Episode 13: Sunday September 13

Dr. Salvatore Pacella, Sam Jejurikar, and Sam Rhee talk addressing a "double whammy" - breasts that become flat and sag. The three plastic surgeons go through an augmentation mastopexy (also known as breast lift plus breast implant) case to increase breast firmness and volume. For many of the moms out there considering breast improvement, you need to watch this episode. Do not miss!

Full transcript (download the PDF)

S01E13  - 3 Plastic Surgeons and a Microphone  - Augmentation Mastopexy FINAL
Dr. Salvatore Pacella: [00:00:00] Welcome everyone. How are you today? We're ready for our next podcast, which is show 13, all about breast lift and augmentation. I'm dr. Sal Pacella from, LA Jolla and San Diego. I have my Instagram handle is. @SanDiegoplastic surgeon, I'm joined by two, incredibly talented surgeons. Dr. Sam Jejurikar from Dallas, Texas.
His Instagram handle is @SamJejurikar and Dr. Sam Rhee from Paramus New Jersey whose Instagram handle is, @Bergen osmetic. East coast, East coast. And then in Sameer you do dude, South South. Oh,  
Dr. Sam Jejurikar: [00:00:40] that's a thing. Okay. Yeah. 
Dr. Salvatore Pacella: [00:00:41] Okay. Yeah, the kids are doing it. You gotta, you gotta get with the program, homie. I'm Mark.
Dr. Sam Jejurikar: [00:00:47] I always learned from you thank you. 
Dr. Salvatore Pacella: [00:00:51] All right. Well, so 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 other qualified health provider with any questions you may have regarding medical care, never disregard professional medical advice, or delay seeking medical advice because of something in this show. Well, gentlemen, I'm going to hand it over now to, to dr.
Jura car from Dallas, Texas. And we're going to talk about, breast lift and augmentation. Everything is bigger in Texas. Is it not? 
Dr. Sam Jejurikar: [00:01:28] Not always. And that's what we're going to talk about. Yeah. Today. so, you know, just, as a, as an intro, I think the term mommy makeover is one that we all hear and patients hear all the time and it's sort of a grab bag term.
You know, when you have, when you guys, when you have children, it's them. Best thing that ever happened to your life, but probably the worst thing that ever happened to a woman's body. And so, breast augmentation with lift is probably one of them, the five most common operations in my practice. Gentlemen, do you guys have the same experience with this?
Like it's just something that you see every day, you know, women coming in after children looking for more, you know, for these sorts of procedures, 
Dr. Salvatore Pacella: [00:02:08] Absolutely. you know, we have a little saying in our practice, children, they fulfill all our dreams, but ruin our bodies, you know, it's, that's true.
Dr. Sam Jejurikar: [00:02:17] I actually disagree with the first part
Dr. Salvatore Pacella: [00:02:23] and, you know, I, I think, you know, what I see here in San Diego and Southern California is, there's a tremendous amount of destruction to the breast after breastfeeding. And there's a whole new layer of this, which is patients who have had previous breast augmentations. You know, a good population of Southern California has breast implants and unfortunately the breast, the breast implant.
Well, fortunately the breast implant stays usually in position, but the entire breast are around it after pregnancy and breastfeeding doesn't doesn't play by those same rules. So that that's, that's a common issue. I see in my practice, 
Dr. Sam Rhee: [00:02:57] I would say as part of mommy makeovers that's one of the biggest parts is rejuvenation of the breast, the breast shape, breast volume. That's a big one. 
Dr. Sam Jejurikar: [00:03:07] And, and you know, Dr. Pacella, I'm glad you brought up that experience. You're having in San Diego with secondary breast surgery. It just gave me an idea for a topic for another show, because that's something we see all the time in Dallas. It's not the case. We'll show it today, but it is a very common thing we'll see in Dallas as well as San Diego. And I'm sure in Paramus too, you see that 
Dr. Salvatore Pacella: [00:03:26] right. And you know, it's and, and there's a. There's a regional and time aspect to this too. I tend to see a lot of this kind of around the late part of winter or the early spring. you know, you're. patients are getting ready to go to the beach for, for the summer.
