Episode 22: Sunday November 15

Drs. Salvatore Pacella, Sam Jejurikar, and Sam Rhee discuss the world's most common cancer which 20% of all Americans will develop by age 70. This is a special episode about facial skin cancer and its surgical reconstruction.

The 3 plastic surgeons present cases of patients and talk about the many factors should be taken into consideration in these complex surgical cases. If you ever wanted to see some amazingly cool surgical reconstructions, this episode is a MUST WATCH!

ADVISORY: some graphic surgical scenes

Full transcript (download PDF here)

Dr. Sam Rhee: [00:00:00] Welcome to another episode of three plastic surgeons and a microphone. today we are, as always, we are with Dr. Sal Pacella from LA Jolla, California. His Instagram handle is @SanDiegoplasticsurgeon. Also, Dr. Sam  Jejurikar from Dallas, Texas. His Instagram handle is @samjejurikar and I am Dr. Sam Rhee from Paramus New Jersey. And my Instagram handle is @Bergencosmetic. How are you guys? 

Dr. Sam Jejurikar: [00:00:25] Wonderful. Doing great. 

Dr. Sam Rhee: [00:00:26] Awesome. As always, 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 upon 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 and never disregard professional medical advice or delay seeking advice, because it's something in this show. 

Dr. Pacella, you're wearing sunglasses today. Is it night, there is this 

Dr. Salvatore Pacella: [00:00:54] We gotta wear sunglasses cause our future's so bright. We have to wear shades getting back to the eighties again. good segue. So the reason I'm wearing sunglasses is guess what? why? Cause we're talking about skin cancer, gents. All right. And. It's important to understand what's and I'm going to get back to this just a second.

Once we talked, talk about our cases, but, today's episode, we're going to talk a bit about, skin cancer and skin cancer reconstruction. This is a topic that is exceptionally close to my heart. It's a passion of mine. I work with a group of, dermatologists that roughly honestly, I'd probably do about 30 to 40 cases a week, sometimes dealing with skin cancer, reconstructions and tell us gents, what's a little bit about, skin cancer in your area. and what you tell your patients for sun protection. 

Dr. Sam Jejurikar: [00:01:54] obviously much as in San Diego, Dallas as a place where the sun is bright.

And, and there are, there's a large segment of patients that just haven't paid enough attention to skin cancer or prevention of skin cancer with the use of sunscreen. Probably the biggest advice that I will tell patients is, You have to wear sunscreen. You have to think about it and make it part of your regimen.

When you leave the house every day, sunscreen, not just on your face, not just on your hands or your arms, but over your entire body. and that's gotta be part of your daily regimen. Prevention is the key because many times, exposure that you get now is going to pop up 10 or 15 years later, as skin cancer.

And so it's what you're doing now will have huge benefits in the future. 

Dr. Salvatore Pacella: [00:02:37] In New Jersey. 

Dr. Sam Rhee: [00:02:38] Yeah. We also have a significant number of people that do indoor tanning. I think it's shifted to some, to spray tanning, but there's still a significant number of people that we'll do 

Dr. Salvatore Pacella: [00:02:50] UV tanning, baby Jersey shore. That's right. You got to get that base before you go out there in the summer. 

Yeah. 

Dr. Sam Rhee: [00:02:59] So we do see a lot of skin aging from that regard. And then also, like you said, the older population, I mean our generation and older. They used to just throw some baby oil on us and then let us burn that first, sunny day and then just, build from that.

yeah, so there's a fair amount of skin cancer as well 

Dr. Salvatore Pacella: [00:03:16] for our viewers out there, skin cancer is exceptionally common. In fact, it is the most common form of cancer that's diagnosed in this country. globally it accounts for over 40% of cancer cases. So this is we talk about pandemics.

This is a global pandemic that we see, over 90% of skin cancers are caused or worsened by exposure to ultraviolet radiation that, from the sun. So that's why, a couple of episodes back, we talked to, about our skincare and skin protection. we talked about utilization of sunblock and that's why the choice of sunblock is so critically important.

