00:00:17
Speaker 1: Pushkin.
00:00:24
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word. This episode contains mentions of body image, weight, and negative body image thoughts. Please protect your well being.
00:01:03
Speaker 3: Aleck to Plastic surgery sits in an interesting intersection between science and aesthetics, medicine and art, biology and identity. But you may be surprised to learn that the roots of plastic surgery are in fact ancient.
00:01:19
Speaker 4: We could go really back to the Egyptians who were performing certain types of plastic surgery, putting rings on the neck to lengthen the neck because a longer, more shapely neck back in hieroglyphic times was more attractive.
00:01:37
Speaker 3: That's doctor Troy Pittman. He's a board certified plastic surgeon who's internationally recognized as an expert in esthetic and reconstructive surgery of the breast and body. He's renowned for his precision, his artistry, and his commitment to treating every patient as an end of one. His practice is at the leading edge of treatment, performing innovative, advanced, and evidence based procedures to help his patients look and feel their best. We've come a long way since ancient times. The techniques and technologies available to plastic surgeons today have never been more sophisticated. So I invited doctor Pittman on the show to walk us through what options are out there, what to look out for when picking a surgeon, and what he helps for the future of his field. It's a surprisingly honest and why reaching conversation about something you just don't actually hear a lot about. I'm a little bit of a history buff, so I found this book from like the nineteen forties or fifties about early facelifts and such. Can you give us a little historical tour through plastic surgery and reconstructive surgery.
00:02:45
Speaker 4: The term plastic surgery actually comes from the Greek word plasticos, and that word means to shape and to mold, and so we have evolved plasticos into plastic because we are shaping and molding. When we talk about the modern era of plastic surgery. So much of the reconstructive surgery came from the wars, so defects that happened, soldiers that were wounded, who lost limbs, body parts, noses, eyelids, lips, all of those things needed to be reconstructed. And it was the reconstructive surgeons who really started pushing the envelope on, well, if we can do this for someone who's wounded, can we extend that to someone who has normal facial aging.
00:03:41
Speaker 1: What are their leading reasons that people come to see you in your office.
00:03:45
Speaker 4: I would say the most common reason as a blanket is patients don't like something about themselves, and so that could be something like large breasts and their shoulders and their neck hurt so they're physically uncomfortable. That could be someone who has stubborn fat in the outer hips and they want to look better. It could be an insecure thing. I do a lot of ear pinning surgery. You have a businessman who's forty years old whose ears stick out to the side and he looks almost kind of juvenile, and it's something that he may have been teased about as a child and he's always lived with and finally, as he's entering mid career, he wants to look more sophisticated and he wants to be taken seriously, and so we do earpinning, and it really does change the face. It can be pregnancy, the rectless muscle, The abdominal muscles get stretched with pregnancy, and they try as hard as they can to work their abs, but they still look like they have laxity of their abdomen or they have loose skin. I think that particularly with women, there is an arc in life and it totally doesn't become about them. It becomes about, first of all, starting a family, and I think we unreasonably put a lot of pres sure on women as being the responsible person to start the family, although it does take two and so they get to midlife and all of a sudden, there's no attention put on them. Their responsibilities go to their children, they go to their partner, it goes to their job for many women, and it's not about them. And then that arc changes. I think later in life, where we see a lot of patients who kids are out of the house, life changes have happened, things may have changed or slowed down at work, and now it needs to be about them again and so I see a lot of women who are in their early sixties who they get blown off, I think a lot by surgeons, like you're sixty years old, why would you want a tummy tuck? Well, because it's about them again, And so that arc goes back, and I think it's really a nice thing to keep in mind as we deal with patients that nobody really ages out of wanting something for themselves.
00:06:15
Speaker 3: Yeah, And I think now as we proactively age, I mean, I've really embraced this in my own personal health and in my practice. I mean, we want to feel great and look great also in our own skin and body as we age. Let's talk about the midlife woman who comes to see you, maybe for a body contouring, just feeling better about herself, better in her body and her skin. Maybe it is for an abdominoplasty or commonly known as a tummy tuck. What do you want to know about her? Do you want to know about where she is hormonally, where she is mentally? What do you want to know about her?
00:06:48
Speaker 4: I want to know all the things you know. The beginning of the conversation anytime we're evaluating a patient pretty basic. We want to know what their health history is. But that's not just about do they have diabetes or do they have high blood pressure or high cholesterol. It's about what changes have they seen recently in their body and what do they attribute those two With the the introduction of all of these GLP one medications, it's so common that I see patients who have been on GLP ones and they've noticed skin laxity, they've noticed changes in their skin quality, and so we want to know what medications are they taking, how much weight have they lost? Is their weight stable? Because if you still have thirty pounds to lose, I don't want to see you yet because we certainly don't want to do body contouring and then have you lose more weight. So I want your weight to be stable. But I also really hone in on where they are in life as far as well inness and longevity. And this is something that is the cornerstone of my practice, and so I do a history with patients of how are you hormonally? Do you feel like your hormones have changed? Do you think you're entering perimenopause or menopause? And have you seen someone about that because a lot of times we see women who've gained weight, and it's not that they've been eating more. It's about their metabolism is slowing because they're going into menopause, and we have to address that before we just take them to the operating room.
00:08:27
Speaker 3: So interesting, even with plastic surgery, the holistic approach is so important. Do you have a particular philosophy that you share with your patients and your philosophical approach to your work, and how do you define success in your work.
00:08:41
Speaker 4: I'll start with the last one because it's the easiest for me. Success in my work is having a happy patient. A happy patient makes a happy surgeon. So I think success is am I able to change this patient, whether it's medically, whether it's surgically. Can I give them a change that's going to make them live their life in a more positive way, make them feel better about themselves. I'm excited to wake up and get dressed in the morning. That's success. I think that we have to take care of the whole patient, and we have to make sure that we're making responsible decisions. Because I do think in the world of social media that we live in, it's easy to commoditize plastic surgery. It's easy to make it trivial, it becomes very superficial in a way, and I think that it's not superficial, and so it is surgery. We do take it seriously. We want to make sure we're treating the whole patient. We want to make sure we're doing safe surgery. I mean that is my philosophy is safety first, make the patients happy, underpromise, over deliver love that.
00:10:02
Speaker 3: I was always kind of insulted when people said to me, you know, you're a surgeon, so you're always going to recommend surgery, And I was like, no, a good surgeon is not always going to recommend surgery. Surgeon may recommend a more minimally invasive procedure or may recommend a non surgical option. For you, what is it the appropriate time to consider elective plastic surgery versus.
00:10:23
Speaker 1: Non surgical options?
00:10:24
Speaker 3: Like what benchmarks do we look at health lifestyle injectibles, what matters most or is it dependent on the particular problem.
00:10:32
Speaker 4: It's dependent on the problem, but it's also dependent on the patient and where they are in their journey, and it depends on the procedure. So when we talk about facial procedures, a lot of what we're seeing now with GLP ones is volume loss and restoring volume a little bit in a way that we can do with filler, getting those wrinkles smoothed out with a little neuromodulator like botox or disport. That's appropriate in some cases. But when that facial volume leads to skin laxity, you have two options. You can tighten the skin or you can overfill the face to revolumeize them. And we all know what overfilling the face looks like. It doesn't look very good, and so those people are going to be better served with a surgical option, and you could really go head to toe to every part of the body. One of the biggest requests that I have from patients. They come in and they say, I've got this little bit of loose skin on my abdomen and I don't really want a tummy tuck, or they're not even heavy enough or have enough loose skin for a tummy tuck, but they have that little loose skin above their belly button. And there isn't really really good non surgical options for skin tightening. We do have some that can do a little bit of skin tightening, like radio frequency devices, micro needling devices like Morpheus that can do skin tightening. And I always tell patients if I can figure out a way to tighten skin like with a magic wand you'll never see me again because I'll make that device and I'll disappear onto an island.
00:12:15
Speaker 3: I would have taken that device. How do you counsel your patients who bring in filtered or these heavily addited imagism their desired outcome. I can imagine somebody coming in and showing you one of these pictures that's all doctored up. How do you set their expectations and what does that patient really need to know or really need to hear from you?
00:12:35
Speaker 4: It is about education. Social media and Instagram have become the plastic surgeon's best friend and worst enemy because it is a medium where we're able to educate and reach patients in a way that we never have before. But these doctored photos influencers posting things where you can easily enhance different body parts with photoshop, just a simple Canva app, you can change all types of things. I will have a patient come in and say I want to look like this, or I want my breasts to look like this, but they have a different body type. They may have completely different breasts. They may have broader shoulders, they may be taller, they may be shorter. If someone comes in and they say, I want Kylie Jenner's breasts, but they don't have Kylie Jenner's body type, or they don't understand that their own body wouldn't accommodate an implant that's that size, I have to delicately say, maybe you would be better served with something like this. It's about education.
00:13:44
Speaker 3: Do you see a shift in what's considered beautiful from something in the past that's just purely genetic, maybe unattainable when you're older, to something that's more inclusive. Now, do you find that there's a shift in terms of what people perceive as beautiful now?
