Trish: Good morning podcast world, or afternoon or evening, or whatever time it is where you are at. Its Trish here from Plastic Surgery. I am here again with Dr Jayson Oates today and we are going to talk about Rhinoplasty. We have been getting quite a bit of enquiry through lately about Rhinoplasty and who is the right person to go to and when you will choose either a plastic surgeon or an ENT or why you choose one over the other and I thought I just wanted to clear up … Anyway I just wanted to speak to one of our ENT surgeon’s which is Dr Jayson Oates from Face Academy from Subiaco and also in Crows Nest. So welcome, Dr Oates…
Dr Jayson Oates: Hi Trish, good to see you again, or talk to you again.
Trish: That was a big long intro wasn’t it.
Dr Jayson Oates: It was.
Trish: I didn’t mean for it to go on that long but anyway. So thanks for joining us today. So can you, just explain to us, I know I have already asked you the question anyway, but I had a client come in this week, online actually and she wanted to have a septoplasty and she said to me ‘oh, I need to have a septoplasty. I need to make an appointment with an ENT and a plastic surgeon and why do I have to have an appointment with both?’ And I was like, well actually I can’t answer that question, so I thought, perfect. I will ask you, so, can you explain to us a little bit about the way it works.
Dr Jayson Oates: Sure
Trish: When you go to whom, or …
Dr Jayson Oates: I guess I’ll start off explaining that the Septum is the dividing cartilage towards the back bone that separates the inside of the nose to a left and a right half and it is meant to run straight down the middle of the nose so it gives you a left and a right nostril. And, if that gets bent, and that can be just the way it grows naturally from birth or from an injury or something like that. Then you have a deviated septum and that can cause functional problems. So, the way it mostly presents is difficulty breathing. Sometimes it’s snoring or sinus problems. Or it can also show externally as well if it is bent enough it will bend the lower half of the nose as well.
So a septoplasty is the operation to straighten the septum and it’s a functional procedure. Its one of the first procedures, as an ENT Registrar in training, that you learn, probably after doing tonsils.
So, if somebody is wanting just a straight septoplasty for say breathing problems, then generally they will probably just go to an ENT surgeon and ENT surgeons do the vast majority of just septoplasties.
If it’s a bit more complicated and they are needing a septorhinoplasty so combining straightening of the septum plus something external as well, then there are those ENT surgeons who have an interest in specialising in rhinoplasty and so they will do a septorhinoplasties and I have a number of ENT surgeons here in Perth who refer me all their septorhinoplasty because they don’t do the rhinoplasty side of it. It used to be a common thing that a plastic surgeon and an ENT surgeon might work together so the ENT surgeon would do the internal bit, straighten the septum maybe harvest cartilage for grafts and that sort of thing and then a plastic surgeon will do the external part. Most plastic surgeons now who really have a focus on rhinoplasty will do their own septorhinoplasty now so I think that collaboration of having two surgeons at the same time, which is really difficult to organise. It is always a pain trying to organise that.
Trish: Oh, I can imagine. It’s hard enough getting one let alone two at the same time.
Dr Jayson Oates: That’s right. And whose list is it going to be on, who is going to where, yeah, it’s always difficult. So that is becoming much less common sort of thing and maybe some of the older plastics and older ENTs still do that but most people who really focus on rhinoplasty do the entire procedure themselves now.
Trish: Got it, got it. So basically, if you go to a surgeon just make sure they are a surgeon that does a lot of them and they either do both if you want both or go to the right surgeon to get what you specifically want to get done.
Dr Jayson Oates: Yes.
Dr Jayson Oates: It’s always hard for the patient to know, especially when you have already paid to go there and see the surgeon and for them to then say ‘well actually I don’t do this operation very much’. But for people like myself who, specialise in certain procedures even though it might be quite a few procedures, you can’t really do everything. You can’t do everything well. Yeah I feel terrible when somebody is in here and they are asking about a procedure that I don’t do. I say ‘I guess I could do it but I don’t really specialise in this area and I think you would be better off going to see somebody else and I will give you a referral’, but especially if they have had to be sitting in the waiting room for half an hour or if I’m running late, but it’s a much better thing to do than to take on cases that you don’t really have the same level of skills that you have got in other areas.
