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

Episode Date: July 29, 2019

In this episode, board-certified plastic surgeon, Zol Kryger, enlightens us about the frighteningly loose laws regulating the industry of plastic surgery, paving the way for a majority of cosmetic procedures being performed by doctors that are not board-certified plastic surgeons. We talk about some of the very serious complications that can occur even in “minimally invasive” procedures, where the incidence rate is only increased by the flood of non-certified doctors who want to offer these procedures to augment their income. Fortunately, Zol provides listeners with a very specific list of important questions to ask a surgeon when considering any of the many cosmetic procedures available. We then go into the specifics of the most common procedures and the risk of complications for each of them, including breast augmentation, tummy tucks, liposuction, Brazilian butt lifts, botox and fillers, facial peels and lasers, and more. By the end of this episode, you'll have a really clear understanding of what these risks are and how you can go about reducing those risks by choosing the right physician. We discuss: Why Zol chose plastic surgery [7:30]; The shockingly high percentage of plastic surgery being done by non-board certified doctors, and the laws that allow it to happen [11:20]; 10 Questions to Ask Your Cosmetic Surgeon (PDF Download) [21:00]; Complications: Why you must ask your doctor about potential complications and how they would deal with them [24:20]; Zol’s first complication, how he dealt with it, and how having a partner to check your work is great for the doctor and patient [32:30]; Breast augmentation: What you need to know—types of implants, complication rates, and Zol’s summary of the safest and most effective way to do it [39:10]; Breast reconstruction following a mastectomy [1:06:30]; Tummy tuck: How it’s done, biggest risks involved, scarring, and how it can address hernias and diastasis [1:13:00]; Liposuction: How it works, the potential complications and risks involved, and the importance of choosing the right doctor in the “wild west” of liposuction [1:26:45]; Butt lifts: Rising popularity, major risks, the frighteningly loose laws regulating the industry, and how the butt lift industry is eerily similar to the subprime mortgage crisis [1:37:00]; What is it about plastic surgery (and not other segments of medicine) that compels (and allows for) untrained doctors to offer these procedures? [1:49:45]; Peter asks Zol if he ever feels emotionally conflicted working in an industry that sometimes can feed off the vanity and insecurity of people [1:56:25]; Does Zol ever turn down patients? [2:02:45]; The risks involved with botox, fillers, facial peels, and laser treatments [2:07:45]; and More. Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/zolkryger/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top-performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peterottiamd.com. Hey everybody, welcome to this week's episode of The Drive. I'd like to take a couple of minutes

to talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on listener support. If you're listening to this, you probably already know, but the two things I care most about professionally are how to live longer and how to live better. I have a complete fascination and obsession with this topic. I practice it professionally, and I've seen firsthand how access to information is basically all people need to make better decisions and improve the quality of their lives. Curating and sharing this knowledge is not easy, and even before starting the podcast, that became clear to me. The sheer volume of material published in this space is overwhelming. I'm fortunate to have a great team

that helps me continue learning and sharing this information with you. To take one example, our show notes are in a league of their own. In fact, we now have a full-time person that is dedicated to producing those, and the feedback has mirrored this. So all of this raises a natural question. How will we continue to fund the work necessary to support this? As you probably know, the tried and true way to do this is to sell ads. But after a lot of contemplation, that model just doesn't feel right to me for a few reasons. Now, the first and most important of these is trust. I'm not sure how you can trust me if I'm telling you about something when you know I'm being paid by the company that makes it, to tell you about it. Another reason selling ads doesn't feel right to me is because I just know myself. I have a really hard time advocating for something that I'm not absolutely nuts for.

So if I don't feel that way about something, I don't know how I can talk about it enthusiastically. So instead of selling ads, I've chosen to do what a handful of others have proved can work over time, and that is to create a subscriber support model for my audience. This keeps my relationship with you both simple and honest. If you value what I'm doing, you can become a member and support us at whatever level works for you. In exchange, you'll get the benefits above and beyond what's available for free. It's that simple. It's my goal to ensure that no matter what level you choose to support us at, you will

get back more than you give. So, for example, members will receive full access to the exclusive show notes, including other things that we plan to build upon, such as the downloadable transcripts for each episode. These are useful beyond just the podcast, especially given the technical nature of many of our shows. Members also get exclusive access to listen to and participate in the regular Ask Me Anything episodes. That means asking questions directly into the AMA portal and also getting to hear these podcasts when they come out. Lastly, and this is something I'm really excited about, I want my supporters to get the

best deals possible on the products that I love. And as I said, we're not taking ad dollars from anyone, but instead what I'd like to do is work with companies who make the products that I already love and would already talk about for free and have them pass savings on to you. Again, the podcast will remain free to all, but my hope is that many of you will find enough value in one, the podcast itself, and two, the additional content exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. My guest this week is my very close and dear friend from medical school, Dr. Zal Krieger. Zal is a board certified plastic surgeon and a member of the American

Society of Plastic Surgeons. He went to med school with me at Stanford and then did his training in general surgery and plastic surgery at Northwestern in Chicago. He grew to med school with me at Stanford and then did his training in general surgery and plastic surgery at Northwestern in Chicago. He grew up in Israel, actually was born in Canada, I think. He grew up in Israel, high school back here in California, then went off to the special forces in Israel for three years before coming back for college and medical school. He specializes in facial rejuvenation with fat grafting and deep plane facelifts, abdominoplasty, breast enhancements, all sorts of complicated plastics and reconstructive surgeries. I wanted to talk with Zal at length because over the past, I don't know, a couple

of years, he'd send me stories or things like that about mishaps in plastic surgery. I was kind of shocked by them, actually. I guess I'm sort of oblivious to this world. And so I asked him, I said, look, why don't we just do a podcast together where we can go into some real detail on some of the common misconceptions about plastic surgery and above all else, provide listeners with a tool to, or set of tools really to help select the right plastic surgeons and to understand what the real risks are of a number of these procedures. And I will say this, I learned a lot during this episode and you'll hear it in my voice. There are at least three instances where he rattles off a statistic and I just can't believe it and I actually have to ask him to clarify it.

So we start by talking about the differences between a board certified plastic surgeon and basically anybody who can do plastic surgery, which turns out to be anyone who has a medical license. We talk about how you would pick a surgeon and what are the common misunderstandings and pitfalls that get a lot of people into trouble. But really we focus very much on breast augmentation, liposuction, the Brazilian butt lift, which I didn't realize prior to this procedure is not only as prevalent as it is, but perhaps more disconcerting than that is arguably one of the most dangerous plastic surgery procedures a person can have. I think by the end of this episode, you'll have a really clear understanding of what these risks are and how you could go about

thinking about it. The other thing we're doing in the show notes to this is we're going to create a really cool checklist that you could sort of download and print out because throughout each of the discussions on, you know, for example, a specific type of procedure, Zoll would sort of rattle off a number of ideas and facts that I think are just kind of worth having in your, in your back pocket. And then of course the section on how you really, what questions should you be asking a plastic surgeon? I think that's also, if nothing else, if you take nothing out of this, simply knowing that is valuable. And frankly, it applies to all of medicine, especially procedural medicine. So surgical, dermatologic, et cetera. Lastly, we close with the discussion about fillers, which

again, I would have thought that there is no possible way that a filler could actually pose harm to people, but it turns out sure enough, there is a way you could be harmed by fillers, which again, all comes back to making sure that if you're going to have these procedures, you have them done by people who really know what they're doing and have spent years and years training in the anatomy of this space. So without further delay, here's my interview with Dr. Zal Krieger. All right, Zali, thank you for coming to Malibu, man. Thank you. It's my pleasure. What a beautiful place. Yeah. I was thinking about this this morning because I woke up to the sound of these waves kind of crashing, which is a beautiful sound. But then I was like, oh, that's going to make for

a difficult podcast because we're going to, the microphones will pick this up. So anyway, I'll apologize in advance to all the listeners. Hopefully the sound of the waves hitting 10 feet from us is not too disturbing. I also heard a rooster crowing outside. I have a neighbor, he's an ER doctor. He lives right behind me and he has essentially a farm in his backyard. He has goats and sheep and chickens and he just got a rooster. So every morning at 5 a.m. rooster starts growing. We have a rooster across the street from us. We have chickens, but the rooster across the street and everybody that stays with us says, oh, does that rooster drive you nuts? Not only does it not drive me nuts, I love it. I love

hearing that rooster at 5 a.m. I'm not sure why. It's good if you wake up at 5 a.m., but if you wake up at 6 a.m., it's not so good. That might be the point. We have our own little rooster in the house that wakes up at 5 a.m., so yeah, the two go hand in hand. Well, I guess I should sort of introduce you a little bit to people today because some of the listeners will have already met Paul Conti through one of the earlier podcasts. And so this is sort of the process of me just introducing all of my med school friends to listeners. So in that band of knuckleheads that we were in medical school, it's possible you were the ringleader of the knuckleheads. I mean, I think that's anyone who's listening, who went to medical school with us will probably say you were the ringleader of that gaggle. And like Paul, you and Paul were the only two who on day one really asserted what you were going to do.

Most of us were leaning one way or the other. We might do this. We might do that. But Paul on day one knew he was going to be a psychiatrist and you on day one knew you were going to be a plastic surgeon. And I remember thinking about both of you guys. I was like, wow, how can they be so sure? Did you remember this? I do remember, yeah.

I actually think it's a great way to go through medical school knowing from the beginning what you're going to do. It helps you focus your attention and your plans as far as research and what you're going to spend more time learning, like anatomy as opposed to other subjects that you know you'll never touch again, like genetics, for example. But yeah, I did start medical school pretty much knowing what I wanted to do. I was influenced a little bit by my father, who began his training.

He's a physician in plastic surgery. And then some exposure to some other plastic surgeons that made me extremely interested in the field. It was actually the part of plastic surgery called microsurgery that got me most interested. Essentially, microsurgery is using a microscope to connect tiny fine structures like blood vessels and nerves, and I was very attracted to the idea of doing this delicate surgery. Other specialties like neurosurgery and ophthalmology do microsurgery as well, but it's a pretty large part of reconstructive plastic surgery. So that's what got me interested into it. And since then, my practice has evolved. I still do microsurgery, but I now do many other

things as well. I feel like before medical school, was it the two years prior or was it between high school and college? When were you in the army? After I finished high school in the United States, I went and volunteered to the Israeli army. And I spent three years in the Israeli army. And then I came back after that and went to university here and then medical school. Got it. Yeah. I am. I'm going to do my best to refrain from telling any of the stories of Orientation Week when we all got into so much trouble.

But the army ringleader, both you and Jason, and then Shayhab, the whole thing was quite a scene. We go through med school. We finish it. Explain to people what, because I think if you're a person listening to this, it's not entirely clear what it means to be a plastic surgeon versus someone who does plastic surgery. Lots of people can do plastic surgery, but there's a very specific type of training and there are generally two paths, correct? There are the sort of combined paths and then there's the sort of do general surgery first. So how does one pick how they're going to become a plastic surgeon? Well, in the beginning, when plastic surgery began as a field,

it was one of the surgical subspecialties. So like vascular surgery or heart surgery or cancer surgery, people first did a general surgery residency and then went and did a fellowship in plastic surgery. Since that time, it's pretty much become its own residency. So anywhere from six to seven years of training focused on plastic surgery with the first few years having an emphasis on general surgery, sort of learning the basics of operating and then focusing more on plastic surgery. You brought up a good point about there are many people who do plastic surgery who are not plastic surgeons. The numbers are probably 90 to 95 percent of all plastic surgery

done in the United States is not done by board certified plastic surgeons. So only a small minority is actually done by plastic surgeons which is mind-boggling to me to think of how complicated some of the things we do are, and to know that there are other specialists who are doing this without really having any formal training in it. Most people don't know, but in terms of the laws in America, any physician, once they receive their MD degree, can perform any procedure they want without any legal repercussions. So a family practice doctor who gets his MD degree, he's one month out from medical school, can decide to do heart surgery, can decide to do brain surgery. He can put a catheter up someone's leg. Now he's going to be

limited by a hospital that won't give him privileges to do it at. And so he's stuck doing things in his office. Or if he builds a small operating room, he can try and do whatever he does in the operating room. But legally, he's allowed to do whatever he wants. And so you have many physicians and even non-physicians all over the United States doing plastic surgery, primarily cosmetic surgery. And they're not breaking any laws doing this they're obviously not doing it in a hospital because hospitals are good at self-policing and regulating and making sure that only people who are board certified in that and with training in that specific procedure can do it so again back to the training in plastic surgery, it's a six or seven year program where

you focus mostly on plastic surgery, primarily reconstructive surgery. You're operating on the whole body. You're learning all the principles of plastic surgery. That's what I did after medical school. I did not know that it was that stark a contrast of the number of procedures being done or the relative proportion being done by non-trained plastic surgeons? I certainly realized that there were many non-plastic surgeons doing it. I wouldn't have guessed that. I would have guessed 50-50 or something. No, the numbers are really high and it's all about the money. I mean, this is all cash pay. None of it is done through insurance and it's a way for other specialists to augment their income.

is done through insurance and it's a way for other specialists to augment their income. So we see even in my community here in the greater Los Angeles area, hundreds and hundreds of physicians of all walks, gynecologists, ER doctors, general surgeons, family practice doctors, internal medicine, who have no training or no knowledge whatsoever, just decide, I'm going to start doing Botox, I'm going to do fillers, then they purchase a laser, then they do liposuction, first office base, then they're doing breast augmentation and other surgical procedures. It's getting more and more common. That I would have never guessed. I could sort of imagine screwing around with Botox, although even just a little bit I've

learned in talking to people who are really good at this, the difference between knowing what you're doing and not knowing what you're doing with Botox is enormous. And furthermore, eventually, if you have enough bad Botox, I mean, you only need to watch reality TV for one day to see what that looks like. So the results of this can actually be irreversible. I mean, you can get enough bad procedures done where even a good person coming along isn't going to salvage it. Absolutely. The classic example for this is a lot of these new liposuction type devices that use a laser or other type of energy to heat up the tissue. And a lot of this is done as an office-based procedure. And so we see multiple physicians out there of various specialties who buy these machines.