You know, they're hitting the Jersey shore and, all over the East coast and heading down to Florida or the Gulf coast, you know, for the summer. And this is, this is something that I really see uptick around February, 
Dr. Sam Jejurikar: [00:03:55] March. And so one of the things I want to ask you, a theme that we have had in previous shows for anyone that's listened to our podcasts before, as we always talk about.
Our Michigan training and how, you know, we felt so prepared to handle a lot of, a lot of cases that come our way, whether it's rhinoplasty, you know, complex reconstructive cases. Dr. Rhee, when did you learn how to do a breast augmentation with lifts? When did you do your first breast aug pexy? 
Dr. Sam Rhee: [00:04:22] Not as much, not at Michigan.
I will say, you know, one of the. I don't know if you remember, but I think I asked you while you were doing your aesthetic fellowship at MEETH, I was picking your brains while you were doing it. And I was asking you what your experience was there, because that was just not something we did very frequently in Ann Arbor 

Dr. Salvatore Pacella: [00:04:44] I agree. I, I really, this isn't the operation after our training in Michigan, that I, I felt like I needed it quite a bit more experience in it quite a bit more strategy on how to make a good operation. And, I did too cosmic, like fellowships one in Marina Del Rey with dr. Grant Stevens, and the other with Dr. Nahai and Dr. Codner in, in Atlanta. And I would say that my education in breast lift and augmentation really. You know, took off with those two fellowships. I, I felt like I had a good eye, a good set of skills. a good toolkit for this operation, which quite honestly is still evolving today. I think, you know, this is, this is an area of plastic surgery where every single patient is different, that the tissue components are different.  The structure of the breast is exceptionally different in everybody and, and we need a different set of tools for every 
Dr. Sam Jejurikar: [00:05:37] patient. And with that, I think, cause there are a lot of things to discuss. Let's go to the picture of the patient I want to discuss today. that's okay. Is this in presentation mode when you look at this 
Dr. Salvatore Pacella: [00:05:48] Slides?
Yeah. There you go. 
Dr. Sam Jejurikar: [00:05:50] Perfect. Okay. Well, and this there's a lady who I just saw in my office. she's three or four months out and the post op results we're going to talk and that's why this case came to mind. But yeah. She's had children. She breastfed her children. subsequent to that time, after having gone through multiple pregnancies, she's now lost a lot of weight.
She wants her breasts fuller. She wants her breasts rounder. She wants more volume. How are you going to describe what you're going to do to this patient? And what do you see here? dr. Buccella tell us how you'd handle this in San Diego. 
Dr. Salvatore Pacella: [00:06:22] Well, so, you know, when I, when I look at a patient like this, very similar to our patient population here in San Diego, clearly a very fit woman, a very athletic, a very in shape gal.
but the, the breasts are. Are not quite, at the position that the rest of her body is in. Obviously there's, there's a laxity of tissue. There's a laxity of tremendous breast support. And, you know, I think not only a challenge is creating shape. But creating longterm tissue support to this gal. And, you know, quite honestly, this is a, this is an area that I, I struggle with a little bit in cosmetic surgery as to who I'm going to need to put additional tissue support into what I mean by that as.
Inherently when we put an implant in a patient, we expect that implant yeah. To stay where we put it with some degree of a little bit of shifting with gravity and in somebody who has as a breast appearance like this, where there's clearly strata or stretch marks, or the tissue is very thin. We also see this in patients with massive weight loss, there is inherently a lack of architecture to the breast.
And oftentimes if we put a big, heavy, thick implant in that patient, it's going to drop down over time. So to me, when I see a patient like this, a lot of the discussion is on additional, extra tissue support. 
Dr. Sam Jejurikar: [00:07:49] Okay. And, and what, what, what. 
Dr. Salvatore Pacella: [00:07:52] What do I use for that? Yeah. Yeah. What do you use for that? 
Dr. Sam Jejurikar: [00:07:55] Do you, how do you make that determination based off of the implant size that you're going to have?
