Mind Pump: Raw Fitness Truth - 2727: The Surgeon Who Rebuilt a Man's Face After a Grizzly Attack! Dr. Benson Pulikkottil

Episode Date: November 13, 2025

Advanced Plastic Surgery with Dr. Benson Pulikkottil His background. (1:42) How success is a lot of luck and just jumping into some opportunity. Pivotal moments on his path into plastic surgery. (4:34) How he met his wife, Lily. (22:45) The MIRACULOUS grizzly bear facial reconstruction story. (27:25) The stories of burn victims he has encountered. (46:57) The future of healing. (53:01) The surgery part is challenging, but the stuff after is where it counts. (55:20) The characteristics of patients who tend to do the best. (1:02:30) Are there certain body parts you have a time window to save? (1:07:36) Exciting medical technologies on the horizon. (1:09:46) Will AI ever replace surgeons? (1:11:38) The importance of collaboration. (1:12:57) The tougher the challenge, the more rewarding it is. (1:15:55) Balancing family/work life. (1:17:05) There are other ways to be successful in life. Would he want his kids to follow in his footsteps? (1:17:53) My wife is a gangster. (1:19:27) The value of strength training, being fit, in his profession. (1:22:11) His 42-hour surgery and building your discipline muscle. (1:25:42) Having a badass partner in life. (1:34:00) Related Links/Products Mentioned Related Links/Products Mentioned Get a free Sample Pack of LMNT's most popular drink mix flavors with any purchase! As always, LMNT offers no-questions-asked refunds on all orders. The 8-count LMNT Sample Pack doubles down on our most popular flavors: Citrus Salt, Raspberry Salt, Watermelon Salt, and Orange Salt (2 stick packs of each flavor): Visit DrinkLMNT.com/MindPump BLACK FRIDAY SALE: 60% off ALL Programs, Guides, and MODs **Code BLACKFRIDAY at checkout** Mind Pump Store Man's face miraculously saved after grizzly bear attack Autoimmune diseases can be associated with depression - PMC Mind Pump Podcast – YouTube Mind Pump Free Resources Featured Guest/People Mentioned Benson Pulikkottil MD FACS (@dr.reconnoisseur) Instagram Website : www.drbensonmd.com Featured Guest/People Mentioned Benson Pulikkottil MD FACS (@dr.reconnoisseur) Instagram David Goggins (@davidgoggins) Instagram  

If you want to pump your body and expand your mind, there's only one place to go. Mind Pump. Mind Pump with your hosts. Sal DeStefano, Adam Schaefer, and Justin Andrews. You just found the most downloaded fitness, health, and entertainment podcast. This is Mind Pump. Today's episode, Advanced Plastic Surgery with Dr. Benson, Pulicole. By the way, this is the guy that literally put somebody's face back on.

True story, Grizzly Bear attack, took someone's face off. This is the doctor that put it back on. He tells that story and more. This is a riveting episode. By the way, this episode is brought to you by Element. This is the electrolyte powder everybody's talking about. It's high enough in sodium to make a difference. No sugar, no artificial sweeteners.

Tastes amazing. Go check them out. Go to drink elementt.com forward slash mind pump with a purchase. You'll get a sample pack of their most popular drink mix flavors. Also, Black Friday for us right now, every Maps program, every bundle of programs, every, everything on our site, 60% off. Across the board, you got to go to Maps Fitness Products.com. Get them all if you want, but you got to use the code Black Friday. By the way, every purchase enters you into a contest.

Two people are going to get a vacation from us at the Park City House that we own. It's amazing. 15 people are going to get personal training for a few months. Once again, 60% off everything, Maps, Fitness Products.com, but you have to use the code Black Friday. All right, real quick, if you love us like we love you, why not show it by rocking one of our shirts, hats, mugs, or training gear over at mindpumpstore.com. I'm talking right now, hit pause, head on over to mindpumstor.com. That's it. Enjoy the rest of the show.

Dr. Policodal, welcome to the show. Did I say that right? You said it perfectly said like my mom. Wow. Yeah, man. We met you at the peptide Congress. This was in Vegas. I spoke there and we were all attending.

and ran into you and you told us a little bit about what you did and how you listened to the show. And you kind of, I mean, fascinating some of the stories you were telling us. You showed us a bunch of crazy pictures. I remember that much. Definitely, definitely. Yeah. Yeah. So for our audience, what do you do?

Tell us a little about your background before we kind of. Sure. First of all, thank you so much. I'm not, I'm geeking out because you guys, I've listened to you for like 10 years, taking advice from you on finance, fitness, family. being a father. I have two young boys too. And I really appreciate the entrepreneurial spirit and each of your personalities. I feel like I'm in my college dorm right now with my bros. Awesome. That's what I feel like. That's great. So my name is Benson Policodal, South Indian. I grew up in

New York, New York City. I'm the medical director of a double verified burn and reconstructive unit. and what I do is there's not many surgeons that kind of do what we do. There's a handful in the country. We do burn surgery. We do hardcore reconstruction. We're double-boarded in plastic surgery, hand surgery, nerve surgery, micro-surgery. Also, I have an aesthetic practice with my wife, Lily Daniele, who is the reason why I'm anything. I'm seriously.

and my two partners, Ryan Anderson, Voitek Voslake, we created our own side aesthetic practice. And so one of the things I love about plastic surgery, it's the ability to change things immediately. And you guys have that same ability. You just don't see it. You sit in this room and you don't see the direct effect until somebody writes a comment or tells you. But you change lives in a similar way. I know people that listen to you that were suicidal and aren't anymore. They've found fitness.

In my world, I fix a tendon, a hand move. So I get that awesome cause and effect. And so I take care of a full gamut of really, really traumatized sick patients. And I have an awesome hospital, Swedish hospital in Englewood, Colorado that, from the administrative level to the from the CEO to the maintenance worker. They all care about patients. They care about our program. And they care about me.

And I care about them. And we are able to take care of some of the hardest, sickest things in the country and in the world. How does a kid in New York growing up decide, I'm going to go into plastic surgery like that? I mean, did you watch a movie or something like that? I mean, that's like a different type of profession to land on. You know, I really feel like success is a lot of luck and just jumping into some opportunity. And my dad always told me, if the window of opportunities open, even a crack, you jump through it. And I've always taken that approach.

I think a pivotal point in my life was when I was in fifth grade. There was a science fair, and I wanted to do something on the heart. So my dad took me to a butcher shop. We got a goat heart. And I took red food dye, and they had left for the day. And I was like, I want to make this thing pump. And so there's no YouTube. There's no internet.

I'm going to be 47 this year. Oh, wow. Yeah, so I think that at that time, you had Funkin Waggnells. We didn't have Britannica. Dude, I had those. Yeah, Funkin Waggnes. We had like multiple editions of the same one, too. Funcan Waggnails was like the, I actually didn't know that.

It was like the multiple meal of encyclopedias. Oh, really? They were the less expensive versions. I was just saying, we had Bertani are. I didn't know that. World book. You'd get them for free when you go shopping. So like you'd buy some milk and you want Funkin' Wals.

We had like the same number 12. Dude. You know, we had a whole set, dude. Oh yeah, we did too. Oh, yeah, we did too.

Yeah, that's great. And so I'd look this stuff up. And what I ended up, what I ended up doing was I ended up taking a fish pump, a fishing from an aquarium, yeah. Turning like a setting on it to make it intermittent.

And I sewed it to, the heart. And my mom came in and she started crying. And I was like, because I took her sewing stuff. And I was like, I'm sorry. She's like, no, this is amazing. She's looking at this hemline. How do you know how to sew?

And I played football when I was a little kid and I'd have to sew on jerseys and fix things. And so that was like the first, and I won first place in that science fair. Wow. And so that moment for a kid, right? It was unbelievable. Yeah. I mean, to watch red food die fill up his heart.

and it wasn't perfect, but it looked really cool for a fifth grader. And I think a pivotal moment in my life was when, you know, my mom's friend told us about this school in New York City called Regis High School. And this is a really special high school. In this high school, if you take a test, it's for all, it's Catholic boys. And if you do well on the test, you get an interview. It's thousands of people apply for this. and if you get past the first 250, you get an interview, and then it's 125 out of that, and that's your class. And this high school is so cool because it's right next to Central Park.

Art class was in the Metropolitan Museum of Art. The gym was in Central Park. I mean, it's unbelievable. And it was the first time I was around. I grew up with a lot of Latin, black, Jamaican, Trindadian, Indian people. And it was the first time I was really around Americans and like Polish and Italian and Russian.

And New York City at that time in the mid-90s was this just bastion of music, art, culture, food. Everything was just so cool. And in this high school, I learned all about myself. And I learned about music, learned about sports, fitness, but it's such a rigorous high school. And getting in and I didn't crush high school.

I just did a little bit above average. And that was hard to do. And this whole community of dudes, we still keep in contact. Yesterday I texted him that I'm going to be on this show and they're all like, dude, you're going to be great. And so we still keep in contact with each other. But my junior year, I wasn't sure what I wanted to do. And I always liked medicine.

