Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / Lose It AND Use It: The Magic of Lipo & Fat Transfer
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. Kirstin (00:12): Hey, Dr. Koehler. Dr. Koehler (00:13): Hey, Kirstin. Kirstin (00:16): You want to know what we're talking about today? Dr. Koehler (00:18): Tell me. Kirstin (00:19): Liposuction. We talk about lipo with a lot of the procedures that you do, but we have not talked about lipo by itself. Dr. Koehler (00:31): Okay. Kirstin (00:31): How often do you do liposuction? Dr. Koehler (00:33): Every week. Kirstin (00:34): Every week. Almost every day, kind of. Dr. Koehler (00:36): Almost every day. Yeah. Kirstin (00:39): All right. Let's do this. Dr. Koehler (00:42): All right. Kirstin (00:42): Can we start with taking fat out? Dr. Koehler (00:47): Sure. Kirstin (00:48): Okay. And then we're going to move around to putting it back in somewhere else. Dr. Koehler (00:52): Okay, sure. Let's start with that. Kirstin (00:55): All right. Tell me how liposuction works. Dr. Koehler (00:58): First of all. It can be done under local anesthesia or general anesthesia or sedation. In my practice, in my hands, I do all the liposuction under general anesthesia for a number of reasons. I want my patients to be comfortable. There's nothing worse than having a patient partly numb, not quite completely numb. They're uncomfortable, it makes everybody uncomfortable, and we're trying to maintain a sterile field, and we don't want people touching or reaching for stuff. It can be very, small areas, for sure, could be done under local or some sedation, but in general, I do it under anesthesia, which I feel is very safe. The modern ways of doing liposuction involves something called the use of tumescent anesthesia, which has been around for now quite a long time. But before we suction the fat off, we actually inject quite a bit of, its IV fluids, normal saline, mixed with some lidocaine and some epinephrine. (01:56): And so the lidocaine helps to provide a numbing effect, the epinephrine constricts the little blood vessels so that there's very little blood loss when we suction the fat out. And then the whole fluid, all the fluid is, well, it helps one to distribute the medication, but there's another reason. So tumescent the word, if you kind of break it down, tumesce means to swell, and that's what we're really doing. We're swelling causing the tissues to swell with this fluid. And the rationale behind that was sort of explained to me one time early on in my training that it's like, well, what is easier to carve, a block of jello or a block of wood? Well, a block of wood is much easier to sculpt than a block of jello. So when your tissues are loose and you're trying to shape them, if they're jiggly and you're using a cannula to suction it, it's just, yeah, you can get fat off, but you're trying to sculpt the whole point of liposuction. (03:01): So we actually make it tense or taut by adding fluid, and then that allows us to better sculpt and remove that fat. So we use cannulas little tubes that have different openings in the tubes, and there's different styles of openings, depending on if you want to more aggressively remove fat or more conservatively remove fat. There's different applications there, which is kind of more of a surgeon's discussion. But anyhow, and then it's just a process of moving the cannula back and forth and then suctioning the fat off. And then there's other tools that we have. I use a power assisted liposuction now for probably, well, more than probably close to 15 years of in practice I did it by hand where it's just elbow grease. You're just moving that back and forth and suctioning it out. Then I invested in a power assisted device, which causes the cannula to reciprocate back and forth, and it makes it just a little easier on the operator, the person removing it, so you don't have to work as hard. Kirstin (04:08): Now, you talked about tumescent. Is that a Dr. Koehler thing or is that an everyone thing? Dr. Koehler (04:12): That's an everyone thing. Actually, it was developed by Dr. Jeffrey Klein. It was a lot of people initially called it Klein solution. His original solution is a little different because he actually adds sodium bicarbonate to his fluid because he did it all under local anesthesia. And so the bicarbonate just makes it not sting as much when you inject it. The original Klein solution is a little different, but yeah, that's sort of a standard technique for anybody that does liposuction these days. Kirstin (04:44): Where are you usually removing the fat from? Dr. Koehler (04:48): Anywhere you have fat, but the most common areas for fat removal are going to be flanks, abdomen, mid back, outer, inner, and outer thighs arms. So like I said, pretty much anywhere, but the most common areas are going to be the abdomen, waist, and flanks just to contour waistlines. So anytime we do a tummy tuck, we're doing liposuction with it. With breast reductions, a lot of