The Way I Heard It with Mike Rowe - 340: Dr. Rahul Seth—My Happy Place is the Operating Room

Episode Date: August 22, 2023

The otolaryngologist and facial reconstructive surgeon that fixed Mike's nose talks about how prevalent deviated septums are, how he prepares for a 12-hour surgery, and the bicycle accident that nearly ended his surgical career.   Mentioned in this episode are Dr. Seth's practice GoldenStatePlasticSurgery.com and Episode 262: Let's Talk About Septums and Scrotums with James Nestor  

Well, hello friends and welcome to another episode of the way I heard it, specifically number 340. More specifically, the episode entitled My Happy Place is the Operating Room. Another terrific quote from another terrific guest to whom I am pleased to introduce you. His name is Dr. Rahul Seth. He's become a friend of mine and he is my doctor. Well, one of my doctors. Well, actually at the moment, he's my only doctor. He's the guy that performed the procedure on me three years ago that allowed me to do something I hadn't been able to do for most of my life, namely to breathe through my nose.

Friends of the podcast will be familiar with the odyssey that was my septoplasty. And I thought I'd put a bow on it and complete this ad hoc public service announcement that my experience has become because so many of you, like thousands of people, people on social media have reached out to ask if the procedure is worth it, to talk to me about their own mouth breathing, to complain and commiserate about living with breathe rights, eight hours a day on your face. It's not for me to say if this procedure is right for you, but I can't tell you that if you're a mouth breather, your world will change. If you find the right doctor, if you get the right procedure, if you take the right steps, to be able to breathe through your know. So I figured I'd talk to the doctor for about 20 minutes, you know, just get his take and maybe share

some his information with you around this procedure. But our conversation got a little more in depth than that. We talked for about an hour, me and Dr. Seth. And I think it's super interesting because this is a 43-year-old, very accomplished surgeon who's performed over a thousand of these procedures, who's married to another surgeon, a woman who's an ophthalmologist. He's got the ears, nose, and throat, and she's got the eyes. Between them, they got your whole face covered. Anyway, I just thought it would be interesting to hear about the challenges of being a doctor in 2003, and my God, there are challenges a plenty. So, on the one hand, I think it could be a useful conversation for anybody who shares my addiction to breathing.

And on the other hand, I think it might be fascinating for anybody who has ever had to turn their head and cough. If you'd like to know more about the man or woman instructing you to do that very thing, listen up. It's episode number 340. My Happy Place is the operating room. And it all starts right after this. Long before she was Peggy Roe, my mom was Peggy Noble, daughter of Carl and Thelma Noble.

It was her father, Carl, who inspired me to pitch a show called Dirty Jobs to the Discovery Channel and later start a foundation that honored the kind of work Carl Noble did for a living, trade work, skilled labor. That foundation is called MicroWorks, and today I'm proud to tell you that we've helped thousands of people get the training they need to begin a career in the skilled trades. In fact, we'd love to help you. You can apply for a work ethic scholarship right now at microwerworks.org. We've set aside $10 million for this year's applicants. Thanks to a number of very effective fundraisers, including the one with my grandfather's name on the label.

I refer, of course, to Noble Tennessee Whiskey, K-N-O-B-E-L, which is now available in a variety of delicious mash bills, all of which you can peruse at Noble Spirits. In fact, if you spend $100 and use code Carl, C-A-R-L, you'll get one tube of orange bitter-infused sugar cubes for free. That's code Carl with a C to get nine sugar cubes, ingeniously engineered to make nine perfect old-fashions every time. It's my favorite way to support Microworks and my favorite whiskey to sip responsibly after a long day of interviewing people on this podcast. Pick up a bottle at noblespirits.com. K-N-O-B-E-L-P-E-L-Pirits.com. Soon may the noble men come to bring a bottle for everyone.

One day when the waitin is done, we'll take a drink and go. How many times this podcast has started when I've been like, I wish we'd started recording this five minutes ago, because never in my life have I had a doctor, especially one as skilled and talented as you, confess to being nervous right before a procedure. in this case, the procedure being a podcast. But you got the idea.

What are you nervous about? How can you possibly be nervous, a man who has held so many lives in the palm of his hand? Well, it's totally different. I work with my hands and my actions. This is a whole different ballgame for me. But you know what? I'm up for the challenge. I'm excited about it.

What did you do today? I should tell people in real time, it's like four, here on the West Coast. I assume you've just come from the office or the lab, the laboratory, the OR, whatever. What was your day like? Well, I operated today. I did surgery. I did a surgery that was very similar to yours, actually, where I helped somebody out, actually a colleague of mine an anesthesiologist who for years has had trouble breathing through the nose. And finally, got up to the point of saying, I got to do this. I got to do this surgery. And funny enough, is leaving the area out of the Bay Area and wanted to get this done before leaving. So I operated

on that patient until about 1230 and then saw patients in the clinic. And that's where I am right now. At the clinic. At the clinic. How old, if you don't mind me asking, was the patient? on whom you operated today. About 40. Why? I mean, look, full disclosure, Doc, the reason I wanted to have you on is to kind of close the loop on this ongoing ad hoc PSA I've been doing about the incredible success story that is now my nose. And, you know, I've been hesitant to tell it prematurely because one of the many, one of the many, one of the many great truths you said coming out of this is, look, this is a process. And just because I'm done operating on you doesn't mean the surgery's over. And just because the bandages come off,

and just because the splints come out, and just because the swelling goes down after two or three or four weeks, doesn't mean you're done. This, you said, is a major procedure right in the center of your face, and it's going to take potentially, I think you said, a couple of years to really understand what this means to you. So before I tell you what it means to me, why don't you tell me why do so many people wait so long in their life to get something done that can have this level of impact on the quality of their life? I think one of the biggest reasons people wait is because they don't realize what breathing could be like. And it's just some hap incident that they are told by a neighbor or a friend.

You know, I got this surgery and it was really helpful. Or they go see a doctor for an unrelated reason, and the doctor looks inside the nose and says, you know what, something's a little blocking up there and your septum might be crooked. Do you have trouble breathing at night? it's usually some other factor or a partner saying, boy, you snore really loud.