00:14:04
Speaker 4: I love that question because the answer is yes. Again, this goes back to giving the patient what is going to make them happy. Not everybody wants to look straight up and down and thin with a tiny waist. I think curvy women are so beautiful. And you know, a lot of the work that I do is I may have somebody who has wider hips who wants a little bit more waste definition, and she wants her chest to match her waist, and that's not really about giving her smaller hips. It's about giving her kind of a larger top to match her hips, to make her curvy. A lot of what we do in liposuction is about shaping, you know. Liposuction is not really for taking someone who's overweight and making them skinny. Liposuction is really about contouring so it can treat small areas of insecurity, like flank fat or kind of those love handles, the muffin top in the jeans in the back that we call those the flanks. Being able to to shape that area gives a beautiful curve to the waste. Being able to enhance them with implants, or being able to make the breast smaller with a breast reduction really really important because we're achieving that balance. It's not about making everybody look like you know, this cookie cutter model, straight up and down.
00:15:34
Speaker 3: I'm very into bodybuilding now and it's it was like, everybody can have a great body, and it's your body, and it's your proportion and your balance and that individualization of what it means to be comfortable in your own body. I mean, it's great now that we don't have one definition of that. What are a few questions that you ask any in all of your patients or potential patients who are interested in an elective surgery kind of to determine whether they're emotionally ready for surgery.
00:16:02
Speaker 4: Number one, do you have any health problems? So right out the gate, we want to know, is there anything that's going to preclude them from having safe surgery. Then we want to, you know, kind of what their goals are, what their life situation is. One of the things that does tend to be a little bit of a red flag is a patient comes in and they say, I'm just in the middle of getting a divorce or I'm just in the middle of an acrimonious breakup and I want to show my partner that they're going to lose me, and I want to look great, so I can, you know, get revenge. That's a red flag. We want you to be emotionally ready for surgery. We want you to be emotionally stable. Just as much as I want your blood pressure to be stable, I want your mental health to be stable. I like to know what they do as a profession because it has to do with recovery. I like to know what they do for fun, because you know, if they're a novice pickleball player and they can't take two weeks off from their pickleball league. I need to know that because some of these surgeries have a little bit of a prolonged recovery. I do probably eighty percent breast surgery, and so we want to know what their size goals are and what they're looking for so we can set expectations. And if someone says that they're looking for something that's totally unachievable, it's important to have that conversation.
00:17:28
Speaker 3: How are AI and three D imaging and three D modeling and changing the way that you plan for surgery for outcomes, predictions or communication with your patients.
00:17:39
Speaker 1: So are you using AI in terms of surgical planning?
00:17:42
Speaker 4: I do. I look back fifteen years ago when I went into practice and I used to draw like stick figures on the page to try and communicate well, this is how we're going to do this, and that was the best I could do. But being able to use imaging to show a woman this is what a breast reduction is going to look like. Your breast will be narrower, they'll be more lifted, we'll see more of your Torso it's a way for me to communicate what's possible with the sur When we're planning breast implant surgery, I can show them this is what it looks like with a four hundred cc implant. If the patient looks at that image and she says, oh my god, that's horribly too big, that tells me a lot. If she looks at that image and she says those look too small, that tells me a lot. And so it's not AI planning the surgery. It's me showing what's possible in a way we've never been able to do before, and guide the patient's reaction to allow me to get inside their head.
00:18:47
Speaker 1: Do you find that your patient satisfaction is higher?
00:18:50
Speaker 4: I think it sets a level of expectation. It is a way to communicate an idea, and I'm very clear that it is AI. It is not a guarantee. It's not like when you are renovating your kitchen and the designer shows you the cam the of the kitchen. You want it to look exactly the looked on the computer design. We're not kitchens, we're not inanimate objects. And so there are differences in people's tissue. There's difference in skin quality, there's difference in bony structures when we're talking about something like a nose job, so there are limitations to it, but it is also my job to help the patient understand that.
00:19:33
Speaker 3: Coming up next, doctor Pittman will walk us through just a few of the more popular elected procedures, including his specialty aesthetic and reconstructive surgery of the breast.
00:19:44
Speaker 5: Back in a minute, I.
00:19:59
Speaker 3: Just want to go through some procedures. I kind of want to start with the face first. I know you do more body work and breastwork, but I would like to speak about facial aging actually a little bit. What changes in our face. I know, fat changes, skin changes, but also our skull and the scaffolding of our face changes.
00:20:17
Speaker 4: Right, Yeah, there is resorption, or think of it as kind of break down of certain parts of the face. And so as we age, the mandible or the jawbone gets thinner, and so you start to lose the scaffolding. The area at the base of the nose actually resorbs, and so we see patients who get drooping of their nose because it's due to lack of skeletal support. When you think of the extreme of a very elderly person, how their jaw looks just so tiny. As the jaw the bone in the jaw starts to resorb. That also changes with the area around the eyes, the cheek support. That's the skeleton part. The worst statistic ever, everyone is gonna really hate this when starting at about the age of thirty, we're losing about one percent of our collagen per year, and so we're also losing the building blocks that hold our skin taut, and so you're getting looser skin, you're getting wrinkles due to loss of collagen. We also have to talk about hormonal changes that happen both in men and in women, but particularly in women. As estrogen levels go down, the skin gets much drier. There's a reason why we're fanatical about using good facial moisturizer because dry skin doesn't age well and can wrinkle. So all of these things that happen with normal aging are things that I spend a lot of time trying to help support with patients. I do a lot of polyalactic acid. It's a medicine called Sculptra. It's a medicine that is injected into the face and it helps you build your own collagen so that gives the skin better tone, better texture. It's misconceived as a filler. A lot of patients feel like putting that in the skin is going to make their face look puffy, and it doesn't. It actually just helps with the turger of the skin. It helps with the collagen building of the face. Interestingly enough, I know you're a history buff. It was initially there's a side effect of HIV medicine that causes the face to kind of collapse in the mid face. It's called HIV lightp bo atrophy. So the medicines that treat HIV actually kill the fat cells in the face, and so there's this skeletal look that HIV patients get, which is very stigmatizing. Sculpture was originally FDA approved and brought to the market to help revolumeize the face in a very natural way and using it in cosmetic medicine.
00:23:13
Speaker 3: Sculptures like usually injected like monthly for six months or something or how's that done?
00:23:18
Speaker 4: So I do at least three sessions and we space them about.
00:23:23
Speaker 3: Four to six weeks apart, and then fillers on top of sculpture. Like once you put in sculpture, do people do fillers on top of that or is that like a no.
00:23:32
Speaker 4: No, you can do filler with sculptra. To me, sculpture is more about the skin itself, skin quality, collagen, fine lines. Filler is more about volumization in specific areas where patients have lost a lot of volume, So in the cheeks, in the upper lateral face where we tend to lose volume. Filler works very very well along the jaw line where you know that those bones have gotten thinner as we've gotten older and we want more support along the jawline. It works well with volumizing lips, It works for under eye hollowing, all of those things.
00:24:16
Speaker 3: Let's talk about eyelids. Leptoplasty, Yes, how common is it?
00:24:21
Speaker 1: Why would somebody do it?
00:24:23
Speaker 4: One of my favorites because I think in anything that we do in plastic surgery, when we look at the complexity of the operation as far as downtime for the patient, incision versus what the patient derives the benefit of the surgery, lefroplasty knocks it out of the water. So we talk about upper bleferoplasty or that heavy skin in the upper eyelids, particularly in patients who like to do botox in their forehead to take care of those forehead wrinkles. That drops the brow a little bit, makes their eyelids feel heavier, makes them look a little sleepy. We take a small strip of skin off the upper eyelid. The incision hides in that upper eyelid crease. It opens the eye. It makes you look like you're the most arrested person in the world. It's not something where you return to the office in ten days and all of your coworkers go, oh my god, you had plastic surgery. Everyone goes, what did you do? It looks like you're well rested, and it's a huge result. We can also take the little fat pads in the under eye that cause those bags. We can take those out through a small incision through the lower eyelid so you don't have an incision. Those can get teased out the eyelid bags go down. It's a very simple, one hour procedure, little downtime, little recovery, major major result. I can't think of any other thing that we do that has that ratio.
00:25:56
Speaker 3: Let's talk about the aging drooping nose for just a moment. What do you do about that? Can you put a thread in there, or what do you do about the aging drooping nose.
00:26:05
Speaker 4: I really hate threads because we see a lot of complications from threading. The droopy tip most of the time comes from lack of nasal support, and so a rhinoplastd I would say not the most simple operation as far as recovery goes, but it's also not a horrible recovery. Using a little cartilage either from your septum, which is the part of the nose in between the nostrils, some of that cartilage can actually be taken out and used as a small little graft or a support. We can use ear cartilage, we can use rib cartilage. We can actually even use cadaveric so it's rib that's been donated and processed from a cadaver or a dead person. We can use those little graphs to resupport the nose and give it better projection. It tends to narrow the nostrils a lot of times. You know, rhinoplast is one of those things where everybody has a different goal depending on where they are in life.
