Eva :
This is Before and After Stories. I am Eva Sheie, and on this podcast, we talk to people just like you and me to find the real beauty of plastic surgery and elective treatments.
Welcome Dr. Bhrany to the before and after stories podcast.

Dr. Bhrany:
Thank you.

Eva :
Will you just tell us a little bit about your background and your training specific to being able to work on noses in particular?

Dr. Bhrany:
Yes, I'd be happy to I'm a facial plastic surgeon and my training was originally in otolaryngology and neck surgery or ear nose and throat surgery. That's where I did my residency, which was a six year training program. 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 the community and do the whole spectrum of what to learn all is a great 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 neck after that was something called microvascular reconstruction.
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 on the full spectrum, but not as major head and neck reconstruction. The fellowship focused a lot on septorhinoplasty, which is a part of what I did for Morgan surgery. So my practice currently focuses primarily on facial plastic 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 a head neck or face after skin cancer, as well as aesthetic procedures like face lifts, [inaudible 00:02:09] in lips and Botox, et cetera.

Eva :
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 like above and beyond what a dermatologist who takes care of skin cancer can handle, is there some crossover there?

Dr. Bhrany:
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 Mohs surgery, which is a specific type of skin cancer type removal that a dermatologist who is specially trained in the Mohs 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 in quotation marks to repair their facial wound after the Mohs dermatologist removes it. Two if the Mohs 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 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 repair.

Eva :
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?

Dr. Bhrany:
I never want to sound I'm overqualified to do anything, but there's a wide spectrum of people who deliver Botox to patients. And I do feel very well-qualified to do it.

Eva :
And it was actually Botox, which led Morgan to find you as his surgeon. And 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?

Dr. Bhrany:
I'd say some of our patients do. I'd say for my practice, the majority of my patients come through 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 marketing in our office that looks at rhinoplasty and so forth. And seeing 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?" Because there are patients who have the type of anatomy that Morgan had, that's quite abnormal and are not really bothered by it. And then 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 that at some point, I'd like to know more about that. And then that's how it evolved.

Eva :
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. But do you see people who don't even know that they have a problem?

Dr. Bhrany:
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 sort of way that they breathe. They may not otherwise. And so I have reached them and I just felt like, Oh, I always thought, I don't 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, you know, there are other options on how you can breathe through your nose.

Eva :
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 that seems strange to me. I thought that that surgery was one that you could not see on the outside. Like 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."

Dr. Bhrany:
You are correct. Typically septoplasty or in 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 a cosmetic rhinoplasty on somebody and they've just labeled a septoplasty too. They label it themselves. Sometimes patients don't have an understanding. So that might be out or maybe we want a 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 to where typically it's just not a septoplasty alone though. At that point it's more like a septorhinoplasty.
And even with Morgan we did more than just a septoplasty. We did an endonasal septoplasty, which means just doing the repair within the nose, no external incisions or made to look at the nose from the external septorhinoplasty 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, what they called a functional rhinoplasty. And so technically he has undergone a functional septorhinoplasty. It's probably not what one would consider to be a cosmetic rhinoplasty where you obviously do see a change in shape on the outside.

Eva :
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?

Dr. Bhrany:
Yeah, so the septum is a part of the nose that separates the right and left nasal cavities. And so the septum is primarily what you would see on the inside of the nose as you described, or there's this soft piece of tissue between your nostrils. If you just touch the tip of your nose and go down called the Colleen Bella, like just right in this area. And if you push onto that, that's the edge of the set and what we call the caudal edge of the septum. And the septum is made up of cartilage and bone. And the septoplasty specifically refers to changing this tape 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 one side more open than they were.
Rhinoplasty refers specifically to changing the shape of the outside of the nose, because the nose is composed of the nasal bones on the outside and the cartilage on the outside, but also the nasal septum, which forms a 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 that may not be one of the specific goals.

Eva :
So Morgan's signature nose that he referred to earlier in our episode, he did not lose any of that. He still has his magical signature nose. Okay. 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?

Dr. Bhrany:
So every preoperative evaluation that we do with our patients, we sit down with them 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 because we know things you're going to forget things on your own that you're not going to remember things that we say. So the handout itself details the instructions of what we expect for the patients to do with... such as with for Morgan, rinsing his nose out three, four times a day with the salt water 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're probably, you are correct, it's probably one of our weaknesses as far as how you're feeling.
I do try to at least describe to the patients know you are going to feel a fair amount of soreness. Most likely, most patients do feel pain with the surgery. Usually well-controlled with what we recommend is Tylenol, ibuprofen, and also provide a narcotic that you can use on top of it. But I tell them 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'll make sure they have enough. So I make it a point to call every patient the night of surgery after I operate. So every patient gets a phone call so we can check in to ensure they're doing okay. And let's say 99% of them actually are doing very well.
But also to, when I'm done with surgery, I speak to the family because the patient is still sedated from anesthesia. And even when I have a conversation with the patient, it may be 45 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 then tell them everything went well, this is how we're doing things. So also just to touch base with them. 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.

