COSMETIC PLASTIC SURGERY OF THE FACE

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BEAUTIFYING YOUR FACE

S01E07 - 3 Plastic Surgeons & a Microphone - Beautifying Your Face
[00:00:00] Dr. Sam Rhee: All right. Welcome to Three Plastic Surgeons and a Microphone. This is episode number seven. Good morning, gentlemen. This is Dr. Salvatore Pacella out of LaJolla, California. His Instagram handle is sandiegoplasticsurgeon and Dr. Sam Jejurikar, Dr. J out of Dallas, Texas. His ig handle is samjejurikar.
And I am Dr. Sam Rhee out of Paramus, New Jersey, and my Instagram handle is bergencosmetic. So welcome today, gentlemen, how are you? 
Dr. Sam Jejurikar: Great. How are you doing? 
Dr. Sam Rhee: Great. All right. So as always our intro. This show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes, only treatment and results may vary based on circumstances, situation, and medical judgment.
After appropriate discussion, always seek the advice of your surgeon or other qualified health provider. With any questions you may have regarding medical care and [00:01:00] never disregard professional medical Viceroy delay seeking advice because of something in this show. And with that, we're going to get right into it.
I know we're going to be talking today about cosmetic surgery of the face. And, Dr. Pacella has, a lot in it store for us in that regard. We're also going to take a look at a couple, well known, photographs of some of, celebrities who, have had some, aesthetic work done for their face.
But the first topic today, which I'm going to bring up here is something that. I think we should talk about, as well. And I know Sal feels very strongly about it too. And this was an article that was originally published a couple of days ago, and then withdrawn, it's called a prevalence of unprofessional social media content among young vascular surgeons.
And it's spawned a large hashtag let's go ahead and read down and then we can describe it a little bit. So basically. It examined publicly, socially available media content. And they felt that such media [00:02:00] content could affect patient choice of physician hospital or medical facility. And they thought that their and their goal was to evaluate the extent of unprofessional social media content among recent vascular surgery fellows and residents.
And this was out of Boston University in Massachusetts. they basically found. They looked at 480 vascular surgeons, 61 or 26% of the accounts that they found had cleared the, what they labeled clearly unprofessional or potentially potentially unprofessional content. Eight accounts had a clearly unprofessional, such as obvious and alcohol intoxication, uncensored, profanity, offensive comments about work.
Patients or colleagues put potentially unprofessional content included, consuming alcohol, controversial, political comments, inappropriate or offensive attire, sensor, profanity, and controversial social topics. And I think one of the things that was mentioned [00:03:00] was, unprofessional content included bikini wearing or swimwear by some of the women. vascular surgeons that they identified. Thoughts, Sal and Sam. 
Dr. Salvatore Pacella: Yeah. So, so first off, let me say, you know, I understand what the authors were trying to do here. The whole idea is to preserve the patient. Dr relationship as being professional, but it, it sort of, it completely backfired. And there's one specific issue that came out here and which is the, the wearing of unprofessional attire.
And unfortunately what they did was they focused on female surgeons wearing bikinis or wearing provocative outfits, et cetera. And you know, this, this is, this just comes off as a completely misogynistic article. condemning women and it's, I certainly don't agree with it. I think it's terrible. and I don't really understand how the journal of vascular surgery was able to publish this.
[00:04:00] People really need to understand that this isn't just something that was posted willy nilly. when, when you apply for an acceptance of an article of academic quality to a major journal and undergoes a significant peer review process. So several other authors had to look at this article and go through it.
And so the fact not only did these authors, write this article, but the article was approved by at least three separate authors. So it just goes to show you the blinders on here. And you know, this article would have had much more validity if they just pulled it out the, the images of bikinis and not use that as a criteria.
So two other things to say here. you know, I, I think this is, well, let me, let me, let me reach out to, Texas Sam and see his thoughts here. 
Dr. Sam Jejurikar: Well, you know, I, I think, I pretty much agree with all that you've said, and I think there's some broader issues. I didn't really hear about this article until I saw all the social media postings over the last couple of days from very intelligent [00:05:00] surgeons and anesthesia anesthesia providers with whom I work, where they sort of talk about the body shaming that's been happening with us. And this hashtag medbikini, that Dr. Rhee talked about, and I think it, this, this I'm I'm, I'm encouraged by the outrage at this article has spawned by the quick decision to withdraw it.
I think it is demonstrative of the bias that we've had in surgery for decades, you know, centuries where there's been an element of misogyny, you know, for years, surgery was a male dominated, profession, regardless of what specialty you're looking at. And with it, there has been some inherent gender bias and massage.
That's gone along with it. And as the world is changing and as surgery is changing, that mentality needs to change, you know, particularly given our field, which is one geared towards aesthetics. There should be no, there should be no room whatsoever for body shaming, people for being attractive, you can be an attractive human being and you can be an incredibly intelligent person.
The world is changing surgery, changing. This is ridiculous context [00:06:00] for an article. it sort of shows that in academic medicine, sometimes you just need a print articles and the things that they think about sometimes, really bear no resemblance whatsoever to moving the specialty forward. So I would agree with everything Dr. Pacella said.
Dr. Sam Rhee: I think one of the things that was especially outrageous is that they considered bikini and provocative Halloween costumes to be unprofessional when they were basically targeting young women surgeons on how they dress during non-work time, that's sort of ridiculous to make those judgments about how we as surgeons dress outside of work, is, as Texas Sam said, profoundly misogynistic. And I think basically reflects an older, outdated, you know, prejudicial culture that, that we've seen in, in surgery and, is no longer accepted, has never been acceptable, but it's certainly not acceptable in 2020. 
Dr. Salvatore Pacella: Right. You know, it's interesting like you, what what's, what's completely, jaw-dropping to me is how they [00:07:00] went about this study.
So these authors actually ghosted several social media accounts to be accepted by other social media accounts in order to do the research. And it's, it's just overall very creepy. You know, how they went about it was a study, you know what I mean? Just, just absolutely crazy. you know, on the same token, it, I think as physicians, we do have to present an aura of professionalism. Okay. And certainly I agree with making, you know, with limiting your political comments, you know, or, Or coming down on people who make racist or, or, or offensive comments, you know, I think that certainly has criteria for a study like this, but the, the pictures and the, the bikini shots.
I mean, it's just, it's just so ridiculous. I mean, why you know, what, how does that affect your ability to care for patients? It does not. 
Dr. Sam Jejurikar: So are you saying [00:08:00] unprofessional for surgeons to talk about their political views? 
Dr. Salvatore Pacella: I think when it becomes offensive to other people, I think we have to have a, a common ground of, of, others' opinions.
So when you, when you do so when you do this in such a way that you, you sound misogynistic racist, bigoted, you know, that that has no place in medicine and in professionalism, just like in any field, you know, So, 
Dr. Sam Rhee: I know 
Dr. Salvatore Pacella: You don't want to be a Doctor Kevin or a Doctor Karen, if you know what I mean, I, 
Dr. Sam Jejurikar: I'm on that bandwagon. My wife, whose name is Karen, but she had literally been living a miserable life for three months. So I'm going to leave that one alone. 
Dr. Sam Rhee: I know that a lot of surgeons are now posting themselve in pictures with bikinis on. So I fully expect both you Sal and you Sam being in hot states to go ahead and join the trend [00:09:00] and post selfies with bikinis on. 
Dr. Sam Jejurikar: Well, I don't believe in body shaming others, or even body shaming myself so that's probably not going to show up. So I think, yeah, but I think it, you know, just to sort of close this topic off, it's been incredibly encouraging to see so many surgeons and anesthesia providers and physicians of all specialties sort of rising up against this. I think the world really is changing for the better. 
Dr. Salvatore Pacella: Yeah, there's, there is a, as you said earlier, there's a tremendous gender bias and surgery. It's a, it's a male dominated field and, you know, we, there are amazing and talented professional female surgeons and you know, it, we need to, we need to be inclusive. You know, this is just a terrible article, terrible article. 
Dr. Sam Rhee: I will say for the record, the, lead author did, Issue a public apology and the editors of the journal retracted the, the [00:10:00] article and they  acknowledged all the errors that were pointed out that you pointed out including the, review process issues, the creepiness in terms of, obtaining these, this data. And, hopefully this will be a teachable moment for, as they used to say in our, for all of us, in medicine. Right.
Okay. Sal, do you want to start us off talking about cosmetic surgery of the face and what your plan is to talk about it today? And then we can maybe sort of for contrast show some celebrities and discuss their plastic surgery as well. 
Dr. Salvatore Pacella: Sure, sure. Sure. Sure. Well, why don't I do this? Let's just go straight to our case here. I'm going to share my screen. Alright. Are you guys able to see this? 
Dr. Sam Jejurikar: Yep. Yep. Okay, great. 
[00:11:00] Dr. Salvatore Pacella: Okay. So, here we have a wonderful older lady she's in her late seventies and came to see me. she just did not like the appearance of her face and, you know, stated that she felt that her face was very deflated. There was excess skin. And overall people always asked her why she looks so tired and uncomfortable and you know, let's, let's just kind of talk about what you guys see here. 
Dr. Sam Jejurikar: Do you want to go first Jersey Sam? Or should I start 
Dr. Sam Rhee: Please, Texas. 
Dr. Sam Jejurikar: So, you know, I think, you know, I think as Dr Pacella mentioned, this is, just sort of chose the effects of gravity over time and the loss of facial volume.
And so. When you look at this at this woman, she still looks wonderful for her age, but she shows the general signs of gravity. So what I'll generally point out to people is if we start with the lower portion of the face, you can see that the jawline has largely been obscured because [00:12:00] the mid facial fat has dropped and as, and has created as fullness of in jowling. She's got prominent called nasal labial folds, or marionette lines around, around the nose. She's got, no, no worries. she, she's got generalized to send to the mid face away from the lower eyelids. You can see that the prominent dark line, which sort of demarcates, the middle portion of the face from the lower eyelids. When you look at the lateral portion of the eyelids, there's this heavy hooding that goes around with it, which shows that the brow has dropped as well. And so, you know, the, the big things to sort of tell patients about when you first see them is One. There's no nonsurgical intervention. That's going to really give them the full appearance they would like this requires what we sort of call pan facial rejuvenation, where we need to think about treating the brows and the eyes and the face and the neck and the chin and this patient, because she's got an under projected chin, potentially adding volume to [00:13:00] the form of a fact round. So a broad sort of expansive approach is needed to this case.
Dr. Sam Rhee: Yes. I second, everything that Texas Sam said, I would, And some of what you also discussed is not only facial aging changes, but just aesthetic facial proportion. So I know when we were residents, we had to do aesthetic analyses of patients and, split the face into thirds and look at proportions.
And you can certainly see, as Sam pointed out that the chin is significantly under projected compared to the rest of her face. And so it's not just aging changes, it's, actual, underlying aesthetic proportions that this patient, disproportion that this patient has. The other thing is, is in addition to the, the gravity changes she's also lost a significant amount of volume. So my guess is just like all of us, if you look at any of her pictures from 20 or 30 years ago, she had way more soft tissue volume, which was elevated and significant, you know, that's [00:14:00] what makes us look useful youthful. So yeah, that involution or loss of volume is also something that you could pretty much tell in this patient as well. 
Dr. Salvatore Pacella: Yeah, those are all very astute comments here, gents. So, you know, in, in San Diego and LA Jolla, there's a huge retirement population. And I, I see a lot of patients who have, have not had any work done throughout their lifetime.
And then, you know, they're still very healthy and still, very vibrant. And, you know, at age 70 80, sometimes they're coming in for facial rejuvenation and it, this makes the, the. It makes it a bit more challenging than somebody who's in their sixties or fifties. So, and, and just to reiterate what you guys were saying here, I think, you know, the pan facial approach is very, very important.
And many times patients just focus on one specific attribute of their face. So for example, their eyes. You know, this, this woman, her, her major complaint was these lower eyelids. Obviously we have a big, lower eyelid [00:15:00] bag here, but we also have this thing right below the eyelid bag called a malar festoon and that's, that's an anatomic issue right here.
There are some ligaments that go directly from the skin all the way to this, to the base of the skull base here. And it, it it's a challenge. If you don't know what you're looking for here to release these ligaments. And so just simply rejuvenating the eyes is not is, is to help with the central face, but it doesn't help this lateral face.
The other issue is that we, we sort of get into this scenario. The older you are that if you start tightening up one aspect of the face, it makes the other aspect of the face look very redundant and unnatural. For example, here, if we were to suspend her lower face only I would make an incision along the, the front of the ear here.
I would tighten this area up, but then all of a sudden that creates this redundancy in the brow area. The analogy I like to use is you know, imagine, imagine yourself, going to [00:16:00] Nordstrom rack and getting a dress or a suit, and you try the suit on it's a size too big. You can't just simply take it to the tailor and tighten up the waistline right. Because if you do that, it's just going to make the the top and the bottom look bunched. Do you have to really recontour the bust the line, the entire, the entire construct of that, of that fabric. And that's really the philosophy of facial rejuvenation. If we want things to look natural, if you want things to look unnatural, you could just certainly tighten things up willy nilly or tighten a little bit of skin, but patients will be sorely unhappy.
