What’s the Skinny on Fat Transfer? An Insider’s Look at The Hottest Trend in Plastic Surgery

It has long been a question that many patients ask during consultation: “It’s too bad you can’t just take this fat from my hips or tummy and bring it up to my breast?”. Ten years ago, I may have answered this question with a whimsical laugh and an “I wish we could!” Today, that answer is a resounding “Yes!”

Fat transfer or fat grafting is one of the fastest growing procedures in cosmetic and plastic surgery. A recent survey by the American Society of Plastic Surgeons*show that over 70% of plastic surgeons are performing this procedure in their practices. While fat transfer has been around for many years, recent advances in surgical technique and technological advances in industry are making the procedure more efficient, more reliable and longer lasting. The procedure is one of the fastest growing procedures that I perform here in San Diego.

Your Eyes Without A Face: Eyelid Rejuvenation for the Young at Heart

I have a soft spot for the 1980’s.  This decade defined my childhood.  Tunes such as this Billy Idol song really take me back to a great place.  Let’s face it, which other time in history could mix peg-leg pants, neon pink tee-shirts and super-mullet haircuts? Ahh…those were the days.

Over the last several years, I have seen many patients who share my same age.  A common request they have is rejuvenation of the eyes and face.  Many patients have said: “I look so tired all of the time…and I can’t stand these bags under my eyes.” As a plastic surgeon in San Diego (and a guy in his 40s), I share similar concerns.  I woke up the other day (after a not so restful night with my infant daughter) and looked in the mirror.  I didn’t quite recognize the guy staring back at me: puffy lower eyelids, dark circles and a scruffy beard (ok…maybe the beard isn’t so bad?)

Dog Days of Summer: Avoiding Injury with Your Loved Ones and Man’s Best Friend

I am a dog lover.  In fact, it’s difficult to imagine my life and my family without our dear adopted labrador retriever.  Turning 11 this month from the date of her rescue when she was just 6 months old, little Montana (pictured above) has never hurt a fly.  But having two young kids in the house, most parents like me worry about protecting our loved ones from getting mixed up with other doggies in the neighborhood.

As a plastic surgeon here in San Diego, I often see a complete other side to what can happen when doggies are not so nice. There are an estimated 70 million dogs living in U.S. households.  Sad to say, millions of people (most of them children) every year visit the ER bitten or injuried by dogs.  According to the American Society of Plastic Surgeons, in 2013 over 26,000 reconstructive procedures were performed to repair injuries caused by dog bites. Most of these injuries occur in the head and neck and can lead to unsightly scarring.
As we approach the heat of summer, its important to teach our children strategies for avoiding injury and respecting man’s best friend.

Botox and Dysport: How To Avoid the Porcelain Doll Look

Here in San Diego, a common question I get as a Plastic Surgeon is: “What do I do about these wrinkles around my eyes?” The first thing I say is: “Those aren’t wrinkles. They are called ‘smile lines'”. The lesson I learned here is that the word “wrinkle” evokes quite an emotional response and is usually synonymous with “are you saying I look old?!!”. But its important to understand that those wrinkles are not just about aging… they are about expression! We wouldn’t be human if we could not express ourselves. For this reason, many performers or actresses that I have encountered over the years in my practice shun the idea of any treatment or injection that will impede their ability to express themselves.

But fear not! There is a way to reap the benefits of neuromodulator injections (i.e. Botox Cosmetic or Dysport) without looking like a porcelain doll or appearing “paralyzed”. The key lies in having your plastic surgeon inject strategically!

The Daddy Do-Over: Cosmetic Surgery for the Other Half

As we round out the summer, those barbeques and beach beers can really bombard our busting bellies. We devote this month’s blog to the unsung heroes of economic vitality: The Suburban Dad.

Most of us live fairly busy lives: education, chiseling away at our career and devoting the needed time for wives and families. But somehow between the trips to soccer practice and the scattered dinner or Monday Night Football game, we (myself included) have missed a few opportunities to keep in shape and try to hold on to the youthful physique that we once had.

Fresh Start Surgical Gifts Honored in NYC

  • Fresh Start Surgical Gifts Honored in NYC

Practicing medicine in 2014 is an interesting endeavor. Many times the patient-doctor relationship is obscured by insurance companies, electronic medical records and pre-authorization requests. Every once-in-a-while, I am reminded why plastic surgery is such a fantastic vocation. As a member of the Board of Directors and a Volunteer Surgeon, I am lucky (and humbled) to be part of Fresh Start Surgical Gifts

Fresh Start Surgical Gifts was founded in the 1980s as a non-profit to treat children who suffered from traumatic injuries or birth defects. Its mission is to provide children with a “fresh start” in life. Our model is much different than the average plastic surgery charity. Instead of traveling abroad to offer our services, where sometimes patients may not have access to appropriate follow-up, Fresh Start welcomes both domestic and international children to San Diego. As they arrive in San Diego, every aspect of their care is donor-funded. From transportation, meals, evaluation, surgery and post-operative recovery. They stay until they are ready to head home safely…it’s that simple. In addition, Fresh Start is one of the only organizations where U. S. children who are “under-insured” can receive cosmetic surgery secondary to deformities of traumatic injuries if their primary insurance denies service or if it is too costly for their families.

2015 Atlanta Oculoplastic & Breast Symposium a Success!

This past weekend, I was invited to speak at the 8th Annual Oculoplastic and 31st Annual Breast Symposia in Atlanta, GA. The dual symposium is a special event hosted by the The Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS). Founded in 1958, the SESPRS is composed of many talented board-certified plastic surgeons from around the Southeastern United States. Their annual scientific meetings create an unparalleled opportunity for intellectual exchange of ideas and are a model for professional surgical education across the country. Their motto of “Beauty and Function” was exemplified during a fantastic four day program!

Dr. Pacella releases the definitive textbook on treatment of skin cancer

Dr. Pacella releases the definitive textbook on treatment of skin cancer: AESTHETIC RECONSTRUCTION AFTER MOHS SURGERY

After years of caring for patients diagnosed with skin cancer, I have heard this story too many times:

A patient sits in my exam room with a large bandage over their nose. What started as a small spot biopsied by their dermatologist has progressed into a large open defect requiring major plastic surgery. The patient sits anxiously, waiting for the final procedure to make them whole again. The patient’s emotions fluctuate rapidly: they may experience guilt about spending too much time in the sun, disbelief in the deformity that they have suffered, and fear of the possibility of permanent scarring.  They are in shock…How I can possibly restore their cosmetic appearance to a time before they were diagnosed with skin cancer?

