of the things that most people really have a hard time with coming out of any surgery minor to major surgery is recovery. And anyone who's ever had kids knows this too or done anything really that requires an intense medical experience of any kind. You guys are so good at giving us instructions and you care so much about how we do, but recovery information goes in one ear and out the other. From the time we get our wisdom teeth taken out to our last child, we do not hear anything you say. And I also know from a data standpoint that when people are not prepared for recovery, it can contribute to both confusion and in a lot of cases lower patient satisfaction and none of us want that. What kinds of things do you do to help people remember what they're supposed to do in recovery when they're in recovery and not forget it before they go into surgery? 

Speaker 3 (11:47):
So every preoperative evaluation that we do with our patients, we sit with 'em to go through the process with them and also with my nurse to discuss what to expect on the day of surgery and what to expect after surgery. And we have a pretty detailed handout. We know things, you're going to forget things and you know that you're not going to remember things that we often say. So the handout itself details the instructions of what we expect for the patients to do, such as for Morgan rinsing his nose out three, four times a day with the saltwater rinse or if there's an incision, how to specifically take care of it. And with regards to what to expect during that process, you probably, you are correct, it's probably one of our weaknesses as far as how you're feeling. And so the week I do try to just at least describe to the patients you are going to feel a fair amount of soreness. 

Speaker 3 (12:39):
Most likely most patients do feel pain with this surgery. Usually well controlled with what we recommend is ol ibuprofen and also provide a narcotic that you can use on top of it. But I tell 'em there's a wide spectrum of how people may feel from some people not really requiring any significant pain medication versus some feeling they do. And we will make sure they have enough. So I make it a point to call every patient the night of surgery on who I operate. So every patient gets a phone call a just so we can check in to ensure they're doing okay. And I'd say 99% of 'em actually are doing very well. But also too, when I'm done with surgery, I speak to the family because the patient is still sedated from anesthesia. Even when I have a conversation with the patient, it may be four, five minutes to an hour after their surgery has been completed, but they potentially still don't remember those conversations even though I talked to them and tell 'em everything went well, this is how we're doing things. So also just to touch base with 'em. So they actually hear it from me as well that everything went well in addition to their family member who was the one with whom I communicated initially. 

Speaker 1 (13:49):
Have you ever had anybody go to Google and really freak out? 

Speaker 3 (13:52):
It does happen, but I try to educate our patients throughout the process from the first consultation when I visit with them throughout the preoperative consultation. But people are going to do it because it's, it's human nature. When we understand and our goal, I tell my staff too, you talk about the check-in. So I check in with the patient in the night of surgery, then I try to ensure that my nurse either checks in the next day or the day after and then they're ongoing issues. Then we continue to check off with 'em. And then we do obviously see everyone at one week. Typically 

Speaker 1 (14:25):
If I had a pro tip to add as a patient, I would say write your questions down when you have them. Because when you get on the phone with the doctor, you're going to forget your questions. 

Speaker 2 (14:34):
Yeah, that's true. And 

Speaker 1 (14:35):
Say, no, I'm great and my nose looks awesome. And then five minutes later you'll remember your question happens every time. 

Speaker 2 (14:43):
Very good point. 

Speaker 1 (14:45):
Okay, let's get down to the most important question that everyone always has. And it's important only until it's answered and then it becomes totally unimportant. And that is cost. Everyone wants to know. A lot of people will spend years, years mentally planning a procedure and they know they need it and they just want to know how much does it cost so they can time when they're going to come see you. And industry-wide, I think people have a really hard time sharing costs ahead of time because they've been trained to get the patient in before they give them the cost information, but there's no reason we can't talk about a range or what's typical. So for Septoplasty, I know Morgan's was covered by insurance partially he told me he had to pay $2,500 out of pocket. And I'm just curious if that's typical 

Speaker 3 (15:42):
When we discuss pricing as well. I mean it's actually a contract between the insurance company and the providers that predetermines how much one is going to get paid for the functional or the medical procedure that he underwent. And so regards to how much the patient's going to pay out of pocket, we often don't know because that's a functional relationship of what type of insurance they have with regard to how much do they have a 10% copay or 20% do they have a certain type of deductible? And then there's some, because patients will typically care about which is appropriate, is it their total fee, how much it's going to cost? And as a surgeon for Morgan's specific surgery, we get paid whatever the insurance pays us. And so we don't know specifically. I mean I can look to see what insurance someone has and then look up the codes and that potentially will to us how much they're going to pay. 

Speaker 1 (16:33):
I don't think we need to know how much you got paid. 

Speaker 3 (16:36):
But for cosmetic surgery, that's a little bit different when it's out of pocket 

Speaker 1 (16:41):
With an insurance, insurance-based procedure, it's always really complicated to figure out. And I wonder if you have someone on staff who's expert at helping people navigate what's covered, is that one way that your team helps people? 

Speaker 3 (16:55):
Yeah, so for every insurance-based procedure, we actually have the procedure preauthorized with the insurance. And so that means that their insurance company is in theory pre authorizing the fact that they're going to pay for that surgical procedure when those medical codes are provided. Now, unfortunately, as a disclaimer, the insurance company always says, well, preauthorization does not guarantee payment for your procedure. But I would say 95, 90% of the time when we have something preauthorized, the insurance company does reimburse us so that it's not an out of pocket for that patient. And if someone in our office has a medically based procedure and the insurance for some reason doesn't cover, we are probably a little bit more very flexible and we don't force people to pay certain things. But typically when it's preauthorized, it always gets it's covered and so we don't have to really deal with that issue. 

