The Peter Attia Drive - #64 - Zol Kryger, M.D.： Navigating the sometimes shady world of plastic surgery—understanding potential complications of common procedures and how to reduce your risk by choosing the right doctor and asking the right questions

00:00:00.000 Hey everyone, welcome to the Peter Atiyah drive. I'm your host, Peter Atiyah. The drive

00:00:10.880 is a result of my hunger for optimizing performance, health, longevity, critical thinking, along

00:00:15.940 with a few other obsessions along the way. I've spent the last several years working

00:00:19.660 with some of the most successful top performing individuals in the world. And this podcast

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00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.020 and other topics at peteratiyahmd.com.

00:00:41.440 Hey everybody, welcome to this week's episode of the drive. I'd like to take a couple of minutes

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00:04:03.160 listen to this. If you learn from and find value in the content I produce, please consider supporting us

00:04:09.080 directly by signing up for a monthly subscription. My guest this week is my very close and dear friend

00:04:14.640 from medical school, Dr. Zal Krieger. Zal is a board certified plastic surgeon and a member of the

00:04:19.140 American Society of Plastic Surgeons. He went to a med school with me at Stanford and then did his

00:04:24.000 training in general surgery and plastic surgery at Northwestern in Chicago. He grew up in Israel,

00:04:29.700 actually was born in Canada. I think I grew up in Israel high school back here in California,

00:04:34.580 then went off to the special forces in Israel for three years before coming back for college and

00:04:40.340 medical school. He specializes in facial rejuvenation with fat grafting and deep plane

00:04:45.420 facelifts, abdominoplasty, breast enhancements, all sorts of complicated plastics and reconstructive

00:04:52.020 surgeries. I wanted to talk with Zal at length because over the past, I don't know, a couple of years,

00:04:57.920 you know, he'd send me stories or things like that about mishaps in plastic surgery. And I was kind of

00:05:02.320 shocked by them, actually. I guess I'm sort of oblivious to this world. And so I asked him, I said,

00:05:06.780 look, why don't we just do a podcast together where we can go into some real detail on some of

00:05:11.360 the common misconceptions about plastic surgery and above all else, provide listeners with a tool

00:05:16.040 to, or set of tools really, to help select the right plastic surgeons and to understand what the

00:05:21.940 real risks are of a number of these procedures. And I will say this, I learned a lot during this

00:05:26.700 episode and you'll hear it in my voice. There are at least three instances where he rattles off a

00:05:32.940 statistic and I just can't believe it. And I actually have to ask him to clarify it. So we start by

00:05:38.540 talking about the differences between a board certified plastic surgeon and basically anybody

00:05:43.540 who can do plastic surgery, which turns out to be anyone who has a medical license. We talk about how

00:05:48.720 you would pick a surgeon and what are the common misunderstandings and pitfalls that get a lot of

00:05:54.480 people into trouble. But really we focus very much on breast augmentation, liposuction,

00:06:01.360 the Brazilian butt lift, which I didn't realize prior to this procedure is not only as prevalent

00:06:06.260 as it is, but perhaps more disconcerting than that is arguably one of the most dangerous plastic

00:06:11.760 surgery procedures a person can have. I think by the end of this episode, you'll have a really clear

00:06:16.920 understanding of what these risks are and how you could go about thinking about it. The other thing

00:06:22.020 we're doing in the show notes to this is we're going to create a really cool checklist that you

00:06:26.340 could sort of download and print out because throughout each of the discussions on, you know,

00:06:32.040 for example, a specific type of procedure is all would sort of rattle off a number of ideas and facts

00:06:37.640 that I think are just kind of worth having in your, in your back pocket. And then of course

00:06:41.240 the section on how you really, what questions should you be asking a plastic surgeon? I think

00:06:46.140 that's also, if nothing else, if you take nothing out of this, simply knowing that

00:06:50.240 is valuable. And frankly, it applies to all of medicine, especially procedural medicine. So

00:06:55.320 surgical, dermatologic, et cetera. Lastly, we, we close with the discussion about fillers, which

00:07:01.500 again, I would have thought that there is no possible way that a filler could actually pose

00:07:05.460 harm to people, but it turns out sure enough, there is a way you could be harmed by fillers, 0.96

00:07:09.420 which again, all comes back to making sure that if you're going to have these procedures,

00:07:14.040 you have them done by people who really know what they're doing and have spent years and years

00:07:20.760 training in the anatomy of this space. So without further delay, here's my interview with Dr. Zal

00:07:27.000 Krieger. All right, Zali, thank you for coming to Malibu, man. Thank you. It's my pleasure. What a

00:07:35.000 beautiful place. Yeah. I was thinking about this this morning because I woke up to the sound of these

00:07:39.900 waves kind of crashing, which is a beautiful sound, but then I was like, oh, that's going to make for

00:07:43.400 a difficult podcast because we're going to, the microphones will pick this up. So anyway,

00:07:47.760 I'll apologize in advance to all the listeners. Hopefully the sound of the waves hitting 10 feet

00:07:52.320 from us is not too disturbing. I also heard a rooster crowing outside. I have a neighbor,

00:07:57.000 he's an ER doctor. He lives right behind me and he has essentially a farm in his backyard. He has goats

00:08:03.860 and sheep and chickens and he just got a rooster. So every morning at 5 a.m. rooster starts growing.

00:08:11.280 We have a rooster across the street from us. We have chickens, but the rooster across the street

00:08:14.540 and everybody that stays with us says, oh, does that rooster drive you nuts? Not only does it not

00:08:19.920 drive me nuts, I love it. I love hearing that rooster at 5 a.m. I'm not sure why. It's good if you wake

00:08:26.320 up at 5 a.m., but if you wake up at 6 a.m., it's not so good. That might be the point. We have our

00:08:32.460 own little rooster in the house that wakes up at 5 a.m. So yeah, the two go hand in hand.

00:08:37.400 Well, I guess I should sort of introduce you a little bit to people today because some of the

00:08:42.340 listeners will have already met Paul Conte through one of the earlier podcasts. And so this is sort

00:08:47.560 of the process of me just introducing all of my med school friends to listeners. So in that band of

00:08:53.880 knuckleheads that we were in medical school, it's possible you were the ringleader of the knuckleheads.

00:08:59.480 I mean, I think that's anyone who's listening who went to medical school with us will probably say

00:09:04.020 you were the ringleader of that gaggle. And like Paul, you and Paul were the only two who on day

00:09:12.240 one really asserted what you were going to do. Most of us were leaning one way or the other. We might

00:09:18.740 do this. We might do that. But Paul on day one knew he was going to be a psychiatrist and you on day

00:09:23.320 one knew you were going to be a plastic surgeon. And I remember thinking about both of you guys. I was

00:09:28.920 like, wow, how can they be so sure? Did you remember this? I do remember. Yeah. I actually

00:09:34.200 think it's a great way to go through medical school knowing from the beginning what you're

00:09:37.580 going to do. It helps you focus your attention and your plans as far as research and what you're

00:09:43.320 going to spend more time learning like anatomy as opposed to other subjects that you know you'll

00:09:48.860 never touch again like genetics, for example. But yeah, I did start medical school pretty much

00:09:54.380 knowing what I wanted to do. I was influenced a little bit by my father who began his training.

00:10:00.160 He's a physician in plastic surgery and then some exposure to some other plastic surgeons that made

00:10:06.480 me extremely interested in the field. It was actually the part of plastic surgery called microsurgery

00:10:12.620 that got me most interested. Essentially, microsurgery is using a microscope to connect tiny,

00:10:19.040 fine structures like blood vessels and nerves.

00:10:21.340 And I was very attracted to the idea of doing this delicate surgery. Other specialties like

00:10:27.960 neurosurgery and ophthalmology do microsurgery as well. But it's a pretty large part of reconstructive

00:10:34.060 plastic surgery. So that's what got me interested into it. And since then, my practice has evolved.

00:10:40.620 I still do microsurgery, but I now do many other things as well.

00:10:45.340 I feel like before medical school, was it the two years prior or was it between high school

00:10:49.420 and college? When were you in the army?

00:10:51.320 After I finished high school in the United States, I went and volunteered to the Israeli army.

00:10:56.740 And I spent three years in the Israeli army. And then I came back after that and went to

00:11:01.960 university here and then medical school.

00:11:04.380 Got it. Yeah. I'm going to do my best to refrain from telling any of the stories of orientation week

00:11:11.700 when we all got into so much trouble. But the army ringleader, both you and Jason, and then

00:11:18.680 Shehab, the whole thing was quite a scene. We go through med school, we finish it. Explain to people

00:11:23.200 what, because I think if you're a person listening to this, it's not entirely clear what it means to

00:11:28.800 be a plastic surgeon versus someone who does plastic surgery. Lots of people can do plastic surgery,

00:11:34.160 but there's a very specific type of training. And there are generally two paths, correct?

00:11:38.860 There were the sort of combined paths, and then there's the sort of do general surgery first. So

00:11:43.460 how does one pick how they're going to become a plastic surgeon?

00:11:47.360 Well, in the beginning, when plastic surgery began as a field, it was one of the surgical

00:11:52.860 subspecialties. So like vascular surgery or heart surgery or cancer surgery, people first did a general

00:11:59.520 surgery residency and then went and did a fellowship in plastic surgery. Since that time, it's pretty much

00:12:06.040 become its own residency. So anywhere from six to seven years of training focused on plastic surgery

00:12:12.820 with the first few years having an emphasis on general surgery, sort of learning the basics of

00:12:17.700 operating and then focusing more on plastic surgery. You brought up a good point about there are many

00:12:24.560 people who do plastic surgery who are not plastic surgeons. The numbers are probably 90 to 95 percent

00:12:30.320 of all plastic surgery done in the United States is not done by board-certified plastic surgeons.

00:12:36.900 So only a small minority is actually done by plastic surgeons, which is mind-boggling to me to think of

00:12:43.000 how complicated some of the things we do are and to know that there are other specialists who are doing

00:12:49.000 this without really having any formal training in it. Most people don't know, but in terms of the laws in

00:12:55.480 America, any physician, once they receive their MD degree, can perform any procedure they want without

00:13:03.260 any legal repercussions. So a family practice doctor who gets his MD degree, he's one month out from

00:13:11.860 medical school, can decide to do heart surgery, can decide to do brain surgery, he can put a catheter

00:13:17.900 up someone's leg. Now he's going to be limited by a hospital that won't give him privileges to do it at,

00:13:24.160 and so he's stuck doing things in his office, or if he builds a small operating room, he can try and

00:13:30.260 do whatever he does in the operating room. But legally, he's allowed to do whatever he wants, and so

00:13:35.040 you have many physicians, and even non-physicians all over the United States doing plastic surgery,

00:13:41.300 primarily cosmetic surgery, and they're not breaking any laws doing this. They're obviously not doing it

00:13:47.960 in a hospital, because hospitals are good at self-policing and regulating and making sure that only

00:13:53.740 people who are board certified and with training in that specific procedure can do it. So again,

00:14:02.600 back to the training in plastic surgery, it's a six or seven year program where you focus mostly on

00:14:09.020 plastic surgery, primarily reconstructive surgery. You're operating on the whole body, you're learning

00:14:13.120 all the principles of plastic surgery. That's what I did after medical school.

00:14:17.300 I did not know that it was that stark a contrast of the number of procedures being done or the relative

00:14:24.100 proportion being done by non-trained plastic surgeons. I certainly realized that there were

00:14:28.260 many non-plastic surgeons doing it. I wouldn't have guessed that. I would have guessed 50-50 or something.

00:14:33.680 No, the numbers are really high, and it's all about the money. I mean, this is all cash pay. None of it is

00:14:40.160 done through insurance, and it's a way for other specialists to augment their income. So we see,

00:14:46.800 even in my community here in the greater Los Angeles area, hundreds and hundreds of physicians

00:14:52.180 of all walks, gynecologists, ER doctors, general surgeons, family practice doctors, internal medicine

00:14:59.580 who have no training or no knowledge whatsoever just decide, I'm going to start doing Botox,

00:15:06.120 I'm going to do fillers. Then they purchase a laser. Then they do liposuction, first office base.

00:15:12.060 Then they're doing breast augmentation and other surgical procedures. It's getting more and more

00:15:17.700 common. That I would have never guessed. I could sort of imagine screwing around with Botox. Although

00:15:24.080 even just a little bit I've learned in talking to people who are really good at this, the difference

00:15:29.080 between knowing what you're doing and not knowing what you're doing with Botox is enormous. And

00:15:34.080 furthermore, eventually if you have enough bad Botox, I mean, you only need to watch reality TV

00:15:40.260 for one day to see what that looks like. So the results of this can actually be irreversible. I

00:15:46.540 mean, you can get enough bad procedures done where even a good person coming along isn't going to

00:15:51.200 salvage it. Absolutely. The classic example for this is a lot of these new liposuction type devices

00:15:58.560 that use a laser or other type of energy to heat up the tissue. And a lot of this is done as an

00:16:05.180 office based procedure. And so we see multiple physicians out there of various specialties who

00:16:11.420 buy these machines. They have reps that come to their office and really convince them that it's the

00:16:17.960 best thing out there since sliced bread. And they start using these devices and they can cause

00:16:23.000 really unrepairable damage, primarily liposuction, the abdomen and, you know, the thighs and just

00:16:30.000 burning the skin and creating all sorts of contour irregularities that are just almost impossible

00:16:35.260 to fix. Our term in plastic surgery is we call them liposuction cripples. They basically have

00:16:41.080 essentially unfixable problems. Yeah. There was a famous example of this. I remember,

00:16:46.100 I can't remember her name, but she was a famous actress. Tara Reid. Yeah. Yeah. Yeah. Was she

00:16:50.920 treated by someone who wasn't? I don't know who treated her, but she did have one of those

00:16:55.240 types of liposuction done on her abdomen and that left her with these burns of the undersurface of

00:17:01.220 the tissue and divots. And when you see someone like that, it looks very strange. You know, it doesn't,

00:17:06.960 it's not the appearance of someone who's lost weight or been pregnant. It's these strange contour

00:17:12.140 abnormalities, divots, areas where it looks like someone just scooped out pieces of fat. There's a lot of

00:17:18.660 people like this walking around who didn't do their homework and they're suffering the consequences.

00:17:24.740 So the regulatory environment doesn't place a restriction on this, which means then it's up

00:17:29.600 to patients to sort of be able to figure this out, but that's pretty hard, right? Because outside of,

00:17:35.020 I mean, the most zeroth order question would be asking, did you train in the specialty to do X,

00:17:41.860 Y, and Z? But beyond that, is it just a rule in your mind that only a plastic surgeon should do

00:17:47.820 something? Because clearly there are plastic surgeons who are probably not very good. And

00:17:51.260 presumably there are people who are not plastic surgeons, but who can train very well to do

00:17:56.300 certain limited things, right? It's a good question. And I think that there are definitely

00:18:01.840 things that other specialties are trained to do and can do. For example, ophthalmologists have a

00:18:08.920 subspecialty called oculoplastic surgery where they learn a lot of eye surgery and I would be

00:18:14.440 totally comfortable. I refer patients with complex issues to oculoplastic surgeons to do eyelid surgery.

00:18:21.320 Then the question becomes, well, what if they want to do a facelift? Some of them might be able to do

00:18:26.340 that. They have the training, they have the knowledge and the comfort, they know the anatomy.

00:18:30.320 You have field, a subspecialty of ENT, ear, nose, and throat, which is facial plastic surgery.

00:18:36.320 They are well trained in that to do rhinoplasty, facelifts, any of the facial procedures.

00:18:42.660 Should those people be doing breast augmentation? Probably not. They have absolutely no training on 1.00

00:18:47.520 any part of the body below the neck. So I do think there are examples where you can go to someone who

00:18:53.700 is not a board-certified plastic surgeon for certain procedures. However, I think it's important to do good

00:19:00.560 research. And, you know, it's tough. You have to know the right questions. It's interesting that I

00:19:05.420 probably only get asked about once a year by a patient, are you board-certified in plastic surgery?