Ten Things to Do Before Your Plastic Surgery

S01E06 - 3 Plastic Surgeons & a Microphone - 10 Things You need to do before Plastic Surgery
[00:00:00] Dr. Sam Rhee: Okay. I think we're live so welcome to another episode of three plastic surgeons and a microphone. Except right now we have two plastic surgeons and a microphone because, our third Sal is either going to show up and, and, as Sam said, a rolling start with our show or maybe, because we're starting on a Saturday, he may not show up.
I don't know. We'll see what happens. 
Dr. Sam Jejurikar: Yes. This is a different time for us, and it's very possible that we even fooled him with our start time. So hopefully, hopefully Dr. Pacella joins us, but we'll get started in the meantime. thanks for, the introduction Dr. Rhee , I'm Sam Jejurikar. Dr. Rhee has a few basic introductions that we need to get through before we can start with the meat of the show.
Dr. Sam Rhee: Sounds good. So. the three plastic surgeons are, as Sam said, dr. J Dr. Sam Jejurkar out of Dallas, Texas. His, Instagram handle is @samjejurikar. and then also our, absentee [00:01:00] plastic surgeon who should, will be joining us hopefully is Dr. Salvatore Pacella out of San Diego, California. His Ig handle is @sandiegoplasticsurgeon.
And I am Sam Rhee out of Paramus, New Jersey. And my Instagram handle is @bergencosmetic. So, we are here weekly, live talking about different, plastic surgery topics and anything that we have that's of interest to us. and, just to start off every show, just remember this show is not a substitute for professional medical advice, diagnosis or treatment.
This show is for informational purposes, only treatment and results may vary based on circumstances, situation, and medical judgment. after appropriate discussion and always seek the advice of your surgeon or other qualified healthcare provider with any questions you may have regarding medical care.
And lastly never disregard professional medical, medical advice, or delay seeking advice because of something in the show. So with that out of the way, Sam, you look like you're in a different location this week. It looks very nice. Where is that? 
Dr. Sam Jejurikar: So [00:02:00] I'm lucky enough to be in Breckenridge. Colorado made a little escape with my family, for the latter half of the week.
I think more like most Americans and we were going stir crazy in our house, in our house. it's interesting. When I talked to my patients, when I talked to. my family, when I talk to my friends, everyone is losing their minds. Everyone is going a little bit stir crazy. And so a place where we thought we could get away and sort of visit nature was Colorado, which is a place we like to come to all the time.
And so it's nice to get away. It's nice to escape the Texas heat for just a few days. but COVID is still on our mind. Just like it is on everyone's mind everywhere in the U S I was your week, Dr. Rhee. 
Dr. Sam Rhee: it was good. I'm not, I didn't travel. Hopefully I'll be able to get to the shore in a week or two I'm here in Jersey.
it's been busy. we just haven't been affected badly as some of the other places have in the, in the country. But the issue really is, is that everything is still on hold. We, haven't progressed in terms of opening more things. we're [00:03:00] still adjusting to everything being outside. My kids are playing contact sports outside for the first time this week, which is, which has been different, I guess that's been good but from a healthcare perspective, Oh, the worst thing right now is you mentioned last week, how your tests are getting delayed. The results are COVID tests are now crazy delayed, like more than a week in some cases. And it's been very frustrating. 
Dr. Sam Jejurikar: Yeah. In fact, I just read in the Wall Street Journal this morning, that CVS, which is one of the nation's largest providers of COVID tests.
It's now taking them a greater than 10 days to get results back for some, for some potential patients, which is tough because people are supposed to quarantine after they get the test until they get the test results back. But, if people lose their symptoms and they don't know human nature is that they want to get out and do things to can.
And so. You know, it's, it seems like every week we talk about COVID and we talk about how, you know, this is supposed to be a, it's not three plastic surgeons talking about COVID, it's three plastic surgeons that are supposed to be talking about plastic surgery, but you just can't get away from it in all [00:04:00] aspects of society.
You know, it was interesting for us traveling out here this week because, you know, I'm, I've, I'm very proud to live in Texas and consider myself a Texan and we're all about civil liberties. but this is a tough situation to be in where you try to balance. Public health demands and civil liberties. So in our state, we have a statewide mass mandate, but there are exceptions that can be made in certain counties.
And there are still many people that are against mass, so on our flight on the way out here, you know, my family is ultra protective about things. we were all wearing masks and even face shields, which got us a bunch of strange looks. but then when we get to Colorado where people are much more concerned about, it seems like on average, not, not trying to pin hole people, but people were.
Much seemed to be in general as a population, more concerned about COVID. everyone was wearing a mask. And so, I think I sent you a couple of pictures. 
Dr. Sam Rhee: He's the cutest kid. 
Dr. Sam Jejurikar: So this is my three and a half year old Julian who is demonstrating that even a three and a half year old with [00:05:00] almost no impulse control of any kind  can  mask for an entire flight, can wear a face shield for an entire flight. I think he was lucky enough to be borrowing my wife's phone and was watching Cars and with proper distraction, he could keep it on for the entire flight. And so it's frustrating when you see patients and adults who, who complain about wearing a mask, say that it's too hard to wear it. I mean, literally a three year old can wear it.
Dr. Sam Rhee: that's very cute. Doing so too. 
Dr. Sam Jejurikar: Yeah. Well, that's just his baseline. He looks like my wife, luckily, so he far more attractive, I think, as a human being than I'll ever be. But, but it's easy to wear a mask and if, you know, there's some data that's out that shows that if everybody wore a mask and did it for, you know, the next four to eight weeks, we could get a handle of COVID and probably get right.
Back to a much more normal life. Other things that I find interesting. Cause I think I sent you one more picture with my older two kids, and this is not meant to be a slideshow of my family, but everywhere we went on the hiking trails yesterday, everyone was wearing a mask. it's a long in Colorado.
that's being followed closely and being enforced very [00:06:00] closely and even out in nature where we're far away from people, every person we encountered. Was wearing a mask. So where are your mouth people? 
Dr. Sam Rhee: I agree. well, first of all, thank God. Your kids are better looking than you are. That's very, 
Dr. Sam Jejurikar: yeah.  And they thank God for that all the time. 
Dr. Sam Rhee: The second thing is it's kind of gotten a little politicized, the whole mask thing. And listen, I understand if I'm. If people don't want to wear masks, that's fine. I mean, I don't, I'm not going to sit there and arrest someone or try to arrest someone or get into some sort of altercation with someone if you're not wearing a mask.
But I feel like you do that. We, I mean, we are science based people. That's what we do for a living is we, you know, we provide medical care and that medical care is based on science. And that science is what guides, what we do. And it guides. how we manage patients and the science that we've seen so far shows that mask wearing, like you said helps.
And [00:07:00] so I don't, I don't want to get into a debate about it. I will never sit there and yell at someone if they're not wearing a mask, but I do. I do know that, like you said, mask wearing helps and you know, the faster we can sort of get through this, and the better. And I think that that can only be helped. by wearing masks. It's not going to hurt us in any way. 
Dr. Sam Jejurikar: Yeah. I mean, we all want life to go back to normal. You do. I do every person out there, but we have to go through this period of time where we were mass so that we can only, so we can truly go back to a COVID free society. So enough about COVID for the week.
Dr. Sam Rhee: So agree with you. Alright, so let's move on to our talk for today. We're talk, what we're going to talk about, which I'm pretty excited about is 10 things to do before plastic surgery. So basically, if you are someone considering six surgery you're or you're, I'm scheduled to have plastic surgery or cosmetic [00:08:00] procedure, what is it that you can do to help yourself ensure that the best outcome and a successful result? Any thoughts before we start, going through these topics. 
Dr. Sam Jejurikar: I think this is a great topic to get, to get our perspective on it. mainly because I think patients, what I've noticed now, and I know you've noticed this as well now, compared to 10 years ago, they use the internet so much more, than they ever did.
And, being able to, get a plastic surgeon's perspective on things rather than, you know, merely just patient perspective is a nice adjunct to what's out there. I don't think we're the definitive source, but I think our opinion matters as much as if not more so than patients sites as well. And so I think it'll be good to, to do this and, and.
It'll hopefully if my patients watch this, it'll save me a lot of time and consultations too. I agree. 
Dr. Sam Rhee: I mean, like, you know, but all of us have had, you know, years and years and years of working with patients and we understand that patients have [00:09:00] sometimes preconceived notions things that they have, like you said, heard or read.
And, listen, sometimes it just helps to remind patients of the things that we know, can really help. To get a good outcome. So let's start with, and these are in no particular order. I just kind of, you know, we threw them all together. not one is more important than the other. So the first one is, do not bankrupt yourself or place yourself in financial distress for your procedure, but also do your research because you get what you pay for.
Dr. Sam Jejurikar: Yeah, I think. I think that's both plastic surgery advice, and also life advice. you know, what we do for a living with aesthetic surgery is a discretionary expense meeting. Nobody has to have plastic surgery to look better. It's something we're choosing to do to make ourselves feel better about our lives, to, to feel better about the way we look, but you have to be in an appropriate place to do so.
If you it's expensive to get plastic surgery, this is Dr. Pacella trying to [00:10:00] call us. So hopefully he's trying to get on right now. I won't put them on blast, but, maybe we could just, maybe we could just message them to get them on that to get them online. But, but, but, but to sort of, To just fall on that, that, that, that line plastic shooter is expensive.
Save appropriately, make sure you can afford it. So there are, financing options that are available. Many of my patients use care credit, which is the largest sort of third party, plastic surgery, finance company. That's out there. they make it so that it's affordable to get plastic surgery. so, there's there's payment plans that extend out over five years so that you can fit it into your monthly budget.
That being said, like Dr. Rhee is saying, if you, if you try to go for the cheapest option. Yeah. Particularly if you try to travel overseas. Geez. I mean, you're going to have problems sometimes, particularly if you have a complication, implications are unfortunate, but they happen in plastic surgery and the person that's going to be most invested in taking care of you is your plastic surgeon.
And so I'm making sure that you're going to a board [00:11:00] certified plastic surgeon who is either close to you or easy to get to. Or who can at least communicate with you frequently is going to be really important. And so you need to do your research. You need to make sure you're getting a qualified person, which is going to be expensive, but at the same time, you have to make sure you can afford it.
Dr. Sam Rhee: Right. I agree with you a hundred percent. This is an investment and as a Sam said, it is discretionary, but this can be a very powerful change in people's lives. And if you're going to make that sort of change to yourself, two things, one is. You're not going to spend everything that you have solely for this thing.
you're going to work it, the you're going to work, into your life in a proper way so that it is not negatively impacting every other aspect of your life. Just like you would for any other major decision that you made. If you blew your money on a Rolls Royce and you had no money to pay for food or your rent then as much as you would get enjoyment out of that Rolls Royce, you're going to have a [00:12:00] lot of stress in your life. And that's sort of the same thing with plastic surgery. You have to be in a position where you can truly make a positive impact in your life, but it's not going to be negatively impacting everything else.
in terms of, and that's why you're going to get someone who is worth the money that you're paying for. all of us know different plastic surgeons. We know that not all plastic surgeons are the same. Some are better at certain things than others. Some, are going to match up better with some, patients.
So you're gonna need to make sure you pay for, and no one who's good is going to be cheap. So make sure you find the person that is right for you, someone who is board certified and someone who has experience in the type of procedure that you're interested in in terms of finance. I don't know about you.
I am a care credit provider. I just recently sort of started dabbling in it. I remember, our bosses, back at Michigan used to say, I don't know if you've ever heard this from Dr. Kuzon, but he used to say, listen, you should only borrow, for a couple of things. Education, Car, House. I have [00:13:00] to borrow money for groceries or for clubbing.
You're in a, you're in a bad situation. And, I think that that's very conservative advice. I, I do think that some of these financing options it's can provide people some flexibility as long as they're responsible in terms of using those, financing options. I do think it is better to finance then to say, do some other things, in terms of your money.
So I agree with that, but I just, I do caution people to really look into the terms and make sure that they're not getting screwed over. 
Dr. Sam Jejurikar: No, I think you're totally right. obviously, like I was saying, like the things that you mentioned, education a home, what was the third thing? You said a car. Yeah, it might have been sure about the car out of Ruth education in a home.
Those are the things that we need to better ourselves in lives, where to have shelter. plastic surgery is in that same category as sometimes as like a nice car. It's it's it's, it's something you want. It's not something you necessarily have to [00:14:00] have, but, you know, everyone's financial situation is different and many Americans utilize credit.
And so it's not that I'm trying to tell people that they should. But their plastic surgery on lay away, or they should get in a bunch of debt to do this. And far from it, many people know what their monthly budget is. They have a better sense as to what their cashflow situations look who it is.
Dr. Pacella. 
Dr. Salvatore Pacella: Hey guys, my apologies. I had some technical difficulties. 
Dr. Sam Jejurikar: No worries. No worries. So, we were, we had started our list, Dr. Pacella about, kind of 10 things that you should, You should do before plastic surgery. And we're on the very first one, which is basically don't make yourself bankrupt to have surgery, but also do your research.
Do you have any insights into that or sort of what you tell your patients in terms of what they can afford and how they should approach surgery? 
Dr. Salvatore Pacella: Well, I think it's, it's important to understand, you know, your resources. I mean, it's interesting patients will pay, you know, come in with a. You know, a Louis Vuitton bag, [00:15:00] but now I want to pay for, you know, a breast augmentation.
So I think if you, if you have the money you want to. 
Dr. Sam Jejurikar: You want to just figure out what's 
Dr. Salvatore Pacella: important for you, but I agree with that. You do not want to financially bankrupt yourself because this is stuff that's only gonna catch up with you on the same token. I think it's important to understand, you know, you have, if you have certain resources, what what's going to last you longer is a, is a breast augmentation, tummy tuck in the last, you your lifetime.
Yes. Most likely, Some physical, device or, you know, iPad, iPhone, you know, things like that. They're not going to last, your, your lifetime. So it's just a matter of getting out what you want. Agreed. 
Dr. Sam Jejurikar: Perfect. Alright, 
Dr. Sam Rhee: let's move on to the next, sorry. 
Dr. Sam Jejurikar: Oh, they'll say I feel like we should ask Dr. Pacella how he's been. We haven't seen him yet and it's straight, it's straight work mode. 
Dr. Salvatore Pacella: I'm willing to talk about it. It's just been a busy week. We, you know, really ramping up surgery and, you know, just been busy all [00:16:00] week long. It's been crazy. How about you guys? 
Dr. Sam Jejurikar: we're good. I'm I'm on a little break right now, so yeah, I'm nice and relaxed, but we're good.
Dr. Sam Rhee: Yeah. All right. So the next item is, do not buy too much paraphernalia. I, if you, You know, as you said, social media is a one, a powerful tool for patients, but I have seen patients that have bought or were told, you have to do this. You gotta do that before you have to get this afterwards. And sometimes it's not that relevant to what that patient's needs or even procedure 
Dr. Sam Jejurikar: yeah, I totally agree with that. Patients buy a lot before surgery and a lot of things, I'm not even sure why they're buying, but they, they got it from a Facebook group. And so I'll, I'll do a liposuction case or a Brazilian Butt lift case on someone. And before I've even done the operation, they've already bought like six different garments.
And, I think going slow with it and talking to your surgeon is key. There is some use for [00:17:00] paraphernalia, for sure that you can buy for, for various operations, but the offices of your plastic surgeon. Should be able to help you, you know, for each thing there's one or two or three things that's really, really useful to have. You don't need to overload yourself with, you know, a thousand dollars  and useless items just to just on the off chance you might need it. 
Dr. Salvatore Pacella: Right. A chances are you're going to have all this stuff anyway for you. You know, I know in my practice we provide bras and, liposuction, compression garments, abdominal binders, things. 
Dr. Sam Rhee: And you know, I remember one time I had a patient with a tummy tuck and a, she was told from her Facebook friends to go get these ultrasound massages right after the surgery. And after about two post-ops, I noticed that the center lower part of her abdomen was starting to get dark. And she ended up at actually getting, skin necrosis and skin death because whoever she went to was just, you know, pounding the heck out of her  abdominal flap with these ultrasonic [00:18:00] massages. And if she had talked to me about it, we ended up having to debris it and do all sorts of treatment for it. she could have avoided a lot of problems if she had just talked to us about it beforehand. So 
Dr. Sam Jejurikar: I agree. 
Dr. Salvatore Pacella: All right.
Dr. Sam Rhee: Next, actually read and follow the instructions from your surgeon both before and after care instructions. 
Dr. Sam Jejurikar: I don't know about you guys. We do tend to inundate our patients with a lot of information and, I understand their desire not to read it it's a lot, but it is worth the time. most of the questions, at least 95% of the questions that you'll have are actually in the information.
And we also have followup information that we give them like each of their postoperative visits to try to keep them on track. if you follow that, And then if you have questions about things you've read, it's more than okay to bring it up with the office. But, but reading and following your surgeon's instructions are going to be most important because every surgeon does things a little bit differently.
And as a [00:19:00] result, there's going to be nuances in how they manage their patients afterwards. Right. 
Dr. Salvatore Pacella: I think, you know, my practice, we have a subset of patients that will read everything. And then a subset of patients that will read nothing. And, I think the important thing is as a, as a plastic surgery office has a nursing staff, clerical staff.
It's very important. I think, to give the highlights of. What to take care of what to do, and then remind patients that, Hey, you know, we have a pamphlet here. We have a, information book. You want to read this at your leisure,  so that's important reminder for us as a, as a provider to have all this. Yeah.