If you're putting it on. Small implant, or are you going to use internal scaffolding? Are you going to do it with only a big implant? How do you do that? 
Dr. Salvatore Pacella: [00:08:04] Yeah, so, so good question. So I think, you know, with, in patients that want a larger appearance and many times, you know, I would say on average patients like this, that come into my office and, San Diego, Probably want on average, a more athletic appearance, you know, probably a small C cup and, you know, perhaps an implant and the 275 to 350 range.
That's somebody that I probably would not suggest tissue support in somebody who wants to be much larger in the, in a small, large, C or a small D range where I'm probably in the four 50 to 500 range. That's somebody who I'm going to. Probably suggest using additional tissue support now, with regard to the products that are out there.
I think a big workhorse that I use is something called Strattice, Strattice, essentially pigskin. That's the same material that we use in, in heart valves, prosthetic heart valves. And it's a big sheet of a device that you get out of a, off the shelf and. What that is used for is to create an internal bra or an internal scaffold to help support the breast longterm.
There are certainly other products on the market made of, some synthetic materials. you know, there's a list of products all throughout, you know, on the shelf you could use for that. 
Dr. Sam Jejurikar: [00:09:18] Okay. And Dr. Rhee, what are your thoughts on what Dr. Pacella said and what, what would you tell this patient? 
Dr. Sam Rhee: [00:09:25] I'm sure you'll talk more about the specific techniques and what you do.
So I'll, I'll let that, go for when you, w what comes up next. But what I would want to say about this particular patient is what you said before. She's thin she looks fit. this is a patient where she probably comes in and says, I don't like my saggy breasts. And this is one of those situations, like you said before, when you have pregnancy, when you have children, you can't out eat or out, exercise yourself into a better shape for your breasts in this situation.
There's nothing she can do physically on her own. That's going to make that better appearing for her. That's why this is a very gratifying procedure. Now the issue really is, is I will have some patients say. okay. I just want to be bigger. So if you just put some implants in, then would that be enough?
And once you start talking about lifts, you're basically talking about putting incisions on the breast. And that is sometimes a challenge to talk to patients about depending on what their expectations are. So the first thing is always talking about incisions, and then the second thing is volume. What, what size or goal they would want to be?
And those are the first two things I generally see. approach with patients with this. 
Dr. Sam Jejurikar: [00:10:40] So, Dr. Paccella let's say your patient in San Diego says I don't want any scars on my breast. I just want you to put a really large implant in there. Will you do it? 
Dr. Salvatore Pacella: [00:10:53] I would send her to Dallas.
Dr. Sam Rhee: [00:11:04] thank God. You're not sending her out to the East coast. That's all I can say. 
Dr. Salvatore Pacella: [00:11:07] Yeah. I, I would say, you know, I, coming from, you know, growing up in the Northeast and training in the Midwest and in the South, you know, my, I have a very conservative aesthetic and, you know, I. Yeah, a big, massive 700 CC implant in this, in this patient.
It's going to look terrible. And more importantly, I have to, I'm going to explain to the patient what I'm going to be setting. If we did that, what I will be setting her up for longterm in life. If I did that without putting any sort of lift or any tissue support, it did a 700 CC implant. You see this belly button right here.
It's probably about a year and a half before those implants are sitting right down here on top of the belly button. And so I, I would do my best to convince her that, you know, this is you can't, you can't choose sometimes as a patient. You can't just pick and choose the operation. That's best for you. 
Dr. Sam Jejurikar: [00:12:02] You gotta 
Dr. Salvatore Pacella: [00:12:03] do it with the surgeon's counsel.
Dr. Sam Jejurikar: [00:12:06] That's right. And you know, and it goes back to the very basic lessons in physics. there's an unyielding force on the breast, which is gravity. And the heavier weight that is, that, or that that's, that's in the breast and more things are gonna stretch out over time. And so you're, you're exactly right.