00:19:10.900 People don't ask that. People are much more focused on what kind of person you are. Do you seem nice?

00:19:17.400 Are you confident? Do you seem caring, empathetic? Do they have a connection with you? They care a lot

00:19:23.880 about price. It's so amazing to me. I have a nurse who's worked for me for five years, and she had some

00:19:30.160 bad plastic surgery by someone else and wanted me to fix it. And I told her I'd be happy to fix it.

00:19:36.960 I gave her the price. I gave her a heavily discounted price. Obviously, she's my nurse.

00:19:42.300 And she went to some other guy who essentially was one of the guys who botched her first surgery,

00:19:47.640 and he told her he would do it for much less cost. He's not well-trained, and he's not that good

00:19:54.880 surgeon. And she ended up having surgery with him just a few days ago, all based on the price,

00:19:59.840 even though his plan and my plan were completely different. She's seen me work. She knows that I'm

00:20:04.900 a safe, good surgeon. She trusts me. And she decided just based on price to go with someone else. So

00:20:11.480 when you see an example like that, here's someone who is in the field. They're constantly surrounded

00:20:16.380 by it, yet they're going to allow something, you know, like money be their determining factor on where

00:20:21.940 to go. You have to imagine that for the average person out there who has very little knowledge,

00:20:27.360 it's difficult for them to make the decision. I mean, people think that plastic surgery is like

00:20:32.000 buying a luxury item, like a Mercedes or Rolex watch, where it doesn't matter if you go to the

00:20:37.020 guy at the mall or if you order it online. A watch is a watch. You know, a car is a car. It's not like

00:20:42.560 that at all. It should be approached no differently than, you know, as I've heard you talk on your podcast

00:20:48.160 with other physicians about picking the right surgeon for a heart surgery or brain surgery,

00:20:54.200 picking the right doctor to treat any type of medical problem. You have to do your research

00:20:57.820 and make sure you're getting the right person. So besides asking if a person is trained in plastic

00:21:03.500 surgery, boarded in plastic surgery, has had any lawsuits against them or files claimed, what other

00:21:10.320 questions can people be asking? So if you had a friend or a relative in another part of the country and

00:21:16.240 they weren't going to come out and see you, but they were going to go and scour the DC area,

00:21:20.740 what would be the checklist you'd give them to narrow down their search?

00:21:24.760 Some of the important questions are how long have you been doing this procedure?

00:21:29.620 How did you learn how to do this procedure? I mean, there's a big difference between saying

00:21:34.700 I've been doing this from the start of my residency. I did a six-year or seven-year residency learning

00:21:39.680 this. We did it hundreds of times and then I've done it hundreds of times on my own since then.

00:21:44.480 That's a big difference than someone saying, well, I didn't really learn this in my training,

00:21:49.780 but I took a weekend course on how to do this. I would ask the person where they trained and what

00:21:56.460 field they trained in. I think that's important. There's no doubt that you can be a great surgeon

00:22:00.680 and train at a lesser known facility with someone who is a great teacher and has taught you well

00:22:08.700 and you're a great student. You don't have to be at the top program to become a good surgeon,

00:22:13.200 but all these things add up. I would definitely ask for referral from patients who've gone through

00:22:19.540 the procedure to talk about it. I would ask for pictures. Good plastic surgeons have a lot of

00:22:24.600 before and after pictures of their work. That's a luxury we have that other surgeons don't really

00:22:29.340 have. They can just say numbers. You know, my success rate at this operation is this,

00:22:34.280 but in plastic surgery, we have photographs to show that. And, you know, a good question to ask

00:22:40.040 is what if something bad happens to me? What's the plan? Where do you have hospital privileges?

00:22:44.700 Do you have hospital privileges for this procedure? You know, the majority of plastic surgery in the

00:22:50.660 United States is done in small surgery centers, either owned by the plastic surgeon or owned by some

00:22:57.200 other physician where they go and work at. And they're not equipped to take care of real serious

00:23:02.600 problems. And so you need to know what happens if there's a problem. Do you have privileges to take

00:23:08.660 care of someone who has bleeding after a tummy tuck? There's a gynecologist who does the full array of

00:23:13.860 plastic surgery in my community. He has a lot of complications. If somebody said to him, are you

00:23:19.220 board certified? His answer is, yes, of course I'm board certified. Now he's not saying I'm board

00:23:23.720 certified in gynecology. He is genuinely board certified, just not in plastic surgery. If you asked him,

00:23:29.740 do you have hospital privileges? Of course he has hospital privileges, but he has privileges in

00:23:34.420 gynecology, not in plastic surgery. So if he has a patient who has bleeding after a tummy tuck,

00:23:41.120 he can admit them to the hospital, but he can't take care of them because he doesn't have privileges

00:23:46.100 for that problem. The reason why the hospital privilege is such a good question is we as physicians

00:23:52.900 police the doctors who come and work at the hospital. So nothing kind of slips through the

00:23:58.860 cracks. We check the training and the expertise and the knowledge and the malpractice history of

00:24:06.700 every physician that gets on staff. So I'm on a credentialing committee at my local hospital. So we

00:24:12.260 look at all this and you only grant privileges to the physicians that are safe and worthy of those

00:24:19.340 privileges. And then only for the procedures that they are adequately trained on.

00:24:25.540 I think on that same thread, another question that probably is helpful is having them describe

00:24:31.640 how they take care of complications. One of the things that happened when we were in medical school

00:24:35.920 that you probably recall is certain states, I think New York was leading the charge, decided to begin

00:24:41.900 looking at cardiac surgeons and listing their mortality rate. And on the surface, that seemed like a pretty

00:24:48.580 good idea, right? Which was, well, if you need heart surgery, you want to be able to look at the menu

00:24:55.160 and see all of the heart surgeons in the state and know what their complication rates are. And so if

00:24:59.960 you take 30 day mortality, which means how many patients that you operate on die within 30 days of

00:25:05.720 the procedure, which usually means something related to the procedure, it's rare that someone has an

00:25:10.600 operation and then 27 days later they get cancers and die. So it turned out that was a pretty lousy proxy

00:25:16.640 because what you were doing was you had surgeons that would cherry pick the simplest cases and the least

00:25:23.180 sick patients. And in some ways, if you're having heart surgery, you actually want the person who has

00:25:28.340 practiced operating on the toughest cases. What I think patients who were savvy figured out was, I don't just

00:25:35.980 want to pick the person with the lowest complication rate, I want to understand how they manage

00:25:41.060 complications. And this gets to your point, which is there's a very big difference between the ICU,

00:25:47.260 when you're talking about heart surgery, that is, the ICU in sort of a podunk hospital that rarely

00:25:54.240 sees complications versus the ICU at a major tertiary center where day and night it's very complicated,

00:26:01.800 very sick patients, and you've got an entire team that can do it. So is there a way to sort of

00:26:07.220 come up with an analogy in plastic surgery, which is how often do you see complication X and what is

00:26:13.840 your protocol or path to deal with that? That's a really important question. And for us, our

00:26:20.980 complications, we divide them into two parts. The early acute complications, which happen immediately

00:26:26.720 after surgery, these are primarily bleeding, infection, fluid accumulation called a seroma,

00:26:32.400 which we would usually see in, for example, a tummy tuck, and then the late complications.

00:26:37.980 And the late complications are primarily aesthetic. So essentially, you just aren't happy with the

00:26:43.040 result. You don't like how it looks. So you want to ask the plastic surgeon what their incidences of

00:26:49.940 each type of complication. You know, how often do you have to take someone back to the operating room

00:26:55.600 for bleeding? How often do people get infection after this surgery? And then if that happens,

00:27:00.140 how do you manage it? It's a key point because someone like myself, I have my own operating room,

00:27:07.300 fully accredited operating facility. So any complication that requires a return to the

00:27:13.260 operating room, like bleeding, for example, I have a facility to take care of this. Somebody who doesn't

00:27:18.600 have a facility where they work at and they do everything in their office, if they have a complication

00:27:24.060 that requires a trip back to the operating room, they're stuck and the patient is financially stuck.

00:27:29.840 I can do it at no charge for the patient. And that's sort of included in their cost.

00:27:34.520 Wait a second. I didn't, I never even thought of that for a moment. So if a patient comes to you

00:27:38.860 and they're getting a tummy tuck and the figure, it costs X dollars and they go home and then they

00:27:45.880 call you that night and say, there's a lot of swelling here. You have them come back in,

00:27:50.040 you look and you realize there's a blood vessel that's still, you know, bleeding. You operate on them

00:27:55.480 in your suite and anesthesiologist comes back in, they're back under anesthesia, they're doing a

00:27:59.900 whole thing. That's bundled within the cost that, which makes sense to me, right? That, that should

00:28:04.380 be. But are you saying that if a patient has a procedure with someone who doesn't have their own

00:28:11.860 accredited OR and the complication has to go into a hospital, the patient is on the hook for that cost?

00:28:19.020 Absolutely. A hundred percent. And that, that's a big source.

00:28:22.660 Do they end up suing the physician after the fact?

00:28:24.620 Yeah, absolutely. That's a big cause of lawsuits, money obviously. And a big part of that is when

00:28:29.940 there's a complication and then the patient is responsible for that. So there would be a

00:28:35.100 circumstance, for example, if I have a patient and they have to go to the emergency room,

00:28:39.220 they're going to have to bear some of the burden of that cost. I'm not going to cover the cost of

00:28:44.360 their trip to the emergency room, but most complications after surgery, I can take care

00:28:50.200 of in my clinic. So that's a key thing to work out ahead of time with the surgeon. What, how are

00:28:56.780 these complications managed both in terms of the actual management, but then from a cost standpoint,

00:29:02.120 how are they managed? And, and that's something you have to work out. And then for the long-term issue,

00:29:07.960 you know, what if there's a problem with the scar? What if there's a little extra skin on one side?

00:29:13.240 What if it's a little uneven where they had the liposuction, whatever the issue is,

00:29:17.660 one implant is higher than the other. How do we address that? I'm not happy. And that's something

00:29:22.660 you have to work out. And I think that's less of an issue of the training of the plastic surgeon

00:29:27.260 and more the individual's integrity and sense of, you know, what is morally correct and fair to do

00:29:35.020 with the patient. And it varies, you know, there's no right answer for some problems. I fix it at no

00:29:40.560 charge. I say, this is clearly, you know, I'm a big, strong believer in admitting when you're wrong.

00:29:47.440 I think patients want that. And that's a, in my mind, a sign of a good surgeon with humility.

00:29:53.420 If I did something wrong, I will say to the patient, I made a mistake here. This did not turn

00:29:58.120 out well. For example, one of your implants is higher than the other implant and that needs to

00:30:02.940 be corrected. And I'm going to correct that at no charge. If it's an issue where nothing was done

00:30:08.680 wrong, but the patient is just unhappy with the result, the implants are too small. I want larger

00:30:13.580 implants. Then in that circumstance, I might do it at no charge in terms of my fee, but I'll make

00:30:19.720 them pay for the new implants and the cost of the operating room and the anesthesia. So it, I think

00:30:25.000 it depends. It's on a case-by-case basis, but these are all really key things to hash out ahead of time

00:30:30.300 with the surgeon.

00:30:32.340 That's an interesting point you raise. I remember in medical school, maybe not medical school,

00:30:35.280 I'm sorry, in residency. And I think I've even discussed this on previous podcasts.

00:30:39.440 There was this real sense that if complications took place, you weren't really permitted to speak

00:30:45.280 with the family after and things like that. And I always found that interesting because I think

00:30:48.960 the research was pretty clear that patients didn't sue necessarily in proportion to the error.

00:30:57.920 They sued in proportion to the lack of communication and the friction with the treating team. So a team

00:31:06.500 that, you know, a physician that was very arrogant and non-communicative after a complication is much

00:31:12.360 more likely to be sued than sort of admitting that you've made a mistake, which is very counterintuitive

00:31:18.080 in our culture, right? To be able to say, I made a mistake here and let's figure out how to fix it. And

00:31:22.840 it turns out that's less likely to elicit a lawsuit.

00:31:26.360 Yeah, absolutely. I've found that in my own practice and observing other doctors as well.

00:31:31.300 I think that people in general, they just want honesty. They want honesty from everyone around

00:31:36.540 them and they want honesty from their doctors. And you just have to be honest. If something happens,

00:31:41.840 if there's a complication, you have to be honest about it. You have to talk about it. You can't run and

00:31:47.140 hide from it. I mean, I've heard other people you've talked to on the podcast, like Eric Shayab talked about

00:31:52.320 this. You have to embrace your complications and not run from them. And people appreciate that. And

00:31:57.760 you're absolutely right. They don't go after doctors in a court of law or in any other way,

00:32:03.500 just because of a bad result. It's more how they feel, how they feel they're treated, how it's dealt

00:32:09.900 with. I think that the financial aspect of it is a major part of distress and unhappiness on the part

00:32:17.520 of the patient. And so it's really key as the doctor to make sure you do what's fair and you

00:32:24.720 stand by your work. I mean, sometimes it's worth it to eat some money and not make a profit on a case

00:32:29.880 if it means that you're doing the right thing for the patient. In business in general, I mean,

00:32:35.680 we see this in all areas of business. You just have to be smart about it.

00:32:39.160 You finished your residency in 07?

00:32:43.660 2008.

00:32:44.540 2008. So do you remember the first time you were in, because it's a pretty scary thing,

00:32:51.860 I'm guessing, when you go from doing that last case as a fellow where, yeah, you're actually doing

00:32:57.660 the entire case, but there's an attending surgeon nearby to now you're the surgeon of record. That

00:33:04.120 first case when you are on your own, do you remember the first complication you had where

00:33:10.300 it was 100% you? I think it's hard to sort of ever say, well, a complication is 100% on the part

00:33:19.400 of the surgeon. But I do remember early on in a microsurgery case very soon after completing training

00:33:26.520 where inadvertently cutting a blood vessel that you were trying to preserve and then spending

00:33:32.880 a couple hours under a microscope trying to repair a blood vessel the size of a toothpick.

00:33:38.940 You know, when you're doing microsurgery, you're working with structures that are very small and very

00:33:44.320 delicate, and you have this device called an electrocautery or bovie that emits heat and is used

00:33:50.360 to coagulate blood vessels, and if it gets too close to one of these blood vessels, you can damage it.

00:33:55.680 And so some of the surgeries we do, specifically like breast reconstruction after cancer,

00:34:00.560 we're relying on one tiny little blood vessel to keep the tissue alive. The blood vessel is

00:34:05.840 essentially one to two millimeters in diameter. And if you get too close to it with a cautery,

00:34:10.960 you can damage it. And so I remember doing that on one case and then having to repair that blood

00:34:16.500 vessel. It's extremely tough. It's humbling because you have no one to turn around to. Like you said,

00:34:21.040 there's no attending physician who can bail you out. I'm very fortunate in my practice because

00:34:26.700 my partner is my brother. He's also a plastic surgeon. We trained in separate programs at the

00:34:32.560 same time. You know him well. And, uh, he's the better looking of the two, right?

00:34:38.640 He's a year younger, but everybody thinks he's older. I actually had a patient who asked me,

00:34:43.700 is your father going to help on the surgery? I took out my phone and I said, if, could you say that

00:34:48.880 again? So I could record that. So I tease him about that, but he's a year younger, but we trained at

00:34:55.520 the same time and, uh, we do a lot of our surgeries together. So it's a big difference when you're by

00:35:01.600 yourself versus having someone else to kind of work it out. And, and at this point now we've been

00:35:08.100 in practice 11 years together and I think we've started to really figure it out, but we still do a

00:35:13.300 lot of surgery together because there is no doubt. I mean, there's a reason why two pilots fly the

00:35:17.980 plane. Each one knows how to do it alone, but when there's another person double checking everything

00:35:22.940 you do and offering a slightly different, you know, view and opinion, it makes a world of difference.