And you breathe so loud through your nose. It's just annoying me incredibly. And we're not really understanding of that or knowing that that's what's happening. And shockingly about estimates are a little bit unknown, but every study that looks at CAT scans shows amongst hundreds. of patients, roughly about 50 to 80% of adults have a deviated septum. And that doesn't mean that every single one of those persons needs an operation, but it just means that this is a problem that's out there.

And for some people, it could become a lot better. Is it like a frog in the boiling water? I think it was for me. You know, I broke my nose the first time when I was probably 16 and then again in my early 20s. And it just got worse and worse and worse. And then I think I got bored of being miserable. So I just stopped thinking about how unpleasant it was to be a mouth breather. And then 10 years went by.

And then 20. And then 30. God, I mean, it's like I was, I think I was 58 when I came to you maybe. What was it, June? was it three years ago? Close to about three years ago. So, 58, yeah. So anyhow, as grateful as I am that I got it done,

not a week goes by where I don't kick myself for waiting so long. And I just, I mean, Chuck's had a front row seat to it. Everybody in my life has heard these stories now. But truly, the humiliating part is why in the world did I wait so long? And I really, you know, I'm throwing it out to the group. I don't have a good answer.

You said that I had a front row seat, and I just want to say that I totally was there for a lot of this where you would come to visit California. We would go out, and I couldn't drop you off at the hotel. You know, if you forgot your little strips, your nose strips to sleep. And, you know, suddenly we're driving around at two in the morning looking for an all-night pharmacy so you can get these things because you would not go to bed without them because you knew. you wouldn't get any sleep at all. I was addicted, Doc. I was addicted to breathe rights. There's just no other way to say it.

And I don't even know how many thousands of dollars how much spent on those things. It's a super sexy look, you know, going to bed with this thing wrapped around the middle of your face. Ridiculous. It's interesting how we develop a norm, an inconvenient and irritating norm

to something that shouldn't be that way. But yet it's something we do 22,000 times a day, right? We breathe 22,000 times a day roughly, but we're willing to not pursue or not really be cognizant of, you know, this could be better. And 22,000 times a day, I could be comfortable. And that really, I think for me as a surgeon who does this surgery, I feel, greatly empowered to help somebody that many times in their existence and be able to give them something that they can enjoy for a long time throughout the day. How many people have you had meaningful follow-up with? How many people stay in touch with you over the years who have had this done?

Well, to tell you the truth, I see patients in the clinic for usually up to about a year. And typically, about six months after the surgery and then I let them go and they know to get in touch with me if they need me if anything changes but my clinic would get too full if I would see every patient back but I have plenty of patients who will drop me a line on on social media or an email saying like hey things are looking great or if they see me around and they thank me for the breathing that they're able to do but To answer your question, not many people come back around like you have and are really thankful. Because, again, I think it becomes a norm.

And we take it for granted what we do because it's so basic to our existence. You did a couple things that I wanted to talk about aside from a successful procedure. You told me the truth in a way that I thought was really interesting. I mean, you're a mild-mattered, understated guy, as you probably have noticed. And you're not terribly excitable, it seems, which I think a lot of people are comforted by in their physician. But there was something kind of chilling in the way you told me, the good, the bad, and the ugly. And I didn't realize it until I had gone. You were the fourth person I talked to.

You know, I talked to one person kind of anecdotally off the record, didn't go into the office, a doctor. And then I went to see two doctors in San Francisco. And all three of them kind of soft peddled this. They all told me, look, yeah, a couple days, you know, be mildly uncomfortable. One said, you know, it's not inpatient, but you don't really have to be out, you know. I could get you out of here pretty quick. and, you know, I just felt like, well, gosh, that just almost sounds too good to be true. And of course, it was.

You said, I'm going to cut you here, and I'm going to cut you here, and then I'm going to cut you here, and then I'm going to cut you here, and then I'm going to pull your nose back, and I'm going to lie it on your forehead. And then I'm going to go into your nasal cavity, this fist-sized giant hole in the middle of your face, and I'm going to move things around. I'm going to physically move and snap things, and I'm going to get it all. Now I'm going to put it back down. And I swear to God, I was looking over my shoulder for the camera because I thought for sure you were messing with me. You were daring me in a very friendly way. And that actually turned out to be the most convincing thing you could have done.

Thanks. It is a, I'm not sure if I describe it that way, but it is a horrible, miserable experience to go through sometimes for some people. It's really interesting. You do the same surgery. and somebody says, oh, you know, that wasn't that bad. And then the next person says, that was the worst thing I have ever gone through. I don't wish it upon anyone.

And so I always take the approach of painting it as the worst case scenario, because I'd rather set expectations real low for what it is to come. And then, you know, if it's not as bad, then great. But, you know, the bottom line is, as you said before, It's in order to, there's different types of deviated symptoms. And I'm happy to go through that and go through the nuances of what the nose is and what the functionality is. And for anybody listening, it's, you know, somebody's surgery could be very, each person's surgery can be very different, depending on what the needs are and where the blockages are of the nose. So with that, I'll give you my spiel.

So the nose is evolutionarily an organ that's designed to slow air down. Otherwise, we would have a hole in the middle of our faces. And we don't. We have this beautiful mystifying structure that is there for a few functions, and that is to warm the air that we breathe, filter it and humidify it, and it does all of that by slowing air down so that it's got a nice laminar flow of air going through it as it does those things. The air that comes in picks up nitric oxide that's within our sinuses. It makes it have better gas exchange of oxygen

release into the blood vessels and pick up carbon dioxide in the lungs. So we really need the nose, which is our first encounter of our respiratory system with the outside world to really be functioning because it's step one. And if step one's not right, then all step thereafter will be challenged. And so there are a few important aspects that are surgical targets for us within the nose that slow that air down. One is obviously the soft tissue of the nose. I mean, you've got bones and there's small muscles and fat and cartilage, all that make up the nose itself. But on the inside of the nose, it's the same pink lining as the inside of your mouth. And we call that mucosa.

