Episode 27: Sunday December 20

Drs. Sam Jejurikar, Salvatore Pacella, and Sam Rhee welcome special guest Dr. Michael Orseck MD. Dr. Orseck is a Board Certified Plastic Surgeon by the American Board of Plastic Surgery. We talk to Dr. Orseck about his expertise regarding DIEP (deep inferior epigastric perforator) breast reconstruction, an advanced microsurgical procedure for breast cancer patients.

He is formally fellowship trained in Cosmetic Surgery, at New York University and the Manhattan Eye Ear and Throat Hospital. Dr. Orseck is also specially trained in reconstructive microsurgery, completing a fellowship in Gent, Belgium.

Since 2014, he has been recognized as one of Castle Connelly’s Top Doctors, and has been voted Best Plastic Surgeon by the readers of the Herald Journal in Spartanburg.

Dr. Orseck has served on the Board of Trustees for the Spartanburg Regional Healthcare System, as well as on the Board of the Spartanburg Regional Foundation. He is also a Trustee for the RYR-1 Foundation, which supports research for Neuromuscular Diseases.

Dr. Orseck serves as an Associate Professor of Surgery, Plastic (AHEC) with the Medical University of South Carolina, where he remains actively involved in education by teaching surgeons in training. He continues to publish his research in many of the top plastic surgery journals.

Full Transcript (download PDF here)
2020.12.20 E01S27 DR ORSECK transcript
Dr. Salvatore Pacella: [00:00:00] Good morning, little elves. Here we are. it's a Sunday. We've got a wonderful podcast. I'm joined by my two colleagues, Dr. Sam Jejurikar. His Instagram handle is @SamJejurikar he's in Dallas, Texas, of course. and Dr. Sam Rhee his. Instagram handle is @Bergencosmetic, and he is in Paramus, New Jersey.
I am, of course, Santa's also known as Dr. Sal Pacella @SanDiegoplasticsurgeon. 
And we've got a special treat for you this evening or this morning, excuse me. But first, before we get into that, I'd like to do our disclaimer. this show is not a substitute for professional medical advice, diagnosis or treatment.
The show is for informational purposes, only treatment or results may vary. 
Based on the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified healthcare professional. With any questions you may have regarding medical care, never disregard professional advice or delay seeking advice because of something in this show.
now, you this morning, you can either be on the naughty list or the nice list. And I'm going to send it over to Mr. Naughty, right over here, Dr. Sam Jejurikar
 Dr. Sam Jejurikar: [00:01:11] on that note, you'll notice that although we are listed as three plastic surgeons, there is a fourth face staring at us. And it's my great pleasure to introduce Dr. Michael Orseck. Dr. Orseck. His credentials are impressive. He is a former president of the South Carolina society of plastic surgeons, he's actually on the board of trustees for a large healthcare system in South Carolina, the Spartanburg regional healthcare system.
but the reason why he's here today is not because of his credentials, but mainly because of his expertise in microsurgical breast reconstruction. So a little bit about. Dr. Orseck, I've actually known him for 15 years. I had the great pleasure and training with him at Manhattan eye, ear and throat hospital, in aesthetic surgery where he is a top-notch aesthetic surgeon, but after he finished his aesthetic surgical training, he decided he wanted even more for his practice.
So he did additional training in microsurgical, breast reconstruction and Ghent, Belgium, where he really focused on, perforator flap reconstruction. using D I E P flaps or deep flaps, which is going to be the focus of today's show. So Dr. Orsak has a booming practice in which he focuses on aesthetic surgery of the face, body and breasts, but he also does a huge number of microsurgical breast reconstructions, and he really is considered to be a regional and national expert on this and star.
Great pleasure to have him on there. Mike, thank you for joining us. 
Dr. Michael Orseck: [00:02:32] thank you for having me. I've been excited all week. 
Dr. Sam Jejurikar: [00:02:35] As an asset, we've been you really class up to joint, particularly compare winners juxtapose next to drunk Santa over there. so Mike, tell us a little bit about how your passion for my surgical breast reconstruction came about.
Why did you decide that you wanted to do this very specialized aspect of plastic surgery? 
Dr. Michael Orseck: [00:02:58] that's a great question. When I decided to come back to South Carolina, following training in New York city, I quickly realized that there was a great need for top-notch press reconstruction. At that point, the patients that were either great implant candidates, or they didn't get breast reconstruction, they were told they couldn't have breast reconstruction.