They have reps that come to their office and really convince them that it's the best thing out there since sliced bread. And they start using these devices and they can cause really unrepairable damage, primarily liposuctioning the abdomen and the thighs and just burning the skin and creating all sorts of contour irregularities that are just almost impossible to fix. Our term in plastic surgery is we call them liposuction cripples. They basically have essentially unfixable problems. Yeah, there was a famous example of this.

I remember, I can't remember her name, but she was a famous actress. Tara Reid. Yeah, yeah, yeah. Was she treated by someone who wasn't? I don't know who treated her, but she did have one of those types of liposuction done on her abdomen and that left her with these burns

of the undersurface of the tissue and divots. And when you see someone like that, it looks very strange. You know, it doesn't, it's not the appearance of someone who's lost weight or been pregnant. It's these strange contour abnormalities, divots, areas where it looks like someone just scooped out pieces of fat. There's a lot of people like this walking around who didn't do their homework and they're suffering the consequences. So the regulatory environment doesn't place a restriction on this, which means then it's up to patients to sort of be able to figure this out. But that's pretty hard, right? Because outside of, I mean, the most zeroth order question would be asking, did you train in the specialty to do X, Y, and Z? But beyond that, is it just a rule in your mind that only

a plastic surgeon should do something? Because clearly there are plastic surgeons who are probably not very good. And presumably there are people who are not plastic surgeons, but who can train very well to do certain limited things, right? It's a good question. And I think that there are definitely things that other specialties are trained to do and can do. For example, ophthalmologists have a subspecialty called oculoplastic surgery where they learn a lot of eye surgery. And I would be totally comfortable. I refer patients with complex issues to oculoplastic surgeons to do eyelid surgery. Then the question becomes, well, what if they want to do a facelift?

Some of them might be able to do that. They have the training., well, what if they want to do a facelift? Some of them might be able to do that. They have the training, they have the knowledge and the comfort, they know the anatomy. You have field, a subspecialty of ENT, ear, nose, and throat, which is facial plastic surgery. They're well trained in that to do rhinoplasty, facelifts, any of the facial procedures. Should those people be doing breast augmentation? Probably not. They have absolutely no training on any part of the body below the neck. So I do think there are examples where you can go to someone who is not a board-certified plastic surgeon for certain procedures. However, I think it's important to do good research. And, you know, it's tough. You have to know the right questions. It's interesting that I probably only get asked about once a year by a patient, are you board certified

in plastic surgery? People don't ask that. People are much more focused on what kind of person you are. Do you seem nice? Are you confident? Do you seem caring, empathetic? Do they have a connection with you? They care a lot about price. It's so amazing to me. I have a connection with you they care a lot about price it's so amazing to me i have a nurse who's worked for me for five years and she had some bad plastic surgery by someone else and wanted me to fix it and i told her i'd be happy to fix it i gave her the price i gave her a heavily discounted price obviously she's my nurse and she went to some other guy who essentially was one of the guys who botched her first surgery and he told her he would do it for much less cost he's not well

trained and he's not that good a surgeon and she ended up having surgery with him just a few days ago all based on the price even though his plan and my plan were completely different. She's seen me work. She knows that I'm a safe, good surgeon. She trusts me. And she decided just based on price to go with someone else. So when you see an example like that, here's someone who is in the field. They're constantly surrounded by it, yet they're going to allow something like money

be their determining factor on where to go. You have to imagine that for the average person out there who has very little knowledge, it's difficult for them to make the decision. I mean, people think that plastic surgery is like buying a luxury item like a Mercedes or Rolex watch, where it doesn't matter if you go to the guy at the mall or if you order it online. A watch is a watch, you know, a car is a car. It's not like that at all. It should be approached no differently than, you know, as I've heard you talk on your podcast with other physicians about picking the right surgeon for a heart surgery or brain surgery, picking the right doctor to treat any type of

medical problem. You have to do your research and make sure you're getting the right person. So besides asking if a person is trained in plastic surgery, boarded in plastic surgery, has had any lawsuits against them or files claimed, what other questions can people be asking? So if you had a friend or a relative in another part of the country and they weren't going to come out and see you, but they were going to go and scour the DC area, what would be the checklist you'd give them to narrow down their search? Some of the important questions are, how long have you been doing this procedure? How did you learn how to do this procedure? I mean, there's a big difference between saying, I've been doing this from the start of my residency. I did a six-year or seven-year

residency learning this. We did it hundreds of times. And then I've done it hundreds of times on my own since then. That's a big difference than someone saying, well, I didn't really learn this in my training, but I took a weekend course on how to do this. I would ask the person where they trained and what field they trained in. I think that's important. There's no doubt that you can be a great surgeon and train at a lesser known facility with someone who is a great teacher and has taught you well and you're a great surgeon and train at a lesser known facility as with someone who is a great teacher and has taught you well and you're a great student you don't have to be at the top program to become

a good surgeon but all these things add up i would definitely ask for referral from patients who've gone through the procedure to talk about it i would ask for pictures good plastic surgeons have a lot of before and after pictures of their work. That's a luxury we have that other surgeons don't really have. They can just say numbers. You know, my success rate at this operation is this. But in plastic surgery, we have photographs to show that. And, you know, a good question to ask is what if something bad happens to me? What's the plan? Where do you have hospital privileges? Do you have hospital privileges for this procedure? You know, the majority of plastic surgery

in the United States is done in small surgery centers, either owned by the plastic surgeon or owned by some other physician where they go and work at. And they're not equipped to take care of real serious problems. And so you need to know what happens if there's a problem. Do you have privileges to take care of real serious problems. And so you need to know what happens if there's a problem. Do you have privileges to take care of someone who has bleeding after a

tummy tuck? There's a gynecologist who does the full array of plastic surgery in my community. He has a lot of complications. If somebody said to him, are you board certified? His answer is, yes, of course I'm board certified. Now he's not saying I'm board certified in gynecology. his answer is yes of course I'm board certified now he's not saying I'm board certified in gynecology he is genuinely board certified just not in plastic surgery if you ask him do you have hospital privileges of course he has hospital privileges but he has privileges in gynecology not in plastic surgery so if he has a patient who has bleeding after a tummy tuck he can admit them to the hospital but he can't take care of them because he doesn't have privileges for that problem. The reason why the hospital privileges is such a good

question is we as physicians police the doctors who come and work at the hospital. So nothing kind of slips through the cracks. We check the training and the expertise and the knowledge and the malpractice history of every physician that gets on staff. So I'm on a credentialing committee at my local hospital. So we look at all this and you only grant privileges to the physicians that are safe and worthy of those privileges and then only for the procedures that they are adequately trained on. and then only for the procedures that they are adequately trained on. I think on that same thread, another question that probably is helpful is having them describe how they take care of complications. One of the things that happened when we were in medical school that you probably recall is certain states, I think New York was leading the charge,

decided to begin looking at cardiac surgeons and listing their mortality rate. And on the surface, that seemed like a pretty good idea, right? Which was, well, if you need heart surgery, you want to be able to look at the menu and see all of the heart surgeons in the state and know what their complication rates are. And so if you take 30-day mortality, which means how many patients that you operate on die within 30 days of the procedure, which usually means something related to the procedure. It's rare that someone has an operation and then 27 days later they get cancers and die. So it turned out that was a pretty lousy proxy because what you were doing was you had surgeons that would cherry pick the simplest

cases and the least sick patients. And in some ways, if you're having heart surgery, you actually want the person who has practiced operating on the toughest cases. What I think patients who were savvy figured out was, I don't just want to pick the person with the lowest complication rate. I want to understand how they manage complications. And this gets to your point, which is there's a very big difference between the ICU, when you're talking about heart surgery, that is, the ICU in sort of a podunk hospital that rarely sees complications versus the ICU at a major tertiary center where day and night it's very complicated, very sick patients, and you've got an entire team that can do it. So is there a way to sort of come up with an analogy in plastic surgery, which is

how often do you see complication X, and what is your protocol or path to deal with that? That's a really important question. And for us, our complications, we divide them into two parts, the early acute complications, which happen immediately after surgery, these are primarily bleeding, infection, fluid accumulation called a seroma, which we would usually see in, for example, a tummy tuck. And then the late complications. And the late complications are primarily aesthetic. So essentially, you just aren't happy with the result. You don't like how it looks. aesthetic. So essentially you just aren't happy with the result. You don't like how it looks.

So you want to ask the plastic surgeon what their incidence is of each type of complication. You know, how often do you have to take someone back to the operating room for bleeding? How often do people get infection after this surgery? And then if that happens, how do you manage it? It's a key point because someone like myself, i have my own operating room fully accredited operating facility so any complication that requires a return to the operating room like bleeding for example i have a facility to take care of this somebody who doesn't have a facility where they work at and they do everything in their office if they have a complication that requires a trip back to the operating room, they're stuck and the patient is financially stuck. I can do it at no charge for the patient and that's sort of included in their cost. Wait a second. I didn't, I never

even thought of that for a moment. So if a patient comes to you and they're getting a tummy tuck and the figure, it costs X dollars and they go home and then they call you that night and say, there's a lot of swelling here. You, you have them come back in, you look and you realize there's a blood vessel that's still, you know, bleeding. You operate on them in your suite and anesthesiologist comes back in, they're back under anesthesia, they're doing a whole thing that's bundled within the cost that, which makes sense to me, right? That should be. But are you saying that if a patient has a procedure with someone who doesn't have their own accredited OR and the complication has to go into a hospital, the patient is on the hook for that cost? Absolutely. 100%. And that's a big source. Do they end up suing the physician

after the fact? Absolutely. That's a big cause of lawsuits, money, obviously. And a big part of that is when there's a complication and then the patient is responsible for that. So there would be a circumstance, for example, if I have a patient and they have to go to the emergency room, they're going to have to bear some of the burden of that cost. I'm not going to cover the cost of their trip to the emergency room, but most complications after surgery, I can take care of in my clinic. So that's a key thing to work out ahead of time with the surgeon. What, how are these complications managed both in terms of the actual management, but then from a cost standpoint, how are they managed? And that's something you have

to work out. And then for the long-term issue, you know, what if there's a problem with the scar? What if there's a little extra skin on one side? What if it's a little uneven where they had the liposuction? Whatever the issue is, one implant is higher than the other. How do we address that? I'm not happy. And that's something you have to work out. And I think that's less of an issue of the training of the plastic surgeon and more the individual's integrity and sense of, you know, what is morally correct and fair to do with the patient. And it varies, you know, there's no right answer. For some problems, I fix it at no charge. I say, this is clearly, you know, I'm a big, strong believer in admitting when you're wrong. I think, this is clearly, you know, I'm a big, strong believer in admitting when

you're wrong. I think patients want that. And that's, in my mind, a sign of a good surgeon with humility. If I did something wrong, I will say to the patient, I made a mistake here. This did not turn out well. For example, one of your implants is higher than the other implant, and that needs to be corrected. And I'm going to correct that at no charge. If it's an issue where nothing was done wrong, but the patient is just unhappy with the result, the implants are too small. I want larger implants. Then in that circumstance, I might do it at no charge in terms of my fee, but I'll make them pay for the new implants and the cost of the operating room and the anesthesia. So I think it depends. It's on a case-by-case basis, but these are all really key things to hash out ahead of time