And that mucosa has these microscopic hair-like projections on it that help move your snot, basically, in the right direction. so that when those filtered particles come into contact with this nice mucosa layer, it's a barrier, it's able to be filtered and channeled down an appropriate pathway, so you can swallow it then, and it keeps the whole system clean. The main determinants of slowing air down are these things called the turbinates. The turbinates are kind of these outshelves that are along the side of the nose, on the inside part, and they stick out. I always compare them to long grapes that are on the inside there.

And interestingly, these turbinates, they can enlarge and then reduce in size. And I can get more into that in detail, but these things are structures that can enlarge too much and start to do too good of a job in the sense that they are blocking air way too. much. And in those situations, we would want to surgically shrink them down. Is it true that there's a link to the turbinate tissue with erectile tissue? Did I actually read that somewhere? Yes, that is true. That is true. It's a similar tissue and in the nose, there is this cyclical enlargement or engorgement that occurs of the turbinate. One side first and on your left and

then on your right and back and forth. So if you notice, I'm not breathing through my right side and then later on in the day, I am now. Well, that's normal respiratory cycle of the nose. We don't know exactly why it does that. And there's a bunch of theories, but it certainly happens. And it's, again, overall a mechanism to regulate the airflow. It's kind of miraculous.

I mean, there's so many miracles on the face itself. but the idea that your nose can change in size internally from one nostril to the next, if your nose is healthy and your septum isn't a hot mess like mine was. It's a pretty miraculous bit of engineering. Well, people are still raving, raving, I tell you, about my mother's performance in the latest Pure Talk commercial. And if you haven't seen it, I encourage you to give it a look on my Facebook page. And read the comments. They're hysterical.

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slash row. You can switch in as little as 10 minutes at puretalk.com slash row. It's a beautiful organ. That's why I love working on it. But isn't it true really that God got it backwards because he put it right above your mouth and, you know, it just drips into your mouth, really. I mean, if you think about it. Design flaw. Yeah. It's a bit of a design flaw, but we've got to work with it. Sorry, you were saying. So the other part is the septum.

Okay, the septum goes straight down the middle of the nose, and it's actually what holds up the nose and the nose lower half of it. I'd like to imagine the nose is kind of like a support beam wall that's going down the middle. It kind of goes right along the front of your nose. along the bottom of your nose, and head straight to the center of your head. And actually, the top of the septum touches the same bone that is the base of your skull base, or where your brain sits. That holds that.

And so this is a really large structure, and it can have crookedness to it. And most of us have a little bit of crookedness, and that's okay. That helps to keep the airflow regulated and ice. but when there's a crookedness that's severe and it starts blocking our breathing, that's when a septoplasty or straightening out that septum makes a lot of sense. And that's what I had. I had a septoplasty. That's correct. There's actually two types of septoplasties. One is the big septoplasti, which is the type you had, and then there's a smaller version of the septoplasti.

I can get into that here. So the wall of the septum, if you imagine it like a, wall. The top part of most walls has a support beam and the sides of walls have support beams. But the center part of the wall, you can almost put a window in or knock part of it down to put a door. And it's not as structurally important, like for your nose. It's not as important. So if your crookedness is occurring mostly in the central portion of that septum, you don't have to make the cuts at the bottom of the nose. that on the skin surface that you were talking about, you can approach all of that crooked part just through cuts within the nose itself. And that's a traditional septoplasty. The downtime is less. Obviously, there's no external incision. You're not going through all of the tissues and into somebody's face.

It's all inside the nose. But what happens if the main structural parts of the septum that are close to the front of the nose or at the bottom, right where your nostrils are. If that's crooked, it's a different ballgame because you cannot disrupt those without supporting them again. Otherwise, your nose will start to fall inward. And you want that to remain nice and stable. So in order to address those structural support beams of the septum, you make the cuts on the outer surface and approach the nose through all of its cartilages, reorient the septum,

take it apart, actually, like you would. wall that's kind of fall and rebuild the structural supports with other spare cartilage, line it up in the middle, get some good foundation going to it, and then line everything based upon that foundation. That's what you had. And that surgery is technically called a functional septo-rinoplasty. So it's got the septo word in it and rhinoplasty in it because the approach is of altering the shape of the nose and the carlages of the nose. We don't really do too much of that in a functional situation, but we have to touch all of those carlages, take them apart and rebuild it all like it in your case, and that's called a functional septal rhinoplasty. Before you said, no, no, I don't

think I said it all quite like that, but that's exactly what you just said right here. And the look that was on Chuck's face, as you were explaining, it was identical to the one on my face, because suddenly I was no longer a guy getting a consult from a doctor who's done. How many of these have you done now? Like a thousand? Are you close to a thousand yet? Yes. Yeah, over a thousand.

Right. So I know I'm talking to a guy who could probably do this, you know, in his sleep, although he never would. He's a professional. But it went from me having a conversation in his world. And suddenly I was back on dirty jobs, right? It was like season two on dirty jobs. and I was talking to a contractor who was trying to explain to me,

like I was a small child, how he was going to have to knock all my walls down in order to rip up everything and put in a new foundation and then build. You literally said, you said, look, Mike, I have to build you an entire new nose. Do you understand? And I said, not entirely, but I think it's serious.

And, you know, to this day, this is the only thing after three years that still sometimes takes me a back. Because I had 58 years of experience, you know, I could push my nose up like a pig snout if I wanted to, not that I wouldn't want to, but I could. You seem to do it a lot like you wanted to. Yeah. It was a fun face. It was a fun face. I can't do that face anymore. So, you know, if I'm trying to make a list of.

cons, that's it. I can't make myself look like a pig anymore. Because this, sometimes when it's cold out and I touch it, I'm surprised at how rigid it is. It's not the nose I was born with. You literally built me a new nose. It doesn't look like it from the outside, but it's a new thing. Right. And in order to make sure that the nose doesn't wander in unpredictably, And I give you a solid result that lasts for years. What we do is we put in stitches to hold everything together so that we don't get that drift. We get that stable result and you end up with some good breathing throughout your life. Isn't a wandering nose technically called a Roman nose?

