Episode 11: Sunday August 30

Drs. Salvatore Pacella, Sam Jejurikar, and Sam Rhee go through a tummy tuck case and discuss what to consider before, during and after your procedure.

They also talk about what is important to consider in choosing your plastic surgeon in order the optimize your results. Do not miss!

Full Transcript (download the PDF) 

S01E11 - 3 Plastic Surgeons & a Microphone - Tummy Tuck
Dr. Salvatore Pacella: [00:00:00] Good morning, everybody. We are back for our, our next show here. I'm sitting here, somewhat live with Dr. Sam Jejurikar from Dallas, Texas, whose Instagram handle is @samjejurikar. I'm also sitting with Dr. Sam Rhee of Paramus, New Jersey, whose Instagram handle is @bergencosmetic. And then of course, myself, I'm Dr. Pacella, of La Jolla and San Diego, California, and I'm @sandiegoplasticsurgeon. Welcome gentlemen, how you doing? 
Dr. Sam Jejurikar: [00:00:31] Doing wonderful, Dr. Pacella, how are you this morning? 
Dr. Salvatore Pacella: [00:00:33] Very good. Good, good. We're fresh off the heels of our last episode talking about that 10 most. infamous plastic surgeons, but, we're going to shift gears here.
I think we need a little breather from that. So, so today we're going to be talking about a, a, a wonderful topic about abdominal plasty, which is an exceptionally common operation we perform as plastic surgeons. Before we get into that and get started, This show is not a substitute for professional medical advice, diagnosis or treatment.
This show is for informational purposes, only treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or qualified health provider with any questions that you may have regarding medical care, never disregard professional medical advice, or delay seeking advice because of something you've seen in the show.
Dr. Sam Jejurikar: [00:01:27] Well, with that, let's transition to talking about tummy tucks and I think this is going to be an interesting contrast to those of you who watched her last episode, last episode, was racy, and about stereotypes, essentially in plastic surgery, presenting patients as being on uneasonable. vain, but tummy tucks are, and I think you guys would agree with us far and away one of the most common operations performed in the U S and in my practice, I'm sure you guys would agree as well. And the patients that we see fall into basically one or two categories, women that have had children and whose body has changed and they can't get it back. No, no matter how much they exercise.
And then people that have lost massive amounts of weight, these tend to be all people. Or are generally people with very high .... .very high in realistic expectations. both of which you can meet. Do you guys have any comments before we jump into the meat of this and just sort of your thoughts about tummy tucks and the patients?
Dr. Sam Rhee: [00:02:18] I'm glad to be covering this because I do feel like it's a patient population that is extremely satisfied and, and, it makes a dramatic difference. 
Dr. Salvatore Pacella: [00:02:27] Yeah. Yeah, it's a, it's a fantastic operation. I'm sure you'll agree that, you know, in New Jersey and then Dallas and in San Diego, you know, moms can be, can be very fixed.
They can stay active, they can keep their muscle tone, but unfortunately once the ravages of pregnancy have taken over, it's near impossible to, to fix that with just simply diet and exercise. And that's where we truly can, I think, give a tremendous amount to our patients. So it is, it is just a fantastic operation.
Dr. Sam Jejurikar: [00:02:58] Well, with that, let's transition to a case presentation. Can you guys see the screen? Okay. Here. Yes. Perfect. Right. So, this is should 
Dr. Sam Rhee: [00:03:07] flip to present mode though. 
Dr. Sam Jejurikar: [00:03:10] Thank you. Slideshow. Slideshow. Yeah. 
Dr. Salvatore Pacella: [00:03:12] Yeah. There you go. 
Dr. Sam Jejurikar: [00:03:14] Thank you, gentlemen. So, this is a patient that I saw in my practice a couple of years ago.
A very typical patient. I think when you look at this patient, she looks like someone who has had two children. And in fact, she was, someone who is in a good level of physical fitness, but felt as though her body doesn't really match the level of health that she has. More than anything. It was her goal just to try to get back to the look that she had prior to having kids. How would you guys typically evaluate and talk to this sort of patient about what she needs when she walks into your office? It's your office? Let's start with Sam Rhee, about how, what your approach would be in Paramus. 
Dr. Sam Rhee: [00:03:51] Thanks Sam.