00:35:30.120 That is pretty unique. I know a lot of really good plastic surgeons, but many of them do.

00:35:34.180 They don't have that luxury. I know. Cause I've been to your surgery center and I've seen you and Gil

00:35:38.740 there, and I've just seen you even discussing the most mundane case. And I remember once you guys were

00:35:44.920 discussing a case that I couldn't believe you would tag team, cause I could see if you were tag

00:35:50.260 teaming like a flap, you know, like one of these really complicated cases where you're going to be

00:35:55.240 under a microscope for hours and the stakes are really high. But I remember the case that you guys

00:35:59.940 were discussing was like a breast augmentation and a hernia repair or something like that, which

00:36:04.220 again, I think most plastic surgeons would bang out, you know, many of those in a day and think

00:36:08.340 nothing of it, but it was very, I really do. I'm glad you brought this up because I remember being

00:36:13.460 struck by how lucky it was for the patients that you could be doing that, which is, wow,

00:36:19.400 every case is what we call a two attending case. Yeah, absolutely. I mean, you know, if you just think

00:36:24.600 of any complicated process that has so many variables and so much thought has to go into it,

00:36:31.720 it's clear one person can do that by themselves and is perfectly capable and trained to do that.

00:36:37.340 But when you have another person, everything you look at in life, there's various perspectives and

00:36:43.040 someone who's standing right next to you is going to see something just a little bit different.

00:36:47.180 What's great about in our practice is that some of his strengths are my weaknesses and vice versa. So

00:36:53.040 as an example, I'm a much faster surgeon than he is. And I'm probably also a less patient surgeon

00:37:01.020 than he is because I'm faster. So I want to get through the surgery and get on and move on. And I

00:37:06.220 believe a lot that in speed actually comes efficiency and safety. And so I don't believe

00:37:12.640 that when you're going faster, you get sloppy. I think in many ways, the faster you go, and we know

00:37:18.320 this from many studies, the less complication rate you have. So there's a lot of advantages to being with

00:37:23.840 a fast surgeon. However, he's a very slow methodical surgeon. So as we reach the end of the case where

00:37:30.620 it's easy to kind of think, well, we're near the end, let's just speed up, there's not much to do,

00:37:36.220 he'll still be putting in the same amount of thought as he was at the beginning of the case,

00:37:40.880 and he'll force me to slow down and won't allow any corners to be cut or anything to be done

00:37:46.920 less than perfect. And so I really appreciate that about him. On the same account, you know,

00:37:53.760 the fact that I'm faster and more decisive, I think helps him because when he is managing the

00:38:00.060 case and he's the primary surgeon on the case, then being able to sort of decisively say, I think

00:38:06.440 this is what we need to do. Let's move forward is really important because in surgery, you always

00:38:11.400 want to be moving forward. I mean, as you know, you can go off on a tangent and two and a half hours

00:38:17.340 later, you haven't made much progress. And for the patients, the longer they're under anesthesia,

00:38:22.180 the longer they're on the table, the higher the complication rate. And so you want to be

00:38:26.440 efficient, especially with larger surgeries. You know, we do surgeries, we do microsurgical

00:38:31.620 reconstructions together that can take us 12 hours or eight hours, the same operation. And it's

00:38:38.620 sometimes we're just in shock, like, how did that just take 12 hours? You know, last week we did this

00:38:43.820 in eight hours. And that's a big difference, both in terms of the toll it takes on us physically and

00:38:50.880 also the risks for the patient being under 50% longer.

00:38:55.020 Yeah. Yeah. The risk of anesthesia, a lot of people don't appreciate that. And I remember having

00:39:00.400 great senior residents in residency that really made that point, which is, look, it's, you know,

00:39:05.980 you're in here to work as quickly as you can safely for that reason. Simply less exposure to anesthesia is

00:39:12.540 better. Let's talk about a couple of operations, maybe in a bit more detail as ways for people to

00:39:19.360 understand how to go through the process and maybe even just be better equipped to know what the

00:39:24.300 complications are. I'll give you an example. Let's start with breast augmentation. Let's separate 1.00

00:39:28.720 this from breast reconstruction following, say, a mastectomy. One I know had a breast augmentation

00:39:35.700 and I don't know, several months later, she told me she had developed this complication where they

00:39:43.120 were, there was like some contracture around it and it was, the, the implant was sitting very,

00:39:47.400 very high. What's the name of that? It's called capsular contraction,

00:39:50.500 capsular contraction, which I'd never heard of. But of course, why would I have heard of this?

00:39:54.060 I don't know anything about plastic surgery. And I was like, huh, that's really odd. Did you know

00:39:59.580 this was a potential complication? And she said, no. And I said, this wasn't discussed in the consent

00:40:04.280 for the procedure. And she said, no. And I said, well, what does the surgeon propose to do now?

00:40:10.040 And she said, just to repeat the procedure and the, you know, the probability of it happening twice

00:40:14.560 is pretty low. And I said, okay, I mean, I guess so. And the surgeon, I think had taken the approach

00:40:20.380 that you described, which was, you know, he was on the hook for this a hundred percent. So,

00:40:24.720 so I don't actually think this is a criticism of the surgeon at all. So he repeated the procedure

00:40:28.700 and sure enough, it happened a second time. And at this point I was like, wait a minute,

00:40:35.620 I think you need to get another opinion before you go back and start fixing this. So,

00:40:39.740 and I remember actually talking with you about this, but let's just start with that as an example.

00:40:44.360 What, what is this? What's the frequency with which it occurs? Why does it occur?

00:40:48.280 How, how would, how should it be managed?

00:40:50.400 So capsular contracture is the most serious complication, long-term complication from breast 0.71

00:40:56.520 augmentation. And the incidence is anywhere from two to 8%. And like with a lot of,

00:41:04.680 that's a pretty broad range.

00:41:05.820 It's a broad range and it varies based on the surgeon. It varies based on the implant type.

00:41:11.340 Some implants have a lower complication rate. Some types of breast augmentation have a lower 0.57

00:41:17.260 complication rate. For example, there are saline implants and silicone implants. Traditionally,

00:41:22.000 saline have a lower complication rate, closer to 2%. The silicone have a higher complication rate.

00:41:28.920 The implants can go under the muscle or on top of the muscle. Implants put in under the muscle tend to 0.93

00:41:34.440 have a lower capsular contracture rate because the muscle provides some sort of protection from it.

00:41:41.400 Implants on top of the muscle have a higher capsular contracture rate. It's really the thing we're trying

00:41:47.380 to avoid the most in plastic surgery. And some surgeons have a higher rate. Essentially what it

00:41:53.280 is, it's the formation of scar tissue. Anytime you put a foreign body inside of, inside of a human

00:41:58.760 being, whether it's in their knee or implant in the breast, the body forms a reaction around it

00:42:05.660 to wall it off. And that's scar tissue. And that's called a capsule. Normally it's supposed to be soft

00:42:11.820 and pliable like a balloon. But if the body forms an abnormal capsule, it becomes hard and it contracts

00:42:19.860 or squeezes down on the implant and causes pain and distortion. And this typically displaces the

00:42:26.540 implant up higher. So the side that's contracted, the breast is very hard. It looks strange. The

00:42:32.780 implant's sitting higher. It even looks smaller because it's being squeezed by this scar tissue.

00:42:37.960 And it can develop within months after surgery. It can take years. We still don't know exactly why

00:42:44.040 it happens. We think bacteria are the culprit. Meaning bacteria are leading to an aggravated

00:42:51.120 response. Correct. And it's strange because there are women who go many years without a problem. 0.99

00:42:57.860 Their breast is soft and their breasts are symmetrical and everything is normal. And then 0.50

00:43:02.460 suddenly they develop capsular contracture. We think the bacteria are coming from somewhere else. For

00:43:07.400 example, they have a sinus infection and then a few months later they get capsular contracture

00:43:11.680 or they had mastitis and then they get capsular contracture.

00:43:16.560 You see a higher incidence of it in women who go on to breastfeed after?

00:43:20.980 Yes. Not significantly, but there definitely is. And especially if they have, if they develop some

00:43:27.320 type of breast infection after having implants. We see the majority of capsular contracture cases

00:43:33.300 happen early within six months of surgery. And that's probably due to bacteria that get in there

00:43:38.880 at the time of surgery. This is an interesting point, isn't it? That I remember first realizing

00:43:44.000 this during a rotation of orthopedic surgery, which was just how high the stakes are when you're

00:43:49.880 putting a foreign body and especially in orthopedics into a joint space. I mean, because if, you know,

00:43:56.200 it's funny, like people think, well, surgery is all done very sterile. I don't think there's a

00:44:00.680 procedure that's done under more sterile conditions than joint replacements because that's where they're

00:44:05.560 wearing the spacesuits, which we think were the funniest things in the world to just take it to

00:44:09.220 that level. So again, it speaks to the nature of how privileged is the site and are you actually

00:44:14.260 leaving something foreign inside? Exactly. And complications that occur early on, such as

00:44:20.760 bleeding or buildup of fluid is a excellent medium for bacteria to grow in. So if you have a woman who 1.00

00:44:27.860 has a small hematoma, a small amount of bleeding on one breast, that woman has a significantly higher risk

00:44:34.020 of developing capsular contracture. And the reason is probably that blood that's bathing the implant

00:44:39.700 is a great medium for bacteria to grow in. So, you know, there's a lot of strategies that are

00:44:46.280 recommended and that we take to minimize the risk of this happening, but yet it still happens in a

00:44:51.560 certain percentage. Back to your patient, actually the data shows that if you get it one time, the chance

00:44:58.680 of getting it a second time is higher. Yeah. In the end, I believe what happened with her was the

00:45:05.780 third procedure, she went to someone different. I don't actually recall what they did different.

00:45:11.660 If they, I don't know. Anyway, the fortunate thing is at least a year or so later, she's totally fine

00:45:18.780 with the third operation. But I remember thinking, God, if this happens a third time, I don't think you

00:45:24.380 have a choice, but to just remove the implants and be done with it. Absolutely. I mean, that's usually

00:45:28.220 the best treatment. A lot of women are not willing to do that. So they're just going to keep looking 1.00

00:45:33.040 for additional options. Okay. So that's, so would you say that's the largest long-term complication

00:45:38.100 of a breast implant? So that is the most common long-term complication. There are some situations

00:45:44.060 where the implants can rupture. The saline implants notoriously leak or rupture because they have a

00:45:50.720 little filling port that saline can leak out of that usually starts around 10 to 15 years after.

00:45:57.100 The new silicone implants are made extremely well and they rarely rupture, but it can happen.

00:46:02.620 When they go back and analyze those implants, most of those implants were damaged at the time of

00:46:07.680 insertion by the surgeon and that weakened the implant and led it to go on and rupture. But rupture

00:46:13.680 is probably less of an issue than the capsular contracture. One of the things that I wanted to talk

00:46:20.300 about, which is a rare complication, but we're seeing it more and more and it's scary is called

00:46:27.140 ALCL. And that stands for anaplastic large cell lymphoma. And this is a type of rare cancer that

00:46:34.340 we're seeing in women who have breast augmentation. Interestingly, it only happens in implants that are

00:46:41.200 textured. So implants can be either smooth on their surface or rough textured on their surface.

00:46:47.780 There's a number of reasons why they develop these rough textured implants, but for some reason,

00:46:54.120 the texturing triggers this autoimmune type response where they not only develop capsular

00:47:00.440 contracture around the implant, but the body sort of goes haywire and develops this lymphoma. It's similar

00:47:08.600 to a cutaneous lymphoma, which is a lymphoma of the skin. So it's not as high risk for metastasis and

00:47:16.000 invasion as a typical lymphoma can be, but it's a type of lymphoma and it occurs in the capsule that

00:47:23.960 surrounds the implant. It can invade into the breast. And when we started to see these cases, the first

00:47:31.620 one was sometime around 10 years ago, they found. We since that time have seen hundreds of cases

00:47:38.240 worldwide. Initially, we were telling women the incidence was maybe one in 300,000. Now they know that

00:47:44.740 with certain implants, it's actually one in 3,000. And to be clear, there are no cases of this in

00:47:50.320 non-textured implants? Correct. All the cases have been only in textured implants, none in smooth

00:47:55.300 implants. So presumably the FDA has to weigh the risk of that because these textured implants are still

00:48:02.340 permitted in use? They're still permitted. They still account for a large number of implants being

00:48:08.680 used. The FDA just met a couple of weeks ago in April, 2019 to review all this. And they decided

00:48:16.960 to let them stay on the market. The European FDA actually pulled a number of the textured implants

00:48:23.540 off the European market. So only allowed smooth implants to continue and just said, there's no point.

00:48:31.040 And I think it's, you know, if you had no other option, you could argue we should keep these implants

00:48:36.320 on. But the smooth implants can do essentially almost anything. What's the advantage of the

00:48:41.520 textured one? The advantage of the textured one is not clear. In my opinion, there is no advantage. But

00:48:47.560 initially, they found a lower rate of capsular contracture with the textured implants. Now,

00:48:52.920 you have to be really careful. I think of any physician I've ever known, you're one of the best

00:48:57.560 at understanding that data can be very misunderstood and misread. And one of the issues we have in my

00:49:05.960 field in particular is that a lot of the studies done on implants are done by plastic surgeons who

00:49:12.640 are on the payroll of the implant companies. And so the implant companies are paying hundreds of

00:49:18.280 thousands and even millions of dollars to plastic surgeons to do studies. And these plastic surgeons

00:49:23.360 have a significant financial interest in the result of the studies. And you really have to question

00:49:29.480 whenever the researcher has such a big financial stake in a certain finding. And because textured

00:49:35.380 implants are more expensive, and a lot of these plastic surgeons were essentially making money on the

00:49:42.620 implants, they wanted a finding that showed that textured implants were better. And I've reviewed

00:49:49.420 the data. I do not believe there's still a big discussion and ongoing controversy in the field of

00:49:55.120 plastic surgery that whether or not textured implants do have any benefits, do have a lower rate of

00:50:00.660 capsular contracture. There was an interesting study done not by a plastic surgeon but by infectious

00:50:06.640 disease doctors and pathologists where they took a bucket of dirty bacteria-laden water and they put

00:50:12.540 a smooth implant in it and then they put a textured implant in it. And the bacteria are 70 times more

00:50:19.800 able to stick to the textured implant than to the smooth implant. A smooth implant, if you pour water on

00:50:26.660 it, it just rolls right off. It's smooth. If you look at it under a microscope, it just looks like a desert

00:50:31.580 flat. The textured implant looks like the Grand Canyon, all these rocks and crevices. So bacteria can stick

00:50:38.320 much more readily onto it. And that's been proven and replicated. If you then go a step further and

00:50:44.940 analyze the capsules, both in cases of this ALCL lymphoma and in cases of capsular contracture,

00:50:53.120 the capsules are full of bacteria. And so you say, okay, well, we think bacteria cause capsular

00:51:00.200 contracture. We know that they stick to textured implants much better. How could you tell me that

00:51:04.500 textured implants have a lower rate of capsular contraction? The answer is they probably don't.

00:51:11.440 And what's the difference in the cost of equally sized implants that are textured versus smooth?

00:51:18.180 It's probably about 20 to 25%. And you alluded to this a second ago, but again, I didn't even

00:51:24.080 realize this. This is how naive I am. Of course, a surgeon gets a surgeon's fee, but I didn't realize

00:51:29.640 that a surgeon makes that part of their compensation is based on a percentage of the cost of the implant.

00:51:36.760 So, you know, most surgeons will mark up the cost of the implant. So if the implant's more expensive,

00:51:41.820 they're going to make more profit. But I think for a lot of these plastic surgeons who were

00:51:45.880 doing the research in the implant companies, they were getting money from the implant companies.