Dr. Sam Rhee: No, Sal I would like to add, I think that, yeah. Issue or issue also can be communication with the patient. So if this patient came in and said, okay, I don't feel like I am myself anymore. I just need some lip filler. And I think that's what will feel, you know, fixing my aging issues then, and you have to talk a lot with that patient.
So [00:17:00] sometimes it's like you said, it's about, not only understanding what the patient needs, but communicating with the patient about what they perceive their issues to be. 
Dr. Sam Jejurikar: Yeah. And along and along those lines, you know, as you said, sort of alluded, this is a woman in her seventies who clearly hasn't been doing fillers or Botox, I'm going to make the assumption that whatever you do to her has to result in a natural aesthetic.
There are patient differences, regional differences, sort of based off of the amount of work people have had up to a given point that influence with their expectations for a final result. So to me, a good result in a patient like this would be something that made her look the way she did 10 or 15 years ago, as opposed to something that would make her look different than she ever has before.
And, and I know that sounds silly, but there are people who want to look dramatically different or have had a lifetime of fillers who already look somewhat unnatural when you're starting with a, and they'll get a very different sort of result, 
Dr. Salvatore Pacella: Right. So, so let's go over, our plan here. So, so obviously, [00:18:00] you know, I did, I did, discuss what they're doing, a pan facial rejuvenation, and let's start from the top here.
So really, you know, looking at the eyebrows, we want to suspend the eyebrows up a bit higher. So I, I described something called a direct brow lift, which is done in the right underneath the skin, as opposed to the, fascia of the face. And that achieves a nice brow lift. We talked about doing an upper blepharoplasty, which is involves removing the skin and adding a little bit of volume with some fat to the upper lid.
The, her lower eyelids, obviously a tremendous amount of deformity here. So I talked about doing an extended, lower lid blepharoplasty or lower lid lift with adding some facial fat in this region. So going back to the facial fat concept, she's really very deflated. So. One of my strategies is not only pulling things up to a higher position, but adding some natural restorative facial volume.
If you look at her face here, it's very elongated, very thin in this area here, very [00:19:00] under deflated right here. And we want to create more of an oval aspect to her face something a little bit more balanced, and that's what we can easily achieve with fat transfer. And then finally doing a, a, a deep smas or high smas facelift.
The smas face lift not only takes the skin and suspends it up, but the deeper, muscle component of the face gets suspended upwards, and that'll really help with this jowling effect. And then finally, we talked about her chin, her chin, anatomically, if you looked at her, her photos, when she was 20, we didn't have any photos, but clearly this chin has been this way her entire life, her chin is very under projected, and it gives us appearance of having a pointed looking face all the way down here. there's virtually minimal balance to her lower face here, and we want to restore some of that balance with that with perhaps a chin implant. One thing I want to point out out here is this distance from her nose to her upper lip compared to the distance from her lower lip to her chin. This is obviously a very long [00:20:00] distance here. We talked at one point about doing something called the lip lift to shorten this distance. So she has a little bit more perky or pouty looking lip. so that is certainly an option. It's somebody with an elongated lip.
This is a very common thing we see in older patients. but she opted against that. So, but everything else, she she's good to go. any comments or how you would address any of these differently? Gents? 
Dr. Sam Jejurikar: No, I was just curious to see your final results and then ask you questions on that. 
Dr. Sam Rhee: Sam and I have not seen or discussed this case with Sal before he presents.
Dr. Salvatore Pacella: All right. So, so here we are, we did a brow lift, upper and lower blepharoplasty, extended lower blepharoplasty, fat transfer to the cheeks and full face and neck lift with a chin implant. Let me show you the side view here. And, you know, just looking at the side view here, you can see the distance that this chin adds to her lower lip. And I used it implant that was about, 1.8 millimeter projection that really helped to balance this position right here. We [00:21:00] want to bring this chin forward up that way. 
Dr. Sam Jejurikar: A few interesting observations, first of all, obviously a great result, obviously dramatic change she looks 20 years younger than she did before. a few tactical questions. Once you said you did a high smas facelift, but you also added some fat as well. Did you say that sort of how much, how much, how much fat in general, do you add to a patient like this? Cause she has so much more youthful volume than she did preoperatively.
Dr. Salvatore Pacella: Yeah. So, in this particular patient I added, about 25 CCS in the cheek and zygomatic area directly. And then into the nasal labial folds a bit. And then usually just a CC or two in the lower lids. 
Dr. Sam Jejurikar: 25 per side or 25 ...
Dr. Salvatore Pacella: Per side, per side. Yes. Okay. Yes. So a substantial, you know, volume, I would say. 
That looks amazing. And then, what kind of incision did you do for your subcutaneous browlift? Did you go on the hairline? Cause we noticed her hair is different. Now that was she hiding or that, 
Yeah. So, I, I actually make two [00:22:00] separate incisions here. So if you see here, you can see a little bit of the cut right here into the central area of the face, but then the subcutaneous brow lift in order to get up here, I, I made a, a hairline incision right here.
So this was not all one particular incision. 
Dr. Sam Jejurikar: And I think what's really awesome about her results was you talked about how you discussed with her potentially doing an upper lid, an upper lip lift. You didn't do it, but yeah. So it looks like you did, which is, which is fantastic. And that just shows how big of a difference adding volume and re suspending things to where they should be, can really make a youthful appearance. I mean, it looks like you shorten that distance without actually doing it. 
Dr. Salvatore Pacella: And I think a lot of this is really the chin implant. Just, just look at the side view here. You know, you can see how that chin implant just really extended to the chin length nicely, and just really magically helps this position of the nose to the upper lip.
By elongating this area here, it makes her face look long, a little bit longer, but more oval shaped. 
Dr. Sam Jejurikar: So for [00:23:00] people listening, a high smas facelift is definitely sort of a more invasive tightening of the smas, really powerful results that come along with it, but sometimes more postoperative swelling.
How long did she feel like she looks socially unacceptable after surgery? 
Dr. Salvatore Pacella: Yeah. So that, that's a great question. So, you know, I tell patients for, if you're just simply talking about a face. And not the eyes, socially acceptable for close to about three to four weeks afterwards. You can still get some swelling in and around the chin and facial area when we're adding the lower eyelids, the lower eyelids without question are, are singularly the, the most swelling that one can have in facial rejuvenation, without question. So I routinely tell patients your lower eyelids may bit be a bit swollen for at least three months after surgery. That may include some swelling of the white of the eyes. Looking like your eyes are tearing some redness associated with the lower eyelids.
So they, they really have to go, to buy into the fact that the lower eyelids are going to be swollen for [00:24:00] several months. 
Dr. Sam Rhee: What I really like about this result? I mean, it is absolutely fantastic is, You know the fact that, I mean, a lot of times when we do rejuvenation, we are restoring, but we're not actually altering facial proportions or at least skeletally. But in this case, by actually doing the chin implant, you have reduced that mentalis strain, the, her upper lip has changed in a very positive way because she had to basically pull her upper lip way down in order to achieve repose with her lips closed. And then adding that support with that chin implant, like you said, basically what allowed her to keep that upper lip length shorter and basically affected those proportions without doing a lip lift for her.
She looks natural without being overdone. And I think a lot of times when you start changing skeletal proportions, you have to watch out for that. And, and this was. a great [00:25:00] example of making someone look youthful within, without changing them, dramatically in that regard.
Dr. Salvatore Pacella: You know, one other, one other issue, that, that I find to be a bit of a challenge has many patients say, you know, Dr. Pacella it's. We, you know, I just don't like the consistency of my skin, you know, this leathery looking appearance to my skin and, and, you know, sitting here in Southern California, San Diego, LA Jolla, there's a tremendous amount of sun damage that most people have, even in their forties or fifties compared to their eighties.
And so, you know, one of. I don't necessarily want to do facial resurfacing, meaning changing the consistency of the skin time of the face with, but that is certainly an option. I work with a cosmetic dermatologist, right that can add a significant amount of laser resurfacing here. But the key here is it's you got to start with the lower foundation of the face.
You got to tighten things up before you start adding laser here. So for example, in this gal, You know, this, [00:26:00] this is without any laser resurfacing or any other, any other modality. And, you know, she still has these pigmentation changes. She's it still has some fine wrinkling here, but overall, if you just see how much smoother her face and neck is, you know, that that just is a bigger bang for your buck when it comes to laser resurfacing after the fact. 
Dr. Sam Jejurikar: Yeah, they go hand in hand, but you're completely right. The foundation has to be addressed first and on the surface stuff is an ongoing and lifetime thing that you, you need to do. around the time of surgery and throughout your life. Otherwise, sun damage will always come back 
Dr. Sam Rhee: On a personal note I just sometimes will throw a chemical peel in at the same time I'm doing either lower lids or mid face. They have to recover anyway. They have to be fairly fair complected. Or have some resurfacing experience. So I know I'm not going to cause hyperpigmentation, but that's, that's a freebie that I'll throw in sometimes.
Dr. Sam Jejurikar: Yeah. I'll, I'll commonly do a resurfacing laser at the same time as well for areas that I haven't undermined or lifted the skin up for our viewers. I'll I'll, I'll do that commonly [00:27:00] too.  
Dr. Sam Rhee: Very nice. 
Dr. Sam Jejurikar: Great. 
Dr. Salvatore Pacella: Alright. Gents.
Dr. Sam Jejurikar: Well, we are, do we have time for one more thing? Or do you think we should wrap it up? Gentlemen? What do you guys think? 
Dr. Salvatore Pacella: Well, we're at about a half hour. I think we can always 
Dr. Sam Rhee: Hit the celebs later. 
Dr. Salvatore Pacella: Yeah. Yeah. That's true. 
Dr. Sam Rhee: I mean, I don't think it's going to top what we just saw anyway. And so why shame some celebrity plastic surgeon out there. 
Dr. Sam Jejurikar: Before already shamed a vascular surgeon we don't know, there's been enough shaming for the day. Great. 
Dr. Sam Rhee: That was amazing. Do you routinely do pan facial rejuvenations like that because that's, that's a pretty dramatic, but also extensive. 
Dr. Salvatore Pacella: Yeah, it is a pretty extensive procedure. something like that would take me probably a good six and a half to seven hours to do, you know, the, the lower eyelids, particularly when she has [00:28:00] so much, deformity there, you know, that, that takes a bit of time to get right.
And, you know, it's a symmetry of both sides that's the issue and, you know, you, you both trained at at great institutions in addition to Michigan, but your fellowship programs. So, you know, the, the, we, I think three of us understand just how intricate the faces and going into the sub smas position is, is a little nerve wracking sometimes and take some talent. So it, you've got to take your time doing a case like this, you know, this is an all day event. So,
Dr. Sam Jejurikar: No one, no one ever said Dr. Pacella is the greatest surgeon. He did my case in three hours. They say he's the greatest surgeon because he took his time. Right? And that's an amazing result. If she's not ecstatic, then there's no point to be in plastic surgery.  Cause that's as good as the result as you can get. 
Dr. Sam Rhee: I like the fact that you took the time to really go through this with her. You can tell, cause you said, listen, we talked about all these different things. And when you make that kind of dramatic change, you know, finding a surgeon who will communicate well and you know, make that patient feel comfortable going into something like this that's important. 
[00:29:00] Dr. Sam Jejurikar: Yeah. And one thing I have definitely learned from Pacella, because you know, we all have our areas of specialty, but Pacella really is considered nationally to be an eyelid specialist. I mean, he is well known for doing that and, It's really true, patients sometimes don't respect the lower eyelids as much as we, as plastic surgeons do.
They think, Oh, it's just this little thing. It's this little structure on the face. I should recover really quickly from it. But it is a tough thing in, in our, in our practices that if you haven't adequately warned people about the swelling they can get after lower eyelid surgery  they can be pretty unhappy.
So I've, I like hearing you emphasize that aspect over and over again, about how much you need to respect a lower eyelids, because that's something that viewers should listen and other plastic surgeons watching, they should also really stress to their patients. 
Dr. Salvatore Pacella: And this is, this is a gal who's never had any facial or lower eyelid surgery before. And I tell patients like this three months of recovery, I also see a fair amount of a revision patients on the lower eyelid, people who have substantial deformities of [00:30:00] their eyelid ectropion or other shortening deformities of the eye and, you know, recovery, those cases, gosh, can take upwards of a year.
It's a real challenge, you know, so, but yeah, but rewarding, nonetheless, I mean, this is, to me, this is some of the most rewarding and fun surgery that we do in plastic surgery. Yeah. 
Dr. Sam Jejurikar: Well, thanks for another illuminating session, gentlemen. Alright. Learned just as I always have. 
Dr. Sam Rhee: Always. 
Dr. Sam Jejurikar: Have a great Sunday everyone.
Dr. Salvatore Pacella: Signing off. 
Dr. Sam Rhee: Take care guys.
Dr. Sam Jejurikar: Take care.