00:27:11
Speaker 3: So I'd love to move into the area which is really your specialty, breast surgery. How did you decide that this was going to be your area of focus and what was your path to this.
00:27:20
Speaker 4: So I started my training in general surgery. General surgery training is you taking out gall bladders and fixing hernia's. It's basically head to toe surgery. And one of the things that really I found fascinating and attractive in general surgery was vascular surgery, so operating on blood vessels, and I really developed an affinity for breast cancer treatment and particularly breast reconstruction. I was drawn to because I would see these patients who had recently been diagnosed with breast cancer and their whole world was collapsing around them and something was really tangibly being taken away from them. They were using their breasts, and here was an opportunity for me to perform a reconstructive procedure on them where I was giving them their breasts back. It seemed so gratifying as a professional to be able to go through that journey with the patients. You learn so much about people. You learn about their family and their relationships and their children. Because the thing about breast cancer, really, I mean most cancer, but with breast cancer, it's a solar system, and the patient with breast cancer is at the center of the solar system, but the children the partners, the mothers, the father is, everyone in the solar system around that patient is affected by that. It was just really a way for me to give back to patients in a very tangible way.
00:29:03
Speaker 1: So let's talk.
00:29:03
Speaker 3: About aesthetic breast surgery and in particular breast augmentation. First, do you find that there is a change in the procedures that you're doing for breast dog recently in terms of maybe it's more fat transfer, maybe mention under the muscle over the muscle. Are women requesting different sizes now or different procedures when it comes to breast dog?
00:29:29
Speaker 4: Oh my god, Elizabeth, We're at our renaissance in breast enhancement surgery right now, and there are so many reasons. It's really the perfect storm of things that have come together that allow us to offer new things. And so one of the things that I've really pioneered in the United States is a minimally invasive way to enhance the breast with the procedure called preserve. What this is is a way to enhance the breast. We're able to put the implants in front of the muscle, so we're not deconstructing the chest wall. Traditionally conventional breast augmentation involved lifting the muscle away from the chest wall, or removing the breast away from them chest wall and putting an implant under it. With these new techniques, it's a tissue preserving procedure, so we're not harming the breast. It's done through a very tiny incision. A pocket is made beneath the breast, but in front of the muscle, so we're not harming the muscle and the implant, which tend to be smaller implants. And I do think we are at the trend of ballerina breasts where the days, particularly in the Northeast, the days of wanting very large breast enhancements have kind of gone out of favor. A lot of that is driven by fashion, but women want a little enhancement. They've lost some volume after breastfeeding or weight loss. They want a little volume. We can put in a smaller implant. We do this minimally invasive, We don't harm the muscle. The recovery is very minimal, meaning like you have your surgery at nine o'clock in the morning, you can go out to dinner the night of surgery. You're back to work in seventy two hours. You're back to your kids in seventy two hours. It's not that long downtime, and that is really probably one of the biggest advances we've had in the world of breast surgery in the last sixty years.
00:31:23
Speaker 3: Talk to me a little bit about fat transfer. Are you doing a lot of fat transfers or is this like new implant technique really kind of replace that for you.
00:31:31
Speaker 4: I think that fat works really well to enhance the breast in certain areas, but to globally make the breast larger with just fat transfer tends to be slightly frustrating for not only the surgeon but for the patient because it's unpredictable. In a normal fat transfer, we perform liposuction, We purify that fat, and then the fat gets injected within the breast, and the fat cell needs to have its blood supply. So think of the fat cell as a tiny little tissue transplant, and in order for that fat cell to live, it needs its own blood supply. So to keep numbers easy, if I put one hundred c sees of fat, we know that predictably about sixty percent of that fat is going to resorb and your body's just going to kind of eat it. I can't really guide the patient on this is what it's going to look like at the end. It's not as predictable as putting in an implant, and so I do fat transfer more for a patient comes in they want a little bit of upper pole fullness in the breast, or they have a little bit of a breast asymmetry in the upper pole, and we need to try and even things out. You know, we have a new product on the market called alo clay. Remember I was talking about cadaver rib. This is cadaver fat. So this is fat that's been donated from dead people. It's been purified, DNA has been removed from it. We use it a lot to do a little hip dip, those flat things that cause your butt to look like you've got soup bowls. It works well there. I'm not a huge fan of putting it in the breast because we don't really know what it looks like on imaging long term, and I worry about imaging and it looking like cancer on a mammogram and predisposing women to breast biopsies down the road. So I'm not a huge fan of the cadaver fat to the breast.
00:33:35
Speaker 3: Yeah, that's one thing I think we always try to be super careful on when we refer patients for fat transfers and such in the breast, to realize that you can have abnormalities on imaging or little areas of fat necrosis that feel just like a little malignancy, and you may end up with biopsies. Let's talk about explants. Are you doing out surgery and why would you do it? Why would a woman want to have explant surgery meaning removal of breast implants.
00:34:01
Speaker 4: Yeah, So here's the thing. I think every woman deserves to have an implant. I think every woman who has an implant deserves to not have implants. There is no editorial or judgment. Breast goals change with life. So a lot of women had breast augmentation in their twenties, they're in their fifties, They're like, I just don't want these anymore. I don't want to worry about the maintenance, I don't want to worry about what happens if they rupture. I want them out, So we take them out. There's a subset of women who feel like the implants are not agreeing with them and are giving them certain symptoms are making them feel ill. If a patient wants the implants out, I take them out.
00:34:43
Speaker 3: Let's talk a little bit about breast reduction. Are you seeing an uptick and breast reduction surgery? And why would a woman consider breast reduction surgery?
00:34:52
Speaker 4: So with every breast reduction comes a lift, meaning the breast gets perkier and rounder. But with every lift doesn't come a reduction. A lot of times it's just extra skin that we have to tailor that skin to lift the breast and make it look perkier. I'm doing so much more breastlifting for patients on GLP ones, and I'm doing less breast reductions because the breasts are getting smaller from the GLP ones. And I just think it's a trend of where we are in medicine. Certainly, there are plenty of women who need breast reductions and we're doing them, but I do think I'm doing more lifts than reductions.
00:35:33
Speaker 3: Talk to us about abdominat plasty. Not a trivial operation, but really high patient satisfaction after you get through that recovery. I think, right, why would a woman have an abdomina plasty?
00:35:46
Speaker 4: So a couple of reasons One of the most common is, as I mentioned before, the stretching of the abdominat wall. There's a little membrane in between your abs that stretches when you're pregnant, and for some women, and this is genetic, for some women it goes back, and for some women it stays stretched out. Women who've had multiple pregnancies, women who've had twins, where their abdomen really gets stretched out. That membrane gets stretched out, and the only way to fix that, that's called the diastasis recdie. It's misconceived by a lot of even physicians that it's a hernia. It's not a hernia because there's no tear in the tissue. It's just the tissue is stretched out. And so the only way to repair that is to surgically put the abs back together and recreate that little membrane. That is the maneuver that makes the tummy tuck. A little bit of a devil of recovery because you're having abdominal surgery for all intents and purposes. The other reason women come for abdominoplasty is they just have loose skin, and it works really well for loose skin in the lower part of the abdomen and we remove that skin. A skin only abdominoplasty is a little bit of softer recovery if you will well, then if we have to do LuSE skin plus abdominal muscle work.
00:37:17
Speaker 5: Still to come.
00:37:18
Speaker 3: Can you undergo plastic surgery if you're taking hormones plus? I'll ask doctor Pittman about some of the red flags to spot when choosing the best surgeon for you. I think modern plastic surgery is much safer, my perception is, than it was in the past. Can you walk us through your safety protocols and what people need to look out for in terms of risk mitigation In terms of having surgery.
00:37:54
Speaker 4: We have a very specific criteria that we look at. I mean, and it's a laundry list of things that we wouldn't do as elective outpatient surgery. And it has nothing to do with age. By the way, we look at physiologic age or how healthy you are, don't look at chronological age. So I operate on eighty five year olds who are in amazing shape. But we obviously want all of your health conditions addressed. We don't want out of control high blood pressure, We don't want out of control blood sugars. We want to make sure that your heart and your lungs are in good condition to undergo general anesthesia. I mean, those are kind of the basic medical things that we look at to make sure patients are safe. One of the things we really worry about is either excess bleeding or blood clots. We have a whole risk score, it's called the Caprini score, where based on your age, whether you are a smoker, whether you've had blood clots in the past, we give you a risk score, and if your risk score is too high for a blood clot, then we don't do surgery on you. Because blood clots to the legs are probably one of the biggest things we worry about with elective surgery because we obviously don't want you to get a blood clot that can travel to your lungs and cause you to have a pulmonary embolism.
00:39:13
Speaker 3: And always important to review with your surgeon. Right your use of hormones. I find that some people kind of forget about that.
00:39:20
Speaker 1: So what do you usually.
00:39:21
Speaker 3: Recommend in terms of transdermal estrogens and progesterone stop or don't stop?
