Epiosde 15: Sunday September 27

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee talk about one of the most transformative body procedures patients may consider - full body lift, also known as a circumferential (360) tummy tuck. The three plastic surgeons go through a body lift case and discuss all aspects about what to consider before, during and after such a procedure. If you ever thought you needed a wholesale change to your body, you need to watch this episode. Do not miss!

Full transcript (download the PDF here)
S01E15 3 Plastic Surgeons and a Microphone - Full Body Lift (Circumferential Abdominoplasty or Tummy Tuck)
Dr. Salvatore Pacella: [00:00:00] Good welcome everybody to show number 15, I'm Dr. Sal Pacella from, San Diego, California, LA Jolla, California. I'm joined today by Dr. Sam Rhee from Paramus New Jersey and Dr. Sam Jejurikar, from Dallas, Texas. if you see on our screen, these are Instagram handles @Samjejurikar  @SanDiegoplasticsurgeon and @Bergencosmetic, how are you guys doing?
Dr. Sam Jejurikar: [00:00:28] Doing wonderful Doctor Pacella. How was life up in the international space station? 
Dr. Salvatore Pacella: [00:00:33] That's fantastic. And listen. I wanted to let you know that I invited a special guest today. Okay. I'm gonna, I'm going to bring him on.
Dr. Sam Rhee: [00:00:44] Buzz Light year. 
Dr. Sam Jejurikar: [00:00:47] Nice. 
Dr. Salvatore Pacella: [00:00:49] He's 
Dr. Sam Jejurikar: [00:00:49] happy to be here. 
Dr. Salvatore Pacella: [00:00:51] He says, you know what? Doctor Jejurikar today. We're going to be talking about circumferential abdominoplasty. 
Dr. Sam Jejurikar: [00:00:58] Race goes. 
Dr. Salvatore Pacella: [00:01:01] Let's go straight to our disclaimer.
Well, 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 on the circumstances, situation and medical judgment after appropriate discussion, they seek the advice of your surgeon or other.
Qualified health provider with any questions you may have regarding medical care, never disregarded professional medical advice, or did they seeking advice because of something in this show, I'm going to hand it back to Dr. Pacella. Thanks. But I'm back. 
Dr. Sam Jejurikar: [00:01:46] Wow. The gravitas is amazing
Dr. Salvatore Pacella: [00:01:53] just for our viewers out here that may have not caught our last show. I've got a new laptop. And unfortunately I did not test the webcam prior to, our last broadcast and it's making me look like I'm in outer space, so. 
Dr. Sam Jejurikar: [00:02:09] Okay. And now he's frozen while he is frozen. And it's quite interesting because he actually told us that he was going to get a new webcam after the last show.
But yet here he is. And now he's got a bad webcam. It's some bad internet connection. 
Dr. Sam Rhee: [00:02:29] The moon is a real, far place to be. That's all I can say. 
Dr. Sam Jejurikar: [00:02:33] Well, I'm, I'm fairly confident he will, he will be back to join us, but, you know, our, our, our topic for the week is going to be kind of a continuation of things that we've talked about before, which, which has been, Body contouring surgery.
And we had a previous episode where we talked about Tommy talks, and so we thought the next evolution would be, you know, tummy tucks are traditionally thought about, for women that have had children, but there's a whole large subsegment of patients who have lost massive amounts of weights, who need even more invasive body contouring procedures.
And, while we're waiting for Dr. Pacella to join us, do you see a lot of these patients in your practice? Dr. Rhee. In New Jersey. 
Dr. Sam Rhee: [00:03:08] I do, I, there are a couple of specialists who do a lot of very large body contouring, procedures. And so I will do some, but I generally, see patients who are really looking for a big one shot deal, where they're doing, they want a lot done at one time. And, sometimes, working with specialists in that situation can be helpful. 
Dr. Sam Jejurikar: [00:03:31] Yeah. And, you know, I think maybe, you're might be in a slightly more fit area of the country, on the whole than I, than I am. I'm not sure, but you know, in Dallas and in Texas in general, there is a large. Number of obese patients.
