Latest / HKB Uncut | A Cosmetic Surgery Podcast / 21. The Truth About Loose Skin After Weight Loss | What Surgery Can (and Can’t) Fix

Transcript

21. The Truth About Loose Skin After Weight Loss | What Surgery Can (and Can’t) Fix · HKB Uncut | A Cosmetic Surgery Podcast

0:00
SPEAKER_01: Do you have a favorite between Bill and I?
0:02
SPEAKER_00: Do I have to pick one?
0:04
SPEAKER_00: Both?
0:04
SPEAKER_00: Neither.
0:06
SPEAKER_00: Pick one.
0:07
SPEAKER_00: Has to be me.
0:08
SPEAKER_00: Also depends on the day.
0:14
SPEAKER_02: Welcome to HKB Uncut, the health, knowledge, and beauty podcast.
0:18
SPEAKER_01: On this show, we unpack the newest techniques and trends in cosmetic surgery, how to tune out the social media noise to make empowered decisions about your appearance, and what you need to know before you book a procedure.
0:28
SPEAKER_01: I'm Dr.
0:29
SPEAKER_01: Bill Cortesis.
0:30
SPEAKER_01: And I'm Gorav Baharty.
0:31
SPEAKER_01: We are board-certified plastic surgeons and co-founders of HKB Cosmetic Surgery, an award-winning practice with 11 locations across six states.
0:39
SPEAKER_02: In other words, when it comes to aesthetics and cosmetic surgery, we've pretty much seen it all, and we want to share our knowledge and unique approach to aesthetics and beauty with you.
0:48
SPEAKER_02: Whether you're interested in cosmetic surgery for yourself or want to separate fact from fiction in the plastic surgery world, we hope you'll tune in each week.
1:10
SPEAKER_01: Today we're going to talk about massive weight loss and massive weight loss surgery.
1:14
SPEAKER_01: And Dr.
1:15
SPEAKER_01: Kleban is an absolute worlds expert on this.
1:19
SPEAKER_01: She does incredible cases.
1:22
SPEAKER_01: I uh I'm I'm always in awe at her results, and that we're gonna have a nice discussion today.
1:27
SPEAKER_02: Yeah.
1:28
SPEAKER_02: Super excited to have you on the show and to talk about one of your passions.
1:32
SPEAKER_02: I know you love this procedure and love taking care of patients.
1:35
SPEAKER_00: Yeah, thanks for having me, and I'm honored to be here to be able to talk about what I love and the patients that I love to take care of.
1:42
SPEAKER_01: You know, when people start contemplating this, they come and see you, explain to the audience kind of what it is like, like what what's the process?
1:52
SPEAKER_01: When do they come see you?
1:53
SPEAKER_01: And um how do you decide what to do?
1:56
SPEAKER_00: So that can be pretty complex.
1:58
SPEAKER_00: Um patients will come at many different times during their journey.
2:01
SPEAKER_00: Some will come during their weight loss while they're actively losing weight, and just to get an idea of what might be out there for them.
2:10
SPEAKER_00: Other patients come once they've lost the weight, feel stable, and all of that, but we won't do surgery until they are kind of at that plateau, stable at their weight and feeling good.
2:21
SPEAKER_00: Um, the process is is pretty in-depth.
2:24
SPEAKER_00: So oftentimes these patients have multiple areas that are affected by the weight loss, and so we're talking head-to-toe rejuvenation.
2:33
SPEAKER_00: And so it's a step-by-step process.
2:35
SPEAKER_00: I kind of ask them what they're interested in talking about, and then mention some other areas that may they may not even know or possibilities that can be improved with surgery.
2:46
SPEAKER_01: What is like massive weight loss?
2:48
SPEAKER_01: Like how much weight are we talking about?
2:51
SPEAKER_00: Well, it depends on where you're starting from, first of all.
2:54
SPEAKER_00: So I have patients that have lost anywhere from say 60, 75 pounds, which that's a significant amount of weight, to up to 200 pounds.
3:02
SPEAKER_00: My patient today lost 140 pounds, and we were doing her second stage surgery, and really excited for her to see her results after that.
3:11
SPEAKER_02: I think you're bringing up a really good point, right?
3:13
SPEAKER_02: It's not necessarily the amount that you lose, but it's more the percentage that you lose from where you start with.
3:21
SPEAKER_02: Because it it it's ultimately what we're taking care of is skin laxity, right?
3:25
SPEAKER_02: And like everybody ends up having multiple skin laxity everywhere, from their face to their body, um, you know, all parts of their their of their body.
3:34
SPEAKER_02: So how do you when you talk to somebody, how do you talk to them about is it gonna be one surgery?
3:39
SPEAKER_02: Is it gonna tackle it all?
3:40
SPEAKER_02: Are we gonna do multiple surgeries, or you know, what's your approach?
3:45
SPEAKER_01: You were alluding to it like it affects everything.
3:48
SPEAKER_01: And so when someone has that kind of weight loss, like it can affect like literally every part of their body.
3:53
SPEAKER_01: Arms, tummy, chest, back, but legs, face.
4:00
SPEAKER_01: So um you can't do all those things at the same time.
4:02
SPEAKER_01: Now I will say that we're able to do some pretty incredible combos, and I'd love to get to kind of hear about like your old favorite combos from massive weight loss surgery.
4:11
SPEAKER_01: But I think staging is is is totally appropriate.
4:15
SPEAKER_01: Sometimes people have I mean, I don't know how about you all, but I've done like I'd love to hear about a company where I've done like three or four stages and nothing wrong with that.
4:23
SPEAKER_01: And but we're doing a lot of stuff each time, right?