00:39:25
Speaker 4: You know, all of the things like hormones, glp ones, nobody says that they're on the medicine because those are like they're cosmetic drugs. But I love that you asked this question because you're certainly the expert in this, and you can correct me if I've been given bad information. We've traditionally told everyone stop everything, stop your estrogen, stop your progesterone, and even in the Caprini score, you get a point a point against you for being on hormone replacement therapy. We now see so many patients who are on bioidentical hormones, and I do think that there is good data to show that bioidentical hormones don't carry with them the same thrombosis factor. Also creams like ydrogen cream, if it's not going through your bloodstream, if it's going through your skin and st not going through the liver, it doesn't affect your clotting if it's a long surgery. I still have women hold birth control pills, but women who are on hormone replacement therapy, I've become much more liberal about letting them stay on it, because it's so miserable with them off of it that it will preclude some women. If I say you have to be off two weeks before and two weeks after a month off of estrogen and progesterone, they won't do it. And I do think the drugs have become better and there is no need to stop them. Do you agree with that?
00:40:47
Speaker 3: By the way, I was always trained that you definitely stop your estrogen, and whether it's oral or transdermal. We know oral estrogen carries a blood clotting risk of two times elevated risk of blood clotting, of course, and when we have surgeries, tissues romboplastins are released, right, so there's an elevated risk of clottings. We have more data now that shows that transdermal estrogens don't increase your risk of clotting, So I totally agree with that. I think you're good.
00:41:09
Speaker 4: Does bioidentical matter.
00:41:11
Speaker 3: All of the transdermal estrogens are estradial, So you just want to make sure that you don't have a synthetic progestin. Like there's some patches now that have a synthetic progestine in them, and I would not want to operate on somebody with a synthetic progestine. I would just make sure they're on natural progesterone. So yes, and so that is yes.
00:41:26
Speaker 4: Got it.
00:41:28
Speaker 3: What are your recommendations for somebody to find a well trained surgeon. You know, we're in the Instagram era where everybody's got there before and aftors on Instagram. Some are honest, many or not. How does one find like a really great plastic surgeon like you? And what red flags somebody look for when they're in a consultation.
00:41:47
Speaker 4: Biggest thing is you want to find a surgeon who has quite a bit of experience with the procedure that you're seeking out, has differentiated themselves as an expert in that field. Looking on Instagram, and if the surgeon has all women in bikinis where you don't really see anything and they're taking selfies in their in lighting, that's not a real before and after. So you want to look for good, consistent, reproducible before and afters, not three before and afters. You want to look at hundreds of before and afters. If you're looking at before and afters on Instagram, you want to make sure that they're standardized. I want my pre to look like my post as far as same pose, same lighting, So it's a very honest appraisal of what you're getting. You want to make sure, most importantly that your plastic surgeon is board certified by the American Board of Plastic Surgery or the American Academy of Facial Plastic Surgery. There are a lot of people out there who call themselves cosmetic surgeons, and they will say they're Board certified cosmetic surgeons. That's different than being a Board certified plastic surgeon or a board certified facial plastic surgeon.
00:43:03
Speaker 3: So maybe cosmetic surgeon would be a red flag to look out for.
00:43:07
Speaker 4: I would say it is a red flag.
00:43:09
Speaker 1: Yeah, any other red flags.
00:43:11
Speaker 4: If they have no before and afters, I think that can be a little bit of a red flag. And go to consults. I think if you're considering any of the surgeries that we've talked about today, I would say you should see at least two people, probably three people, get a first opinion, a second opinion, and a third opinion, and you have to be able to connect with your surgeon. It's a feeling. It's like a date, right, and you'll know, kind of like on a date, you know within the first five minutes like I want to learn more or this is not for me, and so it is a journey you hopefully are going to have an ongoing relationship with this physician, and so you have to have a connection. You have to listen to that little voice in your head. I think exorbitantly expensive surgery or really really cheap surgery, those ends of the spectrum, those can also be red flags.
00:44:12
Speaker 3: It's definitely a viber agostolt that you get, like you either connect or you don't connect with the surgeon and you have to trust them, right. I mean, you literally have a patient's life in your hands. How do you prep a patient for surgery in terms of exercise, food, avoiding alcohol, any special diet that you recommend, or nutrition or any supplements that you recommend.
00:44:35
Speaker 4: I don't love a lot of supplements because a lot of supplements can cause the blood to be too thin and it's not really on the label. So things like ashwagonda root and obviously asprit and things like that. We want you to stop anything that makes your blood thin. In the GLP world that we live in, I want my patients to have a ton of protein, so preoperatively really in life, but preoperatively specifically, I want my patients to have a gram of protein per pound. So if you're one hundred and fifty pounds. I want you to at least be having one hundred and fifty grams of protein a day before surge, because that'll help you heal. One of the things we saw early on when we were operating on a GLP one patients and we didn't really know what was going on, we're wound healing issues and that was really probably because of protein deficiency. And we know this for years with patients who've had gastric bypass. If your protein deficient, if your vitamin B twelve levels and your full eight levels are low, you're not going to heal well. And so we want you to be at least getting your protein on a multi vitamin. Certainly, smoking for me is a deal breaker. So I want my patients four weeks at least before surgery and two weeks after surgery to not be smoking anything. And I say to patients, if you can quit smoking for six weeks, you probably just can quit smoking alcohol. I don't want you getting like blind drunk the night before surgery, but you can have alcohol up until surgery. I don't love patients drinking alcohol immediately after surgery because I just don't want them to get tipsy or if they're taking narcotic pain medicine. I don't want them mixing that with alcohol. Living clean, eating clean, lot of protein.
00:46:23
Speaker 1: Fish oil stop beforehand.
00:46:25
Speaker 4: I don't like fish oil. I want patients to stop their fish oil two weeks, two weeks.
00:46:30
Speaker 1: Yeah.
00:46:30
Speaker 3: And what do you see in the near future for plastic or cosmetic surgery? Where is the industry headed, what are the next innovations? What are you most excited about?
00:46:42
Speaker 4: Well, me, personally, I'm most excited about the breast implant technology that's continuing to evolve. There's so many things that are coming down the pike that are not just about implant safety, as far as rupture, capsular contracture. There are devices that are coming out that can tell your body temperature, that can tell certain temperature differences in the breasts, which can be harbinger for breast cancer detection. There are a lot of things coming within plant technology that I think are going to change breast implants. Minimally invasive surgeries are taking off. We've been doing laparoscopic gallbladder removal and hernia repairs and appendectomies forever, but we are now at a renaissance and minimally invasive surgery for plastic surgery, where we can do surgery with less downtime, less scarring, less bruising, less damage to tissues. We're going to continue to see that evolve. There are certainly so many new neuromodulators fillers coming to the market that are going to give patients more options. Plastic surgery is not going anywhere, and I think that it can be a blessing and a curse because everybody wants in on it, and there's a medspot on every corner in New York City. US issue with medspas being run by people who aren't qualified, underqualified, using fake botox, things like that, and New York Department of Health has really cracked down on that. As we look at the future of plastic surgery, I think it's important to know that everybody wants in and that means a lot of bad players are getting in, and so you have to do your homework. You have to know that the person that you're entrusting with your life basically they know what they're doing.
00:48:46
Speaker 3: As plastic surgery becomes more and more popular, I'm so grateful to doctor Pittman for pulling back the curtain on a field that touches millions of lives every year, yet is so rarely discussed with this kind of honesty and depth. If you're thinking more seriously about elective surgery, I want to leave you with some essentials. Consider this your pre surgery checklist of sorts. First of all, verify or certification in the United States. You want a surgeon who is certified by the American Board of Plastic Surgery, which is recognized by the American Board of Medical Specialties, the governing body for position certification in this country. For specialists in facial procedures, look for certification from the American Board a Facial, Plastic and Reconstructive surgery. And remember if the cost were exorbitantly high or suspiciously inexpensive, that's a red flag we're paying attention to. And of course, review the portfolio of a surgeons before and after pictures. You want to see the work from a broad range of patients with your body type, age, and goals. Consistency matters more than a single spectacular recommendation. Also, be intentional about preparing your body for surgery. Eat in a protein, eat clean, and stop smoking at least six weeks prior to disclose. Every supplement and medication, and if you're taking estrogen or progesterone, be sure to inform your surgeon and also build a recovery time into your actual lifestyle for your optimal healing.
00:50:27
Speaker 5: And finally, trust your instincts.
00:50:30
Speaker 3: The best surgical outcomes begin long before you enter an operating room. They begin with the right questions, the right information, and the right doctor. Dacodi Wima's Health is a production of Pushkin Industries and the Atria Health and Research Institute.
00:50:48
Speaker 1: This episode was produced by Kalaliah.
00:50:50
Speaker 3: It was edited by Amy Gaines McQuaid, mastering by Sarah Bugare.
00:50:55
Speaker 1: Our associate producer is Sonia Gerwit.
00:50:58
Speaker 3: Our executive producer is Alexander Garreton.
00:51:01
Speaker 1: Our theme song was composed by Hannas Brown.
00:51:05
Speaker 3: Concept and creative development by Shavan O'Connor. Special thanks to Vicky Marrick, Alan Tish, David Saltzman, Doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne.