And as a result of bariatric surgery market has gone through the roof. So it is not uncommon for me to do one of these big body contouring cases a week. I mean, it's a fairly, they're fairly common. And so a lot of our presentation, I assume Dr. Pacella is going to come back, join us. But, in the meantime, let's see if we can get this loaded here.
All right. And let me know if you can see this. 
Yes. 
Perfect. Okay. And, I will, I will warn everybody that, I can't see the other two guys while I'm doing this. So will you guys just give me a cue when Dr. Pacella's back?
So, as we have sort of, talked about, Massive weight loss, which let's say for the purposes of this, of this podcast, we can define and say 50 pounds or greater. it's amazing from an overall health benefit, you can see improvement in diabetes. You can see improvement in heart disease. You can see, improvement in energy levels when you lose massive amounts of weight.
But, you can also see massive amounts of extra skin. And so you don't tend to see a lot of this on the internet last night, when I was, as I was getting ready for this, it was actually interesting to me, how few articles you see that aren't on plastic surgery, websites about the results of massive weight loss.
But the fact is, is when you lose. Massive amounts of weight. you get a profound amount of sagging skin, and then you can see it throughout the body. It can be the face, it can be the arms, it can be the trunk, which is the tummy and the back, and the love handles and the buttocks and the thighs. And so patients will come in kind of.
Hey, I've lost all this weight now, what do I do? And they'll ask for you, you know, for your, for your approach. And so one of the things you had mentioned, dr. Ray was that patients are looking for a one shot deal. So when you see one of these patients in your office, do you propose that you do everything to them all at once?
Dr. Sam Rhee: [00:05:38] it depends. I think there are some specialists out there that will do it all. They'll do a circumferential. They'll do the brachioplasty. They'll do the thigh, lift all in a single setting, which can be quite, yeah. an undertaking, if I'm going to be doing a, a patient such as this, I generally will piecemeal it.
just because I generally, fo you know, focus on one area at a time. but I can see the disadvantages and advantages of working both ways. 
Dr. Sam Jejurikar: [00:06:04] Yeah. Like, you know, I'll talk to them in general about. Trying to do it all in about three stages. and I have a preferred order in which I do it, which, the first one's going to be a circumferential body lift, which is what we're going to talk about today.
Then later on, we'll do the arms and the breasts, 
Dr. Sam Rhee: [00:06:21] Sal just joined us. He's back from space. 
Dr. Salvatore Pacella: [00:06:25] Dark side. What happened here? The internet just went down. It was a, 
Dr. Sam Jejurikar: [00:06:29] well generally when you go across the dark side of the moon, the, 
Dr. Salvatore Pacella: [00:06:33] it must have been orbiting around, 
Dr. Sam Jejurikar: [00:06:35] Hmm, 
Dr. Salvatore Pacella: [00:06:36] Roundup major, Asteroid planet. 
Dr. Sam Jejurikar: [00:06:39] Is that what 
Dr. Salvatore Pacella: [00:06:39] you were going to say? Mars, Mars. Mars. Ain't the kind of place to raise your kids? 
Dr. Sam Jejurikar: [00:06:47] Definitely not. Well, you haven't missed much. Basically. We started in talking about how you can lose. You can develop massive amounts of skin excess when you lose weight.
And what I had just asked Dr. Rhee about, and I'll get your opinion is when you see a patient in your office who has lost, let's say greater than 50 pounds or a hundred. Bounds and they come to you and their face has fallen. Their arms are droopy, their tummy is saggy. They've got sagging, but their upper back as a bunch of skin, their inner thighs are full.
How do you approach that patient? How do you tell them you're going to take care of their issues? 
Dr. Salvatore Pacella: [00:07:22] Right. So good question. I think, you know, first off is I try to spend a significant amount of time talking about, what their expectations are. And this really gives me an understanding of what, what they expect to derive from the surgery.
Dr. Sam Jejurikar: [00:07:39] Okay. 