4:25
SPEAKER_01: Yes.
4:26
SPEAKER_01: Um we've done some things together.
4:28
SPEAKER_01: What do you do when someone wants to really try to tackle everything at once and it's doable?
4:32
SPEAKER_01: Well, how's your band and your approach on those cases?
4:35
SPEAKER_00: So most of my patients, I I sort of start with what's the most important to you, because getting that tackled first really gives them this boost of kind of energy and confidence that then makes them excited for those next stages.
4:50
SPEAKER_00: But if we're talking about how to pack in as much life-changing surgery at one time, really starting with the trunk is kind of where we want to start because that tends to be the procedure that takes the longest.
5:02
SPEAKER_00: And then adding on other areas, you know, whatever their priorities are, maybe it's the arms, maybe it's the breasts, maybe it's the thighs.
5:10
SPEAKER_00: You know, it just depends on the patient.
5:13
SPEAKER_01: You know, one of the foundation pieces of of this organization, HKB, one of the reasons why you did the fellowship and you all get to work with Joe Hunstead, is that always we've always been taking care of massive weight loss patients.
5:24
SPEAKER_01: It's like one of the crown jewels of our organization.
5:27
SPEAKER_01: And I think it's important because a lot of a lot of surgeons there are all just kind of latching onto it, just doing this and they haven't don't have experience.
5:33
SPEAKER_01: What's the unique thing is about a massive weight loss body contouring, and and what are some of those nuances that we do differently and we handle appropriately compared to like just a mommy makeover, for example?
5:46
SPEAKER_00: I think with these patients that have lost a large percentage of their body weight, their skin everywhere.
5:52
SPEAKER_00: And so trying to figure out where to place your incisions, where they're gonna end up when you do these procedures, that takes time to understand that and and seeing a lot of these patients over and over again to find that perfect incision placement, to get the patients the results that they're looking for, getting them tight enough without having wound breakdown issues and those sorts of things, that's that's higher level stuff that when you aren't doing these procedures very often, you may leave patients with a lot more skin laxity because you're not used to how tight are you really able to pull these patients and where is that incision going to end up.
6:28
SPEAKER_00: And you know, some of the things that you see is if you're not experienced, maybe the incision's in a place that the patient doesn't want.
6:35
SPEAKER_00: Maybe it's writing too high, writing too low, the vertical incision is off to one side.
6:40
SPEAKER_00: So it's really those little nuances that that take time and persistence and care to get right.
6:49
SPEAKER_02: I mean, even doing incisions with opposing forces, right?
6:53
SPEAKER_02: When you do a bra line back lift, which is actually a removal of that skin and the upper part of the back, and doing a 360 tummy tuck at the same time, which we all do very frequently.
7:04
SPEAKER_02: Again, you're actually opposing kind of tension lines and forces in the in those cases.
7:09
SPEAKER_02: And again, knowing the nuances of how much skin you can actually remove in those areas.
7:13
SPEAKER_02: Or if you're doing a buttocks lift and a vertical thigh lift at the same time.
7:17
SPEAKER_02: You're actually, you know, moving you know, thigh skin whenever you do that.
7:21
SPEAKER_02: So there are complete nuances.
7:23
SPEAKER_02: I think one of the things that sets us apart is the fact that we treat both massive weight loss and regular body contouring patients the same and we look at the 360 evaluation.
7:35
SPEAKER_02: I mean, I think we're one of the first, if not the the first in the entire country to make sure that when we take care of patients, we're looking at the 360 part.
7:43
SPEAKER_02: Or, you know, a lot of a lot of places out there just end up doing two-dimensional body contouring.
7:48
SPEAKER_02: You can't do that.
7:49
SPEAKER_02: We're we're not two-dimensional individuals, right?
7:51
SPEAKER_02: So you have to take care of the whole area.
7:53
SPEAKER_02: So when you take care of the trunk, the anterior part of the front part of the abdomen, you need to look at the back part, right?
7:58
SPEAKER_02: Take care of the buttocks, the lower part of the back.
8:01
SPEAKER_02: That is all part of ultimately what we do.
8:04
SPEAKER_00: I do say that all the time.
8:05
SPEAKER_00: A waist is a 360-degree structure.
8:07
SPEAKER_02: Right.
8:08
SPEAKER_00: And so when you neglect the back, sometimes you're missing a big piece of creating that shape that the patients are looking for.
8:14
SPEAKER_02: Both of you have recently changed kind of your approach to tummy tucks, which I'd love to kind of talk touch on, but you both have kind of gone more to the extended tummy tuck.
8:25
SPEAKER_02: Can you talk a little bit about that and why you've kind of moved to towards that approach?
8:30
SPEAKER_02: Yeah.
8:31
SPEAKER_00: I think that because I'm doing more 360-degree care as far as addressing the trunk, there's some laxity that extends beyond that hip in a lot of patients.
8:42
SPEAKER_00: And seeing more patients on GLP1s, they may not be treated by just a standard tummy tuck.
8:48
SPEAKER_00: And instead of chasing, say, a dog ear, which is a little bit of skin at the end of an incision, we can have that incision lay nice and flat and create a larger result on those patients, and maybe get even a little bit of lift of the outer thigh sometimes, depending on how far around we go.
9:04
SPEAKER_01: Yeah, you know, it's a simple concept, too, that you know, even the most layman can understand once you really make it simple is that when you take something that's circular and you make it linear, there's bunching on the ends.
9:17
SPEAKER_01: And then you have this fixed structure called your ASIS, which is your bone, your pelvis.
9:21
SPEAKER_01: And so when we do these types of contourings, if you just extend it further and go posteriorly, you just the results are just the reason why I've been starting to do more and more is like the results just look so much better.
