Episode 45: Sunday July 25

Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic revisit the tummy tuck, also known as abdominoplasty.
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Our previous episode was one of the most watched, and today we discuss another case and about the many factors which should be taken into consideration when choosing best techniques.
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If you or anyone you know is considering a tummy tuck, this episode is a MUST Sunday 7/25 at 11 AM EST (8A PST)⁠!
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#podcast #plasticsurgery #cosmeticsurgery #rheeplasticsurgery #boardcertified #plasticsurgeon #beauty #bergencosmetic #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bestplasticsurgeon #tummytuck #abdominoplasty #mommymakeover #realpatientrealresult #rheeplasticsurgery #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery #boardcertifiedplasticsurgeon

S02E16 Ep 45 ABDOMINOPLASTY REVISTED

Dr. Sam Rhee: [00:00:00] Hello, and welcome to three plastic surgeons and a microphone as always joined by my fellow colleagues, Dr. Sal Pacella in LA Jolla, California. His Instagram handle is @SanDiegoPlasticSurgeon. Dr. Sam Jejurikar in Dallas, Texas, and his Instagram handle is @samjejurikar. And I am Dr. Sam Rhee in Paramus, New Jersey and my Instagram handle @bergencosmetic. Today we are going to be talking about abdominoplasty. Our last episode was probably almost a year ago and it was one of our most popular episodes. And it's one of those topics that a lot of people have a lot of interest in questions about. So we're definitely going to take a deeper dive in it today and talk a little bit more about it.

But but first as always we have our disclaimer.

Dr. Salvatore Pacella: [00:00:53] This show is not a substitute for professional. So medical advice, diagnosis, or treatment, the 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 advice because of something in this show.

Dr. Sam Jejurikar: [00:01:19] And I think I will lead the discussion today, gentlemen. Like Sam had mentioned our last episode on tummy tuck was one that I already have gotten the most questions and comments about from viewers.

And so we thought we would revisit it. I generally have found and tell me if you guys disagree. Most people don't want it's on me to talk. That's not a thing that anybody ever comes in and says, doc, I really want it so many times, but it's the thing that people are generally reconciled towards. So I kind of thought the way that we would lead the discussion today, that would just show you a case and then ask you a bunch of questions.

So this is a nice woman who's in her mid thirties have had three kids. Who she now says, she's a little overweight. She wants to lose about 20 or 25 pounds. She, you know, she doesn't like the way her tummy looks. We ended up talking about her breast as well and, and did some stuff on her breast, but we'll leave that out of today's discussion, but just wants to note, Dr. Pacella, do I have to have a tummy tuck? Can you just do liposuction on me and make me look bad?

Dr. Salvatore Pacella: [00:02:14] It's a very common question we get. And you know, w what I tell patients is well, two things number one is. There are, there are different two different positions where the fat could be on your belly.

There's external fat, and then there's internal fat. Right. And so that while perfect set up here.

Wow.

Dr. Sam Jejurikar: [00:02:40] It's like, it's we coordinated this.

Dr. Salvatore Pacella: [00:02:43] In oftentimes patients I think have sometimes have some difficulty articulating this or understanding this those patients that have a lot of intrabdominal fat and those are patients that are probably at least moderately overweight to start. Tell me, tuck is going to have a very challenging result to look good because that, that intra-abdominal fat cannot be compressed, one thinks.

And so the protuberance of this fat oftentimes just doesn't create a very nice natural hourglass shape. So patients who are more amenable to getting, or to getting their cosmetic results from a tummy tuck, oftentimes have a lot of external factors. And skin compared to internal fat. The second most important thing that I tell patients is.

The skin can consistency with that. External fat is very important. So let's go back to your previous patient here. All right. So looking at her now, obviously without doing a physical exam on her you know, her, her belly is not massively procurement by any means, and she does have some adiposity on or some some fatty tissue on her love handle area and centrally.