So in, in, New Jersey, we see a lot of moms. We see a lot of relatively fit moms and they're, They're they present exactly the way you, you mentioned they, you know, they don't feel that their appearance matches is what their effort or that their, attempts at being fit, embody. And you know, when I talk to patients about body contouring, I really try to break it down very simply for them.
I think about, are we addressing primarily fat or are we dressing primarily skin excess? And if there's a lot of skin excess in a patient, something simple, like liposuction generally is not going to be a great choice. And so I try to break it down initially with patients on that first consultation about what might be the most appropriate, approach for them, in terms of what might be most helpful.
So, 
Dr. Salvatore Pacella: [00:04:41] yep. So, you know, I think one of the things that, I really try to communicate with patients when we're talking about abdominoplasty is, you know, there there's, there seems to be a, a misconception of why a tummy looks like this. After pregnancy and many people think many patients believe that the two muscles on the inside of the abdomen, the rectus abdominis muscles simply separate and create a bulge called the diastasis.
And that happens to some extent. But the other thing that, that that happens is the, the width of the muscle actually stretches out organically. It's not, it's not that you have these two tight bands of muscle and then they just separate their pregnancy. Everything has stretched out over time with pregnancy.
So if you were to look at a post-pregnancy rectus abdominis muscle, it's sometimes over an over twice the size with than it is a preop prepregnancy. So, so what that, what I tell patients is this, this is very similar to a bungee cord, you know, A bungee cord, which is tight right out of the box. It's going to stretch back and forth.
And that's your abdominal wall before kids? after children, unforeseen, actually that bungee cord has stretched out and it doesn't have the plasticity anymore. And it's just simply functions as a rope. There's no less Tenicity. So when you tighten up the muscles in an active formation, You can make your tummy very thin, but the big problem with post-pregnancy Belize is at rest.
You, there's no way to tighten this up without surgery. So, but looking at this patient, I think, you know, Doctor dr. J and in Dallas doing all the plastic surgery, you do this. This is a wonderful, patient who I think would benefit tremendously from a tummy tuck. You can see she's got that laxity of skin down below.
She's got some strata. You could probably take a good chunk of that, of that discolored skin, out. and overall, if you look at the, the waistline, she's got a fairly petite waistline, which is very nice. She's got. a little bit of hip adiposity, which, once that is, is cleaned up with a little bit of liposuction, she's got a really nice figure.
So I think this is going to be a real home 
Dr. Sam Rhee: [00:06:48] run. Yeah. Yeah. This is something that diet and exercise alone is not going to be able to address. You can see where her area focuses and it's, it's her abdomen. And, and just like Sal said, this is a patient who would be an excellent candidate for that procedure.
Dr. Sam Jejurikar: [00:07:05] So how do you guys handle the patient that comes in and says, but dr. Patella, you know, I live in San Diego. I go to the beach all the time. I don't want to have a scar. can't you just see liposuction? 
Dr. Salvatore Pacella: [00:07:18] Yeah, so, so good question. That's a very common question. We get liposuction does very well for patients with fatty tissue in the abdomen or anywhere.
but it doesn't do very well with skin that is very thin. Okay. And the reason is that skin doesn't retract. So if you just, you can clearly see from this photograph, if you look at this skin on the, the love handle area, the lower back, the flank area that is even from far away a distance, you can see that that skin is thicker.
It has good elasticity to it. So liposuction works phenomenally well for. areas of the body where the skin is thick and there's good elasticy and, and part of the thing we do beforehand, and to check this out is, is to simply just do a physical exam and pinch the skin and see what it looks like that skin.
If I were to pinch on the front of the belly, that would, that would just simply hang there. I wouldn't retract back. And that that's where liposuction is not going to do a very good job of. 
Dr. Sam Jejurikar: [00:08:19] Dr. Rhee. 
Dr. Sam Rhee: [00:08:21] Yes. That's why I always open with skin versus fat. We know that liposuction works well with fat. in this case, I would counsel the patient that there's a very high likelihood that there would be skin excess and drooping with just the liposuction procedure alone.
And that's something I talked to many patients that's about. 
Dr. Salvatore Pacella: [00:08:39] Right. So, so, Dr. Rhee, when you're, so in, in Paramus, obviously you're going to have patients that are wearing. bikinis and bathing suits down the shore for most of the summer, Dr. Jejurikar and myself that are in Dallas and San Diego.