9:33
SPEAKER_01: The negative, I mean, here's the all honesty, this is a longer scar.
9:36
SPEAKER_01: And like, I don't know about you all, I hate scars.
9:39
SPEAKER_01: I really hate them.
9:40
SPEAKER_01: I hate them, I hate them so bad, and I can't wait until we're gonna be able to do surgery without scars, but right now it's not here.
9:45
SPEAKER_01: Um, but the contour and the result that you get is traumatic.
9:48
SPEAKER_01: And then and then doing circumferential like resections.
9:51
SPEAKER_01: I I will tell you that I'm doing more and more kind of lower BMI, which means less of the overweight patients.
9:56
SPEAKER_01: So it's not like your prototypical patient, like, oh, they need a they need a body lift, or you're doing circumferential abdominoplastes, and man, they look insane.
10:04
SPEAKER_01: They look great, and like patients are really happy afterwards.
10:07
SPEAKER_01: Now they are okay with the scar burden, but it's like they just don't want to, they don't want to sit here and have laxity.
10:12
SPEAKER_01: So I think we're we're better at asking our patients directly, hey, does this bother you?
10:16
SPEAKER_01: Because if it does, we can get rid of it.
10:17
SPEAKER_01: The negative, longer scar.
10:20
SPEAKER_01: Um so I think that it's it's it's it's interesting that we're doing more bigger procedures, but we're getting better results.
10:26
SPEAKER_02: Isn't that amazing when you take care of the back, the front looks better?
10:29
SPEAKER_02: Always always?
10:30
SPEAKER_01: Always.
10:31
SPEAKER_01: Always.
10:31
SPEAKER_01: It's crazy.
10:32
SPEAKER_01: You know, the other thing too is like, you know, how often do you guys use?
10:36
SPEAKER_01: So we're obviously with with mass weight loss, you do, you know, excisional procedures.
10:41
SPEAKER_01: How often, though, like you're a huge champion of this, and so are you.
10:44
SPEAKER_01: I mean, you guys are both similar in this and that you are you you always are using lipocontouring as part of what you're doing.
10:51
SPEAKER_01: Talk to us a little bit about your philosophy on liposuctioning with mass weight loss skin resections, and then also using potentially energy platforms.
10:59
SPEAKER_01: Like, do you think it's worth it, or do you just avoid that on those patients?
11:03
SPEAKER_00: With these patients, what you see first is a lot of skin, right?
11:06
SPEAKER_00: So that's what you see first.
11:08
SPEAKER_00: But oftentimes there's some pockets of fat surrounding that skin.
11:12
SPEAKER_00: So once you remove the skin to create the shapes that you're looking for, those nice silhouettes, doing some liposuction really helps with that.
11:19
SPEAKER_00: So the bulk of the procedure is actually the skin removal in these patients.
11:23
SPEAKER_00: But then the fine-tuning that finesse is a little bit of liposuction.
11:27
SPEAKER_00: And then as far as kind of the energy-based technologies, I usually reserve those for you know residual laxity after the fact.
11:35
SPEAKER_00: We pull you really nice and tight.
11:37
SPEAKER_00: I don't see as much or as stronger of a result in some of the massive waste weight loss patients with some of those energy devices than my patients that kind of have better skin quality and those sorts of things.
11:48
SPEAKER_00: So I I think for those patients, skin removal first and then using the energy kind of as a backup, you know, secondary stage if they've got a little bit of laxity that we need to treat.
11:58
SPEAKER_01: What is your um URL's thought?
12:00
SPEAKER_01: You have a massive weight loss patient that's kind of midway, but they just have a lot of skin.
12:05
SPEAKER_01: And they they just want to get this process started.
12:08
SPEAKER_01: And then if they say, well, what happened, can I lose more weight?
12:12
SPEAKER_01: How do you approach that patient?
12:13
SPEAKER_00: That happens kind of all the all the time.
12:15
SPEAKER_00: I have a subset of patients that are kind of plateaued, they can't work out of the gym, the skin's getting in the way, it's just affecting their quality of life.
12:24
SPEAKER_00: And although they're not where they want to be weight-wise, the skin's impacting them so much that it makes sense to do surgery at that point.
12:31
SPEAKER_00: And with those patients, I do counsel them before letting them know, hey, if you lose more weight when you get to your goal weight, you may have a little bit more laxity.
12:39
SPEAKER_00: Maybe we touch up a little bit of things.
12:41
SPEAKER_00: But this may help you get to that point because you're able to actually do the exercises you want to do, actually move the way you want to move and do the things you want to do.
12:50
SPEAKER_00: And it kind of gives them that confidence boost too, of of getting getting their a little reward halfway to, so to speak.
12:58
SPEAKER_01: You know, all of us um get to take care of amazing patients, and um, you know, working can be hard, but there's there's cases you do that just warm you and like just like kind of change you and and make you want to do more.
13:11
SPEAKER_01: Is there a a case or two for a mass weight loss patient that you could tell us about kind of what you did and why it was special?
13:19
SPEAKER_00: I mean, it's so hard to pick one because every story that I hear from these patients are life-changing for me.
13:26
SPEAKER_00: Every patient has something that these surgeries have changed the way that they interact in the world.
13:32
SPEAKER_00: So I'll give you an example from today.
13:34
SPEAKER_00: So my patient today, second stage surgery with me, and she said, you know, before I lost the weight, I wouldn't even go on an airplane.
13:43
SPEAKER_00: I felt embarrassed to walk down the aisle on an airplane.
13:47
SPEAKER_00: And now that I've lost 140 pounds, and now that I have this skin removal, I want to go out and explore the world.