Trish: That’s so true and I am a great believer that … I mean I understand that a lot of surgeons are good all-rounders but I always think there’s usually that one procedure that you kind of excel in and that kind of propels you to be really great at that particular, you know one or two things. But I love the fact that if there is a procedure, and they come to you and although you can do it, you decide not to. Because number 1, either you don’t do many of them or number 2 you’re not that confident in them or number 3 somebody else is going to do a better job.
Dr Jayson Oates: Yeah that’s the thing and ethically it’s hard to take on something when you think that there is somebody who can do a better job than you.
Trish: Yep, yep. That’s so true. That’s so true. And so do you consult for surgery only in Subiaco or do you also consult for surgery in Crows Nest?
Dr Jayson Oates: So, I am only operating out of Perth and Western Australia. We have just got a new doctor consulting out of the Crows Nest office so that we can offer more surgical procedures there as well. Because the practise was just developing to the stage getting busier and busier that we had that clientele that wanted to take things further than just having injectables and threads. So yes that has been great to be able to add that to the Crows Nest office as well.
Trish: Oh fantastic. And just going back to the rhinoplasty, so if someone was to have a septorhinoplasty with you, is that like a long procedure, like does it take a long time, do you have to stay in overnight and can you tell us a little bit about the prep and recovery.
Dr Jayson Oates: Sure, sure. So, there is a lot of variation between simpler and more complicated septorhinoplasties and one of the things is once you have been doing something for a long time and I have been doing this for almost 20 years now, you start getting referred the difficult ones.
It would be nice as I get further in my career for people to start referring me the easy ones.
So, if it was like just a straight septoplasty, you know, half an hour and usually is done under a general anaesthetic, people stay in overnight but they can go home the same day.
Dr Jayson Oates: I do, do, septorhinoplasties under twilight sedation. So I have mentioned before we have got an accredited twilight sedation facility here. With septorhinoplasties you need to get it numb all the way to the back and the septum goes about 8cm back into the nose and they if have got a really sharp bend in the septum it can be hard to get the local anaesthetic to go behind the bend.
So, more difficult septorhinoplasties, I’m most likely to be doing it under a general anaesthetic. So when you are doing a septorhinoplasty it might just be taking off the hump and then cracking the bones and squeezing them together and you know, maybe the whole procedure is done in an hour. But, with a lot of humps, you need to put in what we call spreader grafts and that’s using the cartilage from the hump or from the septum to prevent the nose from becoming too pinched in and thin in the middle and that can happen very gradually over a period of years and so that is a lot more fiddly and takes a bit more time and you are now out to an hour and a half.
You now want to refine the tip a little bit and that might be sculpting a small amount of cartilage off and placing sutures into the tip and now you are getting out to two hours and I get a lot of people with complex breathing problems so when they sniff in the side walls of the nose collapse. So in that case I will be taking cartilage out of the septum and then grafting it into the sidewall of the nose to give it strength so that it doesn’t collapse in so easily. So, yeah, you can now be looking at a two and half hour procedure and often I am explaining to people and saying, if you were having a total hip replacement, they will do that in 45 minutes but your nose is going to take two and a half hours.
Trish: Yep, yep.
Dr Jayson Oates: Yeah, it can be quite a long procedure.
Trish: Okay, and with the recovery, I just found a lot of people are frightened as to what is going to happen afterwards because it is right there, it’s in your face, it’s your breathing, its … Can you tell us a little bit about, like, so you wake up from the anaesthetic …
Dr Jayson Oates: You may or may not have packing in your nose. For the majority of my cosmetic rhinoplasties, especially if I do it under twilight sedation, then generally they won’t have any packing in the nose at all, if you had what we call osteotomies where the bone has been cracked then you will have a stuck on metal splint on the nose. You might be starting to get a little swelling around the eyes and black eyes. But I still do about 50% of my rhinoplasties under twilight sedation. People will stay in our recovery here for two or three hours afterwards. Someone will come and pick them up and they will go home the same day. And then 50% I will do under general anaesthetic, maybe I will do more work with the turbinates. So the turbinate is the ridge of tissue that runs along the side of the nose. There is actually 3 levels of them and often it is the lower one that perhaps is a bit swollen and blocking up the airway.