I think with this patient, I certainly would have a discussion about potentially just using liposuction particularly over the front and sides of the belly. But I will qualify that with saying it's, it's not going to do much for your skin. It makes your skin has decent consistency, decent elasticity.

It may contract a bit, but if you want the tightest look possible, a tummy tuck is good.

Dr. Sam Rhee: [00:04:18] I think so you hit the nail on the head and you said it to Sam people don't come in saying, give me a large incision right down there, you know, on my belly. No, but you're right. Nobody actually comes in very few, actually come in asking for that.

So when you have a patient and you know, I've had patients very similar to ones that look like. Who say, you know what? I don't want that cut. I just, can you just do liposuction for me? I don't want anything else. I'll have that discussion that Sal just had with that patient. And you know, it's really about trying to accommodate that patient, but also letting them know what potential.

You know, consequences are as well. I think that's a given a take that you always have with every patient and you sort of have to work with them. You know, liposuction only removes fat. If you have to remove skin, you're going to have to make a cut somewhere on the body. That's just physical, you know, the physical truth.

And that's something you got to talk to the patient.

Dr. Salvatore Pacella: [00:05:16] Yeah. So say I would say, you know, in this particular patient, you know, if, and again, it's not super detailed, there's a little pixelation, but if that skin has decent lasting six, And stretches a bit. I might consider just simply doing liposuction with maybe what I call mini tummy tuck, which is just removing a small amount of skin inferiorly.

And I think if the patient is. Not keen on the idea of a big, massive incision or the big recovery associated with a tummy tuck. And she realizes that it's, it's not going to get nearly as tight. That may be a decent option, a little mini abdominal plasty with some anterior liposuction. So

Dr. Sam Jejurikar: [00:05:59] in that scenario cell which I think is very reasonable what would you do with her muscles?

Because when you look at the. Particularly the lower portion of her tummy, there's a little pooch. When you plicate the muscle, which is tightening them up, all the people will know what that word means or would you just leave it alone?

Dr. Salvatore Pacella: [00:06:17] Yeah. So good question. I, you know, it's, it's obviously hard to see just on the photograph, but that's going to be one thing I'm going to be really absolutely looking for on my physical exam.

So in this particular patient, to me, This almost looks like that's a fatty deposit versus rectus diastasis

Dr. Sam Jejurikar: [00:06:38] yep.

Dr. Salvatore Pacella: [00:06:39] Got it. Okay. All right. So if that area was just simply fat, it's really amenable to liposuction, but if we've got some pooch and some muscle there in a mini tummy tuck, there's only a limit to the amount of placation you can do, and you can only really do it on the. On the lower portion of thing.

So I would be very, very conservative on that. And you know, begs the question if, if we're going to tighten up the abdominal wall muscles anyway, why not just do the full Monte, you know, that's where the recovery comes in. The recovery comes in, in sewing the muscles. So I agree. I was just

Dr. Sam Rhee: [00:07:13] going to add, if you do the placation just at the lower part of the belly, you can make the upper part look worse.

So I agree with Sal, you gotta, you gotta sort of be careful with that.

Dr. Sam Jejurikar: [00:07:23] Well, I'll jump, jump ahead a little bit here. So she told me Dr. J I I want my comment to be as flat as possible. And I want to lose some weight. I want to lose 25 pounds, 30 pounds. Should I lose that weight in before or after I have the procedure?

What would your guys answer that question?

How much do I have to lose it? All?

Dr. Sam Rhee: [00:07:46] For me, I don't, I don't think I've seen very many patients. They all have goals of losing 20 to 30 pounds. It's always a little aggressive. I don't know if I've ever actually seen, I've seen very few, maybe a few, but not that many actually lose that weight beforehand.

I usually ask them what their happy weight is. If it's 20 or 30 pounds below whatever they are. I'll say, you know, what, if you get to within five to 10 of that happy weight, we're good.

Dr. Salvatore Pacella: [00:08:14] I would say it's always best to lose as much weight as you can prior to surgery. But you know, like Sam, I think these it's rare that anyone can achieve a consistent goal of losing the 20 pounds. They put out two, and if I can get half of that, it's, you know?

