Episode 49: Friday February 4

What if you could have naturally full, perkier breasts WITHOUT breast implants?

Drs. Salvatore Pacella @sandiegoplasticsurgeon, Sam Jejurikar @samjejurikar, and Sam Rhee @bergencosmetic welcome guest Dr. Andrew Trussler. We talk to Dr. Trussler about his expertise regarding auto breast augmentation, or natural breast shaping with a breast lift.

Board certified in plastic surgery, Andrew Trussler, MD, was an All-American swimmer at the University of Southern California. He also graduated Summa Cum Laude from the Keck School of Medicine at the University of Southern California and was a member of the Alpha Omega Alpha medical honor society. After completing general surgery residency at the University of Michigan, Dr. Trussler obtained his plastic surgery training at the University of California, Los Angeles and then completed an aesthetic surgery fellowship at The University of Texas Southwestern Medical Center at Dallas.

Dr. Trussler was an Assistant Professor in the Department of Plastic Surgery from 2007 to 2012 where he served as the director of both the cosmetic residency and fellowship programs, as well as the co-director of the abdominal wall reconstruction program. He now resides in Austin TX with his wife and 5 children, and practices in the Westlake area.

We catch up with Dr. Trussler, who reviews his technique and approach to maintaining volume, shape and size in patients without using implants and demonstrates multiple example cases. If you are interested in natural breast shaping this episode is a MUST

#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetic #aesthetics #mastopexy #breastlift #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery #breastreduction #transformation ⁠#nobreastimplants #boobjob

S03E49 - DR. ANDREW TRUSSLER - AUTO AUGMENTATION (Natural Breast Shaping with Lift)

Dr. Salvatore Pacella: [00:00:00] Good morning, everyone. I'd like to welcome you to our next podcast. I'm of course, Dr. Sal Pacella from San Diego, california at San Diego plastic surgeon, that's Instagram, I'm joined of course by my colleagues. Dr. Sameer Jejurikar who's in Dallas, Texas.

It's @SamJejurikar on his Instagram. And of course, Dr. Sam Rhee out of Paramus, New Jersey, the New York city area, and it's @Bergencosmetic. So we are joined today by a very good friend and former colleague. I'd like to introduce my good friend Dr. Andrew Trussler, we were interns together at the University of Michigan. He was in general surgery. I was in plastic surgery. And then shortly after that, because of my influence, of course, I convinced them to join plastic surgery. He ended up doing his fellowship at UCLA.

He was one of the top stars at UCLA and they did a cosmetic fellowship at Yale. Southwestern shortly after that he joined the faculty at UT Southwestern and was there until 2012 and then decided to go [00:01:00] to private practice in Austin, Texas. One of the greatest cities in the country from what I hear.

Andy does a tremendous amount of cosmetic surgery. He's a great guy, super entertaining prior to introducing him for the very last time. I'm going to hand it over to Sam Rhee, who's going to give us our intro disclaimer.

Dr. Sam Rhee: Thanks. So 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 circumstances, situation, and medical judgment after appropriate discussion, always seek the advice of your surgeon or any qualified healthcare provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show.

Dr. Salvatore Pacella: Andy welcome. It's been a long time, been many years since we've seen your face.

Dr. Andrew Trussler: It's great for great to be on here as good seeing you guys. I hadn't seen, I hadn't seen some of you guys for years and years, so it's cool. Thank you.

Dr. Salvatore Pacella: Andy we're going to talk today about a [00:02:00] really interesting topic that you've done a tremendous amount with, and you've evolved through your practice since.

You're going to be talking about auto augmentation for our listeners out there, what auto augmentation is it's shaping and re configuring the breasts without an implant. So if you've ever decided to get a breast lift or get some augmentation, this is an interesting way to do so without using a silicone breast implant.

So Andy wants to take.

Dr. Andrew Trussler: Yeah, this is a subject that's near and dear to my heart. And something that I started actually at UCLA the influence really for it was, Peter Rubin's article in ASJ probably, I think it was 2005 in the massive weight loss population. And.

Yeah, those patients presented to me, not infrequently. And I feel like those, that population alone with an implant, even though you think that they need an implant for volume, which a lot of them do you can achieve quite a good breast shape and quite as. Good amount of [00:03:00] volume just based on the epithelialized skin and thin glandular tissue.