You know, what I'll say is I totally agree with everything you gentlemen have said. When I, when I look at a patient like this, I'm kind of thinking about three things. I'm thinking about the support, just like dr. Chella talk talked about. I don't, I use a different product. I use more of a synthetic off the shelf product than Dr. Pacella does, but, Same general principle. It's a nice for creating an internal broth to help prevent an implant from dropping. I think about the volume and that leads to a conversation with the patient about what size they want to be in this particular case. This patient wanted to have fullness and roundness, but nothing over the top.
and then. The most important thing, which is why this is different than a traditional Russ augmentation for the purposes of what we're talking about is how much droopiness they have. you know, patients oftentimes recognize that the rest of change, but they don't necessarily understand that, that, it's not just the fact that they've lost volume and their breasts are smaller that their entire soft tissue envelope has stretched out.
And if you think about it, This happens during pregnancy when the breast tissue grows in size and swells in the skin, stretches with it. Once pregnancy is over and breastfeeding is over and the breast issue in balloon it's the skin doesn't go back in the skin I was hanging. And so this generally represents the skin on below.
For the breast tissue that somebody had during pregnancy or breastfeeding, what have you, and relative to the, the bottom portion of the breast determines the amount of droopiness somebody has and the way I generally think about it and tell me if you guys disagree. The more significant. The droopiness is a grade three being the worst right here.
The more significant the droopiness is, the more you gotta do to the breast to make it better. And in general, the more unstable it is when you're putting in an implant. So if somebody has substantial sagging and they want a really big implants, I really try to talk them out of it. Even if I'm adding support, if I'm unsuccessful, I let them know that the chances for needing a revision are pretty high.
If they have reasonably small amount of droopiness and a reasonably small implant, my level of confidence and longevity results goes way up. Do you guys have that same general thought process? 
Dr. Salvatore Pacella: [00:14:21] Yeah, I agree. And you know, The use of tissue support is a relatively recent phenomenon. I would say in the last 15 to 20 years in plastic surgery years ago, you know, the surgeons from the previous generation didn't have the luxury that we have today of, of utilizing this, these sort of synthetic or biologic tissue supports.
And oftentimes what I've, what I've seen in patients who have surgery back in the previous generation is we would re rely upon the skin. To support a heavy implant. And I, and I think that's an error. The more we understand about how tissue support, and, and gravity takes over, you can't use the parenchyma or the tissue of the breast or the skin to support a big, heavy implant.
Dr. Sam Rhee: [00:15:07] You know, we have two competing forces here. We're trying to tighten and minimize the breast on envelope. And then we're also putting in an implant, which is. Increasing that volume within that breast envelope. And someone once said, I don't, I don't know if it was in Michigan or somewhere else. We're basically taking. you know, 10 pounds of potatoes and putting it into a five pound sack, cause we've just reduced the size of the sack and we're just increasing the number of potatoes that we're sticking in. So this is where experience comes into play, where, you know, you know, what you can do in terms of how much lift you can do as Sam in Texas said, it's a challenge when it gets very, very saggy.
And then you're also trying to figure out. How, what size implant you can put in safely in addition to getting that tissue I dove in and 
Dr. Salvatore Pacella: [00:15:58] revisit. Yeah, that's funny. I re I remember that potato analogy slightly different, and I believe it was one of our co-residents was presenting something at a conference and they described this particular resident as.
10 pounds of BS in a five pound bag.
Dr. Sam Jejurikar: [00:16:18] I have no recollection of this, but when we're off the podcast, I'll need to know more clearly. 
Dr. Sam Rhee: [00:16:23] I was thinking the same thing, 
Dr. Sam Jejurikar: [00:16:25] you know, I'm agree with again, everything you guys say. I think we're our thinking is very much aligned when it comes to internal support, which I use a lot, in my patients. I still want to make people realize that even though we're building an internal bra.
It is not infallible. I think an internal bra is very good for helping to prevent the implant from dropping, but it doesn't add additional support to the skin. And so there's a different type of postoperative sagging. We call a waterfall deformity where essentially the implant can stay in place, but the tissue can still sag around it after one of these cases.