So I trim that back and the reason it can swell up a lot and also shrinks down, say when using a nasal spray, is it has got a lot of blood vessels that can dilate and constrict.
So sometimes that can be a bit drippy and so in that first night in hospital, it may have a little bit of blood dripping, they have got a pack in there, it’s a bit gooey and even in the morning, the pack slides out.
I use a very soft, sort of pack, made out of seaweed I guess, it’s like cotton wool and it goes into the nose about 6cm on each side and just slides out. So they are in overnight and they go home the next day. I provide a couple of nasal sprays. So one is a little decongestant nasal spray, and that just helps open the nose up a little bit, because it is not particularly painful for the majority of patients. I guess 1 in 5 come back and say ‘Oh look, that was really uncomfortable’ but most people come back and say ‘it was nowhere near as bad as I thought it was going to be. You know, you said you were going to use this chisel and break the bones and you cut the top off my nose with the hump and you had to cut through the middle part of my nose, you lifted all the skin up and then it didn’t hurt’ and they are really surprised.
Trish: Yeah, it’s funny because I actually had a rhinoplasty done about 20 years ago and I was exactly the same. I was like, you know, he is going to chisel this and chisel that and I was surprised at how, when I came out, the only thing is, I did develop black eyes over the week after coming out, but I was actually surprised I didn’t feel a whole lot worse.
The only thing that was scary, because I had a little baby at the time and when it bumped me I thought I was going to die, every time it bumped my nose for about the first year, it was just so sensitive for anyone to touch.
But what I was going to ask, so I presume this is the case with every nose job, I remember at one point, at the end, is it true that the blood clot or whatever, has to come out of the nose. Does that happen with everyone or does that …
Dr Jayson Oates: No, not necessarily, although, there are incisions made in there and they can drip a little bit and if you have had, as I said, work on the turbinate they can definitely drip, and there are so many convolutions and turns and nooks and crannies in there but, yeah, the blood can congeal and then dry a crust in there. So the second thing we give them is a bottle of nasal spray and tell them to wash their nose out and I don’t care if they do it 20 times a day.
I tell them to gently blow or at least snort and try and get anything out of their nose that they can. And they will usually be told and the nurses in hospital will tell them, you are not allowed to blow your nose and I say that is not really right. I don’t want you blowing as hard as you possibly can say with a hanky or a tissue but I do want you snorting and blowing your nose and using the salt water spray as much as possible. So long as you can feel its getting something out, it’s doing its job, then keep doing it, because you will feel so much more comfortable, it will open your airway up.
So two things that I think worry people the most is a bit of blood dripping in say the first 24 hours, and then the blocked nose and that can be … especially in the first week, especially when they have got a nasal splint on, that is squeezing the nose in a little bit, its swollen on the inside, you have got the dry blood, so anything you can do to wash it out, open the breathing up makes you feel a lot more comfortable.
Trish: Yeah, right. Well I remember with mine, what actually happened is, yeah, there was definitely no blowing of the nose and whatever. And I can just remember, I can’t remember if it was a week later or whatever, just like a … I think I … someone just … I don’t know, I don’t even know who did it, but we kind of pulled this massive blood clot out of my nose and I was like, oh my god, my nose is falling apart, but once that came out I was like, oh, I can breath and it was like a relief. Although I almost had a heart attack when that blood clot came out because it was huge.