00:51:25
Speaker 1: I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
Speaker 1: Pushkin.
00:00:24
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word. This episode contains mentions of body image, weight, and negative body image thoughts. Please protect your well being.
00:01:03
Speaker 3: Aleck to Plastic surgery sits in an interesting intersection between science and aesthetics, medicine and art, biology and identity. But you may be surprised to learn that the roots of plastic surgery are in fact ancient.
00:01:19
Speaker 4: We could go really back to the Egyptians who were performing certain types of plastic surgery, putting rings on the neck to lengthen the neck because a longer, more shapely neck back in hieroglyphic times was more attractive.
00:01:37
Speaker 3: That's doctor Troy Pittman. He's a board certified plastic surgeon who's internationally recognized as an expert in esthetic and reconstructive surgery of the breast and body. He's renowned for his precision, his artistry, and his commitment to treating every patient as an end of one. His practice is at the leading edge of treatment, performing innovative, advanced, and evidence based procedures to help his patients look and feel their best. We've come a long way since ancient times. The techniques and technologies available to plastic surgeons today have never been more sophisticated. So I invited doctor Pittman on the show to walk us through what options are out there, what to look out for when picking a surgeon, and what he helps for the future of his field. It's a surprisingly honest and why reaching conversation about something you just don't actually hear a lot about. I'm a little bit of a history buff, so I found this book from like the nineteen forties or fifties about early facelifts and such. Can you give us a little historical tour through plastic surgery and reconstructive surgery.
00:02:45
Speaker 4: The term plastic surgery actually comes from the Greek word plasticos, and that word means to shape and to mold, and so we have evolved plasticos into plastic because we are shaping and molding. When we talk about the modern era of plastic surgery. So much of the reconstructive surgery came from the wars, so defects that happened, soldiers that were wounded, who lost limbs, body parts, noses, eyelids, lips, all of those things needed to be reconstructed. And it was the reconstructive surgeons who really started pushing the envelope on, well, if we can do this for someone who's wounded, can we extend that to someone who has normal facial aging.
00:03:41
Speaker 1: What are their leading reasons that people come to see you in your office.
00:03:45
Speaker 4: I would say the most common reason as a blanket is patients don't like something about themselves, and so that could be something like large breasts and their shoulders and their neck hurt so they're physically uncomfortable. That could be someone who has stubborn fat in the outer hips and they want to look better. It could be an insecure thing. I do a lot of ear pinning surgery. You have a businessman who's forty years old whose ears stick out to the side and he looks almost kind of juvenile, and it's something that he may have been teased about as a child and he's always lived with and finally, as he's entering mid career, he wants to look more sophisticated and he wants to be taken seriously, and so we do earpinning, and it really does change the face. It can be pregnancy, the rectless muscle, The abdominal muscles get stretched with pregnancy, and they try as hard as they can to work their abs, but they still look like they have laxity of their abdomen or they have loose skin. I think that particularly with women, there is an arc in life and it totally doesn't become about them. It becomes about, first of all, starting a family, and I think we unreasonably put a lot of pres sure on women as being the responsible person to start the family, although it does take two and so they get to midlife and all of a sudden, there's no attention put on them. Their responsibilities go to their children, they go to their partner, it goes to their job for many women, and it's not about them. And then that arc changes. I think later in life, where we see a lot of patients who kids are out of the house, life changes have happened, things may have changed or slowed down at work, and now it needs to be about them again and so I see a lot of women who are in their early sixties who they get blown off, I think a lot by surgeons, like you're sixty years old, why would you want a tummy tuck? Well, because it's about them again, And so that arc goes back, and I think it's really a nice thing to keep in mind as we deal with patients that nobody really ages out of wanting something for themselves.
00:06:15
Speaker 3: Yeah, And I think now as we proactively age, I mean, I've really embraced this in my own personal health and in my practice. I mean, we want to feel great and look great also in our own skin and body as we age. Let's talk about the midlife woman who comes to see you, maybe for a body contouring, just feeling better about herself, better in her body and her skin. Maybe it is for an abdominoplasty or commonly known as a tummy tuck. What do you want to know about her? Do you want to know about where she is hormonally, where she is mentally? What do you want to know about her?
00:06:48
Speaker 4: I want to know all the things you know. The beginning of the conversation anytime we're evaluating a patient pretty basic. We want to know what their health history is. But that's not just about do they have diabetes or do they have high blood pressure or high cholesterol. It's about what changes have they seen recently in their body and what do they attribute those two With the the introduction of all of these GLP one medications, it's so common that I see patients who have been on GLP ones and they've noticed skin laxity, they've noticed changes in their skin quality, and so we want to know what medications are they taking, how much weight have they lost? Is their weight stable? Because if you still have thirty pounds to lose, I don't want to see you yet because we certainly don't want to do body contouring and then have you lose more weight. So I want your weight to be stable. But I also really hone in on where they are in life as far as well inness and longevity. And this is something that is the cornerstone of my practice, and so I do a history with patients of how are you hormonally? Do you feel like your hormones have changed? Do you think you're entering perimenopause or menopause? And have you seen someone about that because a lot of times we see women who've gained weight, and it's not that they've been eating more. It's about their metabolism is slowing because they're going into menopause, and we have to address that before we just take them to the operating room.
00:08:27
Speaker 3: So interesting, even with plastic surgery, the holistic approach is so important. Do you have a particular philosophy that you share with your patients and your philosophical approach to your work, and how do you define success in your work.
00:08:41
Speaker 4: I'll start with the last one because it's the easiest for me. Success in my work is having a happy patient. A happy patient makes a happy surgeon. So I think success is am I able to change this patient, whether it's medically, whether it's surgically. Can I give them a change that's going to make them live their life in a more positive way, make them feel better about themselves. I'm excited to wake up and get dressed in the morning. That's success. I think that we have to take care of the whole patient, and we have to make sure that we're making responsible decisions. Because I do think in the world of social media that we live in, it's easy to commoditize plastic surgery. It's easy to make it trivial, it becomes very superficial in a way, and I think that it's not superficial, and so it is surgery. We do take it seriously. We want to make sure we're treating the whole patient. We want to make sure we're doing safe surgery. I mean that is my philosophy is safety first, make the patients happy, underpromise, over deliver love that.
00:10:02
Speaker 3: I was always kind of insulted when people said to me, you know, you're a surgeon, so you're always going to recommend surgery, And I was like, no, a good surgeon is not always going to recommend surgery. Surgeon may recommend a more minimally invasive procedure or may recommend a non surgical option. For you, what is it the appropriate time to consider elective plastic surgery versus.
00:10:23
Speaker 1: Non surgical options?
00:10:24
Speaker 3: Like what benchmarks do we look at health lifestyle injectibles, what matters most or is it dependent on the particular problem.
00:10:32
Speaker 4: It's dependent on the problem, but it's also dependent on the patient and where they are in their journey, and it depends on the procedure. So when we talk about facial procedures, a lot of what we're seeing now with GLP ones is volume loss and restoring volume a little bit in a way that we can do with filler, getting those wrinkles smoothed out with a little neuromodulator like botox or disport. That's appropriate in some cases. But when that facial volume leads to skin laxity, you have two options. You can tighten the skin or you can overfill the face to revolumeize them. And we all know what overfilling the face looks like. It doesn't look very good, and so those people are going to be better served with a surgical option, and you could really go head to toe to every part of the body. One of the biggest requests that I have from patients. They come in and they say, I've got this little bit of loose skin on my abdomen and I don't really want a tummy tuck, or they're not even heavy enough or have enough loose skin for a tummy tuck, but they have that little loose skin above their belly button. And there isn't really really good non surgical options for skin tightening. We do have some that can do a little bit of skin tightening, like radio frequency devices, micro needling devices like Morpheus that can do skin tightening. And I always tell patients if I can figure out a way to tighten skin like with a magic wand you'll never see me again because I'll make that device and I'll disappear onto an island.
00:12:15
Speaker 3: I would have taken that device. How do you counsel your patients who bring in filtered or these heavily addited imagism their desired outcome. I can imagine somebody coming in and showing you one of these pictures that's all doctored up. How do you set their expectations and what does that patient really need to know or really need to hear from you?
00:12:35
Speaker 4: It is about education. Social media and Instagram have become the plastic surgeon's best friend and worst enemy because it is a medium where we're able to educate and reach patients in a way that we never have before. But these doctored photos influencers posting things where you can easily enhance different body parts with photoshop, just a simple Canva app, you can change all types of things. I will have a patient come in and say I want to look like this, or I want my breasts to look like this, but they have a different body type. They may have completely different breasts. They may have broader shoulders, they may be taller, they may be shorter. If someone comes in and they say, I want Kylie Jenner's breasts, but they don't have Kylie Jenner's body type, or they don't understand that their own body wouldn't accommodate an implant that's that size, I have to delicately say, maybe you would be better served with something like this. It's about education.
00:13:44
Speaker 3: Do you see a shift in what's considered beautiful from something in the past that's just purely genetic, maybe unattainable when you're older, to something that's more inclusive. Now, do you find that there's a shift in terms of what people perceive as beautiful now?