We didn't grow up with money. My parents, you know, my dad was an accountant. My mom was a nurse, but no doctors. I have an older sister and a younger sister, who they're doctors now. But my guidance counselor, John Vigone, he said, hey, Benson, if, you know, one cool thing to do is apply at a high school for some of these medical programs. And I didn't know what that was. And what that is is essentially if you apply and you get in, you get a seat to medical school, you don't have to take the MCAT, you just have to do your four years of college, four years of med school, which is huge to get in. It was extremely competitive, several thousand people applied. And myself with seven other people got in and we're still friends because it's like a unit. And I went to Sienna College, played football over there. I, had a great college experience, learning about sports, learning about fitness, learning about

studying and really intermingling all these three so I could be successful. A really cool part about the program is this particular program, the CNA-Albany Medical College program, is really big on volunteering. And so they pay for you to go away two times. And I went both times, well, three times, two times to the Dominican Republic in children, essentially like a nutrition center where there's really malnourished kids and we were taking care of them, we were feeding them, we were changing them,

it was cool. And the second time, the third time I went, I went back to where we're from in India and I learned a lot about my culture there. And in medical school, medical school's weird. It's like a strange place because you think you know what you want to do. I wanted to be a medicine doc. I wanted to be a nephrologist.

And so my first medical rotation, so in your third year you do a bunch of clerkships. It's where you essentially get a taste of each specialty. And so the medical doc, who my first rotation, and I'll say his name because he was so pivotal in my life, Alan Rauch, he's a hematologist. And he had me buy this huge book, remember, we have like no money. And these two books are like a thousand bucks. I bought these books. I read as much as I could. They're called Harrison's. And he, he, at the end of the week, wanted me to present to him. And so he picked a topic. A thousand, a thousand page book? No, he would tell me the topic. Oh, okay. There's different topics. Damn, that's a lot to get through it a week. Choose your own adventure type stuff, you know.

but he would pick a topic, like the first topic was sarcoidosis. And I picked the topic and I did my talk and I presented to the entire office. And he was like, listen, that sucked. And I was like, that's awesome. And I was like, what do you mean? And he was like, dude, you got to get more into it. You got to get, you're just doing bullet points. And I was like, okay, the next week was some kind of nephropathy.

And he's like, it's not better, man. Like, if you're going to do nephrology, you really need to get deeper into this and understand it more. And I'm like, okay. And every week, I got a little bit better. And I thought at some point, he was like, showing me pity. But at the end of it, he was like, are you sure you want to be a nephrologist? And I'm like getting pissed now because, yeah. You're like, yeah, I'm doing all the work.

I'm doing the work. That's what I want to do. And he's like, I don't think you're going to do well at that. I said, okay, have you thought about surgery? And I'm like, man, the surgeons at that time. are like these mean guys just walking around yelling at med students it's like I'm not into that not into it at all and so then my surgery rotation came and on my surgery rotation another like I remember these experiences because they were so monumental for me um there's a rotation called

vascular surgery this is where you operate on the vessels and the med students don't rotate on this if you get this for two weeks they pretty much take off because they're so big busy, the surgeons, they don't even keep track of having a med student. But I was like, you know what, I'm never going to do surgery. I'm going to take this seriously. So I went in and so a young Indian doc, cool dude, he's playing red hot chili peppers. I still remember. In the OR. In the OR is the Californication album and he's playing, you know, and he's like, hey man. And I'm like, hey, and my hat's like on backwards because I don't know how to put on a surgical hat. It was the first case with him. And he's like, hey, have you, what do you want to do?

It's like, nephrology. And he's like, okay, cool, man. You know, this is a, we're doing a fempop, which is where you take a bypass graft and you bypass the femoral artery to the popliteal artery. He's like, have you ever sewn before? And I'm like, yeah, in fifth grade when I did a science project. I saw a fish pump through a heart. That counts. And so he's talking to me about, like, surgery.

And he's like, do you want to throw some stitches? I said, sure. And so he had part of the, and he's putting his hand on me and guiding my hand and I'm doing this. And he'd let go for a second and I'm just sewing. He's like, dude, have you sewn before? And I was like, just, you know, not nothing crazy. He's like, you know, you're pretty good at this. And that was like sparked it for me.

And I was like, huh, interesting. And my rotations for the rest of that year were in transplant surgery. So I was doing hardcore transplant just cases as a student. Like really like it. And then I applied for general surgery. And I got into a program called UMD&J in New Jersey. This is in Newark, New Jersey. I don't know if you know Newark, but it's a tough town.

Tough. And in the last rotation in medical school, I rotated with the plastic surgery. And I'd already matched into general surgery. And this guy was doing cool things. He was like fixing huge holes in patients after cancer. and putting fingers back on and I had never seen anything like this but I had already matched in general surgery.

So I was a little sad because I'm like, man, I kind of want to do plastics but I didn't have the super, Uber, Uber numbers that my wife had to get in right out of med school. And so day one of general surgery, I'll never forget, I went to Mark Rannick, who's the head of plastic surgery, and I was like, hey, I want to be a plastic surgeon.

And he's like, dude, chill. You're like an intern on day one in July 4th. Like, you know, like do general surgery because there's a big stigma in talking about plastic surgery. Because everyone thinks plastic surgery is breast augmentation fillers and all that stuff. That's right. Yeah. And so I would slowly, I befriended a lot of the plastic surgery residents. And I'm in the ER, like getting these appendectomy set up and doing bowel work and all this stuff.

And these guys roll in white coats. plastic surgery, glasses, hair slick back. I'm like, oh, man, I want to be one of those guys. And I didn't know anything about plastic surgery, really. But I liked the concept of what these little experiences. And what's funny is a lot of doctors pick their pathway that way. It could be a doc like you buy somebody a coffee, and all of a sudden they like you.

And you have a lot of influence on people, just like in your field. And so then I started thinking about how to get into plastic surgery. and one of the ways is having a really strong CV and doing research. And so my second year of residency, there's an opportunity to do research. And most people stay because there was no option to leave Rutgers to do research outside. And I had a spot with the chairman, guy from Boston, Dr. Deich. And somebody told me, they're like, dude, you're doing serjunk research. to get plastics. It makes no sense. You need to do plastics research. But there were no opportunities at UMD&J, which is now Rutgers.

So I talked to Dr. Deich, and I was like, hey, listen, I have an opportunity in Pittsburgh. And I got this opportunity because I emailed every program director in the country. This is like hundreds of people. And only two people responded, Cleveland Clinic and the director at Pittsburgh. said, hey, we have an unpaid research spot for you, if you want, for two years. It'll help bolster your CV, whatever. It's in face and hand transplantation. So I went back to my chair. I was very scared because he's just like intimidating Boston, very famous surgeon.

He's like, okay, you can do it, no problem. And he shook my hand and I broke my contract. That was the first time. anyone has broken a contract because if something happens to him and I want to come back after my research years, there's no spot. So again, another pivotal period was in Pittsburgh doing face and hand transplant work. We were transplanting limbs from mice, like dark mice to light mice, rats taking facial structure from one rat to the other rat and doing all these immunologic. medications to help prevent rejection. And the peak of this was in my second year.

The transplant team had the first double-arm human transplant. And my responsibility was, you know, were peons in the lab, but what was cool was, and it's sad because these are always, it's one of the reasons why I moved away from transplant, because it's amazing to get a transplant, but the person who don't, It was usually some traumatic event. And this was a 17-year-old kid or something like that that had an accident, I believe, or a younger person. And we harvested the arms. And these are the surgeons, the attendings at the time.

My role was to take vertebral bodies, which are the spine, bring them to the bone marrow center, process them, get the cells out of them, bring them back to inject into this. This is part of the immune. Yeah. to help them from rejecting. So I got into this, and this is what got me into plastic surgery, the reconstructive aspect of it,

like working on hands, working on tendons, doing this microsurgery, these sutures that you use for these rats are fourth or fifth the size of a human hair under a microscope. And I'm like, holy crap, I can do this with my hands.

And so that point, I went back to general surgeon, Rutgers and I had a really good resume and you know God was on my side and I was able to get into the number one program at the time for plastic surgery UT Southwestern in Dallas. Now this is this is like the Navy SEALs of plastic surgery and when I went in I was definitely shell-shocked because they expect you from day one to not just have the knowledge base but be technically superb and so what I did was I just I remember

I just heard a podcast about you guys talking about Goggins for example and how some of that may not be beneficial but that's the mentality I took I was going to be the best at what I do and learn it so well

so I for three years at UT Southwestern I'd go home I cut up gummy worms I would practice tendon work with gummy worms I made a little microscope out of a bounty quicker upper inner thing with two lenses. I was practicing. I was learning because technically I was good.

It's just the knowledge we didn't have because you're competing with people that, like my wife, Lily, had started plastic surgery much earlier. And by the time the general surgery and the plastic surgery teams meet, there's a knowledge gap. And so I really focused on getting knowledge and working hard and was ultimately really successful there to the point where a few months ago they asked me to come back after the 10-year alumni event, and it was just a full circle. They were so proud, and I was so proud to be part of that place. But when I finished there, I realized that that's not enough.

Like, you have to have some additional specialization, and to get privileges in hospitals, to take call, to have a financial edge, to have a competitive edge, and get patients and not be irrelevant, I did a hand fellowship. And that's an additional year of training in Pittsburgh. And so after, you know, four years of college, four years of medical school, and 11 years of training, I finally took my first job at 37. And the best part about this is the last year when I was in Pittsburgh was one of the coolest years. Lily and I were married, but we were living separately.

She was doing a hand fellowship in Dallas and I was doing it in Pittsburgh. I lived in a 110 square foot apartment above a garage. It's a bathroom, bro. It was this big. It was this big. But some of the most just simple times that you look back on, and it was great. And right after that, we got this job in Denver as burn surgeons. At the time, there was a different director.