Dr. Salvatore Pacella: [00:07:40] And, and sometimes, you know, With weight loss. There's, there's a huge psychologic component to weight loss as well. patients are, you know, when, when they're super heavy and they go down to a thinner size, although it's, it's extremely helpful for their health. Sometimes they're just simply not help happy with their body appearance.
So I'm really trying to tease out. Exactly what, what their expectations are and what they want to obtain from this. And so let's just say for argument's sake, 
for argument's purpose, it's a head to toe thing for me. in San Diego, I usually want to start. At the keystone area of the body and to me that the central abdomen and build out from there.
the reason being is I've found if I do things in that in a different direction, 
let's say we did the breasts first, right. Then went to the abdomen. Oftentimes what I'm doing on the body, you can pull down what's happening in the breast. same thing goes for the thighs. You know, it could be a, a mutually opposing, Vector of force when we're, when we're tightening things.
Yeah. So I usually want to start centrally in the body and work outwards. 
Dr. Sam Jejurikar: [00:08:46] Here here. I completely agree with that. And that is my approach as well. I'm almost always I'll want to start with the central abdomen. I actually think there's a benefit for the thighs when you do that as well, which leads us well into our case.
So. This is a patient who came into my office a few years ago, who, had actually lost, I think 80 to 100 pounds after having had a, have ever having had a, I want to say a gastric sleeve. And, she was, you know, we'll leave out the other complaints that she had the other portions of her body, and let's just focus on the central abdomen.
She didn't like the fact that she had profound. Skin excess on the back. She didn't like the fact that she had a relatively square body frame. She didn't like the fact that her tummy was sagging and drooping. How would either one of you guys approach this patient, what would you recommend to her that we do for her?
Dr. Sam Rhee: [00:09:38] Well, certainly, and abdominoplasty is something I would be discussing with her right off the bat. She has a lot of skin laxity and excess in the belly. there's a lot of, bulging there. in some patients you do that and we talked about this previously and then, you know, you do liposuction in the back to help address the love handles and so forth.
But in this particular patient, she has. Some significant skin rolls in the back as well. So even if you were just to do liposuction, which you could, and you could probably get a reasonable result, she's going to have a ton of excess skin rolls in the back of her, in her back, which, will persist with just liposuction there.
Dr. Salvatore Pacella: [00:10:21] And you said, what was the extent of her weight loss and how, how did she lose the weight? 
Dr. Sam Jejurikar: [00:10:26] I want to say it was somewhere between 80 to a hundred pounds and, and it was through a gastric sleeve. 
Dr. Salvatore Pacella: [00:10:33] Okay. So, you know, interestingly enough, you know, she looks like a patient who actually has moderately good skin elasticity compared to a lot of.
massive weight loss patients that I experienced where their skin is paper thin. So, you know, looking at her, her back area here, she doesn't have the extensive amount of strata that she has, on the sides. But even, you know, when we look at massive weight loss patients, she, she surprisingly has very little skin effect here.
so I think this is somebody that's going to do pretty well with post liposuction. particularly in those upper fat roles, as opposed to say doing a circumferential abdominoplasty to directly excise those, those roles. Now, the other, the other thing I think to keep in mind here is the, the roles just underneath the bra fat area are actually in a different position than the ones that are on the, on the lower abdomen or flank area.
So what's why that's important for us is if we try to do a circumferential tummy tuck, And we don't release those little fibers bands. In between those two roles, they come out looking very odd. So, so for me, I think I would approach her with, some aggressive liposuction to the back and brought that area in addition to, to straightforward abdominoplasty.  See, I don't know if I would go so far as to do a circumferential. 
Dr. Sam Jejurikar: [00:11:59] Interesting. Okay. Well, I'm. Obviously we know by the topic of today's talk, what I ended up doing. So this'll be it. No, but this will be good. It's good. It's good. The viewers to see that you can have plastic surgeons, All of whom I think are good.
I'm going to give us all the benefit of that doubt who have different approaches to the same issue. So I want to, I want to explore, a little bit, in terms of what you were saying about her skin elasticity on the back. So when I looked at her, I thought. When I looked at her flanks that she had substantial street all the way across the side here, which you can see on this shot.