13:54
SPEAKER_00: And so just even something simple as being able to be on an airplane is something that you don't think about so much.
14:02
SPEAKER_00: And so it's it's great to be a part of that journey.
14:05
SPEAKER_00: I always tell them, you did the work, I'm just the cheerleader at the end, you know, waving the my pom-poms and helping you see all the work that you did.
14:15
SPEAKER_02: These procedures are astonishing what they do for individuals.
14:20
SPEAKER_02: I mean, I think that they're by far one of our most rewarding procedures we do is take care of the massive weight loss patients.
14:26
SPEAKER_02: I mean, they're over the moon, ecstatic.
14:28
SPEAKER_02: You know, one of the common questions I get asked is is a safe how many procedures can I do?
14:35
SPEAKER_02: Because they really they they want to knock out a bunch in in one particular time.
14:40
SPEAKER_02: And kind of walk us through, you know, a patient's coming in, they're like, Doc, I want to get all this done.
14:46
SPEAKER_02: Can I do it safely?
14:48
SPEAKER_02: How much is feasible?
14:50
SPEAKER_02: Is there a length of time in surgery that is the the the mitigating risk factor here, or is there something else, or is it the amount of tissue you remove?
14:58
SPEAKER_02: How do you walk through the patient in regards to kind of their safety concerns and how much can be done?
15:03
SPEAKER_00: Sure.
15:04
SPEAKER_00: So when a patient comes in, there tends to be a laundry list of items.
15:07
SPEAKER_00: And so how do we categorize that in the safest way possible?
15:11
SPEAKER_00: How do we break up those stages?
15:12
SPEAKER_00: And like I said before, I'll I'll try to start with what they want the most and then add things on as I can.
15:18
SPEAKER_00: Keeping things around six and a half hours worth of surgery to keep them safe, keep them warm, that's our number one priority is safety.
15:25
SPEAKER_00: Number two, obviously, is our aesthetic result, but number one is safety.
15:29
SPEAKER_00: Then it's also about, you know, how much can you take off at one time?
15:33
SPEAKER_00: You know, taking more than 10% of somebody's body weight starts to become unsafe.
15:37
SPEAKER_00: And then also the patient's age comes into consideration as well, not just their age, but their kind of physical age, how they interact, you know, are they the type that's in the gym all the time, or are they more sedentary?
15:50
SPEAKER_00: You can do a little bit more surgery on somebody that's starting off healthier, starting off already going to the gym.
15:57
SPEAKER_00: They bounce back so much quicker, and you have to be a little bit more cautious in say older patients or patients that are a little bit more sedentary.
16:04
SPEAKER_02: So let's let's dive into that a little bit more.
16:06
SPEAKER_02: I mean, would would you do, you know, if you're doing the trunk, would you add that trunk component with an extremity or breast or face?
16:17
SPEAKER_02: Or, you know, what what are the typical typical combinations that you would do together?
16:21
SPEAKER_00: So I'd say my most common combinations are trunk and breast, and the trunk can be just the front and some life protection to the back, or an incision that goes all the way around, or an incision that goes all the way around and up and down.
16:34
SPEAKER_00: So there's a lot of different combinations for just the trunk.
16:37
SPEAKER_00: Then usually something with the breast that can be either a reduction, a lift, a lift with an augmentation, different options there, a lift with mesh, there's all sorts of different things that we can do.
16:47
SPEAKER_00: Um, and then typically I'll do a second stage with all four extremities, which patients actually do really well with.
16:53
SPEAKER_00: You would think that it would be very difficult to move around if you have your arms and your legs done.
16:58
SPEAKER_00: But patients do great.
17:00
SPEAKER_00: And so arms and legs can be done at the same time, and then sometimes an upper back lift.
17:05
SPEAKER_00: Some patients don't need that though, it just it just depends.
17:07
SPEAKER_00: And then usually the face is separate just because it takes a little bit longer, or can be a combo case that we do together, potentially.
17:14
SPEAKER_01: You know, the big thing is what you know, it's amazing what she's saying, and it just goes back to kind of you know critical principles in kind of how you approach, you know, the aesthetic patient or or any patient in general is that they're unique.
17:28
SPEAKER_01: They have uh different, you know, issues, they have different physical um limitations, and so you know, selecting what's going to work for that situation is gonna be unique to that situation, and we kind of conform to that.
17:39
SPEAKER_01: And I think the um amazing thing though is the the ability to do larger procedures.
17:44
SPEAKER_01: I we we'll get comments sometimes, um, and sometimes you might even get some hate, some hate comments through other people in the space or other offices via other people, like saying, Well, those guys they do too much at one time, and there's other people doing it.
17:56
SPEAKER_01: The truth is that it's methodical.
17:58
SPEAKER_01: Like, we we you know, when you have somebody in the operating room, like you gotta keep them warm, you gotta avoid any blood loss, you have to, you know, keep them off of anesthesia.
18:07
SPEAKER_01: You know, you basically want to do it and be very efficient, but you also want to do a really great surgery.
18:11
SPEAKER_01: And so, like, there's like it's almost it's like this well-orchestrated, you know, symphony that when we're in there, and so you know, all of us are so such micromanagers in there, and but it's fun to like see how other people do stuff and then see like some of the other results, and like where people where you know where to push, you know where to let go.
18:29
SPEAKER_01: And that's a hard thing in the I would say in aesthetic surgery.
18:32
SPEAKER_01: That's one of the hardest things to to I've ever seen, and like having working with a lot of people, we've we have a lot of people on our teams.
18:38
SPEAKER_01: Some people get it and some people don't.