And so I worked in that population then translate, translated over to a cosmetic population and more recently to. Revision population, our implant revision population who may need or want their implants out. And so from a primary perspective, I think we have a couple of examples of patients who presented to me who basically wanted a breast lift, and didn't want an implant and, or patients that presented with C plus volume that wanted, want to maintain volume in that I feel those patients are the most challenging mass specs, the augmentation patients. I did a ton of mass that's the augmentations, but you know, that operation is fraught with a lot of controls

issues. And I really worked on that operation as well to control the position of the implant. Long-term and things like that. But the larger breasted patient who wants to maintain volume, who needs and could benefit from a lift. These are the [00:04:00] perfect candidates and they're not all massive weight loss patients.

I think those patients. Somewhat few and far between in a way. And it's an operation that's based on on a central mound and then I don't base my structure on dermis. I think that's where the. Results probably fail long-term

Dr. Salvatore Pacella: Just for our for a non-plastic surgery, viewers and listeners out there. So what you're referring to is when you're talking about doing a breast lift and placing an implant at the time the implant and the breasts sometimes act differently, right? We can usually control the position of the. Reasonably well, but sometimes what happens is that breast tissue sort of falls off of the implant and it may bottom out preferentially because it's soft tissue compared to an implant.

Maybe you want to tell us a little bit about some of the challenges you've may have had throughout the years, or let's open it up for discussion about, what you guys do to help control that issue,

Dr. Andrew Trussler: For mastopexy augmentation patients. You're [00:05:00] managing, two different forces you're managing, adding volume and then, somehow repositioning and lifting breast tissue as well.

So I always think of that as melding the two and having those two. Structures stay together. Often you'll see the implant too high or the implant too low. Implant too high is probably related to the breast falling off implant too low. Is this too large of an implant with too little.

And that's the battle when you have a lot of breast tissue and you're putting an implant behind it, you just have a, too much going on there. And those are really challenging patients in the literature. They're the most, those are the patients that are fraught with issues.

And that's why this operation is a really nice office.

Dr. Sam Rhee: Yeah, I think we've talked about this before briefly. And when you're trying to tighten up that skin envelope, and then you're also trying to expand volume, like Andy said, it's you're you have two competing forces and I always likened it to try and to stick 10 pounds of potato in a five pounds.

And then Sal said, no, I've only heard that comparison [00:06:00] with resident

Dr. Salvatore Pacella: inappropriate, Inappropriate.

Dr. Sam Rhee: Anyway so to keep

going. Basically every time you're trying to stuff this implant in, and you're trying to tighten up the skin envelope around. It's like you said, it's fraught with challenge and difficulty, and the fact that you can actually take a breast lift patient and use their tissue in a way to shape and augment their volume with their own native breast tissue is something that I think a lot of patients could actually benefit .

Dr. Salvatore Pacella: Yeah. You're absolutely right. It's I think. Well, we tell patients, is we have four dimensions to control in surgery. There's length, height, depth, but we can't control the fourth dimension, which is time. And that's where I think it's oftentimes really challenging on the table.

You can get a great implant, a great lift. It can look absolutely perfect. And then, the forces of contraction will take over the forces of [00:07:00] gravity will take over and, sometimes the best laid plans in the operating room. Don't turn out exactly correctly later on. So curious to see how you attack this problem.

Dr. Andrew Trussler: Yeah, I think one of my, one of my mentors, he used to tell me the lower pole of breasts is liken to Elizabeth's tail. It's the only thing that grows back. It seems so, really that lower pole control is tough. And I really work at that with massive X Yaga. I really have to work at providing support to the lower pole.

So the implant just, doesn't bottom out and then the tissue and the implant are all protected and in enable it to heal while as well. So yeah it's a tough one in I think patient realization that it is a tough one is hard. Everyone thinks it's an easy operation, but it's just not.

So yeah, I think this is a really nice option.

So this is a typical kind of patient who, doesn't want an implant benefit from a breast lift, but what's a little bit more shape. And so I think if you really look in the lateral and in a three-quarter [00:08:00] view, you can really see where that volume is maintained.

It's above, you have upper pole volume on that. Ironically, there isn't an article where they really said that you can't achieve that without a small implant. And I think with this, you can, and I think the terminology gets a little bit skewed in this day and age with fat grafting, these are not fat grafted patients.