Some of those sunblocks that are made of Ava benzos or some of the ones that can dissipate over time in the water don't block, a substantial portion of both UVA and UVB. The only sunblocks that block. The entire spectrum of reflective sunblocks like zinc and titanium. so the, th this is just a huge concept.

Gents , tell me a little bit about what you, recommend for your patients as far as sunblocks specifically or sunscreen. I should 

Dr. Sam Jejurikar: [00:04:24] like which products in particular that she had products that you say, or that you recommend specifically. I just sent him down to Nina in our skincare.

 Dr. Sam Rhee: [00:04:34] I learned from Nina too, and I think that some of the, physical blocks, like you said, the zinc and the titanium oxide come in micronized forms, which are very natural appearing and they have tents and, Nina mentioned them and those are actually very good ones, too. To use on a daily basis.

Dr. Salvatore Pacella: [00:04:51] it's important for our readers to understand also too, that about 20 to 30% of skin cancers that are out there actually come from pre-existing moles. So if you have a pigmented mole or non pigmented mole, there's a substantial risk that throughout your lifetime, that, that mole may turn into something that's dangerous.

now when we talk about skin cancers, we're really referring to two different types or subclasses of skin cancers. There are what we call melanoma, skin cancers. Obviously those are dangerous. Those you can die from those. and then there are non-melanoma skin cancers, such as basal cell carcinoma or squamous cell carcinoma.

They're substantially less aggressive. It's exceptionally rare to die from those. But I have seen those in patients that have ignored some of those cancers. They can road through vital structures, lead to infection, and sometimes unfortunately to death. these are really. important things to understand.

So I urge all our viewers, regardless of your skin tone or your skin color. you want to have a really good relationship with a dermatologist, every six months or every year, you should really have a full body exam. there are great dermatologists out there which will take photographs of your entire body.

They'll check moles out and, and really examine this throughout, throughout your lifetime. Jen, do you, each of you see a dermatologist. 

Dr. Sam Jejurikar: [00:06:16] I have a dermatologist that I see probably once a year. 

Dr. Sam Rhee: [00:06:21] I rarely, I think I saw one a couple years ago, but not recently. No. 

Dr. Salvatore Pacella: [00:06:24] Yeah. So two, two, plastic surgeons that are in tune to what's going on in the skin.

Dr. Sam Jejurikar: [00:06:30] I see my dermatologist once a year,

Dr. Salvatore Pacella: [00:06:33] my dermatologist you're right. You got a little bit of pigment toyour skin. So you have a little bit of protection. those of us that are a little bit more fair skin, have actually a higher risk of developing skin cancer than those with been mentioned, your skin. the other important thing to understand is.

just looking at the numbers here. so melanoma, although we hear a lot about it, it's relatively rare in the U S there's only about 250,000 patients a year that are diagnosed with melanoma is, and very few of those will go on to be metastatic melanoma or melanoma that spreads to other parts of the body on the contrast non-melanoma skin cancers.

There's roughly about two to 3 million cases diagnosed per year. So really substantially high risk, particularly for those of us that have, exposure to sun. So John's anything to add? 

Dr. Sam Rhee: [00:07:24] some of us don't surf like three, four days a week so 

Dr. Sam Jejurikar: [00:07:28] exactly. I'm a, you're an outdoors man. I'm more of an indoors admin, so I have more protection.

Dr. Salvatore Pacella: [00:07:36] Yeah. that's interesting. I do serve quite a few days a week and, I'm just as guilty as anybody is the not putting on sunscreen when I should, the biggest issue is, just the access to it. I hate to say, it's sitting on my counter a little too like that, so it's a little stick on.

And if I go out there, I remember I put it on, but. I should probably be leaving it in my car, but it melts as a stick. so I SU I really should be doing a better job. Say another interesting story is, I went out, this summer I was surfing quite a bit more than now in the fall.