Second from the left, I met, she had two distinct back roles. and they do have fat in them, for sure. There's still some residual fat in there, but that her skin was really mobile and loose. And the benefit that I had is when I could grab a hold of her, I could slide that around. even though it looked relatively dense, I had the benefit of actually being able to feel her and it was mobile.
It moved around on her. And so I actually came up with a conclusion that, that w about liposuction as a standalone treatment on the back would not be enough. I do think you make a very important point though, which is. Yeah. Even if you're not doing a body lift on this patient, even if you're just doing liposuction release of these bands, that cause that caused that dimpling is really, really, really important.
If you don't do that, you will be left with this shape. So you can do it openly, or you can do it with liposuction in the manner that dr. Patella is, is, is discussing. And, you know, and it really comes down to a trade off. I think, I think you would agree that you can get better skin tightening with a direct excision, right?
You can, with liposuction, it comes down to what the patient's overall goals are. In some patients, avoidance of scars is a paramount importance and other patients, Not having any excess skin is of paramount importance. This patient was in that latter category. So knowing that this patient wants to wear relatively tight clothing where they don't see skin rolls, would that change what you would do in this patient?
Dr. Salvatore Pacella: [00:13:58] Probably, probably. You know, some, some patients are just simply willing to accept a little bit of skin redundancy in the upper back. And a flank area, to avoid a, a bigger scar on the back, I think, you know, or a bigger operation that may cost us a substantial amount more, you know, I mean, the other thing to keep in mind here is.
You know what to dovetail, what we talked about at the beginning of the, or just a few minutes ago about, starting from centrally and going out to the rest of the body. You know, we were sometimes talking about four or five, six operations sometimes for, for massive weight loss. That comes at tremendous, tremendous cost to patients and tremendous recovery.
And many patients may not simply have those resources. So, I really tried to talk through with them on a plan on, on what this is going to entail for them financially. 
Dr. Sam Jejurikar: [00:14:55] dr. Rhee, I'm curious about. Your treatment of the flank region, what you think the relative differences would be in this patient.
If you were to do say an extended tummy tuck with an incision that goes all the way across relative to doing a body lift and their overall correction, you think you could actually achieve.
Dr. Sam Rhee: [00:15:16] That's a really good question. as you said, this really hinges on the patient's expectations, it, are they looking for a home run, a triple, a double? I think there's a lot of, like you said, lateral skin excess here that you're going to have to, you're going to have to make, take that incision beyond the hip, and take it a little bit farther.
And even with that, you may find yourself chasing skin redundancy, redundancy like that, excess, even farther out. that's something that I'm going to sit there and sorta hash out with the patient. Do we go back and do some touch up stuff later, do a big one first and then a smaller one later. Do we just go ahead and bite the bullet and go, you know, circumferential with everything.
This is something, you know, if a patient says I want. The most aggressive procedure. I want the thinnest most hourglass appearance that I can, you can't get that with. Yes. Sort of widening the incision a little bit farther. Have I have to keep going and keep going and keep going with that. and, and that's really the only solution for that sort of. goal 
Dr. Sam Jejurikar: [00:16:27] Dr. Pacella in San Diego. How many times have your patients come to you and said, I want to look snatched. Have you heard that term? Because I hear that for a 
Dr. Salvatore Pacella: [00:16:40] Snatched. 
Dr. Sam Jejurikar: [00:16:42] You haven't heard it? 
Dr. Sam Rhee: [00:16:43] Oh my God. I hear it all the time. 
Dr. Sam Jejurikar: [00:16:45] I hear it every week, 
Dr. Sam Rhee: [00:16:47] girl, I am snatched. 
Dr. Sam Jejurikar: [00:16:49] I want to be snatched, please. 
Dr. Salvatore Pacella: [00:16:52] Please explain 
Dr. Sam Jejurikar: [00:16:53] snatched, is the patient's way of saying that they want a traumatic change in their waist to hip ratio.