Dr. Sam Jejurikar: [00:08:30] Yeah. I, I typically tell people something very similar to what you guys just said.

Get within about 10 to 15 pounds of your goal weight. That's pretty good. If you can do that, I think there's a hypermetabolic state that happens with surgery. You lose some weight and the surgery and all of a sudden Don, and I think when you settle out, you'll be pretty good. So she did lose a little bit of weight before you'll see these post-op pictures, but But 15 pounds probably.

And it loosened up the skin more. So the conversation about a mini tummy tuck, it became less of an issue. So then the next thing we had a conversation about, cause she had a bunch of concerns was scar like both of you have said, nobody wants that scar, but eventually, you know, if you're bothering up by the appearance of your tummy, you're reconciled to it.

But she said. Look, I want to do everything I can about the scar. Tell me what your protocol is to make my scar look as cosmetically acceptable as possible. How would you answer that question either one of you?

Dr. Salvatore Pacella: [00:09:30] So I would usually say, you know, so the first thing is really on me, which is when I repair this in the operating room, I want to repair the skin under.

Minimal tension. If any, I want to close this in multiple layers. I want to make sure that we're not getting an infection. You know, we're going to use sutures that are monofilaments so that we don't have spitting incisions, et cetera. And then after surgery the things that patients can do is I, I tend to use a lot of silicone oil.

And a lot of Agilent, scar treatments, such as laser if needed. So there are multiple things we can do afterwards to improve the scar. I think the key is really patient expectations and, and education. You know, that scar's gonna look the worst probably at about three months. There's this sort of secondary phase of wound healing, which causes a lot of redness.

But that slowly fades after about eight to 12 months. So I think patients, you know, the expectation is just as good.

Dr. Sam Rhee: [00:10:26] I think yeah, I remember, I can't remember who said it, maybe it was cous on at Michigan said scars. The appearance of scars are a combination of a couple of things. One is genetics. Second one is the manner in which the scars made.

And then the third is how you manage the scar afterwards. And so all those three things do play a role. The one that we control as Sal said is the axis. Incision and how we put it together and close it. And, you know, any plastic surgeon who's worth their salt is going to do a good job with that. Or at least the best that they know how.

And then you know, you, you talk to the patient based on who they are. I have a lot of patients who You know, Latin X or, you know, who are African-American, who have a lot of concerns about scarring. And so we're really vigilant afterwards. We do the same things that Sal talks about. I'll I'll start with the silicone gels really, really quickly.

We monitor very diligently and you know, we intervene early if we have to that those are the things that help minimize scarring in most patients.

Dr. Sam Jejurikar: [00:11:28] Yeah. What I would say is, you know, the last time we did this, Sal made a point, which you didn't make this time, but it's so true, which is the meticulous closure that you do.

One of the things that Sal had mentioned that he good last time is that he does wanting closures of the deeper layers to offload attention. Wasn't that you south that said that like you actually go running Scarpa's fascia closure, which I actually Until that episode has largely been doing an interrupted closure, but I adopted that after we did that episode and it's made a huge difference.

It is actually made the consistency of the scar is actually better. So I want to thank you for that. That's a huge point that like surgeons should be doing everything that they can to offload tension on the closure to make the scars look, look as good. The other thing that both of you said, which I a hundred percent agree with was you both mentioned Silicon.

I think silicone and there's other adjuncts that I want to ask you about in a second, but I think silicone either in the form of strips or gels is the gold standard for scar care. How long do you tell your patients? They should be using it for after surgery because I'll typically get people that will use it for a few weeks and say it doesn't work and then just stop using it.

What do you tell them upfront about how long they need to be taken care of her scar?

Dr. Salvatore Pacella: [00:12:40] Six months.

Dr. Sam Rhee: [00:12:41] I said six months. Yep, exactly. Six months. I mean, but honestly, I'll be lucky if I get half that in a lot of patients.