They gave me the position after a year. And it's just been full-on. When did you meet Lily? Where was she at? Yeah. So this is a great story. So when I was in the lab in Pittsburgh, okay. Lily wanted to be a family practice doctor. And she had a similar, like, interest in plastic surgery. So she told her parents, Persian family, very, very controversial. She told him, I want to take an extra year off of med school and do just a year of rotating in plastic surgery. and she did that.

And so she rotated in Pittsburgh when I was a lab resident, and I'm focused on like transplanting rat legs. And I look, and she's presenting, I'm like, a pretty cute girl. And that's all I thought about it. And she makes fun of me because I asked her out to like some horror movie on, like a taco night, and she said no. But whatever. And then what happened was she needed to get back to,

Hopkins, she went to Hopkins undergrad. And on her last day, she asked for a ride. And I was happy to do it, but also, like, it was stressful because I had zero money. And I'm like thinking, man, I got to pay for lunch here. And she actually bought me lunch because I didn't get paid in the lab at all. But randomly what happened, after she left, she matched in plastic surgery at Rutgers. And we just started talking every night for like, just like how, like, all of you guys know, like you talk for hours and you're talking about just random things.

And- Did you reach out to her? She reached out to you. Like, what was the first- She, what really happened was she matched in plastic surgery. She was happy, but not ecstatic. What does that mean she matched in plastic surgery? Perfect, yeah. I feel like I'm, I'm talking.

No, no, sorry. Yeah, I got to explain. That's why I'm here, don't you. No, thank you. So this is why I say, it's, things are so random. in medicine. Yeah. So when you finish any of these things, like let's say you finish medical school,

there's a day called Match Day, where you put a list of the places you want to go for residency, and on March, I think it's 17th, everybody in the country opens an envelope, and this is where you go. Just so randomly? Random. Oh, wow. Well, I mean, you can try to, like, they like you,

and you hope that it's what you want. So if they pick your envelope and you pick them, you matched. Yeah, essentially. Oh, wow. And so that goes to every phase, so whether it's, when I got into, U.T. Southwestern. That was my number one. That's why I was so amped to get in. And then Pittsburgh for hand. And so Lily had a list of places she wanted to go for plastic surgery. And she was very happy to match, but wasn't ecstatic. My buddy and I in the lab, Paula Fruz,

who's a very famous Miami cosmetic surgeon, I remember when she called me and she's like, not super excited. And I'm standing outside the lab. I'm like, hey, Lily, that's amazing that you got in. And I'm watching Paul. Paul's like trying to put a line, a central line in a pig, and the pig is crapping on his leg. And he's like, and I'm like, Lily, you know what? Like any of us would just want this spot.

Like, you should just be really happy. And it was kind of mean. But I'm sitting there. I'm like, in this lab, just toiling, just wanting this opportunity. And so she really took that to heart and crushed residency. And I went back as a general resident. general surgery resident, and she went back as a plastics resident. And she was pivotal in me getting into UT Southwestern

because the day of the UT Southwestern interview, I was late because I was driving from another interview. And I'd already kind of not wanted to go there because I heard it's so intense and it's just, you know, it's a beat down. I wanted a more gentlemanly approach. And as I was listening to them talk about plastic surgery, I was like, this really resonates with me.

The discipline, it's very organized. You get a full throttle experience. And I call Lily. I'm like, Lily, this place is awesome. She's like, yeah, I know, dummy. Like, this is where you should go. And I'm like, I don't have an interview with the chairman, Dr. Rourke. And so she was like, well, you need to go meet him.

I'm like, well, the interview's over. She's like, knock on the door where they're deliberating about the candidates and tell him you want to be at that place. I'm like, dude, like, I'm going to. to be interrupts, knock on the door. So I knocked on the door, he came out and I'm like, Dr. Doric, I want to be at this place, just like a robot.

And it all worked out. It really all worked out. That's great. Tell us about the pictures you showed us. Oh, yeah, yeah. Yeah. So, hey, because it was pretty remarkable. Yeah, yeah.

Did you see them all? Hey, I know, Justin. Yeah, it was the bear attack. Yeah. So tell us about this. Yeah. Because you, I mean, first off, some of the most challenging, and correct me if I'm wrong, areas of the body to operate on or the hands.

It's very, very difficult. And then trying to reconstruct a face because as humans, we can tell when something's a little off on a face. 100%. You have to be precise, unlike doing surgeries inside the body where if it's working, it's working. It's working. When it comes to the face, if something's a little off, like, and people really, they're self-esteem. really gets attached to that. So it's very difficult.

So you talk about the bear attack dude and what you had to do with that. Sure. That was one of our first cases. We had a friend who was a trauma surgeon on call and he called me up and he said, hey man, because there's a specific element of call called replant. Replant means when a part is off your body, you put it back on. You replant it back on. And we were on replant call for hands.

He's like, hey, I got an interesting replant for you guys. I'm like, what is it? It's a guy whose nose and upper lip got ripped off by a grizzly. You guys interested in it? And I'm like, hell yeah. And my wife is like, yeah, let's do it. But there's also a facial plastics call that's a put, and this will come into play later because they were upset that we got the call,

kind of they should have had it, but whatever. So we go in and there's this guy, the story is he's, and his name is out there. So his name is Lee Brooke. He's given up all of the privacy things because he's a speaker. He's done all that stuff. And Lee, I remember looking at him in the ER, he had no face. All I saw were two eyes. His teeth were exposed, no midface, just blood everywhere.

Yeah, what do you have to work with? It's not like the lip and nose or do you have pieces of that or do you have to come up with your own? So there was a bucket. And in the bucket was his nose and his upper lip. And the story is he had hunted two elk in Wyoming and killed one, quartered it, brought it back, came several hours later to get the other one, and looked, and it was like three in the morning,

saw that it had moved. And then he jumped off of an embankment onto a mother bear with cubs. Jumped on to the bear. On to the bear. Oh, my God. He didn't know that he was there on. Yeah, what are the odds?

Three in the morning, that's why, right? Three or four in the morning. And he got totally a. attacked and he he he he he was and we could talk about the the differences in his personality in mind and we're really good friends now but he was telling us at the time you know after the fact that he was stabbing the bear in the face and the bear you know bent the knife and he was shooting the bear and there was no gun and we're just like whatever dude like sure they went back years later and found the knife found the gun found all this stuff so he was he was telling

That's the truth. And we've become really good friends. So he jumps on this bear, gets attacked. He and his brother, I think brother-in-law are there. And he wakes up and he's looking at his midface. That's what this portion is called, your midface on the floor, picks it up, puts it in his pocket, comes down the mountain with his brother. They get flown to the local ER and then they get flown to us. And so I'm looking at this piece in a bucket. it with Lily and I was going to chuck it, get rid of it and start afresh. And she's like, hey, listen, let's look at it under the microscope and see if there's any blood vessels. And so we clean it off and there's the angular artery, which is the, it's an artery that goes on both sides right here that we see. And doing hand surgery, this is why it's a beautiful thing to have a lot of training and a lot of different, just the way you guys do different exercises, you can translate it to different elements in your life, hand surgery, having that hand surgery fellowship was really important because on people who have arthritis of the base of the thumb, you make an incision here, get rid of

the arthritic bone and fix the tendons and do things. But as you access it, there's a blood vessel there, the radial artery in the vein associated with it. So what if we took this piece and connected it there temporarily to start working on the face? So you took, hold on a second. By the way, are the hands particularly vascular? Oh, yeah. Okay, so this is perfect. So what you did is you took the part of the face and attached it to the artery here in the hand to keep it alive. Right here.

To keep it going. To keep it going until we could stabilize this. Because we're working with trauma at this time. Because that was my question is how do you keep that tissue from going necrotic or bad or whatever? Is it good to put it like so, for instance, if this happens and you have access to ice, is that like the move or is it just how you, how you, transported it. That's a great question. So we give lectures to EMS all the time because in Colorado, you get stuff sent from Texas. I mean, I get stuff sent from Cal. You get stuff in New York. And these, you have to specifically tell them that, let's say a finger is amputated. The way to transport that is not in direct ice. You have to put it in like some kind of gauze in a Ziploc bag over a slurry because the ice crystallizes like the cellular components of the, It destroys it. And so you won't know until you connect it.

And you're like, why isn't blood flowing? Because it's essentially frozen. So this facial segment, not only was it, I don't need, I think it was put in ice, but it was like 12 hours later. So we had such low hope that this would work. And so we're. And what are you looking for when you attach it to the art of the hand? Is it going to work?

Is the blood going to go through? Like color back to it or something? Yeah. Yeah. It's like a gray piece of tissue. and I'm sitting there, Lily's, we're doing it together, put the artery together,

and having a good vein was really hard. We finally got the vein together, and there's these two clamps, one on the artery and one on the vein. We removed the vein clamp, and then when I remove the artery clamp, let's see what happens. It turned pink.

And Lily and I looked at each other, and we knew that moment, our life changed. And the reason why I say that was this is a case that had never happened before, and we were so young at that time and so fresh, And we took a break at that point

and we sat on his stretcher outside the room and we actually both started like kind of crying. We were like, holy crap, Lily, this worked. And now we have to figure out the rest of his face. Wow. And so the Trump... Back up for a second. How would you even reconstruct a face without tissue like that?

Where would you get it from? Yeah, so that's the reason why... So Lily's also a craniofacial. Lily did plastic surgery, craniofacial surgery, hand surgery, pediatric surgery. So she had all these ideas, and she was thinking very rapidly. She's like, listen, if we do this from scratch, this person's going to look like crap and need a face transplant. And so we have this segment, which is so hard to make.