They basically want to get dramatic curves and, they want their waist to go in and to have a much curvier body shape. And so, That's what this patient wanted. She wanted to be snatched. So we'll jump, we'll skip to the chase. I ended up actually doing, a body lift on this patient. And, as has been the case in previous podcasts, I use this educational program called touch MD a lot in my practice.
So these are images taken from there, but in the dotted lines is the way this, this is traditionally designed. the incision is much lower. and it comes across the entire ways to used to be called a belt lipectomy and I don't think this is really the class at the way that people will tend to design it as much anymore.
The rationale being nobody wants to look straight. Everybody wants to look curvy. So as a result, we cheat the incision upwards. So it's much like a tummy tuck when we're up. If you're looking in the upper right hand, Part of the screen right here. But instead of ending the incision, you come all the way around the waist.
As you come across the side, here, you take out this belt of tissue. And, this is a big operation. as, as these guys have already alluded to their hesitancy in doing it has to do. More with the, the burden on the patient in terms of the recovery that's involved at longer period of time, that's involved.
And the fact that we keep these patients overnight, maybe two nights when we do this, and there's a lot that need to do to get ready. So the big things that I sorta tell people that they need to do before surgery. Do have to do with a lot of things. You know, the first thing is for any operation, it's important not to smoke, but for these huge body contouring operations, it's important to avoid secondhand smoke tobacco products of any kinds, vaping, electronic cigarettes, anything for at least four weeks ahead of time.
even a microscopic amount of tobacco or nicotine products in the bloodstream can cause profound, catastrophic wound healing complications. And I tell patients if you fall off the wagon, If you have one cigarette during that time, it could be a catastrophe and you need to let us know so we can postpone your surgery.
I also find, and I'm curious if you guys do this as well, that protein supplementation is a huge thing before a big body contouring operations. And this could just be as simple as a tummy tuck. in our, in our practice, we have used this thing called impact protein on the left here. Which is actually a surgical, protein drink.
it's real easy. You just tell them and take it three times. And today for five days before, and for five days after, and it has a huge impact on the ability to minimize wound healing issues. we have the scale over here just to show that. it's important that you need to be at a stable weight when you have your surgery.
I don't tell people what weight they should be at, but I tell them I need to be at a comfortable way. you shouldn't lose a bunch of weight after you have a big body country operation, because we know skin elasticity is compromised. If you lose a bunch of weight, You'll get a bunch of loose skin and you'll look like you need another body lift and obviously you need to be health.
So we, we check, preoperative labs and everyone, and particularly when patients have had bariatric surgery, there's a high risk of vitamin deficiencies and anemia preoperatively. So we make sure that's optimized before we do this. Do you guys have anything else that you do for your patients? Anything that you think is really, really important to kind of help them sail through this process?
Dr. Sam Rhee: [00:20:05] I will say, Oh, go ahead. 
Dr. Salvatore Pacella: [00:20:07] Go ahead. Sorry. 
Dr. Sam Rhee: [00:20:08] I was just going to say, this is all critical. I think even in the best candidates, you, I tell patients you're going to expect some skin breakdown somewhere. It's never going to go perfectly well everywhere. It's such a big incision. It's such a dramatic, aggressive change.
so you're absolutely right. Even a little bit of a problem is going to result in a huge problem afterwards. So I just tell patients, you're going to expect some wound healing issues we're going to have to manage them. I think the malabsorption is a, is a huge issue. And putting patients on supplements is a, is a big thing.
Dr. Salvatore Pacella: [00:20:40] I like to talk to patients about, you know, I refer to this as prehabilitation, you know, so prior to surgery, I want to slightly increase their exercise regimen a little bit, get them walk and get them moving a little bit, you know, and I think that's really important. one other point here, just to, just so we're all on the same clear definition here, according to, you know, the best source, which is urban dictionary snatched is it's the definition of Snapchat, a term used to describe someone or something in a positive manner.
Snatch means looking good and on point. And of course they give a, they give a example here. Girl, did you see her makeup? Yes. She snatched. 
