Episode 46: Friday November 26

THE RETURN OF 3 Plastic Surgeons and a Microphone!

---

After a hiatus - we are back and better than ever!

Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic discuss NON INVASIVE BODY CONTOURING, including the treatment which has been in the headlines - CoolSculpt. Is it better than liposuction? Is it safe? What other options are out there?

---

#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #aesthetic #3plasticsurgeonsandamicrophone ⁠#bestplasticsurgeon #boardcertifiedplasticsurgeon #liposuction #lipo #coolsculpt

Transcript S02E46 NON-INVASIVE Body Contouring

[00:00:00] Dr. Salvatore Pacella: All right. Good morning, everybody. We're back. It's three plastic surgeons and a microphone. We're back. We had a long hiatus but we're happy to see our two additional surgeons and myself as always, of course, I'm Sal Pacella from San Diego, California. We have Dr. Sam Jejurikar from Dallas, Texas, and Dr. Sam Rhee from Paramus New Jersey. How are you guys doing?

[00:00:25] Dr. Sam Jejurikar: It's been a long time. I've missed you guys.

[00:00:29] Dr. Sam Rhee: Absolutely. You guys look better than ever though. Very youthful and rejuvenated.

[00:00:36] Dr. Sam Jejurikar: Well, that's great.

[00:00:37] Dr. Salvatore Pacella: There's been a lot of things going on in plastic surgery in the last couple months in, in and in the world.

So we'll we'll be sure to touch base on all of that. Just before we get started, I want to just go over our disclaimer again, this show is not a substitute for professional medical advice, diagnosis or treatment. The show is for informational purposes only. Treatment and results may vary based on the circumstances, situation and medical judgment after appropriate discussion.

All we seek the advice of your surgeon or other qualified healthcare professional. With any questions you may have regarding medical care, never disregard professional medical advice, or delay seeking advice because of something in this. Fantastic guys. And I'd like to start by saying the topic of the show is going to be something very interesting.

It's I like to refer to it as a song of ice and fire, where that's

[00:01:26] Dr. Sam Jejurikar: from game of Thrones, right?

[00:01:31] Dr. Salvatore Pacella: So, so we're going to be talking about noninvasive treatments cold treatments and hot treatments to freeze or melt your fat accordingly. So with, without delay, I'm going to hand it over to Dr. Sam Jejurikar in Dallas.

[00:01:46] Dr. Sam Jejurikar: Thank you very much cell. Before we get started, the, the inspiration behind this topic is a recent news story that just came up in the last few weeks that I'll touch upon in a, in a few minutes. But it made me realize just how much non-surgical body contouring is actually performed.

I don't know how much you guys in your practice send people for treatments like CoolSculpting or sculpture or anything like that. Is it something you guys use a lot in your own practice?

[00:02:11] Dr. Salvatore Pacella: A little bit. I don't use it specifically in my office, but I do send outpatients to some of my other colleagues that have the devices in the office.

[00:02:20] Dr. Sam Rhee: I don't do it in my, I don't do it in my office either, but and I will generally I'll usually send people for noninvasive treatments, but more for skin related type issues. Like Morpheus eight or something similar to that, I really rarely tell people about CoolSculpt or some of the non-invasive.

I just feel like I don't know. I just feel like the results have never been, super awesome. Although I have heard of a few patients that have gotten good results. I've also seen a couple of patients that had not so great results. And I guess we'll get into that a little bit and we can talk about our own experiences.

[00:02:51] Dr. Sam Jejurikar: Yeah. Well with that I think that's a great way to think about it. Let me pull up this little or these, these few pictures we have here and hopefully you guys, can you guys see my screen? Okay. Yes. Okay. Perfect. Perfect. So we're going to talk about both melting of your fat and cooling of your fats.

Because those are the traditional ways to handle fat removal when you're not doing surgery. So let's start with cooling. Pretty much everyone watching this pop podcast has heard of CoolSculpting. It's been the technology that we're going to talk about today. That's been around the longest and it's actually been FDA approved since 2010.

And it took off like wildfire ever since it was FDA approved. And so we've had more than a decade of experience with CoolSculpting. Do you guys know by any chance how. People, thought about CoolSculpting or that, or that sort of the, the story behind how CoolSculpting was discovered by any chance.

No, but I'm sure you can. Okay. Well, this is really interesting. So there were, there were physicians at mass general who sort of recognized this phenomenon and little kids who who either sucked on ice cube. Or consumed a lot of popsicles where they noticed that the fat in their cheeks would actually atrophy.