Ten Things to Do Before Your Plastic Surgery

WATCH THE PODCAST LIVE:  
https://www.youtube.com/watch?v=_ZSO6wIg3Eg
S01E06 - 3 Plastic Surgeons & a Microphone - 10 Things You need to do before Plastic Surgery
[00:00:00] Dr. Sam Rhee: Okay. I think we're live so welcome to another episode of three plastic surgeons and a microphone. Except right now we have two plastic surgeons and a microphone because, our third Sal is either going to show up and, and, as Sam said, a rolling start with our show or maybe, because we're starting on a Saturday, he may not show up.
I don't know. We'll see what happens. 
Dr. Sam Jejurikar: Yes. This is a different time for us, and it's very possible that we even fooled him with our start time. So hopefully, hopefully Dr. Pacella joins us, but we'll get started in the meantime. thanks for, the introduction Dr. Rhee , I'm Sam Jejurikar. Dr. Rhee has a few basic introductions that we need to get through before we can start with the meat of the show.
Dr. Sam Rhee: Sounds good. So. the three plastic surgeons are, as Sam said, dr. J Dr. Sam Jejurkar out of Dallas, Texas. His, Instagram handle is @samjejurikar. and then also our, absentee [00:01:00] plastic surgeon who should, will be joining us hopefully is Dr. Salvatore Pacella out of San Diego, California. His Ig handle is @sandiegoplasticsurgeon.
And I am Sam Rhee out of Paramus, New Jersey. And my Instagram handle is @bergencosmetic. So, we are here weekly, live talking about different, plastic surgery topics and anything that we have that's of interest to us. and, just to start off every show, just remember this show is not a substitute for professional medical advice, diagnosis or treatment.
This show is for informational purposes, only treatment and results may vary based on circumstances, situation, and medical judgment. after appropriate discussion and always seek the advice of your surgeon or other qualified healthcare provider with any questions you may have regarding medical care.
And lastly never disregard professional medical, medical advice, or delay seeking advice because of something in the show. So with that out of the way, Sam, you look like you're in a different location this week. It looks very nice. Where is that? 
Dr. Sam Jejurikar: So [00:02:00] I'm lucky enough to be in Breckenridge. Colorado made a little escape with my family, for the latter half of the week.
I think more like most Americans and we were going stir crazy in our house, in our house. it's interesting. When I talked to my patients, when I talked to. my family, when I talk to my friends, everyone is losing their minds. Everyone is going a little bit stir crazy. And so a place where we thought we could get away and sort of visit nature was Colorado, which is a place we like to come to all the time.
And so it's nice to get away. It's nice to escape the Texas heat for just a few days. but COVID is still on our mind. Just like it is on everyone's mind everywhere in the U S I was your week, Dr. Rhee. 
Dr. Sam Rhee: it was good. I'm not, I didn't travel. Hopefully I'll be able to get to the shore in a week or two I'm here in Jersey.
it's been busy. we just haven't been affected badly as some of the other places have in the, in the country. But the issue really is, is that everything is still on hold. We, haven't progressed in terms of opening more things. we're [00:03:00] still adjusting to everything being outside. My kids are playing contact sports outside for the first time this week, which is, which has been different, I guess that's been good but from a healthcare perspective, Oh, the worst thing right now is you mentioned last week, how your tests are getting delayed. The results are COVID tests are now crazy delayed, like more than a week in some cases. And it's been very frustrating. 
Dr. Sam Jejurikar: Yeah. In fact, I just read in the Wall Street Journal this morning, that CVS, which is one of the nation's largest providers of COVID tests.
It's now taking them a greater than 10 days to get results back for some, for some potential patients, which is tough because people are supposed to quarantine after they get the test until they get the test results back. But, if people lose their symptoms and they don't know human nature is that they want to get out and do things to can.
And so. You know, it's, it seems like every week we talk about COVID and we talk about how, you know, this is supposed to be a, it's not three plastic surgeons talking about COVID, it's three plastic surgeons that are supposed to be talking about plastic surgery, but you just can't get away from it in all [00:04:00] aspects of society.
You know, it was interesting for us traveling out here this week because, you know, I'm, I've, I'm very proud to live in Texas and consider myself a Texan and we're all about civil liberties. but this is a tough situation to be in where you try to balance. Public health demands and civil liberties. So in our state, we have a statewide mass mandate, but there are exceptions that can be made in certain counties.
And there are still many people that are against mass, so on our flight on the way out here, you know, my family is ultra protective about things. we were all wearing masks and even face shields, which got us a bunch of strange looks. but then when we get to Colorado where people are much more concerned about, it seems like on average, not, not trying to pin hole people, but people were.
Much seemed to be in general as a population, more concerned about COVID. everyone was wearing a mask. And so, I think I sent you a couple of pictures. 
Dr. Sam Rhee: He's the cutest kid. 
Dr. Sam Jejurikar: So this is my three and a half year old Julian who is demonstrating that even a three and a half year old with [00:05:00] almost no impulse control of any kind  can  mask for an entire flight, can wear a face shield for an entire flight. I think he was lucky enough to be borrowing my wife's phone and was watching Cars and with proper distraction, he could keep it on for the entire flight. And so it's frustrating when you see patients and adults who, who complain about wearing a mask, say that it's too hard to wear it. I mean, literally a three year old can wear it.
Dr. Sam Rhee: that's very cute. Doing so too. 
Dr. Sam Jejurikar: Yeah. Well, that's just his baseline. He looks like my wife, luckily, so he far more attractive, I think, as a human being than I'll ever be. But, but it's easy to wear a mask and if, you know, there's some data that's out that shows that if everybody wore a mask and did it for, you know, the next four to eight weeks, we could get a handle of COVID and probably get right.
Back to a much more normal life. Other things that I find interesting. Cause I think I sent you one more picture with my older two kids, and this is not meant to be a slideshow of my family, but everywhere we went on the hiking trails yesterday, everyone was wearing a mask. it's a long in Colorado.
that's being followed closely and being enforced very [00:06:00] closely and even out in nature where we're far away from people, every person we encountered. Was wearing a mask. So where are your mouth people? 
Dr. Sam Rhee: I agree. well, first of all, thank God. Your kids are better looking than you are. That's very, 
Dr. Sam Jejurikar: yeah.  And they thank God for that all the time. 
Dr. Sam Rhee: The second thing is it's kind of gotten a little politicized, the whole mask thing. And listen, I understand if I'm. If people don't want to wear masks, that's fine. I mean, I don't, I'm not going to sit there and arrest someone or try to arrest someone or get into some sort of altercation with someone if you're not wearing a mask.
But I feel like you do that. We, I mean, we are science based people. That's what we do for a living is we, you know, we provide medical care and that medical care is based on science. And that science is what guides, what we do. And it guides. how we manage patients and the science that we've seen so far shows that mask wearing, like you said helps.
And [00:07:00] so I don't, I don't want to get into a debate about it. I will never sit there and yell at someone if they're not wearing a mask, but I do. I do know that, like you said, mask wearing helps and you know, the faster we can sort of get through this, and the better. And I think that that can only be helped. by wearing masks. It's not going to hurt us in any way. 
Dr. Sam Jejurikar: Yeah. I mean, we all want life to go back to normal. You do. I do every person out there, but we have to go through this period of time where we were mass so that we can only, so we can truly go back to a COVID free society. So enough about COVID for the week.
Dr. Sam Rhee: So agree with you. Alright, so let's move on to our talk for today. We're talk, what we're going to talk about, which I'm pretty excited about is 10 things to do before plastic surgery. So basically, if you are someone considering six surgery you're or you're, I'm scheduled to have plastic surgery or cosmetic [00:08:00] procedure, what is it that you can do to help yourself ensure that the best outcome and a successful result? Any thoughts before we start, going through these topics. 
Dr. Sam Jejurikar: I think this is a great topic to get, to get our perspective on it. mainly because I think patients, what I've noticed now, and I know you've noticed this as well now, compared to 10 years ago, they use the internet so much more, than they ever did.
And, being able to, get a plastic surgeon's perspective on things rather than, you know, merely just patient perspective is a nice adjunct to what's out there. I don't think we're the definitive source, but I think our opinion matters as much as if not more so than patients sites as well. And so I think it'll be good to, to do this and, and.
It'll hopefully if my patients watch this, it'll save me a lot of time and consultations too. I agree. 
Dr. Sam Rhee: I mean, like, you know, but all of us have had, you know, years and years and years of working with patients and we understand that patients have [00:09:00] sometimes preconceived notions things that they have, like you said, heard or read.
And, listen, sometimes it just helps to remind patients of the things that we know, can really help. To get a good outcome. So let's start with, and these are in no particular order. I just kind of, you know, we threw them all together. not one is more important than the other. So the first one is, do not bankrupt yourself or place yourself in financial distress for your procedure, but also do your research because you get what you pay for.
Dr. Sam Jejurikar: Yeah, I think. I think that's both plastic surgery advice, and also life advice. you know, what we do for a living with aesthetic surgery is a discretionary expense meeting. Nobody has to have plastic surgery to look better. It's something we're choosing to do to make ourselves feel better about our lives, to, to feel better about the way we look, but you have to be in an appropriate place to do so.