00:51:51.740 I was recently at a plastic surgery meeting. One of the highlights of any meeting I've ever been to,

00:51:57.620 they had a panel of experts talking about textured versus smooth implants. And they had all these

00:52:03.640 world famous plastic surgeons talking about the benefits of the textured implants and why they have

00:52:09.380 better results. And then on the smooth implant side, this woman came up, she's a major leader in the 1.00

00:52:16.300 field of plastic surgeon. She's a Canadian plastic surgeon. And she's never taken a dime from any

00:52:21.580 company, any implant company or anything else. She's authored textbooks. She's absolutely brilliant.

00:52:27.540 I've had a chance to meet her and see her.

00:52:29.120 What's her name?

00:52:29.740 Elizabeth Hall Finley. And she's one of the premier leaders in the field of breast surgery. 0.58

00:52:34.840 She lives in Banff, Canada. And she was up there on the panel. And she basically got up and she put

00:52:41.380 up one slide. And it was a slide from a website called the Sunshine Act, which essentially shows

00:52:48.160 how much money every doctor in America has been paid, all the way from $10 up to millions of dollars

00:52:54.760 from industry. And she had the names of the doctors and the amounts of money. And she had the names of

00:53:00.600 the doctors on the panel going from $3 million at the top to like $150,000 on the low end.

00:53:09.300 And she just put up the slide and then she just walked off. 1.00

00:53:12.860 That's a mic drop.

00:53:13.960 That was her presentation. And I was dying. I was loving it because I've very, for a long time,

00:53:21.800 believed that as honest as you want to be as a doctor, when there is money involved,

00:53:27.620 when you have a vested interest in the result of a study showing something and you will lose

00:53:33.320 money if something else comes out of it, you can't trust yourself. I mean, there's just such

00:53:38.400 inherent bias in that.

00:53:40.640 Yeah, I agree with that completely. And it's really, it's so frustrating to be that critical

00:53:46.100 and to realize that you can't even trust yourself. And that's a hard leap to take,

00:53:52.220 but you really are correct. I think the only way to protect against that is to

00:53:56.260 take yourself out of a position where there's a conflict.

00:54:00.380 Specifically with the textured implants, what I believe led to a lot of the data,

00:54:06.280 and this is understanding the difference between correlation and causation, which I've heard you

00:54:11.100 talk about a lot before, is that there is a newer type of implant and they call it the gummy bear

00:54:17.960 implant and it's a teardrop shaped anatomic implant. So most of the implants we use are round,

00:54:23.520 but these newer implants are teardrop shaped. They were designed, they came out in the year 2000 in

00:54:29.920 Europe and the FDA approved them around the year 2010 in the United States. So for the first 10 years

00:54:36.240 of their development, they were only on clinical trials in the US, but they were being used regularly

00:54:41.200 on hundreds of thousands of women in Europe. 100% of these teardrop shaped implants are textured.

00:54:48.700 And the reason for that is that because-

00:54:51.200 You have to hold it in place.

00:54:52.120 You have to hold it in place. If it rotates, it will be, it will look odd and it needs surgery

00:54:57.480 to fix it as opposed to a round implant that you, you can allow it to freely rotate. 0.98

00:55:02.220 Let me ask a dumb question. Couldn't they make them smooth,

00:55:06.080 but put little tethers on the side that you could suture into place?

00:55:09.520 Yes, they could. And they, and they tried that and we have that with other types of devices that

00:55:14.900 we use. And that was an option. And, and I think that's something that could come in the future.

00:55:19.940 Absolutely. And some surgeons experiment with putting tabs on the back, but these teardrop shaped

00:55:27.080 implants, the reason they developed them is they said, well, the breast is not round. The breast

00:55:30.940 looks more like a teardrop. So let's make an implant that matches the breast. It'll be more natural. 1.00

00:55:36.100 So they started to use these in Europe. These implants require a larger incision to place.

00:55:43.300 And so European women in general have smaller breasts and smaller areola sizes than women in 0.98

00:55:50.100 the United States. Wait, why is that? Genetically, you know, you take like countries like Northern

00:55:55.600 Europe, like Norway and Sweden, these countries, the women tend to have smaller areola than a lot of 1.00

00:56:02.080 the women here where our population has black and Hispanic women, which are going to have larger 1.00

00:56:06.920 areola size. So the fact that you need a larger incision necessitated switching from a very common

00:56:14.840 incision for placing the implant, which is through the nipple to making an incision underneath the fold

00:56:20.340 of the breast. So by switching to this incision and putting in all these textured implants through this

00:56:26.380 incision under the fold of the breast, the surgeons are bypassing a lot of the normal bacteria that

00:56:32.480 exist within the breast. And so they're probably introducing fewer bacteria into the pocket around 1.00

00:56:40.260 the implant. So I believe, and there's now data to support this, that the lower rate of capsular

00:56:46.700 contracture with textured implants is due to the incision being made in a safer place that has less

00:56:54.400 exposure to bacteria and not because of anything inherent about the implant. So when they looked

00:57:00.600 at the data of these women in Europe and said, wow, these women have a lower rate of capsular

00:57:06.020 contracture with these new implants, it must be that these new implants have a lower rate. There's

00:57:11.520 something about the implant, but they're ignoring this secondary issue, which is, well, they were all put

00:57:17.160 in through this incision. And in my own practice, I've followed data on thousands of women. And we found

00:57:23.160 that we definitely have a lower rate of capsular contracture when we go through an incision made

00:57:29.020 underneath the fold of the breast as opposed to the nipple. The trials in the US, because you said

00:57:34.480 that there was about a decade when these were being used in Europe, but there were trials going on in

00:57:38.980 the US. Did the trials in the US randomize to, because you basically have a, you have many options,

00:57:44.920 but at the very least you'd have a two by two, which is textured, non-textured, and then the two

00:57:50.400 incisions. And if you did enough of those under random conditions, you would pretty easily be able

00:57:57.060 to tease out if there's a difference. Yeah, that study was never done. One thing that was done that

00:58:02.240 was very interesting was a study where the reason why they developed these teardrop-shaped implants,

00:58:07.820 they thought they would look more natural. And so they did an interesting study where they showed

00:58:12.700 at a meeting, a plastic surgery meeting, they showed the plastic surgeons in the audience

00:58:17.840 a hundred pictures of women who've had breast augmentation. And they told them 50 of them

00:58:24.420 were with teardrop-shaped implants and 50 were with round implants. And they wanted to see if

00:58:29.340 they could tell. And the plastic surgeons were only right 50% of the time. So it's in fact-

00:58:34.660 Are you kidding me?

00:58:35.280 Yeah. So it's in fact, so here we are the experts where, and I've found this many times,

00:58:40.780 I've shown my brother a picture of results and I said, you like this? You think this is great?

00:58:45.020 Wow. It looks so natural. What implant do you think we use? That's got to be a teardrop-shaped

00:58:49.400 implant. Nope. It's a round implant. And, and so, you know, there's many other factors that lead-

00:58:55.100 Wait a minute. That is the most stunning thing you have said so far in this discussion. And you've

00:58:59.020 already completely surprised me several times.

00:59:01.940 It's hilarious because once that study came out and that was replicated, suddenly we realized,

00:59:07.480 and this study was done several years ago. And so I've mostly abandoned the teardrop-shaped

00:59:12.260 implants because the benefit we thought they had, which is they give a more natural result

00:59:17.960 is, is complete BS. It's not true at all. And this has been proven. And, and secondarily,

00:59:24.140 they have disadvantages. Number one, they're textured. So they have this risk of this lymphoma.

00:59:29.720 They're more expensive. They can rotate and they're harder and firmer to maintain their teardrop shape.

00:59:36.600 And so they feel less natural when you touch them. So with only one supposed advantage and

00:59:42.960 all these disadvantages, I've essentially stopped using them. And I think that's where things are

00:59:47.480 headed. They were very popular when they came out in 2010 and the numbers are decreasing.

00:59:53.980 I know that there's, at this moment in time, you've got, there's going to be women listening to this

00:59:59.000 who are in the process of considering this. And so this forward looking input is helpful,

01:00:03.860 but invariably there will be a woman listening to this who already has an implant that is teardrop 1.00

01:00:09.880 shape and that is textured. Is there anything that that woman needs to do to be, does that woman need 1.00

01:00:14.980 to be concerned? Or if she's doing okay, she's probably one of the lucky ones. I mean, statistically

01:00:19.420 speaking, most women are going to do fine with these implants and hopefully the complications when they 1.00

01:00:24.680 happen are in the past, but is there some sort of surveillance or ongoing concern or consideration

01:00:30.500 for women who have had said implants? I think that these women should see their plastic surgeon at least 1.00

01:00:36.600 once a year and maybe even every six months. I don't think they need to run and replace the implants

01:00:42.020 if there's not a problem. Most of the cases in these patients who have this, develop this lymphoma, and

01:00:48.200 again, the incidence is between one in 3,000 and one in maybe 10,000. We don't know the exact number

01:00:54.160 because not all plastic surgeons report the findings. Are they not required to?

01:01:00.200 No, there's no law requiring it. There's a database where they beg and plead that we do this,

01:01:05.600 but again, the access to that is mostly coming from the American Society of Plastic Surgeons,

01:01:11.260 which is only targeting board-certified plastic surgeons. Like I told you before,

01:01:15.680 you have all these other non-plastic surgeons doing breast augmentation. 0.74

01:01:20.000 What's the percent? When it comes to breast aug, what percent do you think are not being done by

01:01:25.360 board-certified plasticians? In that procedure, only about 15%. So most of them are being done by

01:01:31.840 board-certified plastic surgeons, but there are still cases where these other groups are not

01:01:37.480 reporting any patients where they find this, and they don't even know about it and know how to test

01:01:42.920 for it and do the proper studies if they suspect it. But they have to see their surgeon once a year.

01:01:49.400 There usually are going to be other signs like significant swelling of the breast involved,

01:01:55.340 hardening of the breast, so the women tend to get capsular contracture first. So as long as there's 1.00

01:02:00.000 no problem, I think these women are fine and safe, and they don't need to freak out and rush to change 1.00

01:02:05.720 out those implants. But they should watch them. They might want to consider getting an MRI every few

01:02:11.560 years just to check on things. They should be doing monthly self-exams to feel for any masses.

01:02:17.220 So sort of just the regular stuff a woman should do with her breast in general. But again, the incidence 1.00

01:02:24.120 is low, but it's something you have to be aware of if you have or are considering getting a textured

01:02:29.040 implant. So we've basically said, let's put aside textured implants. Let's put aside teardrop-shaped

01:02:35.720 implants. That means we're focusing on round, smooth implants. Do you have a point of view

01:02:42.900 prospectively on silicone versus saline?

01:02:47.860 The saline implants were developed in the 90s when silicone implants came off the market.

01:02:52.640 Which is like one of the greatest screw-ups in the history of medical regulation against a tech company.

01:03:00.540 Right. It was an example of how a single newscaster on ABC, Connie Chung, could bring women on the show 1.00

01:03:07.480 crying, blaming their problems. I mean, we've seen this with vaccinations where one person said they cause

01:03:13.940 autism and next thing you know, you have thousands of children not getting vaccinated because of this fear

01:03:18.800 and then it's disproven, but it takes a while.

01:03:22.220 There's a great quote and I'm going to bastardize it, but the gist of it is a lie can travel around the world

01:03:28.100 faster than it takes the truth to put its shoes on.

01:03:30.800 That's very true. So the silicone implants came off the market. They were a bad product,

01:03:37.920 the old silicone implants. The silicone was liquid. If you poked a hole in the implant,

01:03:42.460 it would drip out like honey. Then the new implant companies, Mentor and Allergan are the two main

01:03:49.700 companies. They started making new silicone implants, which essentially became widely FDA approved in

01:03:55.540 around the year 2000. And so for almost 20 years now, we've had these newer generation silicone

01:04:00.920 implants and they're quite good. I mean, they look and feel more natural. They're softer. You know,

01:04:06.620 a saline implant is a shell of silicone filled with salt water instead of silicone on the inside. And so

01:04:13.500 the outside is still silicone, but they don't look as natural. They don't feel as natural. They're

01:04:19.220 essentially like a water balloon. They have a higher incidence of rippling and they don't last as long.

01:04:23.580 They start to leak after 10 to 15 years, although there are definitely women that can go longer. 1.00

01:04:28.880 They're a little bit cheaper than the silicone implants. So I still recommend and primarily use

01:04:33.680 silicone implants. I think the women who have saline implants and go to replace them, 1.00

01:04:39.780 they're a good candidate to stick with saline because if they have it and they like it and

01:04:43.360 they're happy with, there's nothing wrong with continuing to use it.

01:04:47.020 Okay. So now we've said, again, going forward, your preference would be smooth, round silicone.

01:04:54.340 Two more points just to get your point of view on. One is location of incision and above or below

01:04:59.360 the muscle. You've sort of talked a little bit about these, but again, what's your view prospectively?

01:05:04.980 As I said earlier, I pretty much now do almost all my implants through an incision underneath the fold

01:05:10.600 of the breast. It's a hidden incision. There are patients where it's going to be more visible,

01:05:15.460 but again, we're trying to avoid capsular contracture. That's the worst complication.

01:05:19.260 And if we believe that bacteria are involved with that, then we want to avoid that. And so an

01:05:24.580 incision through the armpit or through the nipple, you're making an incision in a location where there

01:05:29.260 are more bacteria and you're cutting through nerves, both in the armpit and in the nipple. And studies

01:05:35.420 show that there is a higher rate of pain and numbness and issues associated with going through those

01:05:42.060 two sites. So I tried to dissuade patients from using anything other than an incision under the

01:05:47.640 fold. Do you let the patients decide ultimately? I let the patients decide, but I present a strong

01:05:53.960 argument based on my own experience and the data that's out there. And I think most people,

01:05:59.140 they're willing to listen and do the right thing. I also put most of the implants in under the muscle

01:06:05.800 or behind the muscle as opposed to on top of it. And there's a lot of data that supports the benefits

01:06:11.560 of that. And I think for most women, it just, they like the fact that it looks and feels more natural

01:06:17.100 to have the upper part of the implant covered by the muscle. It's better for mammograms. It's better,

01:06:23.600 God forbid, if you develop breast cancer, it has a lower rate of capsular contracture. It helps support

01:06:28.860 the weight of the implant as opposed to the implant just stretching out the breast when it's sitting on top 0.97

01:06:33.460 of the muscle. So there's many advantages and that's what I do. And a lot of plastic surgeons do that as

01:06:39.620 well. What percentage of the breast surgery you do is augmentation for cosmetic reason without cancer

01:06:47.500 versus reconstruction and or augmentation following cancer surgery? Probably 75% is cosmetic and 25% at

01:06:57.200 this point is reconstructive. In that situation, the latter, meaning the reconstructive, what are your

01:07:03.880 options? Because you can also use tissue flaps and it gets much more elaborate in that situation,

01:07:08.800 doesn't it? Right. I mean, there's various options. You can use a woman's own tissue in the form of a flap 0.98

01:07:14.480 where traditionally we take the tissue from the abdomen and make a new breast out of it. You can use fat

01:07:21.300 and essentially just inject the fat in a series of treatments where you graft the fat into the site

01:07:27.920 where the breast was. We use implants and that is one situation where we might still consider to use

01:07:34.800 teardrop-shaped implant because I think in a reconstructive patient, they're one of the few

01:07:40.080 situations where there still is some benefit. And that's actually the only situation where I'm using

01:07:44.960 the teardrop-shaped implants is for breast cancer reconstruction. Those women have a lot of 0.99

01:07:50.740 monitoring and everyone's on top of them because they've had breast cancer. So my concern with them