And, I found myself really getting exposure to the top of my head here. and I, I'm, clearly losing a little bit of hair here and it's exceptionally challenging to. To keep sunblock on your scalp. It's just not feasible to run it through your hair and rub it in it's hard.

I started surfing with a hat and, I just bought a bunch of pats and rigged in some, a little bit of a chin device to sew in so that, if I lost it in the surf, it's not too big of a deal. So you know that some sun exposure is huge, in the water. It can be reflective right off of the, of the water.

so great. let's, I'm gonna go, and I'm gonna start sharing my screen here. so let's go ahead and I want to show you guys a couple of cases here, right?

Alright. So you guys can see this here, right? Yes. Okay. Okay, so we're going to talk about skin cancer reconstruction. again, I mentioned this was a big passion of mine. I was inspired by my colleague, dr. Mark Codner and, he and I actually have a textbook, that we've published several years ago on aesthetic facial reconstruction.

After most surgery is a specific way of removing cancers. and let's see here. Okay. so one thing I want to determine here as many or chat the audience about is w what is most surgery specifically? So many plastic surgeons out there, particularly in the older community may say, you got a little skin cancer on your lip or your eyelid or somewhere else, and I'm just going to cut that off and close it.

Directly. Okay. But the specifics of curing the patient from that cancer is something very nebulous to us as plastic surgeons. so what I want to really point out here is when. You go see a plastic surgeon or a facial plastic surgeon or an oculoplastic surgeon, and they don't do most surgery. This is the pathology.

This is the way the pathology is processed. It's usually taken out in a little lips. So if we have a tumor, there's no way for the surgeon to identify with their eyes, how deep that tumor is. So if you take it out in the lips, I now easily thought that when I started practice well, the pathologists will slice it into tiny little slices, but that's not actually what happens, what the pathologist will do is they'll take interval slices.

So if you see this diagram right here, what is they'll take several slices at intervals of this bread loaf, if you will. And those are very thin slices. And when those slices are examined under the microscope here, this slice under a, you can see there's no cancer. This slice under B, you can see that there's no cancer going at the margin camps, the slice under C you can see a margin cancer here, but this prob the problem here is there can be extension of the tumor in between two slices.

So you can easily see how there could be a phenomenon where we do the slips. We send it to the pathologist. We get a clear margin, but technically speaking, it's not a clear margin because it didn't examine a slice that was taken. so traditional pathology, when you remove skin campus, there's only about 68% effective in curing the cancer.

Now with most surgery, this is done by specific team or of dermatologists. And what they do is they cut out these cancers and PI. So this pie format allows the surgeon or the dermatologist to examine the slice and they can say, look here at one o'clock we've got a positive margin. We can go back.

So most surgery is designed to remove cancers and examine 99% of the margin. So it's 99% effective. And so what happens is this creates several defects, around the face or otherwise. So here's an example of a, of an older lady she's in her seventies. And you can see here if she had a skin cancer removed from her Island.

Okay. Now this was a fairly extensive basal cell cancer. basal cell cancers are very common in the eyelid. Now, if you recall, when I was at the beginning of our episode here, I was wearing some sunglasses. Okay. Now let me ask you both gents a question here. When you put, when you guys go out in the world, do you put sunblock on your islands?

Dr. Sam Jejurikar: [00:12:24] no, I did not. 

Dr. Salvatore Pacella: [00:12:26] Whenever does. Because why? Because if it's things, the eyes, I have a fight with my kids all the time when they're going out in the world. We got to put sunblock on your eyelids. Why? if you think about how glasses sunglasses specifically are designed, they have a curvature or convexity to them.

So when some, when sun hits on the opposite surface of the sea of the sunglass, what happens is that creates a conduct surface and that those glasses can actually focus UV rays directly on the lower eyelid because of sunglasses that we wear. So it's important to use, obviously use sunglasses, but put on sunblock to your lower eyelids as much as best as you can.