If you it's expensive to get plastic surgery, this is Dr. Pacella trying to [00:10:00] call us. So hopefully he's trying to get on right now. I won't put them on blast, but, maybe we could just, maybe we could just message them to get them on that to get them online. But, but, but, but to sort of, To just fall on that, that, that, that line plastic shooter is expensive.
Save appropriately, make sure you can afford it. So there are, financing options that are available. Many of my patients use care credit, which is the largest sort of third party, plastic surgery, finance company. That's out there. they make it so that it's affordable to get plastic surgery. so, there's there's payment plans that extend out over five years so that you can fit it into your monthly budget.
That being said, like Dr. Rhee is saying, if you, if you try to go for the cheapest option. Yeah. Particularly if you try to travel overseas. Geez. I mean, you're going to have problems sometimes, particularly if you have a complication, implications are unfortunate, but they happen in plastic surgery and the person that's going to be most invested in taking care of you is your plastic surgeon.
And so I'm making sure that you're going to a board [00:11:00] certified plastic surgeon who is either close to you or easy to get to. Or who can at least communicate with you frequently is going to be really important. And so you need to do your research. You need to make sure you're getting a qualified person, which is going to be expensive, but at the same time, you have to make sure you can afford it.
Dr. Sam Rhee: Right. I agree with you a hundred percent. This is an investment and as a Sam said, it is discretionary, but this can be a very powerful change in people's lives. And if you're going to make that sort of change to yourself, two things, one is. You're not going to spend everything that you have solely for this thing.
you're going to work it, the you're going to work, into your life in a proper way so that it is not negatively impacting every other aspect of your life. Just like you would for any other major decision that you made. If you blew your money on a Rolls Royce and you had no money to pay for food or your rent then as much as you would get enjoyment out of that Rolls Royce, you're going to have a [00:12:00] lot of stress in your life. And that's sort of the same thing with plastic surgery. You have to be in a position where you can truly make a positive impact in your life, but it's not going to be negatively impacting everything else.
in terms of, and that's why you're going to get someone who is worth the money that you're paying for. all of us know different plastic surgeons. We know that not all plastic surgeons are the same. Some are better at certain things than others. Some, are going to match up better with some, patients.
So you're gonna need to make sure you pay for, and no one who's good is going to be cheap. So make sure you find the person that is right for you, someone who is board certified and someone who has experience in the type of procedure that you're interested in in terms of finance. I don't know about you.
I am a care credit provider. I just recently sort of started dabbling in it. I remember, our bosses, back at Michigan used to say, I don't know if you've ever heard this from Dr. Kuzon, but he used to say, listen, you should only borrow, for a couple of things. Education, Car, House. I have [00:13:00] to borrow money for groceries or for clubbing.
You're in a, you're in a bad situation. And, I think that that's very conservative advice. I, I do think that some of these financing options it's can provide people some flexibility as long as they're responsible in terms of using those, financing options. I do think it is better to finance then to say, do some other things, in terms of your money.
So I agree with that, but I just, I do caution people to really look into the terms and make sure that they're not getting screwed over. 
Dr. Sam Jejurikar: No, I think you're totally right. obviously, like I was saying, like the things that you mentioned, education a home, what was the third thing? You said a car. Yeah, it might have been sure about the car out of Ruth education in a home.
Those are the things that we need to better ourselves in lives, where to have shelter. plastic surgery is in that same category as sometimes as like a nice car. It's it's it's, it's something you want. It's not something you necessarily have to [00:14:00] have, but, you know, everyone's financial situation is different and many Americans utilize credit.
And so it's not that I'm trying to tell people that they should. But their plastic surgery on lay away, or they should get in a bunch of debt to do this. And far from it, many people know what their monthly budget is. They have a better sense as to what their cashflow situations look who it is.
Dr. Pacella. 
Dr. Salvatore Pacella: Hey guys, my apologies. I had some technical difficulties. 
Dr. Sam Jejurikar: No worries. No worries. So, we were, we had started our list, Dr. Pacella about, kind of 10 things that you should, You should do before plastic surgery. And we're on the very first one, which is basically don't make yourself bankrupt to have surgery, but also do your research.
Do you have any insights into that or sort of what you tell your patients in terms of what they can afford and how they should approach surgery? 
Dr. Salvatore Pacella: Well, I think it's, it's important to understand, you know, your resources. I mean, it's interesting patients will pay, you know, come in with a. You know, a Louis Vuitton bag, [00:15:00] but now I want to pay for, you know, a breast augmentation.
So I think if you, if you have the money you want to. 
Dr. Sam Jejurikar: You want to just figure out what's 
Dr. Salvatore Pacella: important for you, but I agree with that. You do not want to financially bankrupt yourself because this is stuff that's only gonna catch up with you on the same token. I think it's important to understand, you know, you have, if you have certain resources, what what's going to last you longer is a, is a breast augmentation, tummy tuck in the last, you your lifetime.
Yes. Most likely, Some physical, device or, you know, iPad, iPhone, you know, things like that. They're not going to last, your, your lifetime. So it's just a matter of getting out what you want. Agreed. 
Dr. Sam Jejurikar: Perfect. Alright, 
Dr. Sam Rhee: let's move on to the next, sorry. 
Dr. Sam Jejurikar: Oh, they'll say I feel like we should ask Dr. Pacella how he's been. We haven't seen him yet and it's straight, it's straight work mode. 
Dr. Salvatore Pacella: I'm willing to talk about it. It's just been a busy week. We, you know, really ramping up surgery and, you know, just been busy all [00:16:00] week long. It's been crazy. How about you guys? 
Dr. Sam Jejurikar: we're good. I'm I'm on a little break right now, so yeah, I'm nice and relaxed, but we're good.
Dr. Sam Rhee: Yeah. All right. So the next item is, do not buy too much paraphernalia. I, if you, You know, as you said, social media is a one, a powerful tool for patients, but I have seen patients that have bought or were told, you have to do this. You gotta do that before you have to get this afterwards. And sometimes it's not that relevant to what that patient's needs or even procedure 
Dr. Sam Jejurikar: yeah, I totally agree with that. Patients buy a lot before surgery and a lot of things, I'm not even sure why they're buying, but they, they got it from a Facebook group. And so I'll, I'll do a liposuction case or a Brazilian Butt lift case on someone. And before I've even done the operation, they've already bought like six different garments.
And, I think going slow with it and talking to your surgeon is key. There is some use for [00:17:00] paraphernalia, for sure that you can buy for, for various operations, but the offices of your plastic surgeon. Should be able to help you, you know, for each thing there's one or two or three things that's really, really useful to have. You don't need to overload yourself with, you know, a thousand dollars  and useless items just to just on the off chance you might need it. 
Dr. Salvatore Pacella: Right. A chances are you're going to have all this stuff anyway for you. You know, I know in my practice we provide bras and, liposuction, compression garments, abdominal binders, things. 
Dr. Sam Rhee: And you know, I remember one time I had a patient with a tummy tuck and a, she was told from her Facebook friends to go get these ultrasound massages right after the surgery. And after about two post-ops, I noticed that the center lower part of her abdomen was starting to get dark. And she ended up at actually getting, skin necrosis and skin death because whoever she went to was just, you know, pounding the heck out of her  abdominal flap with these ultrasonic [00:18:00] massages. And if she had talked to me about it, we ended up having to debris it and do all sorts of treatment for it. she could have avoided a lot of problems if she had just talked to us about it beforehand. So 
Dr. Sam Jejurikar: I agree. 
Dr. Salvatore Pacella: All right.
Dr. Sam Rhee: Next, actually read and follow the instructions from your surgeon both before and after care instructions. 
Dr. Sam Jejurikar: I don't know about you guys. We do tend to inundate our patients with a lot of information and, I understand their desire not to read it it's a lot, but it is worth the time. most of the questions, at least 95% of the questions that you'll have are actually in the information.
And we also have followup information that we give them like each of their postoperative visits to try to keep them on track. if you follow that, And then if you have questions about things you've read, it's more than okay to bring it up with the office. But, but reading and following your surgeon's instructions are going to be most important because every surgeon does things a little bit differently.
And as a [00:19:00] result, there's going to be nuances in how they manage their patients afterwards. Right. 
Dr. Salvatore Pacella: I think, you know, my practice, we have a subset of patients that will read everything. And then a subset of patients that will read nothing. And, I think the important thing is as a, as a plastic surgery office has a nursing staff, clerical staff.
It's very important. I think, to give the highlights of. What to take care of what to do, and then remind patients that, Hey, you know, we have a pamphlet here. We have a, information book. You want to read this at your leisure,  so that's important reminder for us as a, as a provider to have all this. Yeah.