Dr. Sam Jejurikar: [00:21:26] It is my friends in the body contouring, particularly in the Brazilian butt lift population. It has, the, the new sub context has everything to do with their waist.
and so, maybe urban dictionary needs to add to their and broaden their definition a little bit, but it has a specific, 
Dr. Salvatore Pacella: [00:21:44] you know, who snatched. You know, who looks snatched this guy, 
Dr. Sam Jejurikar: [00:21:49] this is kind of embarrassing, you know, like when do you, I have two teenagers, dr. Rhee, you've got a teenager, you know, when they tell you something and you don't quite get it and the expression, they kind of give on their face.
That's, that's kind of, it's kind, it's kind of what I'm doing with dr. Pacella and this tangent about snatch right now. Oh, one more thing, getting back, getting back on topic here that I want to ask you guys about, and that is in these cases, the complication that I fear the most, and I know you guys share the most isn't wound healing complications, it's blood clots, blood clots are a profound risk for any large body contouring operation, tummy, togs, and even, and these operations even a little bit more.
So how do you talk to your patients about blood clots and how do you treat your patients for blood clots? 
Dr. Salvatore Pacella: [00:22:36] That's a good question. I, you know, I first started out by saying that, you know, of any operation of plastic surgery, body contouring, specifically abdominal plasty is at a slightly higher risk for, for clotting.
And I usually talk about a discussion of bleeding versus clotting. so if you're on blood thinners and you have some bleeding, That's that's a problem, but it's double problem. Meaning if you have a bit of bleeding and it's bruising, sometimes we can just manage that expectantly. if you have a tremendous amount of bleeding, it means a trip back to the operating room, but your cosmetic result won't change and it won't be a permanent issue necessarily.
If you have a clot that's in your legs, that dislodges and goes to your heart, that can be invariably fatal. So that's obviously something that's not reversible. So I'd much rather err on the side side of bleeding rather than clotting. So what I usually do in my practice in San Diego is, if I have a body contouring case, I'll usually start a anticoagulant the day after surgery.
And the reason being is I want to make sure that they're not having a hematoma or some sort of interoperative or postoperative bleeding, and I'll usually start them on a two week regimen of something called Lovenox, which is a self administered shot. usually for 14 days after surgery, but starting the day after.
And usually patients are pretty amenable to doing this. It's pretty easy to give it a. I have my nurse instruct them on post-operative day. Number one, I'm giving it in the thigh area. And, you know, I think it's usually fairly effective. 
Dr. Sam Jejurikar: [00:24:11] How about you Dr. Rhee
Dr. Salvatore Pacella: [00:24:14] Yeah, 
Dr. Sam Rhee: [00:24:15] most of the places I are I'm at, have actually very strict risks, stratification and protocols regarding anticoagulants or blood thinners for these patients.
So, you know, you will be giving them. just before, during and after the operation to a variable period that depending on, on their risk factors. 
Dr. Sam Jejurikar: [00:24:35] Yeah. And I think that is, those are both. Very very, well thought out strategies and it's similar. key thing is you need to, no, if you're having one of these procedures, your surgeon is terrified of blood clots.
We are not terrified of bleeding. We know how to make that stop. The blood clots can ultimately be fatal. And like Dr. Pacella said they are irreversible. So you will be on some form of anticoagulation for some period of time before, during and after surgery. And with that, let's look at what we did. So in this patient, Not much of a suspense.
You know, we kind of knew how I did a body. I lift on her. So that's in fact what I did. One, one of the things that I would point out and the reason I asked dr. Reed, his question is when you take the opera, the incision circumferential around the patient, you are able to get better delineation of the waist relative to the hips.
the incision continues all the way across to the back here I did. what doctor. but Chella had said, I released this upper back area as well, and I did some, some liposuction as well to the faculty. I also, yeah, and that's a topic for another conversation. Put some of that fat into the central portion of the buttock as well, to, to help really change with that, to really help sort of give her some more of a dramatic, waste.