18:40
SPEAKER_01: Like, you get it, you you know how to teach it, and like that's not something that you can just like any plastic surgeon can get because there's like this aesthetic concept of what's beautiful, and like we didn't even talk about Sean is a damn artist, like she can draw anything.
18:54
SPEAKER_01: Um, we'll have to hear about that.
18:56
SPEAKER_01: But I think that goes into one of the reasons why he sh you're such a great sculptor, by you know, in some ways, because there's like understanding the vision, but then being able to execute on that.
19:04
SPEAKER_01: And like we've worked for I mean, Bill, we've seen it all.
19:07
SPEAKER_01: We were talking about the incisions.
19:09
SPEAKER_01: I mean, guys, I've seen the craziest incisions.
19:12
SPEAKER_01: I mean, who one of you all did the case?
19:14
SPEAKER_01: I was one of I think Joe had so Joe Hunts had seen this patient where there was just incisions that didn't make any sense.
19:20
SPEAKER_01: It's like the it's like you get this massive weight loss and you're making incisions in places that make no sense because ideally patients should go to the beach in a bikini and you don't see their incisions, right?
19:31
SPEAKER_01: So I don't know.
19:31
SPEAKER_01: It's it's really surprising.
19:33
SPEAKER_01: And I I just I just I can't can't help but compliment her and your results and their and like story patients because it's not it's not easy.
19:41
SPEAKER_02: But you bring up a really valid point.
19:43
SPEAKER_02: I mean, we we often get patients that have seen a couple other surgeons, been to a couple other consultations, and they're like, hey, I can only do your circumferential tummy tuck and that that's it.
19:53
SPEAKER_02: Or, you know, that's gonna take me six hours.
19:55
SPEAKER_02: How do y'all do it faster?
19:57
SPEAKER_02: Well, I think a lot of it is, you know, the 10,000 hour rule applies.
20:02
SPEAKER_02: I mean, we've done a lot of them.
20:04
SPEAKER_02: I mean, uh when I mean a lot, we have done a lot, and we know how to be efficient and safe at the same time, right?
20:10
SPEAKER_02: And still get exceptional results.
20:12
SPEAKER_02: And because of that, we can end up doing one or two more procedures, you know, all within that six hour, six and a half hour time frame.
20:18
SPEAKER_02: I agree with you.
20:19
SPEAKER_02: I think, you know, you kind of cap it off around that that time frame because one of the understated things you mentioned, which is very true, and we gonna we talk to our fellows about this all the time, is like blood loss and warmth, right?
20:32
SPEAKER_02: If you can limit blood loss in the patient and keep them warm, you do this in a very efficient w manner, patients do extremely well post-operatively.
20:41
SPEAKER_00: It's sometimes amazing when you when you think of all the work that you've done in that, say, six, six and a half hours and the incisions that you've placed on this person's body, and then that night they're up walking around.
20:54
SPEAKER_00: So we keep a lot of these patients overnight at our facility, which is great, and they love it.
20:58
SPEAKER_00: And our nurses get them up, they're walking around, moving around.
21:01
SPEAKER_00: And some patients, you know, come in to this, or people out in the world would think that there is no way that I could get up and move around.
21:09
SPEAKER_00: And they do 100% of the time.
21:11
SPEAKER_01: You raise a really good point too, and it's uh it's something that's interesting to explain to people too.
21:15
SPEAKER_01: Like, you know, incisions typically when when clothes are performed appropriately, and we we deal a lot with skin.
21:21
SPEAKER_01: Like at the end of the day we're dealing with skin and soft tissue.
21:24
SPEAKER_01: That's usually not super painful.
21:25
SPEAKER_01: Now, when we tighten muscles, that can hurt, but how do you handle preventing muscle tightening pain?
21:31
SPEAKER_00: So I help prevent that pain by doing a block.
21:35
SPEAKER_00: So I do an ultrasound guided block of the rectus muscles with something called expro.
21:40
SPEAKER_00: And expril is kind of a long acting numbing medication to help with the pain and discomfort in the abdominal region after something like a tummy tuck.
21:48
SPEAKER_01: So I think you're right.
21:49
SPEAKER_01: And so at the end of the day, like people even after big body counter, like you get someone who does like arm lift, brachioplasty, like they don't have really have much pain.
21:56
SPEAKER_01: Versus someone who's had like a lap coli or a Someone who's had a GI surgery, you know, where you actually have divided muscle or had to like distend the uh new create a pneumoparitoneum, they have real pain.
22:08
SPEAKER_01: Most of our stuff doesn't actually have that much pain.
22:10
SPEAKER_01: I mean, how about like liposuction can hurt a little bit?
22:13
SPEAKER_01: Yes.
22:14
SPEAKER_00: I was gonna say, don't forget about liposuction.
22:18
SPEAKER_02: Excision of skin and fat less painful.
22:22
SPEAKER_02: Whenever you do liposuction, it can be painful.
22:25
SPEAKER_02: I mean, it's it's just it's it's tough recovery.
22:28
SPEAKER_02: You know, I I don't want to sugarcoat it on patients, but liposuction can be tough.
22:33
SPEAKER_02: But it is, I think whenever you know, we talked about it, we touched on it.
22:37
SPEAKER_02: I think it's almost mandatory on all our body contouring to do some version of liposuction because they need us.
22:44
SPEAKER_01: But it's interesting.
22:45
SPEAKER_01: The lipo thing is, you know, it's people say, well, why does it hurt?
22:48
SPEAKER_01: Well, remember, it's like if you're treating like the trunk and you're like doing liposuction, you're like extracting little bits of fat, you're going all the way around.
22:54
SPEAKER_01: That's a huge surface area.