So this, so this, lady unfortunately developed the skin cancer. She had it resected. This is about three rounds of most surgery, and you can see here, it took about 80% of her eyelid off. so Jen, tell me a little bit about, obviously both of you are not, don't do a ton of reconstructive surgery.

you have had this in your training and did it earlier in your practice. So tell me how you would approach this here. 

Dr. Sam Rhee: [00:13:32] I would send them to dr. Sal pacella.

Dr. Sam Jejurikar: [00:13:34] A couple of things before I get into this, I want to thank you for the explanation about the benefits of most surgery versus a traditional elliptical excision. I think that. was the most clear explanation I've ever actually heard about why processing skin cancers through Moses superior to the standard elliptical excision.

And I bet most plastic surgeons don't even know that. So that was very beneficial. in all seriousness, this is not a case that I would do OB, because. for our viewers out there, this looks complicated, but for the plastic surgeons that may be watching this, they all recognize this as incredibly complicated.

And when you, when you look at an eyelid defect like this, you have to think about basically three things that you're trying to reconstruct. You're trying to reconstruct the inner lining of the eye, which is called the conjunctiva or. Basically the skin of the inside of the eyelid, you obviously have to reconstruct the skin on the outside.

Then you actually have to bring about some form of support in the inside of the eyelid as well, some form of structural support. And there is a variety of complex ways to do this. And there are surgeons like dr. Pacella who do this on a, on a multiple times a week basis. And there are surgeons like me and dr. Rhee, who did this during our training 15 to 20 years ago. and the form of reconstruction that would be involved is gonna involve dr. Pacella having done multiple different flaps, likely haven't used the graft of some kind to recreate the lining of the inside of the eye of the eyelid.  but it's a complicated, multi-step, multi, multiple steps to the first reconstruction and then multiple steps down the road to contour it and fix it. So I'm excited to see what he actually did. 

Dr. Salvatore Pacella: [00:15:04] All right, great. dr. Rhee, any comments? 

Dr. Sam Rhee: [00:15:07] I was just thinking about how Sam addressed that.

And that would be exactly what I would do for an oral case. 

That was perfect. if I was a resident and I had an answer that I was, I would do exactly what Sam did was described the D the issue described the general strategy, but then try to, come up, finagle, some of it like that. And that's. That's why Sam did so well in residency, he was such an analytical and good talker. I love that. 

Dr. Sam Jejurikar: [00:15:38] I know what I know. And I know what, I don't know.

Dr. Salvatore Pacella: [00:15:41] Yeah. So for the viewers out here, not, they are correct. not the average, plastic surgeon in the world would be doing a case like this. I did a, I did a specific fellowship in oculoplastic surgery. I feel very comfortable in and around the eyelid for both cosmetic, surgery of the eyelid and reconstructive surgery.

So this is a case I really, truly enjoy. okay, so let's go. the choice of reconstruction that I chose here is, a common technique in oculoplastic surgery called a Hughes flap. And so what that is there was a skeleton to the upper and lower eyelid, and that skeleton is called the tarsal plate.

And it's about six millimeters stick on the lower eyelid and about eight millimeters thick on the upper eyelid. So this lady had a complete district disruption and destruction of her lower tarsal plate. So what we did was we're actually going to use a piece of the upper eyelid to reconstruct the lower Island.

So what we do is we flip the eyelid on itself and then cut. Right longitudinally through the middle of the eyelid on the inside and bringing this little membrane down. This is called the tarsal plate and it's attached by a membrane of tissue. So we're bringing this down to the lower eyelid and suturing it into the lower eyelid here.

So you could see these black sutures. This tissue is the tarsal plate coming from the upper eyelid, which I sutured to reconstruct the posterior lining. And support of the lower islands. So this reconstructs, the back of the eyelid, so to speak. So now what I did here on the right side is we support the corner of the eye with something called a Canto Pepsi, which supports and creates tightness of the corner of the eyes.