with the surgeon. That's an interesting point you raise. I remember in medical school, not medical school, I'm sorry, in residency, and I think I've even discussed this on previous podcasts, there was this real sense that if complications took place, you weren't really permitted to speak with the family after and things like that. And I always found that interesting because I think the research was pretty clear that patients didn't sue necessarily in proportion to the error. They sued in proportion to the lack of communication and the friction with the treating team. So a team that, you know, a physician that was very arrogant and non-communicative after a complication is much

more likely to be sued than sort of admitting that you've made a mistake, which is very counterintuitive in our culture, right? To be able to say, I made a mistake here and let's figure out how to fix it. And it turns out that's less likely to elicit a lawsuit. Yeah, absolutely. I've found that in my own practice and observing other doctors as well. I think that people in general, they just want honesty. They want honesty from everyone around them and they want honesty from their doctors. And you just have to be honest. If something happens, if there's a complication, you have to be honest about it. You have to talk about it. You can't run and hide from it. I mean, I've heard other people you've talked to on the podcast, like Eric Shab talked about this. You have to embrace your complications and not run from them. And people appreciate that. And you're absolutely right. They don't

go after doctors in a court of law or in any other way just because of a bad result. It's more how they feel, how they feel they're treated, how it's dealt with. I think that the financial aspect of it is a major part of distress and unhappiness on the part of the patient. And so it's really key as the doctor to make sure you do what's fair and you stand by your work. I mean, sometimes it's worth it to eat some money and not make a profit on a case if it means that you're, you're doing the right thing for the patient in business in general. I mean, we see this in all areas of business. You just have to be smart about it. You finished your residency in 07, finished your residency in 07? 2008. 2008. So do you remember the first time you were in,

because it's a pretty scary thing, I'm guessing, when you go from doing that last case as a fellow where, yeah, you're actually doing the entire case, but there's an attending surgeon nearby, to now you're the surgeon of record. You know, that first case when you are on your own, do you remember the first complication you had where it was 100% you? I think it's hard to sort of ever say, well, a complication is 100% on the part of the surgeon. But I do remember early on in a microsurgery case very soon after completing training where inadvertently cutting a blood vessel that you were trying to preserve and then spending a couple hours under a microscope trying to repair a blood vessel the size of a toothpick. You know, when you're doing microsurgery, you're working with structures that are very small and very delicate. And you have this

device called an electrocautery or BOVI that emits heat and is used to coagulate blood vessels. And if it gets too close to one of these blood vessels, you can damage it. And so some of the surgeries we do, specifically like breast reconstruction after cancer, we're relying on one tiny little blood vessel to keep the tissue alive. The blood vessel is essentially one to two millimeters in diameter. And if you get too close to it with a cautery, you can damage it. And so I remember doing that on one case and then having to repair that blood vessel. It's extremely tough. It's humbling because you have no one to turn around to. Like you said, there's no attending physician who can bail you out. I'm very fortunate

in my practice because my partner is my brother. He's also a plastic surgeon. We trained in separate programs at the same time. You know him well. He's the better looking of the two, right? He's a year younger, but everybody thinks he's older. I actually had a patient who asked me, is your father going to help on the surgery? I took out my phone and I said, could you say that again so I can record that? So I tease him about that. But he's a year younger, but we trained at the same time and we do a lot of our surgeries together. So it's a big difference when you're by yourself versus having someone else to kind of work it out and and at this point now we've been in practice 11 years together and I think we've started to really

figure it out but we still do a lot of surgery together because there is no doubt I mean there's a reason why two pilots fly the plane each one knows how to do it alone but when there's another person double checking everything you do and offering a slightly different view and opinion, it makes a world of difference. That is pretty unique. I know a lot of really good plastic surgeons, but many of them do, they don't have that luxury. I know because I've been to your surgery center and I've seen you and Gil there, and I've just seen you even discussing the most mundane case. And I remember once you guys were discussing a case that I couldn't believe you would tag team. Cause I could see if you were tag teaming like a flap, you know, like one of these really complicated cases where you're going

to be under a microscope for hours and the stakes are really high. But I remember the case that you guys were discussing was like a breast augmentation and a hernia repair or something like that, which again, I think most plastic surgeons would bang out, you know, many of those in a day and think nothing of it. But it was very, I really do. I'm glad you brought this up because I remember being struck by how lucky it was for the patients that you could be doing that, which is wow. Every case is what we call a two attending case. Yeah, absolutely. I mean, you know, if you just think of any complicated process that has so many variables and so much thought has to go into it, it's clear one person can do that by themselves and is perfectly capable and trained to do that. But when you have another person, everything you look at in life, there's various perspectives and

someone who's standing right next to you is going to see something just a little bit different. What's great about in our practice is that some of his strengths are my weaknesses and vice versa. So as an example, I'm a much faster surgeon than he is. And I'm probably also a less patient surgeon than he is because I'm faster. So I want to get through the surgery and get on and move on. And I believe a lot that in speed actually comes efficiency and safety. And so I don't believe that when you're going faster, you get sloppy. I think in many ways, the faster you go, and we know this from many studies, the less complication rate you have. So there's a lot of advantages to being with a fast surgeon.

However, he's a very slow methodical surgeon. So as we reach the end of the case where it's easy to kind of think, well, we're near the end, let's just speed up. There's not much to do. He'll still be putting in the same amount of thought as he was at the beginning of the case, and he'll force me to slow down and won't allow any corners to be cut or anything to be done less than perfect. And so I really appreciate that about him. On the same account, you know, the fact that I'm faster and more decisive, I think, helps him because when he is managing the case and he's the primary surgeon on the case, then being able to sort of decisively say, I think this is what we need to do. Let's move forward is really important because in surgery,

you always want to be moving forward. I mean, as you know, you can go off on a tangent and two and a half hours later, you haven't made much progress. And for the patients, the longer they're under anesthesia, the longer they're on the table, the higher the complication rate. And so you want to be efficient, especially with larger surgeries. You know, we do surgeries, we do microsurgical reconstructions together that can take us 12 hours or eight hours, the same operation. And sometimes we're just in shock, like, how did that just take 12 hours? You know, last week we did this in eight hours. like, how did that just take 12 hours? You know, last week we did this in eight hours.

And it's, that's a big difference, both in terms of the toll it takes on us physically, and also the risks for the patient being under 50% longer. Yeah. Yeah. The risk of anesthesia, a lot of people don't appreciate that. And I remember having great senior residents in residency that really made that point, which is, look, it's, you know, you're, you're in here to work as quickly as you can safely for that reason, simply less exposure to anesthesia is better. Let's talk about a couple of operations, maybe in a bit more detail as ways for people to understand how to go through the process and maybe even just be better equipped to know what the complications are. I'll give you an example. Let's start with breast augmentation. Let's separate this from breast reconstruction following, say, a mastectomy. One I know had a breast augmentation and,

I don't know, several months later, she told me she had developed this complication where there was some contracture around it and the implant was sitting very, very high. What's the name of that? It's called capsular contraction, capsular contraction, which I'd never heard of. But of course, why would I have heard of this? I don't know anything about plastic surgery. And I was like, huh, that's really odd. Did you know this was a potential complication? And she said, no. And I said, this wasn't discussed in the consent for the procedure. And she said, no. And I said, well, what does the surgeon propose to do now? And she said, just to repeat the procedure and the, you know, the probability of it happening twice is pretty low. And I said, okay, I mean, I guess so. And the surgeon, I think had taken

the approach that you described, which was, you know, he was on the hook for this a hundred percent. So, so I don't actually think this is a criticism of the surgeon at all. So he repeated the procedure and sure enough, it happened a second time. And at this point I was like, wait a minute, I think you need to get another opinion before you go back and start fixing this. So, and I remember actually talking with you about this, but let's just start with that as an example. What, what is this? What's the frequency with that as an example. What is this? What's the frequency with which it occurs? Why does it occur?

How should it be managed? So, capsular contracture is the most serious complication, long-term complication from breast augmentation. And the incidence is anywhere from 2% to 8%. And like with a lot of... That's a pretty broad range. Yeah, it's a broad range. And it varies based on the surgeon. It varies based on the implant type. Some implants have a lower complication rate. Some types of breast augmentation have a lower complication rate.

For example, there are saline implants and silicone implants. Traditionally, saline have a lower complication rate, closer to 2%. The silicone have a lower complication rate. Closer to 2%, the silicone have a higher complication rate. The implants can go under the muscle or on top of the muscle. Implants put in under the muscle tend to have a lower capsular contracture rate because the muscle provides some sort of protection from it. Implants on top of the muscle have a higher capsular contracture rate. It's really the thing we're trying to avoid the most in plastic surgery. And some surgeons have a higher rate. Essentially what it is, it's the formation of scar tissue. Anytime you put a foreign body

inside of a human being, whether it's in their knee or implant in the breast, the body forms a reaction around it to wall it off, and that's scar tissue. And that's called a capsule. Normally, it's supposed to be soft and pliable like a balloon. But if the body forms an abnormal capsule, it becomes hard and it contracts or squeezes down on the implant and causes pain and distortion and this typically displaces the implant up higher so the side that's contracted the breast is very hard it looks strange the implant sitting higher it even looks smaller because it's being squeezed by this scar tissue and it can develop within months after surgery it can take. We still don't know exactly why it happens. We think bacteria are the culprit. Meaning bacteria are leading to an aggravated response. Correct. And it's strange

because there are women who go many years without a problem. Their breast is soft and their breasts are symmetrical and everything is normal. And then suddenly they develop capsular contracture. We think the bacteria are coming from somewhere else, for example, they have a sinus infection, and then a few months later they get capsular contracture, or they had mastitis, and then they get capsular contracture. Do you see a higher incidence of it in women who go on to breastfeed after? Yes, not significantly, but there definitely is. And especially if they have, if they develop some type of breast infection after having implants, we see the majority of capsular contracture cases happen early within six months of surgery. And that's probably due

to bacteria that get in there at the time of surgery. This is an interesting point, isn't it? I remember first realizing this during a rotation of orthopedic surgery Which was just how high the stakes are when you're putting a foreign body And especially in orthopedics into a joint space I mean absolutely because if you know, it's funny like people think well surgery is all done very sterile I don't think there's a procedure that's done under more sterile conditions than joint replacements Because that's where they're wearing the spacesuits, which we think were the funniest things in the world, to just take it to that level. So again, it speaks to the nature of

how privileged is the site and are you actually leaving something foreign inside? Exactly. And complications that occur early on, such as bleeding or buildup of fluid, is an excellent medium for bacteria to grow in. So if you have a woman who has a small hematoma, a small amount of bleeding on one breast, that woman has a significantly higher risk of developing capsular contracture. And the reason is probably that blood that's bathing the implant is a great medium for bacteria to grow in. So, you know, there's a lot of strategies that are recommended and that we take to minimize the risk of this happening, but yet it still happens in a

certain percentage. Back to your patient, actually the data shows that if you get it one time, the chance of getting it a second time is higher. Yeah. In the end, I believe what happened with her was the third procedure, she went to someone different. I don't actually recall what they did different. If they, I don't know. Anyway, the fortunate thing is at least a year or so later, she's totally fine with the third operation. But I remember thinking, God, if this happens a third time, I don't think you have a choice, but to just remove the implants and be done with it. Absolutely. I mean, that's usually the best treatment.

A lot of women are not willing to do that. So they're just going to keep looking for additional options. Okay. So would you say that's the largest long-term complication of a breast implant? So that is the most common long-term complication. There are some situations where the implants can rupture. The saline implants notoriously leak or rupture because they have a little filling port that saline can leak out of that usually starts around 10 to 15 years after. The new silicone implants

are made extremely well and they rarely rupture, but it can happen. When they go back and analyze those implants, most of those implants were damaged at the time of insertion by the surgeon, and that weakened the implant and led it to go on and rupture. But rupture is probably less of an issue than the capsular contracture. One of the things that I wanted to talk about, which is a rare complication, but we're seeing it more and more, and it's scary, is called ALCL, and that stands for anaplastic large cell lymphoma. And this is a type of rare cancer that we're seeing in women who have breast augmentation. Interestingly, it only happens in implants that are textured. So implants can be either smooth on their surface or rough textured

on their surface. There's a number of reasons why they develop these rough textured implants, but for some reason, the texturing triggers this autoimmune type response where they not only develop capsular contracture around the implant, but the body sort of goes haywire and develops this lymphoma. It's similar to a cutaneous lymphoma, which is a lymphoma of the skin. So it's not as high risk for metastasis and invasion as a typical lymphoma can be, but it's a type of lymphoma and it occurs in the capsule that surrounds the implant. It can invade into the breast. And when we started to see these cases, the first one was sometime around 10 years ago, they found. We, since that time, have seen hundreds of cases worldwide. Initially, we were

telling women the incidence was maybe 1 in 300,000. Now they know that with certain implants, it's actually one in 3,000. And to be clear, there are no cases of this in non-textured implants? Correct. All the cases have been only in textured implants, none in smooth implants. So presumably the FDA has to weigh the risk of that because these textured implants are still permitted in use? They're still permitted. They still account for a large number of implants being used. The FDA just met a couple of weeks ago in April 2019 to review all this, and they decided to let them stay on the market. The European FDA actually pulled a number of the textured implants off the European market. So only allowed smooth implants to continue and just said, there's no point. And I think it's, you know,

if you had no other option, you could argue we should keep these implants on, but the smooth implants can do essentially almost anything. What's the advantage of the textured one? The advantage of the textured one is not clear. In my opinion, there is no advantage. But initially, they found a lower rate of capsular contracture with the textured implants. Now, you have to be really careful. I think of any physician I've ever known, you're one of the best at understanding that data can be very misunderstood and misread.