It's so hard to make a nose. Why don't we try to use it? That was her logic behind it. But if it's gone, let's say you don't have that segment. You take tissue like you can take your rectus with the blood supply, the artery in the vein, and you can kind of stuff that. this is not an aesthetic thing at this point. This is going to be to save their life or temporize them for an eventual

face transplant in one of these transplant centers. But we had the piece. And so we really wanted to try to figure out how to make it work. And so when it lit up, that's what they say, when this tissue gets blood flow,

it lit up and we went back and we were like, hey, we got to figure out the face now. So Lily did a bunch of bony work put plates on we washed out the face together and we put dressings on and we just let that chill that night the flap the the nasal segment became purple and so what that means is when you have arterial blood going in that's oxygenated venous blood the vein takes it away that's deoxygenated so the vein had some issue so we went back in we tried to fix the vein but it was still there was a

purplish hue to the tissue. And if you leave it like that, the tissue clots often becomes necrotic, like you said. So this is where we go old school and we have to use medicinal leeches. And so what leeches... Because the anti-coagulant effects of the... Yes, exactly. Suck it, huh? Well, no, they have compounds that break...

Herodin. Yeah. It's a compound that breaks clots, but also the mechanical act of removing that deoxygenated blood allows, in time, It takes about 12 days is what the studies say for new veins to take this. So we were leaching him. Nurses were like putting a leach on him every couple hours, taking it off for like 12 days. That's crazy. Do you just have leeches laying around there?

There's a number called 1-800 leeches. Shut up. Seriously, look it up. Look it up. I swear. It's a real thing. It's a real thing. You call it 100 leeches.

Pharmacy comes and they send you a bunch of sterile leeches. Okay, so I'm trying to envision this tagline. We suck. We suck hard. Okay, this guy is, I'm sure, laying in a bed and his nose is attached to his hand the whole time? The whole time. That's wild. But now we're...

But now we're... No, that's... And we should look at the pictures. I'll keep them clean for you at some point just because there's... We're so proud of this because it's... It's just... Hadn't been done, right? It's incredible.

But it's like, it's a husband and wife's team just trying to figure this. It's just such a... It's a storybook for us. And then his face was like a big gap here. And so we got him through that first surgery, and now we're trying to figure out what to use to close this gap to just get him stable to heal. And one of the techniques is it's called free flap. A free flap is a piece of tissue that has an artery and a vein. So you take it off, it almost looks like an island with two tails, artery and vein.

And the whole body has these all around them. Like your body is profused and has blood flow in these different territories, and you just have to know where they are. And one of them is by the leg here. And so when people have cancer of the jaw or mandibular issues, one of the treatments for it is the E&T surgeon will take the mandible out, and you need a new mandible. So we take the fibula out from here to here,

a segment that doesn't really affect your ankle or knee too much. We take the bone out with the overlying skin, artery in vain. We cut it according to 3D constructs to match this segment, and we plug it into the carotid vessels. Does it, so they then have a piece missing from there, but the tibia does the job. The tibia does the job. You lose, they say there's 15% is what you lose, but honestly, with our patients, I don't really see that. Yeah. And so that is in the, again, plastic surgery, it's awesome because you don't have to get so stuck in the text, the funk and wagnalls.

Yeah. You get to, if you know anatomy and you can logically think and you're creative. I was just going to say, you get really creative. You get creative. And so we didn't, the rest of his body had bite marks and cuts. So all we had was this segment, which was an ideal. He didn't need bone. We just needed the skin.

So we took the skin with the blood vessel. We also took the bone and put it in the fridge just in case some of the bony work didn't heal down the future. And we put a big plug over his face. So he did not look human for a while. And he had this patch here of skin, two eyes and a lower lip. And we let him stabilize. The trauma team saved his life at Swedish. And it's a level one trauma center.

And those guys were amazing. and now he's outpatient and now we can start taking off the save your life hat and put on the reconstructive kind of artistic Wow so that's just like a patch to bridge to bridge you have to wait till he's like

okay yeah he had hand fractures he had all the stuff that needed to be taking care of how long does that take before you can then so how long does he look like that before we had him but that thing was on his arm for like two years oh shit yeah whoa wait his nose is attached to his hand two years?

Two years. Get the fuck out of here. 100%. So he's walking around? Like what I mean with a, or is he in the hospital the whole time? No, no. He's really funny, man.

He'd like, he'll be at restaurants in Pennsylvania and be like, I got to blow my nose. Yeah. What? That's crazy. He's, he's the funniest guy, man. He's a guy you may want to have interview one day. But, um, so then now we went to a major conference in microsurgery, the American Society of Reconstructive microsurgery.

and we found two of the thought leaders, these gray-haired guys that do a lot of this stuff, and we were waiting in line to talk to them because everyone wants their autograph or something. And we just had, I drew on a napkin our case that I wanted to present. Like, this is where we're at, this is what we're thinking. And so both of them are like, huh. And we're like, what do you think?

You guys did a good job. We have no idea what to do. And so we're like, oh, thanks. And so interesting, I didn't mention this. He had a cleft lip and a cleft nose. So part of that lip and part of the nose had a little mark in it. And over the two years, that half got necrotic and died. So we were left with this half nose.

And we were like, what are we going to do with this? This doesn't look like a nose anymore. And so first things first, he needed an upper lip. And so this is a cool, this is also a cool picture. Lily found one paper that talked about putting a tissue expander, which is a balloon that expands the scalp. And over a period of three months, you get, it looks like an extra skull up here, a big bubble of tissue.

And so... It stretches it. It stretches it. You put a little fluid every couple weeks. What's that for? Is that to use the tissue or is that for a different procedure? For the tissue, because what... There's two blood vessels here, the superficial temporal artery.

One here and one here. So she essentially planned out a headband flap, like a headband, drew it out, put the expander underneath, and then we cut it like this and just brought it as an upper lip. Hair was even growing down. And then, you know, plastic surgery is cool because you essentially do small moves. We do a big move and then you whittle it away. And so we removed the two segments and now he had this big handlebar mustache, which was a scalp. And he loved it. He loved it.

It's like growing straight down. I'm going to show you all this, man. You got to see it. It's just, it's amazing because he sends us a picture. And we were like at this point, we were like kind of hoping he didn't want to use the forearm because it's so hard. We're like,

maybe you want to do a prosthetic. And because a prosthetic, you know, they're awesome looking. But it's a prosthetic. It's like the Groucho Marxian, your time. But he ultimately wanted to use that tissue. So now we had to really think this through.

So it was on his arm and we used the existing radial tissue, the arm tissue, and kind of created that other half with it. And took the blood vessels, the radial artery and the vein with it out, plugged it on his nose and so did it to his neck vessels. When we did that and put it the right way down, it turned blue. and so we moved things around in the neck and whatever we did, it would not stay the right color. So the only way it would stay the right colors, we had to put it upside down. And so for three weeks, he had his nose upside down.

And there's a really cool video of us taking them to the OR and me releasing it and turning it right side down because it had enough time to mature the blood vessels. And so... How did you figure that out? Are you just moving it around? There's a little machine called a Doppler machine that lets you listen to the blood flow. And when you turned it, it would go away.

And I'm like, damn. We have to do this for a while. Yeah. And so. How is his breathing and everything? He's got a trache, yes. Yeah, he's got a trick. And so he finishes that course.

He's in the ICU. And he puts a picture of himself on Facebook. He's so thankful. He's like, my docs, they did this. This happened. But it looked like a big ball. on his nose. And I'm looking at it, I'm like, and Lillian, I'm like, this is, it's not a good nose. And so we started thinking, what if we make this the internal part of your nose? And so we went

with that plan now. And we used rib cartilage, took a piece of rib to give him what's called the dorsum, your cartilage to give him the shape of the nostrils. And now he needed a cover, because you're looking at innards now because we've been whittled this down to the inner portion and we needed something to cover it. So again, we used that expander. We put it under his forehead. We drew out a nose like this shape

and over a period of a month, we released it, flipped it down, kept it connected. So there's blood flow going like this. Wow. And then at three weeks we released it. It's so wild. Do that. It's amazing.

It's amazing that this works. That it works, that you can stay alive the whole process. That, like, that's wild. You can troubleshoot your whole way through all that. For beginning and the end, how long did this whole process take for this guy? Probably like two and a half, three years. And even now, like, there's still little things we tweak. Like, every now and then he has a little thickness in his nose.

So one of the most beautiful experiences was we, were in, he had his nose, he's sitting there in the ICU. And this was essentially, we thought, going to be functional for breathing, but he'd lost his sense of smell, and we thought. And it was really for aesthetics. Because these patients, they're not trying to be on the cover of GQ, man. What they're trying to do is just get milk, get gas, and not be stared at. Burn patients, trauma patients.

That's all they want to do is live a normal life. And so his wife was cutting an orange, and he, he, He was just like, oh, I smell an orange. And everyone freaked out because his olfactory sense, his smell was intact. That's remarkable. It was unbelievable. And we didn't do anything for that. That just meant that the beard didn't attack it.

How do you, how do you work? So burn has to be the other incredibly challenging thing. Because how do you get skin that was severely burned to, I don't know, grow back or look like it wasn't severely burned? What does that look like? Is that still very difficult, almost impossible? Like, how do you do that? Yeah, I mean, the cool thing about our burn unit, it's, I think, and I'm a super confident guy about this,

we are the best in the world. And the reason why I say that is we're double-board, sort of out plastic reconstructive surgeons. Four of us, we love each other. We love taking care of patients, and we love complexity and really getting people back. We love when we get pictures of these patients doing the stuff that they used to do. So when you come in,

with the big burn. It's not necessarily the burn that kills you. It's the inflammatory cascade afterwards that gets you. So kidney shutting down. Infection, lung issues. So back in the day,

the way they treated big burns was if you had a big burn, like 30, 40, 50, 50s, they just did wound care and everybody was dying. There was a fire, I think in the 40s or 50s, in Florida where multiple people got burned. I mean, I think maybe 100 or more.

