WATCH THIS EPISODE LIVE: 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 And this was an article that was originally published a couple of days ago, and then withdrawn, it's called a prevalence of unprofessional social media content among young vascular surgeons.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.