And one of the issues we have in my field in particular is that a lot of the studies done on implants are done by plastic surgeons who are on the payroll of the implant companies. And so the implant companies are paying hundreds of thousands and even millions of dollars to plastic surgeons to do studies. And these plastic surgeons have a significant financial interest in the result of the studies. And these plastic surgeons have a significant financial interest in the result of the studies. And you really have to question whenever the researcher has such a big financial stake in a certain finding. And because textured implants are more expensive, and a lot of these plastic surgeons would make, were essentially making money on the implants, they wanted a finding that showed that textured

implants were better. And I've reviewed the data. I do not believe there's still a big discussion and ongoing controversy in the field of plastic surgery that whether or not textured implants do have any benefits, do have a lower rate of capsular contracture. There was an interesting study done not by a plastic surgeon, but by infectious disease doctors and pathologists, where they took a bucket of dirty bacteria-laden water, and they put a smooth implant in it, and then they put a textured implant in it, and the bacteria are 70 times more able to stick to the textured implant than to the smooth implant. A smooth implant,

if you pour water on it, it just rolls right off. It's smooth. If you look at it under a microscope, it just looks like a desert flat. The textured implant looks like the Grand Canyon, all these rocks and crevices. So bacteria can stick much more readily onto it. And that's been proven and replicated. If you then go a step further and analyze the capsules, both in cases of this ALCL lymphoma and in cases of capsular contracture, the capsules are full of bacteria. And so you say, okay, well, we think bacteria cause capsular contracture. We know that they stick to textured implants much better. How could you tell me that textured implants have a lower rate of capsular contraction? The answer is they probably don't. And what's the difference in the cost of equally sized implants that are textured versus smooth? It's probably about 20 to 25 percent. And you alluded to this a second ago, but again,

I didn't even realize this. this is how naive I am. Of course, a surgeon gets a surgeon's fee, but I didn't realize that a surgeon makes that part of their compensation is based on a percentage of the cost of the implant. So, you know, most surgeons will mark up the cost of the implant. So if the implant's more expensive, they're going to make more profit. But I think for a lot of these plastic surgeons who were doing the research in the implant companies, they were getting money from the implant companies. I was recently at a plastic surgery meeting. One of the highlights of any meeting I've ever been to, they had a panel of experts

talking about textured versus smooth implants. And they had all these world famous plastic surgeons talking about the benefits of the textured implants and why they have better results. And then on the smooth implant side, this woman came up, she's a major leader in the field of plastic surgeon. She's a Canadian plastic surgeon. And she's never taken a dime from any company, any implant company or anything else. She's authored textbooks. She's absolutely brilliant. I've had a chance to meet her and see her. What's her name? Elizabeth Hall Finley. And she's one of the premier leaders in the field of breast surgery. She lives in Banff,

Canada. And she was up there on the panel. And she basically got up and she put up one slide. And it was a slide from a website called the sunshine act which essentially shows how much money every doctor in america has been paid all the way from ten dollars up to millions of dollars from industry and she had the names of the doctors and the amounts of money and she had the names of the doctors on the panel going from three million dollars at the top to like 150 000 on the low end and she just put up the slide and then she just walked off that was her that was her that was her presentation and i was dying i was loving it because i've i've very for a long time believed that as honest as you want to be as a doctor,

when there is money involved, when you have a vested interest in the result of a study showing something and you will lose money if something else comes out of it, you can't trust yourself. I mean, there's just such inherent bias in that. Yeah, I agree with that completely. And it's really, it's so frustrating to be that critical and to realize that you can't even trust yourself. And that's a hard leap to take. But you really are correct. I think the only way to protect against that is to take yourself out of a position where there's a conflict. specifically with the textured implants, what I believe led to a lot of the data, and this is understanding the difference between correlation and causation, which I've heard you talk about a lot before, is that there is a newer type of implant, and they call it the gummy bear implant, and it's a teardrop-shaped anatomic implant. So most of the implants we use are round, but these newer implants are

teardrop shaped. They were designed, they came out in the year 2000 in Europe and the FDA approved them around the year 2010 in the United States. So for the first 10 years of their development, they were only on clinical trials in the US, but they were being used regularly on hundreds of thousands of women in Europe. 100% of these teardrop-shaped implants are textured. And the reason for that is that because... You have to hold it in place. You have to hold it in place. If it rotates, it will look odd and it needs surgery to fix it, as opposed to a round implant that you can allow it to freely rotate. Let me ask a dumb question. Couldn't they make them smooth,

but put little tethers on the side that you could suture into place? Yes, they could. And they tried that. And we have that with other types of devices that we use. And that was an option. And I think that's something that could come in the future. Absolutely. And some surgeons experiment with putting tabs on the back. But these teardrop shaped implants, the reason they developed them is they said, well, the breast is not round. The breast looks more like a teardrop. So let's make an implant that matches the breast. It'll be more natural. So they started to use these in Europe. These implants require a larger incision to place. And so European women in general have smaller breasts

and smaller areola sizes than women in the United States. Wait, why is that? Genetically. You take countries like Northern Europe, like Norway and Sweden, these countries, the women tend to have smaller areola than a lot of the women here where our population has black and Hispanic women, which are going to have larger areola than a lot of the women here where our population has black and Hispanic women, which are going to have larger areola size. So the fact that you need a larger incision necessitated switching from a very common incision for placing the implant, which is through the nipple, to making an incision underneath the fold of the breast. So by switching to this incision

and putting in all these textured implants through this incision under the fold of the breast. So by switching to this incision and putting in all these textured implants through this incision under the fold of the breast, the surgeons are bypassing a lot of the normal bacteria that exist within the breast. And so they're probably introducing fewer bacteria into the pocket around the implant. So I believe, and there's now data to support this, that the lower rate of capsular contracture with textured implants is due to the incision being made in a safer place that has less exposure to bacteria and not because of anything inherent about the implant. So when they looked at the data of these women in Europe and said, wow, these women have a lower rate of capsular contracture with these new implants. It must be that these new implants

have a lower rate. There's something about the implant, but they're ignoring this secondary issue, which is, well, they were all put in through this incision. And in my own practice, I've followed data on thousands of women, and we found that we definitely have a lower rate of capsular contracture when we go through an incision made underneath the fold of the breast, as opposed to the nipple. The trials in the US, because you said that there was about a decade when these were being used in Europe, but there were trials going on in the US. Did the trials in the US randomize to, because you basically have a, you have many options, but at the very least, you'd have a two by two, which is textured, non-textured, and then the two incisions.

And if you did enough of those under random conditions, you would pretty easily be able to tease out if there's a difference. Yeah, that study was never done. One thing that was done that was very interesting was a study where the reason why they developed these teardrop-shaped implants, they thought they would look more natural. And so they did an interesting study where they showed at a meeting, a plastic surgery meeting, they showed the plastic surgeons in the audience 100 pictures of women who've had breast augmentation. And they told them 50 of them were with teardrop

shaped implants and 50 were with round implants and they wanted to see if they could tell and the plastic surgeons were only right 50 of the time so it's in fact kidding me yeah so it's in fact so here we are the experts where and i've found this many times i've shown my brother a picture of results and i said you like this you? You think this is great? Wow, it looks so natural. What implant do you think we use? That's got to be a teardrop shaped implant. Nope, it's a round implant. And so, you know, there's many other factors that lead. Wait a minute, that is the most stunning thing you have said so far in this discussion. And you've already completely surprised me several times. It's hilarious because once that study came out and that was replicated, suddenly we realized, and this study was done several years ago. And so I've

mostly abandoned the teardrop shaped implants because the benefit we thought they had, which is they give a more natural result is, is complete BS. It's not true at all. And this has been proven and, and secondarily, they have disadvantages. Number one, they're textured, so they have this risk of this lymphoma. They're more expensive, they can rotate, and they're harder and firmer to maintain their teardrop shape. And so they feel less natural when you touch them. So with only one supposed advantage and all these disadvantages, I've essentially stopped using them.

And I think that's where things are headed. They were very popular when they came out in 2010, and the numbers are decreasing. I know that there's, at this moment in time, you've got, there's going to be women listening to this who are in the process of considering this. And so this forward-looking input is helpful. But invariablyably there will be a woman listening to this who already has an implant that is teardrop shape and that is textured. Is there anything that that woman needs to do to be, does that woman need to be concerned?

Or if she's doing okay, she's probably one of the lucky ones. I mean, statistically speaking, most women are going to do fine with these implants and hopefully the complications when they happen are in the past, but is there some sort of surveillance or ongoing concern or consideration for women who have had said implants? I think that these women should see their plastic surgeon at least once a year and maybe even every six months. I don't think they need to run and replace the implants if there's not a problem. Most of the cases in these patients who have this, develop this lymphoma, and again, the incidence is between 1 in 3,000 and 1 in maybe 10,000. We don't know the exact number because not all plastic surgeons report the

findings. And so there's not... Are they not required to? No, there's no law requiring it. There's a database where they beg and plead that we do this. But again, the access to that is mostly coming from the American Society of Plastic Surgeons, which is only targeting board certified plastic surgeons. Like I told you before, you have all these other non-plastic surgeons doing breast augmentation. What's the percent, when it comes to breast aug, what percent do you think are not being done by board certified plasticians? In that procedure, only about 15%. So most of them are being done by board certified plastic surgeons. But there are still cases where these other groups are not reporting any patients where they find this. And they don't even know about it and know how to test for it and do the proper studies if they suspect it. But they have to see their surgeon once a year. There usually are going to be other signs like significant swelling of the breast involved, hardening of the breast. So the

women tend to get capsular contracture first. So as long as there's no problem, I think these women are fine and safe and they don't need to freak out and rush to change out those implants, but they should watch them. They might want to consider getting an MRI every few years just to check on things. They should be doing monthly self-exams to feel for any masses. So sort of just the regular stuff a woman should do with her breast in general. But again, the incidence is low, but it's something you have to be aware of if you have or are considering getting a textured implant. So we've basically said, let's put aside textured implants, let's put aside teardrop-shaped implants.

That means we're focusing on round, smooth implants. Do you have a point of view prospectively on silicone versus saline? The saline implants were developed in the 90s when silicone implants came off the market. Which is like one of the greatest screw-ups in the history of medical regulation against a tech. Right. It was an example of how a single newscaster on ABC, Connie Chung, could bring women on the show crying, blaming their problems. I mean, we've seen this with vaccinations where one person said they cause autism and next thing you know, you have thousands of children not getting vaccinated because of this fear and then it's disproven, but it takes a while. but it takes a while. There's a great quote and I'm going to bastardize it but the gist of it is a lie can travel around the world faster than it takes the truth to put its shoes on. That's very true. So the silicone implants came off the market. They were a bad product, the old silicone implants. The silicone was liquid. If you poked a hole in the implant, it would drip out like honey. Then the new implant

companies, Mentor and Allergan are the two main companies. They started making new silicone implants, which essentially became widely FDA approved in around the year 2000. And so for almost 20 years now, we've had these newer generation silicone implants and they're quite good. I mean, they look and feel more natural. They're softer. You know, a saline implant is a shell of silicone filled with salt water instead of silicone on the inside. And so the outside is still silicone, but they don't look as natural. They don't feel as natural. They're essentially like a water balloon. They have a higher incidence of rippling and they don't last as long. They start to leak after 10 to 15 years, although there are definitely women that can go longer. They're a

little bit cheaper than the silicone implants. So I still recommend and primarily use silicone implants. I think the women who have saline implants and go to replace them, they're a good candidate to stick with saline because if they have it and they like it and they're happy with, good candidate to stick with saline because if they have it and they like it and they're happy with there's nothing wrong with continuing to use it. Okay so now we've said again going forward your preference would be smooth round silicone. Two more points just to get your point of view on one is location of incision and above or below the muscle. You've sort of talked a little bit about these but again what's your view prospectively? As I said earlier, I pretty much now do almost all my implants through an incision underneath the fold of the breast.