Dr. Sam Rhee: I agree with Sal there's two groups. It's the ones who try to put together the Ikea furniture without even looking at the instructions. And then the ones who read it five times beforehand, and then. proceeds. So, yeah, I think, I think you're both right. just try to follow what it is and we try it.
Like you said, there's a lot of information as an [00:20:00] office. We try to at least hit on the high points verbally and make sure that they're aware of the most important things. But yeah, if you can read it, it's going to help everyone a whole lot. Number seven, quit smoking or any illicit substances months before, and be honest and tell your surgeon.
Dr. Sam Jejurikar: I think this might, this might be the biggest thing and the most important thing. Is that what you were about to say patella, go ahead. Go ahead. Yeah. Smoking. You get a lot of information from a doctor's office and it's hard to prioritize. What's the most important. This is probably number one on the list for me, smoking causes huge problems in cosmetic surgery.
And just because you may have gotten your gallbladder taken out or your appendix taken out and you were smoking and you were fine. Plastic surgery is totally different. We lift up skin flaps, we divide blood vessels. We move things around. It's much more susceptible to major wound healing complications, and even a trace amount of carbon monoxide, nicotine tar benzene, [00:21:00] like 30 things from cigarettes can cause profound problems with little blood vessels within. w within your skin cause the skin to necrosis or die, and lead to terrible results. And so my general rule is don't smoke at all, and don't use any replacement nicotine products for at least four weeks before your surgery.
And if you cheat, tell us it's better to screw up your schedule than to get a horrible result from a completely elective procedure. 
Dr. Salvatore Pacella: Yeah, I agree. I was just going to ask you both, like what your criteria is for being off of cigarettes or nicotine prior to surgery. Sameer, you said, four weeks Jersey Sam, 
Dr. Sam Rhee: I think usually four to six. If, if they're honest with you, that's a big, if. 
Dr. Salvatore Pacella: Yeah, I have a little special criteria here. You know, if you read some of the literature in plastic surgery, some of it is short as two weeks, and I can tell you, yeah. You know, I think that's just not enough. We, I, I've seen patients for cancer [00:22:00] operations that have quit for two weeks ahead of time and had massive problems.
So, you know my criteria is really three months of being off of any nicotine products. And, and what that tells me is, you know, they've really actively quit.
Dr. Sam Rhee: I mean, I've known some surgeons that will, drug test for a nicotine preop. And I have not done that. but I do feel like most patients, if they are really truly addicted to smoking or nicotine, it's a really hard habit to quit.
It's harder than probably most. And I will say that most patients. That I have seen that are really addicted. It is very hard for them to quit. They will fudge. They will tell you, you know, I'm down to one every other day or, you know, listen, if there's, if you're smoking and you're, you know, even if it's one a day or one every other day, just let your surgeon know and let them make that decision for that for you about [00:23:00] what, what is safe if you can't quit, you shouldn't.
Be undergoing a cosmetic surgery procedure. I know people who have asked me, should I be taking broth? Should I be eating too much broccoli? Cause I've heard that causes inflammation and then smoke. And their priorities are not right. If you really are going to spend this kind of money, then do the right thing and get that nicotine out of your system. 
Dr. Sam Jejurikar: Yeah. And that, and that's just, that'd be clear to people listening. That's not just cigarettes. That's, e-cigarettes that's smokeless tobacco that that's patches, gum, all of that stuff. And, even if you were using an e-cigarette and it says it has no nicotine in it, do not believe it.
It's not regulated. It's so harmful from a wound healing or wound healing standpoint. And like Sam said, Talk to your surgeon, not all operations are the same. You know, my, my concern with a facelift or a rhinoplasty, it might be different than it might be for a liposuction case. But having that dialogue is going to be very, very, very [00:24:00] important to appropriately assess risk before your surgery.

Dr. Salvatore Pacella: there's probably even more nicotine per dose in nicotine gum than there is actually in cigarettes. You know, it's a, it's an exceptionally powerful dose in, in gum. 
Dr. Sam Rhee: Agreed. Some of the people I've seen trying to quit say that it's too strong. and they've had problems with some of the, like alternative methods.
So yes, you're absolutely right. So, all right. Number six. So set up your home properly. that means sort of like nesting stock up with your, preplanned meals, the fruits and vegetables, the, you know, stuff that, you know, will be, easily sort of digestible the. The stuff that will help you with recovery, maybe having a recliner, recovery area, maybe an area in your living room.
So you don't have to go three flights to your bedroom. basic dressing supplies, all the easy stuff. We'll make it easier for you to get around during, during your recovery period. 