And that was sort of the inspiration by how they realized that you could actually cool fat actually get atrophy of fat cells and do so without actually damaging the surrounding tissue. So if you've ever heard the term Popsicle panniculitis, that's how that was the inspiration behind CoolSculpting when CoolSculpting first came out about a decade ago We didn't really talk so much about staging it or doing multiple treatments.

We talked about doing one isolated treatment and I would tell people, look, you get this, this version of cell death called apoptosis by which it's called programmed cell death, where essentially the fat cells sort of shrivel up and over the span of two to four months, get reabsorbed the next.

Excreted by your body. And it worked well. What we sort of realized with CoolSculpting is it wasn't the equivalent of liposuction. If people want an, all of their fat gone and they had the time to recover from surgery, CoolSculpting was never going to be the right choice. But if they didn't have a lot of time, CoolSculpting was a procedure that they could come in and.

Get a treatment on with an applicator placed over the, the area in concern sometimes have multiple applicators set up at the same time each treatment would take about an hour. And then over the span of a few months, they'd lose about 20% of their fat as we started using CoolSculpting more.

And we started using this process by which we would try to get a little bit greedier and we would actually do stack treatments where people would come in every four to six weeks and get a repeat treatment and we would lose more fat. So in this picture, On the top. This is someone who just had one treatment and I'll say an exceptionally good treatment, not a typical treatment with CoolSculpting.

And you can see that this gentlemen lost a good amount of his fat, but he still has love handles presence. They haven't gone away, but he looks like he looks substantially smaller, this patient on the bottom. If you look at this critically, they've had two CoolSculpting sessions. And so this, this picture on the right was about eight weeks after the second CoolSculpting session.

And you can see that the overall girth of the abdominal wall is substantially less, but you know, if you look at this critically, what do you guys think about the skin elasticity here? It looks a little wrinkly, right? So and so, and so one of the things that you'll see with CoolSculpting is it is specifically isolated for the reduction of fat.

It has almost no effects on this. The reason I started thinking about CoolSculpting, I'm actually, sorry. One more thing, when you look at overall patient satisfaction levels, you'll read on the internet where people say that patients are 90 or 95% satisfied, but the only time it's been objective, we looked at in a peer reviewed study.

It's the patient's satisfaction of about 73%. And perhaps there's selection bias in the patients that come to see me. But you know, most of the patients that I see that have had. Aren't that thrilled with their results. They typically are in my office to get to get liposuction. And because CoolSculpting has become so prevalent, I mean, it's offered in a wide range of doctor's offices, not just plastic surgeons, but dermatologists, family practitioners.

There's a CoolSculpting machine. Every block. It seems like. Sometimes I think the technology is somewhat misapplied and it's used on patients that aren't going to get the best results. Who do you guys think? If you were to send someone to get CoolSculpt. What's the, who's the sort of patient that you think would get a good resolve from CoolSculpting.

Who's the sort of patient that you think wouldn't get a good result from CoolSculpting?

[00:07:13] Dr. Salvatore Pacella: Well, so I think where I usually see it fitting in is in patients that have say good skinny last. Love handles or perhaps, areas that are very spot difficult to treat. Interestingly enough, those are areas that are very amenable to liposuction anyway. Right? So there, it's not really a patient who has, say a post-pregnancy double twin pregnancy has excess skin, a little bit of fat and muscle laxity.

That's not a patient for for cool.

[00:07:47] Dr. Sam Jejurikar: Yeah.

[00:07:48] Dr. Sam Rhee: For me, the indications are really small. I would say the only way I could really see this working is for someone who has very mild or moderate, really mild fat deposition who's just really adverse to liposuction.

That's the bottom line, because I would say in my experience, And I'm very biased. I don't own a CoolSculpt machine and I do liposuction. So I understand that I'm a very biased observer when it comes to this type of technology. But for me there are very few indications where I would say CoolSculpt is going to win out.

And that's basically anyone who just doesn't want to do liposuction for whatever reason, but in almost every other situation, I feel like liposuction is going to get you a better.

[00:08:34] Dr. Sam Jejurikar: I would agree with both of you guys, a hundred percent. Liposuction is always going to be the gold standard for fat reduction.

And I particularly Sam's point people that don't want liposuction. Me, for instance, as a surgeon always generally recommends liposuction to people that are in my office. But me as a patient, doesn't really have the time to recover from liposuction. So CoolSculpting might be something I would consider because there's no downtime really associated with it.