Oh, dude. That's nice. Anybody? Is this thing on? Just let me take care of the jokes from this point out. if you wouldn't mind. Go ahead. I'm going to have to steal that one.

Oh, please. Wandering nose, Roman nose. Good. Yeah. So you must have been, I'll talk more about this in the preamble, so you know we will have laid some pipe here, as it were. But, you know, I had a horrible experience with the drugs and the bleeding. I was a bleeder.

I was a bleeder. And, you know, when I called you. Songs were written about it. Did you know that? Bill Dumas wrote a song. People wrote songs about my nose, who. listen to this podcast as a result of listening to what happened when I took all that hydrocodone and the bleeding didn't stop and I went on a long strange bloodbath of a trip and I called you

the next morning and I said, look, I'm having these like active fantasies of getting a pair of needle-nosed pliers and pulling these splints out of my nose just so I can breathe again because I think I might be bleeding to death up here. When I told you that, did you think I was a crazy person or had you heard all this before. And plus, we're all locked down. It's still full masks, right? It's still at the height of all that stuff. But you were like, no, come on in the office, Mike. I'll have a look. We'll see what's going on there. You were so Mr. Rogers with me. Kill me. I remember that phone call. The splints are put in. They're one of the biggest fears people have. And it used to be that surgeons would pack the inside of the nose with like three feet of gauze inside of each nostril.

I mean, it's insane how much you can fit inside of each nasal passage. But thankfully, we do not do that anymore, and we put these plastic splints inside of there. And there's plastic sheets, and still, even though they're not three feet of gauze, and they don't quite feel that way, but they are irritating and make patients miserable. Fortunately, they stay in for the five to seven days afterwards and we're able to take it out. But it just makes the recovery miserable because you can't really breathe. You're right. You were a bleeder.

And I'm sorry about that. I don't know why, but yes, it was messy. I saw the videos. I think I remember FaceTiming with you from your bathroom. And it was weird. weird, but we got you through it, but it was... It looked like the final reel of Carrie. There was just nothing but bloody tissues everywhere

because every three seconds for two days, a single drop of blood would fall from my nose. And in my adult state, it just got me thinking, well, surely there must be a giant pool of blood that's collected in front of my brain because the only reason it's coming out in drips, I mean, no air could possibly have gotten through their nostril. It was so packed with snot and splints, and yet the blood was coming through.

And it just got in my head, and suddenly I was trapped in an Edgar Allan Poe story or like a Hieronymus Bosch painting. It was all just, I really got in my head with it. And you were like, listen, the whole thing with the pliers and the pulling out of the splints, that's a bad idea. If you really want them out, I'll take them out. But come on. Why would you want to do that? You've come this far. And you kind of shamed me.

You're like, you don't want to be that guy, do you? That guy who couldn't take it. A little bit of blood. You're going to ring the bell during hell week? Damn right, I was about to ring that bell. Yeah. I always tell people it's going to be the just most miserable week. Like, you got punched in the nose.

and you've got the worst flu ever. And then on top of that, I think that there was, in your case, a little bit of delirium from the narcotics, which I think made it all more challenging. And that's a whole other topic to go over as those things. But they're good to manage pain, but they can really take a toll on somebody. Let me ask you a really simple question about that, because I've heard, I think maybe from you, but maybe some others as well.

Like with the hydrocodone and some of the other narcotics that are typically prescribed, what would you say the ratio of importances or efficacy vis-à-vis the narcotic versus the acetaminophen or the aproxin sodium or whatever the actual, you know, pain reliever is in a larger amount than you would normally ingest. Yeah, so I think I'm understanding the question correctly, how efficacious or how worthwhile is it taking hydrocodone versus taking some of the other stuff that we have around the house, like Tylenol and Motrin, that's not necessarily going to cause issues. And the answer is, you know, we try to go the route of Motrin or

ibuprofen, as it's known, and Tylenol first. As long as the first, as long as the first two to three days are good after some narcotic use. We can start to transition over to that. But a lot of times when the pain is there, the only thing that will take the edge off for most people is going to be the hydrocodone, although we do want to use it sparingly. I think on average patients after this type of surgery

will use up to about 20, but typically even less than that, around 10 of the pills, simply over the first couple of days where it's bad enough that you want some of that. I like to get patients off of it as quickly as possible because it's crazy to hear how quickly anybody can get addicted to pain pills

without even trying or knowing it as we know a massive epidemic. And part of our responsibility as physicians is to limit supplies of those and to counsel our patients regarding good practices and best practices of taking those medications. Do you think differently now about that than you did say 10 years ago? Absolutely.

Absolutely. And I think you have to. I think the rules and the laws and the regulations require us, which is a great thing. But for every surgery that we do, we practice what's called or we apply what's called multimodal anelgesia. And what that means is exactly what we were talking about. We're using different classes of pain medicines along with opioids, sort of synminafin, ibuprofen, gabapentin, which work in different ways, in order to collectively alleviate pain without relying or having to rely on opioids. I do really big surgeries for head and neck cancer and reconstruction

of them. And these are huge, you know, 12-hour surgeries where patients are in the hospital for a week, and, you know, it's painful. And even in this population, we really try to limit opioid use and apply multimodal analgesia as essentially a mandate in our hospital systems. Can I ask you, I mean, what is it like to perform a 12-hour surgery? What's it like to have, like, maintain that level of focus, that kind of concentration for that length of time, how do you do it? Practice. I think that's why training, you know, especially for surgical fields, is long. My residency was six years long and a fellowship an additional year.

So seven years of learning how to stand in one spot for that many hours without taking a break, you can almost, like in a yogic way, you can just train your body that I'm not going to use the restroom. I'm going to focus. I think me personally, I don't even realize I do it. Somebody told me I do this, but I do something with my hands, and I do this stretch when I first start a surgery, and I take a few deep breaths, and then it's almost like I'm in the zone. But obviously, for every surgeon, it's a little bit different. And for many surgeries, they're not that long. Some of the work that I do does go on that long. And I know if I leave the room for a break, everything slows down.