Dr. Salvatore Pacella: don't know. sorry. [00:25:00] so, you know,  patients often times ask a specific question. I have I've stairs in my house. I have stairs leading up to my condo stairs in my home.
Do I need a wheelchair or what should I do? Should I stay somewhere else? And, you know, stairs. Are good. Particularly if you're having body surgery or abdominal plasty surgery, one of the risks we have with a big, long body case, the risk of DVT or blood clots in your legs and having stairs in your home.
Is a good thing because we want you to get up and move and, and, and use your legs and step up and doubt. We don't want you running stairs. I think the important thing to understand is you don't have to set up your home. Exactly. Right. You could set up a few things, but you don't have to move out of your home, but it's important to make sure that you have somebody there to assist you with going up the stairs.
Dr. Sam Jejurikar: Yeah, it's funny. You brought up the stairs. I get that question all the time too. And I have also, I've never had that good of an [00:26:00] answer to it, but it's so true. There's nothing wrong with stairs at all. The patients are definitely afraid of going. I mean, I get that question once a week, probably. I think another thing that you just said that so important.
In the setup of your home is making sure you have somebody to help you. sometimes people don't want to inconvenience their friends or their family, and that's fine. There are services out there that you can hire to have somebody help you. But if you think you're going to have a big cosmetic operation and then take care of yourself, it's going to be very difficult.
And your outcome's going to be a lot worse than the risk of a blood clot, because you're, it's just hard for you to get up and down. Is it going to be substantially higher? 
Dr. Sam Rhee: Agreed. that's actually, one of the other ones is having a appropriate support. 
Dr. Sam Jejurikar: Oh, I blew it. 
Dr. Sam Rhee: No, it's good. So we'll cover it now. I agree a thousand percent, I think, Sal's patient, Elaine had mentioned that there are services available that can help you with certain things, during recovery and, you know, especially my patients who live in New York, in Manhattan, they're all very isolated and they, they. For such a big city, they don't [00:27:00] necessarily have neighbors or people that they can rely on.
And, you're right. sometimes it's not so much the setup, but it's, who's going to help you with that setup that makes it more efficient, right. Review, which medications to take or not take beforehand. 
Dr. Salvatore Pacella: You know, this is, this is exceptionally important particular, particularly if with our older patients, many medications that are out there can cause excessive bleeding. some patients are blood thinners, which can be unfortunate for plastic surgery.
And, if in my practice, the most important meeting we have with patients is something called a preop appointment. that pre-op appointment is done. It usually, hopefully about two weeks prior to surgery at that time. myself and my nursing staff we'll go over exactly what medications to take or not take.
We have a full list. so it's important to really bring that to your preop appointment. it's important to understand exactly whatever you're on. and you know, sometimes you [00:28:00] sometimes, for example, you know, our younger patients may have a workout or something and they will forget, and they'll take a handful or a couple of tabs of Motrin say, and that can lead to significant bleeding after surgery.
So, I think the onus many times is on us in the plastic surgery staff. To understand or have patients understand exactly what to take and what not to take. 
Dr. Sam Jejurikar: Yeah, totally agree with Sal. We don't do a formal revisit for many of our patients, but we review it all online ahead of time. I think I'm getting, depending on the procedure, relative risks of certain medication changes, but sort of the big classes of medications that we worry about are blood thinners.
And those aren't just prescription blood thinners. That cause those can be asprin. Those can be nonsteroidal. Antiinflammatories like Motrin, like Dodger. The cello was referring to another big class was weight loss medication. a lot of patients like to take phentermine and there's a lot of potentials that can cause from a cardiac standpoint with anesthesia.
and then over the counter supplements, most of the over the counter supplements that you buy for your mental health, [00:29:00] aren't really regulated. And so there can be a lot of, things that cause bleeding complications in some of those supplements. So in general, if it's not completely necessary or recommended to you by another physician, we have you stop taking those two.
Dr. Sam Rhee: I agree, with both of you, I think, I see a lot of patients on phentermine, the weight loss medication, which is surprising to me a little bit, the, contraceptive medications, birth control pills. that's a big one. The, the herbal supplements, can be an issue. I usually am okay with stuff like arnica.
Cause a lot of people want to take that. What do you feel about some of the other things that, people want to take before surgery? 
Dr. Sam Jejurikar: Yeah, in fact, for a lot of, a lot of patients, will actually recommend they take arnica and bromelain to help with postoperative bruising and swelling and I'm, and I'm more than okay with that.
And for, Before I get to that certain nonsteroidals I'll actually use for breast augmentation, for instance, like different, a different class of nonsteroidals, but in general, things like, you know, Gingko or st John's warts, [00:30:00] they can have an, an, an issue with bleeding for most operations that worried about it.
But for facial aesthetic procedures, rhinoplasty, blepharoplasty, that sort of thing. I do want them off of it for two weeks ahead of time. How about you sell. 
Dr. Salvatore Pacella: you know, we have a list of all the over the counter, you know, natural supplements and things that we, we don't want you to take. And, you know, I I've had, I've had a little bit of a interesting time with arnica that I, you know, for some patients that works really well for other patients, it just doesn't seem to do anything. So, you know, I, I think, I tell patients if you want to take it, that's great. I don't necessarily recommend it or not recommend it. 
I don't know. What's your experience 
Dr. Sam Jejurikar: with arnica? Both of you. Mine's the same as yours. Sometimes it helps sometimes it doesn't, it's relatively underpowered, but it's a nice little adjunct. Yeah, yeah. 
Dr. Sam Rhee: Yeah. I've seen some anecdotal experiences where it seemed to make a huge difference. And then, like you said, sometimes it doesn't seem to make any [00:31:00] difference.
the only other thing I was going to add I forgot was, I'll see a lot of, younger women with borderline low hemoglobin or slightly, you know, just a little bit anemic and, You know, usually it's because of heavy menstrual cycles. And so it's helpful if you can get them on some iron a month or two beforehand, that that seems to help with recovery.
So I try to push, iron supplementation for a lot of patients. They don't like it cause it may make them constipated. But I think for a lot of patients that may be helpful. Yeah. 
All right. we already talked about it. Arrange for help afterwards. If you have, children pet care, just care for yourself going up and down the stairs.
Transportation. anything else to add for this one? I know we covered it a little bit. 
Dr. Sam Jejurikar: Not really. 
Dr. Sam Rhee: Okay. Don't party before your surgery. 
Dr. Sam Jejurikar: I think you specifically mean don't use a lot of, alcohol [00:32:00] or illicit substances before your birthday. I mean, before your surgery, birthday is a different issue and that's true for a lot of same alcohol can cause problems with bleeding during surgery. So, You know, most of us have in our preoperative directions for patients not to drink for a couple of weeks ahead of time.
And there's a reason for it. It's not that we're trying to be draconian or try to take away your lifestyle. It can cause problems with your surgery. Surgery is not only a big financial event. It's a big time commitment as well. And it's not just the actual surgical procedure. It's the planning ahead of time and getting ready for it.
And so, you know, not smoking, not drinking, not using illicit drugs, all very helpful to help prevent complications. 
Dr. Salvatore Pacella: Yeah. And I think the important thing with alcohol is it's it's, it can cause a significant amount of dehydration. And when you're undergoing general anesthesia, you're sleeping, you go to sleep. If you are exceptionally dehydrated, like alcohol can make you, particularly the day after, You know, a, a night out, that can cause significant [00:33:00] problems with blood pressure. It can be very difficult, for the anesthesiologist to maintain. So, so hydrate yourself, but not with alcohol. 
Dr. Sam Rhee: What do you think about partying afterwards? I do have patients who ask when they can start having a glass of wine or two after procedures. And also wasn't there a plastic surgeon that from Texas who used to brag that his patients would go out dancing after, after breast augs. 
Dr. Sam Jejurikar: Yeah. It's a big marketing thing. A 24 hour breast augmentation and John Tebbets made that, made that popular.
And, it's been sort of passed on to other surgeons who advertise a 24 hour coverage. And it's a marketing thing. I think most of our patients have close to the same 24 hour recovery where they feel pretty good after 24 hours. But, I generally, it really depends on the operation for facial cosmetic procedures.
I ask people not to drink for two weeks afterwards for smaller procedures, whether it's liposuction of a small volume or a breast, I might be fine with it after a week provided they're off all their pain meds. but, but it's [00:34:00] individualized for, for every procedure. And it's important for every procedure. Just the relative extent, changes a little bit.
Dr. Salvatore Pacella: Right. I, I, I couldn't add anything more. I think, you know, when patients are off of their pain medication is when I say, you know, you can, you can go back to one or two drinks in the evening if you like, but no party. And for a couple of weeks, at least not the kind you do. So I know what cheap, I'm a cheap date. I have a half a glass of wine and it's. 
Dr. Sam Rhee: Puts you down. Yeah. As you're getting older, that's why. All right. number two, arrange for the appropriate time afterwards. So depending on your procedure, you may need days or weeks. it's not just the, initial aches, pains or bruising, but, other restrictions that you may have after your procedure, if you work, can you afford to take that time off of work? That includes stay at home moms. that sort of thing. 
Dr. Salvatore Pacella: think it's important for us. you know, as the provider to really hammer this down with patients before surgery. [00:35:00] Cause cause some patients just don't have a realistic expectation about what amount of pain or discomfort they're going to be in. some patients with a heavy surgery, say a mastopexy augmentation, a tummy tuck they'll have a surgery on a Friday and expect to be back by Monday.
And I just don't think that's very realistic at all. Obviously. But for some procedures, say a little bit of minor liposuction, it's possible to go back to work a couple of days later. So, the other thing I would say is we were going to have to fill out, some disability paperwork or, you know, an excuse from work, et cetera.