Dr. Sam Rhee: I agree with Sal there's two groups. It's the ones who try to put together the Ikea furniture without even looking at the instructions. And then the ones who read it five times beforehand, and then. proceeds. So, yeah, I think, I think you're both right. just try to follow what it is and we try it.
Like you said, there's a lot of information as an [00:20:00] office. We try to at least hit on the high points verbally and make sure that they're aware of the most important things. But yeah, if you can read it, it's going to help everyone a whole lot. Number seven, quit smoking or any illicit substances months before, and be honest and tell your surgeon.
Dr. Sam Jejurikar: I think this might, this might be the biggest thing and the most important thing. Is that what you were about to say patella, go ahead. Go ahead. Yeah. Smoking. You get a lot of information from a doctor's office and it's hard to prioritize. What's the most important. This is probably number one on the list for me, smoking causes huge problems in cosmetic surgery.
And just because you may have gotten your gallbladder taken out or your appendix taken out and you were smoking and you were fine. Plastic surgery is totally different. We lift up skin flaps, we divide blood vessels. We move things around. It's much more susceptible to major wound healing complications, and even a trace amount of carbon monoxide, nicotine tar benzene, [00:21:00] like 30 things from cigarettes can cause profound problems with little blood vessels within. w within your skin cause the skin to necrosis or die, and lead to terrible results. And so my general rule is don't smoke at all, and don't use any replacement nicotine products for at least four weeks before your surgery.
And if you cheat, tell us it's better to screw up your schedule than to get a horrible result from a completely elective procedure. 
Dr. Salvatore Pacella: Yeah, I agree. I was just going to ask you both, like what your criteria is for being off of cigarettes or nicotine prior to surgery. Sameer, you said, four weeks Jersey Sam, 
Dr. Sam Rhee: I think usually four to six. If, if they're honest with you, that's a big, if. 
Dr. Salvatore Pacella: Yeah, I have a little special criteria here. You know, if you read some of the literature in plastic surgery, some of it is short as two weeks, and I can tell you, yeah. You know, I think that's just not enough. We, I, I've seen patients for cancer [00:22:00] operations that have quit for two weeks ahead of time and had massive problems.
So, you know my criteria is really three months of being off of any nicotine products. And, and what that tells me is, you know, they've really actively quit.
Dr. Sam Rhee: I mean, I've known some surgeons that will, drug test for a nicotine preop. And I have not done that. but I do feel like most patients, if they are really truly addicted to smoking or nicotine, it's a really hard habit to quit.
It's harder than probably most. And I will say that most patients. That I have seen that are really addicted. It is very hard for them to quit. They will fudge. They will tell you, you know, I'm down to one every other day or, you know, listen, if there's, if you're smoking and you're, you know, even if it's one a day or one every other day, just let your surgeon know and let them make that decision for that for you about [00:23:00] what, what is safe if you can't quit, you shouldn't.
Be undergoing a cosmetic surgery procedure. I know people who have asked me, should I be taking broth? Should I be eating too much broccoli? Cause I've heard that causes inflammation and then smoke. And their priorities are not right. If you really are going to spend this kind of money, then do the right thing and get that nicotine out of your system. 
Dr. Sam Jejurikar: Yeah. And that, and that's just, that'd be clear to people listening. That's not just cigarettes. That's, e-cigarettes that's smokeless tobacco that that's patches, gum, all of that stuff. And, even if you were using an e-cigarette and it says it has no nicotine in it, do not believe it.
It's not regulated. It's so harmful from a wound healing or wound healing standpoint. And like Sam said, Talk to your surgeon, not all operations are the same. You know, my, my concern with a facelift or a rhinoplasty, it might be different than it might be for a liposuction case. But having that dialogue is going to be very, very, very [00:24:00] important to appropriately assess risk before your surgery.