The other two indications that I would say in terms of patients that get good results, you can't be too fat. If you're morbidly obese, the applicator's actually just have a hard time sucking up the fat and the results tend to be very unimpressive. And if you're super thin I think we've sort of seen over time that patients that are really thin it's harder to cool the fat because of the proximity of the fatty tissue to the underlying muscle, which is a little, a little warmer and the results don't tend to be as good.

So you can't be too skinny. You can't be too fat. You have to basically be okay with results that are going to be improved, but not perfect. And stacking treatment. Sorry.

[00:09:38] Dr. Salvatore Pacella: So you mentioned something very interesting. You said CoolSculpting has very little effect on the skin. So if given a patient that is a CoolSculpting candidate, you did regular traditional power assisted liposuction.

And, in, in my experience, those patients get really pretty decent skin retraction. Right? If given the same patient for CoolSculpting, are you saying that there's less skin retraction?

[00:10:06] Dr. Sam Jejurikar: I think so. Because I think it's rare for any of us that are talking here to just do liposuction and not at least think about the skin.

Although what we typically tell patients is that liposuction is geared towards fat removal. We all have things that we do during the surgery itself to try to promote skin retraction. When you're talking about power assisted, there's usually a step at the end of the operation, where you're doing fat redistribute redistribution with your fat, with your cannular.

To basically smooth out the fat and in the process you traumatize the undersurface of the skin, which I think is, can promote some, some new college information over the ensuing months. I typically use an energy modality, which we'll talk about at the very end of this in combination with, with, with patients who I don't think have great skin elasticity.

Obviously, if someone has great skin elasticity, like you had sort of mentioned in your indications for someone that's going to do well with CoolSculpting, they'll get skin traction, but if they have poor elastics I think they'll have extra skin or their skin will hang that. Does that answer your question?

Perfect. Perfect. So here's what got me thinking about CoolSculpting. And I don't know if both of you guys saw this. I imagine you would. It was a big news story, but Linda Evangelista the super model from the 1990s, put forth a Instagram post and announced simultaneously a lawsuit against Zeltiq which is the subsidiary of Allergan that owns CoolSculpting.

And in it, she developed paradoxical adipose hyperplasia. This is not Linda evangelists says tummy in this picture. I'm just going to put that out there. I haven't seen what it looks like, but this is a patient that's at CoolSculpting and you can sort of see it as block in the lower portion of their abdomen, which is PAH or paradoxical adipose hyperplasia, which happens.

And I'm going to use air quotes rarely after CoolSculpting. And I'm using air quotes because nobody really knows how often it actually happens. First time, it was really reported in the literature was 2014. They said it happened one in 20,000 times. The manufacturer says in their own literature that it happens about one in 4,000 times. There was a letter to the editor in Plastic and Reconstructive Surgery in 2016, where the authors had said, when they were using a large applicator to treat the lower portion of the abdomen or the flanks, they saw it in one in 138 cases. And they talked about some modifications that they did, where they would use smaller applicators and kind of distribute the cooling a little bit differently with the use of multiple smaller applicators in that they thought that reduced the frequency. And probably the most comprehensive review that was published just last year and the aesthetic surgery journal.

And they surveyed over 2000 patients from Canada. And they said that the incident was probably about one in 2000. So it's definitely a thing that I've seen multiple times and multiple patients who have come to me probably eight to 10 times in the last five years who have developed this for treatment. Have you guys seen this at all?

[00:13:10] Dr. Sam Rhee: I've seen two. And the worst was someone. Had a bra like the behind the back bra area. And it was, it was quite amazing how hypertrophied the fat was there. It, it looked almost like those blocks that you just showed in the belly, but it was around the back. And the thing that concerned me about it was if you have a complication with liposuction and I, and listen, you can have a complication from any aesthetic treatment.

We know that. A lot of it is really operator dependent. Right? In fact, all of it really is operator dependent. You find someone who's as experienced as you possibly can be with any treatment, and you're going to reduce the risk of complications. And I would say, I don't know the exact statistics, but I would say in the experience.

Physician plastic surgeon who knows how to do liposuction, I would imagine the risk of complications is going to be relatively low, definitely lower than one in 130. It might approach one in 4,000 or one in 20,000 and is my guests. And you're never going to get more fat resulting from liposuction.