This is all breast tissue. On a central mountain. So it's on a blood supply that I just refashioned and around the nipple and it actually forms almost an implant, like shape that's attached to the the pear ostium into the upper pack as well. And I use an absorbable suture on everything,

This is only three months. I think she's lost a little bit of weight as well, but I see patients back for a long period of time. I think I'm honest with patients as far as telling them, Hey, there may be some scar vision type stuff in the lower pole, things like that, but nothing that would necessitate reoperation.

But so I do see patients back for scarf air, well over a year, and I think the [00:09:00] results do last, I think. There's maybe habitual changes in the patient that I'll see sometimes with a Breslin functionally there's improvement. So patients may be a little bit more active and things like that. So you'll see some weight shifts and weight fluctuations, but long-term, I think I saw this patient back a couple of weeks ago in term.

They're good. And years. Yeah I think having follow-ups over a year's important, and I think these are fairly short results, but they do last for as long as the patient wants them. And I've had one patient come back for an implant for more volume or for volume augmentation in the upper pole.

And then a year later we took that implant out. I think it was like a one 90 CC implant too. So it's not like it was huge. And that's one out of a series of probably. Closest closer to a thousand patients probably right now. [00:10:00] No, like in the consultation, I give them Hey, this is your option. Long-term too. In fact, grafting is in the cards. I have done that. I have done that in combination with more importantly, the patient who comes in for implant removal, auto augmentation may have, may I may call it and say, Hey, you don't have a huge amount of volume, but, you know, Doesn't want an implant back in, right?

So you could add some background into that. So I think this patient, sure. That would be an option and a smaller implant, like , a lower profile implant would be another option as well. And that's on the table. I usually have, if we're going to do that, wait at least a year to consider that.

But as I said, those are few and far back.

Dr. Sam Rhee: This is a great [00:11:00] result. The first time I ever saw something where there was an auto log with a mastopexy was James Groton who described something with a superior pedicle, and then taking the inferior tissue and sort of hiking it underneath. But I don't know about how long that would last Amy alderman, when we talked to her last year, if you guys remember, she talked about something similar to this that she developed with Halston.

And I think she did the same thing you're describing, which is securing it to periosteum or something really stable. And so I thought maybe you could describe that a little bit more and see how that contributes to the Jevity.

Dr. Andrew Trussler: Yeah. So if you think about the, and I wish, I guess I should have had a preoperative marking patient, but the preoperative, what you're gaining, what you're getting the augmentation from is basically the meat, the inner and outer Derma glandular wings that comprise a wise type pattern.

These are Y site pattern skin incisions, and then everything within the wise type pattern is wrapped on itself. So the [00:12:00] upper triangle of that Westpac. That's what I'm securing to the periosteum into the pack. I use OPDs for that and I use a three point. I used to just use one point, but I felt like a medialize the nipple a little bit, put a little bit too much tension on it.

So I think if you go almost true superior, have some stabilization, throughout the medial aspect of the breast that can really secure that. I know it lasts for quite a long time. Cause there, you can actually feel a little bit of maybe some fat necrosis and, or just a little bit of scar tissue at the upper aspect of the pedicle sometimes.

That softens over time, but yeah, you can usually palpate the periosteum of the, fourth, third rib on the inner aspect in this work. Laterally immediately on that. You have to elevate flats and, that's the thing. You really take things apart and put things back together. This operation I'm a little, I'm more aggressive with the upper pole, this section and my skin flats now than I was a little bit hesitant to [00:13:00] really, rewrap the skin over the mound, but not really work.

Dr. Salvatore Pacella: Yeah, I think that's the key here for an operation like this. And, when I do even a breast reduction that's on a small PA smaller patient I think the key is really elevating the superior skin flap all the way up to the Peck, because that allows you to sort of really get tissue up really high because, as you met.

It's just going to always go down again. So yeah, I think oftentimes if you don't do that to section all the way up, you're just going to get an inverted slope to the upper pole. Yeah. And

Dr. Andrew Trussler: I saw Amy's presentation and I've the literature is out there, but it's not.

As complete as what you would think and try to get this stuff, out there and within a a readable kind of manuscript, but it's a yeah. You'll see. You'll see that. Sal said is you'll see that flat upper pole than a projecting breast. And that's just cause things aren't detected as far as, and then the lateral aspect I am doing, [00:14:00] the skin flaps are attached to the lateral chest as well to periosteum.