And I, I want to caution patients. It's okay. It's a lot easier to ask for more time off and be released early than it is to get additional time off. It's just a lot more paperwork if you're going to add another week after. So if you have the ability to take a little bit of extra time off, we can always write you back for forgetting back early.
Dr. Sam Jejurikar: Absolutely. Yeah. And I think, I would just add a little bit to what Sal said. There's not only the physical [00:36:00] discomfort with some of these bigger operations. Sometimes you may feel great, but if you've had say a facelift or your eyes don't, you may look terrible. And so, you may have the ability to work from home.
If you, and in those sorts of situations, you're going to be better off if you're actually, utilizing that because certain operations, You know, if you have a facelift, for instance, I'll tell people it could be two or three weeks before you look socially acceptable, even with camouflage makeup and you have to plan accordingly.
And so if you don't have that and you need, and you have an important event or an important meeting, and it's 10 days out from surgery and you don't look that way, you're going to be very unhappy. And it's mainly just because of a failure to plan appropriately.  
Dr. Sam Rhee: Nothing makes me more nervous and a patient who says.
I want this procedure because in a month I'm getting married or I'm going to my daughter's wedding. I feel a tremendous amount of anxiety when that happens, because shores, it always seems like the recovery is always slower in those situations. So I want to [00:37:00] make sure that patients, if they got something big coming up, they give themselves plenty of time to make sure that they recover from that so that we're not.
You know, stressed about, you know, why are they still swollen or that blah, blah, blah, blah, blah, like that sort of thing. Perfect. I don't know why this is number one. We have one bonus one after this, but, this is not the most important, but it's still number one, shaving or waxing your surgical sites four to seven days before surgery, as opposed to the night before the morning of surgery, which can increase risks for bacterial colonization.
Dr. Sam Jejurikar: yeah, don't do it. I just, I'm still trying to figure out how this is. Number one on the list.
Dr. Salvatore Pacella: I know. The other thing is we can do this for you, you, during the search, before your surgery, after you're asleep, we always prep and prep the area to make sure there's no excess of hair that you know, it's not going [00:38:00] to get away in the incision. So, you know, if you're, if you're worried about us as surgeons, we could take care of that for you.   
Dr. Sam Jejurikar: So the only, the only one thing I would make an exception to is if you are getting a haircut implantation, you may find it beneficial to do it yourself the night before. So you can shave your entire head and just not abortion of it. That's the one operation I might make a little bit of an a, of an, a, of an exception for it.
Dr. Salvatore Pacella: Texas, Sam, how do you feel about manscaping the surgeon manscaping prior to their surgery? 
Dr. Sam Jejurikar: You mean me personally as an individual? Yes. I'm a big, I'm a big fan of certain really has nothing to do with it. 
Dr. Salvatore Pacella: For the plastic surgeons out there. According to Texas Sam, maintain your manscaping regimen.
Dr. Sam Rhee: He's very smooth. He's a very smooth surgeon for sure. 
Dr. Sam Jejurikar: Well, I'm assuming that, that, that Jersey, Sam probably is fairly hairless given his, so he can make fun of this whole issue, but me being a hairy Indian and you being a hairy Italian, you know, these are issues we have to think [00:39:00] about.
Dr. Sam Rhee: Yeah. I'm definitely low maintenance. There's not a whole lot of hair there. Alright. 
Dr. Salvatore Pacella: it's like, no, really you can take off your sweater.
Dr. Sam Jejurikar: Go ahead. 
Dr. Sam Rhee: alright. And the last one, get in the right mindset in regards to expectations. So have a conversation with your surgeon, don't get lulled into false expectations or things that you may have seen elsewhere or by your friends or social media. 
Dr. Sam Jejurikar: Yeah, I think you've mentioned this before. Jersey, Sam, where, a patient will, you know, who might have a BMI of 35 will come in with a postoperative liposuction, Brazilian butt lift result of a patient with a BMI of 20 and, and will want to look like that. Everyone's body starting point is different and that's, everyone's finishing points going to be different as well. not to say you shouldn't expect great things out of your surgery, but [00:40:00] it's all going to be relative to your starting point. 
Dr. Salvatore Pacella: Yes. It's eh, this is of critical importance, I think. And a lot of the onus on this is the surgeon and surgical team and the expectations to explain this ahead of time. patients oftentimes bring in photographs. In fact, you know, in my breast augmentation patients, I want them to print out photographs of, of, things they get from the internet to say, Hey, this is what I want to look like.
And that's what I. That's why I think a preop appointment is very critical because I'll go over those photographs and say, Hey, this is, this is achievable. This is not really, in the realm of what we can achieve either. so it's, it's, this is a critical, critical importance. 
Dr. Sam Rhee: Yeah. I, I, try to be relatively conservative in terms of, you know, I don't think surgeons should ever promise or guarantee anything.
And I certainly don't, but I feel if a patient has [00:41:00] something that, you know, and they'll the know patients will and say, okay, I understand what you're saying. I understand what you're saying, but still in their own mind still have something that is not realistic. It's, it's hard to communicate with patients and get to understand what they want for sure.
And whether they, and know whether they understand what it is that you. Believe you can achieve for them. I think that's why you sell, have those photographs, because that really helps. I think that's why, digital imaging, what a Texas Sam uses can be very helpful. Whatever means we can use to try to understand our patients and understand what they want.
And then also get them to understand what we think we can deliver is really important. And then if they're in that right mindset, then I think they'll definitely be very happy with the procedure. 
Dr. Sam Jejurikar: Couldn't agree more with the gentlemen.
Dr. Sam Rhee: So that's everything that I have listed. Are there any other, things that [00:42:00] patients should do before surgery? 
Dr. Sam Jejurikar: You know, I think this is a nice overview in the sense that, there's a lot to do before surgery, but planning is a PR is important. Make sure you have people, make sure you have the necessary items that are there.
Make sure you have enough time off, make sure you communicate with your surgeon. If you do those things, that's 95% of it. 
Dr. Salvatore Pacella: Right. And you know, I think, the other thing I would say is it's important to. For patients to really decide well in advance that they are doing the right surgery for them many times.
And again, I'm going to go back to that preop appointment. that's, that's why I think it's exceptionally critical that I see these patients ahead of time before the surgery for a informal, preoperative assessment. Because many times we'll go over again, the surgical plan and sometimes their expectations have changed.
Sometimes they want to change what they do. And I think that's, that's [00:43:00] exceptionally important to hammer out ahead of time. It gives a, it gives the surgeon and the patient a second opportunity to look, look at the plan and, and restructure it if needed. 
Dr. Sam Rhee: Yeah. I think the key when I listened to both of you is communication, whether it's with your surgeon's office or the surgeon or reading what they communicate to you, it's really about, if you and I will have patients who will ask the same question wash and then call our office like three times in a row. But most of the, I mean, most of the time we really encourage it.
If you're not sure, if you have a question check with your surgeon's office, talk to their staff, talk to, you know, everyone involved and, and make sure that you're on the right page because, regardless of all of these things and you know, you might not have a lot of time. It could maybe be a week or less that, you know, you see the, the search it's possible before you decide to do something and, you know, that's okay.
As long as you're in close communications with that surgeon and his [00:44:00] office. 
Dr. Sam Jejurikar: Yeah. And in the year 2020 with the current pandemic, a lot of this as is possible, even via telecommunication. I do a lot of these consults now in the evening via zoom when we're done operating communication is now possible, even when the office isn't open.
And so if you have questions, get them answered, review expectations, just like Pacella and Rhee are saying. It'll, it'll make all the difference in you being happy with your results and getting exactly what you're wanting. 
Dr. Sam Rhee: Very good. Wow. I finished a sorta early with our talk today. is, is there anything else going on that you guys want to cover?
Dr. Sam Jejurikar: I just, I'm curious. You said things are ramping up for you guys right now. You guys are not, are not slowing down at all. 
Dr. Salvatore Pacella: Yeah. I mean, the state of California in general is slowing down substantially, but, you know, in, in healthcare, we are still proceeding to go forward and, and, and again, I, I attribute that to the, to the [00:45:00] testing capabilities that we have, you know, we've just been widespread testing, you know, we at least at the hospital system, we have not had a shortage. We've had a little bit of a surplus for our patients, on like say, you know, I'm watching newscasts from people waiting eight hours to get testing. So, you know, I, I again was taking it week by week. I don't know if that's going to change, but you know, it's, it's been getting busy 
Dr. Sam Jejurikar: and what's the typical turnaround time for your testing?
Dr. Salvatore Pacella: usually within about, I'd say. Probably about a day, you know? Wow. 
Dr. Sam Rhee: Wow. That's 
Dr. Sam Jejurikar: that's PCR testing. Wow. 
Dr. Salvatore Pacella: It's a PCR testing. Yeah. So again, this is, this is a testing for preop, for the cause our, our hospital rules are, you have to have a, a negative test within 48 hours of the surgical time. So usually we're sending patients ahead of time, two days to get the COVID test. And then usually it's back by 24 hours. 
And I think what you're seeing there is a lot of. [00:46:00] And so w in some of the hospitals where I'm affiliated much faster turnaround time, because a lot of these third party companies that are doing the testing now are actually contracting with larger, larger organizations, like scripts for you, for instance, where all of their tests get sort of bumped up and were individual guys in private practice like you and me, Sam, our patients get bumped on the list.
So we were talking before you got on, right. where, even CVS is now is experiencing sort of a 10 day turnaround time in terms of their, in terms of their testing. So that's insane. So it's sort of all over the map. 
Dr. Sam Rhee: Yeah. And then, yeah, like Sam was saying, and then asking your patient to quarantine during that time.
It's a very, very long time. So it's been a little frustrating, for us, for sure. 
Dr. Sam Jejurikar: Yeah, well, gentlemen, enjoy your weekends. I'm going to enjoy this beautiful day in Colorado and try not to think about COVID too much. 
Dr. Sam Rhee: All right. Thanks. Very much guys. Enjoy we'll talk to you later. [00:47:00]