It's a hidden incision. There are patients where it's going to be more visible, but again, we're trying to avoid capsular contracture. That's the worst complication. And if we believe that bacteria are involved with that, then we want to avoid that. And so an incision through the armpit or through the nipple, you're making an incision in a location where there are more bacteria and you're cutting through nerves, both in the armpit and in the nipple. And studies show that there is a higher rate of pain and numbness and issues associated with going through

those two sites. So I try to dissuade patients from using anything other than an incision under the fold. Do you let the patients decide ultimately? I let the patients decide, but I present a strong argument based on my own experience and the data that's out there. And I think most people, they're willing to listen and do the right thing. I also put most of the implants in under the muscle or behind the muscle as opposed to on top of it. And there's a lot of data that supports the benefits of that. And I think for most women, it just, they like the fact that it looks and feels more natural to have the upper part of the implant covered by the muscle. It's better for

mammograms. It's better, God forbid forbid if you develop breast cancer it has a lower rate of capsular contracture it helps support the weight of the implant as opposed to the implant just stretching out the breast when it's sitting on top of the muscle so there's many advantages and and that's what i do and a lot of plastic surgeons do that as well what percentage of the breast surgery you do is augmentation for cosmetic reason without cancer versus reconstruction and or augmentation following cancer surgery? Probably 75% is cosmetic and 25% at this point is reconstructive. In that situation, the latter, meaning the reconstructive, what are your options? Because

you can also use tissue flaps and it gets much more elaborate in that situation, doesn latter, meaning the reconstructive, what are your options? Because you can also use tissue flaps and it gets much more elaborate in that situation, doesn't it? Right. I mean, there's various options. You can use a woman's own tissue in the form of a flap where traditionally we take the tissue from the abdomen and make a new breast out of it. You can use fat and essentially just inject the fat in a series of treatments where you graft the fat into the site where the breast was. We use implants, and that is one situation where we might still consider to use teardrop-shaped implant. Because I think in a reconstructive patient, they're one of the few situations where there still is some benefit. And that's actually the only situation where I'm using the teardrop-shaped implants is for breast cancer reconstruction. Those women have a lot of

monitoring and everyone's on top of them because they've had breast cancer. So my concern with them is less about developing some type of lymphoma. I also think that because they've had a mastectomy, their body's ability to mount this autoimmune type response is lower because their lymphatics have mostly been cut. And so I'm a little bit less concerned, but of course we still watch those women closely. When we meet with women who have breast cancer and who are going to undergo breast reconstruction, we talk to them about the options, what their goals are. going to undergo breast reconstruction. We talk to them about the options, what their goals are.

A lot of it has to do with what type of recovery they want. The flap or autologous tissue-based procedures where we use a woman's own tissue have a much bigger recovery as opposed to just putting in implants. And a lot of women aren't willing to undergo that. What is the advantage of the autologous? Does it look better when you have a flap? Does it look more natural? It does look more natural. And the main advantage is you never have to deal with an implant and the complications associated with the implant for the rest of your life. You know, you can't reject your own tissue. It's soft, it's natural. And it's especially good for a woman who's only doing one side where she has a natural breast, especially if it's more of a flat hanging breast on the other side, it's hard to match that with an implant. If a woman's doing both sides, we'll usually lean more towards implants. But again, it's really on a case-by-case

thing. And how often do women in that situation require tissue expanders? And is it often a multi-stage procedure? Or what's the sequence of events from the mastectomy to the reconstruction? One of the things that's changed a lot in the field of breast cancer, you know, when you go back to the beginning of the mastectomy, one of the great mentors and great surgeons, Halstead, who I think was from your alma mater, he initially thought that you had to cut everything out for breast cancer and he would remove all the skin, all the breast and the muscle. And the muscle, yeah.

And everything. And where we've, yeah, and where we've come to today is to a nipple sparing mastectomy where essentially a lot of women are candidates for removing the breast, but keeping all of the skin, including the nipple behind. In that case, you can go directly to an implant reconstruction because you're not trying to manufacture new skin. In the case of women who have to have their nipple removed, so you're removing a portion of the skin, you need to now restore skin that's been removed in the mastectomy. And that's where a tissue expander comes in where we stretch out the skin and that's a multi-step process that takes a few months until we put in a final implant. Wow. You know,

I was talking with somebody about this recently and they made a point about there's no analogous cancer, I guess, that is where you're dealing simultaneously with the cancer risk, you know, you have to remove this, these cells, but also sort of the, the threat to your psyche and the threat to your image. And even if you look at something like testicular cancer or prostate cancer, it's not quite as visible in terms of the change that, that you're going through. I mean, obviously there's functional deficits that occur, but do you find yourself dealing with the psychology of that? I mean, dealing with a patient who's sort of shell-shocked and going through this simultaneous loss, right? Like the loss of this tissue and the cancer risk, but then the loss of part of my

femininity. Yeah, absolutely. I remember when I was starting out in practice, I somehow, I don't remember the circumstance, but there was a woman who was part of my team, whether it was a nurse or a PA, was in the room with me with a breast cancer patient. And the patient started to cry when we started to talk about her diagnosis and the treatment. And I sort of sat there, you know, a little uncomfortable, not sure what to do, and she was crying. And the woman who was in the room with me, the nurse, if it was, she grabbed a tissue and gave it to the patient and then hugged her. And that episode really stuck in my mind because it made me feel inadequate at the time. And I didn't know if it was because I was a man or because I didn't have breasts and hadn't

undergone breast cancer, or I didn't have a family member who'd had breast cancer. I wasn't sure what the reason was. I hadn't received the adequate sensitivity training, but I just felt inadequate to deal with it. And I think since that time, I've become better at developing the empathy and the understanding for what these women are going through. A lot of it has come through getting to know the husbands and the understanding for what these women are going through. A lot of it has come through getting to know the husbands and the children and the parents where, you know, I talk to them and spend time with them and kind of get a better feel as the man what they're going through. It's a very complicated process and a lot of good hospitals have social workers and psychologists

that help the women. We're seeing more and more breast cancer in younger women these days. So it's a very devastating thing. I mean, for a lot of women, they associate their femininity to a large degree with their breasts and losing that has a profound impact on them. That was a pretty awesome summary, at least to me. I think I learned more about breast reconstruction in the last few minutes than I've ever known. Let's turn our attention to another operation. What would be sort of another very common operation that shows up liposuction or your pick? Yeah, I think a tummy tuck is one of the top five procedures along with breast augmentation and rhinoplasty, facelift, liposuction. Okay. So tummy tuck, let's define that for people. What's a tummy tuck?

A tummy tuck is essentially a procedure that involves removal of all the excess skin in the abdomen below the belly button in the central abdomen. It also typically involves tightening of the muscles that get stretched out as a result of pregnancy. 95% of tummy tucks are done on postpartum women who've had children, and their bodies have changed to a large degree after childbirth. This is probably as good a time as any to define the difference between a diastasis and a hernia, since the two sort of happen under these circumstances as well. And I assume that if either of those are present, this is the time to fix them? Absolutely. A large number, I would say maybe even as high as 20% of women after pregnancy

develop a hernia in the belly button. You know, the belly button was the site of your umbilical cord when you were in utero. And so there was always an opening there and it scars closed when you're born, but it's an inherent spot of weakness. So the act of pregnancy where the abdominal wall is stretching and the pressure inside is building up as the uterus grows can pop that open. And a lot of women develop hernias. So essentially a little tiny hole where the belly button was and the fat on the inside poo a little tiny hole where the belly button was, and the fat on the inside pooches through that hole into the belly button. So it gives you an outie, if you will, which is essentially a hernia. A diastasis is different. It's a separation of the rectus muscles, so the

six-pack muscles move aside, and then there's a gap in between. In many ways, it's similar to a hernia in that you have a weakened central area where stuff is pushing out against. And I've had patients with severe diastasis where you can literally see their intestines through their skin. It looks like a worm moving around inside. And that's because the tissue is so thinned out in between the muscles. Both of these would be addressed at the time of a tummy tuck. Now, the diastasis doesn't have the risks that an untreated hernia have. I mean, that's the other thing that patients should understand is an untreated hernia can be catastrophic. Yeah, absolutely. Because with an untreated hernia, if something pushes through

that hole and gets stuck, we term it an incarcerated hernia, that tissue can necrose or die away. And if it's part of the intestine, that can become life-threatening. We know a little bit better now that if a hernia is asymptomatic, so a woman has no symptoms from it at all, same is true with a man, you can just sit and wait on that. You don't have to treat it. Once it starts to cause pain or any other symptoms, it should be treated. Let's just take a sort of a typical example of a patient. So a woman who's had two children, she's late 30s, early 40s, doesn't want to have kids anymore.

Is that important that this is only done after she's done having children, I assume? Yeah. I mean, if you do it on someone and they end up getting pregnant afterwards, they can kind of wreck the beautiful result that you do. You can still get pregnant. You stretch everything out. A tummy tuck can be done a second time if necessary. But ideally, and I tell patients, wait until you're done with children. So let's say just for the sake of example, she has, pick one, a hernia or a diastasis. Is one easier or more difficult to repair in the context of the tummy tuck, assuming they're both of modest

size, not enormous? I think the diastasis is, it's a little bit easier because you're not dealing with concerns of damaging the bowel or the hernia coming back. You know, the diastasis is generally not going to come back. You're bringing the muscles together. And that's a more common scenario, the women who have the diastasis, where they're, instead of having a flat abdomen, it's sort of protuberant and convex outward. And especially, you know, classically after a large meal, these women, their belly is sticking out. And I joke that the absolute indication for a tummy tuck is if one of your children asks you if you're having another baby after a large meal. We'll call that the Krieger test.

By the way, on that note, I want to just tell the listeners, you should never ask a woman if she's pregnant. I have a lot of patients who people say, when are you due? Have you had the baby yet? There's a lot of thin women who have very low body fat and a huge diastasis, and they look like they're six months pregnant. Never ask a woman if she's pregnant. Yeah, there's a great comedian. I think it's Brian Regan who's got a whole bit on this. And I think the takeaway from his bit was the only time it is

socially acceptable to ask a woman if she is pregnant is if the head is coming out and you can see it. The baby's crowning. Right. If the baby's crowning, you actually see the head coming out. At that moment, you are permitted to say, oh, Susie, are you pregnant? But anything before that, no, you just shut that down. So does it matter, Zal, one way or the other, if women have had vaginal deliveries versus c-sections which also of course introduced that fan and steel uh incision been like it's sort of very very low abdominal incision because that's cutting through muscle we can still do a tummy tuck in either way are they more susceptible one way or the other no No, I don't think they're more susceptible. I think it has to do with genetics and the size of the baby and the

weight at which one gained weight during the pregnancy. But I think that with the C-section patients, we have the option to correct a lot of the issues from the C-section like scar tissue and indented tethered scars that bother a lot of patients or skin that hangs over the scar. So there's that additional benefit. So you'll go through the C-section? I'll actually go below it and cut it out completely because I want to make my own new incision. I think that in general, the vaginal delivery patients, and I don't know if it's from the act of pushing during labor or whatnot. Maybe it's just the factors that coalesce to lead to them having a vaginal delivery.

Yeah, it might be that a woman who can have a vaginal delivery has more elastic skin. She is more able to stretch. And while that permits her to have the vaginal delivery, it also makes her more susceptible to the stretching of the fascia. Right. And so we tend to see a little bit more of a diastasis there, but the rate of C-sections has increased so dramatically in the US. I mean, I don't know the numbers, but it's probably approaching 40 to 50% now. It's so common now to see women coming in who've had C-sections and are coming in for tummy tucks. So what is the actual procedure?

So you're making the incision and obviously there's a lot of skin removal. How are you going from this incision just basically at the pubic line all the way up to above the belly button to fix the diastasis? Are you, I don't, what are you? We're essentially lifting up all of the skin

off the abdominal wall all the way up to the xiphoid, so right up to the breastbone. And we're exposing the entire abdominal wall. It's basically like an anatomy textbook. You're staring at the whole abdominal wall with the skin lifted up. And then we do the muscle tightening or the hernia repair. And the muscle tightening you do, you are literally bringing sutures together to pull the rectus muscles back such that you're, you know, when people look at a six pack, what they realize is the reason it's not a three pack is there's a fascial piece that goes down the middle

that separates the left and the right side. And that maybe ought to be what an inch apart. Even if that may be less half an inch to an inch. Got it. So a woman with a diastasis will show up and that will be inches apart. Correct. And not only are the muscles apart, the fascia has been stretched out. So the muscles, instead of being flat, are actually protuberant. So you kind of get this sort of like mini beer belly, if you will. And so we're tightening the fascia, which is the outer layer of the muscle and bringing it together so that the abdominal wall then becomes flat and tight.