times we're liposuctioning along the lateral chest wall. So even with surgical procedures, it's an add-on to a lot of the surgical things that we do. Kirstin (05:24): How much fat can you remove in a session? Dr. Koehler (05:29): Yeah, well, that's actually a little bit of a difficult question. Only reason I say that is, yeah, there's a number that people will throw out. So there's different societies that have come out to say that up to five liters of fat is safe to remove in one session, but there's some states that actually have state laws limiting the amount of fat that a person can remove. But five liters is a standard number. I like to try to explain this to people kind of like back when in general surgery when we would treat patients with burns, you have first, second, and third degree burns. Well, part of the whole determining the severity of the injury is not only the thickness or the depth of the burn, but also the body surface area that is being affected. If I had a heavy patient, and let's say I was going to take off five liters of fat from their abdomen and their waist, and I could get that easily off from their abdomen, waist, they were just a bigger person. (06:35): And then I had another patient that was small that I was only going to take off three liters of fat, but I was going to take it from their arms, their mid-back, their posterior flanks, their inner and outer thighs and their abdomen. Which is safer taking three liters off or five liters off? Well, in that circumstance, it's probably safer to take the five liters off because we're getting it off of one area and we're not causing tissue trauma to multiple, multiple areas of the body. Whereas even though the smaller patient that I got less fat off of, I had to create a lot more tissue trauma to get that off. And so even though there's an answer that people will use to say, oh, five liters, well, it depends on a lot of other factors. So that's where doctor's judgment comes into play, and there's a lot of other things that go into it, but five liters, it works out to be about 11 pounds. So that's the most that you can pretty much get off. Kirstin (07:33): So is liposuction a weight loss procedure? Dr. Koehler (07:39): You've heard me say this a zillion times. Kirstin (07:42): I knew you would love that question. Dr. Koehler (07:44): Not, not, I repeat, not a weight loss procedure at all. I, and I don't mean to sound awful because patients ask me this all the time and I just want to scream sometimes not at them, but I get it. They want to Kirstin (08:00): At society. Dr. Koehler (08:02): And everybody wants to know, how much did you suck off? How I'm like, I don't even that even, I have to look back and look. I don't go, ah, I got five pounds off. Not that, how did I get the contours that I want? And that would be the, so it's all about, it's a contouring procedure, but it's no different, right? You go to the ER and you get cut and they're like, how many stitches do you put in? I'm like, I don't count them. I don't know. I don't know a single doctor that does, but I'll throw out a number. You want 20. Does that sound good? Is that enough? But it is just something people are very curious about. But the truth of it is people are often like, you'll show 'em like we took canisters of fat off, and the contours are significantly different, but it's often a lot less weight than people think it is. Kirstin (08:54): People call in here all the time wanting 360 lipo. Are there different types of liposuction, like HD lipo, 360 lipo, high definition? Dr. Koehler (09:05): Well, yeah. Well, okay. Lipo 360 is not a procedure. Okay, well, it is and it isn't. Okay. It's, that's a marketing term to describe liposuction, which would be all the way around your torso, 360. So we lipo your abdomen, we lipo your anterior and your posterior flanks and your back. So to just make it sound catchy, it's Lipo 360, which just means we're liposuctioning all the way around your waist and back. It's still liposuction. It's not a different procedure. It's like if I said, oh, I'm going to liposuction your abdomen, flanks and back, and then you went and saw somebody else and they said, oh, I'm going to do lipo 360. Same difference. Kirstin (09:57): Same thing. Dr. Koehler (09:58): It's just different, it's a coin term for an area that we're doing, but it's not a different, it's not like, oh, that other doctor said they would do Lipo 360 on me. Well, it's the same. It's just liposuction and it's describing an area. High definition liposuction is a little bit different, but also the same. It's still liposuction. However, high definition liposuction a little is a, it's done technically different than traditional liposuction in the sense that with regular liposuction, we're just taking off to smooth and achieve a contour. High def liposuction is a technique where we're really trying to accentuate the shadows and the contours to give the appearance of a very sculpted athletic look. (10:53): So people who want