You have to be careful with the, where the Peck basket comes out and things like that. So you navigate around that, but the skin and creating that lateral breast folds not. Not with the actual amount, but that's really what the skin and I'll do that on majority of patients.

Does he leave drains in? No, I don't use drains in the breasts. Yeah, I don't. Yeah. The goal is to have no dead space in there and there's really not. There, coming out there, they look very Accentuated upper pole is very essential. Cause it's if you don't have that doesn't get that doesn't get better.

It gets, things go lower, not higher.

Dr. Salvatore Pacella: You know what one thing I've done before in a patient like this that didn't want an implant is utilizing some ADM just to support the actual breast mound very similar to how you would do a pre-pectoral breast reconstruction or at least, three quarters of the way.

And I found that to be moderately successful. It does have some expense to it. Patients do have to pay for. ADM or an acellular dermal matrix [00:15:00] or some sort of mesh to hold things into position. But I've been pretty happy with that operation. So do you have any additional slides, Andy?

You get some other.

Dr. Andrew Trussler: Yeah, we have we have plenty more, but that's a good point. I have a couple of patients, I think maybe one or two patients that I have not primarily, but there can be a little lateral descent in the breast tissue or in the mound. And so I have gone back. I just, I believe on just one patient, I use gala flex on her.

I don't know if I should use a trade name on this, but I have no financial implications on that, but so I've used that and I like that. I think it, it serves all the purposes I need it for. But it, for reinforcement, especially on the outer aspect, that lateral aspect on a rounded chest, I think it can help reinforce things, but I don't do things primarily on that.

I really, I don't feel I need it on everyone. It isn't at an expense. It's a foreign body. So if I don't need it, I'm to use it. Yeah.

Dr. Salvatore Pacella: Keep it organic. [00:16:00]

Dr. Andrew Trussler: Keep it grain.

Dr. Salvatore Pacella: this is a great result.

Dr. Andrew Trussler: Yeah. So this is actually a patient who wants to maintain volume. Okay. Dense breasts too. I think that's the other thing just

Dr. Sam Jejurikar: this is a gorgeous result. Imagine this patient you, to be just a little bit

Dr. Andrew Trussler: from breast is she's

Dr. Sam Jejurikar: how you were sort of alluding of all the

Dr. Andrew Trussler: from breast is she's great longterm.

So this result holds true more. Now

Dr. Sam Jejurikar: you think there would be a role

Dr. Andrew Trussler: or, maybe eight month results, something like that. And there you go. There are no impact. Volumes up. This is what the patient wanted. I'm sure I could say there's a little bit, maybe a little bit large, but you can see from the lateral view that upper pole stays true.

Yeah.

Dr. Salvatore Pacella: That's

Dr. Sam Rhee: great. Yeah. Super

Dr. Salvatore Pacella: impressive.

Dr. Andrew Trussler: And this is a patient. This is a pretty early result out of town patient, but you know, you can see where volumes down a little density to abreast.

I think this patient would be really challenging to even consider putting an implant behind. And this is [00:17:00] a result from a lateral view in three quarters.

Dr. Sam Rhee: It's impressive because if you didn't tell me, I would've guessed possibly that you had put a spot plant in.

Dr. Andrew Trussler: That's what it looks like. Sometimes I'll trick the office staff.

Dr. Sam Rhee: You'll show them this and

Dr. Andrew Trussler: they'll think that they're. Do you have the implant information on this patient?

Dr. Sam Rhee: I would totally believe it actually. Do you ever do any liposuction in the lateral aspect of the chest wall in

Dr. Andrew Trussler: order to, yeah, no, I so all that, see that, that indentation on the outer.

That's that I have a series of OPDs sutures that really go right down to the river right there. So that's a little bit more accentuated than what it will be. Long-term but I actually utilize a lot of that tissue. If you look at the auto augmentation in the, in the oncology. Uncle plastic literature, they're really harvesting outer breast flap.

So I really do harvest quite a significant outer breast flaps. So that's I actually use that, but you can [00:18:00] see that scar extends onto the outer chest. So I really don't do any liposuction in that area or feel like I need it,

Dr. Salvatore Pacella: I guess, tell me, Andy, tell me a little bit about the pain patients have after this, with those deeper sutures to the periosteum and things like that.