22:55
SPEAKER_01: That's the thing, is you don't see it.
22:57
SPEAKER_01: And it's just like it's like, I mean, the surface area is massive.
23:00
SPEAKER_00: Kind of messes with their minds too.
23:01
SPEAKER_00: They have these tiny incisions, and it's like, oh, I hurt everywhere.
23:04
SPEAKER_00: Yeah.
23:04
SPEAKER_01: And all those nerves are getting banged up, bruised up, and and now we're doing energy, we do ultrasonic energy, and you do um Renuvion and things like that.
23:12
SPEAKER_01: So you're you're causing a tremendous amount of trauma.
23:16
SPEAKER_01: I mean, you know, this is an interesting thing that we can we can talk about, but it's it's amazing what we do as you know, as surgeons, and like I'd love to hear you guys' comments on this.
23:25
SPEAKER_01: What are we doing?
23:25
SPEAKER_01: We're just basically using, we're we're traumatizing the patient.
23:29
SPEAKER_01: We're hurting the patient purposefully to allow their wound healing cascade to then take over and do the rest.
23:37
SPEAKER_00: Well, there is a lot of that in regenerative medicine in general.
23:40
SPEAKER_00: I mean, if you think about what a CO2 laser is, if you think about what microneedling is, I mean a CO2 laser is creating a controlled burn of the face to allow our body to heal and create collagen, and then microneedling, sticking needles in your face to cause collagen deposition.
23:56
SPEAKER_00: So there is a lot of that in what we do for sure.
23:59
SPEAKER_02: What are some of the nuances or challenges you face in the uh in breast surgery in the massive weight loss patient?
24:06
SPEAKER_02: Because these are these are not easy cases.
24:08
SPEAKER_00: No, and and uh those patients we will see oftentimes the breast is sitting in a place where we don't want it.
24:16
SPEAKER_00: It's sitting way down on the ribcage, almost on the abdomen.
24:20
SPEAKER_00: And so how do we get that breast back up onto the chest?
24:23
SPEAKER_00: How do we restore volume?
24:24
SPEAKER_00: How do we create the correct nipple placement?
24:28
SPEAKER_00: And sometimes it's you know, we we're doing a single stage surgery with plan for revision for some skin excess.
24:35
SPEAKER_00: Because a lot of times on table everything looks perfect, and then that skin quality is so impaired from weight gain and weight loss that things just drop pretty rip rapidly sometimes in these patients because of that poor skin quality.
24:49
SPEAKER_02: So I think you bring up a really good point.
24:51
SPEAKER_02: I think you know having that conversation with patients ahead of time that there's a good chance we'll we're gonna have to revise your breast lift because your tissues just won't hold.
24:59
SPEAKER_02: Even if we use mesh, it still may do that.
25:02
SPEAKER_01: What's on the horizon for our area in in dealing with um skin excess?
25:07
SPEAKER_00: Aaron Powell You know, it's so hard to say because we've been doing skin excision with big incisions for such a long time.
25:16
SPEAKER_00: These non-invasive or minimally minimally invasive devices provide some result, but we've haven't found anything yet that I think provides us with the same amount of change that incisional surgery can.
25:29
SPEAKER_00: And so if we find that, then that's gonna be obviously the new horizon.
25:33
SPEAKER_00: If we can find a way to get that skin to shrink down, that that would be great.
25:39
SPEAKER_00: But then there's also the other side of how do we prevent the skin from ending up like that way in the first place?
25:45
SPEAKER_00: So are there things that patients can be doing during their weight loss?
25:48
SPEAKER_00: Are we gonna learn that there are certain peptides out there that when used in conjunction with weight loss may help prevent you know some of the thinning of the skin that we see?
25:58
SPEAKER_00: I don't know.
25:58
SPEAKER_00: I really don't know.
26:00
SPEAKER_02: What I can safely tell you is we're gonna see a lot more of this.
26:03
SPEAKER_02: GLP ones are here to stay.
26:05
SPEAKER_02: More and more individuals are getting on it.
26:07
SPEAKER_02: We're gonna see way more weight loss patients.
26:11
SPEAKER_02: Um, and so I encourage every you know patient to really analyze where they go, what they do, who they allow to do surgery on them to take care of it.
26:22
SPEAKER_02: Because there's gonna be a lot of patients, and everybody's gonna be saying they can do this.
26:26
SPEAKER_02: But to your point earlier, there's nuances with these surgeries and techniques, and you really want to go to somebody who does a lot of these.
26:33
SPEAKER_02: And Dr.
26:34
SPEAKER_02: Cleveland, you are one of the best, if not the best, in the country doing it.
26:39
SPEAKER_02: Excited to have you um part of the practice and here and partners with us and it's been on this journey.
26:45
SPEAKER_00: A good six years so far.
26:46
SPEAKER_00: Can you believe that?
26:47
SPEAKER_01: Oh, we're all just getting started.
26:49
SPEAKER_00: I know.
26:50
SPEAKER_00: So just like the weight loss, the skin removal surgery process can be a long process.
26:56
SPEAKER_00: So each surgery has about a six-week recovery, of intense recovery out of the gym, you know, not living life to your fullest, so to speak.
27:08
SPEAKER_00: Um and then staging surgeries at least three months apart, but a lot of patients do longer.
27:13
SPEAKER_00: Because they're in recovery for six full weeks, they're not ready to jump back in so quickly.
27:18
SPEAKER_00: And it's it's a lot, it's a it's a big surgery.
27:20
SPEAKER_00: We're removing a lot of skin.
27:22
SPEAKER_00: But I mean, the smiles on their faces when they come back in is it's amazing.