00:14:04
Speaker 4: I love that question because the answer is yes. Again, this goes back to giving the patient what is going to make them happy. Not everybody wants to look straight up and down and thin with a tiny waist. I think curvy women are so beautiful. And you know, a lot of the work that I do is I may have somebody who has wider hips who wants a little bit more waste definition, and she wants her chest to match her waist, and that's not really about giving her smaller hips. It's about giving her kind of a larger top to match her hips, to make her curvy. A lot of what we do in liposuction is about shaping, you know. Liposuction is not really for taking someone who's overweight and making them skinny. Liposuction is really about contouring so it can treat small areas of insecurity, like flank fat or kind of those love handles, the muffin top in the jeans in the back that we call those the flanks. Being able to to shape that area gives a beautiful curve to the waste. Being able to enhance them with implants, or being able to make the breast smaller with a breast reduction really really important because we're achieving that balance. It's not about making everybody look like you know, this cookie cutter model, straight up and down.
00:15:34
Speaker 3: I'm very into bodybuilding now and it's it was like, everybody can have a great body, and it's your body, and it's your proportion and your balance and that individualization of what it means to be comfortable in your own body. I mean, it's great now that we don't have one definition of that. What are a few questions that you ask any in all of your patients or potential patients who are interested in an elective surgery kind of to determine whether they're emotionally ready for surgery.
00:16:02
Speaker 4: Number one, do you have any health problems? So right out the gate, we want to know, is there anything that's going to preclude them from having safe surgery. Then we want to, you know, kind of what their goals are, what their life situation is. One of the things that does tend to be a little bit of a red flag is a patient comes in and they say, I'm just in the middle of getting a divorce or I'm just in the middle of an acrimonious breakup and I want to show my partner that they're going to lose me, and I want to look great, so I can, you know, get revenge. That's a red flag. We want you to be emotionally ready for surgery. We want you to be emotionally stable. Just as much as I want your blood pressure to be stable, I want your mental health to be stable. I like to know what they do as a profession because it has to do with recovery. I like to know what they do for fun, because you know, if they're a novice pickleball player and they can't take two weeks off from their pickleball league. I need to know that because some of these surgeries have a little bit of a prolonged recovery. I do probably eighty percent breast surgery, and so we want to know what their size goals are and what they're looking for so we can set expectations. And if someone says that they're looking for something that's totally unachievable, it's important to have that conversation.
00:17:28
Speaker 3: How are AI and three D imaging and three D modeling and changing the way that you plan for surgery for outcomes, predictions or communication with your patients.
00:17:39
Speaker 1: So are you using AI in terms of surgical planning?
00:17:42
Speaker 4: I do. I look back fifteen years ago when I went into practice and I used to draw like stick figures on the page to try and communicate well, this is how we're going to do this, and that was the best I could do. But being able to use imaging to show a woman this is what a breast reduction is going to look like. Your breast will be narrower, they'll be more lifted, we'll see more of your Torso it's a way for me to communicate what's possible with the sur When we're planning breast implant surgery, I can show them this is what it looks like with a four hundred cc implant. If the patient looks at that image and she says, oh my god, that's horribly too big, that tells me a lot. If she looks at that image and she says those look too small, that tells me a lot. And so it's not AI planning the surgery. It's me showing what's possible in a way we've never been able to do before, and guide the patient's reaction to allow me to get inside their head.
00:18:47
Speaker 1: Do you find that your patient satisfaction is higher?
00:18:50
Speaker 4: I think it sets a level of expectation. It is a way to communicate an idea, and I'm very clear that it is AI. It is not a guarantee. It's not like when you are renovating your kitchen and the designer shows you the cam the of the kitchen. You want it to look exactly the looked on the computer design. We're not kitchens, we're not inanimate objects. And so there are differences in people's tissue. There's difference in skin quality, there's difference in bony structures when we're talking about something like a nose job, so there are limitations to it, but it is also my job to help the patient understand that.
00:19:33
Speaker 3: Coming up next, doctor Pittman will walk us through just a few of the more popular elected procedures, including his specialty aesthetic and reconstructive surgery of the breast.
00:19:44
Speaker 5: Back in a minute, I.
00:19:59
Speaker 3: Just want to go through some procedures. I kind of want to start with the face first. I know you do more body work and breastwork, but I would like to speak about facial aging actually a little bit. What changes in our face. I know, fat changes, skin changes, but also our skull and the scaffolding of our face changes.
00:20:17
Speaker 4: Right, Yeah, there is resorption, or think of it as kind of break down of certain parts of the face. And so as we age, the mandible or the jawbone gets thinner, and so you start to lose the scaffolding. The area at the base of the nose actually resorbs, and so we see patients who get drooping of their nose because it's due to lack of skeletal support. When you think of the extreme of a very elderly person, how their jaw looks just so tiny. As the jaw the bone in the jaw starts to resorb. That also changes with the area around the eyes, the cheek support. That's the skeleton part. The worst statistic ever, everyone is gonna really hate this when starting at about the age of thirty, we're losing about one percent of our collagen per year, and so we're also losing the building blocks that hold our skin taut, and so you're getting looser skin, you're getting wrinkles due to loss of collagen. We also have to talk about hormonal changes that happen both in men and in women, but particularly in women. As estrogen levels go down, the skin gets much drier. There's a reason why we're fanatical about using good facial moisturizer because dry skin doesn't age well and can wrinkle. So all of these things that happen with normal aging are things that I spend a lot of time trying to help support with patients. I do a lot of polyalactic acid. It's a medicine called Sculptra. It's a medicine that is injected into the face and it helps you build your own collagen so that gives the skin better tone, better texture. It's misconceived as a filler. A lot of patients feel like putting that in the skin is going to make their face look puffy, and it doesn't. It actually just helps with the turger of the skin. It helps with the collagen building of the face. Interestingly enough, I know you're a history buff. It was initially there's a side effect of HIV medicine that causes the face to kind of collapse in the mid face. It's called HIV lightp bo atrophy. So the medicines that treat HIV actually kill the fat cells in the face, and so there's this skeletal look that HIV patients get, which is very stigmatizing. Sculpture was originally FDA approved and brought to the market to help revolumeize the face in a very natural way and using it in cosmetic medicine.
00:23:13
Speaker 3: Sculptures like usually injected like monthly for six months or something or how's that done?
00:23:18
Speaker 4: So I do at least three sessions and we space them about.
00:23:23
Speaker 3: Four to six weeks apart, and then fillers on top of sculpture. Like once you put in sculpture, do people do fillers on top of that or is that like a no.
00:23:32
Speaker 4: No, you can do filler with sculptra. To me, sculpture is more about the skin itself, skin quality, collagen, fine lines. Filler is more about volumization in specific areas where patients have lost a lot of volume, So in the cheeks, in the upper lateral face where we tend to lose volume. Filler works very very well along the jaw line where you know that those bones have gotten thinner as we've gotten older and we want more support along the jawline. It works well with volumizing lips, It works for under eye hollowing, all of those things.
00:24:16
Speaker 3: Let's talk about eyelids. Leptoplasty, Yes, how common is it?
00:24:21
Speaker 1: Why would somebody do it?
00:24:23
Speaker 4: One of my favorites because I think in anything that we do in plastic surgery, when we look at the complexity of the operation as far as downtime for the patient, incision versus what the patient derives the benefit of the surgery, lefroplasty knocks it out of the water. So we talk about upper bleferoplasty or that heavy skin in the upper eyelids, particularly in patients who like to do botox in their forehead to take care of those forehead wrinkles. That drops the brow a little bit, makes their eyelids feel heavier, makes them look a little sleepy. We take a small strip of skin off the upper eyelid. The incision hides in that upper eyelid crease. It opens the eye. It makes you look like you're the most arrested person in the world. It's not something where you return to the office in ten days and all of your coworkers go, oh my god, you had plastic surgery. Everyone goes, what did you do? It looks like you're well rested, and it's a huge result. We can also take the little fat pads in the under eye that cause those bags. We can take those out through a small incision through the lower eyelid so you don't have an incision. Those can get teased out the eyelid bags go down. It's a very simple, one hour procedure, little downtime, little recovery, major major result. I can't think of any other thing that we do that has that ratio.
00:25:56
Speaker 3: Let's talk about the aging drooping nose for just a moment. What do you do about that? Can you put a thread in there, or what do you do about the aging drooping nose.
00:26:05
Speaker 4: I really hate threads because we see a lot of complications from threading. The droopy tip most of the time comes from lack of nasal support, and so a rhinoplastd I would say not the most simple operation as far as recovery goes, but it's also not a horrible recovery. Using a little cartilage either from your septum, which is the part of the nose in between the nostrils, some of that cartilage can actually be taken out and used as a small little graft or a support. We can use ear cartilage, we can use rib cartilage. We can actually even use cadaveric so it's rib that's been donated and processed from a cadaver or a dead person. We can use those little graphs to resupport the nose and give it better projection. It tends to narrow the nostrils a lot of times. You know, rhinoplast is one of those things where everybody has a different goal depending on where they are in life.