01:07:56.480 is less about developing some type of lymphoma. I also think that because they've had a mastectomy,

01:08:03.300 their body's ability to mount this autoimmune type response is lower because their lymphatics have

01:08:10.920 mostly been cut. And so I'm a little bit less concerned, but of course we still watch those women 1.00

01:08:15.960 closely. When we meet with women who have breast cancer and who are going to undergo breast

01:08:21.080 reconstruction, we talk to them about the options, what their goals are. A lot of it has to do with

01:08:26.160 what type of recovery they want. The flap or autologous tissue-based procedures where we use a

01:08:32.200 woman's own tissue have a much bigger recovery as opposed to just putting in implants. And a lot of 1.00

01:08:37.060 women aren't willing to undergo that. What is the advantage of the autologous? Does it look better 1.00

01:08:42.740 when you have a flap? Does it look more natural? It does look more natural. And the main advantage

01:08:47.940 is you never have to deal with an implant and the complications associated with the implant for the

01:08:52.720 rest of your life. You know, you can't reject your own tissue. It's soft, it's natural. And it's

01:08:58.260 especially good for a woman who's only doing one side where she has a natural breast, especially if 1.00

01:09:04.160 it's more of a flat hanging breast on the other side, it's hard to match that with an implant. 0.92

01:09:09.400 If a woman's doing both sides, we'll usually lean more towards implants. But again, it's really on 1.00

01:09:16.020 a case-by-case thing. And how often do women in that situation require tissue expanders? And is it 0.93

01:09:22.320 often a multi-stage procedure? Or what's the sequence of events from the mastectomy to the

01:09:28.500 reconstruction? One of the things that's changed a lot in the field of breast cancer, you know, when you

01:09:34.260 go back to the beginning of the mastectomy, one of the great mentors and great surgeons, Halstead,

01:09:41.040 who I think was from your alma mater, he initially thought that you had to cut everything out for

01:09:45.800 breast cancer. And he would remove all the skin, all the breast, and the muscle. And the muscle, 0.86

01:09:50.420 yeah. And everything. And where we've, yeah, and where we've come to today is to a nipple-sparing

01:09:55.740 mastectomy, where essentially a lot of women are candidates for removing the breast, but keeping 0.71

01:10:00.940 all of the skin, including the nipple behind. In that case, you can go directly to an implant

01:10:06.420 reconstruction because you're not trying to manufacture new skin. In the case of women who 1.00

01:10:12.020 have to have their nipple removed, so you're removing a portion of the skin, you need to now 1.00

01:10:17.180 restore skin that's been removed in the mastectomy. And that's where a tissue expander comes in, where we

01:10:23.320 stretch out the skin. And that's a multi-step process that takes a few months until we put in a

01:10:29.060 final implant. Wow. You know, I was talking with somebody about this recently, and they made a

01:10:33.980 point about there's no analogous cancer, I guess, that is where you're dealing simultaneously with

01:10:42.440 the cancer risk, you know, you have to remove these cells, but also sort of the threat to your

01:10:49.460 psyche and the threat to your image. And even if you look at something like testicular cancer or

01:10:53.980 prostate cancer, it's not quite as visible in terms of the change that you're going through.

01:10:59.360 I mean, obviously there's functional deficits that occur, but do you find yourself dealing with

01:11:04.000 the psychology of that? I mean, dealing with a patient who's sort of shell-shocked and going through

01:11:09.440 this simultaneous loss, right? Like the loss of this tissue and the cancer risk, but then the loss of

01:11:16.300 part of my femininity. Yeah, absolutely. I remember when I was starting out in practice,

01:11:22.320 I somehow, I don't remember the circumstance, but there was a woman who was part of my team,

01:11:28.120 whether it was a nurse or a PA, was in the room with me with a breast cancer patient.

01:11:32.620 And the patient started to cry when we started to talk about her diagnosis and the treatment.

01:11:38.080 And I sort of sat there, you know, a little uncomfortable, not sure what to do. And she was

01:11:42.760 crying. And the woman who was in the room with me, the nurse, if it was, she grabbed a tissue and gave

01:11:48.480 it to the patient and then hugged her. And that episode really stuck in my mind because it made

01:11:53.280 me feel inadequate at the time. And I didn't know if it was because I was a man or because I didn't

01:12:01.740 have breasts and hadn't undergone breast cancer, or I didn't have a family member who'd had breast 0.93

01:12:06.340 cancer. I wasn't sure what the reason was. I hadn't received the adequate sensitivity training,

01:12:10.860 but I just felt inadequate to deal with it. And I think since that time, I've become better

01:12:18.020 at having, developing the empathy and the understanding for what these women are going 0.74

01:12:24.060 through. A lot of it has come through getting to know the husbands and the children and the parents

01:12:29.820 where, you know, I talk to them and spend time with them and kind of get a better feel as the man,

01:12:35.380 what they're going through. It's a very complicated process. And a lot of good hospitals have

01:12:40.500 social workers and psychologists that help the women. We're seeing more and more breast cancer

01:12:45.560 in younger women these days. So it's a very devastating thing. I mean, for a lot of women,

01:12:50.580 they associate their femininity to a large degree with their breasts and losing that has a profound

01:12:56.700 impact on them. That was a pretty awesome summary, at least to me of, I think I learned more about

01:13:03.240 breast reconstruction in the last few minutes than I've ever known. Let's turn our attention to

01:13:08.100 another operation. What would be sort of another very common operation that shows up, liposuction

01:13:14.060 or your pick? Yeah, I think a tummy tuck is one of the top five procedures along with breast 1.00

01:13:20.940 augmentation and rhinoplasty, facelift, liposuction. Okay. So tummy tuck, let's define that for people.

01:13:27.360 What's a tummy tuck? A tummy tuck is essentially a procedure that involves removal of all the excess skin 0.91

01:13:34.500 in the abdomen below the belly button, in the central abdomen. It also typically involves

01:13:41.340 tightening of the muscles that get stretched out as a result of pregnancy. 95% of tummy tucks are done

01:13:48.360 on postpartum women who've had children and their bodies have changed to a larger degree after childbirth. 0.53

01:13:54.920 This is probably as good a time as any to define the difference between a diastasis and a hernia 0.99

01:14:00.740 since the two sort of happen under these circumstances as well. And I assume that if

01:14:07.240 either of those are present, this is the time to fix them? Absolutely. A large number, I would say

01:14:13.180 maybe even as high as 20% of women after pregnancy develop a hernia in the belly button. You know,

01:14:19.440 the belly button was the site of your umbilical cord when you were in utero. And so there was always an

01:14:24.520 opening there and it's scars closed when you're born, but it's an inherent spot of weakness.

01:14:29.780 So the act of pregnancy where the abdominal wall is stretching and the pressure inside is building

01:14:35.360 up as the uterus grows can pop that open. And a lot of women develop hernias. So essentially a little 1.00

01:14:41.580 tiny hole where the belly button was and the fat on the inside pooches through that hole into the 1.00

01:14:47.540 belly button. So it gives you an outie, if you will, which is essentially a hernia. A diastasis is

01:14:53.980 different. It's a separation of the rectus muscles. So the six pack muscles move aside and then there's

01:14:59.980 a gap in between. In many ways, it's similar to a hernia in that you have a weakened central area

01:15:06.800 where stuff is pushing out against. And I've had patients with severe diastasis where you can

01:15:11.060 literally see their intestines through their skin. It looks like a worm moving around inside. And that's

01:15:17.680 because the tissue is so thinned out in between the muscles. Both of these would be addressed at

01:15:23.540 the time of a tummy tuck. Now, the diastasis doesn't have the risks that an untreated hernia

01:15:30.180 have. I mean, that's the other thing that patients should understand is an untreated hernia can be

01:15:36.420 catastrophic. Yeah, absolutely. Because with an untreated hernia, if something pushes through that

01:15:42.780 hole and gets stuck, we term it an incarcerated hernia, that tissue can necrose or die away. And

01:15:49.320 if it's part of the intestine, that can become life-threatening. We know a little bit better now

01:15:53.940 that if a hernia is asymptomatic, so a woman has no symptoms from it at all, same is true with a man,

01:16:00.280 you can just sit and wait on that. You don't have to treat it. Once it starts to cause pain or any other

01:16:06.000 symptoms, it should be treated. Let's just take a sort of a typical example of a patient. So a woman 1.00

01:16:12.680 who's had two children, she's late thirties, early forties, doesn't want to have kids anymore. Is that 1.00

01:16:17.820 important that this is only done after she's done having children, I assume? Yeah. I mean, if you do

01:16:23.860 it on someone and they end up getting pregnant afterwards, they can kind of wreck the beautiful 1.00

01:16:28.560 result that you do. You can still get pregnant. You stretch everything out. A tummy tuck can be done a 0.99

01:16:34.480 second time if necessary. But ideally, and I tell patients, wait until you're done with children.

01:16:40.980 So let's say just for the sake of example, she has, pick one, a hernia or a diastasis. Is one

01:16:45.660 easier or more difficult to repair in the context of the tummy tuck, assuming they're both of modest

01:16:50.260 size, not enormous? I think the diastasis is, it's a little bit easier because you're not dealing with

01:16:56.220 concerns of damaging the bowel or the hernia coming back. You know, the diastasis is generally not

01:17:02.180 going to come back. You're bringing the muscles together. And that's a more common scenario,

01:17:06.680 the women who have the diastasis, where they're, instead of having a flat abdomen, it's sort of 1.00

01:17:12.720 protuberant and convex outward. And especially, you know, classically after a large meal, these women, 0.89

01:17:20.200 their belly is sticking out. And I joke that the absolute indication for a tummy tuck is if one of

01:17:26.840 your children asks you if you're having another baby after a large meal.

01:17:32.320 We'll call that the Krieger test.

01:17:34.260 By the way, on that note, I want to just tell the listeners, you should never ask a woman if she's 0.99

01:17:38.240 pregnant. I have a lot of patients who people say, when are you due? Have you had the baby yet?

01:17:44.020 There's a lot of thin women who have very low body fat and a huge diastasis, and they look like 1.00

01:17:48.960 they're six months pregnant. Never ask a woman if she's pregnant. 1.00

01:17:52.500 Yeah, there's a great comedian. I think it's Brian Regan who's got a whole bit on this.

01:17:57.880 And I think the takeaway from his bit was the only time it is socially acceptable to ask a woman if

01:18:05.260 she is pregnant is if the head is coming out and you can see it. 1.00

01:18:08.880 The baby's crowning.

01:18:09.320 Right. If the baby's crowning, you actually see the head coming out. At that moment, you are permitted

01:18:13.920 to say, oh, Susie, are you pregnant? But anything before that, no, you just shut that down.

01:18:20.080 Yeah. So does it matter, Zal, one way or the other, if women have had vaginal deliveries 0.99

01:18:25.700 versus C-sections, which also, of course, introduced that fan and steel incision,

01:18:32.340 been like it's sort of a very, very low abdominal incision, because that's cutting through muscle.

01:18:39.480 We can still do a tummy tuck in either way.

01:18:41.620 Are they more susceptible one way or the other?

01:18:43.960 No, I don't think they're more susceptible. I think it has to do with genetics and the size of

01:18:48.200 the baby and the weight at which one gained weight during the pregnancy. But I think that

01:18:53.820 with the C-section patients, we have the option to correct a lot of the issues from the C-section,

01:18:59.280 like scar tissue and indented tethered scars that bother a lot of patients or skin that hangs over

01:19:05.460 the scar. So there's that additional benefit.

01:19:08.920 So you'll go through the C-section incision?

01:19:11.200 I'll actually go below it and cut it out completely because I want to make my own new

01:19:15.860 incision. I think that in general, the vaginal delivery patients, and I don't know if it's

01:19:22.600 from the act of pushing during labor or whatnot, maybe it's just the factors that coalesce to lead

01:19:28.640 to them having a vaginal delivery. 0.83

01:19:30.220 Yeah. It might be that a woman who can have a vaginal delivery has more elastic skin. She is 1.00

01:19:35.200 more able to stretch. And while that permits her to have the vaginal delivery, it also makes her 1.00

01:19:40.000 more susceptible to the stretching of the fascia.

01:19:43.000 Right. And so we tend to see a little bit more of a diastasis there. But the rate of C-sections

01:19:49.020 has increased so dramatically in the US. I mean, I don't know the numbers, but it's probably

01:19:54.100 approaching 40 to 50% now. It's so common now to see women coming in who've had C-sections and

01:20:00.400 are coming in for tummy tucks.

01:20:02.460 So what is the actual procedure? So you're making the incision, and obviously there's a lot of skin

01:20:09.220 removal. How are you going from this incision, just basically at the pubic line, all the way

01:20:15.440 up to above the belly button to fix the diastasis? Are you, I don't-

01:20:20.020 We are essentially lifting up all of the skin off the abdominal wall, all the way up to the 0.99

01:20:25.220 xiphoid. So right up to the breastbone. And we're exposing the entire abdominal wall. It's basically

01:20:31.420 like an anatomy textbook. You're staring at the whole abdominal wall with the skin lifted up.

01:20:36.880 And then we do the muscle tightening or the hernia repair.

01:20:41.040 And the muscle tightening you do, you are literally bringing sutures together to pull the rectus

01:20:45.480 muscles back such that you're, you know, when people look at a six pack, what they realize is

01:20:50.780 the reason it's not a three pack is there's a fascial piece that goes down the middle that

01:20:56.720 separates the left and the right side. And that maybe ought to be what, an inch apart?

01:21:01.340 Even if that may be less, half an inch to an inch.

01:21:04.320 Got it. So a woman with a diastasis will show up and that will be inches apart. 1.00

01:21:09.680 Correct. And not only are the muscles apart, the fascia has been stretched out. So the muscles,

01:21:15.680 instead of being flat, are actually protuberant. So you kind of get this sort of like mini beer belly,

01:21:21.480 if you will. And so we're tightening the fascia, which is the outer layer of the muscle,

01:21:26.020 and bringing it together so that the abdominal wall then becomes flat and tight. 0.88

01:21:32.200 What percentage of the time are you doing this on a man? Because certainly a man who's lost a lot

01:21:36.580 of weight could be in the same situation, correct?

01:21:39.300 Yeah, they're definitely a minority. Five to 10% of patients are men with this operation. And almost

01:21:45.160 all of them are massive weight loss patients who've lost a lot of weight. They usually don't have a

01:21:49.900 diastasis, so they don't need the muscle tightening. And it's all about just the skin removal in those

01:21:55.760 cases. What are the biggest risks to this procedure?

01:21:59.980 Biggest risk is fluid accumulation called the seroma after the surgery. You know, you've created

01:22:05.300 such an enormous amount of space where you've lifted up the skin that you could put easily a 0.97

01:22:11.540 liter of fluid to fill in that area. And so we use drains to drain the fluid out. And the risk is if

01:22:18.580 you don't have enough drains or they're not in the right spot. And then after the drain comes out,

01:22:23.360 the fluid can accumulate. And the incidence is about 10% to 15%.

01:22:28.500 And if a woman develops that complication, does it require drainage or does it go away on its own? 0.98

01:22:33.820 It usually requires drainage. And in rare cases, it'll go away on its own.

01:22:38.420 And do you, as the plastic surgeon, do the drainage or does an interventional radiologist do it?

01:22:41.860 We do everything. I mean, in my practice, we manage all the complications. Occasionally,

01:22:46.360 we'll send someone to an interventional radiologist. If, for example, the fluid is in

01:22:52.580 one small specific spot and you need an ultrasound to see where it is and we need them to put in a

01:22:57.440 special type of drain. But 95% of the time, we're managing it ourselves in the clinic.

01:23:03.500 So even if a woman develops a seroma, do they typically resolve with the appropriate

01:23:07.880 follow-up drainage?

01:23:09.040 Yeah, they usually do.

01:23:10.760 Okay. Is it a big risk of bleeding or are you pretty much staying away from major blood vessels?