So it doesn't droop. And then I've lifted up all the skin tissue. And the whole idea is that I'm going to advance the skin upwards in order to reconstruct the skin component of the eyelid or the front of the Island. And so this is her right after surgery here. So you can see this membrane is bringing blood supply to that tarsal plate reconstruct into the.

The back portion of the Island. And now all this kind of bruise skin is very thin skin from the cheek and lower eyelid, which I advanced upwards in order to reconstruct the lower eyelid front surface. So this is a two-stage procedure. So obviously she's going to have her eyelid. Believe it or not.

So shut for a period of time for about three weeks. And this is what it looks like after three weeks, you can see how bruise and damage this skin is right after surgery, but now it's gotten some blood supply. It's got some. some space, some ability to reconstruct it's, it's a hardiness and this tissue actually grows up on top of this little muscle membrane here.

And so this is her after three re three weeks, right before I'm about to go and sever this connection to open up the eye again. So 

Dr. Sam Jejurikar: [00:18:33] can I ask a  question?

Dr. Salvatore Pacella: [00:18:34] ?Absolutely. 

Dr. Sam Jejurikar: [00:18:35] so when you reconstruct the skin by advancing, the lower eyelid skin and cheek skin, there's a tendency that, you know, better than any of us for the eyelid to want to retract afterwards.

So you talked about how you did a, was it a camp, the Pepsi, or I can't the plasty. How did  you support the eyelid and prevent that retraction afterwards? 

Dr. Salvatore Pacella: [00:18:53] so right at the corner here on the inside of the eyelid, I placed a suture, a permanent suture that's secured to the bone of the orbit.

And so what that does is it creates a little bit of a tightness or a sling. Imagine a hammock. If you have a Hamot that loosens up over time, it's going to drop down. But if you tighten up the sides of the hammock, that hammock is going to stay nice and taut. So four days of swelling, the forces of scar contraction can really bring down the lower islands.

So without that Canto Pepsi, I could have done a ton of work here, but if I didn't do that Canto pixie, that eyelid may drop down a centimeter. so that capital Pepsi is really key to maintaining the tightness of the lower eyelid. 

Dr. Sam Jejurikar: [00:19:34] And you said you use a permanent suture when you do that? 

Dr. Salvatore Pacella: [00:19:36] That's right.

Yeah. For Mersilene suture, which is a breed, a permanent suture. Okay. All right. so moving on here. So this is right before, I'm about to sever this connection. So we take the patient back to the operating room and what I do is put a little, safety instrument. So I don't hit the cornea. And I simply divide that segment, with a little knife to, to basically open up the eyelid again.

So you can see here, this photograph, the eyelid is inverted. That's the section from the upper eyelid. That the little wound that we see here is where we. Took tissue from the upper Island and moved it down to the lower eyelid. And now this is the new eyelid position here. Now things look very bad here doesn't necessarily look exactly like an eyelid, but if you look at the position of her arm here, that's actually in a position.

So this is her before surgery right here. Okay. With the wound. And this is her after surgery, about a year later. So you can see here, the lid position on both sides looks equivalent. And the only difference here you see as this just ever so slight redness to the lower eyelid. Now, if you look very closely here, she doesn't have any lashes here, obviously because, that skin that we brought.

Forward or up is, does not have any lash bearing component to it. But with a little bit of makeup, a little bit of sometimes a little bit of tattooing will do the job that tends to work fairly well for patients. and more importantly, she's able to function and keep her eyelid close without difficulty.

How it would be hard pressed to say that anybody that looks at her from across the room or in a conversational distance with notice that she had 80% of our Island group. 

Dr. Sam Jejurikar: [00:21:22] That's a great result, very difficult reconstruction. And that looks remarkable, 

Dr. Sam Rhee: [00:21:27] Sal when you work with your, team, it's gotta be tough because with Mo's you don't know what your final defect is going to be until they complete their resection and margins are clear.

So how often will you get these, you don't know if you're going to get a very small reconstruction to handle or a very big one. how do you handle that? 