00:27:11
Speaker 3: So I'd love to move into the area which is really your specialty, breast surgery. How did you decide that this was going to be your area of focus and what was your path to this.
00:27:20
Speaker 4: So I started my training in general surgery. General surgery training is you taking out gall bladders and fixing hernia's. It's basically head to toe surgery. And one of the things that really I found fascinating and attractive in general surgery was vascular surgery, so operating on blood vessels, and I really developed an affinity for breast cancer treatment and particularly breast reconstruction. I was drawn to because I would see these patients who had recently been diagnosed with breast cancer and their whole world was collapsing around them and something was really tangibly being taken away from them. They were using their breasts, and here was an opportunity for me to perform a reconstructive procedure on them where I was giving them their breasts back. It seemed so gratifying as a professional to be able to go through that journey with the patients. You learn so much about people. You learn about their family and their relationships and their children. Because the thing about breast cancer, really, I mean most cancer, but with breast cancer, it's a solar system, and the patient with breast cancer is at the center of the solar system, but the children the partners, the mothers, the father is, everyone in the solar system around that patient is affected by that. It was just really a way for me to give back to patients in a very tangible way.
00:29:03
Speaker 1: So let's talk.
00:29:03
Speaker 3: About aesthetic breast surgery and in particular breast augmentation. First, do you find that there is a change in the procedures that you're doing for breast dog recently in terms of maybe it's more fat transfer, maybe mention under the muscle over the muscle. Are women requesting different sizes now or different procedures when it comes to breast dog?
00:29:29
Speaker 4: Oh my god, Elizabeth, We're at our renaissance in breast enhancement surgery right now, and there are so many reasons. It's really the perfect storm of things that have come together that allow us to offer new things. And so one of the things that I've really pioneered in the United States is a minimally invasive way to enhance the breast with the procedure called preserve. What this is is a way to enhance the breast. We're able to put the implants in front of the muscle, so we're not deconstructing the chest wall. Traditionally conventional breast augmentation involved lifting the muscle away from the chest wall, or removing the breast away from them chest wall and putting an implant under it. With these new techniques, it's a tissue preserving procedure, so we're not harming the breast. It's done through a very tiny incision. A pocket is made beneath the breast, but in front of the muscle, so we're not harming the muscle and the implant, which tend to be smaller implants. And I do think we are at the trend of ballerina breasts where the days, particularly in the Northeast, the days of wanting very large breast enhancements have kind of gone out of favor. A lot of that is driven by fashion, but women want a little enhancement. They've lost some volume after breastfeeding or weight loss. They want a little volume. We can put in a smaller implant. We do this minimally invasive, We don't harm the muscle. The recovery is very minimal, meaning like you have your surgery at nine o'clock in the morning, you can go out to dinner the night of surgery. You're back to work in seventy two hours. You're back to your kids in seventy two hours. It's not that long downtime, and that is really probably one of the biggest advances we've had in the world of breast surgery in the last sixty years.
00:31:23
Speaker 3: Talk to me a little bit about fat transfer. Are you doing a lot of fat transfers or is this like new implant technique really kind of replace that for you.
00:31:31
Speaker 4: I think that fat works really well to enhance the breast in certain areas, but to globally make the breast larger with just fat transfer tends to be slightly frustrating for not only the surgeon but for the patient because it's unpredictable. In a normal fat transfer, we perform liposuction, We purify that fat, and then the fat gets injected within the breast, and the fat cell needs to have its blood supply. So think of the fat cell as a tiny little tissue transplant, and in order for that fat cell to live, it needs its own blood supply. So to keep numbers easy, if I put one hundred c sees of fat, we know that predictably about sixty percent of that fat is going to resorb and your body's just going to kind of eat it. I can't really guide the patient on this is what it's going to look like at the end. It's not as predictable as putting in an implant, and so I do fat transfer more for a patient comes in they want a little bit of upper pole fullness in the breast, or they have a little bit of a breast asymmetry in the upper pole, and we need to try and even things out. You know, we have a new product on the market called alo clay. Remember I was talking about cadaver rib. This is cadaver fat. So this is fat that's been donated from dead people. It's been purified, DNA has been removed from it. We use it a lot to do a little hip dip, those flat things that cause your butt to look like you've got soup bowls. It works well there. I'm not a huge fan of putting it in the breast because we don't really know what it looks like on imaging long term, and I worry about imaging and it looking like cancer on a mammogram and predisposing women to breast biopsies down the road. So I'm not a huge fan of the cadaver fat to the breast.
00:33:35
Speaker 3: Yeah, that's one thing I think we always try to be super careful on when we refer patients for fat transfers and such in the breast, to realize that you can have abnormalities on imaging or little areas of fat necrosis that feel just like a little malignancy, and you may end up with biopsies. Let's talk about explants. Are you doing out surgery and why would you do it? Why would a woman want to have explant surgery meaning removal of breast implants.
00:34:01
Speaker 4: Yeah, So here's the thing. I think every woman deserves to have an implant. I think every woman who has an implant deserves to not have implants. There is no editorial or judgment. Breast goals change with life. So a lot of women had breast augmentation in their twenties, they're in their fifties, They're like, I just don't want these anymore. I don't want to worry about the maintenance, I don't want to worry about what happens if they rupture. I want them out, So we take them out. There's a subset of women who feel like the implants are not agreeing with them and are giving them certain symptoms are making them feel ill. If a patient wants the implants out, I take them out.
00:34:43
Speaker 3: Let's talk a little bit about breast reduction. Are you seeing an uptick and breast reduction surgery? And why would a woman consider breast reduction surgery?
00:34:52
Speaker 4: So with every breast reduction comes a lift, meaning the breast gets perkier and rounder. But with every lift doesn't come a reduction. A lot of times it's just extra skin that we have to tailor that skin to lift the breast and make it look perkier. I'm doing so much more breastlifting for patients on GLP ones, and I'm doing less breast reductions because the breasts are getting smaller from the GLP ones. And I just think it's a trend of where we are in medicine. Certainly, there are plenty of women who need breast reductions and we're doing them, but I do think I'm doing more lifts than reductions.
00:35:33
Speaker 3: Talk to us about abdominat plasty. Not a trivial operation, but really high patient satisfaction after you get through that recovery. I think, right, why would a woman have an abdomina plasty?
00:35:46
Speaker 4: So a couple of reasons One of the most common is, as I mentioned before, the stretching of the abdominat wall. There's a little membrane in between your abs that stretches when you're pregnant, and for some women, and this is genetic, for some women it goes back, and for some women it stays stretched out. Women who've had multiple pregnancies, women who've had twins, where their abdomen really gets stretched out. That membrane gets stretched out, and the only way to fix that, that's called the diastasis recdie. It's misconceived by a lot of even physicians that it's a hernia. It's not a hernia because there's no tear in the tissue. It's just the tissue is stretched out. And so the only way to repair that is to surgically put the abs back together and recreate that little membrane. That is the maneuver that makes the tummy tuck. A little bit of a devil of recovery because you're having abdominal surgery for all intents and purposes. The other reason women come for abdominoplasty is they just have loose skin, and it works really well for loose skin in the lower part of the abdomen and we remove that skin. A skin only abdominoplasty is a little bit of softer recovery if you will well, then if we have to do LuSE skin plus abdominal muscle work.
00:37:17
Speaker 5: Still to come.
00:37:18
Speaker 3: Can you undergo plastic surgery if you're taking hormones plus? I'll ask doctor Pittman about some of the red flags to spot when choosing the best surgeon for you. I think modern plastic surgery is much safer, my perception is, than it was in the past. Can you walk us through your safety protocols and what people need to look out for in terms of risk mitigation In terms of having surgery.
00:37:54
Speaker 4: We have a very specific criteria that we look at. I mean, and it's a laundry list of things that we wouldn't do as elective outpatient surgery. And it has nothing to do with age. By the way, we look at physiologic age or how healthy you are, don't look at chronological age. So I operate on eighty five year olds who are in amazing shape. But we obviously want all of your health conditions addressed. We don't want out of control high blood pressure, We don't want out of control blood sugars. We want to make sure that your heart and your lungs are in good condition to undergo general anesthesia. I mean, those are kind of the basic medical things that we look at to make sure patients are safe. One of the things we really worry about is either excess bleeding or blood clots. We have a whole risk score, it's called the Caprini score, where based on your age, whether you are a smoker, whether you've had blood clots in the past, we give you a risk score, and if your risk score is too high for a blood clot, then we don't do surgery on you. Because blood clots to the legs are probably one of the biggest things we worry about with elective surgery because we obviously don't want you to get a blood clot that can travel to your lungs and cause you to have a pulmonary embolism.
00:39:13
Speaker 3: And always important to review with your surgeon. Right your use of hormones. I find that some people kind of forget about that.
00:39:20
Speaker 1: So what do you usually.
00:39:21
Speaker 3: Recommend in terms of transdermal estrogens and progesterone stop or don't stop?