01:23:14.680 Bleeding is a small risk. And I think the cases where it happens are the patients with larger

01:23:20.960 blood vessels. Massive weight loss patients have very large blood vessels. And so it's

01:23:26.980 understanding when you need to tie off a blood vessel as opposed to just cauterizing it and really

01:23:32.560 being meticulous and careful. And again, that goes back in my practice to having the two surgeons.

01:23:37.900 Every single thing is double-checked. It's easy to miss something when you're by yourself.

01:23:43.220 And uncontrolled blood pressure, so patients who have high blood pressure after surgery,

01:23:49.160 that is an increased risk for bleeding, specifically on procedures on the face.

01:23:54.420 And what about long-term complications? What are the cosmetic

01:23:57.240 issues that come up after women have had this? 1.00

01:23:59.960 The main thing people complain about is the scars. They're unhappy with the appearance of the scar.

01:24:05.200 A lot of patients gain weight or things stretch out and they end up with loose skin after the surgery.

01:24:11.140 So it's nice and tight for the first year, but then it loosens up and they're unhappy with that.

01:24:16.580 Occasionally, patients' deep fascia stretches out and so they have a little bit of a recurrent diastasis and

01:24:22.920 they're unhappy with that. But most of the patients are pretty pleased. When you combine liposuction with

01:24:28.900 the tummy tuck, you raise the stakes. It increases the complication rate a little bit. And liposuction

01:24:35.600 patients in general, I mean, it's a whole nother discussion, but there's a lot of unhappiness and

01:24:41.160 dissatisfaction when it comes to liposuction.

01:24:44.460 Can you predict in advance if a woman, assuming she hasn't already had a scar, she's never had a 0.98

01:24:49.960 surgical procedure, I guess this is true for men as well, but since we're talking about a pretty big

01:24:54.720 incision here in the tummy tuck, can you predict who's going to get a hypertrophic scar or a keloid?

01:24:59.980 I mean, I know keloids tend to be more common in African-American than white or Hispanic, but even 1.00

01:25:06.960 absent a keloid, just people have very different scar morphology. And given the size of the scar here,

01:25:13.180 that would seem to play a role in the long-term cosmesis, right?

01:25:17.900 Yeah, for sure. And it's tough. I mean, in general, you really can't predict unless someone already has

01:25:24.060 evidence of bad scarring, what's going to happen. It's definitely a genetic thing. Asians and dark 1.00

01:25:31.040 skin patients have a higher risk of keloiding. Their skin is thicker and it's more sebaceous and

01:25:36.820 it tends to scar worse. So we're always concerned more about that with our darker skin patients.

01:25:42.540 But even in fair skin patients, we'll sometimes see bad scarring. Patients who have infections or any

01:25:48.920 delay in the healing are at higher risk for developing keloids. But the tension on a scar

01:25:54.980 is a big contributor to how the scar is going to turn out. So areas of very high tension, like a

01:26:00.820 tummy tuck where the two edges are pulling apart as opposed to an incision where it's just an axis

01:26:06.180 incision, like cutting over a hip to get down to the joint, the high tension scars tend to be much

01:26:12.220 worse. So in patients who were closing it under a lot of tension, where we've cut out a lot of skin

01:26:18.620 and we're kind of going for the home run to make it as tight and flat as possible. We'll do things

01:26:23.580 to minimize the tension, but that tension is a big risk for the poor scarring. The proof in this is

01:26:30.400 that the area of highest tension is in the very center of the scar and that usually is the area

01:26:35.500 that scars poorly. Whereas as you go out towards the side of the scar, towards the hip bone, the scar

01:26:41.340 becomes more faint and less noticeable because there's less tension there. So you just sort of alluded

01:26:48.320 to liposuction. So let's go, let's go there next. This is one of those procedures where I'm guessing

01:26:53.840 what percentage of them being done are not being done by board certified plastic surgeons.

01:26:59.800 This is something where we probably see a large, large number. I mean, if I had to guess,

01:27:06.860 probably talking about 80 to 90% of the procedures are being done by non-plastic surgeons in an office

01:27:15.020 based setting. There are anywhere from 20 to 30 devices out there that perform different types of

01:27:23.140 liposuction. And a lot of this is done in an office based setting. And so doctors, non-plastic surgeons

01:27:30.700 are purchasing these devices and offering this to patients. And there are non-invasive devices. A popular

01:27:39.200 one is called cool sculpting, which I don't do. I'm not a big believer in. You kind of wave a magic wand

01:27:47.220 over the person. It freezes the fat. I mean, I always said, if freezing the fat works, why are the Eskimos 1.00

01:27:54.800 so fat? Maybe they're not cold enough. Yeah. And then you have devices that heat it up. So it's like,

01:28:03.120 wait, do you want to freeze it or heat it up? I'm not a believer in a lot of these technologies.

01:28:07.960 They have a lot of risks associated with them. A lot of risks of burns, contour irregularities.

01:28:14.860 Most board certified plastic surgeons do what's called just traditional liposuction,

01:28:19.780 where it's essentially the movement of a cannula that causes the fat to break down. And then you

01:28:25.620 just suck it out. You're not using additional laser or radio frequency or ultrasound forms of energy

01:28:31.920 to remove the fat. What does it look like? I mean, I think we're talking about subcutaneous fat here,

01:28:37.840 we're not talking about removing visceral fat or things that are below fascia. So everything is

01:28:41.840 above this very thick connective tissue. But when you put a cannula, I guess maybe we should just

01:28:47.840 explain some of these terms we're using. So a cannula is what? How would you explain that to

01:28:51.740 somebody? The cannula is a hollow, long metal or plastic device that is inserted underneath the skin

01:29:00.140 into the fat. And that's what breaks the fat down and sucks it out. 0.90

01:29:04.480 Why is it that if you took a person who has lots of subcutaneous fat and you put a

01:29:09.220 five millimeter incision in them and you stick a five millimeter cannula and you just hook it up to

01:29:14.300 a vacuum, why doesn't it just uniformly suck out all the fat? 0.84

01:29:19.080 The fat is actually connected pretty well to the overlying skin. There's connective tissue and

01:29:25.860 different parts of the body. It's connected to various degrees. For example, the fat on the soles

01:29:31.760 of the feet and the palms is extremely strong and tough fat. The fat in the buttocks where we sit

01:29:38.600 is also very rigid in fat. It's difficult, be extremely hard to liposuction that. So just creating

01:29:44.280 suction won't suck it out. It's stuck there. You have to actually break it apart. And that's how it's,

01:29:51.920 whether it's done with a form of energy or just the mechanical energy generated by the movement

01:29:57.580 of the cannula that breaks the fat apart. Who first did this procedure? I mean, how long has

01:30:03.460 this procedure been around? It's been around a long time, probably 50 years, and it was invented

01:30:07.820 by a dermatologist. So it's difficult as a plastic surgeon to judge dermatologists who do liposuction

01:30:13.760 because they actually invented it. So, you know, I think dermatologists who have adequate additional

01:30:19.720 training, they're not usually doing this in their regular residency, could probably do some areas

01:30:25.100 of liposuction. But again, I think that you have to distinguish between specialties where you spent

01:30:30.980 a lot of time in the operating room as opposed to specialties that didn't. You know, like we talked

01:30:37.240 about, I was in the military. I spent a little bit of time in the ocean and diving. And so, yeah,

01:30:42.880 I can go in, but that's not my area of expertise like someone who's a Navy SEAL where they're so

01:30:48.400 comfortable in the ocean. I mean, the same thing is true in the operating room. You're either a surgeon

01:30:53.140 or you're not a surgeon. If you're a surgeon, you've spent literally years of time in the operating

01:30:59.020 room and your comfort level with dealing with everything is very different. A surgeon once said

01:31:05.120 to me, you know, a good surgeon knows how to take care of any complication they create. And

01:31:09.300 the complications from liposuction are astounding. I mean, there are multiple cases of patients puncturing

01:31:17.020 lungs and puncturing liver and intestine. Well, I mean, you'll have to explain to me

01:31:22.040 how that happens outside of the most egregious malpractice. I mean, this is all happening

01:31:30.620 outside of fascia. So how is it that the patient is so big that the surgeon, I mean, I'm trying to

01:31:36.360 be sensitive to the surgeon making the mistake as well, but to give someone a pneumothorax or to

01:31:41.800 puncture their liver, you have to take that cannula. And instead of moving outside of the

01:31:47.340 plane where the fat is, you have to turn the cannula inward, right? Right. So, you know,

01:31:52.380 the most common area of liposuction is the abdomen. So if someone is liposuctioning the upper abdomen,

01:31:58.000 you obviously have to understand the anatomy. You have a rib cage there. So you have to stay above

01:32:03.000 the ribs. But if you're not paying attention, you're not feeling and aware with what you're doing,

01:32:08.240 it'd be pretty easy to slip underneath the rib. Well, if you go underneath the rib, the next thing

01:32:13.520 you encounter there is the rectus muscle and then the diaphragm. And so these thin cannulas are actually

01:32:21.100 riskier, a one to two millimeter cannula. It's easy to just push right through the abdominal wall 0.99

01:32:27.160 and into the next layer. Why not use a blunt cannula instead of a sharp?

01:32:32.840 They are blunt. They are blunt. But it's still, there have been multiple, multiple cases of this

01:32:38.100 happening. And does anyone ever do this with an, like, because if you're doing liposuction on someone

01:32:42.820 who's subcutaneous fat, but they're not incredibly big, presumably the risk of this is lower? Is this

01:32:48.860 more? You would think so, but we still see it in thin patients. So ultrasound guidance wouldn't help

01:32:56.060 when you're in those areas? It probably would. It's sort of impractical because then you have to

01:33:01.660 introduce an ultrasound sterilely. And then you need either the person doing the liposuction knows

01:33:06.940 how to use the ultrasound or they have to bring in someone else. So that is not typically done. I

01:33:11.960 think it would increase the safety, but you know, a well-trained surgeon who knows the anatomy and

01:33:17.700 knows what they're doing, they have to get pretty lost to end up in the lung or the liver.

01:33:23.240 What's the typical path they're taking to the lungs? Is it inferior through the diaphragm as well?

01:33:27.040 Yeah. It's through the diaphragm. Or when they're liposuctioning the side of the bra line,

01:33:32.360 which is a common area during a breast reduction or another procedure, women want to get rid of that 1.00

01:33:36.960 bra fat. And so you have to stay outside of the rib cage. So if you're the angle of the cannula is 0.77

01:33:43.480 wrong, you could easily puncture in and end up in the lung. And liposuction is a dangerous procedure

01:33:49.980 if not done properly. And we see incredible complications and death rates from it. Electrolyte

01:33:56.940 problems from fluid shifts. You know, there's tremendous fluid shifts that happen after liposuction,

01:34:03.640 volume overload, pulmonary edema, fluid in the lungs essentially. And we see these and it's really

01:34:10.340 an issue of where are you doing the liposuction in the office or in the operating room? Are you

01:34:14.740 monitoring the patients during and after the procedure? Another major risk with liposuction

01:34:19.980 is lidocaine toxicity. So overdosing the people with lidocaine because you're obviously having

01:34:26.120 to numb up the area before you liposuction it. So how do you numb them up? You numb up where you

01:34:31.220 make the incision. You then introduce fluid full of lidocaine into the area. It also has epinephrine

01:34:38.520 in it. So it causes constriction of the blood vessels to decrease the bleeding. And does any of that

01:34:43.400 make its way into the patient's actual bloodstream so that their heart rate goes faster, which the

01:34:49.140 epinephrine would do? Interestingly, it takes about 8 to 12 hours as a delay after the liposuction

01:34:55.360 for it to see peak levels of these substances in the bloodstream. And so you're done with a procedure

01:35:02.380 after a couple hours, patient recovers for another hour, they're home. So these levels are occurring at

01:35:08.060 home. And that's when you have to really understand what you're doing, what volumes your

01:35:13.200 putting into the patient, making these calculations. And a lot of the people doing this in the office

01:35:19.740 are not thinking about it. And that's where they run into trouble.

01:35:23.020 I mean, you get more nervous doing liposuction, I'm guessing, than either of the two procedures

01:35:26.760 we've discussed beforehand.

01:35:28.440 I mean, I think I'm at the point where I'm pretty comfortable, but I'm very conservative with what I do.

01:35:33.760 I try to avoid very large volume liposuction. That's where it becomes risky, where you're

01:35:38.840 trying to suck up more than, you know, about 10 pounds of fat at a time. That's what we would

01:35:44.960 consider 5 liters, which is, you know, slightly over 10 pounds is what's considered large volume

01:35:49.920 liposuction. And that's where the risks really go way up.

01:35:53.980 What are some people doing out there in the community?

01:35:55.880 I mean, they're doing everything, 20 pounds, 30 pounds of liposuction, 8 hours of liposuction all

01:36:02.520 day long. I mean, just, it's the Wild West. Like I said, anyone can do anything and there's no

01:36:08.240 laws or regulations governing what's done. It's buyer beware.

01:36:15.880 Yeah. And what is the typical cost? How does liposuction get priced?

01:36:19.520 Most people price it by the area. So it might run anywhere from $1,000 if you're just doing one

01:36:26.320 limited area in an office-based procedure, you know, up to $7,000 to $8,000 depending on going

01:36:34.140 into multiple areas over several hours. And what's the range in price that you see between

01:36:40.640 sort of highly trained, you know, dermatologist or plastic surgeon versus the, you know, people who

01:36:46.780 are doing this with less training? I think in general, the people with less training who are

01:36:50.780 not board certified plastic surgeons are usually charging much less, especially if they're doing

01:36:55.260 things in the office. And, you know, you can see a two to three fold price difference, you know,

01:37:00.740 something that a family practice doctor, or we have a female gynecologist in my community who does a lot 1.00

01:37:07.280 of office-based liposuction and she's charging a third of what I might charge for the same procedure,

01:37:14.000 doing it in the operating room with anesthesia. And then there's regional differences, you know.

01:37:19.140 So even though you guys might actually make the same amount per procedure, you have to spread your

01:37:24.640 cost out much more because if you're, if you have an anesthesiologist there and you're doing it in

01:37:28.020 the operating room, your costs have increased dramatically. Correct. Okay, let's go on to

01:37:33.260 butt lifts. This is the dangerous one, right? Yeah, this is the real dangerous one. This is

01:37:39.180 extremely popular these days and getting more and more popular social media. You know, Kim Kardashian

01:37:46.020 has probably accounted for a billion dollars spent in the U.S. on this procedure. It's very popular in

01:37:52.760 Central and South America. There's definitely a ethnic and racial preference for this procedure.

01:38:01.460 There's a great, I went to a great meeting in Miami. Miami is like the New York City for Central and

01:38:07.800 South American doctors. So they love to come to Miami for the nightlife and the restaurants and they

01:38:14.740 just love it there. This meeting had thousands of plastic surgeons. 80% are from Brazil and Argentina

01:38:21.180 and Mexico and Central America. And so they showed four butt pictures on the screen to the plastic

01:38:27.900 surgeons. And you know, the, everyone in the audience has a little button thing that they can

01:38:32.540 choose. And they say, okay, we want you to rank your favorite, what you think is the ideal buttocks. 0.60

01:38:38.900 And so people pick and then they show the result. And of course the big, huge, giant round butt is the 0.99

01:38:44.780 most popular. And then they said, we want you to click your country of origin, where you're from. 0.94

01:38:50.260 And there's just a beautiful correlation between the Brazilian and the South American plastic surgeons 0.98

01:38:55.720 and the preference for this type of butt. So a lot of it depends on the aesthetic of the surgeon.