And so even if you have scaffolding, it doesn't give you carte blanche. You just pick any implant size you want and expect there not to be a complication. Great. 
Dr. Salvatore Pacella: [00:17:07] Jersey, Sam, round Northern New Jersey Manhattan, New York. obviously, you know, CrossFit is a big issue, right? CrossFit is a big pastime 
Dr. Sam Rhee: [00:17:18] for me. Yes. 
Dr. Salvatore Pacella: [00:17:18] Yeah. And, You know, you have a lot of athletic patients in that region. What, what, what Dr. Sam in Dallas was alluding to here is, you know, you don't have carte blanche over things. So tell me about your strategy with athletic patients and the position of the implant below the muscle, above the muscle, additional tissue support, et cetera.
Dr. Sam Rhee: [00:17:42] Well, I would actually say that in LA Jolla, you probably have more athletic patients than you have in Manhattan. And in Northern New Jersey, the weather's nicer over there. You guys are surfing and out on the beach all the time. We're, we're at the shore, but only for the summer. And so I would say 
Dr. Salvatore Pacella: [00:17:58] I'm talking about like the, you know, the fitness models, the bodybuilders, the CrossFit have first rule of CrossFit.
Always talk about CrossFit. 
Dr. Sam Rhee: [00:18:10] That is exactly right. 
It's a good thing. This isn't my CrossFit podcast, otherwise. you're right. So when you have a very athletic patient, the, where you place the implant makes a big difference, especially if you're placing it under the muscle, you can get, when they are contracting their pecs, you can have issues associated with that.
Sometimes you have to discuss with the patient, especially, you know, in regards to the volume of the implant, how much breast tissue they have in addition, because if you have a very thin athletic patient, an implant is going to show more than someone who has more existing breast volume. So. You know, placement of the implant, size of implant. , all of those things, are probably even more, important to talk about with the patient when they are very thin or very athletic. 
Dr. Sam Jejurikar: [00:18:59] Yeah. You know, I think on the animation deformity that Dr. Rhee is talking about is a very cool party trick for many people, essentially, where they flex their, they flex their upper body.
They can get their breast and move around. And you know, where you put the implant in front of the muscle or behind the muscle. I in my mind is a, is a big decision making when I'm doing a straight forward breast augmentation for most cases, unless the patient has a large amount of breast tissue. Even if they're very athletic, I'll put it behind the muscle.
If I'm doing a simultaneous lift, because first you're scaffolding, it, it really makes sure, yeah, you need it. You need to have, you need to have the implant behind it, the muscle you, so the bottom edge of that scaffolding to the, to the, essentially to the rib cage and the. The top agile, so to the pack and you can hold the implant in place.
And so, you know, there, there is no perfect solution for everybody and the animation deformity where when they flex their breast will move. It's just one of the things that goes along with it. so gentlemen, I'll go back and remind you of our case. How would you describe the lift? You're going to perform on this patient?
I'll give you two options. What we call a lollipop lift, which is an incision around the areola and a straight line coming down, or a more traditional lift, which is what we call a wise pattern, which is going to be an anchor pattern. Dr. dr. Ray and Paramus. Tell me when you do a lift on this patient, how are you going to do it?
If you're using an implant? 
Dr. Sam Rhee: [00:20:22] I'm going straight to a wise pattern. I mean, that's my preference. maybe I'm more conservative, but I feel, I need a significant amount of resection of the skin and repositioning and that's, that's what I would stick to. 
Dr. Sam Jejurikar: [00:20:37] What about you? Dr. Pacella and LA Jolla. What is your approach?
Dr. Salvatore Pacella: [00:20:41] Well, so I think it, it really depends on the degree of lift here. And, you know, if I'm just simply doing a lift of a couple of centimeters to. Two centimeters max, I'm a minimum tissue resection. I would probably, I do a lollipop, but I think, I think the lollipop is very limited. Can you go back? Can you go to the next slide that shows the yep.
So, you know, my, my, my challenge in my hands here is, is this area right here immediately. And oftentimes we have an implant in, and the tissue is stretching. I do tend to see a bit of bunching in this area, which is not really fantastic. I, I just think I have much more control with a wise pattern. And you know, when patients complain about scars or we, I shouldn't say complain, but when we.