You know, they're, they're wearing them a few a longer times of the year, but tell, tell me a little bit about where that scar is. What do you tell patients when it comes to a wearing a bikini bottom or a bathing suit? 
Dr. Sam Rhee: [00:09:05] That is one of the biggest concerns patients always have. Where's the scar going to be located?
And the simplest thing I can say is it's similar in position to a C-section scar, except it extends longer on each side. So depending on how much skin excess there is, it can extend usually to about hip to hip. But it's located in a way such that if you're not going to see your C-section scar, as long as you place that abdominal plasty scar properly.
It should also be camouflaged in, in the same way 
Dr. Salvatore Pacella: [00:09:37] Dr. Jejuikar and, In your practice in Dallas, where, where do you, where do you place that incision for? it let's say somebody has a C-section scar. Where would you place the incision, below the C-section scar? Would you try to take it out or do you do go go right within the scar would 
Dr. Sam Jejurikar: [00:09:55] so, I'll this, this slide here is from an educational program that I use in my office called touch MD.
I'm not sure if you guys use it as well, but it's, I always point out what's wrong with this picture when I show it, show it to the patient. So to take a step back people, that's the question I asked about the scar. it is something that's so many people have an objection to. And what I generally will tell people is.
We can't do a lot about the length of the scar that you need for the procedure, but we can do a lot about the location and we can do a lot about the quality. And so in this picture here, this is sort of drawn. this incision is drawn to fall right below the lower portion of the abdominal wall. But if you think about it with this operation, you were closing the abdominal wall under some degree of tension.
Ultimately it's your skin is loose at the end of the tummy tuck. What was the point of having a tummy tuck? When you have that degree of tension, the scar has a tendency to rise up. 
So the way I will design my scar is I want it to fall very much in a bikini bottom. so I will, when I Mark the patient actually stretch their abdominal wall skin upwards, meaning that the scar is actually going to fall three or four centimeters across the very top of the vulva. It's going to be incredibly low. We're going to err on the side of keeping it low down here. And then as you come across laterally, it's going to go right at the junction of the, of the thigh and the lower portion of the abdominal wall. And by doing that, we can make sure that it really will be hidden in a bathing suit every now and then you'll, you'll run across a patient who's, who has a different style of bathing suit.
Maybe they'll they'll wear a more high waisted ones. So you have to air the scar, upwards, sometimes people like more of a, of a shorts look to their, to their bikini bottom. So you'll go across, but the key is you can really alter the position of a scar to fit into a bathing suit bottom.
Dr. Salvatore Pacella: [00:11:43] That's it? That's a great point. you know, early on when we were residents, you know, we had. say plastic surgeons toward their middle age. And I would remember seeing as mentors and remember seeing the incisions for the tummy talks and they were very high wasted, you know, it's like the sort of 1980s, Pamela Anderson type of bikini that kind of rides up the high area here.
And, you know, it's important for us. I think as cosmetic surgeons in our respective parts of the country to understand, you know, the styles that occur in, in women's. Bathing where, I mean, it's, it's not too bad, not too bad of a process to keep up with that. I think it's, you know, good. But, you know, the, the, the bikini bottoms will drift up and down over a span of six or seven years, believe it or not.
And so, it goes up, it goes down and the boy shorts have a lower, A lower thickness, a lower riding on the hipbone. So it's important for us to keep in mind, you know, as styles change exactly where we're keeping, keeping that scar. And I think, you know, what, what I try to do is I, I try to have patients bring in a bikini bottom, or a pair of undies that they would usually wear.
We'll try to stick that incision right within that. But I always err on the side of, of trying to keep it right within the crease of the, of the hip. 
Dr. Sam Jejurikar: [00:13:03] Yeah. Now talk to me about. quality of scars. What kind of things do you guys do with your patients postoperatively and over what period of time do you tell them?
They have to manage their scars after surgery. 
Dr. Sam Rhee: [00:13:16] So I'll start with a scar you're right. Scar management is one of the most important things, obviously for abdominoplasty is the most visible heart of the procedure. I managed scars are very, very long time and patients, I, have a fair number of patients who have darker complexions who, tend to have, potentially darker scars. And so I am a big proponent of a silicone gel sheeting. I am also pretty proactive when it comes to, treating scars with either topical, cortisone or injectable cortisone, like a Kenalog type of a solution. If I need to.