Dr. Sam Rhee: [00:00:00] Welcome to Three Plastic Surgeons and a Microphone. This is our 12th show. And today we are going to be talking about rhinoplasty. We have as always Dr. Sam Jejurikar from Dallas, Texas. His Instagram handle is @samjejurikar. Dr. Salvatore Pacella from La Jolla, California. His Instagram handle is @SanDiegoplasticsurgeon.
Dr. Salvatore Pacella: [00:00:26] West Coast baby 
Dr. Sam Rhee: [00:00:30] that's what all the surfers do when they're out there. 
And then a 
Dr. Salvatore Pacella: [00:00:35] locals only, bro. That's right. 
Dr. Sam Rhee: [00:00:37] That's how you recognize the locals. They do that to each other. 
and then I am Sam Rhee from Paramus, New Jersey. And my Instagram handle is @Bergencosmetic. Remember, this show is not a substitute for professional medical advice, diagnosis, or treatment that shows 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 other qualified health provider with any questions you may have regarding medical care and never, never disregard professional medical advice or delay seeking advice because of something in that in the show. So with that today, we are going to be talking about rhinoplasty and I will give it up to Dr. Sal Pacella to begin talking. 
Dr. Salvatore Pacella: [00:01:21] Good morning, gents, how are you both?
Dr. Sam Jejurikar: [00:01:24] Doing wonderful. Dr. Pacella. How about yourself? 
Dr. Salvatore Pacella: [00:01:27] Fantastic. It's it's been a usual sunny and hot weather. How's how's everything going? Did you guys get, did you get hit by any a hurricane there? Texas Sam? 
Dr. Sam Jejurikar: [00:01:36] We got, we got very, very lucky here in Dallas. the hurricane veered off to the East before we even got any remnants of it.
I think I got about three drops of rain on a, on my grill, on the backyard. And that's all that I noticed from the whole thing. Yeah, we got very lucky. 
Dr. Salvatore Pacella: [00:01:54] Yeah. And, Dr. Rhee from New Jersey, you, how's the Jersey Shaw. 
Dr. Sam Rhee: [00:02:00] Everything's good here on the East coast. nothing unusual. We're just getting geared up to get back to school and with the kids and sorta deal on with, With that right now.
Dr. Salvatore Pacella: [00:02:10] Yeah. Good. Good. All right. Well welcome gents.  so today's podcast, we're going to talk about something a little bit different that we haven't spoken about previously. And that's about rhinoplasty also kn own as nose jobs to the general community. And, you know, this, this is an area of the face and of the body where arguably function interacts with, with form and cosmetics, more than any other place in the body. I mean, it is a exceptionally challenging operation and, and I would say that most surgeons that I know have given up rhinoplasty in their practice early on were w Texas, Sam, or Jersey, Sam, you, any comments on that?
Dr. Sam Jejurikar: [00:02:54] You know, I'm I definitely haven't given it up. I think there are people that specialize in rhinoplasty. So in most large cities, there are rhinoplasty surgeons that are that's really all that they do. In fact, one of my partners is a internationally famous rhinoplasty surgeon. but it's true of the, of the 11 guys that are sort of affiliated with my group, probably five of them perform rhinoplasty.
The other ones that just gotten far away from it. Cause it's such a different skill set than other things we do in surgery. 
Dr. Sam Rhee: [00:03:21] Absolutely. I think it's one of the most dramatic changes that you can make to the face. It's one that as a Sal in San Diego has said is so functional also as well as aesthetic.
And for me, I still do rhinoplasties but I have. I know what I can do, and I know what I can't do if there's a complicated redo, or, a multiple, you know, redo you know, someone who's had multiple operations on their nose, I will send them to one of the specialists that Dr. Jejurikar mentioned someone who has a lot of experience.
if it's something I feel very capable about and that I know I can achieve a result with, I will do it, but I definitely pick and choose, I know, is within my my skillset 
Dr. Salvatore Pacella: [00:04:03] in, in Manhattan or in Northern New Jersey. Do you see a, this is a very popular operation. 
Dr. Sam Rhee: [00:04:10] Yes. There are a lot of people who, It's funny.
There are, there are probably more people interested in rhinoplasty than actually get rhinoplasties. I see so many patients who are interested in it, not sure whether they should proceed with it. And then, you know, at some point, do do it, it's something that they circle around for a real long time sometimes before they actually do it.
Dr. Salvatore Pacella: [00:04:32] And, and, you know, the thing I find practice in San Diego and the Hoya is, you know, we, we have a huge population of patients that have both functional and cosmetic concerns. And you know, what I, what I tell patients is. You know, I give him this simple analogy. Anything you do to change the function of your nose can obviously change the aesthetics of your nose.
For example, let's imagine you, he had the biggest nose in the world with massive nostrils. And if we wanted to reduce the size of that, not it could easily see, you can easily see how that would affect the, the airflow through the nostril. Obviously you're breathing through something this big compared to something that big, consequently, let's say you.
You had a very small nose that we wanted to expand the nose. If your nose was just simply removed and you're breathing through a hole in your nose, obviously, so you could see how that would affect the cosmetics. So it's just absolutely critical to, to not underplay this concept of function versus cosmetics.
And those are two fundamentally different things. Sam and Dallas, would your thoughts? 
Dr. Sam Jejurikar: [00:05:38] I think that is a beautiful analogy. I've actually never heard that before, but I think that's a very apropos. It's very true. You know, I think, this operation more often than not the people that come into my practice, I'm gonna imagine the same.
It's going to be true in San Diego for you, with Dr. Pacella and, and, in New Jersey for you. Dr. Rhee is. People want their noses in general, they're coming to us for the aesthetic aspect of it. And they're not thinking so much about the potential consequences in regards to their breathing. and it's not just the nostril is like, like you mentioned, there's the septum, which is an area people don't traditionally see, there's a thing called the internal nasal valve, which I'm sure we'll touch upon later on, which is higher up in the nose, which can be a source of issues and trying to create that balance.
very much can sometimes go against their primary reason for being with us, which is to improve the, the reason, to improve the appearance of their notes. Just out of curiosity, before we move on, do you guys see in your practice, a large demand for now surgical rhinoplasty, Dr. Pacella. San Diego, is that a popular thing?
Dr. Salvatore Pacella: [00:06:37] I do actually as part of my affiliation with MD Anderson and, and also being part of a large, multi specialty group with, head and neck surgeons and otolaryngologist, I, I work with at least. 10 to 15, ear nose and throat doctors. And just for our listeners out there in ear nose and throat doctor is a, is a physician specifically, trained in diseases of the nasal cavity or airway or, or throat.
And so these, these types of docs oftentimes get, referrals for nasal airway obstruction. And when patients come in, they ask him questions. Hey, well, what about this hump on my nose? And many of them don't feel comfortable addressing the cosmetic yeah. Aspects. So I get those, I do, you know, serve, those patients for both functional and cosmetic reasons, but on the consequences.
Well, you know, being part of, being a cancer reconstructive doctor as well, I, I do, Take care of a fair amount of patients that have, really bad noses from the functional standpoint, either from trauma or nasal reconstruction. So that is a fairly large chunk of the, of the rhinoplasty patients.
I see no cleft lip, cleft lip, patients, rhinoplasty, et cetera. So, yeah. Well, why don't we, why don't we dive in here to, to the case here. So I'm going to, I'm going to share my screen here. Okay. Oh, you got it. Okay, great. Hmm, hold on a second. Sorry, gents. No problem.
Dr. Sam Rhee: [00:08:04] I was doing that. I was just going to comment on nonsurgical rhinoplasty as well. Sam. Yeah, that's been a growing. part of my practice too, for people who are looking for relatively minor changes, it can be a very powerful tool. you know, they hear a lot about liquid rhinoplasty or, you know, terms similar to that.
And that's a pretty easy noninvasive or not easy, but a relatively noninvasive way for people to change their appearance and see. Whether changing their nasal appearance is something that really liked to do. 
Dr. Sam Jejurikar: [00:08:39] Yeah. I I'm. The reason I brought that up is I've seen a huge increase in demand for liquid rhinoplasty and for relatively minor touch ups.
Like in the last month I've had no, no less than a half a dozen, young women who were getting ready to go to college who wanted a little, a little change before they went to, before they went to school. So just curious if you guys are seeing that same trend in other portions of the country 
Dr. Salvatore Pacella: [00:09:01] a little bit.
Yeah. Yeah. All right. Great. Well, okay. Let's you, you okay with sharing the screen there? Yes. Okay. Alright, so, we'd have our, you could see my first slide here. Yeah. Okay. So nasal surgery rhinoplasty. So, I want to show you a very challenging first case here. Okay.
Dr. Sam Jejurikar: [00:09:24] That's an oblique view of Dr. Pacella.
Dr. Salvatore Pacella: [00:09:31] So obviously, you know, we're with levity here. So this is a, this is an operation, obviously. That's okay. Is, you know, smack no, arguably no other area of the body is smack dab right in the middle of the face. And there is a reason why I love performing rhinoplasty so much. And it's, and the main reason is it's interplay with the, you know, and being a, being both the reconstructive and cosmetic eyelid surgeon.
you know, this goes part and parcel to the same thing. When we're talking with people at a conversational distance. Really when it comes to focusing on that person and speaking with that person, the eyes and the nose create a huge interplay. This is a, a attractive young lady here. And if you're, if you, if I just showed that slide to you, where are you going to focus your conversation on looking at this woman?
You're all going to focus right here. And that, that central triangle, the face is so critically important to, So communication to a human interaction and an any degree of deformity or, or shape disturbance in the nose can interplay with that human interaction. Jen, your thoughts? 