If they are overweight. Medical issue or especially radiation. with that information, there was so many patients that weren't getting properly treated. being the new guy in town, these patients started knocking on my door and just one after the other, and, decided that it was time to really, turn up the training that I had.
Excellent training that I learned from, But one of my mentors, Dr. Ritter, it's often the microsurgery, to really offer this to patients. And as you had mentioned, with all this new influx of patients, I quickly realized that there were other microsurgical options. that needed to be offered to my patients.
So I left my practice really quick and went to Belgium for a few months and really fine tuned some other operations, not only the day, but pap flap, scab flops, so on and so forth and came back. And my. it's just, took off from there. 
Dr. Sam Jejurikar: [00:04:15] So you had mentioned that you felt like there were patients that weren't getting appropriate treatment and I'm sure you still do some implant, based form of reconstruction.
How do you determine who's a great candidate for a microsurgical breast case? 
Dr. Michael Orseck: [00:04:29] I think the easiest, patients, or decisions to make would be a patient who's had mastectomy in the past and radiation. though, there are some doctors that will try to expand that, in my mind, I think in most positive search of mine, it's pretty bad idea.
So bringing in new nine radiated healthy tissue, makes a lot of sense. 
Dr. Sam Jejurikar: [00:04:50] Okay. and, in the hands of the plastic surgeons that don't do a lot of aged procedures for instance, myself. this is a incredibly time consuming, laborious process to do these sorts of cases. When you do a, a typical bilateral reconstructive case using, microsurgical techniques, let's say a deep flap.
How long does it take you to do that operation now? And how long did it take you when you first started going. 
Dr. Michael Orseck: [00:05:16] when I first started, I wouldn't undertake bilaterals and I remember unilaterals would take 10 to 12 hours. but today's Sunday and Friday, I did bilateral. James labs with nipple sparing. Mastectomy is so we were done in seven hours. 
Dr. Sam Jejurikar: [00:05:30] Wow. That's really good. That's great. And typically, how long do your patients tend to stay in the hospital when you do a case? 
Dr. Michael Orseck: [00:05:37] Two days and a bilateral three days. And now that we do a lot of, out of town, patients sometimes will stay a full five days before we let them go back.
Back to their other States. So for, 
Dr. Sam Jejurikar: [00:05:48] Oh, 
Dr. Salvatore Pacella: [00:05:50] sorry. Yeah. and Mike, do you tell us a little bit about the or setup that you have there? you work with, obviously a mastectomy surgeon, but what is your team consistent? 
Dr. Michael Orseck: [00:06:00] So my team consists of, I have a PA, she's been with me for a couple of years. She came from, Knoxville Tennessee, very talented.
so she will prepare the chest. dissect out the, internal mammaries. while I dissect out the flaps, now I have a scrub tech who's incredibly talented as well, Deseret. and she helps me dissect out the flaps. then I also have one or two associates who will pop in, if they're available between cases and, maybe I'll, I'll dissect out a flat, but the chest is radio.
Pass it up to the chest and they'll do the micro while I hook up while I dissect out another flap. So there's always, operating, going on, whether it's the chest or the ads. we really try not to waste a lot of time. 
Dr. Salvatore Pacella: [00:06:46] Do you wait for both mastectomies to be done before you start working or, are you able to prepare to, prepare the abdomen while the general surgeon is doing or the breast surgeon is doing their work up top?
Dr. Michael Orseck: [00:06:57] Yes. Yes. I always work at the same time. th that shaves off a lot of time for the patient. As a matter of fact, many times, one of my assistants is dissecting out one of the chest after the mastectomy has been performed while the oncology surgeon that's doing the mastectomy on the other side, that gets a little crowded, but it works fairly well in certain patients.
That's great. 
Dr. Sam Jejurikar: [00:07:20] Mike, you've been nice enough to actually put together a couple of cases that to help illustrate what's achievable with these sorts of operations. Would you mind sharing them with us? 
Dr. Michael Orseck: [00:07:29] Certainly. So the first case I wanted to discuss was that young woman, who underwent bilateral mastectomy with immediate reconstruction with deep flaps.
And this slide will show her pre-op photos, her intermediate photos after the first stage and the second stage. So you can see, a lady with a BMI around 38. With significant asymmetry TOSAs so through a, skin-sparing mastectomy, we performed, her reconstruction. Now, if you look at the intermediate stage, after the deep flaps, you'll see, she has some significant asymmetry, some boxiness of the brass.
just to overall an okay result, but certainly needs some fine tuning. And in the final picture, we can see she has a nice symmetric result, nicely rounded out. and the reason why I wanted to show this to you was I think we get hung up on trying to do these operations through tiny little incisions, the smallest scars possible.