27:27
SPEAKER_00: Once they get through that recovery, I don't think I've had a single one say it's not worth it.
27:32
SPEAKER_01: Yeah, one thing I'll say though about um staging too, and why I love staging, and we all love staging, and we all do it.
27:39
SPEAKER_01: You do it, I know it for a fact.
27:41
SPEAKER_01: It's because we care about our results, also.
27:43
SPEAKER_01: You're not doing real massive weight loss surgery if you're not adjusting and improving your results.
27:48
SPEAKER_01: Every massive weight loss patient usually has something you need to tweak.
27:51
SPEAKER_01: It's just the way it works, and a good surgeon always points that out and always says, you know, I see this.
27:58
SPEAKER_01: When we do your next stage, we're gonna tighten this up.
28:00
SPEAKER_01: Like, I mean, we do it all the time because number one, it's just a better result.
28:04
SPEAKER_01: And I think that it's really important to know that like that's the deal with uh weight uh mass weight loss, skin removal surgeries that it is is a it is a multiple procedures, and it's at the patient's time.
28:14
SPEAKER_01: Like it could take six months, it could take five years, um, depending on what's going on, because everybody has shit going on, everybody's busy.
28:22
SPEAKER_01: Like, you know, imagine if you had to have three surgeries in a year, like there's just no way.
28:26
SPEAKER_01: And so when these patients do it, and they are like functional, like some of them are like big-time professionals doing all this stuff, and they're jacked and shredded, and they have kids.
28:33
SPEAKER_01: I mean, like, I don't know how people do this stuff.
28:35
SPEAKER_01: It's impressive.
28:36
SPEAKER_01: It's remarkable, to be honest.
28:38
SPEAKER_02: But it's just doing the right thing for the patient.
28:40
SPEAKER_02: Yeah, you know, that's it, and take care of them, treat them like you would want to be treated, and that's kind of what we do.
28:46
SPEAKER_00: Yeah, and I always I use this analogy a lot with my patients, because I'm a woman, I can use this analogy.
28:52
SPEAKER_00: Is that I feel like massive weight loss, skin removal surgery is almost like doing a wedding dress fitting.
28:59
SPEAKER_00: So if anybody has been married or even heard of someone been that's been married or has a friend that's been that's married, you know that you get your first fitting and they do something, they tweak a little bit, they get things mostly right.
29:11
SPEAKER_00: That's the big one.
29:12
SPEAKER_00: Then you go in for a second fitting, and then somehow there's like a third and a the fourth, there's like always little tweaks to get things perfect.
29:21
SPEAKER_00: But if you get a pair of pants tailored, you're only going in one time.
29:25
SPEAKER_00: But for something as big as a wedding dress, you're going in multiple times to get it just right.
29:30
SPEAKER_00: And so I kind of give them that example, and it it it's kind of a nice way to think about things.
29:35
SPEAKER_00: It just kind of puts it into context of real life.
29:37
SPEAKER_01: I love that.
29:38
SPEAKER_00: So if we're re redoing the entire surgery, then yes.
29:42
SPEAKER_00: If we're doing a small little skin excision, you know, sometimes they don't even have to go to sleep for that.
29:47
SPEAKER_00: We can just numb it up in the office, takes 10, 15, 20 minutes, remove a little bit of skin, and they're on their way back to work.
29:55
SPEAKER_00: Um, but still not soaking the incision, so no pools and that kind of thing, but really much easier downtime for little tweaks.
30:02
SPEAKER_02: Do you have a favorite procedure in in the massive weight loss patient?
30:06
SPEAKER_00: I think it changes patient to patient, day to day.
30:09
SPEAKER_00: It's whatever gives the biggest result.
30:11
SPEAKER_00: So whatever that patient has, wherever their skin is the most, the most fat that they have, the biggest result that I can get, that's my favorite.
30:20
SPEAKER_00: And so if a patient comes in and all of their laxity is in their trunk, then I'm gonna love doing their tummy tuck.
30:27
SPEAKER_00: If it's all in their thighs, I'm gonna love doing their silush because it's just gonna be life-changing for them.
30:31
SPEAKER_01: Do you have a favorite between Bill and I?
30:34
SPEAKER_00: Do I have to pick one?
30:35
SPEAKER_00: Both, neither.
30:37
SPEAKER_01: Pick one.
30:38
SPEAKER_02: Has to be me.
30:39
SPEAKER_00: Also depends on the day.
30:41
SPEAKER_02: Is there a pet peeve when it comes to these patients in regards to is there specific I I can tell you mine per se, but I'd love to hear if there's something that like, you know, the listeners and and people who are watching our podcasts are seeing that they're like, hey, don't go in and ask your surgeon that.
30:59
SPEAKER_00: I think it's it's having realistic expectations about what your body has been through.
31:04
SPEAKER_00: Not just what your body looks like that day and what we can achieve, but what it's been through and how that skin's gonna respond.
31:12
SPEAKER_00: Because the massive weight loss patient, their body doesn't respond the same way as someone that hasn't lost that amount of weight.
31:18
SPEAKER_00: And so you just have to realize that it's gonna be a little bit different.
31:22
SPEAKER_00: They're gonna have a little bit more skin laxity.
31:23
SPEAKER_00: I can't even no matter how tight I pull them, they're always gonna relax a little bit more than your average patient.
31:29
SPEAKER_02: I think my difficult one, I'd love to hear yours see, is when somebody wants a lot of skin removed through a small incision.
31:36
SPEAKER_00: Oh well, yeah.
31:37
SPEAKER_00: I don't even I don't even talk about that.
31:40
SPEAKER_02: And it happens all the time with the arm lift, right?