And sometimes you've got to take a break. Sometimes it's great to take a break, a visual break, or just to take a breath of fresher, you come back refreshed. And my job as a surgeon is to know when I've reached that point where I need to take 10 minutes. Sorry, I have to ask you about this. The way you just said it right now, it's a 12. hour surgery and you take a deep breath and then 12 hours later you haven't moved from that spot. Sometimes you'll take a break, but it sounds like rarely. So you're not eating, using the bathroom

for 12 hours? Correct. So not every time, but I'd say a good chunk of times I try to go all the way or can often. I know with age, I'm at 43. I know as time goes on, I'll probably be much more prone to a kidney stone. One of my mentors in my fellowship told me that happens at some point in your life when you do this. And, you know, I think as long as your body can do it, you can. But I think every personality is different. When I concentrate, I concentrate hard and I can just dive in. And I know my parents told me that I was like that from a very young age. And I can just sit there and focus. But that's why I do what I do. And somehow I ended up in this field, it just ended up fitting by complete accident and a fitting my personality. I mean, that is a

yogi-like thing. Are you, is there a spiritual element to it? Are you a meditator? You know, when you say you get in the zone, what does that look like? I mean, I just can't imagine standing in one spot for 12 hours and not eating, drinking, or using the bathroom. I think that. I think that, that, again, I think it's habit and it's training, but for me, it's my own personal, meditative, almost safe spot. I'm there. I have the next 200 steps of the surgery that I need to do, and I know what I'm going to do, and it's just getting through all those in a way that's going to work, and then taking a look back and saying, okay, that was awesome. And that's the kind of the meditative aspect of it for me and the rewarding part of it for me.

But I got to say, as I'm getting a little bit older in this, I do end up having to take that break every now and then. But still, quite often, I will go all the way through. There must be stories. Like, there must be legendary stories that circulate among your community of surgeries that either became complicated in an unanticipated way. and require doctors to go 15, 18 hours. And I'm curious, too, about environmental eventualities. I mean, what happens in an earthquake? What happens if a surgeon midway through a procedure

actually has the kidney stone right there make the move and has to get out of the sketch? Who comes in? Who's standing by? That's the stuff that kind of worries me more than anything else, because you're awfully good at what you do, and you're the master of your own domain on the inside. But the crap that can go wrong out in the world is kind of endless.

Yeah, I mean, anything can happen. And this is why it pays to have friends around and to always have a backup plan and to have partners. And to understand that, okay, you know what, if this needs to end, let's say there's something catastrophic, there's an earthquake, and we have to stop what we're doing because the generator's not working. Or in a situation I've been in the, you know, the patients, you know, for some reason, you know, very sick to start with, but now becoming unstable, we got to wrap it up no matter where we are.

And so there's always an exit, exit route that can be there if any of these unforeseen circumstances occur, at least in my field that I am, but something like a heart transplant surgeon. that may not be possible for them. And that's when we rely on partners and backup generators and backup machines, et cetera. We can circle back to like the specifics of the surgery you do most often. And really the main reason I want it to have you on. But if you don't mind, I would love to ask you just about being a doctor in 2023. You know, when I met you, you were working over in the,

In the big system, what is it, UCSF? Correct. And I was really struck by the reality of your day and the, just the amount of people who you saw and the amount of work that you did and your role in that system and how that whole big system, when it worked right, worked really well. But I was also super curious about what are you going to do with the rest of your career? Like, how do you decide when to step out as you've done in private practice? And you're married to a woman who is, is she eyes and ears?

She's an ophthalmologist, an eye doctor. That's so great. You guys have the whole face covered between you. We got it all covered, yeah. We just need our son to be a neurosurgeon, and we've got it. Perfect. Two kids? Two kids.

Okay, so you're 43. You're married. You got two kids. you're both doctors, and I think the thing that made me laugh out loud when this topic came up last time, you said, yeah, I'm like a middle class, lower middle class Silicon Valley doctor. Like, what? So how's it going? How's your business right now? And how do you feel about being a doctor?

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If you could eat a stare, if you could eat a cow, don't take a chance on a foreign ranch, get good ranchers now. Yeah, going back to that comment, you know, Bay Area and Silicon Valley, just the cost of everything is inflated, as I think the entire nation knows. I mean, even being a two-surgeon family of earners, you know, we're kind of like, well, how do we afford this house that we want? And so it's challenging. I first admit, I rent my home and, you know, one day hope to own one.

But, you know, I think the harder thing as two physicians is how do we balance our kids, our family, our patients, responsibilities, emergencies that are coming up? And being on call and I was like, honey, are you on call or I'm on call too? Oh my gosh, what are we going to do? You know, this is the challenge. And this is where we lean on in our community. And we lean on our parents and especially my wife's parents who help out. And without that, it's just really hard. But I have to say that UCSF is, it was a great place to work.

I'm still affiliated with the UCSF and still teach fellows in residence, a fellow somebody in their last year of training in our specialty. And I just think it's an amazing organization. And like you said, when it works well, it's just, it's amazing how much talent there is and how much people care. It's just, it's truly a center of excellence. And I ultimately came to this point in my life where, you know, I think when I first met you, it was just patience work. Patience work, research, writing, publishing, just in the grind, just eyes closed, charged forward and advance. And then I think that begins to wear on you. And I think I kind of did it

to myself and just really took myself into the ground. And I eventually just had to step away from it for my own sanity and for my family. That was really what it was about. And that really didn't happen until I was commuting on bicycle from our clinic where you would come see me. me in the middle of San Francisco to the Cal train so I could take the train down to the South Bay because that's where my wife works and that's where we live. And so I could get work done on the train instead of waste time in a car. And I unfortunately was in a really bad bicycle accident and had to take three months off in my recovery. And during that time, I just didn't know if I was going to operate, be able to do my line of work. And I kind of feel like it was the, that, you know, that

the hand of God, I was like, here, I got to just push you to knock some sense into you a little bit and made me rethink just a lot of things. And I think sometimes these big life-altering events make us think again. That must have scared the hell out of you. You started this conversation by saying, I work with my hands. What was hurt in the accident, exactly? Yeah, I don't think I ever told you this, but yeah, I broke my elbow. Oh, man. Into five pieces. And fortunately, I got to find a really wonderful surgeon, and she put me back together just

beautifully. And I think about her every day. And although I was just like half a day of work for her, she was a lifetime of work for me. And so it gave me some perspective as a patient as well. Well, that's kind of beautiful. I took half a day of your life. And for the last three years, I think about you every day. Every time I take a deep breath, you know, I'm one of a thousand people that came through your world over there.