And the surgeons at that time thought about, what if we just excise the source of this inflammatory, the source where the inflammation starts? So they'd cut away the burned skin and put dressings on. They noticed... And let it heal from there. Well, do that first and see what happens. The patients were living at that point.

It will never heal on its own unless it's a really small burn that the skin around it can close. But if you have a big burn, you need skin from your body on it in some fashion. So fast forward to what we do now. So now if a patient comes in 20, 30, 40, 50 percent burn, we stabilize them. The resuscitation, we give them fluids, we watch their hearts. And our ICU doctors are just badass.

They just come in and they save people that you think would die in transport. So now it's our part. They, usually the second day, we go in and we essentially just take a scalpel or an instrument and remove that burn until you get to healthy bleeding tissue. Now it's about temporizing them. So we in our unit use donated human skin. And I put that, a recent post on my Instagram was holding a sheet of human skin that was like this big. That gets donated. It's a gift.

It's a real blessing to have this stuff. and we essentially put this on to temporize them, the body will do everything except accept it. So it'll start growing, it'll start healing, but it can't accept it because there's an immunologic barrier there. And so now, depending on the size of their burn, let's say they're like 30% burn, you have 70% of their body, which is not burn, that you can use to help transplant from that side onto your burn. So some cool things we do. Anytime a burn over 30% comes, we take two specimens from the groin about that big. We send it off to a company.

The company takes that skin and they make a really thin epithelial layer, very thin epithelial layer. So they're essentially making skin, but it's not full thick. It's not like... Are they taking the stems of the cells and having to grow? No, they take the epithelial. They're thinning it, right?

Nope. They take it and put it in. culture under a hood and they just grow sheets of it in petri dishes. Oh, wow. But it's like very, very, very thin. Right. The thing that kills these patients is infection. One of your best barriers for infection is skin.

And so what we do is, and that takes about three weeks. So now we're doing, we have the donated skin and you have this cooking in the background. We start planning on optimizing nutrition, which is huge. This is what we talk about, creatine, those kind of things, vitamins, all that stuff. Really helps. amino acids, protein. What are the things that help grow? Okay. Oh, yeah. I mean, like, they're on tube feeds that are optimized for protein. Their protein losses are just unbelievable when you don't have skin. Yeah, I said that because the original, the original studies on, when you look up the

old studies on essential amino acids, branched amino acids, they were all done on burn victims. It was all burn victims is where we got the data that it helps with, you know, some of the stuff. And when you think about in medicine, a lot of the advances happen in really violent and dark times, wars, big tragedies, things like that. Huge need. Yeah. And so now you have this patient, he's got, he or she has donated skin on, you bring them back, you change out the donated skin, and you find the areas where they have normal

skin, and you take what's called a dermatome, which is essentially a, it looks like a tool that extremely thin slices of skin. So you put it on the normal areas, and you harvest skin off of them. you put it through a machine called a mesher, which takes that skin and puts holes in it so you can stretch it out. Wow. And then you start covering them, right?

At the same time you're covering them, you get that company to send you the thin sheets and you can sometimes put that on top to help fill in those gaps. Sometimes, so if you don't have a lot of donor sets, let's say you're 80% burned, when they have 20% of your skin available, you take the skin, you mesh it.

Now there's different patterns. There's one to one which is like small holes. There's eight to one which are huge holes. So you have, it looks like a sheet with just lines. Now to help allow for those skin cells to close, that's when the company helps a lot with that thin skin in between because it acts like a bridge. How does the, because we met you, I met you at the peptide Congress.

Sure, yeah. So I'm assuming now you're looking at using peptides to accelerate or help this process, things like GHKCU. Yeah. BPC. Yeah, no, BPC-157, GHCU. All of these things are awesome, but medicine is slow. If you notice at that peptide conference, the people moving the needle aren't the docks necessarily. It's people like you guys talking about it.

It's the people who are actually using it. And what I feel is just modern day medicine take, there's so much red tape to get that stuff through. For me to even change addressing kind of algorithm. It takes a lot of effort. So peptides aren't incorporated yet, but there is no doubt that that'll be the future of this stuff for healing. I mean, I used BPC had IT-Ban syndrome for,

like two months, I did it for two and a half weeks went away. Completely. And so, I mean, I'm not here to, like, give medical advice about peptides, but just anecdotally for me, they've helped me. And I just see the way medicine is going. So can you not, so right now you can't use it with patients? You can't. Oh, wow.

Unless it was, what, private? Because if it was like someone like, I'll pay out of pocket, do whatever. Well, I was to say, are you even allowed to do that? Like, hey, I can't recommend this to you, but I've heard or seen. You can, and there's like non-unformed people that can, that have been doing that. I mean, in my aesthetic practice, I talk to patients about the benefits of peptides after a facelift, after, you know, aesthetic surgery. Because they can go do their research and essentially if they want, buy it on their own. And I can only tell, I mean, I tell them the risks that it's, there's no long-term studies on this.

but there's no doubt that there's benefit in these these these peptides it's just with medicine you need to go through the randomized control trials you need to ensure that they're not harming patients it's going to take a decade before it's possible yeah it's possible but uh how how hard is it to uh to reattatch parts of the hand because it's such a yeah i mean there's there's constant movement yeah so much articulation and so much touch and so much we do with their hands. And I mean, if you look at the anatomy of a hand, it's like, good luck. I would actually would have thought, because isn't there, there's more nerve endings in the feet than they're in the hands. I would think the feet would be as hard or harder. Does that not make a difference? We don't, there aren't from, from, you know, just hearing that, you know,

I think there's more nerve endings just because we're making more contact. But I'm actually not sure if that's the case. But I think that the foot, there's a lot more give. If you lose toes, you're not going to be able to engage in life. So it's not as big of a deal. If my foot doesn't look as good, it doesn't move quite as good. Plus, you're not playing a piano with your foot. You're not picking up a fork with your foot.

And so when it comes to hands, now essentially the hand is skin. And this is a different type of skin than the rest of your body. The souls and the hand, this is called glabrous skin. There's more nerve endings. There's different architecture to it. And so it's skin underneath it. there's actually a lot of muscles, small intrinsic hand muscles, there's nerve, there's bone, there's tendon, there's tendon, there's, uh, on this side, same thing, skin, tendon, bone,

ligaments. All of these things when you, when you, when you, and we, I do a lot of wide awake surgery. So if somebody comes in with the tendon cut, I'll, I'll numb their entire hand. And do it while they're awake? Do it while they're awake. So I can get the tendon to the right excursion. So, so you can ask them to do something. I ask them to open up. And if it's a little low, I'll tighten it up. I see. And so when you're watching this, this dance of extensor tendon with flexor tendon and just motion, it's hard not to be amazed. It just is because it's like you said, it's so complex. And when these structures get cut, it's very, very hard to make them perfect. But recently I had a patient, um, She's 20-something. She was, you know, having a hard time, and she tried to kill herself.

She took a box cutter and went right at her wrist longitudinally so deep she cut the bone. And what's interesting is I got the call in the middle of the night. I went over all the tendons, all the arteries, all the nerves, and I put them back together, spent all this time. and it looked really cool, really good repairs, went home, went to sleep. She came back in on a Wednesday, and I take care of a lot of these patients. Some of them don't even show up for follow-up

because they're in their mind state. The first thing she says is, I'm really sorry. So you don't have to be sorry. I'm just like, no, no. I heard one that you are called to your kids were crying. And it's the first time, like I've ever heard a patient say something like that. And I was like, listen, this person's different. And so to answer your question, the surgery part is challenging, but the stuff after is where it counts.

Sure. So I knew this girl was different than the rest. So she was coming to therapy all the time. And it's really important because your body is not as smart as you think. When you fix a bone, the bone heals, but it scars everything else above it. So you have to differentially move things. You guys know this when you train people, like body parts and muscles slide over each other. And if you don't, if you're not aware of that.

It's not exactly like a puzzle. It's not. And so the hand therapist is crucial in making sure the tendons move just enough so scar doesn't happen on the bones. And additional surgeries and function isn't limited. How do you attach tendon? Is tendon to tendon or tendon to muscle harder to attach? Tendent to muscle.

Because tendon to tendon, when you look at a tendon, this is also amazing. Look, you don't really see blood vessels with your eyes, but there are microscopic blood vessels there. And so you take a suture. So imagine a tendon in, tendon in like this. You put a suture in like this. You wrap it around and you have it come out this way. And you do the same format.

Oh, I see. And then when you tighten it, it connects this way. And if you've seen a tendon, there's some substance to them. Whereas like muscle is just loosey. I was just going to say, how do you attach a tendon to a muscle? So there are some techniques in the muscle. You can take a baseball stitch. And sometimes if I have a loose piece of muscle, like a lawnmower injures, the muscle is cut.

You do a baseball stitch on it. And attach to the stitch. It attached to the stitch, exactly. Does it heal back just as strong? It can. Okay. And there's techniques you can do. You have some extraneous tendons in your body, like this tendon right here is called the Palmeris.

You can take that out. And use it for grafting. And I do that all the time. Why is it sometimes I see? People will get a torn bicep and they just leave it torn and they don't pull the bicep back down and reattach it. Is it because it's like, eh, I waste the time?