Eva :
Have you ever had anybody go to Google and really freak out?

Dr. Bhrany:
It does happen. But I try to educate our patients throughout the process from the first pre consultation line visit with them throughout the preoperative consultation. But people are going to do it. It's human nature. When we understand our goal, I tell my staff too. And like, you need to be talking about the check-in. So I check in with the patient the night of surgery. Then I try to ensure that my nurse either checks in the next day or the day after. And if there are ongoing issues then we continue to check off with them. And then we do obviously see everyone at one week typically.

Eva :
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 and say, "No, I'm great. And my nose looks awesome." And then five minutes later, you'll remember your question. Happens every time.
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.

Dr. Bhrany:
When we discuss pricing, I mean, it's actually a contract between the insurance company and then the providers that predetermines how much one is going to get paid for the functional under the medical procedure that he underwent. And so in 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% copay. 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, right? How much it's going to cost them. As a surgeon for Morgan's specific surgery, we get paid whenever the insurance pays us. And so we don't know specific. I mean, I can look to see what insurance someone has and then look up the codes and that potentially will get to us how much they're going to pay.

Eva :
I don't think we need to know how much you got paid.

Dr. Bhrany:
But for cosmetic surgeries, that's a little bit different when it's out of pocket. Yeah.

Eva :
With an 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?

Dr. Bhrany:
So for every insurance-based procedure, we actually have the procedure pre-authorized with the insurance. And so that means that their insurance company is in theory preauthorized in 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 authorization does not guarantee payment for your procedure, but I would say 95, 90% of the time when we have some 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 insurance for some reason doesn't cover it, we are probably a little bit more, very flexible, and we don't force people to pay certain things, but typically when it's green authorized, it always gets covered. So we don't have to really deal with that issue.

Eva :
It's like learning an entire other 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 from nearby or do you see people from all over the place?

Dr. Bhrany:
I do see people from all over the place, but I'd say majority within the Seattle area or Pacific Northwest. We'll have people from Montana and Idaho and Oregon things. But for right now, majority probably.

Eva :
And you still have an academic component to your work life. Are you teaching often? How often is that?

Dr. Bhrany:
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 EDA. And so yes, I am pretty heavily involved with an academic atmosphere as well.

Eva :
How does the fellow help you with your day-to-day work or is he of a completely different job? Is it he or she?

Dr. Bhrany:
Fellow specifically spends two to three days a week with me in the operating room. And it's more of, it's an apprenticeship model, at least in facial plastic surgery. And so they assist in surgery to learn how we do certain things also and they work with us in a clinic, 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. And at the same time as well they're learning to do the procedures that we're doing as well.

Eva :
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?

Dr. Bhrany:
At the university of Washington, you cannot, but there are certain institutions that have fellow rate clinics and things like that. And fellow rates surgeries. And that's oftentimes actually there are facial plastic surgery fellowship, where I do know there are mainly more private practice, actually the ones that will have... you can have your surgeon done with me, or we can have a done with my fellow at a lower rate. So that is possible in certain atmospheres. In our environment, university of Washington, that is not possible.

Eva :
I have two questions before we kind of 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?

Dr. Bhrany:
I think that is a challenge, but I think there are things that we 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 ever. And to have an understanding of if someone is pushing you one way or the other, or seems like I hate to say it this way, trying to like push a sale or some sort, I think those physicians or surgeons that you may want to just think again or 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 this office open or something like that, to see if they're giving that impression that they're trying to push hard on giving you a sale. I guess the most straightforward way to say it is that if it seems that someone's trying to push you and sell you one way or the other, that is the type of surgeon, I'd probably 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 who are probably the most trustworthy.

Eva :
I like to say, look around because if you see that somebody who'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.

Dr. Bhrany:
Yeah. And that's a very good thing that you can do from the different media, from what you can collect that. And maybe I was focusing more on when you're with the surgeon, but you're absolutely correct. A hundred percent.

Eva :
Yeah. It's a combination of a lot of things. And instinct is certainly one of those, probably the most important one.

Dr. Bhrany:
But also to also think if there's a way, and it may not be possible, if they know of people in the community to ask who they would recommend.

Eva :
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?

Dr. Bhrany:
The best way to reach out to our practice is to directly call us if they're going to do that, you know, we have our phone number and happy to give that as well. And Seattle face the skin.com is our website. And we try to demonstrate all the procedures that we do and our philosophy and mission, how I do things. And hopefully they get to know us from that aspect on their own time.

Eva :
If you'd like to tell your story on this show, or if you're a medical professional, who would like to submit someone else's story for consideration, send us a message@beforeandafterstories.com or follow a message us on Instagram at before and after stories podcast. I'm Eva Sheie, the host and producer of Before and After Stories. And my co-host is Queenie Dahlen. Our engineer is Denam Cruiser. Before and After Stories is a production of the axis. T H E A X I s.io. That's access like access of Eva.