01:39:01.720 In California, we do a lot less of this because my ideal and a woman in California's ideal body is 0.97

01:39:08.320 maybe more of the athletic toned sort of body type, as opposed to in Miami where everybody wants to have

01:39:15.520 this rounded, you know, large protuberant buttocks, but it's very popular. I mean, we still see a lot

01:39:21.900 of patients asking for this. How many of these do you do a year? I probably do 20 to 30 a year.

01:39:29.260 And, and your peers in Miami would do how many? They might do four to five a day. This is like,

01:39:35.040 there's some, I know one guy where he's literally doing seven to eight a day of these procedures.

01:39:40.100 Like it's like a factory. This is one of the most dangerous procedures in all of plastic surgery. And

01:39:46.240 we actually have had meetings in our societies and, and, and almost to the point where they want to put

01:39:52.760 a moratorium and just stop doing these procedures. The issue is what, what the Brazilian butt lift is,

01:39:59.260 is, is injecting fat into the butt to enlarge it. That fat is liposuction from one part of the

01:40:04.820 body and then inject it into the butt. So there's no mechanical lift that's going on.

01:40:10.080 The lift is accompanied just by, I didn't, I didn't even.

01:40:13.180 Filling it up. Yeah. It's just filling, it's like inflating a balloon.

01:40:16.640 All this time.

01:40:17.620 Yeah. It's just filling it up with fat as much as you can get in there. The issue is inadvertently

01:40:23.420 injecting fat into the veins in the butt. And then they, the fat gets transported to the lungs and

01:40:29.680 causes a fat embolus, which has a high risk of fatality. And so there have been multiple deaths,

01:40:36.400 most of them in Florida, but multiple deaths in, in South America, even in California, we've had

01:40:42.840 deaths from this procedure. When they autopsy these patients, they uniformly find their lungs full of

01:40:49.640 fat that was basically transported from the veins in the butt where the fat was accidentally injected.

01:40:57.000 And so there's a lot of recommendations about how to avoid this and, you know, using smaller volumes,

01:41:03.380 injecting it more superficially, but it's still very popular. I mean, despite the risks, women still 0.99

01:41:08.820 want this. What are the stated risks of a fat embolus from this procedure? In other words, if you

01:41:14.840 walk into a responsible doctor's office or someone walks into your office and says, what's my risk of

01:41:20.360 this? What percent would you quote? It would probably be one in a thousand would be the risk. Maybe,

01:41:25.520 maybe even higher. And I guess this is a great example. As a fatal fat embolism, there's probably

01:41:31.140 cases where it's happening and it's not fatal, like, like a regular pulmonary embolism and we

01:41:36.100 don't catch it. You know, it's interesting. This is a great discussion about the asymmetry of risk

01:41:40.360 because you might listen to this and think, well, one in a thousand is not that bad. But I was telling

01:41:45.260 you earlier today, I mean, I had to keep my phone on during this interview because I have a patient who

01:41:49.440 I sent into the emergency room to rule out a pulmonary embolism. And, you know, we're talking

01:41:55.700 about this this morning and, you know, the patient was saying, well, you know, I've got this pain in

01:42:00.080 my calf and I've been flying a lot and, you know, was sort of thinking, I wonder if I do feel a little

01:42:07.640 short of breath. You know, it's hard to say. So look, listening to the patient's story, I think the

01:42:11.940 probability that they have a pulmonary embolism is actually quite low, but it's not zero. And

01:42:17.960 I said, just to make the math easy, let's assume there's a 1% chance you have a pulmonary embolism

01:42:23.580 or a 0.1% chance you have pulmonary embolism. You have to consider the cost of doing something

01:42:29.100 versus the cost of doing nothing. And then the cost of being wrong in both of those situations.

01:42:34.240 So the cost of being wrong, if you don't go in to the ER, you just stay where you are,

01:42:42.420 you don't go anywhere, meaning wrong, meaning you have a pulmonary embolism, but you don't do

01:42:46.820 anything about it. That cost is infinitely greater, though far less likely than the cost of you going

01:42:53.820 into the ER, not having a pulmonary embolism. So there's a cost to that. Cost you time,

01:42:59.260 cost money, it's a pain in the ass. No pun intended. In this case, not referring to a butt lift, 1.00

01:43:03.980 but that's a finite cost. Whereas the other one becomes an infinite cost. So it's so funny,

01:43:09.820 I went out for a run this morning. This is actually what I was thinking about, not this example,

01:43:13.840 but I was thinking about, I wish somebody would build a really good risk model for patients to

01:43:20.100 help them understand the asymmetry of risk. Because if you say, look, there's a 5% chance of you getting

01:43:26.220 a seroma, or there's a 0.1% chance of you getting a fat embolism, I'm not sure everybody appreciates

01:43:33.080 the difference. The 5% seroma has a much lower consequence to it. So that might be a tool to help

01:43:41.060 patients understand this. Because the other thing with a fat embolism, not only is it devastating,

01:43:46.400 but you don't get much of a warning necessarily from when the complication is taking place.

01:43:52.040 And it's almost impossible to treat when it happens.

01:43:54.520 Yeah, yeah. That's another great example. So you mentioned a guy who's doing six of these a day,

01:44:00.480 seven of these a day. I mean, presumably he's not getting many complications, right? Or he wouldn't

01:44:05.800 be able to do that, right? No, he is. I mean, it's shocking to me how tolerant people are of

01:44:11.640 complications. I mean, when you look, there is a recent expose done by USA Today about these Miami

01:44:18.780 plastic surgery clinics, where they've had tremendous number of deaths and complications.

01:44:26.140 And people just keep going back because they are so price conscious. I mean, these places will do it

01:44:33.340 for cheaper than anywhere else will. So you get fries and a drink with the procedure and it's like

01:44:41.000 a happy meal. Yeah. And patients don't care. And people have this idea that if you're a doctor,

01:44:47.960 you're safe and you know what you're doing and you're going to do the right thing. If there's a

01:44:52.620 clinic and it looks semi-clean, that they don't need to worry. And the problem is the laws are not

01:44:58.880 out there to 100% protect the patients. They're actually in the process now of amending a lot of

01:45:04.820 the laws in Florida, which has just been way too liberal in terms of what they allow to happen.

01:45:12.940 I mean, everything is driven by money. You get these lobby groups. You know, a good example would be

01:45:18.940 optometrists do not have training to do surgical procedures, but they might lobby to allow them to do

01:45:26.240 blepharoplasty, so eyelid surgery. And they're paying money to politicians and then laws are getting

01:45:32.240 passed that allow them to do this. That's not in the interest of the patients. Patients do not need

01:45:37.460 more doctors who know how to or are able legally to perform eyelids. Did you say optometrists?

01:45:42.840 Optometrists. Not ophthalmologists. No, optometrists. Or dentists who want to do facelifts. So they're

01:45:47.620 lobbying state legislators to allow them to do facelifts. I would argue that a dentist does not have

01:45:54.200 training to do a facelift. They're used to working through the mouth. Now you're talking about

01:45:59.040 working very far away from the mouth using principles and techniques that they have no

01:46:03.760 training in. They just want the money. So they're doing this for the money, not for the benefit of

01:46:08.200 the patient. It's not like patients are suffering because there's not enough good facelift surgeons

01:46:13.100 out there. That's just not true. So, you know, finances drives a lot of this and not necessarily

01:46:20.500 patient safety. The groups that try and protect patient safety don't have the money and the backing

01:46:26.540 to pressure the legislators to do everything that is in the best interest of the patients.

01:46:32.940 I suppose the argument that these groups would put forth is, look, in the end, the patients get

01:46:37.120 to choose. It's a free world. We're just trying to create a bigger market and an efficient market

01:46:42.000 should sort this out. But it doesn't because there's not transparency and there's not adequate

01:46:49.840 oversight. Like when you look at the situation in Florida, you have surgery centers that are doing

01:46:57.240 only plastic surgery being owned by businessmen with long laundry list of convictions and crime.

01:47:05.360 They're not doctors at all. In some states, only doctors can be involved where they're literally

01:47:10.500 not just owning the surgery center. They're involved in the day-to-day running and making sure that

01:47:15.460 the doctors working at the facility are well-trained. In Florida, there's no rules about the doctors who

01:47:22.720 are working at these facilities. You have doctors who've lost their license and licenses are suspended.

01:47:28.400 They don't care. These guys are just doing it for the money. And so, it's really buyer beware. And all

01:47:34.980 of the burden falls on the patients to do their homework and do their research. And for a lot of

01:47:40.880 uneducated, less sophisticated patients, they don't know what to ask. They don't know what to look for.

01:47:47.260 And they're the ones who are suffering, you know, a lot of minority patients. They're the ones who are

01:47:52.560 suffering the brunt of these complications. And in Miami, there's a huge advertising blitz on

01:47:58.880 Hispanic radio stations and billboards in the inner city where they're specifically targeting less

01:48:05.840 sophisticated groups that they feel aren't going to do the same amount of homework and research.

01:48:11.960 This sounds eerily reminiscent of the subprime crisis.

01:48:15.920 Yeah, absolutely. Yeah.

01:48:17.480 Going back to the procedure for a moment, so you'll do your 20 or 30 of these a year. Does this get you

01:48:23.040 nervous to do this procedure? I mean, what steps would you take to reduce the risk of inadvertently

01:48:29.220 cannulating a vein?

01:48:30.760 I think that for me, the thought process is no different than with any surgical procedure.

01:48:38.080 You having trained in surgery know this, understanding anatomy is just the absolute

01:48:43.800 key to doing good surgery. If you know where things are, you know how to avoid them and how to stay out

01:48:50.260 of trouble. And so it's all about understanding anatomy. Simple things like how you bend the surgical

01:48:57.380 table with the patient laying prone on their stomach is going to affect the position of the blood vessels

01:49:05.160 relative to the surface anatomy. So if you have the patient laying flat as opposed to bending the bed

01:49:12.460 30 degrees where it's in sort of a beach chair type position, that's going to change the position of

01:49:18.720 the anatomy. And so understanding anatomy is really the key, which goes back to my point about why

01:49:25.840 if you didn't train and learn the anatomy, it's so difficult to do safe surgery.

01:49:32.680 Yeah, it's actually scary for me to think about it. You only need to see so many things go really

01:49:38.020 wrong in an operating room to be reminded of how even when you know what's going on, things can turn

01:49:44.740 in an instant. And then to imagine if you're flying a little blind and you don't actually know where the

01:49:50.720 vascular beds are. I never really thought of it that way. I guess I just, I don't think I really

01:49:54.820 appreciated what a Brazilian butt lift was. You know, I mean, my field is very challenging

01:50:00.420 and different than other, other areas. You know, when you get on an airplane, for example,

01:50:05.680 you don't think twice about, you assume that that plane has been checked over. You assume that it's

01:50:11.860 received all the maintenance. You assume that the pilots are competent, that they aren't drunk,

01:50:17.020 that they slept enough. You assume that the runway has been checked. There's no debris on it.

01:50:22.420 You make all these assumptions and you fly and you feel safe. And most of these assumptions are true.

01:50:27.780 When you go into a hospital, you make the same assumptions. You assume that the doctor taking

01:50:33.720 care of you is knowledgeable and trained. You assume that the bed that they put you in has been

01:50:38.840 cleaned. You assume that people have washed their hands before they touch you. You assume that the

01:50:43.700 nurse is giving you the correct medication and she's checked it. You make a lot of assumptions and

01:50:48.320 it should be that way. There should be a system set up. But what is so unique and scary about the

01:50:55.580 field of plastic surgery is it really exists outside of the same degrees of regulation because you have

01:51:03.720 people who on their own just woke up one day and decided, I'm just gonna start my own airline company

01:51:11.860 and I'm just gonna hire some Yahoo pilot and I don't need to check the runway and I don't need to do

01:51:16.940 maintenance because that costs a lot of money. And they just do their own thing and you get on that

01:51:22.100 airplane, you go to that surgery center and you are without your knowledge taking a lot of risk. When a

01:51:28.720 non-plastic surgeon is doing something in their office or in their little surgery center, it's not being

01:51:34.240 regulated and checked like an accredited surgery center is. As a board-certified plastic surgeon, I am only

01:51:40.800 allowed to do procedures at accredited surgery centers that have been checked over and accredited

01:51:46.580 by the government or by a state agency. That's not true for a lot of office-based surgery centers.

01:51:53.560 It seems like it's really a confluence of two issues. So let's use another example you gave. So going back

01:51:59.080 to the beginning, right? And by the way, I think you have to have a license to do this, correct? You have to

01:52:03.880 have a medical license which you can get after one year of training. Just a medical license. That's right. So I don't

01:52:07.820 think technically you couldn't do this the day after finishing medical school, but you could do this

01:52:11.120 the day after finishing an internship. So why is this problem not occurring in cardiac surgery? Or why

01:52:18.280 is this problem not occurring in orthopedic surgery, at least with respect to joint replacements? My guess

01:52:24.300 is twofold. One, nobody wakes up and says, I really want to have a coronary artery bypass today. You know,

01:52:31.980 today is the day I, you know what? I'm not happy with my aortic valve. I got to get this thing

01:52:37.280 switched out. In other words, patient demand isn't really driving cardiac surgery. It's being really

01:52:44.080 driven by the pathology. The cardiologist is sending you to the cardiac surgeon and you're sort of going

01:52:49.920 because you trust the cardiologist, et cetera. Similarly, yes, of course, a patient who has sort of an

01:52:56.940 issue with their knee and it's chronically hurting will ultimately wind up seeing an orthopedic

01:53:01.740 surgeon, but they're usually going through several levels. They'll see their primary care doctor.

01:53:05.200 Their doctor sends them to an orthopedic surgeon. The orthopedic surgeon goes through a whole bunch of

01:53:09.840 checks and balances. It's very rare that someone wakes up, says, you know what? I've had it with

01:53:14.740 this knee bugging me. I need a knee replacement. Let me just Google knee replacement and anyone can show

01:53:20.340 up. That's the first thing. So the demand is not really coming straight from patient to ultimate

01:53:26.020 practitioner. The second thing is the complexity of the case. At the end of the day, you want to do a

01:53:31.720 coronary artery bypass graft. You want to do a hip replacement. That's really complicated. You are

01:53:36.340 not going to, in a million years, figure out how to do that without going through the formal training.

01:53:42.020 Whereas in the end, liposuction, relatively simple procedure. And as you pointed out, the simpler the

01:53:47.700 procedure, the more likely. My guess is there aren't too many non-plastic surgeons doing deep flaps.

01:53:55.160 Right. Or even a breast reduction only done by plastic surgeons. It's a complicated procedure. 0.90

01:53:59.680 Right. And then the third piece is this hospital piece. There's a huge divide between what happens

01:54:06.200 in a hospital and what doesn't. The moment you walk into an accredited hospital, the bar is just

01:54:14.040 raised dramatically. And it would require outright fraud for a charlatan to be in there doing that,

01:54:20.320 which of course I'm sure happens from time to time. But that's an abject failure of the system.

01:54:25.080 So it's really these three things together, which is what procedures can be done completely outside of

01:54:30.740 the purview of a hospital. What procedure can be done that's relatively simple to learn, at least

01:54:36.620 to be able to fake it. And what procedures are being driven by enormous patient demand where the

01:54:44.020 patient directly comes to the practitioner. I mean, to me, it's those three things that have created

01:54:49.980 this trifecta of disaster. And another way to put it is that in a lot of patients' minds,

01:54:57.340 plastic surgery is not in the same category as other types of surgery. It's more like getting

01:55:03.400 a haircut or getting your teeth bleached or getting your nails done. It's cosmetic procedures. Oh,

01:55:09.340 I'm just going to go in for a little afternoon liposuction. And so people don't think about it

01:55:14.340 in the same way as they think of other surgical procedures. And then the money is such a big part

01:55:20.300 of it because there's so much money in this field. Right. When you get your knee replaced,

01:55:24.940 your insurance is hopefully paying the majority of it. Right. This is all patients are paying out

01:55:29.380 of pocket for it. And other doctors who are primarily insurance-based doctors, which is most

01:55:37.500 physicians in America, see this lucrative cash paying procedures and they want a piece of it.