Let's just put it that way. You'll never have more fat than when you started with. And if you do have complications with liposuction from liposuction itself, it's probably going to be relatively minor. You can't even tell who are the patients that are going to have paradoxical hyperplasia. Can you, It just happens randomly.

So that's, that's a little concerning that you, you can't actually even predict who's going to get complications from CoolSculpting.

[00:14:43] Dr. Sam Jejurikar: The only thing I would say to that is I think you're right to a degree. I do think that the incidents of paradoxical adipose hyperplasia has increased as more and more physicians have gotten aggressive with stacking the treatments.

There's a lot of thought process that as people have started to try to get more and more and more fat removal, as opposed to just doing one treatment, the incidence of it has increased. And then again, as I sort of mentioned Changing the way applicators are used. I think as for instance, instead of treating the lower abdomen with one giant applicator, treating it with two smaller ones has been shown to probably result in less of a likelihood of getting this pH, which by the way, is also called a stick of butter.

It looks like a stick of butter, which is why this book. I realized there was a reason why I put a picture of butter on the slide, but it's, that's why people, that's how patients sort of identify that they have this discussion. I've just been staring at this block of butter butter. Oh yeah. That's why

can you treat this

[00:15:47] Dr. Salvatore Pacella: with regular liposuction to dig and remove it? Yes.

[00:15:50] Dr. Sam Jejurikar: Maybe. So Sam said yes. And that's the way I've always treated it.

[00:15:58] Dr. Sam Rhee: I was just about to say Zeltiq will reimburse the patient. For liposuction treatment, if they get pH, if you submit all of your documentation. So this, I imagine this happens more often than, than the company is letting on because they have a very standardized procedure of how to deal with pH or paradoxical adipose hyperplasia.

They have this whole formalized procedure and. As you wrote there, it's not more CoolSculpting the way to treat it in Zelle. Teaks mind is with liposuction.

[00:16:33] Dr. Sam Jejurikar: Yeah, two things that kind of add to that as part of the reimbursement thing, there is an NDA that patients sign. So yeah, we don't actually know how many patients have done that.

Linda van Jaleesa refused to sign all of that, which is why I think I got so much publicity. The company, th the only definitive way to really get rid of it is actually direct excision. The most people have had very good success. An energy modality, whether it's power assisted, live Hora Vaser and liposuction removing it.

I have had one patient that recurred after I did Vaser and liposuction and I had to have a second treatment. So it's not foolproof, but it is definitely much less morbid than directly excising except. But yeah, it's a, it's a real thing. So, any more thing, so I guess my take a message with CoolSculpting is I still think there is a place for it.

I think it's certainly a very cost effective treatment at this point because it comes to supply and demand and the supply of CoolSculpting machines out there are it's quite high and the demand has gone down as there's newer technologies that we're going to talk about, but you can still get pretty good results with.

This is what I would say, but you have to watch out for these complications and if you are unwilling to, to take those risks it's, this is a complication that is unique to CoolSculpting and nothing else we're going to talk about

[00:17:47] Dr. Sam Rhee: again, I think one of the biggest problems with this is that cell teak marketed to everyone.

Physician out there, like you said, it was on every corner. And I was bombarded constantly with ads to get, to purchase one of these machines. And I think once you throw five bazillion machines out there with people who may not have a whole lot of experience, managing aesthetic body content, You're going to get problems.

Like you said, they're trying these machines in ways that are probably not really indicated. And the rash of complications in Sue's just like with many other aesthetic treatments that we've seen out there. So I feel like some of the blame actually lies with Zelle teak, to be honest with you and the fact that you just have to find providers that know what they're doing in general.

Just like with every other aesthetic treatment, whether it be Botox or something that's supposedly safe or non-invasive, the per the person who administered it and does it, it does matter.

[00:18:45] Dr. Sam Jejurikar: I totally agree. And, and let's, let's move onto the next technology cause we spent plenty of time on. So I'm in 2015, the first FDA D the FDA approved the first device for for removing fat by heating the skin, which is affectionately been known as warm sculpting, but that was actually sculpture, which is not what we use in our practice.

It was the first FDA approved device. And it was a similar process as opposed to gently cooling the skin. You gently heat the skin and much like you get programmed cell death, like you do with cooling. You also get programmed cell death over several months with heating the skin. And so typically people would see 20 to 25%.

Loss over several weeks when there but one of the differences in which people sort of kind of notice at the time was that you could have some secondary benefits on the skin. So when you use radio-frequency over the ensuing months, you can get increased production of both collagen and elastin in the skin, which helped profoundly with skin elasticity.