Dr. Salvatore Pacella: there's probably even more nicotine per dose in nicotine gum than there is actually in cigarettes. You know, it's a, it's an exceptionally powerful dose in, in gum. 
Dr. Sam Rhee: Agreed. Some of the people I've seen trying to quit say that it's too strong. and they've had problems with some of the, like alternative methods.
So yes, you're absolutely right. So, all right. Number six. So set up your home properly. that means sort of like nesting stock up with your, preplanned meals, the fruits and vegetables, the, you know, stuff that, you know, will be, easily sort of digestible the. The stuff that will help you with recovery, maybe having a recliner, recovery area, maybe an area in your living room.
So you don't have to go three flights to your bedroom. basic dressing supplies, all the easy stuff. We'll make it easier for you to get around during, during your recovery period. 

Dr. Salvatore Pacella: don't know. sorry. [00:25:00] so, you know,  patients often times ask a specific question. I have I've stairs in my house. I have stairs leading up to my condo stairs in my home.
Do I need a wheelchair or what should I do? Should I stay somewhere else? And, you know, stairs. Are good. Particularly if you're having body surgery or abdominal plasty surgery, one of the risks we have with a big, long body case, the risk of DVT or blood clots in your legs and having stairs in your home.
Is a good thing because we want you to get up and move and, and, and use your legs and step up and doubt. We don't want you running stairs. I think the important thing to understand is you don't have to set up your home. Exactly. Right. You could set up a few things, but you don't have to move out of your home, but it's important to make sure that you have somebody there to assist you with going up the stairs.
Dr. Sam Jejurikar: Yeah, it's funny. You brought up the stairs. I get that question all the time too. And I have also, I've never had that good of an [00:26:00] answer to it, but it's so true. There's nothing wrong with stairs at all. The patients are definitely afraid of going. I mean, I get that question once a week, probably. I think another thing that you just said that so important.
In the setup of your home is making sure you have somebody to help you. sometimes people don't want to inconvenience their friends or their family, and that's fine. There are services out there that you can hire to have somebody help you. But if you think you're going to have a big cosmetic operation and then take care of yourself, it's going to be very difficult.
And your outcome's going to be a lot worse than the risk of a blood clot, because you're, it's just hard for you to get up and down. Is it going to be substantially higher? 
Dr. Sam Rhee: Agreed. that's actually, one of the other ones is having a appropriate support. 
Dr. Sam Jejurikar: Oh, I blew it. 
Dr. Sam Rhee: No, it's good. So we'll cover it now. I agree a thousand percent, I think, Sal's patient, Elaine had mentioned that there are services available that can help you with certain things, during recovery and, you know, especially my patients who live in New York, in Manhattan, they're all very isolated and they, they. For such a big city, they don't [00:27:00] necessarily have neighbors or people that they can rely on.
And, you're right. sometimes it's not so much the setup, but it's, who's going to help you with that setup that makes it more efficient, right. Review, which medications to take or not take beforehand. 
Dr. Salvatore Pacella: You know, this is, this is exceptionally important particular, particularly if with our older patients, many medications that are out there can cause excessive bleeding. some patients are blood thinners, which can be unfortunate for plastic surgery.
And, if in my practice, the most important meeting we have with patients is something called a preop appointment. that pre-op appointment is done. It usually, hopefully about two weeks prior to surgery at that time. myself and my nursing staff we'll go over exactly what medications to take or not take.
We have a full list. so it's important to really bring that to your preop appointment. it's important to understand exactly whatever you're on. and you know, sometimes you [00:28:00] sometimes, for example, you know, our younger patients may have a workout or something and they will forget, and they'll take a handful or a couple of tabs of Motrin say, and that can lead to significant bleeding after surgery.
So, I think the onus many times is on us in the plastic surgery staff. To understand or have patients understand exactly what to take and what not to take. 
Dr. Sam Jejurikar: Yeah, totally agree with Sal. We don't do a formal revisit for many of our patients, but we review it all online ahead of time. I think I'm getting, depending on the procedure, relative risks of certain medication changes, but sort of the big classes of medications that we worry about are blood thinners.
And those aren't just prescription blood thinners. That cause those can be asprin. Those can be nonsteroidal. Antiinflammatories like Motrin, like Dodger. The cello was referring to another big class was weight loss medication. a lot of patients like to take phentermine and there's a lot of potentials that can cause from a cardiac standpoint with anesthesia.
and then over the counter supplements, most of the over the counter supplements that you buy for your mental health, [00:29:00] aren't really regulated. And so there can be a lot of, things that cause bleeding complications in some of those supplements. So in general, if it's not completely necessary or recommended to you by another physician, we have you stop taking those two.
Dr. Sam Rhee: I agree, with both of you, I think, I see a lot of patients on phentermine, the weight loss medication, which is surprising to me a little bit, the, contraceptive medications, birth control pills. that's a big one. The, the herbal supplements, can be an issue. I usually am okay with stuff like arnica.
Cause a lot of people want to take that. What do you feel about some of the other things that, people want to take before surgery? 
Dr. Sam Jejurikar: Yeah, in fact, for a lot of, a lot of patients, will actually recommend they take arnica and bromelain to help with postoperative bruising and swelling and I'm, and I'm more than okay with that.
And for, Before I get to that certain nonsteroidals I'll actually use for breast augmentation, for instance, like different, a different class of nonsteroidals, but in general, things like, you know, Gingko or st John's warts, [00:30:00] they can have an, an, an issue with bleeding for most operations that worried about it.
But for facial aesthetic procedures, rhinoplasty, blepharoplasty, that sort of thing. I do want them off of it for two weeks ahead of time. How about you sell. 
Dr. Salvatore Pacella: you know, we have a list of all the over the counter, you know, natural supplements and things that we, we don't want you to take. And, you know, I I've had, I've had a little bit of a interesting time with arnica that I, you know, for some patients that works really well for other patients, it just doesn't seem to do anything. So, you know, I, I think, I tell patients if you want to take it, that's great. I don't necessarily recommend it or not recommend it. 
I don't know. What's your experience 
Dr. Sam Jejurikar: with arnica? Both of you. Mine's the same as yours. Sometimes it helps sometimes it doesn't, it's relatively underpowered, but it's a nice little adjunct. Yeah, yeah. 
Dr. Sam Rhee: Yeah. I've seen some anecdotal experiences where it seemed to make a huge difference. And then, like you said, sometimes it doesn't seem to make any [00:31:00] difference.
the only other thing I was going to add I forgot was, I'll see a lot of, younger women with borderline low hemoglobin or slightly, you know, just a little bit anemic and, You know, usually it's because of heavy menstrual cycles. And so it's helpful if you can get them on some iron a month or two beforehand, that that seems to help with recovery.
So I try to push, iron supplementation for a lot of patients. They don't like it cause it may make them constipated. But I think for a lot of patients that may be helpful. Yeah. 
All right. we already talked about it. Arrange for help afterwards. If you have, children pet care, just care for yourself going up and down the stairs.
Transportation. anything else to add for this one? I know we covered it a little bit. 
Dr. Sam Jejurikar: Not really. 
Dr. Sam Rhee: Okay. Don't party before your surgery. 
Dr. Sam Jejurikar: I think you specifically mean don't use a lot of, alcohol [00:32:00] or illicit substances before your birthday. I mean, before your surgery, birthday is a different issue and that's true for a lot of same alcohol can cause problems with bleeding during surgery. So, You know, most of us have in our preoperative directions for patients not to drink for a couple of weeks ahead of time.
And there's a reason for it. It's not that we're trying to be draconian or try to take away your lifestyle. It can cause problems with your surgery. Surgery is not only a big financial event. It's a big time commitment as well. And it's not just the actual surgical procedure. It's the planning ahead of time and getting ready for it.
And so, you know, not smoking, not drinking, not using illicit drugs, all very helpful to help prevent complications. 
Dr. Salvatore Pacella: Yeah. And I think the important thing with alcohol is it's it's, it can cause a significant amount of dehydration. And when you're undergoing general anesthesia, you're sleeping, you go to sleep. If you are exceptionally dehydrated, like alcohol can make you, particularly the day after, You know, a, a night out, that can cause significant [00:33:00] problems with blood pressure. It can be very difficult, for the anesthesiologist to maintain. So, so hydrate yourself, but not with alcohol. 
Dr. Sam Rhee: What do you think about partying afterwards? I do have patients who ask when they can start having a glass of wine or two after procedures. And also wasn't there a plastic surgeon that from Texas who used to brag that his patients would go out dancing after, after breast augs. 
Dr. Sam Jejurikar: Yeah. It's a big marketing thing. A 24 hour breast augmentation and John Tebbets made that, made that popular.
And, it's been sort of passed on to other surgeons who advertise a 24 hour coverage. And it's a marketing thing. I think most of our patients have close to the same 24 hour recovery where they feel pretty good after 24 hours. But, I generally, it really depends on the operation for facial cosmetic procedures.
I ask people not to drink for two weeks afterwards for smaller procedures, whether it's liposuction of a small volume or a breast, I might be fine with it after a week provided they're off all their pain meds. but, but it's [00:34:00] individualized for, for every procedure. And it's important for every procedure. Just the relative extent, changes a little bit.
Dr. Salvatore Pacella: Right. I, I, I couldn't add anything more. I think, you know, when patients are off of their pain medication is when I say, you know, you can, you can go back to one or two drinks in the evening if you like, but no party. And for a couple of weeks, at least not the kind you do. So I know what cheap, I'm a cheap date. I have a half a glass of wine and it's. 
Dr. Sam Rhee: Puts you down. Yeah. As you're getting older, that's why. All right. number two, arrange for the appropriate time afterwards. So depending on your procedure, you may need days or weeks. it's not just the, initial aches, pains or bruising, but, other restrictions that you may have after your procedure, if you work, can you afford to take that time off of work? That includes stay at home moms. that sort of thing. 
Dr. Salvatore Pacella: think it's important for us. you know, as the provider to really hammer this down with patients before surgery. [00:35:00] Cause cause some patients just don't have a realistic expectation about what amount of pain or discomfort they're going to be in. some patients with a heavy surgery, say a mastopexy augmentation, a tummy tuck they'll have a surgery on a Friday and expect to be back by Monday.