Dr. Salvatore Pacella: [00:21:49] So two things I would say, I got another, case to show you, but let me, let me stop sharing for a second so we can chat.

so very good question. So how do I predict how much is going to be resected? So the number one is I always see these patients in consultation ahead of time. So it's intuitive that we would need to do that. But to be quite honest with you, if you were, if you're a plastic surgeon around the country, dealing with dermatologists or most surgeons, many times what happens is you get a frantic call on a Friday afternoon that.

This patient has a big hole that we need to do something about it, right? So you don't have the luxury of planning ahead of time. So fortunately, a handful of most surgeons I work with and we have a really good multi-disciplinary process for evaluating these patients ahead of time. So with examining their phone graphs, examining their physical exam before the resection, I can usually have a 95% sure.

Chance I'm going to either need to do it in the office or in the operating room. So in general, most of the eyelid procedures I tend to do in the operating room, just because it's a little bit more comfortable for the patients. But every once in a while, like on the cheek, say it gets a little bit larger.

So I know that if the patient is gone for three, four, five, six rounds of most surgery, I'm going to need to probably delay their case in the office and take them to the opera. And I think in general, the key is you have to be prepared there with a plan B plans to you have to know enough about these types of reconstructions to plan everything ahead of time.

Very good. all right, so now I have a little video here. I'm gonna just share my screen again here. It's just a quick video. sorry for the faint at heart here. this is a little bit of a larger reconstruction and, I want to show you a chance here. Okay, so it can, you can see this video here.

Okay. Great. All right. Okay. This is a video that was featured in my textbook here. so I'm just going to fast forward here. So this is a gal who had a skin cancer that you can see diagnosed, ahead of time. Unfortunately, this was present for many years. And if you look here, this is her left nostril, which is normal.

And then you see her right nostril and you see this kind of white, pink plaque here. So w what do you guys think about this here? When you see this. 

Dr. Sam Jejurikar: [00:24:15] This is, this is a complicated, when they're done with the most surgery, she's going to have a large defect that, it goes beyond, we have time to discuss, but it's going to involve multiple subunits about the nose, and it's also going to involve the cheek.

So reconstruction is going to involve, Not just fixing the hole, but fixing the hole in a way that's going to require her nose to still look like a nose. So the side of the nose is going to need to be reconstructed in a way that's different than the cheek, the nostril rim, which we call the ALA is going to need to be reconstructed as well.

and it's a fun case, complicated reconstruction. Cause you have to think about each area separately as you do the reconstruction. 

Dr. Salvatore Pacella: [00:24:53] Yeah. So th this is, so th the thing that struck me about this case is we're not even starting from a normal position here. We're starting from, an area that has already been eroded substantially by skin cancer.

So when I'm planning this reconstruction, I have to think what normal looks like now, what preoperative Moe's surgery looks like. So that's the challenge here. So let's fast forward here. I want to show you her. Okay. All right. So this is her Dean here from Moe's surgery. So you can see here this involved a good chunk of the cheek, a substantial portion of the lip. section of the ALA of the nose, which is this round portion of the nose and a couple of segments of the nose, which is called the nasal sidewall.

So this is a huge challenge. So obviously this is somebody that's going to need to go to the operating room. we have to think about preserving the nostril function. Not just the nostril appearance. So we're going to have to line the nose, the inner surface of the nose. We're going to have to use some tissue support to the nose, and then we're going to have to do multiple stages of reconstruction to get this lady looking close to normal here.

so what I did was a three-stage procedure here. All right. Video player. Okay. So here we are. So basically what, should have gloves out here. Sorry. so what I did was I used a piece of tissue to build the foundation of the corner of the nose. So this is what's called a V to Y flap. This flap goes in.

To the center portion of the nose here to build some structure and foundation for everything to be built upon. I have this other small piece of tissue to reconstruct the lip, which are bringing up words to reconstruct the corner of the nose called the ALA. So now you can see her, I've put a little piece of cartilage in the nose to reconstruct the lining, to maintain the tissue support.