Speaker 1 (17:47):
It's like learning an entire another language dealing with insurance. So it'll be a great day if this ever gets better for consumers, but I don't have a lot of hope for that. So in the Seattle area, do you think that the majority of your patients are coming nearby or do you see people from all over the place? 

Speaker 3 (18:06):
I do see people from all over the place, but I'd say majority are within the Seattle area or Pacific Northwest. We'll have people from Montana and Idaho and Oregon things, but for right 

Speaker 2 (18:16):
Now, majority are probably in the Seattle area. 

Speaker 1 (18:18):
And you still have an academic component to your work life. Are you teaching often? How often does that? 

Speaker 3 (18:27):
I'm in my private practice actually two to three days a week, and I'm actually a faculty surgeon at the University of Washington two to three days a week too. So I'm part-time in private practice and part-time in academic practice. And through that academic practice I work with residents, medical students, and I have a fellow of whom I'm the director of the Facial Plastic Surgery Fellowship at. And so yes, I am pretty heavily involved with an academic atmosphere as well. 

Speaker 1 (18:49):
How does the fellow help you with your day-to-day work? Or does he have a completely different job? Is he or she? 

Speaker 3 (18:56):
The fellow specifically spends two to three days a week with me in the operating room and it's more, it's an apprenticeship model of how we at least in facial plastic surgery. And so they assist in surgery to learn how we do certain things also when they work with us in the clinic occasion. But our fellows primarily with us in surgery assisting, and they do actually help in the sense of it's having another pair of hands working with you for certain things that can help expose certain wounds and make things more efficient at the same time as while they're learning to do the procedures that we're doing as well. 

Speaker 1 (19:30):
If you are the kind of patient who's willing to let a teaching hospital treat you, can you actually get cosmetic surgery for a lower price if you let the fellow do your surgery 

Speaker 3 (19:46):
At the University of Washington, you cannot. But there are certain institutions that have fellow rate clinics and things like that and fellow rate surgeries, and that's oftentimes actually there are facial atory fellows where I do know they're mainly more in private practice, actually the ones that will have, you can have your surgeon done with me or you can have it done with my fellow at a lower rate. So that is possible in certain atmospheres in our environment at the University of Washington, that is not possible. 

Speaker 1 (20:16):
I have two questions before we wrap it up. The first would be credentials are impossibly hard for people to understand. Even I after 17 years have a really hard time understanding some of the nuance of training among doctors. And so I wonder if you have any ways that you could suggest to people who are meeting with surgeons or considering surgery, especially on their face or their nose, ways to look for red flags that have nothing to do with reading somebody's cv. Is there anything that you can think of that would be a reasonable proxy for that? 

Speaker 3 (20:56):
I think that is a challenge, but I think there are things that you could probably trust yourself and feeling. How comfortable do you feel speaking about this procedure with the doctor you are? Does it seem as if you're being pushed in a certain way or not? I would say the surgeons that probably I would trust the most are the ones who give you all the options available, whether they can be surgical options or even no intervention whatsoever. And to have an understanding if someone is pushing you one way or the other or seems like, I hate to say this way, trying to push a sail or some sort. I think those physicians are surgeons that you may want to just think, again, I think about twice because the surgeons I trust or the people I trust are the ones who, if you make it feel like that surgeon needs to do that surgery to keep his office open or something like that, if they're giving you that impression that they're trying to push hard on giving you a cell. I guess the most straightforward way to say is that if it seems that it's someone's trying to push you and sell you one way or the other, that is the type of search I probably would stay a little bit away from or just be careful because the ones who are giving a straight answer and being open to answering your questions and don't appear defensive about their opinion of what they suggest for you, I think are the ones you're probably going to be the most trustworthy. 

Speaker 1 (22:17):
I like to say look around because if you see that somebody's only got body photos or doesn't have any photos or doesn't really have anything on their website that says that they have experience with nose surgery or rhinoplasty or they don't have any rhinoplasty reviews, but they are pitching rhinoplasty to you, you should probably get a few more consults. 

Speaker 3 (22:41):
And that's a very good thing that you can do from the different media from which you can collect that. And maybe I was focusing more on when you're with the surgeon, but you're absolutely correct. Hundred percent, 

Speaker 1 (22:51):
Yeah, it's a combination of a lot of things and instinct is certainly one of those, probably the most important one. 

Speaker 3 (23:00):
But I also too also think if there's a way and it may not be possible, that they know of people in the community to ask who they would recommend. 

Speaker 1 (23:10):
Definitely asking another doctor is a great way to go. The nurses also know, they all know too. So if someone wanted to reach out to you specifically and learn more about what you do, maybe they're in Seattle, maybe they're somewhere else, what's the best way to reach out to your practice? 

Speaker 3 (23:30):
The best way to reach out to our practice is to directly call us. If they're willing to do that, we have our phone number and I'm happy to give that as well. And Seattle Faces skin.com is our website. We try to demonstrate all the procedures that we do and our philosophy and mission, how we do things, and hopefully they get to know us from that aspect on their own time. 

Speaker 1 (23:50):
This episode originally aired on the before and After Stories podcast. If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of the Axis THEX i.io.