Dr Jayson Oates: Yeah, we will get patients in, the day after or two days after and try to give the nose a bit of a vacuum, and that can make it a whole lot more comfortable right from the very start. At one week we are taking the splint off and if they have had any stitches in the skin of what we call the columella, that bit of skin between the nostrils, and we will vacuum it again at that point. The cleaning out of the nose, it only takes a little bit to make a big difference.
Trish: Yep, yep. So tell me, does the septoplasty, it obviously attracts an item number, do they both or just one or …
Dr Jayson Oates: There are item numbers for both but it depends on the indications. So, septoplasty basically yes, that has always got an item number and a rebate from Medicare and from your private insurance if you have got it, but for a rhinoplasty if your doing it, say, like I was describing, putting grafts into the side wall for the collapsing valve and for improving breathing, that has got an item number.
If you are doing it for trauma and they have got a deviated nose and you are straightening the nose backup, that has got an item number.
But if you are just doing it to take the hump off or to refine the tip a little bit, then that doesn’t have an item number.
Trish: Okay. Got it. So it depends on the indication as to whether you get an item number or if you can claim anything back from Medicare.
Dr Jayson Oates: Exactly.
Dr Jayson Oates: And, the insurance companies are getting more and more strict, on this. They don’t want to be paying for cosmetic rhinoplasty.
Trish: Yep. They are getting strict on everything. They are getting strict on everything to the point of ridiculousness sometimes, but anyway.
Dr Jayson Oates: Yes, indeed.
Trish: Yep. Oh awesome. Well that has been fantastic, so I reckon you have answered all my questions. There is nothing else that I can think that anybody, yeah, I have covered all the questions that we have been getting lately.
Dr Jayson Oates: Great, it’s often considered the pinnacle of cosmetic surgery, because, it’s the most unforgiving area obviously right in the middle of your face. It has got a combination of bone, cartilage, skin, people can have extremely high expectations there, so it is where you can get the most satisfaction, as a surgeon, for producing a really good result.
It is also the area which probably causes the most anguish when somebody comes in and you have done something where you think actually, you know, that’s made a really nice difference and they say ‘but you see this tiny little thing, this little area here, and you know, with the light in my bathroom, or elevator and stuff like this. Like in the elevator when I am going to work and the light comes, and I can just see this half a millimetre imperfection …’
It’s the area that people get the absolutely pickiest …
Trish: Yes, because we are so critical of ourselves and for myself, when … like I went into my plastic surgeon who was Dr James Katsaros in Adelaide 22 years ago and I told him exactly what I wanted.
I was like, right, this is what I want. I want the bump gone, I want the nostrils narrower, I want the little ski jump at the end, I want it smaller, I want an ‘Australian’ nose, and he said to me, ‘I’m sorry, I’m not going to do that for you, I am going to keep your roman features, otherwise it would look ridiculous. But what I am going to do, I am going to get rid of the bump and I am going to narrow it out’.
I was really upset and I was like, oh my god, like, that is not what I want. Anyway, I went ahead and had it done and now years later, now that I think because I have seen noses that just have been overdone, you know, not generally these days, but you know, in the olden days and I think, oh my god, I’m glad that he actually did the right thing by me. Because it is so subtle and I still actually have the same nose it’s just a little bit more refined and I am so glad he didn’t listen to me, because god knows what I would look like if he listened to me.
Dr Jayson Oates: Well that is the problem and sometimes, they can look okay for a short period of time but, over time they don’t necessarily age well. So it’s a very insightful decision by your surgeon, 22 years ago.
Trish: Thank goodness, yeah. Don’t ever do what I want, do what’s the right thing. Well thank you, so much for your time today. We really, really appreciate it.
Dr Jayson Oates: Your welcome. Good talking to you again Trish.
Trish: Everyone out there, if you are looking for a consult with Dr Oates, you can just, either come through our website and find him online or you can email firstname.lastname@example.org or you can actually just go onto his website which is academyfacebody.com.au which is a fantastic website I might point out. Thanks Dr Oates.
Dr Jayson Oates: Thanks Trish. Talk to you …
Trish: Have a good day.
Dr Jayson Oates: Bye.