But as you all know is great aesthetic surgeons. If a woman that's presented such as this lady wants, it has better refinements of the breast. I don't think any of us would choose anything, but a wise pattern type operation. So for an aesthetic patients to put those types of scars in some stress, we shouldn't hesitate at all to do that in a reconstructive patient.
And I think, once we liberate ourselves and realize we need to get the nicest shape possible, and scars we can manage, I think we can wind up with results like this 
Dr. Salvatore Pacella: [00:09:23] and ju just for our viewers out there. I let's just take a step back for the non-plastic surgeons watching here, correct me if I'm wrong, Mike, this first photo on the left that's prior to any mastectomy, correct?
That's right. Okay. And then you, she had this eight hour operation or both breasts were removed through a nip, an incision around the nipple, correct? All right. And then you went in and you did, you took two big, large pieces of fat from the abdomen and hooked up to the chest wall with blood vessels to the chest wall to make what's the bottom photo, right?
And then after that, a few months later, you did a nipple reconstruction to make this absolutely perfect. So that the gravity of this here for everyone out there is, the, this just looks like a little operation here. This is a massive operation where both breasts are removed for, reconstructive or for cancer reasons and an unbelievably.
Hardy reconstruction is performed, which basically you can't tell. that is just phenomenal. Absolutely fantastic work. 
Dr. Sam Jejurikar: [00:10:39] Was this patient radiated too Mike or no? 
Dr. Michael Orseck: [00:10:43] No. This patient was not, but 
Dr. Salvatore Pacella: [00:10:44] for, again, 
Dr. Sam Jejurikar: [00:10:45] for our viewers, just to belabor what Dr. Pacella said. 
Dr. Salvatore Pacella: [00:10:49] This 
Dr. Sam Jejurikar: [00:10:49] looks like a woman who underwent a tummy tuck and a breast reduction, and got a great result from a non-cancer operation.
This is a lady who had cancer, who had her breasts entirely rebuilt, Dr. Orissa and his team hooked together blood vessels under a microscope, underneath the rib in the chest wall to create these what appear to be healthy appearing breasts. And then got like a, an absolute, this is the best result I've actually ever seen in an obese patient.
and then you didn't point it out, but you look at her abdominal wall and how much smaller it is. It looks as though she had a tummy tuck and a breast reduction. So Dr. Warrick is very modest and understated as always, but this is an exceptional results. 
Dr. Sam Rhee: [00:11:31] what is amazing to me is hearing you talk about doing a wise pattern and it never occurred to me. Why didn't we ever do these on oncologic patients? We do them all the time. Like you said, aesthetically for regular healthy patients. Is this a concept you came up with yourself or did you 
Dr. Salvatore Pacella: [00:11:54] I'll tell you why we don't do it? the, these keep in mind, gents, it's not everyone, there's a big difference in mastectomy surgeons across the country.
Some leave, tiny little flaps, others leave Hardy thick flaps. Some of it is patient dependent based on what's left behind. a main reason why I think we have all steered away from wise pattern incisions is because the tip of the incision right here, that T junction, if you have already exceptionally thin flap, that's a flap that we're always worried about dying.
I have, I have huge challenges in my practice with this, so Mike, sorry. I interrupted. Go ahead. 
Dr. Michael Orseck: [00:12:34] Yeah, sure. I think the incorporation of a skin sparing, nipple sparing, mastectomies are great in the right patient. but certainly this patient we could have done nipple-sparing and giving her back the same, appearance of her breasts actually worse because the flap would have fallen down right behind the nipple.
She would have had no upper pole fullness. Sure we could have done it. Scarless the star would have been in her crease underneath our breasts, but I would guess that most women would like this final result rather than so look exactly how she did pre-op with some scarring, she has some scarring, but overall I think it's much better.
Dr. Sam Rhee: [00:13:15] because I think when I see a lot of, microsurgical breast reconstruction, the intermediate result is more the normal. Average result that I've seen. So when did you start saying, listen, I need to do better shaping. I need to make this more aesthetic. I, the incisions are not so much of an issue as the final breast shape, 
Dr. Michael Orseck: [00:13:36] right?
So that is all part of my journey through breast reconstruction. for the first couple of years, it was staying up almost, 36 hours straight. Just hoping that the flaps survive. And then once you get your flap survival rate to where it needs to be, and then you worry about, how do I get these flops, even though it's survived to minimize or eliminate fat necrosis, because as we know, fat necrosis is, It was about the worst thing that we can get.