Dr. Sam Rhee: [00:10:43] I absolutely, I think that's one of the reasons why masks are 
Dr. Salvatore Pacella: [00:10:46] so. yes. 
Dr. Sam Rhee: [00:10:48] difficult in terms of human interaction, because you would think the eyes would be enough to react with someone, but no, you need that lower part of the central triangle to really feel like you're connecting us with something, buddy. 
Dr. Salvatore Pacella: [00:11:00] That's a great point about the masks. 
Dr. Sam Jejurikar: [00:11:02] Yeah, no, it's so true. And I like how it looks like it's an equal lateral triangle, the way you have it as well.
Cause that really are the ideal, the ideal proportions, the nose fits in nicely between the inner portion of each eyelid and, and if it's off and if that balance is off, the whole facial balance is off. Right. 
Dr. Salvatore Pacella: [00:11:20] So, so this is our, this is our patient here. So she is a, just as an intro here. This is, a very nice young lady, 23 years old, who came to see me, you've referred from her, otolaryngologists or her ear nose and throat doctor, had a significant amount of nasal airway obstruction.
Difficulty breathing. She was a bit of an athlete. when she ran, it was very challenging for her to take a deep breath. but clearly also did not like the cosmetic or aesthetic appearance of her nose. And, let's, hand it over to you guys. Tell me, you know, what you see here and what your thoughts are on, on her nose.
Dr. Sam Jejurikar: [00:11:58] I'm happy to go for. So, you know, this is very typical of many of the noses that we'll see. I basically will, will group rhinoplasties and there being two categories, rhinoplasties where you want to make the nose smaller and rhinoplasties where you want to add it and make it bigger. And in different the cities, you tend to have a predilection of one type versus.
Versus another. And this particular case, when you look at this young lady, the thing that you're drawn to more than anything is what we call the dorsal hump. So the portion of her nose, which is a portion of which is boney and a portion of which has cartilage, Doesn't have balance compared to the rest of her nose.
So I know this is something that she brought up to you when she first came in. The other thing that you look at when you look at this young lady is that overall her nose just appears long. when you look at where the tip of her nose is, and you think about the angles you want it to have with her face, the nose is plunging or going downward.
So the steps that we take during surgery are going to be geared largely towards. Raising the tip up and reshaping it and also reducing the size of the upper portion of her nose. 
Dr. Salvatore Pacella: [00:13:01] Absolutely. 
Dr. Sam Rhee: [00:13:01] Absolutely. One of the other things, one of the things that we did in training and that we all learned was how to do a facial analysis and how to evaluate the proportions of the nose.
And this is one of those things that we had a lot of training and we could go on, we could literally talk for an hour about the facial analysis and the nasal analysis and in a patient. it's super technical. It's not something that. I think patients would necessarily be interested in. but you could certainly talk a long time.
I'm about her, her about breaking down the technical aspects of it. But the only other thing I would want to comment on top of what Sam said though, is, it looks like she has a little bit of, a little bit of a C shaped deformity where the nasal bones are angled a little bit off to the, to her. Right.
but everything else Sam said was spot on. 
Dr. Salvatore Pacella: [00:13:53] Right. So, Jersey, Sam, that is, that is very correct. And a suit to view. So you can see here just the entire nasal platform is shifted off to the left here. And, you know, that's a, that's a challenging thing to fix. Oftentimes, you know, what I, what I tell patients is, In fact, let me go, let me go to the next slide here.
So this is, these are a couple of diagrams that appeared in my textbook aesthetic facial reconstruction after MOHS surgery for nasal reconstruction, but I think they're excellent excellent diagrams to talk about cosmetic nasal surgery. This gentleman who is in this photo is my good friend, Rob. Hi, great.
I brought him into the office one day. He's one of our reps for breast implants, and I said, you want to be in a textbook here, take a picture. And so, so we did this little overlay on his nose. So, what Jersey Sam is referring to here is there is a, there's an interplay here between the bony aspect of the nose and the cartilaginous aspect of the nose and a common misconception that I, I had when I first started studying nasal anatomy as well.
This area of the nose called the nasal ALA that the bottom or rim portion of the nose. Okay. You would think anatomically that there's cartilage down there. But there actually is no cartilage whatsoever down there. All this is is a, is a tube of fibrous tissue with fat surrounding it. It's, it's very much like a PVC pipe, PVC pipe underneath the sink.
And what I tell patients is when there is a break in that PVC, PVC pipe is very difficult to bend. You cannot flex it very much. If you take it and pull on it. Very difficult to change shape. But as soon as you cut a little tiny hole in that PVC pipe, all of a sudden, there's a, there's a fracture point of weakness and that can bend.
And that's why it's so critical to understand the anatomy of this area. Because if we start cutting into this area for, for functional or cosmetic reasons, and this fibrous tube is disturbed, all of a sudden that fibers tube can collapse and that can cause devastating nasal airway obstruction.
and you know, going back to this gal here, if you look at her, her skin, okay. So let's, let's just look at the base view. This is what we call the worm's eye view of the nose. If you look at the distance from her tip to this base of the ALA, which is a side of the nose, do you see, do you guys appreciate how this is smaller, shorter on the side?
Yeah. Right. So, so we can do everything we can to reconstruct this nasal cartilage right here and get it. Absolutely pencil. Perfect. Within. Fractions of a millimeter, but sometimes the issue is the soft tissue envelope of the skin. For 23 years, her nose has been re draped over this cartilage that has been short.
So it gets what happens to that skin. That skin is contracted. So the skin has some, an inherent memory to it. And when we put the, the nose back together or after reconstructing the cartilage framework, That skin wants to go exactly back to the, to the position that it was in. So we have to oftentimes do some maneuvers to mitigate that.
So, gents any comments on that? 
Dr. Sam Jejurikar: [00:17:05] You know, it's, one of the ways that we all learned to think about the nose, which is not as popular anymore, but I think is very apropos for this example is. So I think of the nose and particularly from the worms I'm view that you have, it will start to hear it as a tripod.
there's, there's essentially three legs of the tripod, one being the, the right ALR the right nostril room, one being the left nostril rim, and the other being the septum right here. And much like a tripod, if one leg is extended further than the other they'll whole nose will shift. And so Dr. Pacella is right in the sense that even though there is a fibro fatty framework, only along this outer portion sometimes to fix that, you have to add cartilage to actually give support to the skin where there wasn't any before.
And so it will be very interesting to see what he actually did to straighten the out, you know, going back to that, the fact that, or her overall nose is crooked. there's, there's a multitude of reasons why we see that it's not just the bones you see on the outside. I suspect that when dr. Buccella did her surgery, her septum was quite long as well.
And that curvature is contributing to that imbalance of the tripod. 
Dr. Sam Rhee: [00:18:08] It's funny. Cause a lot of patients, or if you just looked at her, the most people would say, Oh, she has a huge beak to her nose and you just got to shave down that big hump. But I know the minute I saw her and I saw it at worms, I said, How, how is dr.
Patella going to manage the tip? How is he going to support it? These are the sort of technical aspects. how is he going to shape it? Those are the technical aspects that make rhinoplasty so complex and. Very artistic because there are probably 15 different ways you could approach this. 10 of which would be perfect, five would be adequate and, you know, and that's something that is a constant, learning challenge. 
Dr. Salvatore Pacella: [00:18:50] That's a great point. And, and, you know, I just, the intricacy of rhinoplasty, it, it is truly an artistic. operation. I can literally, you know, I have, unfortunately many times I have a little short little attention span in life and in surgery and, and doing a long three or four hour case on the breast or the abdomen it's, you know, after the, the 3.5 hour Mark, it just gets a little, little taxing.
But I could literally look under the micros or look under my loops and in a, in a headlight at the same spot on a nose for, for four or five hours. And, and, you know, not, not, still be engaged. I mean, it's just a beautiful operation. I do. I truly enjoy it. now the other, the other important thing to talk about with this patient is, is the function, of course.
So clearly her initial. Issue with the otolaryngologist was breathing. Obviously you can see how our nose is fairly constricted with dr.  and Dallas referred to as the internal nasal valve. That was quite a obstructed. So hat on the inside of her nose, these fleshy little pieces of meat called the turbinates, which were quite large.
And so the combination of having large septal deviation, turbine and hypertrophy. Internal nasal valve obstruction really made her, her breeding very challenging. So our goals with this operation are not only to make this, this beautiful young gal look better, but to help her breeding and help her athletics and overall help her life to life for breathing.
All right, so I'm okay. So why don't we now go into the post operative results here? So, so this is her and, you know, I, I truly believe in the fact that, you know, not to a, on many of our plastic surgery colleagues along the country, but you see, In Instagram, you know, a phenomenon of shooting on table results right afterwards, you know, Oh, here's, you know, I'm the expert in this breast surgery.