to have a six pack and they don't have a six pack, they've got maybe a keg and they want to just get a six pack like that, but they want to have that definition. So what you do in those circumstances is you have to selectively remove more fat and you have to get superficial fat, and you have to do it in a way that's very artistic to try to create these shadows in the right locations. Because when it's all said and done, you don't have any more muscle. You've just created shadows in a way that give that appearance that you have more definition, maybe a more muscular physique. HD liposuction, which is great in the right patients, but I always say it's kind of like, okay, let's say you get HD high def liposuction in you're 33. What's going to happen when you're 53? Because if you don't maintain your weight, it's just fat that's been sculpted more. And so now if you put on 20 pounds between 33 and 53, now you've got a bunch of grooves in your fat and you might have all this extra fat. So I'm not opposed to high def liposuction, but it is something that I definitely have a very, if you're the kind of person that, no, I'm dedicated, I have a hard time getting the definition. I work out all the time and I want to try to get that added definition, great. But if you're just a little overweight and you're wanting to give that appearance, I'd be a little more cautious. Kirstin (12:24): Okay. What about Renuvion? Dr. Koehler (12:27): Renuvion is interesting tool. I've used it now for, gosh, a while. I don't know how long have I had it for before covid, anyhow, I don't remember. It is a coagulation device and it uses radiofrequency energy and a helium plasma to basically heat some of the undersurface of the skin and to tighten up some of the collagen up underneath there to get nonsurgical skin tightening. And when it comes to nonsurgical skin tightening, I'll just tell everybody there's things that might be helpful to a mild, maybe a moderate degree, but really surgery's, if you have lots of loose skin, nothing's going to replace surgery. So the Renuvion is a nice tool for people that, let's say they want, I use it for several areas. So somebody comes in and they want upper arm liposuction and they've got a little bit of skin laxity, and I really don't want to put a scar on their inner arm to do an arm reduction. (13:37): You liposuction, and then after you're done liposuction, you put the Renuvion in to help provide that little bit of extra skin tightening. Again, it's not going to be tons, but it will help. And I think in certain cases like that, very helpful. I've used it on some cases where a woman is like, they are borderline a tummy tuck candidate, but they really don't want to tummy tuck. And we can, I mean, we're not going to achieve results like a tummy tuck, but we can provide some added benefits. So it's a decent tool. There was, I think it was a few years ago though, it was 2022, they came out with a FDA warning for Renuvion, and it had to do with, I think they said, oh, well, the complications for Renuvion could be as high as 0.4%. And I was like, 0.4%. I mean, that's nothing really. But I think it came out as a report because I think there was a lot of optimism that this could provide really good skin tightening, but it is a thermal device and it can create scarring and burns and other things. So I think it was just, it wasn't any recall or anything like that. It was just sort of a generalized public update to let people know. Anyhow, but we still have it. I use it. I wouldn't say I use it frequently, frequently, but in the right patients, it's a good tool. Kirstin (15:09): What about while we're talking about fat reduction CoolSculpting? Is there a line to be drawn between who's a good CoolSculpting patient versus somebody who needs liposuction? Dr. Koehler (15:21): Well, to me, liposuction would always be preferred over CoolSculpting. The only time I would say CoolSculpting is the option is for the patient who says, I absolutely will not do surgery, and I'm looking for modest reduction in fat and I do not want surgery. Kirstin (15:40): All right. Now we're going to talk about the best part, fat transfer. Do most people decide to use the fat from lipo to add volume to other areas like their backside? Dr. Koehler (15:52): It just depends. It depends on the patient's desires, but yes, gluteal augmentation, and we talk in one or other episodes, not everybody's wanting a big gluteal augmentation. Sometimes it's just for shape. And so we are still doing quite a few Brazilian butt lifts to add some volume or treating hip dips and other little things. I had a lady here recently, she'd had a hip surgery and she had a pretty depressed scar on her hip, and so we did some fat grafting to help smooth that out. So yeah, we use fat grafting. It's not with every case, but yeah, it's something that we do routinely. Kirstin (16:32): Are there other places that you transfer the fat to? Dr. Koehler (16:35): Buttocks is probably the most common. Sometimes