When we sort of talk about scars and I try to talk to them about the scar that goes underneath the breast, to be honest with you, most patients are pretty forgiving of it incision underneath the breast, right. They sorta tell me, well, you know, it's hidden underneath the breast. I don't really see it. It's not too big of an issue.
So I just think that, you know, I prepare patients for the wise pattern and if I could get by with a vertical that's great. But you know, going into the operation, it's usually a, a consent and implied consent for a wise 
Dr. Sam Jejurikar: [00:21:57] pattern. I, I, agree entirely with what dr. Patella said and dr. Ray, I try to do a circle vertical and, or a lollipop and, 95% of the time end up adding at least a small T across the bottom.
So you can control the bunching of the skin that happens on this bottom portion. 
Now, Sam, can I ask you a question here? 
Dr. Sam Rhee: [00:22:18] both, 
Dr. Salvatore Pacella: [00:22:19] Texas, Sam, and then, and then Jersey Sam after. Alright. I'm I'm a patient. Well, doc, I don't understand. You've got all this extra tissue here. And my nipples are round. Can you just do this round incision and tighten everything up through one circle like this 
Dr. Sam Jejurikar: [00:22:36] right in there?
Yeah. Yeah. And, and I have tried that it's called the Benelli mastopexy for our viewers and a lot of people will actually come and asking it by name. and so. It makes sense, at least in name all, you know, at least theoretically that you should be able to bunch all your skin towards this Ontraport to get rid of the extra skin and slide the aerial up.
The problem is, is when you do that, it, you know, you're going from one moment in time to the other, when, when you're done with surgery, but you don't change. The properties of the skin. So when you do that type of operation in variably, unless you're doing more than about a centimeter of lifts, what you'll end up seeing over time as number one, Russ gets his fat, this flat pancake you look, because the tissue sort of relaxes and the lower portion of the breast will expand.
Making people look like they need to get a revision, breast lift. And as that happens, the areola can stretch and spread over time as well. So you get this jaggedy. Poorly scarred areola. And so I've done many revisions on that case. almost none of which I was the primary surgeon for. it's just not a great operation.
It's a very underpowered operation in most cases. 
Dr. Sam Rhee: [00:23:44] I agree with Sam a hundred percent. I tried those, I abandoned it a long time ago, unless you have a tiny amount of lift, you need to achieve it. You end up chasing yourself afterwards. and the results are just not very good. Yeah. 
Dr. Salvatore Pacella: [00:23:58] And I agree. And where I see that fairly limited is, is what you describe as the waterfall deformity here.
So, you know, coming, looking at that, that forced dimension time, right. 
Dr. Sam Jejurikar: [00:24:12] Where, where, 
Dr. Salvatore Pacella: [00:24:13] where that waterfall deformity occurs this right at the bottom here. And I am usually fairly aggressive in removing this tissue here because I don't want to see that waterfall deformity long time. And with the Benelli, mastopexy, it's very difficult to do that with a wise pattern.
It's fairly easy to do that. So, so it's just a limitation of the technique for sure. 
Dr. Sam Jejurikar: [00:24:35] Before I get to the postop results, two more questions. one, What order do you do the surgery? Do you put in your implant first and then do your lift or do your lift duty or lift first and put in your implant and to, as you're talking implant selection, what things are you taking in mind?
Is there a certain type of profile? You favor a certain type of implant. You favor a certain size. You favor what's what's your general approach. Either want to be. Gentlemen can start. 
Dr. Sam Rhee: [00:25:00] I'll start. I usually will do, I'll put, I'll do the aug part first, but I will put the spacer in and I'll leave the spacer in while I do all of my skin stuff.
And then once I'm our tissue envelope stuff, and then once I'm happy with that, that's when I take the spacer out and I put the final implant in. 