And I just don't think that's very realistic at all. Obviously. But for some procedures, say a little bit of minor liposuction, it's possible to go back to work a couple of days later. So, the other thing I would say is we were going to have to fill out, some disability paperwork or, you know, an excuse from work, et cetera.
And I, I want to caution patients. It's okay. It's a lot easier to ask for more time off and be released early than it is to get additional time off. It's just a lot more paperwork if you're going to add another week after. So if you have the ability to take a little bit of extra time off, we can always write you back for forgetting back early.
Dr. Sam Jejurikar: Absolutely. Yeah. And I think, I would just add a little bit to what Sal said. There's not only the physical [00:36:00] discomfort with some of these bigger operations. Sometimes you may feel great, but if you've had say a facelift or your eyes don't, you may look terrible. And so, you may have the ability to work from home.
If you, and in those sorts of situations, you're going to be better off if you're actually, utilizing that because certain operations, You know, if you have a facelift, for instance, I'll tell people it could be two or three weeks before you look socially acceptable, even with camouflage makeup and you have to plan accordingly.
And so if you don't have that and you need, and you have an important event or an important meeting, and it's 10 days out from surgery and you don't look that way, you're going to be very unhappy. And it's mainly just because of a failure to plan appropriately.  
Dr. Sam Rhee: Nothing makes me more nervous and a patient who says.
I want this procedure because in a month I'm getting married or I'm going to my daughter's wedding. I feel a tremendous amount of anxiety when that happens, because shores, it always seems like the recovery is always slower in those situations. So I want to [00:37:00] make sure that patients, if they got something big coming up, they give themselves plenty of time to make sure that they recover from that so that we're not.
You know, stressed about, you know, why are they still swollen or that blah, blah, blah, blah, blah, like that sort of thing. Perfect. I don't know why this is number one. We have one bonus one after this, but, this is not the most important, but it's still number one, shaving or waxing your surgical sites four to seven days before surgery, as opposed to the night before the morning of surgery, which can increase risks for bacterial colonization.
Dr. Sam Jejurikar: yeah, don't do it. I just, I'm still trying to figure out how this is. Number one on the list.
Dr. Salvatore Pacella: I know. The other thing is we can do this for you, you, during the search, before your surgery, after you're asleep, we always prep and prep the area to make sure there's no excess of hair that you know, it's not going [00:38:00] to get away in the incision. So, you know, if you're, if you're worried about us as surgeons, we could take care of that for you.   
Dr. Sam Jejurikar: So the only, the only one thing I would make an exception to is if you are getting a haircut implantation, you may find it beneficial to do it yourself the night before. So you can shave your entire head and just not abortion of it. That's the one operation I might make a little bit of an a, of an, a, of an exception for it.
Dr. Salvatore Pacella: Texas, Sam, how do you feel about manscaping the surgeon manscaping prior to their surgery? 
Dr. Sam Jejurikar: You mean me personally as an individual? Yes. I'm a big, I'm a big fan of certain really has nothing to do with it. 
Dr. Salvatore Pacella: For the plastic surgeons out there. According to Texas Sam, maintain your manscaping regimen.
Absolutely. 
Dr. Sam Rhee: He's very smooth. He's a very smooth surgeon for sure. 
Dr. Sam Jejurikar: Well, I'm assuming that, that, that Jersey, Sam probably is fairly hairless given his, so he can make fun of this whole issue, but me being a hairy Indian and you being a hairy Italian, you know, these are issues we have to think [00:39:00] about.
Dr. Sam Rhee: Yeah. I'm definitely low maintenance. There's not a whole lot of hair there. Alright. 
Dr. Salvatore Pacella: it's like, no, really you can take off your sweater.
Dr. Sam Jejurikar: Go ahead. 
Dr. Sam Rhee: alright. And the last one, get in the right mindset in regards to expectations. So have a conversation with your surgeon, don't get lulled into false expectations or things that you may have seen elsewhere or by your friends or social media. 
Dr. Sam Jejurikar: Yeah, I think you've mentioned this before. Jersey, Sam, where, a patient will, you know, who might have a BMI of 35 will come in with a postoperative liposuction, Brazilian butt lift result of a patient with a BMI of 20 and, and will want to look like that. Everyone's body starting point is different and that's, everyone's finishing points going to be different as well. not to say you shouldn't expect great things out of your surgery, but [00:40:00] it's all going to be relative to your starting point. 
Dr. Salvatore Pacella: Yes. It's eh, this is of critical importance, I think. And a lot of the onus on this is the surgeon and surgical team and the expectations to explain this ahead of time. patients oftentimes bring in photographs. In fact, you know, in my breast augmentation patients, I want them to print out photographs of, of, things they get from the internet to say, Hey, this is what I want to look like.
And that's what I. That's why I think a preop appointment is very critical because I'll go over those photographs and say, Hey, this is, this is achievable. This is not really, in the realm of what we can achieve either. so it's, it's, this is a critical, critical importance. 
Dr. Sam Rhee: Yeah. I, I, try to be relatively conservative in terms of, you know, I don't think surgeons should ever promise or guarantee anything.
And I certainly don't, but I feel if a patient has [00:41:00] something that, you know, and they'll the know patients will and say, okay, I understand what you're saying. I understand what you're saying, but still in their own mind still have something that is not realistic. It's, it's hard to communicate with patients and get to understand what they want for sure.
And whether they, and know whether they understand what it is that you. Believe you can achieve for them. I think that's why you sell, have those photographs, because that really helps. I think that's why, digital imaging, what a Texas Sam uses can be very helpful. Whatever means we can use to try to understand our patients and understand what they want.
And then also get them to understand what we think we can deliver is really important. And then if they're in that right mindset, then I think they'll definitely be very happy with the procedure. 
Dr. Sam Jejurikar: Couldn't agree more with the gentlemen.
Dr. Sam Rhee: So that's everything that I have listed. Are there any other, things that [00:42:00] patients should do before surgery? 
Dr. Sam Jejurikar: You know, I think this is a nice overview in the sense that, there's a lot to do before surgery, but planning is a PR is important. Make sure you have people, make sure you have the necessary items that are there.
Make sure you have enough time off, make sure you communicate with your surgeon. If you do those things, that's 95% of it. 
Dr. Salvatore Pacella: Right. And you know, I think, the other thing I would say is it's important to. For patients to really decide well in advance that they are doing the right surgery for them many times.
And again, I'm going to go back to that preop appointment. that's, that's why I think it's exceptionally critical that I see these patients ahead of time before the surgery for a informal, preoperative assessment. Because many times we'll go over again, the surgical plan and sometimes their expectations have changed.
Sometimes they want to change what they do. And I think that's, that's [00:43:00] exceptionally important to hammer out ahead of time. It gives a, it gives the surgeon and the patient a second opportunity to look, look at the plan and, and restructure it if needed. 
Dr. Sam Rhee: Yeah. I think the key when I listened to both of you is communication, whether it's with your surgeon's office or the surgeon or reading what they communicate to you, it's really about, if you and I will have patients who will ask the same question wash and then call our office like three times in a row. But most of the, I mean, most of the time we really encourage it.
If you're not sure, if you have a question check with your surgeon's office, talk to their staff, talk to, you know, everyone involved and, and make sure that you're on the right page because, regardless of all of these things and you know, you might not have a lot of time. It could maybe be a week or less that, you know, you see the, the search it's possible before you decide to do something and, you know, that's okay.
As long as you're in close communications with that surgeon and his [00:44:00] office. 
Dr. Sam Jejurikar: Yeah. And in the year 2020 with the current pandemic, a lot of this as is possible, even via telecommunication. I do a lot of these consults now in the evening via zoom when we're done operating communication is now possible, even when the office isn't open.
And so if you have questions, get them answered, review expectations, just like Pacella and Rhee are saying. It'll, it'll make all the difference in you being happy with your results and getting exactly what you're wanting. 
Dr. Sam Rhee: Very good. Wow. I finished a sorta early with our talk today. is, is there anything else going on that you guys want to cover?
Dr. Sam Jejurikar: I just, I'm curious. You said things are ramping up for you guys right now. You guys are not, are not slowing down at all. 
Dr. Salvatore Pacella: Yeah. I mean, the state of California in general is slowing down substantially, but, you know, in, in healthcare, we are still proceeding to go forward and, and, and again, I, I attribute that to the, to the [00:45:00] testing capabilities that we have, you know, we've just been widespread testing, you know, we at least at the hospital system, we have not had a shortage. We've had a little bit of a surplus for our patients, on like say, you know, I'm watching newscasts from people waiting eight hours to get testing. So, you know, I, I again was taking it week by week. I don't know if that's going to change, but you know, it's, it's been getting busy 
Dr. Sam Jejurikar: and what's the typical turnaround time for your testing?
Dr. Salvatore Pacella: usually within about, I'd say. Probably about a day, you know? Wow. 
Dr. Sam Rhee: Wow. That's 
Dr. Sam Jejurikar: that's PCR testing. Wow. 
Dr. Salvatore Pacella: It's a PCR testing. Yeah. So again, this is, this is a testing for preop, for the cause our, our hospital rules are, you have to have a, a negative test within 48 hours of the surgical time. So usually we're sending patients ahead of time, two days to get the COVID test. And then usually it's back by 24 hours. 
And I think what you're seeing there is a lot of. [00:46:00] And so w in some of the hospitals where I'm affiliated much faster turnaround time, because a lot of these third party companies that are doing the testing now are actually contracting with larger, larger organizations, like scripts for you, for instance, where all of their tests get sort of bumped up and were individual guys in private practice like you and me, Sam, our patients get bumped on the list.
So we were talking before you got on, right. where, even CVS is now is experiencing sort of a 10 day turnaround time in terms of their, in terms of their testing. So that's insane. So it's sort of all over the map. 
Dr. Sam Rhee: Yeah. And then, yeah, like Sam was saying, and then asking your patient to quarantine during that time.
It's a very, very long time. So it's been a little frustrating, for us, for sure. 
Dr. Sam Jejurikar: Yeah, well, gentlemen, enjoy your weekends. I'm going to enjoy this beautiful day in Colorado and try not to think about COVID too much. 
Dr. Sam Rhee: All right. Thanks. Very much guys. Enjoy we'll talk to you later. [00:47:00]