you can do it in men in their chest to help give them, instead of doing pec implants, you can actually put fat up underneath the pec muscle and give them a little bit more fullness. And again, hip dips we talked about. Sometimes I'll inject fat into hands, people who have aged to hands and they want to have kind of more youthful looking hands, we can put fat in there. And then of course, we use it very regularly for as part of facial rejuvenation procedures, when we're doing facelift and whatnot, we'll put a little bit of fat in tear troughs, cheeks, lips, temples. I mean, there's lots of different places we'll add it in small amounts to the face. Kirstin (17:18): Do you ever do fat transfer to the breasts in women? Dr. Koehler (17:23): So yes, if you call my office and ask if I do it, I mean, yes, we do it, but is it something that I enjoy doing? The answer is no. And not that I don't enjoy doing it, but I just want to share, that if fat grafting to the breast was a really good procedure and you're looking for an augmentation, you should be able to call five offices and have people say, yes, we absolutely can give you breast augmentation with fat, but most places they use it as a tool with an implant. Sometimes if somebody just needs a little enhancement of their cleavage, they'll do a breast implant and then some fat grafting to help enhance cleavage or other things. But as a primary tool to augment a breast, the reason that you don't see it very popular is because, well, it has problems, potential problems. (18:15): I may have shared with you before, but I'll share it again, a personal story. I had a lady that I took her implants out, about a year later, she wanted a tummy tuck. She said, Hey, you put some fat in my breast. I said, yes. I told her that it's not all going to stay. We don't know how much of it's going to stay. It could be 50%, it could be less, it could be more, but that's what she wanted to do. And then I explained to her that there can be problems. You could have cyst formation, oil cysts, you can have fat necrosis, you can get calcifications and all these things can appear abnormal on a mammogram. And she said, well, okay, but that's fine, but I don't want an implant and let's do that. So we did it. And then about eight months later, I get a phone call, she's crying on the phone, and she said, I went and got my mammogram and my radiologist read my mammogram and said that it looks awful, and I've got all these calcifications. (19:12): And he said, I should have never have had fat grafting done. He said, it's malpractice. I said, well, it's not considered malpractice. It was, and that's an interesting thing, because up until about 2009, a lot of people did consider it malpractice because it altered, you could have oil cysts and calcifications and all these things that could alter mammograms. And one of the thoughts that people had back then is that with fat grafting, you're taking some of these growth factors in stem cells and you're injecting 'em into another area. And let's just say a person has maybe a dormant, like a pre-cancer or a cancer, or they've recovered from cancer. (19:56): By putting that in there, is that adding fertilizer to that situation or fuel to the fire, so to speak? And so people were very concerned that it wasn't a good idea to put fat in the breast. But in 2009, American Society Plastic Surgeons came out and other people spoke out about it that fat grafting was an acceptable tool in the breast, but it didn't negate all these things that still occur. But we just have better imaging tools nowadays, and it's used very commonly as part of breast reconstruction after breast cancer. So it's like it is a tool that we use. But anyhow, point is fat grafting in the breast can be used. It is not a primary tool. It's often used as a secondary kind of help to get little added benefit, but yes, be used in the breast. Kirstin (20:47): Okay. Dr. Koehler (20:47): That's the long answer. Kirstin (20:50): We like the long answer. Dr. Koehler (20:51): Yeah, I know. Kirstin (20:54): How much fat, when you just say you're doing a BBL or a fat transfer to the buttock, how much of the fat stays or does any of it shrink? Dr. Koehler (21:04): Yeah, a lot of it's going to go away. I mean, depending on the papers you read, anywhere from 40 to 80% of the fat's going to stay. I usually try to say, well, we hope about 50% of the fat stays or more, but we just don't know it. Some people, it stays better than others. So you sometimes hear people say, well, can you just put more in there then? Well, it sounds like, okay, well, if you go, oh, 50% of it's going to go away, just double it, add more fat. But this is not how it works because if you put even more fat in there, the way these fat cells survive until they get their own blood supplies is from the nutrition, from the interstitial fluid that's in there, and if you put so much fat in there, you're kind of choking off the nutrition to these fat cells. And it's sort of