And so when you looked at patient satisfaction scores, a few months afterwards, it tended to be. With, with radio-frequency techniques. What we use in our practice is a, is a, is a treatment called evolve. And it just sort of illustrates some of the things that you can do with heat that you can't do with cooling that only can you get fat removal, but you definitely can also see some tightening of the skin.

And you can also start to see some muscle development. They've, they've very cleverly marketed as tight trim and tone as the different treatments, but they're all using different benefits of radio frequency to get results on, not just the fat, but also on the skin and the muscle. So here's a, here's a patient who underwent one cycle of treatment.

And what we typically will do with one cycle of treatment is come in weekly for six weeks. To get a relatively quick 20 minute treatment with with any the evolve probes. There's four to six of them hooked up at a given time. So it's a quick treatment, but you have to do them staggered over the span of a, of a few weeks, but this is one trip, one cycle of treatment.

When you sort of see that at, after a few weeks have gone by, after the treatment, there's an overall just, again, not all the fat's gone, but the abdomen is substantially smaller. And you can tell that this. Has tightened somewhat with this treatment when you guys agreed that unlike the CoolSculpting picture, you can definitely see the skin's a little bit tighter.

There's not the same sort of wrinkles that you might've seen. And this is someone that I would look at. Who's getting liposuction that I would be afraid of would, would would have some, some excess skin. Now. I think we would all agree this isn't the same result as we would get after, after after liposuction, but for a no downtime procedure, I think the results are pretty amazing.

Another patient here real similar, where they've, they've undergone a cycle of evolve. They've had this gentle heating of the skin and then after several weeks they lose a good amount of fat. But, and their skin has tightened down without having a lot of loose skin. I think in both this picture and the one I showed you before in both of them.

If I were to objectively look at this, the same problems that they had before the treatment exists, but it's just better, right? Like this patient still has extra fat of the entire abdominal wall, but it's better. So, if that's the sort of treatment that sort of results that a patient's going to be happy with, I think I'm using a radio-frequency noninvasive treatment, like sculpture, like evolve are going to give you results.

They'll be happy with that. They're looking for the flu. Best result they can. That's when it's time to see a plastic surgeon and have

[00:22:00] Dr. Sam Rhee: it's pretty impressive actually. Does this work safely for all skin types or all ages or, are there any sort of limitations in regards to patient population or.

[00:22:11] Dr. Sam Jejurikar: Skin types, not really any limitations, all ages. I think you and I, all three, all three of us would agree that as patients get older, there are less density isn't as good. So, in older patients, I tend to be much less impressed with the results of radiofrequency treatments as patients in their fifties and sixties, I don't tend to see these quality of results from a skin tightening standpoint.

And then patients in their thirties and forties, that haven't lost massive amounts of weight. And haven't developed a bunch of stretch marks from pregnancy. Yeah, I think it can get really good at.

[00:22:43] Dr. Sam Rhee: I mean, I don't want to be the CrossFit, a hole here, but a lot of these body consequences.

[00:22:49] Dr. Sam Jejurikar: Ju just to be clear, when you say CrossFit and you start talking about it, you were automatically in April

[00:23:00] Dr. Salvatore Pacella: CrossFit, always, always talking about.

[00:23:08] Dr. Sam Rhee: All right. So I'm going to be the CrossFit a-hole here and I'm going to talk about it, but let's face it. A lot of aesthetic body contouring, these patients would benefit a great deal from lifestyle changes, right? They would do better if they nutritionally improved, if they improved their fitness level. All of these things.

[00:23:27] Dr. Sam Jejurikar: I think, I think you have this confused with your other podcast. Dr. Rhee forgot where he was for a second. He forgot. He forgot the Three Plastic Surgeons talking about treatments.

[00:23:43] Dr. Salvatore Pacella: A vegan, a CrossFitter walk into a bar. Who stops talking first?

Before I get canceled, I just want to reach out to my vegan colleagues. I am also on a plant-based diet.

[00:24:02] Dr. Sam Rhee: Oh, so you're gonna apologize to the vegan guys, but not the CrossFit guys out there.

[00:24:06] Dr. Sam Jejurikar: I fully, I actually fully back Dr. Pacella on that.