I think prevention in terms of managing scars is the most important thing. 
Dr. Sam Jejurikar: [00:14:00] Yeah. Dr. Pacella, any different strategies you take in the, a very sunny San Diego? 
Dr. Salvatore Pacella: [00:14:06] Yeah. So, so you know, these, these scars are challenged and I, I got to admit that my, my evolution of scar management has changed throughout, you know, my 12 years of practice.
And part of that is actually what's done in the operating room. So, this is a little bit of a technical issue, but, yeah, early on in residency, we were taught to close these areas of the, so there's really three layers we have to close. We have to close the. The deeper fascia called Scarpa's fascia events, the scar from stretching over time.
Then we have to close something called the deep dermis, which is the deeper layer of just skin. And then there's the top layer skin called the epidermis. Okay. And usually that's done in three layers. And so, you know, in residency, you both probably remember. We would do a lot of interrupted sutures with, with the type of suture called , which is a braided suture.
And  I started doing that at practice. I noticed. That, you know, that causes a lot of inflammation, braided sutures, cause it's a tremendous amount of inflammation that can sometimes out to the outside world. And that just creates a really bad scar. So I've really tried to minimize the total amount of interrupted sutures that I use.
And so I'll just put. Well, a strategic couple interrupted sutures in Scarpa's fascia just to hold position, but then also do a locking running suture from side to side and that, and that's with a monofilament suture. And what that does is at least in my practice, I think it cuts down on the total amount of inflammation.
It still is a tight repair of Scarpa's fascia and, but it gets, gets rid of those knots that may spit over time. I try to do something very similar to a. To the deep dermis and the epidermis to avoid knots ex internally. So, and I think that's helped a thousand percent in the appearance of my scars.
Dr. Sam Jejurikar: [00:15:59] I agree completely with that. I, I do something very similar instead of using a monofilament. This is very technical. I use, a braided suture that's meant that that's avoided not to.... I'm sorry, yeah. a barbed suture that's avoided that's meant to avoid having any knots in it whatsoever. But I agree that is, that is an excellent technical point, but I think it goes to a bigger picture.
You know, it's really important for your surgeon to pay attention, to closing all three of those layers. Believe it or not. Going back to our training. There was actually debate within the plastic surgery community about whether or not you needed to close that deepest layer. Scarpa's fascia, many surgeons thought it was unnecessary for closure, but I think almost all plastic surgeons would agree.
So I do know some that do not, that you don't close Scarpa's fascia. You can, You get the same quality of closure. And I think all of us here would say that if you don't close that deep layer of the scar will widen over time. So the bottom line is as a patient. It's a great idea to have this conversation with your surgeon.
What steps are you going to take to make sure my scar doesn't doesn't separate. So I'll talk about these things with my patients. And then I also tell them. Particularly in my patients with pigmentation. you need to think about managing your scar for six to 12 months after surgery. You know, most people want to think about their surgery, and then sort of be done with it.
And you know, within a few weeks I should move on, but where the scar is concerned, you have to be obsessive about it. So for, we have a regimen in our practice where we'll use just like Dr. Rhee mentioned, he does a New Jersey where we'll, we'll use silicone based treatment for up to six months afterwards.
If there's any signs of there being any darkness, we'll think about adding bleaching creams, adding broadband light therapies. If there's. redness, we'll add pulse dye lasers, or fractionated CO2 lasers, but the key is to be proactive all along and with that in the vast majority of patients, you can actually get a great result with their scars.
Any, any other technical points you guys want to touch upon before we sort of move on 
Dr. Sam Rhee: [00:17:52] No, I love the barbed sutures. 
Dr. Salvatore Pacella: [00:17:54] Yeah. tell me a little bit about, your thoughts on progressive tension, suture and drains. 
Dr. Sam Jejurikar: [00:18:00] So, so, so the, the, and, or plastic surgeons that really popularize that are the Pollacks who are in Dallas.
And I know Tom Pollack fairly well. I'm a believer in progressive tension seizures and for the people that are out there, what they are, or their sutures that actually go from the undersurface of the skin, to the muscle layers right here. And the purpose is, is that you can actually close off the dead space entirely and avoid potentially using drains.