And for the patients found necrosis is an area of the flap that doesn't get good blood supply. And it turns into a firm nodule. It actually feels like cancer and it doesn't heal well and it trains, and it's very hard to manage the second stage. So getting the flaps to survive, avoiding fat necrosis, and then shaping, really getting the best aesthetic results I can get.
Came later and going to a lot of meetings and, learning from some great aesthetic surgeons, such as actually the one that you had on last week, Amy learned a lot from her about shaping the breast. but so taking the aesthetic lessons that I had at Manhattan eye and ear and listening to a lot of reconstructive surgeons and a lot of aesthetic surgeons just realized.
There's so much more that we could be doing to shaping the reconstructed breast and just. throwing a slab of tissue up there and calling it a breast. 
Dr. Salvatore Pacella: [00:15:08] Mike, you make a tremendous point here, which is, I think so many times we get, we, we get pigeonholed into our specialty.
Oh, that's your only anesthetic surgeon. You're on the Instagram, you're just, you're not doing anything challenging. The reconstructive surgeons say, Hey, Those people that do cosmetic surgery that are in another class, we were dealing with humanity here or.
Curing people from cancer, but we are all one specialty and there are lessons that can be learned easily from reconstructive surgery that are applied to aesthetics and aesthetics to reconstruction. And I think you've hit the nail on the head here, and that's a major reason why I have.
I've been so happy to be involved with skin cancer reconstruction of the face. And I take a lot of what I learned in the cosmetic facial world and apply it to reconstructive surgery. And you have done exactly that with this type of case and it just hits it, your training, it hits it, your dedication, so that's just phenomenal.
Dr. Sam Jejurikar: [00:16:06] Absolutely. Absolutely. 
Dr. Salvatore Pacella: [00:16:09] And fat Santa's putting you on the nice list. 
Dr. Michael Orseck: [00:16:11] Okay. I see. I see. 
Dr. Sam Jejurikar: [00:16:14] Okay.
Dr. Michael Orseck: [00:16:15] I, I wasn't expecting to be on the nice list. That's great. I'll take, 
Dr. Salvatore Pacella: [00:16:21] maybe you get a visit from Hanukkah Harry too. 
Dr. Michael Orseck: [00:16:24] Exactly. Exactly. I really should have brought my 
Dr. Sam Jejurikar: [00:16:28] glasses. Did you say you got a second case too? Mike? 
Dr. Michael Orseck: [00:16:33] I do. I do. so just the before and after the previous case. Okay. Moving on.
second patients, another young woman who had a genetic predisposition to cancer, as well as currently having cancer. She two underwent immediate flap reconstruction at the time of her mastectomies. And this young woman also had the wise pattern shaping. and I just wanted again, to highlight, my lack of reluctance put extra stars on a breast to get the results I'm looking for.
So again, a woman with asymmetry, significant ptosis, cut out a lot of her skin at the time of mastectomy. And, put in a little skin paddle. That's the, that's actually her abdominal skin, that little oval of tissue at the bottom of each breast. Now, certainly someone could have said, Hey, let's just fat graft, the upper poles and try to give volume.
those aren't really shaped like breasts. And if you look at the final picture, adding some additional scarring, and hiding those scars the best you can coupled with some fact grounds and really gives a beautiful shape and, same principles as before, using, aesthetic surgery principles that we do every day in our practice, breast reductions.
Breast lifts with, or with implants with, or without implants is the same pattern. And you can get reconstructive results just like this. And Samira, as you said before, that was the best result you'd ever seen in your life. I'm very, humbled by that, but it's, something that's been invented for the last.
75 years, I would imagine, but just incorporating it into reconstructive surgery, I think is fairly new and this is what we can do 
Dr. Salvatore Pacella: [00:18:29] standing on the shoulders of giants. 
Dr. Michael Orseck: [00:18:30] exactly. I didn't invent any of this. I just borrowed a little bit here and there. 
Dr. Salvatore Pacella: [00:18:34] Now, Mike, can I ask you what's the, tell us a little bit about the timing in between these first and second stages.
what do you do? How do you factor in the patient's chemotherapy? what, when are you doing the next phase? 
Dr. Michael Orseck: [00:18:49] Sure. today many patients are receiving chemotherapy before their mastectomy. that's called neoadjuvant chemotherapy in that patient. I like to wait six to eight weeks until they get their mastectomies and to do immediate reconstruction.