Dr. Pacella releases the definitive textbook on treatment of skin cancer

Dr. Pacella releases the definitive textbook on treatment of skin cancer: AESTHETIC RECONSTRUCTION AFTER MOHS SURGERY

After years of caring for patients diagnosed with skin cancer, I have heard this story too many times:

A patient sits in my exam room with a large bandage over their nose. What started as a small spot biopsied by their dermatologist has progressed into a large open defect requiring major plastic surgery. The patient sits anxiously, waiting for the final procedure to make them whole again. The patient’s emotions fluctuate rapidly: they may experience guilt about spending too much time in the sun, disbelief in the deformity that they have suffered, and fear of the possibility of permanent scarring.  They are in shock…How I can possibly restore their cosmetic appearance to a time before they were diagnosed with skin cancer?

2015 Atlanta Oculoplastic & Breast Symposium a Success!

This past weekend, I was invited to speak at the 8th Annual Oculoplastic and 31st Annual Breast Symposia in Atlanta, GA. The dual symposium is a special event hosted by the The Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS). Founded in 1958, the SESPRS is composed of many talented board-certified plastic surgeons from around the Southeastern United States. Their annual scientific meetings create an unparalleled opportunity for intellectual exchange of ideas and are a model for professional surgical education across the country. Their motto of “Beauty and Function” was exemplified during a fantastic four day program!

The Daddy Do-Over: Cosmetic Surgery for the Other Half

As we round out the summer, those barbeques and beach beers can really bombard our busting bellies. We devote this month’s blog to the unsung heroes of economic vitality: The Suburban Dad.

Most of us live fairly busy lives: education, chiseling away at our career and devoting the needed time for wives and families. But somehow between the trips to soccer practice and the scattered dinner or Monday Night Football game, we (myself included) have missed a few opportunities to keep in shape and try to hold on to the youthful physique that we once had.

Botox and Dysport: How To Avoid the Porcelain Doll Look

Here in San Diego, a common question I get as a Plastic Surgeon is: “What do I do about these wrinkles around my eyes?” The first thing I say is: “Those aren’t wrinkles. They are called ‘smile lines'”. The lesson I learned here is that the word “wrinkle” evokes quite an emotional response and is usually synonymous with “are you saying I look old?!!”. But its important to understand that those wrinkles are not just about aging… they are about expression! We wouldn’t be human if we could not express ourselves. For this reason, many performers or actresses that I have encountered over the years in my practice shun the idea of any treatment or injection that will impede their ability to express themselves.

But fear not! There is a way to reap the benefits of neuromodulator injections (i.e. Botox Cosmetic or Dysport) without looking like a porcelain doll or appearing “paralyzed”. The key lies in having your plastic surgeon inject strategically!

Your Eyes Without A Face: Eyelid Rejuvenation for the Young at Heart

I have a soft spot for the 1980’s.  This decade defined my childhood.  Tunes such as this Billy Idol song really take me back to a great place.  Let’s face it, which other time in history could mix peg-leg pants, neon pink tee-shirts and super-mullet haircuts? Ahh…those were the days.

Over the last several years, I have seen many patients who share my same age.  A common request they have is rejuvenation of the eyes and face.  Many patients have said: “I look so tired all of the time…and I can’t stand these bags under my eyes.” As a plastic surgeon in San Diego (and a guy in his 40s), I share similar concerns.  I woke up the other day (after a not so restful night with my infant daughter) and looked in the mirror.  I didn’t quite recognize the guy staring back at me: puffy lower eyelids, dark circles and a scruffy beard (ok…maybe the beard isn’t so bad?)

What’s the Skinny on Fat Transfer? An Insider’s Look at The Hottest Trend in Plastic Surgery

It has long been a question that many patients ask during consultation: “It’s too bad you can’t just take this fat from my hips or tummy and bring it up to my breast?”. Ten years ago, I may have answered this question with a whimsical laugh and an “I wish we could!” Today, that answer is a resounding “Yes!”

Fat transfer or fat grafting is one of the fastest growing procedures in cosmetic and plastic surgery. A recent survey by the American Society of Plastic Surgeons*show that over 70% of plastic surgeons are performing this procedure in their practices. While fat transfer has been around for many years, recent advances in surgical technique and technological advances in industry are making the procedure more efficient, more reliable and longer lasting. The procedure is one of the fastest growing procedures that I perform here in San Diego.