Dr. Sam Jejurikar: [00:12:47] Yeah. I told them a year actually telling them they need to be babying their scar and obsessing over their scar over a year.

Let's say you had them doing silicone and their scars are looking okay, but they're still a little bit thicker. And there were a few months out. What other things do you, do you tell people are useful for their scars? Post-operatively. Do you think microneedling for instance is useful for scars? Do you think lasers are useful for school?

Dr. Salvatore Pacella: [00:13:12] I definitely think I th I definitely think laser is, is a key component. You know, I work very closely with the cosmetic dermatologists and, you know, the blade of lasers can really tremendously help with the appearance of scars early on. You know, I've throughout my career, I've really gotten away from injecting scars with silicone.

Or I'm sorry Kenalog or steroid. And you know, I have just found that it is just so inconsistent and it doesn't distribute through the scar very easily. There's oftentimes pockets of white material when you try to inject it. It's just very, very challenging. I will say though I know the discussions about abdominal plasty, but in the face.

I've been starting to use a lot of five F-you injection, particularly around the eyelid that I find much easier to inject can be very effective in breaking up scars having done it in a larger scar though.

Dr. Sam Rhee: [00:14:06] I it's, we all have our preferences. I, if I see any sort of scar hardcore scar hypertrophy, I do a combination of topical and Kenalog injections.

I, for me it works pretty well. I mean, it's not that often that I have to get to that point, but but that's something that I've seen. Done for a while. And I'm, I'm okay with, I agree that it is a little inconsistent. I will have to see the patient back probably in about six weeks and, and sort of see how they're doing with it.

When I first started doing that maybe 10 or 15 years ago, I don't know what I was doing back then. I don't remember, but I overdid it I way overdid it. And I had issues with that. Now I don't know, I guess it's experience for me just doing it. I, I tend to know what I can do with it and just sort of, it seems to work for me as long as I keep a close eye on.

Dr. Sam Jejurikar: [00:14:54] It's very interesting listening to the two of you because I couldn't agree more. I think that less is more we're Kenalog. I use it a little bit, but I have realized that the dilution and the amount needs to be a lot less than I did earlier on. I also think there's a role for microneedling for sure.

Or thick. It's actually easy to do it. Actually. I've seen it lead to some remodeling and picker scars in darker pigmented patients. I like bleaching creams, a lot hydroquinone creams. I think they help a lot for some of the dark brown discoloration that you see in lighter skin patients. I like the broadband light treatment and discoloration, but I think there's a lot of things.

I think the great thing is, you know, seeing how you guys have relationships with people that are cosmetic dermatologist, we have a, we have a skincare center just finding a person that really is sort of passionate about treating that and having the right amount of time. It can really lead to some good results with scars.

The next question though, that you have for me is Dr. Jay. I want to know if you're going to do any liposuction at the same time you do my tummy thought. And how would you answer that question? And if so, where would you do liposuction on this, on, on this patient? Or go back to your pictures?

Dr. Salvatore Pacella: [00:15:57] Yeah, absolutely. I mean, I think every single abdominal plasty I do I add in liposuction to at least the love handle kind of lower back flank area. And many times along the way. I think that is crucial. You know, when I think about abdominal rejuvenation, we really want to do a 360 degree rejuvenation. If we, if you tighten up the tummy muscles, tighten up the skin, and then you've got these, this kind of muffin top on the side, nobody's happy with that.

Right. Definitely add some liposuction. Now the question becomes, how do we incorporate liposuction into the actual procedure on the front of the tummy. And that's something that I think has evolved tremendously in my practice over the last several years. For example another view segue here,

Dr. Sam Jejurikar: [00:16:49] Hand-drawn by me this morning. Thank you very much. Yeah.

Dr. Salvatore Pacella: [00:16:53] You know, so traditionally we. You know, in plastic surgery, it was, it was a serious to liposuction, anything on the abdominal plasty skin flap. And I think philosophy's changing as long as you're not super aggressive. So for example, at the upper portion of the chest here on the upper abdomen, many patients have some fatty roles here, right above, above the the rib cage area.