There's a couple of reasons. One is you have another muscle, the brachialis that can do that function. Sometimes people are... So it's more aesthetic than anything. Well, one of the reasons it may not be possible. The tendon may be, the tenderness portion may not be enough

to implant back into the bone. But a lot of times people who have that will get that fixed. It's easier than like a peck, for example. I was just going to say a peck is really challenging to fix. It typically tears up here in the armpit, and that's pretty difficult. Yeah, because it's all muscle at that point. Wow.

Wow, that's interesting. That's fascinating. So, yeah, to me, the hands are so fascinating because what I was told or not taught, because it was not something I learned necessarily, but what I would hear the surgeons that I trained, and I'd never trained a hand surgeon, but I did train general surgeon, and vascular surgeon, a lot of anesthesiologists,

they would talk about how like the hands were just like, yeah, that's tough. That's really, really tough because of just all the moving parts and how intricate the hands are and how much feel there is. And so that's got to be one of the more difficult areas too. Hand is very challenging. And really when we're on call for hand,

if the arteries cut, you have like four to six hours before they start losing tissue and get necrotic, things like that. If the nerve is cut, you have like 12 to 18 months after you repair to see if it'll come back. So the nerve is actually one of the most, like if there's an injury there. Resilient? No, no. It's actually if you cut like the median nerve or one of the major nerves, that's what really dictates your function.

Yeah, there's no nerves, no juice moving to the muscle. And so sensation, motion, like you said, and where you cut it makes a difference. If you cut a nerve up here, the chance of you. you getting sensation and feeling in your arm and your hand is much less than if you cut it here. I love asking doctors, especially surgeon, this question, what are some of the characteristics that you notice in patients who seem to do the best? Mm-hmm.

Are there personality traits or characteristics? Or what about, like, healthy bodies? Like when you're working on somebody who's fit and strong and healthy people, or somebody that's not, but that makes a difference. 100%. And I talk. talk about this a lot with my colleagues. Like, I'm sure you noticed, and I notice, a lot of doctors aren't the healthiest.

And it's not that they don't want to be healthy. It's, there's something in the culture of medical school, of training, where you give everything. You sacrifice your health. You sacrifice everything. At some point, you'll get to it. I've never been that way. You know, I've always really felt that it's a sport. And for me to perform in the operating room, has to be mobile.

I have to be strong. I have to be able to. And so I train every morning at 4.50. I train today. And so I think that when I have a patient, I try to convey the importance of that. Part of it is, hey, listen, you're going to get through this and you're going to crush therapy. You're going to get your function back.

You're going to be able to hold your kids. You're going to be able to work. Here's what I need from you. I need you to think positively. Like, I'm a scientist when it comes down to it. But I'm also very holistic. Like my family is generations of Ayurvedic medicine, things like that. Positivity, what you think manifests itself.

Like, there's so many times where I'm like, you know what, this is going to be okay. And it's okay. Have you seen the correlation between depression and autoimmune disease? And they've actually been able to see that the depression leads to more autoimmune disease, not necessarily. Interesting. Yeah. And I'm wondering if the immune system responds because of this, like, you know, you focus on how much you hate yourself so much. I wonder if the immune system starts to react.

There's some truth to that. So when we do these big cases, like, you know, a piece of tissue here, put on somebody's neck. We're actually doing a huge one on Friday, covering somebody's brain with their litmus muscle. Me and Lily are going to do that. What we do is the scientific portion is the surgery. It goes really well. Then all the other stuff, no chocolate, because there's, after surgery, there's a risk of chocolate causing vasoconstriction, which is the blood vessels shut down, close up. Coffee, there's some risk of coffee causing that. We put them in a room with the

window so that they can have a circadian rhythm. We make sure that their family isn't like stressing them out. We don't want epinephrine in there to shut down those blood vessels. Sometimes I'll give them a book and I'll say, hey, they'll find out what they like to do. Do you guys use PDE5 inhibitors for blood flow during surgeries? Like which one? Like Viagra, scialis. Would those help? Or is that? So we do some medications like, like Lidicane, for example. Okay. And paparine, these are, these are medications that take out what's called vasospasm.

When you touch a blood vessel, there's a nervous system on every blood vessel. That's how we, you know, you do a cold plunge or a sauna. That's how you dilate and constrict. This can be harmful when you're doing these surgeries because it can all of a sudden constrict. And then your whole flap is, the piece of tissues clot it off. So putting these medications gives you a temporary window where you can sew it and allow for blood flow back and forth. And yeah, I mean, there's a very holistic approach to this too,

besides the scientific part. Patients who come in that are positive, I've seen somebody that has a horrendous injury with a positive attitude do really well versus somebody who doesn't have such a bad injury, but has a negative attitude and doesn't feel like they're going to succeed do poorly. And it's with work too, like.

Like if there's a study with hand, if you're out of work for something like three weeks, the chance of you going back to work is like single digits. Do you have any favorite partners that you work with? Like, you know, do you need to work? Do you work closely with other practitioners like, you know, other doctors that aren't doing what you do? But you're like, hey, you go to this guy because I work very well with them and we work together. Well, we, part of plastic surgery, which is really cool, is a lot of the work we do is somewhat unpredictable. And like we'll be on call and the orthopedic surgeon's like, hey, man, can you come to room four?

And you come in. Hey, we took out the tumor and there's a lot of tibia exposed. Can we figure out a plan? Oh, right. And so they call you in. They call us in the neurosurgeons when they do spinal surgery and they put a bunch of hardware in, instead of just closing up, they'll call us in to use the muscles to cover the hardware. So if any infection gets in, it doesn't cause a hardware infection. So routinely we'll get called, hey, we're unable to close over the scalp.

Are you guys available to just one of you guys? And there's always an on call one of us. Right now, it's Lily. Can you come by to room eight and just see what needs to be done? And so we'll figure something out to get closer. Is there a typical time frame? Because I remember when I just had a high school, we went for our senior trip to Hawaii, my friends and I. It was the beginning of the week.

and my buddy gets drunk and gets in a fight. And this dude split his lip all the way from the bottom of his nose, flayed it wide open. And we had to rush from the hospital. And they actually had to wake up a plastic surgeon and fly him in or something like that to come do the work like in the middle of the night. Is there certain body parts or certain types of injuries that you've got a small window that you've got to attack it if you're going to save it or be able to reconstruct it?

Or is it different or is it kind of universal? So like ever, you got a certain window, pretty much anything, if you want me to be able to save that, that limb or part or. Yeah. So with nerves that are motor, so there's sensory nerves. Yeah. You touch something, you feel it. And then there's motor.

Motor nerves, when they're cut, you really want to get to them within a couple of days, like soon. Because once they're cut, the end point, so your nerve is like this, there's an endpoint that accepts the signals. The endpoints, like, I'm not getting signals. It shuts off. It shuts off. and it starts turning into scar over time.

So you don't want that to happen like in your hand and stuff like. So that's, if somebody tells you, hey, this guy came in with a samurai cut to his wrist, he has no function of his hand. We're taking that to the OR that night. We're going to fix the nerve. The artery, artery is another thing. If blood flow is not there, we're going to fix that right away. But like a lip, for example, that's often done emergently.

At least we do it because if you wait too long, the swelling is so hard to really approximate mate and get the, get it to line up just right. Get it to line up just right. Okay, that's why they were so. So we'll often do that at the time, but that can, that can wait. That's something that, you know, you can wait on. Like as far as health and survival, but for aesthetic reasons, that's why they did it. Because, yeah, I remember the next day, his shit was like this.

Yeah. I mean, I'd never seen it. I'd never seen it look like that. At that point, you have to go back and try to line. It's just logistically, it's easier and it's better for the patient. Nobody wants to sit at night. I didn't think it was like a life or death thing, but it's like, man, It was very urgent.

They flew someone in. It was a big deal. Any interesting new technologies on what you're doing? Because I see articles, and I'm sure it's years out. But they're like, you could grow, you know, from your own stem cells and nose or your own this or you own that. Like, is that all kind of on the horizon? A lot of it's on the horizon. One of the cool things we do is when we take skin, you know, there's the creation of skin where in that, you know, a company that like I talked to you about sends it back in three weeks.

But you can also take skin. and scrape off some of the cells, like the epithelium, and put it into a solution that we do at the bedside, not in the operating room, but we're kind of making it with saline and things like that. And for facial burns, for example, patients, a common burn that we get is the older person who is on oxygen, but decides to smoke a cigarette.

Oh, lights it on fire. And they have a facial burn. It happens every week. Oh my gosh. And so that skin is, it's very superficial often, and so that'll come off. And when you spray this solution, it can help regenerate to the point where there's new data coming out that for people like me who have melanin, it can restore melanin into some of these burns. because that's one of the things that if I had a burn, I'd lose my melanin with some of the skin grafts and things like that.

But, yeah, I mean, aside from that, there's cool things happening in surgery, like the robot, I'm sure you've heard of that. They're using robotic surgery for head and neck, for different, they're trying to incorporate into different aspects of plastic surgery. I mean, AI is pretty cool. you know. I know, just, how would you use?