[00:24:11] Dr. Sam Rhee: All right, I'm gonna, I'm gonna, I'm just the last preachy thing I'm going to say about this is, is I do talk all of my aesthetic body, contouring patients, especially if I feel I asked them, listen, do you think you could do better with your lifestyle, with what you're doing in terms of what's going on? And if you feel like you can, you should do it before you get an aesthetic procedure. And I think, holding our patients accountable to a certain degree is really important because some of these

changes they don't like about themselves where they come in to see us are in large part due to things that they might be able to improve on their own as well. And so I'm not saying no to aesthetic body contouring but I'm saying it's synergistic with the stuff that you can do in your life to make

[00:24:56] Dr. Salvatore Pacella: yourself better, I'm going to start, I'm going to start recommending Popsicle therapy.

So for facial

[00:25:05] Dr. Sam Jejurikar: cosmetic, You just have to make sure they symmetrically apply the popsicles each inside of each sheet. And now that I'm done abusing Dr. Rhee, he's a hundred percent, right. A healthy, any procedure we talk about whether it's surgical or nonsurgical is not a substitute for a healthy lifestyle, which includes both diet and exercise for sure.

But you know, sometimes, and I think you would agree with us, Sam, that the two go hand in. You know that that changes in lifestyle and simultaneous body contouring procedures together, just give a synergistic result, but sometimes you can't achieve with either alone.

[00:25:37] Dr. Sam Rhee: I agree. And I've seen that.

[00:25:40] Dr. Sam Jejurikar: Yeah, for sure. So then, now I'm going to talk about something that these guys will have an easier time getting behind, which is liposuction. Yes. Liposuction is the gold standard. The treatments that we talked. Are best for people that either just don't want to have surgery because they're afraid of surgery or don't have the time for surgery.

But with liposuction, if you want to talk about the gold standard for fat removal, it's still going to be that because we all know we can remove a lot more fat with liposuction. And a lot of times we can do. Better whether it's related to skin, whether it's related to the muscle with liposuction and using things like radio-frequency or ultrasound, which is commonly known as body tight or J plasma or Vaser all of which I use body tight and I use Vaser a lot in my practice.

You guys may use other things, but, but using energy modalities in combination with lifestyle, Can to some degree help with skin elasticity as well. So, I think you can also get more precision in terms of the results. So, here's a, here's a patient that had liposuction. You just, you can accomplish so much more in terms of developing the underlying abdominal wall structure and making the overall abdomen look smaller.

Here's a lady who. Probably didn't even need liposuction. She looks like she's in great shape, but you can just shake the body much more precisely when you do liposuction and the fat that you take out with liposuction, you can use in other places. So in this patient, we took out fat from her love handles and our abdomen.

We put it in her hips and we make her look curvy. And so, liposuction is still going to be the gold standard by which you can, you can get great results. So that's all I really have to say. I don't know what closing thoughts you guys have on this topic. I know you guys do a ton of body contouring as well, so I don't want to hog the spotlight.

Oh, great, great

[00:27:19] Dr. Salvatore Pacella: presentation. I think I think that's just reiterate. So in our, in our world, we, w what I think makes us. Unique among aesthetic providers or cosmetic providers as board certified plastic surgeons is you can be assured that when you come in to see us you're going to get a bespoke or tailored treatment.

Not when you're a hammer, the whole, whole world is not a nail. So, we're going to give you what you're going to, what's going to be best for you, or we'll at least talk about the options for you.

[00:27:50] Dr. Sam Rhee: Yeah, I completely agree. We see more patients of all types, mild lipid dystrophy to significant lipid district, tons of fat and we know how to deal with it.

And I hate to say it, but it's true. South said being a board certified plastic surgeon just gives you every, every tool in your disposal. The other two things I was going to say is one is a, I do love the fact with liposuction. You can recontour and actually change proportions, which is which is very powerful, especially when you're looking to redistribute.

And then my last one is sort of facetious. Did you put all those ovals on because for the dude that oval went down about like two thirds of his thigh and I just wanted to know

[00:28:33] Dr. Sam Jejurikar: he's a powerful man,

[00:28:36] Dr. Sam Rhee: just checking.

[00:28:37] Dr. Sam Jejurikar: This is taxes, there's a saying we have down here, everything is bigger in Texas.

[00:28:43] Dr. Sam Rhee: I'm glad, you know what? I'm very impressed. I'm very impressed with the men of Texas.

[00:28:47] Dr. Sam Jejurikar: That's nice. Yeah. Yeah. Awesome. Well, on that note, gentlemen, always great to catch up with you guys enjoyed this conversation a lot and until we see each other again, take care.