What do you, how do you manage that? How bad.

Dr. Andrew Trussler: Yeah. So all council patients is not uncommon where that will be the point of discomfort not the upper chest, but the outer chest in all counsel patients beforehand. Hey, that, that, that can hurt. I think sometimes it doesn't, it's not uncomfortable right away, but as a student, Dissolve sometimes two to three weeks, you'll have this kind of, they'll actually hear a pop and I'm like, well, that's probably one of those sutures breaking free.

And so I do a series around four sutures out there. Just because I feel like it needs a little bit of support. So at around 10 days, They'll feel a little bit more discomfort, inflammation, things like that. I'm a big proponent of anti-inflammatories I don't use a huge amount of lyposomal bupivacaine, [00:19:00] but I always inject in that area with, directly in that area with bupivacaine and that seems to get them through the, at least the initial kind of discomfort, but long-term I haven't had any.

Longterm issues in that area, but it is, it can be uncomfortable, but it's usually this delayed discomfort. That's not doesn't require anything other than maybe just increasing, maybe a little bit of ibuprofen. Let's see here. Do we have another? So another patient, a large breasted doesn't want, doesn't need an implant long chest too. You can see where the chest hits probably a longer IMF. I've tried to lift IMF. I think that's really challenging. And I think that those are the patients that could benefit from some reinforcement, maybe some gal flex or something like that.

But this is an auto augmentation patient maintains volume. As a look of an implant and maintain

now, this is this actually an interesting slide. This is a patient who presented to me that had implants. She had salient implants, I believe like 430 CC salient implants. Didn't want them any more felt she was too big. And [00:20:00] just. A little bit more. And I felt like, it's interesting when you remove the implant, you actually see the ptosis, the true laxity of the brass, because I feel like that capsule around holds the breast up.

So once you take out the castle and take out the implant, I put the Peck back down and then so all the Ottawa mutation is prepectoral and same Y site pattern. Tissue mass that's wrapped on itself. And then this is what you can gain. A lot, she was very, didn't have a huge amount of breast tissue.

This is a 400, I think 440 CC salient implant. And then this is her without the implant with an auto augmentation, no fat grafting. That's very

Dr. Sam Rhee: impressive because correct. If you've ever seen, I mean, we've seen it, but a lot of patients, obviously haven't, if you take out a 400 CC implant, you get nothing. It looks like a completely deflated balloon.

And for you to take that existing tissue and refashion it into a very natural [00:21:00] and, nicely lifted breast volume is very impressive. Especially before. You saved them an operation. You basically did it in once in one step. You didn't you didn't delay,

Dr. Andrew Trussler: which is great. That's the hard one on that because the literature on that one's out there too, and yeah, I think it's it's one of those operations where, you know, patients really, they'll present say I don't want an implant and this is an option. It's not an option for everyone. It's an option. If you see through where she's going to be after you remove the implant and use everything you can without deforming the lower pole or making it too tight, I think this is a really nice option, but it's, it is a really, it's a challenging surgery.

And on these patients, I do superior pedicles and then an inferior. Mound underneath of that, because if you think about where the incision is, if it's a sub-area polar IMF, you've really delayed the nipple. And you're not really, I don't feel you're not really going to have a central Mount, obviously.

So I do superior [00:22:00] pedicles on here. It's a different type pattern, but same principle of I do anchor that, that lower Mount up to the periosteum and then refashioned it.

Dr. Sam Rhee: How much ptosis are you willing to tolerate in terms of these patients? Like how how much ptosis, where we say this is not something that I would feel comfortable doing?

Dr. Andrew Trussler: With the central mound, I feel like I, I do breast reductions. I do a lot of superior pedicle breast reduction, so I've really, I pushed superior pedicles a little bit in central mounds as well. I guess I don't want to put a limit on it, but I'm I have a pretty broad, I don't have a, I don't have a number to give you, and I think if you looked on one of those patients, I think the third example, she had quite a bit of ptosis and that's a central mountain.

And I think the blood supply to this to, The central aspect of the breasts is fairly secure. And so there's no undermining under there. And I really have a limited, I've had a couple inferior aspect of the aerial or, a little bit of [00:23:00] necrosis, but they're few and far between not any nipple loss or anything like that.