I personally still like using drains, although I do progressive tension sutures and virtually all of my patients progress is attention sutures, do that and do add 15 to 20 minutes to my case. But I do find that drain out, but tends to be substantially lower. and I don't have to keep drains in for very long.
I personally think though, that using drains in patients after surgery helps their swelling get better, faster. One of the things. Yeah. And one of the things dr. Patella touched upon. when he was talking about muscle, is that you get generalized stretching of the muscle. Well, the same is true with the skin.
And if you think about it, one of the reasons we need to have this surgery and have this procedure perform is because patients have lost the elasticity of their skin. So my goal is to get their swelling, to go down as quickly as possible after surgery. I think drains are helpful for that. I think lymphatic massage has helped her for that as well.
So I use both of those in my practice to try and get the skin to retrain as quickly as possible after surgery. 
Dr. Salvatore Pacella: [00:19:21] Yup. Go ahead. 
Dr. Sam Rhee: [00:19:23] I do use progressive tension sutures, I think they are helpful. I also think they help to a certain degree with the, scar wide widening as well. You can take some tension off the closure a little bit with that.
I also still use drains even with that. I just, I'm a belt and suspenders kind of guy, I guess, what that sort of thing, 
Dr. Salvatore Pacella: [00:19:40] you know, one other technical point about progressive tension sutures that, you know, I like, is, you know, if you, if you look at a, you know, really good looking female abdomen, it, it's not flat.
Okay. There is, there's a little bit of a, just a gentle pooch as you get down lower. Okay. And that that's a sign of a really beautiful midsection. The other sign is a, is sort of a, a, A reinforcement of the natural abdominal musculature. So what I tend to do is above the belly button all the way to the, to the, so the notch of the sternum, and then down to the pubis, I try to do a little bit of aggressive liposuction in the flap at the midline.
And what that does is it, it sucks out a little bit of fat up and down and creates this little bit of a gully. Okay. One of the. Surgeons. I used to work with Dr. Grant Stevens used to call this a champagne line. Alright. And, yeah, exactly. And so creating that little notch, I think works really nice because it, and, and your progressive tension sutures are done just underneath there.
And that causes a little bit of indentation in the central line. And that creates that nice contour to the abdomen. I think, I think that's an important technique to get some appearance. 
Dr. Sam Jejurikar: [00:21:02] Yeah, totally agree. So, so just touching upon, you know, we talked about a lot of technical points, but for those viewers who just don't understand how the operation works very quickly, going through this diagram right here.
Imagine that on the top left, you have a prepregnancy look, your surgeon will essentially design an incision. That's going to allow them to get access to the abdominal wall. They'll also have to make an incision around the belly button. And the reason for that is the belly button is a closed stock.
That's actually attached to your abdominal wall. Once you make this incision, your surgeon can lift all the skin up. See these rectus abdominis muscles that have separated. Put sutures back into it to actually bring the abdominal wall back together and to restore integrity. And then there's this maneuver, you know, near the end of the case where the surgeon will actually flex you on the operating table to basically make your skin as loose as possible and with your skin and being loose, they'll remove all of the excess, including the opening where the belly button had been, and then actually create a new opening for the belly button.
Bring out the belly button sewed into place and then do a meticulous closure at the end. And that's, what's involved with the tummy talk. before I show the post-ops, is there any other steps of the operation or anything else that either you Dr. Pacella in San Diego or you Dr. Rhee, New Jersey want to add?
Dr. Sam Rhee: [00:22:18] I think belly buttons are a big concern for patients. The appearance of that. And I think there are a lot of variety of ways of create, you know, bringing that umbilical stalk   up and creating that new, hole for it. So I'm always interested in hearing tips and tricks about that. 
Dr. Sam Jejurikar: [00:22:36] Belly buttons. Correct me if you guys feel differently there as times the bane of my existence, because you think about it, you know, what is the belly button?
The belly button is this it's the remnant of the umbilical stock, but it's a bunch of scar. That's basically formed this indentation with a relatively poor blood supply and a plastic surgery. You heal your plastic surgeon talking about blood supply all the time. That's how you heal things. You cut all the way around it.