And that can sometimes be really problematic if we don't hit that a little bit with some liposuction, the other place I like to do it is centrally in the abdomen. Oftentimes a beautiful abdomen has a little bit of a central dip. And so I think that's a really nice place to do it.

Dr. Sam Rhee: [00:17:39] I agree, a hundred percent with Sal.

I do a way more liposuction with my tummy tucks now than I ever have in the past. I, I think we talked about it before the 360 is super important. The flanks as a Sal said the back and yeah, the upper abdomen I used to, you know, they used to scare us about it when we were learning about this stuff that you would devascularize the flap and I guess it's with experience again.

Now I just feel like I can do a much more aggressive job in that area. Then I used to, without having to worry about that sort of devascularization

Dr. Sam Jejurikar: [00:18:11] this picture that Sal referred to as a, as a nice segue is a modification of a, of a, kind of a classic picture. Steve Wallach and Al Alan Monterosa, both of whom are mentors of mine did to sort of help define the blood flow to the abdominal wall with liposuction.

So green, basically the love handle area, and you can incorporate the back and do as well as a safe space. For us to do and feel pretty good about, you can obviously do as much liposuction as you want to under the skin flap as well that you're going to take off. I mean, you know, unless I'm doing back rafting and I need fat, for some reason, I don't typically do that, but the question sort of becomes the central portion of the abdomen.

Yellow is what we've kind of viewed to be a zone of extreme caution around it a little bit less, but we worry about the blood flow. And so what I'll often pose to the question. You want me to try to hit a home run on your case? Or do you want me to hit a single or a double? And what I mean by that is they're going to look great with the tummy thoughts, but to really get a sculpted, look on the upper half.

A lot of times you have to do some aggressive liposuction and the potential risk of that is some healing issues. The healing issues typically happen at the lower portion of the abdomen. It heals, you know, it can be messy for a few weeks and a little disconcerting that people, if they get healing issues.

But I have found as I have gotten much more aggressive with my life assumption, which I definitely have the incidence of getting some minor wound healing complications. He's not insignificant. Have you guys seen that as well?

Dr. Salvatore Pacella: [00:19:35] I just haven't been overly aggressive. You know, I, I really just limit my liposuction to the upper pole a bit. And then centrally, I rarely go into the areas that are kind of along the central column. Yeah.

Dr. Sam Rhee: [00:19:48] For me, it depends if the patient has any comorbidities, I'm pretty conservative. And then I'll tell the patient, sometimes we may have to do a little bit more.

In the future, if there's an issue it's patient specific for me. I, I it really just depends on the individual, how much fat there is to begin with as

Dr. Sam Jejurikar: [00:20:06] well. Yeah, it's, it's the rare patient that I will liposuction the entire opera flap on don't get me wrong, but sometimes people are very demanding in terms of what they want and see, they have to understand the risk that goes along with it.

I'm not trying to say that everyone should get aggressive life at all, but I'm saying it's worth having that conversation, which I do. About the amount of liposuction you can do and that up wrap them in and what the potential consequences are. So the next thing she wanted at talk about and just to kind of move along for the issue of time is swelling.

What can I expect for swelling? How long am I going to look big? How, how would you guys answer the questions and what sort of things do you try to do to help us swelling after surgery?

Dr. Salvatore Pacella: [00:20:45] Yeah, I think you know, swelling is a huge part of the postoperative recovery. I mean, I, I routinely. Tell patients to expect to be swollen for six months to a year afterwards. In particularly the, the distance or the anatomy real estate between the belly button and the upper waistline area, that area is markedly swollen for months and months and months afterwards.

And it can also be numb. And patients just really need the expectation of that. So oftentimes for a good four to five weeks, use an abdominal binder and compress that relatively snug and tight. And then after that time, I usually have them stay into some sort of compression garment for about three months that could be Spanx or, you know, really snug yoga pants that go all the way just below the bra line.

Yeah.