Dr. Salvatore Pacella: [00:25:22] Yeah, aye. Aye. Aye. Same way. I mean, early on in my career, I would do the skin resection first and then choose the implant accordingly. And a few, sometimes I find myself sweating a little bit during the operation.
How am I going to get this close if I use a particular size of implant? So, so I've kind of backed off now and I do. The the implant section. First, I try to preserve as much of that pocket and tissue coverage as I can, I'll use the spacer or a, or a sizer temporarily. So in my device, so in my tissue support, make sure the breast mound is as perfect because I can get it. and then do my soft tissue work around it. And then simply before I close everything, I'll put in the permanent implants. And the main reason I don't. I don't put the implants and then start working on the breast. It's just for infection risk. I want to put the implant, the final implant in as close to the end of the case as I can.
Dr. Sam Jejurikar: [00:26:19] Okay. And then, what do you tell your patients preoperatively about scarring? Like what, what do you do? Like what measures do you guys take in your practice to help control scarring, men over what period of time? Well, 
Dr. Salvatore Pacella: [00:26:35] yeah, so, you know, why, we use a lot of, I think, you know, the first step in scarring is what we talked about a week or two ago in our podcasts, which is the, the type of suture we use.
I think that has a critical. effect on the appearance of scarring. So I really want to minimize not so long the incision. So I'll use a monofilament suture on the day of surgery. I'll try to minimize the total amount of knots, use some blocking sutures or Barb sutures. but after the fact, You know, keeping the incision clean, obviously doing general wound care is important.
And then once the incision is healed, I tend to use a lot of silicone appointments. I like wait minutes. They're a little easier to put on that silicone tape. If a patient really wants to use tape, I'm certainly amenable to that. I think silicone is really, a key factor in scar parents. 
Dr. Sam Rhee: [00:27:21] I agree with Sal meticulous closure is important for sure.
I like Barbed sutures for my closures. and some kind of you, you alluded to the time, afterwards, and yes, you have to follow these patients in terms of their incision, healing and their appearance for, for a long time. And some kind of silicone is what I use to either. strips or, or a topical. but, I'm a big fan of that too.
Dr. Sam Jejurikar: [00:27:46] Yeah. So I'm a, I do things very similar to you guys. And the reason I asked that question about the order of implant versus mastopexy is I thought everybody did it the way you guys described myself, included. But, but it turns out there are some plastic surgeons still who will put in, there, we'll do that their lift first and then put in their implants.
Generally they're restricting themselves to smaller implants, lower profile implants, which for our listeners are implants that don't have as much roundness to them, just so that, that doesn't put any, any additional tension on their, on their closure, which. I just don't really quite get that, but there are people that still do that.
I almost entirely in my practice use silicone gummy implants. I suspect you guys are the same way. almost, and I noticed that you guys, even, we all sort of gloss over that question now because it's not even a most likely surgeons, but. Still every now and then we do get patients that do request saline.
and then, for scar care idea, most of the same things that you guys do in terms of closure. I do use silicone ointment. I also use, some pulse dye, laser and broadband light after surgery as well to try to accelerate the process. But I think we, we do things all very, very similar way. so, Postoperative results.
And I'll admit these are not, longterm followups. These are about four months out. cause I just saw the patient in the office this week and I thought she'd be a good case for the podcast. I'll also confess that I did it. Tell me, talk on this patient as well. So her tummy looks a little bit different, but that is not the focus of this.
for this patient I did, largely circumvertical or lollipop lift, which is a small transverse extension in the fold here. But I think this illustrates dr. Patella's point pretty well. You barely even see, see the scar, you know, when, when it crosses over and some of this is a crease, but you don't really see the scarring.
All that much is a really well hidden location. It's a very forgiving place to actually to put that incision. four months out, you still see some pinkness of the scar right here, and I think that's fairly typical. And, and that should continue to fade over the next few months. We used a relatively sensible size implant, and I can't remember the exact size.
I want to say it's around 345 CCS. so for that reason, I did not use any sort of internal scaffolding, but it was part of our decision making. And in fact, she's already told me, she wished she had done a little bit bigger. And so had we done that? I would've used a, I would have used some scaffolding and that's.