What percentage of the time are you doing this on a man? Because certainly a man who's lost a lot of weight could be in the same situation, correct? Yeah, they're definitely a minority. Five to 10% of patients are men with this operation and almost all of them are massive weight loss patients who've lost a lot of weight. They usually don't have a diastasis, so they don't need the muscle tightening. And it's all about just the skin removal in those cases. What are the biggest risks to this procedure? Biggest risk is fluid accumulation called the seroma after the surgery. You've created such an enormous amount of space where you've lifted up the

skin that you could put easily a liter of fluid to fill in that area. And so we use drains to drain the fluid out. And the risk is if you don't have enough drains or they're not in the right spot, and then after the drain comes out, the fluid can accumulate. And the incidence is about 10% to 15%. And if a woman develops that complication, does it require drainage or does it go away on its own? It usually requires drainage. And in rare cases, it'll go away on its own. And do you, as the plastic surgeon, do the drainage or does an interventional radiologist do it? We do everything. I mean, in my practice, we manage

all the complications. Occasionally, we'll send someone to an interventional radiologist do it? We do everything. I mean, in my practice, we manage all the complications. Occasionally, we'll send someone to an interventional radiologist if, for example, the fluid is in one small specific spot and you need an ultrasound to see where it is and we need them to put in a special type of drain. But 95% of the time, we're managing it ourselves in the clinic. So even if a woman develops a seroma, do they typically resolve with the appropriate follow-up drainage? Yeah, they usually do. Okay. Is it a big risk of bleeding or are you pretty much staying away from major blood vessels? Bleeding is a small risk. And I think the cases where it happens are the patients with larger blood vessels. Massive weight loss patients have very large blood vessels.

And so it's understanding when you need to tie off a blood vessel as opposed to just cauterizing it and really being meticulous and careful. And again, that goes back in my practice to having the two surgeons. Every single thing is double checked. It's easy to miss something when you're by yourself. And uncontrolled blood pressure, so patients who have high blood pressure after surgery, that is an increased risk for bleeding, specifically on procedures on the face. And what about long-term complications?

What are the cosmetic issues that come up after women have had this? The main thing people complain about is the scars. They're unhappy with the appearance of the scar. A lot of patients gain weight or things stretch out and they end up with loose skin after the surgery. So it's nice and tight for the first year, but then it loosens up and they're unhappy with that.

Occasionally patients' deep fascia stretches out and so they have a little bit of a recurrent diastasis and they're unhappy with that. But most of the patients are pretty pleased. When you combine liposuction with the tummy tuck, you raise the stakes. It increases the complication rate a little bit. And liposuction patients in general, I mean, it's a whole other discussion, but there's a lot of unhappiness and dissatisfaction when it comes to liposuction. Can you predict in advance if a woman, assuming she hasn't already had a scar,

she's never had a surgical procedure, I guess this is true for men as well, but since we're talking about a pretty big incision here in the tummy tuck, can you predict who's going to get a hypertrophic scar or a keloid? I mean, I know keloids tend to be more common in African-American than white or Hispanic, but even absent a keloid, just people have very different scar morphology. And given the size of the scar here, that would seem to play a role in the long-term cosmesis, right? Yeah, for sure. And it's tough.

In general, you really can't predict unless someone already has evidence of bad scarring what's going to happen. It's definitely a genetic thing. Asians and dark-skinned patients have a higher risk of keloiding. Their skin is thicker and it's more sebaceous and it tends to scar worse. So we're always concerned more about that with our darker-skinned patients. But even in fair-sk skin patients, we'll sometimes see bad scarring. Patients who have infections or any delay in the healing are at higher risk for

developing keloids. But the tension on a scar is a big contributor to how the scar is going to turn out. So areas of very high tension, like a tummy tuck where the two edges are pulling apart, as opposed to an incision where it's just an axis incision, like cutting over a hip to get down to the joint, the high tension scars tend to be much worse. So in patients who were closing it under a lot of tension, where we've cut out a lot of skin and we're kind of going for the home run to make it as tight and flat as possible, we'll do things to minimize the tension, but that tension is a big risk for the poor scarring. The proof in this is that the area of highest tension is in the very center of the scar, and that usually is the area that scars

poorly, whereas as you go out towards the side of the scar, towards the hip bone, the scar becomes more faint and less noticeable because there's less tension there. So you just sort of alluded to liposuction. So let's go there next. This is one of those procedures where I'm guessing what percentage of them being done are not being done by board certified plastic surgeons. This is something where we probably see a large, large number. I mean, if I had to guess, probably talking about 80% to 90% of the procedures are being done by non-plastic surgeons in an office-based setting. There are anywhere from 20 to 30 devices out there that perform different types of liposuction.

And a lot of this is done in an office-based setting. And so doctors, non-plastic surgeons are purchasing these devices and offering this to patients. And there are non-invasive devices. A popular one is called CoolSculpting, which I don't do. I'm not a big believer in. You kind of wave a magic wand over the person. It freezes the fat. I mean, I always said, if freezing the fat works, why are the Eskimos so fat?

Maybe they're not cold enough. Yeah, and then you have devices that heat it up. So it's like, wait, do you want to freeze it or heat it up? I'm not a believer in a lot of these technologies. They have a lot of risks associated with them, a lot of risks of burns, contour irregularities. Most board-certified plastic surgeons do what's called just traditional liposuction, where it's essentially the movement of a cannula that causes the fat to break down, and then you just suck it out. You're not using additional laser or radio frequency or ultrasound

forms of energy to remove the fat. What does it look like? I mean, I think we're talking about subcutaneous fat here. We're not talking about removing visceral fat or things that are below fascia. So everything is above this very thick connective tissue. But when you put a cannula, I guess maybe we should just explain some of these terms we're using. So a cannula is what? How would you explain that to somebody? The cannula is a hollow, long metal or plastic device that is inserted underneath the skin into the fat. And that's what breaks the fat down and sucks it out. Why is it that if you took a person who has lots of subcutaneous fat and you put a five millimeter incision in them and you stick a five millimeter cannula and you just hook it up to a vacuum, why doesn't it just uniformly

suck out all the fat? The fat is actually connected pretty well to the overlying skin. There's connective tissue and different parts of the body. It's connected to various degrees. For example, the fat on the soles of the feet and the palms is extremely strong and tough fat. The fat in the buttocks where we sit is also very rigid in fat. It's difficult, be extremely hard to liposuction that. So just creating suction won't suck it out it's stuck there you have to actually break it apart and it's the that's how it's whether it's done with a form of energy or just the mechanical energy generated by the movement of the cannula

that breaks the fat apart who first did this procedure i mean how long has this procedure it's been around a long time probably 50, and it was invented by a dermatologist. So it's difficult as a plastic surgeon to judge dermatologists who do liposuction because they actually invented it. So, you know, I think dermatologists who have adequate additional training, they're not usually doing this in their regular residency, could probably do some areas of liposuction. But again, I think that you have to distinguish between specialties where you spent a lot of time in the operating room as opposed to specialties that didn't. You know, like we talked about, I was in the military. I spent a little bit of time in the ocean and diving.

And so, yeah, I can go in, but that's not my area of expertise like someone who's a Navy SEAL where they're so comfortable in the ocean and diving. And so, yeah, I can go in, but that's not my area of expertise, like someone who's a Navy SEAL where they're so comfortable in the ocean. I mean, the same thing is true in the operating room. You're either a surgeon or you're not a surgeon. If you're a surgeon, you've spent literally years of time in the operating room and your comfort level with dealing with everything is very different. A surgeon once said to me, you know, a good surgeon knows how to take care of any complication they create. And the complications from liposuction are astounding. I mean, there are multiple cases of patients puncturing lungs and puncturing liver and intestine. Well, I mean, you'll have to explain to me how that happens outside of the most egregious

malpractice. I mean, this is all happening outside of fascia. So how is it that the patient is so big that the surgeon, I mean, I'm trying to be sensitive to the surgeon making the mistake as well, but to give someone a pneumothorax or to puncture their liver, you have to take that cannula and instead of moving outside of the plane where the fat is, you have to turn the cannula inward, right? Right. So, you know, the most common area of liposuction is the abdomen. So if someone is liposuctioning the upper abdomen, you obviously have to understand

the anatomy. You have a rib cage there. So you have to stay above the ribs. But if you're not paying attention, you're not feeling cage there. So you have to stay above the ribs. But if you're not paying attention, you're not feeling and aware with what you're doing, it'd be pretty easy to slip underneath the rib. Well, if you go underneath the rib, the next thing you encounter there is the rectus muscle and then the diaphragm. And so these thin cannulas are actually riskier, a one to two millimeter cannula. It's easy to just push

right through the abdominal wall and into the next layer. Why not use a blunt cannula instead of a sharp? They are blunt, but it's still, there've been multiple, multiple cases of this happening. And does anyone ever do this with an, like, cause if you're doing liposuction on someone who's subcutaneous fat, but they're not not incredibly big presumably the risk of this is lower is this more you would think so but we still see it in thin patients so ultrasound guidance wouldn't help when you're in those areas it probably would it's sort of impractical because then you have to introduce an ultrasound sterilely and then you need either the person doing the liposuction knows how to use the ultrasound

or they have to bring in someone else. So that is not typically done. I think it would increase the safety. But a well-trained surgeon who knows the anatomy and knows what they're doing, they have to get pretty lost to end up in the lung or the liver. What's the typical path they're taking to the lungs?

Is it inferior through the diaphragm as well? Yeah, it's through the diaphragm. Or when they're liposuctioning the side of the bra line, which is a common area during a breast reduction or another procedure, women want to get rid of that bra fat. And so you have to stay outside of the rib cage. So if the angle of the cannula is wrong, you could easily puncture in and end up in the lung. And liposuction is a dangerous procedure if not done properly. And we see incredible complications and death rates from it, electrolyte problems, from fluid shifts. There's tremendous fluid shifts that happen after liposuction, volume overload, pulmonary edema,

fluid in the lungs, essentially. And we see these, and it's really an issue of where are you doing the liposuction, in the office or in the operating room? Are you monitoring the patients during and after the procedure? Another major risk with liposuction is lidocaine toxicity, so overdosing the people with lidocaine because you're obviously having to numb up the area before you liposuction it. So how do you numb them up? You numb up where you make the incision. You then introduce fluid full of lidocaine into the area. It also has epinephrine in it. So it causes constriction of the blood vessels to decrease the bleeding. And does any of that make its way into the patient's actual bloodstream so that their heart rate goes faster, which the epinephrine

would do? Interestingly, it takes about 8 to 12 hours as a delay after the liposuction for it to see peak levels of these substances in the bloodstream. And so you're done with a procedure after a couple hours, patient recovers for another hour, they're home. So these levels are occurring at home. And that's when you have to really understand what you're doing, what volumes you're putting into the patient, making these calculations. And a lot of the people doing this in the office are not thinking about it. And that's where they run into trouble. I mean, you get more nervous doing liposuction, I'm guessing, than either of the two procedures we've discussed beforehand. I mean, I think I'm at the point where I'm pretty comfortable, but I'm very conservative with what

I do. I try to avoid very large volume liposuction. That's where it becomes risky, where you're trying to suck up more than, you know, about 10 pounds of fat at a time. That's what we would consider 5 liters, which is, you know, slightly over 10 pounds of fat at a time. That's what we would consider five liters, which is slightly over 10 pounds is what's considered large volume liposuction. And that's where the risks really go way up. What are some people doing out there in the community? I mean, they're doing everything,

20 pounds, 30 pounds of liposuction, eight hours of liposuction all day long. I mean, just, it's the wild west. Like I said, anyone can do anything and there's no laws or regulations governing what's done. It's buyer beware. Yeah. And what is the typical cost? How does liposuction get priced? Most people price it by the area. So it might run anywhere from $1,000 if you're just doing one limited area in an office-based procedure, you know, up to $7,000 to $8,000 depending on going into multiple areas over several hours. And what's the range in price that you see between

sort of highly trained, you know, dermatologist or plastic surgeon versus the, you know, people who are doing this with less training? I think in general, the people with less training who are not board certified plastic surgeons are usually charging much less, especially if they're doing things in the office. And, you know, you can see a two to three fold price difference, you know, something that a family practice doctor, or we have a female gynecologist in my community who does a lot of office-based liposuction, and she's charging a third of what I might charge for the same procedure, doing it in the operating room with anesthesia.