like it's counterproductive. Sometimes you just have to tell people they might need a second or third session of fat grafting if they're wanting to get to a certain size or a result. It's just a reality. I mean, when you take cells from one area and you move them and they don't happily get moved, they're forced somewhere else, they may not survive. So it's just part of the process. Kirstin (22:13): How is facial fat transfer different than body contouring, fat transfer? Do you take it from somewhere else? Do you spin it down differently? Dr. Koehler (22:25): Yeah. Well, it's more delicate. We use smaller particles of fat, whereas when we harvest the fat for BBLs, we're using pretty big cannulas. And so the particles of fat that we're getting are actually large size particles, but we're also injecting it kind of in the deeper part. We're not going in the muscle, but we are going in the deeper part of that deeper layer of fat. And so we can put these big chunks of fat in there, and it doesn't result in lumpiness or irregularity. But when we're in the face, we're going to want to use smaller particles of fat. So when we suction it, we use a cannula that's teeny tiny. It's smaller than a straw. It's like a little teeny tiny cannula. We want to get small particles of fat. And then for fat grafting, Sidney Coleman was kind of the pioneer on fat grafting for the face. (23:13): And for a lot of people, not everybody does this, but a lot of people, we still use that technique where after we've harvested the fat, when we use it, we harvest it with 10 cc syringes, and then we put it in a centrifuge and then we spin it for three minutes, and then we take the oil layer off, we take the liquid off, and so all we're left with is the concentrated fat, and we are going to use that fat to graft into the face. And sometimes we have these little filters that we can actually decrease the particle size. So if we're doing a delicate area, maybe the under eye, we'll use a smaller particle of fat. If we're doing an area where we're trying to give maybe more structure like a cheek, we'll use maybe bigger particles of fat. And then sometimes we'll use it not for fat grafting at all, but just for the growth factors. (24:03): And so you hear people nowadays in facial fat grafting talk about nanofat, where we basically pass it through a bunch of filters. It gets really, really small, and we're not actually transferring any cells at this point. We're actually just transferring growth factors. So that is injected not under the skin, but actually into the skin. So we're in the dermis of the skin. And so using that, we can help with skin texture, tone, fine lines and wrinkles, but it doesn't add any volume. So for facial fat grafting, we have sort of larger particles of fat to provide structure, smaller particles of fat for delicate areas, and then we use just sort of the growth factors to affect the dermis of the skin. So we use it very differently in the face. Kirstin (24:54): Okay. Now for recovery. How long is recovery on liposuction or lipo fat transfer? Dr. Koehler (25:04): Well, we generally tell people for liposuction, I mean, the first week you're going to be out for sure for a week. If you're doing it with a BBL, it may take 10 days, 14 days. A lot of it depends on your personal toughness, but one to two weeks you should be definitely back to work, regular daily activities. Now, not exercise or anything like that, but within two weeks back to regular daily activities. You are going to still be sore even six weeks afterwards, after, if you've had liposuction and you touch it at six weeks later, you don't want to touch it, cuz it's still sore. It hurts and it's numb. It doesn't feel normal, and the skin is like you touch it, it doesn't feel like it's yours and it's going to take months for that to come back. So there are a lot of weird feelings that go along with it. But as far as needing to take pain medicine after two weeks, yeah, it still hurts, but you just got to use common sense and working out six weeks, then you can start getting back to the gym. Kirstin (26:06): Will patients see their new body shape immediately or does it take a little while to see the results? Dr. Koehler (26:12): Depends. So maybe a bigger patient, especially if we want maybe one that we took a little bit more fat off, they're going to see an immediate result. But there's still quite a bit of swelling. On a smaller patient, you do some liposuction and then their swelling kicks in and it looks like there's not much change. So smaller patients may take a little longer for the swelling to totally subside to see the difference. But we usually tell people, you're not going to see your final results for six months. But yeah, at six weeks, most people can absolutely see a definite change. It's just not where it's going to end up. Kirstin (26:47): Do patients seem to wear compression? Dr. Koehler (26:50): Usually, we like people to have to wear compression 24 hours a day for the first two