But wait a minute. So you're riding your bike to Caltrans, so you can do some work on the train, on the way home. You're hit by a car. You're lying there in the street, presumably. What are you thinking as a doctor who works with his hands, who clearly still has a presence of mind to diagnose the fact, just to put it in clinical terms, your arms all beat to shit? I was completely scared. There was no other way to put it. Just clarify, I didn't get hit by a car.

There was just a pothole. I mean, it's kind of embarrassing, but I didn't see the pothole. You're kidding. A pothole? Yeah, I flew off my bike. I stopped my fall with my arm as an instinct, but then the arm ended up breaking. It was really funny. I remember being there on the ground, and people saw the accident.

So they came over, and I was like, okay, I'm just going to get up here. And there's a guy who goes, dude, don't get up. Your arm is effed up. And then the first thing I was like, what? I need that. Like we all do. I need that arm. It's my favorite arm.

Yeah. And I didn't even know it. That's my septoplasty arm. Yeah. And so it was wild. It was wild time. I will say another bit of a public service announcement as part of this, since we're talking about that quite a bit, is I was wearing a helmet.

And thank God I was wearing a helmet. Because my helmet cracked. And I had a concussion. If I had not had the helmet on, it would be my skull that would have cracked. And so it just, it goes to show, you know, how important it is to wear a helmet, protect yourself when you're on a two-wheeled vehicle. And very ironic because I wrote this paper, the research paper, on injuries to the face when wearing a bicycle helmet and you can reduce quite a bit with a helmet to injuries of the face of the upper part,

but the lower part remains very vulnerable. And so one of the things about the paper was, and it was published in JAMA Odleyringology, that, you know, people should consider wearing full-face helmets if you're going fast enough, even on a bicycle. Because we showed in this data that after looking at 85,000 bicycle accidents, that there's a lot of injuries to the lower face. And so it was very ironic to be one of those accidents in the end. Yeah, you wind up being a statistic, a case study in one of your own papers. That's right.

So, yeah, I probably should have made the point earlier on. It's not just nose. You do whole face reconstructions. You'll do, I mean, talk a little bit about the totality of what you do beyond just helping people breathe better. Thank you for that opportunity, and I think it's great for people to know what's possible in medicine. So I'm a facial plastic and reconstructive surgeon. That's a subdivision of the field of E&T or the proper name, Odleyringology, head and neck surgery. And so what that really means is I take care of all aspects of bone, soft tissue, skin, other issues of the head and neck when it comes to altering.

the shape or reconstructing it. So part of what I do is reconstruction for head and neck cancer. And I spent a lot of my career at UCSF doing that. Basically, if somebody has a cancer that goes into the jaw and the jaw needs to be removed by a surgeon who is specialist in cancer removing, then it needs to be reconstructed. You can't just leave somebody without half of their jaw. So what I do is I reconstruct that. I'll take the fibula bone, which is part of the lower leg, and your lower leg is like a chicken bone of a chicken wing, and you've got one big bone and one small bone. The tibia is the big bone, the fibula is the small bone, and you don't necessarily need the fibula, unless you're a pretty advanced athlete.

And so I can actually, we can take out that fibula bone. There's a little artery called the perineal artery that feeds it and some veins on the back of it. We can take out the bone with the artery and vein that are feeding it, do an auto transplant. Take that piece out, shape it, side, cut it into the shape of the jawbone that we need, and plate and screw it together. And then like a plumber under a microscope, though, I can attach the artery of the leg to a spare artery in your neck, which is about two, three millimeters only. That's why a microscope is needed and do the same thing with the vein. So now

you've taken a piece from one part of the body, put it into it. to another and given it a blood supply. It's you, it's part of you, so you don't need to be on any drugs or medication or anything like that, but it's the most beautiful way to remake somebody of a big missing area. And that's called a free flap. I've done many, many of those. And then that's an exciting thing where patients just feel so indebted to you as a surgeon and that you're able to give them form and function back. Yeah, but it's not just form and function. It's their face. Right? I mean, when I think form and function, okay, better range of motion, fixed my rotator, good, I can straighten my leg, great, but you're talking about, you're talking about identity. Right.

I don't even know how to articulate that, but that level of impact on somebody's life to hand them their identity back, that's got to be worth a Christmas card or something. Yeah, exactly. And it's beautiful that we can do this for people. and reconstruct tongues. It's crazy. Yeah, and throats and voice boxes. It's so cool. That's why I went into reconstructive surgery because it's just so cool

to give somebody their face back. I have a question. You mentioned a spare artery in the jaw. I kind of hitched on that. I'm thinking, what is it just like the red-headed stepchild of arteries? How do you have a spare artery? Good question.

So there are many branches of the carotid artery that feed your tissues of your face and you don't need every single one of them. In fact, you don't need most of them because there's enough collateral flow and flow coming from other parts of the head and neck because there's just a lot of blood supply of the face and head and neck.

You can take one of those away and not have any problem to the tributary it was going to. That's crazy. Who figured this out? I mean, that must have been a big paper. That must have been a big convention somewhere. You know, ladies and gentlemen, come in order. You're not going to believe this.