Dr. Sam Rhee: [00:21:35] Yeah. There's a lot of swelling for a while. I wan I caution patients because I've had a couple patients that went and saw a therapist without asking me and getting some sort of ultrasonic treatment or some other treatment, and actually causing a skin necrosis in the abdominal flap as a result of it.

And, you know, they're just so hell bent on dealing with the swelling on their own, what they want to do with it. And And I just tell them, listen, you have to, you have to take your time with this. This is this is not a super fast process. Like some other. Procedures are so yeah, compression, you know, that that's important, but also avoiding, you know, things that can actually be detrimental.

Dr. Sam Jejurikar: [00:22:18] I have two questions for you guys. One, do you think drains are helpful in the minimization of swelling and two, is there any point in time after surgery where you do feel comfortable with either lymphatic, massage or endocrinology or any other form of external treatment to help us? Well?

Dr. Salvatore Pacella: [00:22:35] You know, there has been a big push in plastic surgery to avoid drains and abdominal plasty. And I, I will say I just have not bought into that. You know, a, a small patient with minimal fat minimal dissection. Then amount of skin maybe could tolerate not having a drain, but I it's just such a large surface area to collect fluid, particularly the fact that you often get some of this exit aid from the liposuction fluid that's coming into the wound or the abdominal plasty subcutaneous space.

So I routinely use drains in everybody and sometimes they're in for weeks on end it's it's it's challenge. I would usually say that for lymphatic massage, I would probably give it a good six weeks before any of that kind of aggressive other, you know, manual lymphatic massage, I would recommend,

Dr. Sam Rhee: [00:23:28] I'm with I'm with Sal.

I I do quilting, sutures and all that, but even with that, I I still use drains on all my patients. I agree. The liposuction, having all of that. Liposuction medicines still there can, can play a role, especially for the F you know, initially. And I'm just conservative with it. I I don't like being overly aggressive when I feel like the longterm consequences can be of issue.

I'm also conservative, like I said, I've had a couple bad experiences with patients going to see Therapists for some sort of massage type treatment. So I just tell them to hold off for about six weeks. It's just, you know, I think if you have a provider that you trust that you can work with, then, you know, as as we've talked about with scar management, that's one thing.

But if you're working with a variety of different people or you don't know what they're doing for my, on my end, I just eat

Dr. Salvatore Pacella: [00:24:21] very

Dr. Sam Jejurikar: [00:24:21] conservative. I really agree with that last point that you just made going to providers that, you know, and work with and can communicate with. I think it helps a lot. I will, I'll answer the second question for my, you know, first I do.

I'm a big fan of lymphatic massage or entomology. I think the sooner they start it. You know, beyond the first 10 days or so. I like it personally. I think that the goal, the name of the game for me, is getting as long to go away as quickly as possible. I feel like the less that can be stretched out afterwards when you're dealing with patients that have poor scandal plasticity, which is by definition, a tummy tuck patient.

I think the better the results are. Typically I'll start it. You know, we, we do it through our center about 10 or 14 days after surgery. And I've been very happy with that. I haven't noticed any wound healing complications that I would attribute to that relative to other factors, but but yeah, definitely would be on the lookout for that.

And I agree with both of you guys on drains. No use range in the beginning of my career, went through a couple of years span where I tried not, not to use them at all. And I just thought the patients look swollen and didn't look as good. Personally. I know there were people that had good results, not using grains, but for me, because I'm so focused on swelling going down as quickly as possible, just like you guys.

I like the drains. So she had one more concern and that concern was, am I going to hurt after surgery? How long am I going to hurt for? And what are you going to do to try to make my pain better? How would you guys treat pain with your standard protocol?

Dr. Salvatore Pacella: [00:25:46] Well, just like we talked about several episodes ago.

Abdominal plasty prediction.

It can be a painful operation, particularly when we're talking about placation of the musculature. You know, there are various options for treating pain at a local level. I think one of the most common things surgeons use is experential, which is an injection. Mark cane and injectable long acting anesthetic.