And then there's regional differences, you know. So even though you guys might actually make the same amount per procedure, you have to spread your cost out much more because if you have an anesthesiologist there and you're doing it in the operating room, your costs have increased dramatically. Correct. Okay, let's go on to butt lifts. This is the dangerous one, right? Yeah, this is the real dangerous one. This is extremely popular these days and getting more and more popular social media you know kim kardashian has probably accounted for a billion dollars spent in the u.s on this procedure it's very popular in central and south america there's definitely a ethnic and racial preference for this procedure

there's a great i went to a great meeting meeting in Miami. Miami is like the New York City for Central and South American doctors. So they love to come to Miami for the nightlife and the restaurants and they just love it there. This meeting had thousands of plastic surgeons, 80% are from Brazil and Argentina and Mexico and Central America. And so they showed four butt pictures on the screen to the plastic surgeons. And you know, everyone in the audience has a little button thing that they can choose. And they say, okay, we want you to rank your favorite, what you think is the ideal buttocks. And so people pick and then they show the result. And of course, the big, huge, giant round butt is the most popular.

And then they said, we want you to click your country of origin, where you're from. And there's just a beautiful correlation between the Brazilian and the South American plastic surgeons and the preference for this type of butt. So a lot of it depends on the aesthetic of the surgeon. In California, we do a lot less of this because my ideal and a woman in California's ideal body is maybe more of the athletic, toned sort of body type as opposed to in Miami where everybody wants to have this rounded, you know, large protuberant buttocks. But it's very popular. I mean, we still see a lot of patients asking for this. How many of these do you do a year? I probably do 20 to 30 a year.

And your peers in Miami would do how many? They might do four to five a day. This is like, there's some, I know one guy where he's literally doing seven to eight a day of these procedures. Like it's like a factory. This is one of the most dangerous procedures in all of plastic surgery. And we actually have had meetings in our societies and almost to the point where they want to put a moratorium and just stop doing these procedures. The issue is what the Brazilian butt lift is, is injecting fat into the butt to enlarge it. That fat is liposuction from one part of the body and then injected into the butt. So there's no mechanical lift that's going on? The lift is accompanied

just by... No, it's just filling it up. Yeah. It's just filling. It's like inflating a balloon. All this time. Yeah. It's just filling it up with fat as much as you can get in there. The issue is inadvertently injecting fat into the veins in the butt, and then the fat gets transported to the lungs and causes a fat embolus, which has a high risk of fatality. And so there have been multiple deaths, most of them in Florida, but multiple deaths in South America. Even in California, we've had deaths from this procedure. When they autopsy these patients, they uniformly find their lungs full of fat that was basically transported from the veins in the butt where the fat was accidentally injected. And so there's a lot of

recommendations about how to avoid this and, you know, using smaller volumes, injecting it more superficially, but it it more superficially. But it's still very popular. I mean, despite the risks, women still want this. What are the stated risks of a fat embolus from this procedure? In other words, if you walk into a responsible doctor's office or someone walks into your office and says, what's my risk of this? What percent would you quote? It would probably be one in a thousand would be the risk, maybe even higher. And I guess this is a great example. As a fatal fat embolism, there's probably cases where it's happening and it's not fatal, like a regular pulmonary embolism, and we don't catch it. You know, it's interesting. This is a great discussion about the asymmetry of

risk. Because you might listen to this and think, well, one in a thousand is not that bad. But I was telling you earlier today, I mean, I had to keep my phone on during this interview because I have a patient who I sent into the emergency room to rule out a pulmonary embolism. And, you know, we're talking about this this morning and, you know, the patient was saying, well, you know, I've got this pain in my calf and I've been flying a lot. And, you know, was sort of thinking, I wonder if I do feel a little short of breath. You know, it's hard to say. So look, listening to the patient's story, I think the probability that they have a pulmonary embolism is actually quite low, but it's not zero. And I said, just to make the math easy, let's assume there's a 1% chance you

have a pulmonary embolism or a 0.1% chance you have pulmonary embolism. You have to consider the cost of doing something versus the cost of doing nothing and then the cost of being wrong in both of those situations. So the cost of being wrong if you don't go in to the ER, you just stay where you are, you don't go anywhere. Meaning wrong, meaning you have a pulmonary embolism, but you don't do anything about it. That cost is infinitely greater, though far less likely than the cost of you going into the ER, not having a pulmonary embolism. So there's a cost to that. Cost you time, cost money. It's a pain in the ass. No pun intended. In this case, not referring to a butt lift, but that's a finite cost.

Whereas the other one becomes an infinite cost. So it's so funny. I went out for a run this morning. This is actually what I was thinking about. Not this example, but I was thinking about, I wish somebody would build a really good risk model for patients to help them understand the asymmetry of risk. Because if you say, look, there's a 5% chance of you getting a seroma, or there's a 0.1% chance of you getting a fat embolism,

I'm not sure everybody appreciates the difference. The 5% seroma has a much lower consequence to it. So that might be a tool to help patients understand this. Because other thing with a with a fat embolism not only is it devastating but you don't get much of a warning necessarily from when the complication is and it's almost impossible to treat when it happens yeah yeah that's another great example so so you mentioned a guy who's doing six of these a day seven of these a day i mean presumably he's not getting many complications, right? Or he wouldn't be able to do that, right? No, he is. I mean, it's shocking to me how tolerant people are of complications. I mean, when you look, there is a recent expose done by USA Today about these Miami plastic surgery clinics where they've had tremendous number of deaths and complications and people

just keep going back because they are so price conscious i mean these places will do it for cheaper than anywhere else will and they so you get fries and a drink with the procedure and it's it's like a happy meal yeah and and patients don't care. And people have this idea that if you're a doctor, you're safe and you know what you're doing and you're going to do the right thing. If there's a clinic and it looks semi-clean, that they don't need to worry. And the problem is the laws are not out there

to 100% protect the patients. They're actually in the process now of amending a lot of the laws in Florida, which has just been way too liberal in terms of what they allow to happen. I mean, everything is driven by money. You get these lobby groups. A good example would be optometrists do not have training to do surgical procedures, but they might lobby to allow them to do blepharoplasty, so eyelid surgery, and they're paying money to politicians

and then laws are getting passed that allow them to do this. That's not in the interest of the patients. Patients do not need more doctors who know how to or are able legally to perform eyelids. Did you say optometrists? Optometrists. Not ophthalmologists.

No, optometrists. Or dentists who want to do facelifts. So they're lobbying state legislators to allow them to do facelifts. I would argue that a dentist does not have training to do a facelift. They're used to working through the mouth. Now you're talking about working very far away from the mouth, using principles and techniques that they have no training in. They just want the money. So they're doing this for the money, not for the benefit of the patient.

It's not like patients are suffering because there's not enough good facelift surgeons out there. That's just not true. So, you know, finances drives a lot of this and not necessarily patient safety. The groups that try and protect patient safety don't have the money and the backing to pressure the legislators to do everything that is in the best interest of the patients. I suppose the argument that these groups would put forth is, look, in the end, the patients get to choose. It's a free world. That's right. We're just trying to create a bigger market and an efficient market should sort this out. But it doesn't because there's not transparency and there's not adequate oversight. Like when you look at the situation in Florida,

you have surgery centers that are doing only plastic surgery being owned by businessmen with long laundry list of convictions and crime. They're not doctors at all. In some states, only doctors can be involved where they're literally not just owning the surgery center, they're involved in the day-to-day running and making sure that the doctors working at the facility are well-trained.

In Florida, there's no rules about the doctors who are working at these facilities. You have doctors who've lost their license and licenses are suspended. They don't care. These guys are just doing it for the money. And so it's really buyer beware. And all of the burden falls on the patients to do their homework and do their research. And for a lot of uneducated, less sophisticated patients, they don't know what to ask. They don't know what

to look for. And they're the ones who are suffering, you know, a lot of minority patients. They're the ones who are suffering the brunt of these complications. And in Miami, there's a huge advertising blitz on Hispanic radio stations and billboards in the inner city where they're specifically targeting less sophisticated groups that they feel aren't going to do the same amount of homework and research. This sounds eerily reminiscent of the subprime crisis. Yeah, absolutely. Yeah. Going back to the procedure for a moment. So you'll do your 20 or 30 of these a year. Does

this get you nervous to do this procedure? I mean, what steps would you take to reduce the risk of inadvertently cannulating a vein? I think that for me, the thought process is no different than with any surgical procedure. You, having trained in surgery, know this. Understanding anatomy is just the absolute key to doing good surgery. If you know where things are, you know how to avoid them and how to stay out of trouble. And so it's all about understanding anatomy. Simple things like how you bend the surgical table with the patient laying prone on their stomach is going to affect the position of the blood vessels relative to the surface anatomy. So if you have the patient laying flat as opposed to bending the bed 30 degrees where

it's in sort of a beach chair type position, that's going to change the position of the anatomy. And so understanding anatomy is really the key, which goes back to my point about why if you didn't train and learn the anatomy, it's so difficult to do safe surgery. Yeah, it's actually scary for me to think about it. You only need to see so many things go really wrong in an operating room to be reminded of how even when you know what's going on, things can turn in an instant. And then to imagine if you're flying a little blind and you don't actually know where the vascular beds are, I never really thought of it that way. I guess I just, I don't think I really appreciated what a Brazilian butt lift was. You know, I mean, my field is very challenging and different than other areas. You know, when you get on an airplane, for example,

you don't think twice about, you assume that that plane has been checked over. You assume that it's received all the maintenance. You assume that the pilots are competent, that they aren't drunk, that they slept enough. You assume that the runway's been checked, there's no debris on it. You make all these assumptions and you fly and you feel safe. And most of these assumptions are true. When you go into a hospital, you make the same assumptions. You assume that the doctor taking care of you is knowledgeable and trained. You assume that the bed that they put you in has been cleaned. You assume that people have washed their hands before they touch you. You assume that the nurse is giving you the correct medication and she's checked it. You make a lot of assumptions and it should be that way. There should be a system set up. But what is so unique and scary about the

field of plastic surgery is it really exists outside of the same degrees of regulation, because you have people who on their own just woke up one day and decided I'm just gonna start my own airline company and I'm just gonna hire some yahoo pilot and I don't need to check the runway and I don't need to do maintenance because that costs a lot of money and they just do their own thing and you get on that airplane you go to that surgery center and you are without your knowledge taking a lot of risk when a non-plastic surgeon is doing something in their office or in their little surgery center it's not being regulated and checked like an accredited surgery center is as a board certified plastic surgeon i am only allowed to do procedures at accredited

surgery centers that have been checked over and accredited by the government or by a state agency. That's not true for a lot of office-based surgery centers. It seems like it's really a confluence of two issues. So let's use another example you gave. So going back to the beginning, right? And by the way, I think you have to have a license to do this, correct? You'd have to have a medical license, which you can get after one year of training. Just a medical license.

That's right. So I don't think technically you couldn't do this the day after finishing medical school, but you could do this the day after finishing an internship. So why is this problem not occurring in cardiac surgery? Or why is this problem not occurring in orthopedic surgery, at least with respect to joint replacements? My guess is twofold. One, nobody wakes up and says, I really want to have a coronary artery bypass today. You know, today is

the day I, you know what? I'm not happy with my aortic valve. I got to get this thing switched out. In other words, patient demand isn't really driving cardiac surgery. It's being really driven by the pathology. The cardiologist is sending you to the cardiac surgeon and you're sort of going because you trust the cardiologist, et cetera. Similarly, yes, of course a patient who has sort of an issue with their knee and it's chronically hurting will ultimately wind up seeing an orthopedic surgeon, but they're usually going through several levels. They'll see their primary care doctor, their doctor sends them to an orthopedic surgeon, the orthopedic surgeon goes through a whole bunch of checks and balances. It's very rare that someone

wakes up, says, you know what, I've had it with this knee bugging me, I need a knee replacement. Let me just Google knee replacement and anyone can show up. That's the first thing. So the demand is not really coming straight from patient to ultimate practitioner. The second thing is the complexity of the case. At the end of the day, you want to do a coronary artery bypass graft, you want to do a hip replacement, that's really complicated. You are not going to, in a million years, figure out how to do that without going through the formal training. Whereas in the end, liposuction, relatively simple procedure. And as you pointed out, the simpler the procedure, the more likely. My guess is there aren't too many

non-plastic surgeons doing, you know, deep flaps. Right. Or even a breast reduction only done by plastic surgeons. It's a complicated procedure. Right. And then the third piece is this hospital piece. There's a huge divide between what happens in a hospital and what doesn't. The moment you walk into an accredited hospital, the bar is just raised dramatically and it would require outright fraud for a charlatan to be in there doing that, which of course I'm sure happens from time to time, but that's an abject failure of the system. So it's really these three things together, which is what procedures can be done completely outside of the purview of a hospital, what procedure can be done that's relatively simple to learn, at least to be able to fake it, and what procedures are being driven by enormous patient demand where the patient directly comes to the practitioner. I mean, to me, it's those three things