To a, to buttock ratio. but this is what I think is possible with a circumferential. 
can I ask what, what sequence you did the fat transfer, the Brazilian 
butt lift with that? I did it, at the very end of the case. So I started off the procedure prone. I did fly bell and I did the back portion. I turned her supine and I finished off and did the tummy tuck.
And then I turned her prone again and added fat. So lots of position changes in this case. So they'll lose the very last thing I did, one of the things and again, Conversation for another, for another day, but we don't like to put a lot of pressure on the fats. So positioning issues tend to be, tend to be, tend to be difficult when you've done that bad transfer.
But, and as a result, I don't tend to do as much of it anymore, as I used to. This is a few year old case. it's but it is possible. It is possible to do it and to get appropriate positioning postoperatively. It just takes a lot of work. 
Dr. Salvatore Pacella: [00:26:43] Yeah, that's good. That's a great result. really good result.
You can see, you know, just an hour glass appearance on the back view. I mean, she'd look, she looks snatched. 
Dr. Sam Jejurikar: [00:26:53] Definitely snatched. Not a lot of people can do this. Dr. Pacella, I know you can doctor recap. Maybe Henry can, a lot of people
Dr. Sam Rhee: [00:27:06] this talking about the position changes and, and the technical aspects of it involved. This is really a team approach. It's it's there's there are moving parts in terms of managing the risk factors. There is, a team approach to positioning, to getting the sequence of events right here. this is a dramatic, huge, improvement that the patient, which is what the patient wanted.
And this is an aesthetic, which, in New Jersey, I see a lot of where they want that. I can't believe Sal has never heard that word
almost every other day where, they really want those big hips, that wide sort of, lower, figure that no one wants their, lateral thighs touched or their anterior thighs touch. They just want that waist quote, snatched as possible. And the only way to have achieved that in this patient is to have.
I'm done that circumferential, which is very impressive. 
Dr. Sam Jejurikar: [00:28:06] Thanks. Yeah. You know, I find these to be satisfying. It, they do very much require a team approach, but, I'm fortunate to work in a surgery center where all we do is plastic surgery. And so we're able to do these very efficiently. and so it's not, I remember in residency that every time you would turn a patient, it was a, Mind numbingly slow and arduous process, but in the real world, yeah, I don't think it's, it's pretty efficient.
Yeah. Yeah. It's very different. So, well, do you guys have any other last thoughts on, on body lifts or massive weight loss or any, any last minute pearls you want to throw out? Our viewers? 
Dr. Sam Rhee: [00:28:42] I think it is very satisfying for these patients. I think especially after a massive weight loss, they feel. That they put, you know, cause, especially even with gastric, or bariatric surgery, the patient has to put a lot of their own effort and time.
And it's not magic from the procedure that, where they lose all that weight. So, you know, there are a lot of failed bariatric patients out there too, who did not lose. Enough weight after their procedure. So for them to have achieved that successful weight loss, and then to come to us as plastic surgeons, be at Dallas, be at San Diego, be at New Jersey and say, I did all this.
And yet I'm not where I want to be to be able to finally get them to that, to that, goal that they have in their head after all of that effort is tremendously satisfying.
Dr. Salvatore Pacella: [00:29:30] Gotta be snatched. Consider myself. I consider myself school today. Check school.
Dr. Sam Jejurikar: [00:29:41] Well, gentlemen here is I here's praying that the next time we have a show, Dr. Pacella has fixed his technology issues. 
Dr. Sam Rhee: [00:29:49] He looks handsome face even better than ever after that. 
Dr. Sam Jejurikar: [00:29:52] Exactly. 
Dr. Salvatore Pacella: [00:29:53] You know, you know what looks snatched right now with looking up at the camera? My neck line snaps right now, 
Dr. Sam Rhee: [00:30:02] those bunches of a flesh colored rectangles that I'm looking at right now.
Yes. No, it looks really 
Dr. Salvatore Pacella: [00:30:06] good.
Dr. Sam Jejurikar: [00:30:10] Alright. 
Dr. Salvatore Pacella: [00:30:11] To infinity and beyond 
Dr. Sam Jejurikar: [00:30:14] have a wonderful weekend.