That's a comment. I'm sure you guys have heard multiple times, many times. but, but, your thoughts, 
Dr. Salvatore Pacella: [00:30:09] one question for you, was this a high profile implant and used? 
Dr. Sam Jejurikar: [00:30:13] It was a, it was, a moderate profile plus implant that we Oh, interesting. Yeah. I try not to use too many high profile implants simultaneously at the time of her breast lift.
I find those. Generally a high profile implant for, for our listeners is a rounder type of implant that actually, when you do your closure around it, at least in my hands can lead to a little bit, more spreading of the scars. So I did not use that 
Dr. Sam Rhee: [00:30:38] well, I think it's an, obviously an excellent result.
It's fantastic. She has some pretty significant tan lines. So she's obviously been outside and enjoying it herself 
Dr. Salvatore Pacella: [00:30:49] pretty 
Dr. Sam Rhee: [00:30:49] quickly. So she obviously feels pretty happy about her results because she looks like she's been wearing a bikini and, you know, well, you know, gone out and enjoyed herself, I would say.
the projection looks fantastic. It, the funny thing from a regional variation standpoint is, I have a lot of patients in this range. I have very few that feel like they would want to have gone bigger. I, do like the shape that you achieved with the lift, around the implant. I think that's fantastic.
And I can only imagine she's, she's extremely happy with that. Did you, do, I assume you did everything in one shot and, how long afterwards do you allow them to resume sort of regular activity and sun exposure and all that sort of thing. 
Dr. Sam Jejurikar: [00:31:35] So, you know, it's, I think I'm a phenomena that many plastic surgeons see is that there's this rush for patients to get surgery shortly before they're going on a vacation.
And, there is a tape that will actually recommend our patients. You use, if they're going on a beach vacation, that's impregnated, zinc oxide. So, as a result, they can get into the sun. A little bit faster than they might otherwise, because they're basically have this tape over their incisions that has zinc oxide all over it.
So I'm not too worried about them getting darkening or hyperpigmentation of their scar in terms of regular activity. if I ever had just on the breasts, I don't let them do any form of exercise for about four weeks postoperatively at four weeks, I'll let them do light aerobic activity three months before I let them do it heavy, heavy, Or heavy lifting with the upper body three months you say?
Yeah. For remodel. Wow. Okay. If I'm using scaffolding, I really, I have seen a couple of cases where there's been light disruption of the scaffolding from possible contraction of the pec muscle. So I'm, I'm fairly conservative, but I let them do a rabbinic activity stuff at about four weeks. But, with a tummy tuck, I don't let, I don't let people do any sort of exercise to learn about six weeks.
And so it was six weeks for 
Dr. Salvatore Pacella: [00:32:44] her. It's a great result. It's really natural, really full. Nice. Thanks 
Dr. Sam Jejurikar: [00:32:50] guys. we're good. let's see, get up. So, we are, at that time yet again, it just magically always gets to the 30 minute Mark and it's, in a little bit fast. any final thoughts from either of you gentlemen?
Dr. Sam Rhee: [00:33:04] I really love this operation in the sense that it really is. One that patients can achieve on any level by themselves. only through what we do, can they get to this point? the satisfaction rate is amazingly high and it's one, that's still challenge. Like you said, there are so many different aspects to working with the patient goals, figuring out their volume, figuring out their shape.
Figuring out internal tissue support that is still being, you know, we're still all learning as much as we know about it. We're still learning more about it every day. And I just listened to you guys. You guys keep pushing and pushing and pushing. It's not that you guys are happy with what you've done.
You guys have gotten to a certain level of, of expertise. But what I love love about the podcast is you guys keep pushing to get more and better these techniques, which is what I'm trying to do too. 
Dr. Salvatore Pacella: [00:33:58] Yeah, 
Dr. Sam Jejurikar: [00:34:00] well, gentlemen, let's call it a wrap. Thank you again, everyone. Have a wonderful weekend. Can't wait to do it again.
Dr. Salvatore Pacella: [00:34:06] Thanks again. Take care.