that have created this trifecta of disaster. And another way to put it is that in a lot of patients' minds, plastic surgery is not in the same category as other types of surgery. It's more like getting a haircut or getting your teeth bleached or getting your nails done. It's more like getting a haircut or getting your teeth bleached or getting your nails done. It's cosmetic procedures. Oh, I'm just going to go in for a little afternoon

liposuction. And so people don't think about it in the same way as they think of other surgical procedures. And then the money is such a big part of it because there's so much money in this field. Right. When you get your knee replaced, your insurance is hopefully paying the majority. Right. This is all patients are paying out of pocket for it. And other doctors who are primarily insurance-based doctors, which is most physicians in America, see this lucrative cash-paying procedures and they want a piece of it. I mean, they want to augment their income with it. It's just so funny. I always think about how different it is to be a plastic surgeon. I'm probably the only specialty where when people go to the emergency room, I do emergency call

at a local busy hospital where they ask for a plastic surgeon. You know, little Sally's has a cut on her cheek and the mom's like, I want a plastic surgeon. I demand a plastic surgeon. You know, little Sally's has a cut on her cheek and the mom's like, I want a plastic surgeon. I demand a plastic surgeon. Nobody's asking for a cardiologist when they need to have chest pain and or an EKG. I think we're in a different category than all the other doctors where patients think that, you know, for whatever reason, we're just much more readily available and we're sort of technicians that they can just summon at a whim. Do you find yourself ever feeling conflicted where on the one hand, you're in a profession which sort of feeds off the vanity and insecurity of people, both of which you don't seem to necessarily display yourself. And on the one hand, you sort of have this obligation, like, look, if a person is committed

to doing procedure X, Y, or Z, I, Saul Krieger, might not actually even understand the rationale for this. I think this person looks perfectly wonderful. I don't think they need to do anything. But one, there's an economic incentive. I mean, at the end of the day, this is how you make a living. Two, I think knowing you, I can say you also feel like, well, if this person's going to have this procedure done and it's a Brazilian butt lift that I think is probably ridiculous, I would certainly rather they do it with me. And I have a much higher probability of getting them home safely than they go to somebody else. So how do you process all of those sort of emotions and thoughts? I think about it simplistically that I'm like many other doctors, I'm just helping people. People come to me with a problem, just like they come to any doctor with a problem.

Psychiatrists see people with psychiatric problems and the rest of the physicians see people with physical problems and i i'm it's a combination of both i'm like a psychiatrist with a knife basically i fix a lot of psychiatric problems with a knife now that might sound do you think you're fixing them i do sometimes i do and and that's and a key key part of being a good plastic surgeon is understanding, am I going to fix this problem with the knife? Or is this a problem that requires some other type of treatment? I'll give you a good example. Take a girl who's 18 years old. She just finished high school. She's about to go off to college. She's a beautiful girl, but she has a huge giant nose. She was born with a big giant nose.

She inherited it from her Middle Eastern father. And it looks horrible on her face. She's completely self-conscious about this nose. If you did a photo manipulation with a computer program and showed her a picture of her face with an altered post-surgical nose, she's crying. She loves it. You showed those two pictures to any person in anywhere in the world. They would say the one girl looks hideous and the other girl looks attractive. It's the same girl before and after surgery. If you do surgery for that girl, you change her life. You help her in a profound way. She's not excessively vain. She's not psychologically ill. She doesn't have mental problems. She looks in the mirror and sees a nose

that is way out of proportion to her face. She's bothered by it. She's been teased about it before she compares herself to other people. Now, yeah, you could make an argument that we should live in a society where we don't care about the size of people's noses and we don't care about the way people look. But until that happens, which I doubt is happening anytime soon, people attach importance and value to the way they look. So yeah, I think operating on that girl, I'm doing her a huge service. I'm helping her. I'm essentially a psychiatrist with a knife. She doesn't need that surgery. She's not doing it because she has cancer. She's not doing it because she's not able to exercise or function because she can't breathe through the nose. She's doing it for the appearance. But we all know that girl.

We've all met someone like that. We might even be that person. And so making that change is profound. I mean, if you have a woman who's happily married, she's normal, she has children, she functions regularly in life, and she believes, whether rightly or so, that her husband does not find her attractive because her body has changed after having children and she has a big roll of skin hanging over her c-section scar and she wants it gone it gets in the way of her exercise it affects her during her periods of intimacy with her husband she's super self-conscious about it you're going to change that person's life doing that so there's nothing wrong with that most of my patients are normal. I don't

take care of porn stars. I don't take care of people who have body dysmorphic disorder where they say, I can't go outside because of this part of my body. I try to avoid celebrities. They're a huge pain in the butt. I just take care of regular people. I do functional surgery and I do aesthetic surgery. That same girl with the nose, maybe she can't breathe through her nose and that's her problem. So ultimately the way I try to stay grounded and wake up in the morning and go to work

and do a good job and then come home feeling satisfied and like I help people is to understand that my job is to evaluate someone, try and understand what the problem is, and then know, am I able to help them in a safe, ethical way and make a difference for them? That actually makes a lot of sense. And it, you could argue that what's the difference in the vanity that says, I don't like the fact that my nose is crooked and I want to have it straightened versus someone who comes to me and says, I want to live longer. You could argue those are equally vain statements and meaning both totally reasonable cases to be made for trying to help that person. It goes back to something I've heard you talk about in the podcast about the difference between increasing

the length of your life versus improving the quality of your life. You know, do I want to live to be 100, but the last 15 years I'm in a chair and I can't get up and move and my brain doesn't work? No, none of us want that. We want quality of life. That's what it's about. And so quality of life is a really complex issue. There's so many factors that go into it. It's avoiding injury. It's feeling healthy. It's not having medical problems.

It's feeling good about yourself. It's being able to do the things you enjoy. The list goes on and on and on. So what I'm trying to do is to contribute to quality of life. And it's just one aspect of quality of life. I mean, I always wonder like if you succeed with your goal to get people to live longer, we're going to have a lot of really old looking people walking around. Do you ever turn patients down who show up through the normal channels, either through a referral or

just on their own, but after you sit down with them, you come to the conclusion that, you know what, I could certainly mechanically fix whatever it is they're asking, but it's, this is not the root of the issue. And you just, you get the sense that you're going down a slippery slope with them. Yeah, for sure. And, and, and the hardest thing to do as a plastic surgeon is to see the dollar signs in front of your eyes. I could make a lot of money if I do the surgery and turn the person away. I mean, just think of any businessman where someone comes and says, I'd like to purchase this. And you say to them, actually, no, I don't think you should purchase this. Yeah, I do it at least once or twice and sometimes more a day when I see people.

Once or twice a day? Yeah, absolutely. You're turning somebody down purely because you don't think they're the right candidate? I thought you were going to say once or twice a month. No, once or twice a day. Tell me the one that you did yesterday. Tell me one that you turned down and how did you explain to the patient that without offending them that you didn't think this was in their best interest? without offending them that you didn't think this was in their best interest? So a very common patient I turn down is an overweight patient who comes in for liposuction.

And this is one of my most common ones that I turn down. And they have this idea in their head that they can use liposuction as a means of weight loss. And again, I go back to my principle of just be honest with people. And I just say to them, you know, in a way, I don't think people want to hear your fat. And I basically explain to them, there's a limit on what we can achieve with liposuction. We can only suck out subcutaneous fat. You have a lot of visceral fat. I explained to them that I can only remove a certain amount of safely. I talked to them about the effects on the skin, that if you take too much fat, you leave them with loose skin. But if you lose the weight gradually, it's better. And ultimately, I talk to focus on health and well-being and that the

difference between losing 15 pounds through liposuction versus losing 15 pounds through diet and exercise is profound. That's actually been studied. So they're much better off. And I say, this is how much I would charge you. Let's sit together right now and talk about how you could take the same amount of money, get a gym membership, hire a nutritionalist, change your eating. You're going to very easily lose 15 pounds that I would suck off. You're going to be healthier. You're going to look better. It's a much better use of your money. People appreciate it. And I sort of feel like I'm investing in my business doing this because this person is going to walk away saying, wow, this guy's an honest plastic surgeon and I'm going to refer someone to him if I need to. So

yeah, maybe I'm losing that patient, but I'm going to gain someone else in the future. Another type of patient that we see is people who have what's called body dysmorphic disorder. They are just simply totally fixated on something. They've had multiple surgeries. There are a number of red flags that we look for. We have an acronym called SIMON. Avoid the SIMON. we look for. We have an acronym called SIMON. Avoid the SIMON. It stands for single, immature male, overly narcissistic. SIMON. The SIMON is a young guy. He's single. He's not been married. He may be gay, but usually straight. And oftentimes it's his nose or some other body part. And he basically is cannot function. My life, I can't go outside. I can't date. No women want to talk to me because of this body part. It doesn't take long to understand that guy should not have surgery.

He needs counseling. So we, you know, I usually won't give them the number of a psychiatrist, but sometimes I'll have to resort to my go-to line, which is I don't have the skill and knowledge necessary to help you in a way that is going to make you happy. We see people who've had multiple surgeries. Which by the way is true. It is true, yeah. People who've had multiple surgeries, and the first thing they do is start bad-mouthing other surgeons. Yeah, I had this surgery done, and he botched it, and you can see how horrible this is, and he was such a jerk, and he charged me all the...

That's the first thing they do. Anytime someone bad-mouths another plastic surgeon, there's a very low chance I'm going to ever operate on them, just from that moment on. Now, there are exceptions. You know, people have had botched surgery. Maybe it wasn't a plastic surgeon who did it. But if it was a board-certified plastic surgeon and I know that person and I know they're smart and reasonable,

then I know right away that this person has problems and no one else could make them happy. I'm probably not going to make them happy. Any other procedures that we should give people kind of the skinny on? You know, I think that today these minimally invasive procedures like Botox and filler and facial peels and laser treatments, they're very, very popular. Stem cell treatments where they harvest your stem cells and inject them in your face. There are all sorts of things out there. And, you know, when you look at the full field

of plastic surgery, the minimally invasive things are rapidly increasing because people want cheap and quick and easy with low risk and, you know, very little downtime. These procedures are not without risk. It's just a golden rule in surgery and in plastic surgery. If something has no risk, no recovery, no downtime, low cost, it has no result. That's just a rule. There's nothing out there that you can just do it in the office in 30 minutes and achieve a remarkable result. All of these things have risks. We've seen probably 25 reported cases of blindness from filler injected near the eyes, one of the most popular procedures, and that's a pretty horrible risk. How does that happen? What's the, what's the technology?

Enters into an artery and gets transported retrograde and then flows into the retinal artery and obstructs the retinal artery and causes blindness. But aren't these fillers typically done beneath the eye? Yeah, but it's easy to get into the wrong spot. There's an artery that comes out on the side of the nose just below the inside inside corner of the eye, that if you get the filler in there, it can transport. People inject filler in the forehead and in between the eyebrows for the wrinkles. And there's an artery that comes out right above the eyebrow that if you inject it in there, it can get transported backwards retrogradely against the flow and enter into the retina. So, I mean, there are, you know,

we see patients who have permanent pigment damage from lasers and peels done on the face. None of these, we've recently seen several HIV cases from these vampire facials where people have PRP blood harvested and then spun and re-injected into their face. It's not proven. You mean it's done from multiple donor pools? No, from their own, but the machines are not adequately cleaned and processed. And so they're contaminated with blood from another patient who maybe has HIV. There was just a recent reported several of these in the popular press, several patients in one clinic, this happened to them.

So these procedures are not without risk. Again, you got to do your homework. You have to know who you're going to. You have to really research. I mean, the great thing about Dr. Google these days is you can find out all this information online. There's a lot of resources. The American Society of Plastic Surgeons has a great website. It talks about every procedure. It talks about

the risks of every procedure. But just to be knowledgeable going in, I mean, knowledge is power in these things. And to understand that there's just no free lunch. You can't just undergo one of these lunchtime procedures without risk. Well, Zal, this is super helpful. I think what we'll probably do is, with your help, put together a little checklist for patients. Maybe we'll include this in the show notes, something they can just download as a PDF or something and use as sort of, I'm thinking about having a fill-in-the-blank procedure. Here are the questions I want to be asking.

Some of them will be just general questions, right? But then some of them can be procedure-specific and almost put together a cheat sheet of this stuff because I think this is super helpful. Well, I really appreciate it, man. This has been exciting to sit down. And I haven't seen you in like over a year, so it's great. And it's weird because we only live like a couple hours away from each other.

It's tragic. We're busy. I'll take any opportunity to get together with you. Thanks, man. Thanks. You can find all of this information and more at peteratiamd.com forward slash podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog at peteratiamd.com. Maybe the simplest thing to do is to sign up for my

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