Because obviously the skill of the hand for you to do so many things, I think, and then the real-time pivots, human is so important. But I got to imagine there's got to be ways that you could, you know, plug something into AI and like, if we do this, what are the potential outcomes? If we do this and then, like, do you use it like that already? Or will you, like, what do you see? Not yet. I mean, for surgeons to say that AI won't replace them is, I think,

ego. And the reason why I say that is because for a product to do well, you probably need it to be good like 80% of the time. Now, when you have surgery with me, I'm going to treat you like a family member. I'm going to give you every drop of my brain and sweat and hands to make sure that the outcome you have is the best. Now, is that necessary for you to be functional? I don't know. Now, this is where AI may come in and say, hey, you know, what he does, that extra 20% is not necessary for being functional. Health insurance pays this. And so that's what I'm a little worried about. But at the end of the day, there are nuanced things that we do that I just don't know how, based on this, I'm reacting this way.

I don't know if that's something that AI can pick up maybe. I mean. Interesting. Do you, because I know you're in medicine, you do, you have to be so specialized. You have to know it's so deep. And sometimes there isn't like that cross communication. When it comes to like the face, do you work, do you ever work with neurologists with like when people have things like trigeminal neurologia or pain? And then do you guys work together and kind of learn from each other?

Like, what does that look like with you guys at that level? Do you guys all sit down and go, all right, let's talk about these things? We do. I mean, we have, not with the neurologist, but like part of the burn team is every Wednesday, we have a multidisciplinary team rounds. Okay, cool. So on that rounds, we talk about every patient, sometimes 50 patients. And the people there are case managers, social worker, trauma, ICU, dietitian, pharmacy. Oh, wow. And it's long.

We go, and everybody says something. Oh, wow. And then we get really great care that way. And that's why burn units are really important because not just a surgeon doing some skin grafts. It's a multidisciplinary approach. But, you know, an example of that is, you know, we work with neurology in the sense that there's a cool surgery that we do for headaches. Where neurology, there's, for example, occipital pain, they're injecting Botox, they're injecting steroids, and there's no relief. Yeah.

And so we get them as kind of a last resort. Put some lydicane into that area. And if their pain is resolved, we know maybe there's an option for surgery here. And so we'll make an incision down the middle of the scalp. We'll raise the tissue up. And there's three nerves here, the occipital nerves and the third occipital nerve. And the greater and lesser occipital nerve and the third, they're kind of like this. three on each side.

And all we do is we find them and we free the compressing tissue over them. Sometimes it could be from a trauma, whiplash. Sometimes it could be a blood vessel that's pulsating on it. That's got to be life-changing for somebody who suffers from like chronic headaches all the time. I had a patient once that I did this procedure on.

She had the procedure. I'm operating another room and the nurse is like, hey, you need to go talk to that patient. And I'm like, oh no, what's going on? I go back and I'm like, hey, what's going on? And she's like, this is the first time I have zero pain. I don't know if you know, but I was so suicidal. So, I mean, that gives you a lot of a lot of just satisfaction.

And it's a challenging surgery, but it's not like putting a face back together. And this thing that you kind of think, you're on the next case, it's made such a difference, just releasing tissue on a compressed nerve. Do you get more, it sounds like you do, I think I already know the answer, but do you get the harder the case is, is like the more exciting for you? Yeah. Like the challenge. Yeah. This is going to be interesting.

Yeah. I think that, yeah. I think that that really is as much as we get older, you know, my family is my number one priority. And when we didn't have kids, that's all I wanted was the hardest case. be the biggest badass, tell everybody. Like, this is what we do, because we were trying to build a name for ourselves. And I'm still that way. I still want challenging cases.

But what you start noticing is what is a big case to you is a big case for anyone undergoing surgery, whether it's a carpal tunnel. Sure. For them, it's always. Yeah, they're not sleeping. Right. Like the headache person. Yeah, the headache person.

She was suicidal. You saved her life. Or a trigger finger. Like, I think it takes one. one, two minutes to do a trigger finger, and people come back and like, now I can like move my hand. Now I can hunt. Now I can fly fish. Now I can do all these things, you know? Wow. It's cool. Yeah. That's great. How do you guys balance family? Because you're both surgeons. Yeah. And you got kids. What does that look like? It's hard, man. It's, it's, it's, I don't think

there is balance like in life. As much as I want to say, you know, everyone wants to get balanced. I think there's points in your life where you're focused on certain things and point. in your life where you're not. And I, like I said, I had this, I don't want to say it's unhealthy. This just drive to be the best resident, be the best technically, figure out all about surgery until my first son was born. I saw him and it's just like, I was like, things got to change now. And I remember the moment I'm holding him and I'm like, I got to make sure like you're okay.

Doing what you do, would you encourage your sons to go into the same field? Because sometimes people will do something. It's very challenging. They're like, I love it, but I don't want my kids to do it because it's just a lot. So I used to say I don't want them to do it because the pathway was so hard. It's not just the years of schooling. You lose friends. Your parents are like, hey, we're having this event.

You can't come. Or, you know, I remember Thanksgiving where I had the day off. and I'm at Thanksgiving and I'm a resident. And the resident who was there was sick and the attendants like, dude, you need to come in. So you just go in. And there's a lot of sacrifice to that. So unless you truly love it and I'm going to gauge that with my kids, unless they like really love it, I think it's, I think it's a, there's other ways to be successful in life. And you really have to, I feel very fortunate because I'm friends with a lot of doctors.

And I love what I do. I love it. I love it to the 10th exponential whatever. A lot of my friends, they don't love it. They're burnt out. They're trying to get out. They're looking for side hustles. They're doing all this stuff.

At its core, surgery and plastic reconstructive surgery and aesthetic surgery, I love it. Now, do I like notes and do I like the healthcare system? And do I like, no. But the job itself, it's amazing to go meet patients, talk to them. hear the changes you can make and ultimately like share that with your your loved one like my wife

we talk about this stuff I'm like what's a date like now it's not as much like back in the day before the kids we'd all you talk to about rules I mean the OR used when we got to our hospital the OR was upset because they'd hear us

fighting and we're not fighting we're like arguing about family I'm like Lily we should go to the facial artist she's like dumb ass go to the thyroid artery it's bigger and better. And the OR's like, oh my God, they're fighting. We're just, we're just like talking it out.

You communicate on another level than that. And we're like looking at each other like this over the microscope. And they're getting, they're getting uncomfortable. Are you guys ever like in the middle of the OR? You're doing something. You look up. You're like, I love you, honey.

Absolutely. You know, so. Great stitch. The crazy story about Lillian, I mean, she's beautiful. She's a double board certified surgeon. Um, she's an amazing mom. So when she was pregnant, she worked until like nine and a half, like nine months, right?

She calls me. I'm in a, a flap. I'm doing a big procedure. She's covering somebody's brain. And she calls me and she's like, hey, I'm like, what's up, Lily? She's like, my water broke. Mid surgery? Mid surgery?

Shut your face. She was doing surgery still. And so I'm like, I didn't even know what that meant because we're, he's five weeks early. Oh, he's early. that's why okay and so I'm like oh my god what what do I like I'm going from being a married

guy with no kids to that moment I know this is happening I'm like Lily I'm in the middle of a case just like don't worry I'm going to drive myself I'm like no no you got to find somebody she's like now I'm going to drive so she drove herself gangster and has a C-section the next morning

kid is fine and we have to take our handboards we were supposed to have like this later but the timing of the kid made it so that she had just gotten the C-section and two days later she's taking her handboards and she's on pain meds, she's on all the stuff

and I'm, we're in the Prometric Test Center, I don't know if you guys ever been to a test center like that but there's a computer here and a computer here and I look and I get up during the break she's asleep, I kick her chair like get up like and she comes up to me, it's like, you know, I left 10 blank. I'm like, holy crap, you know, because I felt

decent about it that I passed it. And I was like, man, hope she doesn't like not pass it because this is not fair. You should do better than you? Ten points out. Ten points out. Ten points out. I do it. You'll hold that over you forever. Yeah. It does. That's great. Any hobbies outside of outside of work and family? Absolutely, man. Fitness has been huge for me. I remember, uh, fourth grade i was like kind of chubby and i had a cousin basil this kid uh just a beast just an athlete from from the get-go he he august 15th fourth grade uh 630 he taught me my first set up i remember the time because i looked at the clock when i was doing i couldn't even do it he's pulling me up and so i just started really getting into at that time it's like muscle fitness and you know you're

watching predator and rambo all of these these i these i i i don't know these i i i don't know that don't look like the people now, but that's who I wanted to be. And in the Indian community, it wasn't like normal to play sports. Like, I didn't know anyone. Baseball ran track. I played football.

I worked out. He worked out with me. And I remember doing push-ups and doing push-ups. And finally, like, my cephalic vein came. And I was like, I got a vein. And so it was huge for me. I mean, all throughout high school, we opened the first real gym in our high school.

mean, and I'll give him a shout out, Sean Leonardo and Harold Riggs. These, these were high school, but they are high school buddies of mine that we'd come, I mean, in high school at 5.30 in the morning to just work out. And then college playing football, that was awesome. And training is a huge part of my life. How much of an advantage, again, I trained a lot, at one point, I trained a lot of surgeons, and they would tell me how they would make them better at their job. 100%. Yeah. How much of an advantage is it to? It's night and day. Yeah.

Well, talk about that. Why? Why? Because to, especially if you're a surgeon, especially if you're new, you're, you're, you know, you're, the schedule can be crazy. Yeah. And so the thought is, I'm going to take time out to go work out. I'm so fried or I don't know.

Like, talk about the advantage of being fit. Yeah. For what you do. I mean, I used to do the evening workout and then I realized I was missing out on kid time. So we make our life. at that time, now we don't need this nanny. We had a nanny come at five in the morning so I could get to the gym downstairs.