We found another artery in the jaw. And I'm thinking if you take that fibula, you don't really need it. How does this stuff happen, doctor? I mean, can you walk it back to a moment where somebody's like, I got some questions about the old fibula? You know, there was a huge amount of advancement in the surgical fields in the 60s, 70s, kind of post-World War II around the World War I and 2 is where you saw a need for reconstructive surgery take off because of the injuries that would occur. And so as the decades that followed thereafter, those became more and more sophisticated. And the 60s, 70s, 80s, that's when you saw in the 80s, the fibula flap come about and that was

discovered by somebody here. And the failure rates were massive back then. As you can imagine, it's just kind of unknown territory. So like half of the free flaps they would do would die. And a decade later, it was, well, now we have 70, 80% success. A decade later, it just got better and better. and to the point that now, you know, success rates of this surgery are about 99%. It seems like with regard to risk, whether it's with a medication or a vaccine or a new procedure,

it seems like there's just so many forces aligned against it. I just didn't think it was possible anymore in the medical field to get the OK to do a procedure that has a 60% failure rate because maybe it'll be better. next year and the year after that, but that's still basically how it works. I mean, how is could it work, I guess. Yeah, and I think, you know, if you ask people now to sign up for a 60% success rate surgery, I think that would be more challenging, but decades ago, it wasn't as regulated and bred innovation and advancement. There still is plenty of advancement, but I think we're much more careful about it. You know, surgical sciences continue to advance in many ways. And I think the next

big line of surgical advancement is going to be applications of, you know, gene therapy and precision-based genetic therapy applied surgically and all sorts of very cool, innovative stuff that is not necessarily around the corner, but soon we'll begin to see it and will again redefine. the field of medicine. What's AI going to do in your world? Very interesting. And I don't think we've talked about this at all, but ahead of time, it's interesting. You asked this, in my particular world, I wanted to figure that question out. Like, how can we incorporate AI, which is, you know, essentially doing many computations in an automated way to come up with solutions. And I team I'd actually written and done a research paper with a group out in Calgary about the face

and understanding which facial features go with one another appropriately and how to characterize the features as feminine or masculine, average, not average. And with 3D imaging and computational analysis called geometric morphometrics, we can do this. And that was kind of my first. venture into AI and its application directly to what I do. Part of what I do is cosmetic. What I do is I change people's faces, you know, bigger nose, smaller nose, altering the shape of the cheeks, jaw, whatever it is beyond reconstruction, but also in an elective way. And so we found through that research that there's potentially a really cool application

of AI to the face and its application to surgery. using that data to create when somebody says, you know, I want this really tiny nose. I can say, well, you know, that's not the best nose. Actually the best fit nose for your face, dependent upon the other features of it that would be the most attractive just by pure data is a nose that looks like this.

And I can help you achieve that. That's where I think, at least in my field, AI is going. And we actually, we didn't talk about this at all before it's funny you mentioned it, but we actually formed a company that has such a software. Interesting. I was actually talking about artificial insemination, but whatever. This whole artificial intelligence thing sounds pretty interesting, too. So I'll be in.

Isn't this something you do called photomorphing or whatever to show people what the effects of the surgery will look like? Absolutely. Is that an AI thing also? That's not as much AI in its current state. So morphing is done more of a hands-on way. Like, another way is called pixel pushing. So you're basically able to take pixels of a person's image and pull it one way or another, like take a hump down of somebody's nose by removing those pixels and substituting them by the adjacent pixels.

No one ever adds a hump just as an observation, right? No. The hump is always the proximate call. of someone's unhappiness. That's correct. Less hump. Less hump is better. Going back, again, just to the brute realities of living in the Bay Area, I'm just really

fascinated by two surgeons living together, renting a home, trying to, just dealing with the struggles that everyone deals with. Where did you go to school? And how much did it cost when the dust settled? I went to school at University of Rochester in upstate New York. I went to undergrad there. I got my major in engineering and then my MD degree there as well. And I was at Cleveland Clinic for my residency and then UCLA for my fellowship.

And the cost of my medical education, I was actually fortunate. I just got a ton of scholarships. And so I think I left with about an 80 to 100,000 debt. But the average person graduating medical school these days comes out with a debt of around 400,000 or more. So it's just staggering education cost. And you combine that with a cost of living challenge. It just becomes a struggle. And it's no wonder people are choosing not to go into medicine.

That is a clear and obvious roadblock. But what about insurance? what's the practical reality of that on top of everything else? I'm just asking, I'm not trying to pry, but I just, I wish people were more curious or maybe just had a better understanding of what it's like to, not just to be a doctor, but to be a surgeon, a working surgeon, who stands in one place for 12 hours at a time after putting him or herself into a trance, essentially, shutting down their bodily functions, focused entirely on the welfare of,

of their patient. I don't want you thinking about $450,000. You owe the, you owe some school. I mean, it's just the stress, man. The stress. That is just beyond imagination to me. I think it's across the board. You know, I think we're talking about me and my experience,

but I don't know how people in the Bay Area do it. And our other communities and a city is going to be the next Bay Area. with housing being lacking. And how are we, how are we even going to sustain any livelihood that way? I hope it does change. I hope it does get better.

But it's, for us, it's a challenge, causes a lot of stress. I try to zone it out and go to my happy place, which is the operating room. But when you're out, it's hard.

My happy place is the operating room. It really is. Dr. Seth, I want to ask you something about, the cost of the medical stuff in general. Before we press record, I was telling you about this this hump. I think it's called a CT, not a hump, no, a CT scan on my heart to check the calcium levels, you know, in the different parts of my heart and, you know, to see how at risk I am for a stroke or an aneurism or a heart attack. And insurance does not cover this procedure.

but it only costs $150, which comparatively seems like not a lot of money, you know, and really an important thing. I also think about like LASIC surgery. You know, LASIC surgery when it came out, it was like $10,000, $5,000 an eye. And now it's like, I'll do it for $89.99 on, you know, both eyes. It's just come down in price. And it seems like elective stuff or stuff that people pay for out of their own pockets has gone down in price, while everything that is covered under insurance has gone up in price. Is there any correlation there? Great question. And I don't claim to be an expert on insurance. And so I apologize to the listeners if I say something wrong, but it really goes to show that we have a broken system. And this is what we were talking about is, you know,

it's this cat and mouse game basically is that so if an insurance is going to cover it they're going to pay only x percentage like 10% of what anybody's going to charge or 30% and so then the price of that goes 10x higher to compensate for the return to get what you whoever's manufacturing or making it anticipated or need it for their business. The sad part is if a patient who doesn't have insurance, who doesn't have insurance coverage for a particular physician and has to pay out of pocket for a particular facility or whatever it is, they will get a discount, but largely they have to pay these exorbitant rates that sometimes you hear about that is being charged to them

just because the values that are out there are hyperinflated due to the reduced reimbursement that comes back. The patients get caught in the middle of that. So it would be so nice if we valued and earned what the true valuation is of something. So apples to apples system, again, a big piece of insurance overhaul. I don't claim to be an expert about it. I see the numbers and the challenges from a patient perspective. And I'm just so confused as to why the system is like this. and it seems to think of broken. I asked you straight up before we did this procedure. I said, what's this thing cost?