So I feel really good about that pedicle and feel like you can apply that to a lot of.

Dr. Salvatore Pacella: That's great. That's great. Well, Andy, this is these are really great results and I think it really represents an operation that is somewhat under the radar that we don't necessarily offer patients very frequently because it's quite honestly, it's a lot easier. To just put in an implant, but obviously the potential for implant related issues are high.

So this is a, it's a really great option for them. How many patients would you say you've done in your career with this operation?

Dr. Andrew Trussler: I just had the numbers probably if I take like implant removal, Ottawa, primary Ottawa, things like that. There's, I'm going to say it's approaching probably a thousand.

Oh, that's great. Yeah, that's great. Yeah, it's a lot. a, It's a big, it's a, I do them not infrequently in my practice. And I, initially when I first started doing them, they'd be in the massive weight loss patients. And but now I've expanded to, as I said, implant, removals really common to [00:24:00] see, the patient who comes in that.

Has already done that experiment where someone has put a big implant into a tonic breast to quote unquote, fill it out. And year later they're in my office with enough breast issue, it hasn't been sacrificed. They haven't done a lift, take the implant out, do an auto augmentation with a superior pedicle.

I think that operation is. What I see a little bit more frequently, but the primaries are great. They're predictable. But it's taken some time that operation and it's taken some time to get to where, you can really call your shot on it. Yeah.

Dr. Sam Rhee: Great. This is definitely something that is very technique specific.

And I would say there's probably a pretty good learning curve associated with it, and you'd really want. know exactly how you're raising those flaps and how you're positioning them in order to achieve that really nice result there. So I'm looking forward to seeing you publish this because I think a lot of people will benefit, but we really need very, like you said, there's stuff out there, but not as much, that would be very helpful from [00:25:00] a.

Practical specific technique oriented perspective that would help more surgeons achieve these kinds of results in these

Dr. Andrew Trussler: patients. I think right now, if you look at the literature it's really veering over to oncoplastic. I ran into Mike St. Sierra a couple months ago, and he was really intrigued by it.

And I think we're gonna, we'll put our heads together. I have this during the pandemic. I actually started writing it up and it's kinda been one of those things that have pick up and put down and things like that. But I feel like it. It's an operation. That's gonna need some explanation too, because there is that learning curve.

They do take me roughly around three and a half hours to do that's the other thing. It's it's not a short operation. It's not a quick operation. The recovery is very equivalent to, any really breast surgery. But yeah, there is a pretty steep learning curve, I think. Hopefully, the contribution would be such where I've experienced Hey, here's how you graduate into doing this.

But yeah, I think there's patients that do challenging patients that don't have they have a thin breast envelope with an implant to. [00:26:00] Just like that last result. I think there's a, definitely a need for it. You can definitely get more than what you think. And patient satisfaction with that in particular is through the roof.

Dr. Salvatore Pacella: That's great. That's great.

Dr. Andrew Trussler: The results are amazing. And I can't wait to see this in print because I think somebody plastic surgeons would what, from learning

SYNCED AUDIO WAV: your

Dr. Salvatore Pacella: technique, there really are.

Dr. Andrew Trussler: Yeah, thanks. Thanks. It's, as I said you work on this stuff and I think one thing that I've found is, I'll find things throughout this technique that don't work, or, if I have some scars, some bottoming out, I have had that.

And so it's just, yeah. How to prevent that, but it's approaching this in a really individual way. Cause there's all these parameters, there's all these variables in there with the breast tissue, density, skin, quality, all these things are really, you have to take into account.

And yeah, I think that's all part of it,

Dr. Salvatore Pacella: well, Andy, thanks so much. This has been great. It's been great to see you and we'll we'll have to have you on again to talk about some other things and we'll leave you with this, the [00:27:00] Texas Longhorn. Okay.

Dr. Andrew Trussler: Now man, it's Friday. We're We're coming back in the sleeping giant.

Dr. Salvatore Pacella: Is it this, or is it this? How do they do

Dr. Andrew Trussler: it fight on?

Dr. Salvatore Pacella: Oh, I thought the Longhorn thing was

Dr. Andrew Trussler: this that's one part we don't do that. That's not in my household, in my household. It's all about V for victory. that's good. Sign it off

Dr. Salvatore Pacella: guys. Well, thanks again. Take care, Danny.