If someone is planning to definitely have postoperative radiation, I will also do the immediate reconstruction, leaving the side to be radiated a little bit larger to anticipate some shrinkage after radiation. So we tend to not shy away from post-operative radiation. Like I would, if someone was going to have implant based.
And I think that cuts down on the number of operations. and the patient still winds up, the very good results. As a matter of fact, the scarring on the radio side is often better than the non-radiating side. 
Dr. Sam Rhee: [00:19:47] I have a couple of questions real quick. One is, what is your percentage of, implant-based reconstructions versus autologous reconstructions?
Dr. Michael Orseck: [00:19:55] Would you say? I do, 80% autologous reconstruction. we have some very good. surgeons in town who, if the patient really expresses a strong desire for implant-based reconstruction day, we'll also go to those doctors before they see me, but I still do a fair amount. there's. As we know, just some perfect candidates, B cup breast who already has implants, that did very well with our implants, who was not planning on radiation to spray, just to use a preexisting capsule, to switch out for some larger implants.
Dr. Sam Rhee: [00:20:31] And then for your autologous, what are your breakdowns in terms of deeps versus say like a pedicle of  or any other type of, autologous? 
Dr. Michael Orseck: [00:20:41] Yeah. pinnacle Leticia MIS I'd say is about one out of every 10 or 15. So I used that in my, morbidly obese patients or someone who has as a, an abdomen that's not usable, or else.
also if their inner thigh isn't usable. 
Dr. Sam Rhee: [00:20:58] And then what was the learning curve? what was the hardest thing to conquer or figure out? because as we all know, microsurgery is in a very exacting, surgeon based. the surgeon determines the outcome. We always know that's the,  research studies have shown that over and over again, it's the surgical experience.
So what was it that got you to where you were now? what lessons 
Dr. Michael Orseck: [00:21:20] did you learn? as you mentioned before, standing on the shoulders of giants, I visited a lot of surgeons, over the years and, visiting Bob Allen, Lisa Wu from pan it, pick up all these, just little techniques that seem little at the time, but they're just monumental in.
Giving you a safer and more efficient result. But I think that the concept, that's allowed me to consistently get great results in the last few years is really the avoidance of fat necrosis because trying to get a certain volume out of your deep flaps, I think is a little narrow minded. I think.
If you wind up with a smaller flap, but that's perfectly well vascularized, second stage, procedures such as fat grafting, or even putting a small implant behind the flab, just gives beautiful results. w with a soft brass at the patient feels like it's normal, no postoperative imaging was, result issues, which brings me to, augmenting these patients, after they've had a flap, which has become very common patients are seeing on the internet and actually coming to me saying, asking for a hybrid operation, meaning a deep flap with a delayed placement of a small implant behind it.
So that's become very popular, which helps us, really focus on making sure we only deliver well vascularized tissue that we can augment with an implant or fat. Crafting later. 
Dr. Sam Jejurikar: [00:22:55] I think Mike, that's why I was so impressed with your first case because given the size of that patient, if there wasn't a great microsurgical breast reconstruction, and it was just a standard breast reduction without a flap, you might be more likely to see fat necrosis in a patient like that.
But it's true in many ways with some of these larger patients or at least larger breasts, When you have such a well basketball eyes flap, their final result just looks beautiful. and that, that does eliminate these complications and it also helps the results so much. 
Dr. Michael Orseck: [00:23:25] Sure. 
Dr. Salvatore Pacella: [00:23:25] Now, like I got a question for you, I do a fair amount of, Breast reconstruction, but it's mostly implant and expander based.
and I got to say that the, as I'm sure you're, you'd agree that the biggest challenge, the most frustrating thing we deal with in plastic surgery is postoperative radiation. And it seems to me like the indications for radiation are expanding. many times we're in a situation where patients may not.
But going into the operation, we think they're going to be safe. They're not going to need a post-operative radiation. And then, the indications for radiation are expanding. Those types of patients are getting radiated after surgery. And my, the only option I have many times as when I place an implant is to overexpand it.
And. Hope for the best. and hopefully the implant won't constrict down and then subsequently put a smaller implant in at the time of the exchange. T tell me a little bit about your experience with postoperative radiation when you're doing it. you're doing a bilateral flap.
you set it up. So for success, what do you do in the, in the patients that are unknown radiation candidates? 
Dr. Michael Orseck: [00:24:34] I think, One of the most helpful things to do is to actually make that breast a little bit larger. you can almost universally expect the breast to shrink somewhat. And I think by doing that, we don't run into a lot of problems, with a breastfeeding.