We built a gym. 4.50 in the morning. I'm doing, I sit in the, we have an infrared sauna. I'd sit in there just kind of loosen up. Then do like a pretty powerful push-pull workout. And I'd always try to sprint at the end. And part of it is when you go to the operating room,

you're contorting your body in a lot of different ways. Yeah. And it's, it wasn't, it's not unusual for, surgeons to pull their back doing something stupid and be out or they, they hurt their neck. And so for me, part of it is that, but it's a mental edge to, because I also do cold plunge and son. I've done that for 27 years, cold plunging. And that really, when you do that in the morning, the rest of the day is easy for me.

Yeah. If you start out with something that sucks, is that bad? Something that, yeah, embrace the suck, right? There's something to that for sure. If you do that, the rest of the days is it gives you a mental legend surgery. It lets you think clearer. I typically don't eat breakfast because I found that if I eat a big breakfast, I'm a little bit shaky. Sure.

Yeah. And so I like to be super stable. Don't eat breakfast. At around 11 or 12 or 10, I'll take a huge protein bolus. And then I'll keep that going for the day. What's the longest you've been in the O-1? where you're working on somebody? 43 hours.

43 hours straight? Hold on a second. So this is stuff that always blows me away. And the first time I understood this, I was training a general surgeon who had done a Whipple procedure. And she was in the hospital. She was in the OR for hours and hours and hours.

And my question is always like, what if you got to go to the bathroom? Like, what do you do? You take breaks. Yeah. Okay. So that's going to say, how do you do that?

Do you go take a nap? Because it's 43 hours. No, never. So this was a very unusual case. That will never happen. How many? Red Bulls are you drinking? Like, what do you do? No, I don't because you don't want to shake.

Oh, that's right. And so this was a case that I was the chief resident and there was an attending there. And it was a mandibular reconstruction, same like this leg was being used. And very detailed attending. It took a long time to get this leg out and put it on one side of the neck. The vessels didn't work. Then tried a different vessel. It didn't work. And then now you're like doing the other leg and five. Finally it worked and it took it I'm not kidding you it took 43 hours and so in between I took like I don't know five or six breaks not long eight something came back and then there's residents that are coming in between you're not sleeping No I don't know that's crazy

The adrenaline keeps you a huh there's also like a long time ago. That's like 20 Well hold on so I'm gonna ask you a controversial Tunnel falling asleep this might be a little controversial but I know that now when you're a a resident when you're out there, you're trying. Sure. They now have limitations on how long they'll let you work and stuff. I've heard arguments on both side. One side says, yeah, yeah, we're going to put limitations because there's only so much they can learn and there's a lot of mistakes.

The other side says, you've got to go and go through the crap because sometimes you'll be in the OR for hours and hours and hours. Where do you stand on it? Do you think that they've made it too easy? So I went through the older past. pathway where my first year there wasn't any restrictions at all. Yeah. And my residency was a little bit slow to keep the restrictions in the beginning. Now it's very regular.

Now here's what I have to say about it. There's literature that shows when you're tired, you are essentially drunk. Right. Yeah. And you can't be that way. Right. But at the same time, not everything happens between nine and five. o'clock. A lot of stuff happens in the middle of the night, at this time, at that time.

And so I think we have to find a happy medium because there's an extreme where you're in the hospital, 43 hours, which is not, I don't think that's right. But then people are being pulled out of a case that they're in because they're over hours. So what I tend to find is a lot of these newer surgeons that have problems are finding people like myself and sending patients, to us because we've had that experience and we have that, it's almost like a discipline. Here's my, I have an opinion. I would love your thoughts on this. Yeah. I think that there are people that are not like the average person that can operate better than the average person under a lot of sleep restriction or stress. And I feel like you kind of want that process to whittle down to the

people that can do that. And maybe that's what it serves. Maybe that's, that's kind of what it serves because there's going to be situations where, hey, I know when you went through residency, we had all these regulations and rules, but out here,

you're going to be, there are going to be times when you're sleep deprived. Yeah. And you've got to be able to perform. And we don't want the people who can't perform when they're under that stress. It's hard to know yourself like that. I'm one of those people.

Like, I feel like I've, my entire life, I've really, when I like, something, I love it, and I focus on it. And in the operating room, when you're there, it's, you're in flow state. You are, all that matters is you're going to get this patient, that right outcome, get them off the table, they're going to be alive, they're going to be safe. And you don't remember, you don't like sit there and an hour past, two hours. Yeah, you're clock watching.

No, you're, you're getting it done. And afterwards, that's when you're like sitting at the computer trying to finish the note and you're out dead. And so I think that there is truth to that. I think that you have to know the kind of surgeon you are. Are you the surgeon that wants to do five or six small cases and be done? Or do you want to be the person that is the end of the line that if it doesn't work, this person gets an amputation? And that's kind of the mentality I am.

And so to hone that and do that, it's not just being in the OR. It's some of the jobs I've worked in. I used to do an inventory job that I would work 24 hours straight. I used to, you know, like study for hours on end. All of those things builds muscle. Yeah. This discipline muscle. And this is something that I really believe about surgeons.

You can't be a sloppy person and be expected to be this neat, awesome certain. You can't be a bad person who cheats on certain things and then be a great surgeon because your natural tendency is to fall back into that when stress happens. So if you're a cheater and you have a corner to cut in surgery, human nature is to cut that corner. So I really feel like when you talk about training, when you talk about family, you talk about finances, they're all interrelated. You have to really think about them in the same way. So I think that type of surgeon, it's a little taboo to promote that this day. I knew it was controversial. But that's who I want as my surgeon. You know, I want the guy that or girl that has seen it all

is, you know, by being in the hospital, by working hard, by reading, by understanding the pathology, they have the experience and they can adjust. Is this where the reputation, you actually said it earlier, the surgeons were kind of like these jerks that walked around like that? Yeah. Is that where that reputation comes from because they're like so focused. And so if you don't understand that, they can seem like they're just... I mean, it was brutal residency for, for, I mean, I had it tough, but even further back, it was, it was harder. Like, they called it residency because you lived there. Oh, yeah. And so these, these people were, uh, there was no attending, and this, none of this is right. There was no attending supervision for some of these people. They were

operating on people to doing, you know, trying to figure things out on their own. They're having family strife. And so this gets manifested in being mean to a medical student. I trained a woman who was a general surgeon, but she was, so this was 15 years ago. She was already in her early to mid-60s. And so, and the other surgeons would talk about her because they're like, you don't know. They're like, when she went through, back when she did, it was much harder and it was harder for a woman to go and do what she did. And that's why she's such a badass. And so they would do we just talk about this woman. like she was and she was incredible i mean i see that with lily like you know it's a very male dominated sport even now and in her training she was in one of the roughest places in newark new jersey and

she's this amazing surgeon but she always dressed up she never like looked sloppy she always was positive and if she ever had acted assertive you know they said that she was being a bee you know Like not, not, you got to be though. Yeah. And you have to, you have to control your own destiny. You have to make sure that who's going to advocate for you more than yourself. So she really was a proponent for herself. And that's why she got, she was successful.

But that's, you know, swimming upstream. And so I think it's harder. Have you seen that translate into her being a mother? I bet she's a badass mom. She's an amazing mom. She, um, and we have two boys and they're crazy boys. and they're crazy boys. They're like four and seven,

and they do things that, you know, I fly fish. I've been doing 15 years. Lily got me into that. She was doing it for 30 years, but I never grew up doing that stuff. And my seven-year-old, he catches trout on three flies.

He skis blacks. I never skied until two years ago. And so she's really big on giving them these experiences. If it's up to me, they'll like, you know, they'll hang out with me. I'll do the stuff, but I won't be thinking about, okay, let's go on a Disney cruise or let's, you know, go to Costa Rica and visit the Osa Peninsula with the boys.

It'll be nice for them to see birds of prey, you know, like things like that. And so she's a badass mom. I mean, I've heard about your wives and they're the similar DNA amongst them with high functioning husbands. That's great. Well, I appreciate you making the time to come over here, man. I know you're real busy. Yeah.

It was really awesome meeting you at the Epitai Congress. Yeah, absolutely. this was an interesting, fascinating conversation. Yeah, man. Appreciate you coming on, my friend. Absolutely, man. I'm really honored and let me know if you guys ever have, you guys can get my cell number, if you guys have hands.

I hope we never have to call you. No, but if we do, you're the man. I'm close to my number, sure. No, but the cool thing is, like, who you see on the billboards is not necessarily always the best person for things. And so doctors are connected with who they would go to. So take down my cell number if you guys have a lot of friends and family out in Cali. And so if you have issues or if you're worried about something, let me know.

Thank you. Appreciate you. Appreciate you. Thank you, man. Thank you, man. Thank you guys. Thank you for listening to Mind Pump. If your goal is to build and shape your body, dramatically improve your health and energy,

and maximize your overall performance, check out our discounted RGB Superbundle at Mindpumpmedia.com. The RGB Superbundle includes Maps and a boss. Maths Performance and Maps Aesthetic. Nine months of phased expert exercise programming designed by Sal Adam and Justin to systematically transform the way your body looks, feels, and performs. With detailed workout blueprints and over 200 videos, the RGB Super Bundle is like having Sal Adam and Justin as your own personal trainers, but at a fraction of the price.

The RGB Super Bundle has a full 30-day money-back guarantee, and you can get it now plus other valuable free resources at mindpumpmedia.com. If you enjoy this show, please share the love by leaving us a five-star rating and review on iTunes and by introducing Mind Pump to your friends and family. We thank you for your support, and until next time, this is Mind Pump.