weeks, and then we usually go to part-time wear like 12 hours a day for the next two weeks. And then after that, as they feel comfortable, and for a lot of people going, sometimes even several months with compression, they find it very useful because they might wake up in the morning and they look in the mirror and they're like, I look good, I feel good. And if they don't work compression, they come home, it's six o'clock and they're like, oh my God, I'm so swollen. I don't like how this looks. And so the compression, although it's not going to maybe change the ultimate result at that point, it definitely helps with that whole swelling issue. That takes time. That's why it takes six months for all that kind of stuff to resolve. Kirstin (27:40): Are there any other aftercare items that patients should buy when they get liposuction, or is it a relatively easier procedure to take care of yourself afterwards? Dr. Koehler (27:50): Well, I mean, I would say we're going to provide the initial garment for you to wear, but you might have drain tubes and stuff like that, and until your drains are all out, then you can switch to a faja, which is what it's definitely a better garment. And if you're doing a BBL, then it's nice to have the faja with the cutout for the buttocks. So you're not putting compression on the buttocks, but you're compressing all the areas around it, which had liposuction. (28:17): And so usually you'll start off with a firm one, but not super firm. And then after a few weeks, some people, as the swelling comes down, then that garment's not fitting as snugly, then you'll bump it up to even a more like a firmer fitting faja. Sometimes after liposuction, we'll have people get little rollers, almost like a little pizza roller, and you can, if you have a little lump or bump or a ridge, you can kind of help massage that with any little lumps or bumps. If you had a BBL, some people will get special pillows to help when they're sitting, so they're not putting pressure on their buttocks. Sometimes with the garments can create creases in the skin. There's foam that you can purchase to put underneath your garments so that the foam is not creasing the skin, like the garment can sometimes make little creases, and that'll help prevent that. So not everybody needs all those things afterwards, but definitely those are some of the other items that we can certainly discuss depending on the circumstances. Kirstin (29:19): I know that lipo incisions are tiny, but how long do they take to heal? Dr. Koehler (29:26): I mean, once we take, if you have a drain tube or whatever, a lot of times they're sutured closed if there's no drain. So I'd say within four to six weeks they're still red, but they're closed. And depending because of liposuction, that tube is going in and out, it creates friction at that incision site. And so sometimes it can stay a little red and irritated for longer than you might think. So it may take several months for the redness and everything to kind of calm down. Kirstin (29:59): Can you see lipo scars? Like if someone's on the beach? Dr. Koehler (30:04): Not mine, Kirstin (30:08): Not yours, or the ones that you give? Dr. Koehler (30:10): The ones I give you don't see. Well, so we try to place those puncture sites in hidden areas. So a lot of times I'll have somebody either bring in a bathing suit top or their bra at least, so that when we're putting the puncture sites for maybe doing mid back, that we put them underneath an area that's going to be covered. And same thing when we're doing posterior flanks, we put it below where the bathing suit would be, or on the abdomen, we'll put an incision on the inside of the belly button. So we often are trying to hide the position of those scars, not depending on the area. We sometimes can't completely hide it, but usually they're so small and they're in kind of not very visible areas. You'd have to really be looking for 'em to see them. Kirstin (31:01): Okay. Some people want to combine their lipo with procedures like tummy tuck or fat transfer, like we've said. How does getting multiple treatments at once affect recovery? Or does it? Dr. Koehler (31:16): Oh, it does. I mean, you do more stuff, you hurt more. I mean, yeah. So each patient is different like I mentioned. We're looking at how much work we're doing in general, what areas we're operating on, all these things. And so yeah, it definitely is more recovery, but sometimes people are like, I only have the time for one recovery and provided it's a safe, what we're talking about doing, and it's not unreasonable. Yes, you can add those. It's just plan on being a little bit more sore, but knock it out and be done. Kirstin (31:49): Okay, awesome. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler. Dr. Koehler (32:02): Thanks, Kirstin. Kirstin (32:03): Go back to making Alabama beautiful. Dr. Koehler (32:05): Working on it. Announcer (32:08): Got a question for Dr. Koehler. Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.