And you know, this is what the breast looked like on the table. But I think the true test of time is, is key. I, I really only want to shoot these results at a year, and this is a year. Okay. And, you know, I think that tells us what happens to the nasal tip afterwards. It tells us what happens to the shifting of the pressure of the skin on the nose, after, after a year.
So. So, what I did in her is, we made a little incision at the base of the nose right here. I lifted everything up to expose it and then basically straightened out the septum. I removed a substantial portion of the septum very safely, and we put that. Extra septum on the back table. They use for spare parts, if you will.
I also did a bilateral what's called a submucosal turbinectomy so we don't damage the function of the turbinates. We just simply make them smaller. and then I did a series of maneuvers where we, we cut the bones of the nose and break them to widen the base of the nose a bit and open up this nasal passage in addition to reworking.
All of this cartilage at the nasal tip here, and that involves putting a graft at the tip of the nose to, to maintain the legs of that tripod as dr. Jerker and Dallas mentioned, and then adding a little bit of cartilage along the nasal rib, just a smidge to help maintain this tripod periods. So why don't we just run through and I'll come back to these.
So this is her oblique view on the left side oblique view on the right side, and then side views. And then of course the worm's eye view to things here, 
Dr. Sam Jejurikar: [00:22:27] it's a very dramatic change. yeah. It's, I'm sure she loved the, that transformation. 
Dr. Sam Rhee: [00:22:32] Yeah. It really balances out her face. It's very harmonious and I, I think it also shows some of the things you wouldn't necessarily understand when you first look at a patient is that you actually have to widen the nasal bones in order to.
You think she has a huge nose, but you actually need to do that in order to, to achieve more cosmetic harmony. you see her tip and, you know, all of the tip shaping that you did there, to balance out her nose and to make it look, but you didn't over do the tip. So a lot of what, you see with bad rhinoplasties with celebrities or sort of, In Hollywood, are these, you know, crazy, the, snub tips. that look really tiny and are totally pushed up. And she has a very natural, tip shape, which is balanced and harmonious with her face. 
Dr. Sam Jejurikar: [00:23:28] And I'm sorry if I missed it. What did you say you did for her internal nasal valve? Did you do something for that? 
Dr. Salvatore Pacella: [00:23:33] just, out fractured the nose and then, with the, yeah, so basically out fractured the nose, did some osteotomies on the sides here and spread our graphs essentially to, 
Dr. Sam Jejurikar: [00:23:46] okay.
Yeah. And that's the thing. Well, one of the things dr. Patella did are things that you don't even see on this patient. You know, he put grafts between her septum and the cartilage up high. I bet her breathing is dramatically transformed even though her nose looks smaller. 
Dr. Salvatore Pacella: [00:24:00] Yeah. There's difference. 
Dr. Sam Jejurikar: [00:24:02] That's a, that's a huge change in both the functional and anesthetic manner for this patient.
Dr. Salvatore Pacella: [00:24:08] Right. And when one of the, one of the areas, one of the, the yard sticks we want to look at after surgery and, and on, on the table during surgery is, is this area right here. This is what we call the. The dorsal nasal aesthetic lines. And you can see in this patient here, and this should be a gentle, gentle slope from the tip of the, what we call the rate X here in between eyebrows to the deck, down to the tip of the nose.
And you could see her. She's got a pretty dramatic triangle sitting here, preoperatively here, and there's a break in that. In that contour of the nose. And then afterwards, this is a, just a gentle curvature of the nose sitting right here in a, in a relatively straightish line. and to me, that's a, that's a huge yard stick that I look at on the table, to make sure my everything is straight and to make sure that the aesthetics is perfect.
Dr. Sam Rhee: [00:24:55] A technical question. When you do your osteotomies, do you do them internally or do you do external audits? 
Dr. Salvatore Pacella: [00:25:01] Excellent. Excellent question. So, You know, I, I just want to hint at the pedigree that we, we had at the university of Michigan. So dr.  and dr. Ray both trained with me, obviously at Michigan, we, we had a tremendous amount of training and rhinoplasty are one of our, Our professors, dr.
Haskell Newman was one of the founding members of the rhinoplasty society. we also had some expertise yeah. By a gentleman named dr. Robert O'Neil, who was, one of the pioneers of rhinoplasty. And so this is a. This is an area of plastic surgery where we really have a fantastic, I think background and what, what you're referring to here is I'm sorry, what was the original question?
I just kind of went,
Dr. Sam Jejurikar: [00:25:51] you 
Dr. Salvatore Pacella: [00:25:52] are awesome. 
Dr. Sam Rhee: [00:25:54] External or internal nasal osteotomies. Do you do that? 
Dr. Salvatore Pacella: [00:25:58] Okay, so, so Dr. Newman. taught us, the technique of external osteotomies. Okay. And what, what these referring to is when you break the nose, how do you break the sides of the nose? Well, the external osteotomy is a procedure where you make a little cut in that and the extra portion of nose and use a little tiny little, tiny little plate.
I'm a sharp little chisel, if you will, to just gently fracture this area here under a control fashion. And I would say that for the first five years of my rhinoplasty practice in San Diego, I did external osteotomies and quite honestly, I just, you know, although we had great training in that, it's just something where my evolution has shifted substantially.
and. You know, I just don't feel like I got great control of fracturing that area. And it was very difficult for me to fracture out a little bit laterally. So now what I do is an internal lateral osteotomy. So I'm oftentimes right near the turbinates and where I do my submucosal resection of the turbinates on the inside.
I just basically pass an osteotome underneath here. And it really allows me to fracture quite laterally. I think w what this has really allowed me to do is when we had more medial or more central osteotomies, I would see this kind of box, like deformity to the nose. People oftentimes have this bony prominence here that is pretty aggressive when they have a large dorsum.
And so allowing me to do the internal osteotomies that could fracture that out a little wider and just get a better shape in this transition zone.
Dr. Sam Jejurikar: [00:27:36] what was the question again? 
Dr. Salvatore Pacella: [00:27:39] Yeah,
no, no, I know, 
Dr. Sam Jejurikar: [00:27:44] I 
Dr. Salvatore Pacella: [00:27:44] know. Yeah. I was fortunate. I 
Dr. Sam Jejurikar: [00:27:48] agree with all of your, your thoughts about the quality of our rhinoplasty education at Michigan. I was fortunate enough that when I went to New York, after Michigan, I trained with Nixon ball and Sharelle Aston who, Only did internal osteotomies and then why joined a practice that had Steve bird and Rorick in it?
Who, and so there's no consensus on this question. I, I, I do a combination of both, but probably 90 10 internal osteotomies over, over external. 
Dr. Sam Rhee: [00:28:15] It's funny. I, It's funny. Cause I trained the same way you guys did at Michigan. And then, when I was at UCLA, we did internal nasal osteotomies and then I, I did it both ways for awhile now it's 90 10 for me external.
And I just feel like, I, I know what Sal's saying about getting that control, especially if you have to like bring it out the nasal bone. Okay. But I just feel like, you know, different tools, whatever you feel comfortable with. There's like a sound Sam said, and there's no consensus and whatever feels good in your hands.
And as long as you achieve the results you want to achieve, that's why I asked because it's, there's no. Necessarily good answer for it. It's it's what you feel comfortable. Yeah. 
Dr. Salvatore Pacella: [00:28:57] You know, clearly I think one of the artistic acts aspects of plastic surgery, cosmetic surgery of the nose and faces, you know, you have to have different arrows in your quiver and not every arrow is going to accomplish what you need.
So, and, and that's the broader you're trained. The more tools you have in your toolkit. I think the better, 
Dr. Sam Rhee: [00:29:16] the other point that you made, I mean I'm as guilty as anyone else about posting on table results for certain types of procedures. But I I've admitted. It's a social thing. 
Dr. Sam Jejurikar: [00:29:26] I do it all the time.
It's just what's expected in the current age, 
Dr. Sam Rhee: [00:29:29] but for rhinoplasties you cannot. And I do counsel patients. It takes a long time for that swelling and for the final shape, especially for the tip to come into focus. And, it's one of those that take some patients, especially when you're doing. you know, a fairly big rhinoplasty as you did here too, you know, for the final postoperative result to, to show.
Dr. Salvatore Pacella: [00:29:54] Like, 
Dr. Sam Rhee: [00:29:54] I don't think anyone should show an on table result for rhinoplasty. I think most of those should really be reserved for, you know, long longterm results. Cause that's really, like you said, where you're going to see 
Dr. Salvatore Pacella: [00:30:04] it. 
Dr. Sam Jejurikar: [00:30:05] Yeah. I mean, I think it all depends on the purpose of showing that on table result.
Let's be honest half the time it's on Instagram. It's to say, look, I do rhinoplasty. That's true. That's really, that's really the purpose behind it. You know? 
Dr. Salvatore Pacella: [00:30:19] Hashtag Insta. Good. Exactly.

Dr. Sam Jejurikar: [00:30:26] why is that? that was an excellent result. Dr. Pacella and an excellent presentation as always. I always feel a little bit smarter after I talk to you, gentlemen. 
Dr. Sam Rhee: [00:30:36] Same. Absolutely. That was an awesome case and really, really fine result. I I'm sure that patient functionally and cosmetically was, was thrilled and the fact that she's young and was able to do it.
I'm at an age where I think she's going to benefit for decades. This is going to be something that was life changing for her in so many different ways, which is really what our goal is. Right. We really want to make such super positive changes in our patients lives. 
Dr. Salvatore Pacella: [00:31:04] Great. Well, 
Dr. Sam Jejurikar: [00:31:07] I think on that note, we'll just, let's call it a, let's call it a podcast gentleman.
Thank you as always and have a wonderful week. 
Dr. Salvatore Pacella: [00:31:13] Great. Thank you. Take care of yourself. Take care. Alright.