So you eliminate, you eliminate the blood supply coming from around it and then, yeah, to tighten the muscles aggressively across the bottom of it. So you constrict some of the blood flow going to it. So I generally find that in the first six weeks, I have a lot of conversations about belly buttons and how great they don't look in that time.
I generally find that they can be a little too small in the beginning. So we'll use maneuvers like a foam earplug to try to open it up. I don't, I err on the side of making it too small, cause it's a lot easier to make a belly button bigger later on than it is to shrink it down in size. But I'll use all absorbable sutures.
I'll tack down the belly button if at three o'clock, six o'clock, nine o'clock and 12, 12 o'clock position with sutures that go from the skin all the way down to the muscle to really give an, any look to my patients. 
Dr. Salvatore Pacella: [00:23:49] Yeah. You know, it's interesting for our viewers out there and listeners, You know, this is, I think the sign of, of really good plastic surgeon is what.
You know, these two gentlemen that I'm with today are sort of echoing, which is, you know, we're, we're, we're taught in residency program a certain, you know, step of the operation, one, two, three, four, but you know what, we're not really taught and we can't possibly understand is that. Is is the fourth dimension of things.
Time, how things heal. Okay. You only get that through experience. And, and I will say that like these two gents I'm constantly reevaluating the things I do to try to make them better. And there are things we notice about the human body that. That we don't necessarily pick up on early in our training that, you know, Oh, wow.
The abdomen always falls in a certain way when I do this. Right. And so that's, that's just keeping in mind exactly what you're doing. And belly buttons are exactly like that. So early on. You know, the cookie cutter operation for belly button was you just cut a simple round or oval hole and stick it in.
But to me that doesn't really look like a belly button. Right. And I think they understanding of that is you have to understand how scars heal, particularly circular scars. If I have a scar that I make, if I have a scar, that's this log. Okay. And I'd come back six months later, that scar is going to be shorter.
So if I convert that line into a circle like this, What's going to happen in six months is that scar is gonna shrink down. And that creates a very tight and very constricted belt the button. But if you look at a good looking guy, belly button, where is it? Tight and constricted, it's tightened constricted over the upper pole.
The bottom portion is really nice and smooth. So when I do a closure for a belly button, I actually make the top very rounded, sharp. And then the bottom I convert into a little zigzag or a little Chevron with the idea of that'll break up the scar down below. It'll create a nice contour, a nice flow. We have a little bit of excess tissue on the bottom, and I want a nice slope to that.
I want it to be a little bit hooded and tight at the top of the, of the belly button. That's just something I picked up with time. And I think it just, just evaluating your technique and trying to improve this over time just 
Dr. Sam Rhee: [00:26:03] helps, you know, Listening to you. I really enjoy these talks for one thing is that we all have done these procedures many times and we're all.
We all get good results, but what separates good results from next level results are all the little things I hear from you guys. So when Sam in Dallas is talking about doing the sutures at the different o'clock positions or sales, talking about shading, the, abdominal contour to get a more natural, you know, flow to it.
Those are the next level things that. I love hearing about, because that is what makes a good operation into an amazing operation. 
Dr. Sam Jejurikar: [00:26:46] Well, thank you, dr. Ray. well, let's go ahead and look at this patient's post stop results. This is actually a very early postoperative result and I'm actually intentionally showing an early postoperative result just so patients can get an idea of what we talk about when we say patients have swelling.
So this is a patient that's actually, on the left, you're looking at preop and on the right, you're looking at posts up about six weeks out from surgery. And what do you see? Well, you basically see that there's still some swelling across the lower abdomen. there's swelling across the upper abdomen as well.
I use procrastinate tension sutures, not only were Dr. Pacella was talking in the midline here, but also across the side to try to create some oblique definition as well. you get an idea of what the belly button looks like early on. It's sort of a narrow slit and you see how we hide the scar for hiding the scar super low.
So it's going to be hidden in the pubic region coming across the junction of the upper thigh and the lower abdomen. And the next view, I actually am trying to demonstrate what we were talking yeah. About, about the bikini line. We really want to be able to hide that scar and camouflage that scar so that you can actually see patients, being able to go to the beach, being able to go to the pool and not show the sequella of having had a tummy tuck.
and then when you look at alternate views, This is what we're talking about in terms of, you know, I'll tell my patients, you can expect to have swellings for six months, to, you know, it's a nine months after surgery. and this is what we're talking about. Even six weeks after surgery, you can see, she has a little bit of a pooch here, but she looks amazing, right?