Unfortunately we don't have it on formulary at my health system. So instead I use something a little bit more unique. It's called a pain pump. What it is is two little tiny catheters that can sewn into the. The muscle repair. So I actually, so these catheters right at the level underneath the muscle repair and they slip in and out very easily.

And then I, at the end of the case, I hook this up to a big bowl, which the patient will carry around with them for about four days. And it's got about 400 CCS of this long acting anesthetic, which is just constantly being injected. And I, I have found that to be really nice because I think it really can do a huge job of taking the edge off.

Dr. Sam Rhee: [00:26:54] For me, I have I don't use pain pumps, although I have in the past. It's just one of those things that you know, I found personally I, they work, they definitely work. I just found them to try to uncover some, yeah, just for me as a solo practice guy to incorporate into my practice, just managing that.

I It, it, you know, I have been experimenting with Gabapentin, which I think has been very helpful in, in, in a lot of patients. And that's thanks to Sam. And our last episode we were talking about post-operative pain management. And I, I do offer expert will I have mixed feelings about it.

I know. I think I dunno, I think Sam, I don't know if you're a big believer. I think you are, but you'll tell me about it. I've been pretty happy with injecting a lot of marketing at the end of the case and just sort of, you know, getting them by for the first couple of days, they generally tend to do.

Okay. It's a, it's an upcharge for me for expert role. And I'm okay with it. I just, maybe it's just my own experience or the, you know, it's, like I said, it's in my hands. It wasn't something that I told every patient, listen, this is something that's a game changer, but you know, maybe I have to revisit it.

I know, I know you and a couple other people have told me this is something that's Super helpful.

Dr. Sam Jejurikar: [00:28:09] You know, I, I, I think it's helpful. Just I think a pain pump is helpful. It seems to work great in some people and maybe not so great in some others. You know what I think it's, I think you know, we've had a lot of conversations about this sort of multimodal approach to treating pain.

It's another. It's another, you know, another tool that you can use. I think Gabapentin is a nice narcotic thing that we can use. I've been using Celebrex more which is, which is a non-steroidal anti-inflammatory, which is nice. No, I think all of our goal is to make people comfortable while minimizing the amount of muscle relaxants and narcotic pain medication they're on.

But ultimately you know, it is going to hurt no matter what you throw at them, there are just no way to get rid of the pain. And so those were her big concerns. Here are her post-op results. You know, she's I actually don't have any pictures of the scar, which is ironic given that we talked about it.

So sorry about that guys. But you know, she's, she had some pretty aggressive liposuction of the upper abdomen. I tightened her muscles all the way, you know, from from stem to stern. And this is a, this is her about six months out.

Dr. Salvatore Pacella: [00:29:06] You know, and go back to the obliques if you can there Sam, but, you know, so I think, you know, a takeaway point here is just, just look at the hour glass improvement T's achieved here.

I mean, that's really substantial. It almost looks like you removed a couple of ribs.

Dr. Sam Jejurikar: [00:29:20] No ribs were harmed during a

Dr. Salvatore Pacella: [00:29:23] case. Yeah. I mean, that's just a Tess Testament to really dump location and extra liposuction done on the lower back. Right.

Dr. Sam Rhee: [00:29:32] Yeah. That's what south said about the us, that central portion of the album making that sort of Holloway sort of look that looks that, that looks really nice.

That that looks natural. It looks like really, really aesthetic.

Dr. Sam Jejurikar: [00:29:45] Well, you know, I think unless you guys have any other closing thoughts, I continue to learn from you guys. And I just. Going over these cases and seeing your guys' approach to things. Because I think, you know, if you're doing general surgery, there's really one way to take out a gallbladder, but in plastic surgery, there are so many different ways, the same pacing, so many different plots of surgeons that could results doing things differently that I continue to love talking to you guys morning for me guys.

Dr. Sam Rhee: [00:30:12] Exactly.

Dr. Sam Jejurikar: [00:30:13] Well, thanks. Yeah. Thanks for watching a, yet another podcast. And until next time, have a great Sunday.