Very small afterwards. And the reason why that's important is because before, when I was discussing about making a post-op deep breast, the problems I've had augmenting a postoperative deep flap is the radiated Tim flat. And you would think that was a big chunk of healthy tissue. you don't have the implant based problems relative to.
Radiation anymore. That's not true. even putting in a small little, 200 CC implant, behind a radiated flap, in my career has had some issues for the vast majority have done fine. But the times that I've had issues with augmenting a deep flap or in the radiation patients. So I think it's important to make that flap larger.
So we're not looking at trying to make it larger after the radiation. A quick 
Dr. Sam Rhee: [00:25:51] technical question. do you use couplers for any of your anastomosis and how do you monitor your flaps? Post-op 
Dr. Michael Orseck: [00:25:58] so I use couplers for all of my Venous anastamoses. I borrowed a little tip from a paper from MD Anderson.
If the venous anastomosis is less than two millimeters, especially in a radiated side to hand. So the vein. so that's the only instance where I'll roll the ham so vain. but otherwise 99.9% are coupled the artery is done with an interrupted 900 nylon. A few of them I will run, but the vast majority are interrupted nine on islands.
Now for monitoring, I use both an implantable Doppler probe and a Vioptics tissue oxygen saturation monitor. the reason why I use both, is sometimes, one is usually glitchy and a two in the morning. If I have a Vioptics signal, that's not picking up, we gets a call from the nurse and I asked her to put the venous Doppler up to the phone and I hear a roaring vein.
I can easily go back to sleep. but, if you have a problem with both and the flat flux, a little difference, then it's time to call the O R for sure there's a problem. And they're having the patient in the, or by the time I get to the hospital, how much? So I like two methods of, observation and I can't reliably.
Expect the nurse, maybe a new grad to interpret, the temperature of the color, the turgor of a flap, especially in a, skin span with a tiny skin bone. 
Dr. Sam Rhee: [00:27:31] that always brings up the question in my mind for these, micro surgeons is how much longer do you plan on. continuing with microsurgery because you know that's not so easy on the lifestyle, because like you said, you never know when you have to go back. It's, very, arduous the whole situation in terms of, this, so what is your plans like how long do you foresee yourself doing microsurgery for? 
Dr. Michael Orseck: [00:27:56] I don't first see stopping anytime soon. I've got to tell you that I love doing this more than anything. it is such a thrill to be able to help people, and the technical challenge and the mental challenge.
It's all, just brings me immense professional satisfaction, personal gratification as well. It's just, it just feels good to be able to accomplish something like this. fortunately, gosh, I hate, I hope I'm not jinxing myself, but we have very few. Early anastomotic vascular problems. So that's just, it, they're far and few between, raised flats with two or three perforators, a little slip, a muscle in between if you have to, not relying on single perforator flaps and it's massive perforator.
We just have very few problems, early on, but granted, I can't go too far. I can't, if I do when I'm Friday, even if I'm not on call for the weekend, I certainly can't go out of town. so you're right. It does hinder, some aspects of my life, but, we plan around it and make sure that there's weeks, while when I won't have flaps where, we can get out of town for awhile.
Dr. Sam Jejurikar: [00:29:04] luckily with there being a global pandemic, there really is nowhere to go. So might as well have a bunch of flaps. 
Dr. Michael Orseck: [00:29:13] That's right. That's right. 
Dr. Sam Jejurikar: [00:29:14] No, Mike, these are amazing results. And, again, I don't, I just hope our viewers understand just how special these results are and breast cancer is a horrible diagnosis, there is clearly a silver lining for your patients that they can get these sort of aesthetic results and be treated successfully for their cancer.
Dr. Salvatore Pacella: [00:29:31] that's great stuff. Great stuff. 
Dr. Sam Jejurikar: [00:29:34] Thank you so much for sharing it with us. And, I think that's about our time for today. So we'll wrap it up and, again, if patients want to find you or find your team, what's the best way of particular, if they're not in Spartanburg for them to find you Mike? 
Dr. Michael Orseck: [00:29:47] Sure.
my website is, Orseck, ORSECKMD.com. But Instagram is @doctor.orseck. we have an easy way is to contact the office of just want a little bit of information. Just shoot us a line. We'll get right back to you. 
Dr. Sam Jejurikar: [00:30:04] Wonderful. have a wonderful Sunday, John, a wonderful Sunday gentlemen.
And thanks so much everyone for watching. Take care.