I mean, the change between pre and post op is remarkable, but there's still some degree of swelling. 
Dr. Salvatore Pacella: [00:28:17] Right. And I think, you know, the thing I, I really like about this result here is you, you didn't just concentrate on the front of the abdomen. And I, I will bet that this patient came to see you and chatted with you about her tummy and probably mentioned very little about her lower back area, the fat rolls around her lower back.
And, and I, I imagine, you know, look just looking at this result here, you did some liposuction on the lower back here. And so what you did really well is. Is keep in mind that this is a 360 degree rejuvenation. You know, she's only going to see the front of her, of herself looking straight on in a mirror, but you know, you're gonna, you're gonna have to turn to the side to look at the back and just getting that whole hour glass shape, I think is really, really important.
So those two operations, liposuction, abdominoplasty go, or a yin and yang, 
Dr. Sam Jejurikar: [00:29:07] you know, that's a very good point. Pretty much every patient it's it's interesting patients will ask me. Okay. You know, is it extra to get liposuction done at the time of my tummy talk and I'll tell them all liposuction is part of it.
How many talk? I don't separate out liposuction at all, but about one or 2% of my patients who legitimately have no fat, but lipid fixity of the back, the flanks, the tummy is a huge part of doing it. Tommy talk. 
Dr. Sam Rhee: [00:29:32] Yeah. And patients don't often realize it, but they will, after the procedure, trust me. That's, that's very important.
Dr. Salvatore Pacella: [00:29:38] You got to get rid of the muffin top. 
Dr. Sam Rhee: [00:29:39] That love handle area. Absolutely. Yeah. 
Dr. Sam Jejurikar: [00:29:42] And if you go back to this diagram too, part of the, you know, part of the thing that hopefully you can realize is as you come out to the side here, You're not getting out as much skin as you are centrally here. So you really need to do that aggressive liposuction on the back and the flanks for the reasons dr.
Patel on San Diego mentioned, skin is tighter. You can remove fat there and expect the skin to tighten down where essentially you have to excise as greater amount. But if you leave out the light, we have a section along the flanks in the back. You're not going to get that whole, recontouring of the entire silhouette.
So, 
Dr. Salvatore Pacella: [00:30:15] great result. Thank you. 
Dr. Sam Jejurikar: [00:30:17] Thank you, gentlemen. so, let's see if we can stop sharing. We're good. Good. Perfect. So, that gets us right along our 30 minutes that we're trying to stick to. Is there any last thoughts that you guys have about tummy tuck or anything you want patients to come away with after, after today's show?
Dr. Sam Rhee: [00:30:35] I thought that was an awesome result. That was, it sort of showed and highlighted the, the things that are so important in order to get a great result, which is placement of the incision, contouring thinking of these things. And this is why you need a surgeon work regardless of where you are in the country be at West coast, you know, Texas East coast that does, that anticipates these things for you because a lot of these patients will not necessarily necessarily ask or think to inquire about all of these things. And if you have an experienced surgeon, like Sam they're, they're going to tell you exactly what they, you, you will, I need in order to get something like that, this is what they envision.
But a lot of patients don't actually know enough to be able to ask. For it, if, if, if you only provide what they want, not what they want, what they ask for, but not exactly encompass the entire, concept of what an abdominoplasty really means. You'll only get a half measure. 
Dr. Sam Jejurikar: [00:31:34] Yeah. Dr. Pacella any, any last words?
Dr. Salvatore Pacella: [00:31:38] No, I think it's great. I think, you know, tummy tucks in general, I think are, our patients are one of our, probably the population that's the most satisfied with their choice of cosmetic surgery. It's just a phenomenal operation that does amazing things. And patients are, are very, very happy with them.
Yeah, just to echo what these gentlemen say. Tell me talks are one of the most common popular, one of the most common operations that we do, but, you know, Dr. Rhee in New Jersey, Dr. Pacella in San Diego, no, the little variations that we need to get top-notch results. So with that, we'll call our show to an end and looking forward to seeing everybody next week.
Dr. Sam Rhee: [00:32:15] Great. Thanks again. All right. Take care. Okay