00:39:25
Speaker 4: You know, all of the things like hormones, glp ones, nobody says that they're on the medicine because those are like they're cosmetic drugs. But I love that you asked this question because you're certainly the expert in this, and you can correct me if I've been given bad information. We've traditionally told everyone stop everything, stop your estrogen, stop your progesterone, and even in the Caprini score, you get a point a point against you for being on hormone replacement therapy. We now see so many patients who are on bioidentical hormones, and I do think that there is good data to show that bioidentical hormones don't carry with them the same thrombosis factor. Also creams like ydrogen cream, if it's not going through your bloodstream, if it's going through your skin and st not going through the liver, it doesn't affect your clotting if it's a long surgery. I still have women hold birth control pills, but women who are on hormone replacement therapy, I've become much more liberal about letting them stay on it, because it's so miserable with them off of it that it will preclude some women. If I say you have to be off two weeks before and two weeks after a month off of estrogen and progesterone, they won't do it. And I do think the drugs have become better and there is no need to stop them. Do you agree with that?
00:40:47
Speaker 3: By the way, I was always trained that you definitely stop your estrogen, and whether it's oral or transdermal. We know oral estrogen carries a blood clotting risk of two times elevated risk of blood clotting, of course, and when we have surgeries, tissues romboplastins are released, right, so there's an elevated risk of clottings. We have more data now that shows that transdermal estrogens don't increase your risk of clotting, So I totally agree with that. I think you're good.
00:41:09
Speaker 4: Does bioidentical matter.
00:41:11
Speaker 3: All of the transdermal estrogens are estradial, So you just want to make sure that you don't have a synthetic progestin. Like there's some patches now that have a synthetic progestine in them, and I would not want to operate on somebody with a synthetic progestine. I would just make sure they're on natural progesterone. So yes, and so that is yes.
00:41:26
Speaker 4: Got it.
00:41:28
Speaker 3: What are your recommendations for somebody to find a well trained surgeon. You know, we're in the Instagram era where everybody's got there before and aftors on Instagram. Some are honest, many or not. How does one find like a really great plastic surgeon like you? And what red flags somebody look for when they're in a consultation.
00:41:47
Speaker 4: Biggest thing is you want to find a surgeon who has quite a bit of experience with the procedure that you're seeking out, has differentiated themselves as an expert in that field. Looking on Instagram, and if the surgeon has all women in bikinis where you don't really see anything and they're taking selfies in their in lighting, that's not a real before and after. So you want to look for good, consistent, reproducible before and afters, not three before and afters. You want to look at hundreds of before and afters. If you're looking at before and afters on Instagram, you want to make sure that they're standardized. I want my pre to look like my post as far as same pose, same lighting, So it's a very honest appraisal of what you're getting. You want to make sure, most importantly that your plastic surgeon is board certified by the American Board of Plastic Surgery or the American Academy of Facial Plastic Surgery. There are a lot of people out there who call themselves cosmetic surgeons, and they will say they're Board certified cosmetic surgeons. That's different than being a Board certified plastic surgeon or a board certified facial plastic surgeon.
00:43:03
Speaker 3: So maybe cosmetic surgeon would be a red flag to look out for.
00:43:07
Speaker 4: I would say it is a red flag.
00:43:09
Speaker 1: Yeah, any other red flags.
00:43:11
Speaker 4: If they have no before and afters, I think that can be a little bit of a red flag. And go to consults. I think if you're considering any of the surgeries that we've talked about today, I would say you should see at least two people, probably three people, get a first opinion, a second opinion, and a third opinion, and you have to be able to connect with your surgeon. It's a feeling. It's like a date, right, and you'll know, kind of like on a date, you know within the first five minutes like I want to learn more or this is not for me, and so it is a journey you hopefully are going to have an ongoing relationship with this physician, and so you have to have a connection. You have to listen to that little voice in your head. I think exorbitantly expensive surgery or really really cheap surgery, those ends of the spectrum, those can also be red flags.
00:44:12
Speaker 3: It's definitely a viber agostolt that you get, like you either connect or you don't connect with the surgeon and you have to trust them, right. I mean, you literally have a patient's life in your hands. How do you prep a patient for surgery in terms of exercise, food, avoiding alcohol, any special diet that you recommend, or nutrition or any supplements that you recommend.
00:44:35
Speaker 4: I don't love a lot of supplements because a lot of supplements can cause the blood to be too thin and it's not really on the label. So things like ashwagonda root and obviously asprit and things like that. We want you to stop anything that makes your blood thin. In the GLP world that we live in, I want my patients to have a ton of protein, so preoperatively really in life, but preoperatively specifically, I want my patients to have a gram of protein per pound. So if you're one hundred and fifty pounds. I want you to at least be having one hundred and fifty grams of protein a day before surge, because that'll help you heal. One of the things we saw early on when we were operating on a GLP one patients and we didn't really know what was going on, we're wound healing issues and that was really probably because of protein deficiency. And we know this for years with patients who've had gastric bypass. If your protein deficient, if your vitamin B twelve levels and your full eight levels are low, you're not going to heal well. And so we want you to be at least getting your protein on a multi vitamin. Certainly, smoking for me is a deal breaker. So I want my patients four weeks at least before surgery and two weeks after surgery to not be smoking anything. And I say to patients, if you can quit smoking for six weeks, you probably just can quit smoking alcohol. I don't want you getting like blind drunk the night before surgery, but you can have alcohol up until surgery. I don't love patients drinking alcohol immediately after surgery because I just don't want them to get tipsy or if they're taking narcotic pain medicine. I don't want them mixing that with alcohol. Living clean, eating clean, lot of protein.
00:46:23
Speaker 1: Fish oil stop beforehand.
00:46:25
Speaker 4: I don't like fish oil. I want patients to stop their fish oil two weeks, two weeks.
00:46:30
Speaker 1: Yeah.
00:46:30
Speaker 3: And what do you see in the near future for plastic or cosmetic surgery? Where is the industry headed, what are the next innovations? What are you most excited about?
00:46:42
Speaker 4: Well, me, personally, I'm most excited about the breast implant technology that's continuing to evolve. There's so many things that are coming down the pike that are not just about implant safety, as far as rupture, capsular contracture. There are devices that are coming out that can tell your body temperature, that can tell certain temperature differences in the breasts, which can be harbinger for breast cancer detection. There are a lot of things coming within plant technology that I think are going to change breast implants. Minimally invasive surgeries are taking off. We've been doing laparoscopic gallbladder removal and hernia repairs and appendectomies forever, but we are now at a renaissance and minimally invasive surgery for plastic surgery, where we can do surgery with less downtime, less scarring, less bruising, less damage to tissues. We're going to continue to see that evolve. There are certainly so many new neuromodulators fillers coming to the market that are going to give patients more options. Plastic surgery is not going anywhere, and I think that it can be a blessing and a curse because everybody wants in on it, and there's a medspot on every corner in New York City. US issue with medspas being run by people who aren't qualified, underqualified, using fake botox, things like that, and New York Department of Health has really cracked down on that. As we look at the future of plastic surgery, I think it's important to know that everybody wants in and that means a lot of bad players are getting in, and so you have to do your homework. You have to know that the person that you're entrusting with your life basically they know what they're doing.
00:48:46
Speaker 3: As plastic surgery becomes more and more popular, I'm so grateful to doctor Pittman for pulling back the curtain on a field that touches millions of lives every year, yet is so rarely discussed with this kind of honesty and depth. If you're thinking more seriously about elective surgery, I want to leave you with some essentials. Consider this your pre surgery checklist of sorts. First of all, verify or certification in the United States. You want a surgeon who is certified by the American Board of Plastic Surgery, which is recognized by the American Board of Medical Specialties, the governing body for position certification in this country. For specialists in facial procedures, look for certification from the American Board a Facial, Plastic and Reconstructive surgery. And remember if the cost were exorbitantly high or suspiciously inexpensive, that's a red flag we're paying attention to. And of course, review the portfolio of a surgeons before and after pictures. You want to see the work from a broad range of patients with your body type, age, and goals. Consistency matters more than a single spectacular recommendation. Also, be intentional about preparing your body for surgery. Eat in a protein, eat clean, and stop smoking at least six weeks prior to disclose. Every supplement and medication, and if you're taking estrogen or progesterone, be sure to inform your surgeon and also build a recovery time into your actual lifestyle for your optimal healing.
00:50:27
Speaker 5: And finally, trust your instincts.
00:50:30
Speaker 3: The best surgical outcomes begin long before you enter an operating room. They begin with the right questions, the right information, and the right doctor. Dacodi Wima's Health is a production of Pushkin Industries and the Atria Health and Research Institute.
00:50:48
Speaker 1: This episode was produced by Kalaliah.
00:50:50
Speaker 3: It was edited by Amy Gaines McQuaid, mastering by Sarah Bugare.
00:50:55
Speaker 1: Our associate producer is Sonia Gerwit.
00:50:58
Speaker 3: Our executive producer is Alexander Garreton.
00:51:01
Speaker 1: Our theme song was composed by Hannas Brown.
00:51:05
Speaker 3: Concept and creative development by Shavan O'Connor. Special thanks to Vicky Marrick, Alan Tish, David Saltzman, Doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne.
00:51:25
Speaker 1: I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