And you said, I really couldn't tell you. Wow. What other industry? What other industry is like that? Yeah. It's a heck of a thing. But it's also true, right, that if I came to you and said, look, I want you to straighten my nose out, I breathe fine.

That's elective versus I can't breathe at all. I'm a mouth breather. I need help. That goes in another category. Do you know what the difference in cost is between those two things? Is there one? So again, this becomes a pretty complicated question because the cost for an insurance-based procedure ends up getting divided up into categories of facilities fees and a physiology fees. We're talking to surgery here. And then surgeon-prudgeon professional fees. And any one of those can be hyperinflated compared to the other in order to compensate for a cost. And typically it's the physician fees, a professional fee, that gets super downgraded. And it's one of my big problems with the way the system is set up is what I believe is

the continued devaluation of the physician. And the higher exponential valuations attributed to facilities. And I'm not saying that facilities aren't worth it, but it just, the system has really gotten so confusing that even those in it, us in it, when a patient asks how much is this going to cost, I have no idea. But I hope one day that we can level these things out and have true value that's quality-based and merit-based be given for what it's actually worth.

Well, look, my goal again and all this, just to kind of land the plane here, because I know you probably have a bunch of patients lying there waiting for you to change their lives, is that there's no reason to be a mouth breather, really, I mean, unless you like it. And I know if you're in this area, I can recommend Dr. Seth, but what do you recommend, Dr. People do, who, want to explore to see if this is the right procedure for them. Where do they start?

Yeah, thanks for bringing it back to this. And first of all, if you can't breathe through your nose, it's been a long-term problem and you are mouth breathing all the time. And the best first step to do is to take a look at your breathing habits. Are you asked the same questions that I asked the patients? When is my breathing a problem? Is it at night? Is it at daytime? Is it activity-based? Is it when I'm exercising? Is it my sleep? How is it affecting each one of those things? How is it affecting my life in general?

And if you find the answer to those questions after you've done a deep dive about it, you've observed yourself and how your breathing is for a week or two, you know what? I wish my breathing was better. It's just not as good, and it's affecting my quality of life. The next step to take would be to see either your primary care physician, if you need a referral to a specialist, with the ultimate goal of seeing an ear, nose, and throat, or an otolaryngologist. What the ENT or otolaryngologist will do is because there's so many reasons where somebody can have a blockage, one of them is deviated septum,

which is what we talked about. And turbinate hypertrophy. Another one could be that you have polyps or sinusitis. It's a good idea to figure out what may be going on. And if you need a specialty surgery or if you need a surgery, then that would be the next step to address that. Usually after having some medications, medications may include a steroid spray like Fluticocone.

That's available over the counter. And this can help decrease some inflammation if it's present. Ultimately, this would be the course and the appropriate timeline to get assessed and determine if you are a surgery candidate, because the big important takeaway is that not everybody with nasal blockage is a surgical candidate. Some are, and for others, medications are a good route or even practicing to breathe. I know you had Mr. James Nestor and his book, Breath, gave just as a a wonderful book in his podcast with you, super informative and I encourage listeners to also take a

listen to that to understand the value of breathing. Yeah. I mean, look, if you own it, it becomes meaningful. It's not a thing you just do because it's fashionable, at least for me. And once I read that book and once I really started to think about my life, I just thought, why am I going to bed every night with a breathe right on if I don't have to do that. And then I went down the road and I did, you know, I got a second and third opinion. Then I met you. And, you know, I like the cut of your jib. I like the way you laid it out. You were honest and you were right. It was a miserable week. But the next week was better. And the week after that was pretty great. And now I don't meditate much, but every now and then I'll sit and I'll close my eyes because I can.

I can, it's very hard to meditate if you're a mouth breather. So much of it changes. Exercise changes. I think I had a cold a couple of months ago, but I'm not sure because so much air is coming through my nose now, it didn't get blocked up the way it always used to. Food tastes different. I think my voice actually sounds a little different. 100%.

Yeah, I've noticed that. I noticed that not right away, but I can totally hear a difference. you were clogged before. You could hear it. I didn't notice it at the time because you have a great voice, but your voice is greater now. You're reaching your full potential

for your voice. You're coming into it. It's at 61. My point is, I don't think I'm the only frog in the boiling water. You know, anecdotally, I've talked to so many people,

Doctor, who are curious about you and are curious about this story. So thank you for coming on and just putting it out there. It goes without saying, if you're in the Bay Area, or if you have access to a plane and you want to get it done right. Do you have a website?

I hate to turn it into a commercial, but you've got a private practice now, so let's do it. How do people find you? Yeah, my website is goldenstateplasticsurgery.com. It's pretty easy, goldenstateplasticsurgery.com. And I have a whole page actually on nasal obstruction and a lot of what I've talked about here. I really appreciate you saying all those nice things. I just, I'm honored to give great care. And I'm so glad that you've done well and the quality of life that you've shared with

this improvement and just makes my day. It makes me so happy to be able to do what I do. Well, thanks. This was really great for me, too, because your profession really is a noble one. And there's so much of what you do that is shrouded, I think, in mystery and a lot of people's minds. I mean, you're changing people. It's just a hell of a thing. And then to just kind of put that right alongside the story of a guy who hit a pothole on the way home,

damn near cracked his head open, shattered his elbow. You're just humans, you guys. You're just humans trying to live and dealing with loans and insurance and kids. And then you're standing still for 12 hours, getting cancer out of somebody's neck. Man. Hell of a thing you've chosen to do, doctor. I'm glad you're on the case. Thank you so much.

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