And now I have this substrate or this foundation that I'm sitting right here that I know I can build tissue upon. Myself. If I were to just take tissue and put it into the hole, it may collapse on itself. So I need a little bit of extra substrate of tissue. So what do we do to reconstruct this corner of the nose?

We're going to use some tissue from her forehead. So this was what's called a forehead flap. So this flap is designed by an artery near the eyebrow, and this artery gets rotated or this a flap of tissue gets rotated down to the nose. Right here. And it's going to stay in position for a period of several weeks in order to bring healthy, thick blood supply to the site.

Okay. So now I have this flap in position right here, and that's going to reconstruct the ALS. over time, this segment of the forehead flap is going to go away. Okay. So now, what I'm going to do in here is I'm going to thin that flat. So it doesn't really still look like a nose right now. It looks very thick and bulky.

So I'm going to take this opportunity at the second stage of surgery to aggressively thin this flap out so that it looks and contours like a nose. So what we do is we leave it attached and then I go on the inside and I. Then this area out a bit, and we replaced the flat back in a position to make it just as well contour.

Now about four weeks later, we're going to do the final surgery called the division and insetting. And what that involves is I'm going to take out the segment. That's going from her eyebrow to her nose. So that everything can be, get back into position here. So now that it's now grown its own blood supply, we've removed that segment here and I'm going to clean up this segment so that it gets well sculpted to look exactly like a nose.

Okay. so now this is her, going forward.

Okay. So this was her original defect, as we talked about. Okay. And now video flare is a little last year. Okay. So this is her. After the fact you saw that big hole she had in her face. And now this is her in the office. Clearly we have some scars here, but the key here is go. Scarf will fade over time. That can be covered with a little bit of makeup, but the nostril rim is what we're looking at here.

And you can see this nostril rim is substantially bigger and thicker than it was even before she had her skin cancer removed. What I'm using as a model is the opposite side of the nose. Not necessarily the preoperative side here. So that will reconstruct her, her nostril, ALA that corner of the nose.

And you can see here, we've got a little bit of tissue thickness, a little bit of tissue bulk here. We can always revise this over time, but this is the difference between before, during most surgery. And then after about six months afterwards. That's great. 

Dr. Sam Jejurikar: [00:29:34] I think dr. Pacella, you are humble as always, but that is an amazing reconstruction and a really good illustration.

For, I think the people watching this show that one we're sunscreen. So you don't end up in that situation, but to, should you not? And you develop a problem like that. There are solutions, but I want to congratulate you. Those are phenomenal results, both of them. And I particularly liked the illustration of the forehead flap disorder.

Viewers can really see how complicated the reconstruction can be. 

Dr. Salvatore Pacella: [00:30:02] Yeah. I, as I mentioned, this is a topic in a discipline of plastic surgery that I just am truly passionate about. I think it's, it really is taking, segments of the body that's been destroyed and attempted to rebuild it to a state of normality.

it's very similar to what we do in cosmetic surgery. In fact, it's probably the ultimate cosmetic surgery. We're taking a deformity and making it as inconspicuous as possible. So 

Dr. Sam Rhee: [00:30:27] I know you a lecture, nationally about this. I think you just did a, at our national meeting recently about this. yeah, this is not for the run of the mill plastic surgeon.

This is for, this is a high-level reconstructive stuff that is absolutely creative. It builds on multiple principles. You have to be, you have to have skill as well as a high level of creativity in order to, achieve those kinds of results. So that's amazing, 

Dr. Salvatore Pacella: [00:30:53] right? 

Dr. Sam Jejurikar: [00:30:54] with that, let's wrap up yet.

Another great episode of the show, dr. Coachella, thank you again for imparting your knowledge, both to dr. Rhee and myself into our all viewers. And until we meet again, 

Dr. Sam Rhee: [00:31:04] Wear sunscreen!