31:42
SPEAKER_02: Everybody's like, hey, I want all this gone, but can you just do a small incision in the armpit?
31:47
SPEAKER_02: And like, there's no way.
31:48
SPEAKER_00: And I've I want patients to know, I've tried them all.
31:51
SPEAKER_00: It does not work.
31:53
SPEAKER_02: I mean, and again, I the way I answer that is like the more incisions you have, the more I can remove.
31:59
SPEAKER_02: That's just the way it is.
32:01
SPEAKER_00: And it's just, you know, small surgery, small results, big surgery, bigger results.
32:06
SPEAKER_01: Do you have an EG?
32:07
SPEAKER_01: My pet peeve is like, well, you know, doctor, the biggest thing for me is gonna be how much this costs.
32:11
SPEAKER_01: And I just like, you know, like I for me, when patients do that, it's like, listen, I want you need to focus on like what you want to get, how you're gonna get it, do your research on who's gonna give it to you.
32:21
SPEAKER_01: And I would not be trying to find like a bargain surgeon.
32:25
SPEAKER_01: I would not be trying to like find the lowest price thing.
32:27
SPEAKER_01: I mean, that just baffles me.
32:28
SPEAKER_01: And when patients try to introduce that into the room with me, and like, I don't want to have to worry about money.
32:33
SPEAKER_01: I want to worry about like, you know, creating this the best possible plan for this patient, achieving this for you, and being there to take care of it.
32:40
SPEAKER_01: I mean, we all want to do that same thing, like that's our philosophy.
32:43
SPEAKER_01: So I it's a kind of a pet peeve because like I just like at the end of the day, they know that we're a premier place, they know that it's it's gonna be very expensive because it's uh it's a technically demanding surgery that literally takes hours and and it might require other things to be tuned up, but we're gonna tune it up.
32:59
SPEAKER_01: So I'd say that's my biggest pet peeve.
33:01
SPEAKER_00: Yeah, I think that's one of my pet peeves just in general.
33:04
SPEAKER_00: Mostly because I don't know the answer.
33:05
SPEAKER_00: Yeah.
33:06
SPEAKER_00: And so I'm like, I don't know.
33:07
SPEAKER_00: Insane.
33:07
SPEAKER_00: We don't even know.
33:09
SPEAKER_01: It's like I'm I don't have to do surgery.
33:10
SPEAKER_00: And we're there trying to make sure that you know the surgical part is taken care of.
33:15
SPEAKER_00: Like that's our number one.
33:16
SPEAKER_00: We want to make sure that we cover all our bases, make sure you are really well informed about that.
33:20
SPEAKER_00: And that's why we have other team members that talk about the financials, that talk about set scheduling and all of that.
33:27
SPEAKER_00: So it's I do think that that really helps us be able to focus on our craft and not have to focus on the other.
33:33
SPEAKER_00: So I think um Dr.
33:34
SPEAKER_00: Cortestis and I have very similar verbiage when we talk about recovery for our patients.
33:39
SPEAKER_00: We usually say the first two weeks sucks for these types of procedures.
33:43
SPEAKER_00: These bigger procedures, that's when most of the swelling is setting in, that's when you're stiff, that's when you're not gonna be able to do things around the house as easily.
33:51
SPEAKER_00: And then you're still gonna be a little bit a little bit tired, fatigued for the next month or so.
33:56
SPEAKER_00: Six weeks you're gonna start feeling better.
33:59
SPEAKER_00: But most patients take two to four weeks off work from a lot of these procedures, and it depends on what you do.
34:04
SPEAKER_00: Me as a surgeon, I'd probably have to take four weeks off if I had these combined procedures.
34:08
SPEAKER_01: This has been a really awesome episode.
34:10
SPEAKER_01: I'm gonna wrap it up.
34:11
SPEAKER_01: But one thing I think we wanted to discuss, and it's just because I have I have a bunch of young ladies at home in my house, and um I know becoming a um female surgeon takes a lot.
34:23
SPEAKER_01: Becoming a female plastic surgeon takes a lot.
34:26
SPEAKER_01: What uh what advice do you have for uh young ladies who are um interested in doing something really difficult like you've done?
34:33
SPEAKER_01: Um what are what are some tips and things that got you through where you've gotten and help you every day?
34:38
SPEAKER_00: I think having a strong support system is number one because you always want to have somebody in your corner when you're feeling like you're not good enough or it's a hard day or something like that.
34:48
SPEAKER_00: I always kind of struggled with finding mentors and things in plastic surgery, but I always had a really strong support system with my friends and my family.
34:57
SPEAKER_00: So it doesn't necessarily have to be somebody that you look up to in that field.
35:02
SPEAKER_00: It obviously helps.
35:03
SPEAKER_00: And I would say that would have made my life easier.
35:06
SPEAKER_00: However, I think being able to lean on the people around you when you're going through tough times, and I mean, as you guys know, I mean you've been through it, plastic surgery training is tough.
35:17
SPEAKER_00: And so being able to have people that support you through that is is really important.
35:22
SPEAKER_01: Thank you for tuning into this episode.
35:24
SPEAKER_01: This has been a great discussion on massive weight loss and massive weight loss surgery.
35:27
SPEAKER_01: If you have any other questions or interested in any other topics related to this, please uh message us directly or visit our website or our social media handles.
35:39
SPEAKER_02: Thank you for listening to HKB Uncut.
35:41
SPEAKER_02: If you enjoyed this episode, please subscribe to us on Apple, Spotify, or YouTube.
35:45
SPEAKER_01: To book a surgery consultation or med spa appointment with our team, visit our website at hkbsurgery.com or head to the links in our show notes.