01:55:44.260 I mean, they want to augment their income with it. It's just so funny. I always think about how

01:55:49.280 different it is to be a plastic surgeon. I'm probably the only specialty where when people go

01:55:54.740 to the emergency room, I do emergency call at a local busy hospital where they ask for a plastic

01:56:00.540 surgeon. You know, little Sally's has a cut on her cheek and the mom's like, I want a plastic surgeon. 0.99

01:56:06.460 I demand a plastic surgeon. Nobody's asking for a cardiologist when they need to have chest pain

01:56:12.680 or an EKG. I think we're in a different category than all the other doctors where patients think

01:56:19.220 that, you know, for whatever reason, we're just much more readily available and we're sort of

01:56:25.540 technicians that they can just summon at a whim. Do you find yourself ever feeling conflicted

01:56:33.080 where on the one hand, you're in a profession which sort of feeds off the vanity and insecurity

01:56:41.080 of people, both of which you don't seem to necessarily display yourself. And on the one

01:56:47.400 hand, you sort of have this obligation, like, look, if a person is committed to doing procedure X,

01:56:51.440 Y, or Z. I, Zal Krieger, might not actually even understand the rationale for this. I think this

01:56:57.400 person looks perfectly wonderful. I don't think they need to do anything. But one, there's an

01:57:02.620 economic incentive. I mean, at the end of the day, this is how you make a living. Two, I think knowing

01:57:06.880 you, I can say you also feel like, well, if this person's going to have this procedure done and it's 0.64

01:57:12.000 a Brazilian butt lift that I think is probably ridiculous, I would certainly rather they do it with me 1.00

01:57:17.280 and I have a much higher probability of getting them home safely than they go to somebody else. So 0.97

01:57:22.860 how do you process all of those sort of emotions and thoughts? I think about it simplistically that

01:57:31.260 I'm like many other doctors, I'm just helping people. People come to me with a problem, just like

01:57:38.220 they come to any doctor with a problem. Psychiatrists see people with psychiatric problems and

01:57:44.960 the rest of the physicians see people with physical problems. And it's a combination of both. I'm like

01:57:50.980 a psychiatrist with a knife, basically. I fix a lot of psychiatric problems with a knife. Now that

01:57:56.280 might sound... But do you think you're fixing them? I do. Sometimes I do. And a key part of being a good

01:58:03.000 plastic surgeon is understanding, am I going to fix this problem with the knife or is this a problem

01:58:09.920 that requires some other type of treatment? I'll give you a good example. Take a girl who's 1.00

01:58:16.540 18 years old. She just finished high school. She's about to go off to college. She's a beautiful girl,

01:58:22.780 but she has a huge giant nose. She was born with a big giant nose. She inherited it from her 1.00

01:58:28.260 Middle Eastern father and it looks horrible on her face. She's completely self-conscious about this nose.

01:58:35.300 If you did a photo manipulation with a computer program and showed her a picture of her face

01:58:41.360 with an altered post-surgical nose, she's crying. She loves it. You showed those two pictures to any

01:58:49.320 person in anywhere in the world. They would say the one girl looks hideous and the other girl looks 1.00

01:58:53.820 attractive. It's the same girl before and after surgery. If you do surgery for that girl, you change

01:59:01.500 her life. You help her in a profound way. She's not excessively vain. She's not psychologically ill.

01:59:08.540 She doesn't have mental problems. She looks in the mirror and sees a nose that is way out of

01:59:13.440 proportion to her face. She's bothered by it. She's been teased about it before. She compares herself to

01:59:20.200 other people. Now, yeah, you could make an argument that we should live in a society where we don't care

01:59:25.400 about the size of people's noses and we don't care about the way people look. But until that happens,

01:59:31.380 which I doubt is happening anytime soon, people attach importance and value to the way they look.

01:59:39.660 So, yeah, I think operating on that girl, I'm doing her a huge service. I'm helping her. I'm

01:59:44.340 essentially a psychiatrist with a knife. She doesn't need that surgery. She's not doing it because she has 1.00

01:59:50.940 cancer. She's not doing it because she's not able to exercise or function because she can't breathe 1.00

01:59:57.340 through the nose. She's doing it for the appearance. But we all know that girl. We've all met someone

02:00:02.160 like that. We might even be that person. And so making that change is profound. I mean, if you have

02:00:10.180 a woman who's happily married, she's normal. She has children. She functions regularly in life. And

02:00:17.020 she believes, whether rightly or so, that her husband does not find her attractive because her

02:00:23.300 body is changed after having children and she has a big roll of skin hanging over her C-section scar

02:00:29.280 and she wants it gone. It gets in the way of her exercise. It affects her during her periods of

02:00:35.020 intimacy with her husband. She's super self-conscious about it. You're going to change that person's life 0.99

02:00:40.420 doing that. So there's nothing wrong with that. Most of my patients are normal. I don't take care of

02:00:46.920 porn stars. I don't take care of people who have body dysmorphic disorder where they say I can't go

02:00:54.220 outside because of this part of my body. I try to avoid celebrities. They're a huge pain in the butt.

02:01:00.560 I just take care of regular people. I do functional surgery and I do aesthetic surgery. That same girl 0.99

02:01:07.740 with the nose, maybe she can't breathe through her nose and that's her problem. So ultimately, the way

02:01:13.040 I try to stay grounded and wake up in the morning and go to work and do a good job and then come home

02:01:19.440 feeling satisfied and like I help people is to understand that my job is to evaluate someone,

02:01:27.740 try and understand what the problem is and then know am I able to help them in a safe, ethical way

02:01:34.380 and make a difference for them. That actually makes a lot of sense in it. You could argue that

02:01:39.620 what's the difference in the vanity that says I don't like the fact that my nose is crooked and I

02:01:45.800 want to have it straightened versus someone who comes to me and says I want to live longer.

02:01:51.900 You could argue those are equally vain statements and meaning both totally reasonable cases to be

02:01:57.720 made for trying to help that person. It goes back to something I've heard you talk about in the

02:02:01.840 podcast about the difference between increasing the length of your life versus improving the quality of

02:02:09.360 your life. You know, do I want to live to be a hundred but the last 15 years I'm in a chair and I can't

02:02:14.800 get up and move and my brain doesn't work? No, none of us want that. We want quality of life. That's what

02:02:20.580 it's about and so quality of life is a really complex issue. There's so many factors that go into it.

02:02:27.320 It's avoiding injury. It's feeling healthy. It's not having medical problems. It's feeling good about

02:02:32.720 yourself. It's being able to do the things you enjoy. The list goes on and on and on. So what I'm

02:02:39.240 trying to do is to contribute to quality of life and it's just one aspect of quality of life. I mean,

02:02:46.880 I always wonder like if you succeed with your goal to get people to live longer, we're going to have a

02:02:53.540 lot of really old looking people walking around. Do you ever turn patients down who show up through

02:03:01.760 the normal channels either through a referral or just on their own but after you sit down with them,

02:03:05.920 you come to the conclusion that, you know what, I could certainly mechanically fix whatever it is

02:03:12.780 they're asking but this is not the root of the issue and you get the sense that you're going down

02:03:17.980 a slippery slope with them? Yeah, for sure. And the hardest thing to do as a plastic surgeon is to

02:03:24.060 see the dollar signs in front of your eyes. I could make a lot of money if I do the surgery

02:03:30.120 and turn the person away. I mean, just think of any businessman where someone comes and says,

02:03:36.200 I'd like to purchase this and you say to them, actually, no, I don't think you should purchase

02:03:40.000 this. Yeah, I do it at least once or twice and sometimes more a day when I see people.

02:03:45.180 Once or twice a day? Yeah, absolutely.

02:03:46.420 You're turning somebody down? Absolutely.

02:03:48.540 Purely because you don't think they're the right candidate? I thought you were going to say once or

02:03:51.980 twice a month. No, once or twice a day.

02:03:53.880 Tell me the one that you did yesterday. Tell me one that you turned down and how did you explain

02:03:58.440 to the patient that without offending them that you didn't think this was in their best interest?

02:04:04.560 So a very common patient I turned down is an overweight patient who comes in for liposuction

02:04:10.800 and this is one of my most common ones that I turned down and they have this idea in their head

02:04:17.280 that they can use liposuction as a means of weight loss. And again, I go back to my

02:04:23.880 principle of just be honest with people and I just say to them, you know, in a way, I don't

02:04:28.960 think people want to hear your fat and I basically explain to them there's a limit on what we can

02:04:34.200 achieve with liposuction. We can only suck out subcutaneous fat. You have a lot of visceral fat.

02:04:39.440 I explain to them that I can only remove a certain amount of safely. I talk to them about the effects

02:04:45.560 on the skin that if you take too much fat, you leave them with loose skin, but if you lose the

02:04:50.240 weight gradually, it's better. And, and ultimately I talk to focus on health and wellbeing and that

02:04:56.260 the difference between losing 15 pounds through liposuction versus losing 15 pounds through diet

02:05:02.580 and exercise is profound. That's actually been studied. So they're much better off. And I say,

02:05:08.520 this is how much I would charge you. Let's sit together right now and talk about how you could take

02:05:14.200 the same amount of money, get a gym membership, hire a nutritionalist, change your eating. You're

02:05:19.800 going to very easily lose 15 pounds that I would suck off. You're going to be healthier. You're going 0.99

02:05:24.480 to look better. It's a much better use of your money. People appreciate it. And I sort of feel like

02:05:30.080 I'm investing in my business doing this because this person is going to walk away saying, wow, this

02:05:35.500 guy's an honest plastic surgeon and I'm going to refer someone to him if I need to. So yeah, maybe I'm

02:05:41.040 losing that patient, but I'm, I'm going to gain someone else in the future. Another type of

02:05:46.760 patient that we see is people who have what's called body dysmorphic disorder. They are just simply

02:05:53.320 totally fixated on something. They've had multiple surgeries. There are a number of red flags that we

02:06:00.160 look for. We have an acronym called SIMON. Avoid the SIMON. It stands for single immature male,

02:06:07.120 overly narcissistic. SIMON. The SIMON is a young guy. He's single. He's not been married. He may be gay, 0.98

02:06:20.360 but usually straight. And oftentimes it's his nose or some other body part. And he basically is,

02:06:28.380 cannot function. My life, I can't go outside. I can't date. No women want to talk to me because 1.00

02:06:33.440 of this body part. It doesn't take long to understand that guy should not have surgery.

02:06:39.700 He needs counseling. So we, you know, I, I usually won't give him the number of a psychiatrist,

02:06:44.960 but I'll, sometimes I'll have to resort to my go-to line, which is I don't have the skill and

02:06:52.160 knowledge necessary to help you in a way that is going to make you happy. We see people who've had

02:06:59.160 multiple surgeries. Which by the way is true. I mean, it is true. Yeah. People who've had multiple

02:07:03.540 surgeries and the first thing they do is start bad mouthing other surgeons. Yeah. I had this

02:07:08.820 surgery done and he botched it and, and you can see how horrible this is. And he was such a jerk 1.00

02:07:14.500 and he charged me all the, that's the first thing they do. Anytime someone bad mouths another plastic 1.00

02:07:19.460 surgeon, there's a very low chance I'm going to ever operate on them just at, from that moment on.

02:07:25.460 Now there are exceptions, you know, people have had botched surgery. Maybe it wasn't a plastic

02:07:30.240 surgeon who did it, but if it was a board certified plastic surgeon and I know that person and I know

02:07:35.420 they're smart and reasonable, then I, I know right away that this person has problems and no one else

02:07:41.940 could make them happy. I'm probably not going to make them happy. Any other procedures that we

02:07:46.200 should give people kind of the skinny on? You know, I think that today these minimally invasive

02:07:52.560 procedures like Botox and filler and facial peels and laser treatments, they're very, very popular

02:08:00.640 stem cell treatments where they harvest your stem cells and inject them in your face. There are all

02:08:06.920 sorts of things out there. And, you know, when you look at the full field of plastic surgery,

02:08:11.020 the minimally invasive things are rapidly increasing because people want cheap and quick and easy with

02:08:17.040 low risk and, you know, very little downtime. These procedures are not without risk. It's just a

02:08:25.260 golden rule in, in surgery and in plastic surgery. If something has no risk, no recovery, no downtime,

02:08:33.820 low cost, it has no result. That's just a rule. There's nothing out there that you can just do it in

02:08:39.040 the office in 30 minutes and achieve a remarkable result. All of these things have risks. We've seen

02:08:46.000 probably 25 reported cases of blindness from filler injected near the eyes, one of the most popular

02:08:53.720 procedures. And that's a pretty horrible risk. How does that happen? What's the, what's the

02:08:59.440 technique? The filler enters into an artery and gets transported retrograde and then flows into the

02:09:06.180 retinal artery and obstructs the retinal artery and causes blindness. But aren't these fillers 1.00

02:09:13.900 typically done beneath the eye? Yeah, but it's, it's easy to get into the wrong spot. There's an

02:09:20.260 artery that comes out on the side of the nose, just below the inside corner of the eye, that if you get

02:09:26.080 the filler in there, it can transport. People inject filler in the forehead and in between the eyebrows

02:09:31.320 for the wrinkles. And there's an artery that comes out right above the eyebrow that if you inject it in

02:09:37.580 there, it can get transported backwards retrogradely against the flow and enter into the retinal. So,

02:09:45.100 I mean, there are, you know, we see patients who have permanent pigment damage from lasers and peels done

02:09:52.740 on the face. None of these, we've recently seen several HIV cases from these vampire facials where people 0.83

02:09:59.980 have PRP blood harvested and then spun and re-injected into their face. It's, you know, it's

02:10:06.120 not proven. You mean it's done from multiple donor pools? No, from their own, but, but the machines are

02:10:13.660 not adequately cleaned and processed. And so they're contaminated with blood from another patient who

02:10:19.080 maybe has HIV. There was just a recent reported several of these in the popular press, several

02:10:24.740 patients in one clinic that's happened to them. So these procedures are not without risk. Again,

02:10:32.040 you got to, you got to do your homework. You have to know who you're going to. You, you have to really

02:10:37.100 research that. I mean, the great thing about Dr. Google these days is you can find out all this

02:10:41.920 information online. There's a lot of resources. The American Society of Plastic Surgeons has a great

02:10:47.700 website. It talks about every procedure. It talks about the risks of every procedure. But just to be

02:10:53.520 knowledgeable going in, I mean, knowledge is power in these things. And to understand that there's

02:10:58.900 just no free lunch, you can't just undergo one of these lunchtime procedures without risk.

02:11:05.320 Well, Zal, this is super helpful. I think what, what we'll probably do is with your help, put together

02:11:10.020 a little checklist for patients. Maybe we'll include this in the show notes, you know, something they can

02:11:14.200 just download as a PDF or something and, and use as sort of, I'm thinking about having a fill in the

02:11:20.720 blank procedure. Here are the questions I want to be asking. Some of them will be just general

02:11:25.260 questions, right? But then some of them can be procedure specific and almost put together a

02:11:29.620 cheat sheet of this stuff. Cause I think this is super helpful. Well, I really appreciate it, man.

02:11:33.500 This has been exciting to sit down and I haven't seen you in like over a year. So it's great. And

02:11:38.820 it's weird because we only live like a couple hours away from each other. It's tragic.

02:11:42.320 We're busy. I'll take any opportunity to, uh, get together with you. Thanks, man. Thanks.

02:11:50.200 You can find all of this information and more at peteratiamd.com forward slash podcast.

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The Peter Attia Drive - July 29, 2019

#64 - Zol Kryger, M.D.： Navigating the sometimes shady world of plastic surgery—understanding potential complications of common procedures and how to reduce your risk by choosing the right doctor and asking the right questions

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