Speaker 1 (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
Welcome everyone, to The La Jolla Cosmetic Podcast. I am your hostess, Monique Ramsey, and I'm so glad you joined us today. I think you're going to really enjoy this episode. We're going to be talking about what losing massive weight, maybe 100 pounds or more, does to your body and how we can fix it. So welcome, Dr. Salazar, to the podcast.

Dr. Hector Salazar (00:37):
It's a pleasure being here and I always enjoy our conversations, Monique. So it's an honor.

Monique Ramsey (00:44):
Thank you. So Dr. Hector Salazar is a board certified plastic surgeon here at La Jolla Cosmetic, and he loves doing surgery and he especially is very skilled at doing body surgery and body contouring. So we thought he'd be the perfect person to talk about body lifting, let's call it. I think massive weight loss can be something that is already going to be very life changing for a patient, but then taking that to the next level of having the extra skin removed. Can you think of any stories that come to mind about a patient like that?

Dr. Hector Salazar (01:22):
Oh yeah, absolutely, Monique. I would say that, I mean, as we know now the concept of health is not only the absence of disease, but it's also wellbeing. It's involved. It's about feeling that you look and that you are in the state that you want to be. Losing weight is imperative in order for some patients to achieve a much healthier lifestyle and to go back into or close to an ideal weight that would keep them away from developing several diseases. Like high cholesterol or diabetes and metabolic syndrome. And once the patient makes the decision to start losing that weight, which is a very, very, very tough decision, they start working hard. As you know, they can either have that weight loss through diet, through diet and exercise, or sometimes through weight losing procedures such as this sleeve gastrectomy or Roux-en-Y gastric bypass or the balloon placement in their gastric chamber. And that will allow them to lose the weight.

Dr. Hector Salazar (02:32):
So, patients start losing that weight. They're very motivated. They have been waiting for a long time to see that result. They lose the weight, they feel lighter. Everything's looking better in life. But what tends to happen is that the weight loss tends to be pretty quick, pretty rapid. And when you're coming from a very high weight and you're going into a steep weight loss, then what happens is that you start developing extra tissue. You start losing some of the fat, but then the skin has been stretched and now the fat has been lost and now you have an extra layer of skin that does not belong to you anymore because you don't have that underlying fat.

Dr. Hector Salazar (03:22):
When we see this patient sometimes, so let's say as you were correctly saying, I mean, after they've lost 100 pounds or 80 pounds, they talk to us and they say, "Well, Dr. Salazar, you know what? I'm very happy. And I feel very light but at the same time, I'm not happy with my body image." Sometimes they even go to an extreme in which they say, "I like my previous body more." Why? Because they felt that the previous body fit, that somehow the fat content was matching the skin and now there's not so much fat content. They feel lighter, they feel better, they're healthier, but then they have all this extra tissue. They have this extra skin that it's not going to go away with exercise or by dieting.

Dr. Hector Salazar (04:09):
You were asking me about a specific case that I remember. And I do remember a very, very young patient. He had morbid obesity when I met him for the first time. He was in his early twenties, it was a male patient. And I met him because he was determined to lose weight. I mean, he had a BMI, the relationship between his height and weight of more than 43, 44, he was big.

Monique Ramsey (04:40):
Wow.

Dr. Hector Salazar (04:40):
And it was all about his eating habits and his lifestyle. And when I met him, he was very determined and he said, "Dr. Salazar, I'm going to lose the weight. I'm committed. I just want to have this conversation with you because I'm going to come back in about two years, and most likely, I've studied and I know that I'm going to need the help of a plastic surgeon." And in a way, I talked to him about different options. I also talked to him about making sure that he would visit with a nutritionist, that he was not getting malnourished during this process to touch base with his primary care doctor. He was still seeing his pediatrician as a matter of fact, but then he was transitioning into a regular doctor and he said, "You know what, Dr. Salazar, no. What I want to do is I want to have a healthy way of losing my weight. I've never tried, really never tried doing it through pure exercise and diet, and I'm going to try that."

Dr. Hector Salazar (05:35):
So he did that. Two years later, literally he showed up and he said, "Look at me." And he had a BMI that was close to 20 to 21.

Monique Ramsey (05:48):
Wow.

Dr. Hector Salazar (05:49):
I mean, a completely different person. A completely different person. His face, everything looked much, much better. He looked healthier. He had a healthy lifestyle. He was exercising regularly. He even showed me his biceps and, oh my God, I touched it. And it was like rock hard, but he says, "Okay, are you ready? You're going to be examining me." All this extra folds and folds of skin. Not only in his abdomen, also in his chest and his arms.

Dr. Hector Salazar (06:20):
And then I asked him, "I mean, how did you do it?" "Pure exercise and diet, as I told you." I said like, "Oh, perfect." So he lost a significant amount of weight, developed all this extra skin. And then he said, "You know what, Dr. Salazar, give me your recommendations. It's going to take me probably anywhere from six months to a year to be ready for surgery, in every sense. But I still want to plan ahead of time for that." And I said, "Okay, let's do it." I examined him. We recommended for him several procedures that we might be talking about in a little bit. And he's, I would say, a very, very successful case of body contouring after massive weight loss.

Monique Ramsey (06:59):
So when somebody loses a lot of weight, what's typically physiologically happening to the body? I mean, the fat's going away.

Dr. Hector Salazar (07:08):
Exactly. Think about this, we're born and we die with the exact same amount of fat cells. Right? So, it's like muscle. When you exercise your muscle, the muscle cells that you have, they get bigger. It's not that you get more muscles. Right? So the same thing with fat cells. Fat cells, when we eat, what we do is we increase the size of those storage facilities, but the storage facility is still there. So if you lose weight, that fat cell is going to get tinier and tinier and tinier, and it's still going to be there. So, as you're losing weight, your fat cells are decreasing in size. So your fat, your subcutaneous tissue is shrinking and shrinking. And then you have the dermis, or the skin, attached to that tissue, but it's not part of the fatty tissue. So it does not behave in the same way.

Dr. Hector Salazar (08:02):
The faster you lose the weight, the most likely that you're going to need a procedure for you to get that extra skin removed. It tends to happen that patients that have weight loss through procedures that are surgical like the sleeve or the gastric bypass, the weight loss pattern, it's very steep. So most likely all of those patients will require some sort of excision of extra skin, extra tissue. Patients that, let's say, "I'm going to lose a hundred pounds, but over the course of three, four years, little by little." Really, it doesn't happen that way because, I mean, normally does not happen that way. But if that would happen, most likely, very little, very little percentage of patients would actually require to excise or get rid of some of that extra skin. I know that I gave you a very long answer for a very short question, but I wanted everybody to be in the same channel.

Monique Ramsey (09:01):
So, speed of the weight loss really does matter.

Dr. Hector Salazar (09:05):
It matters. It matters. But imagine if you're going to go into a very strict diet to lose, I don't know, like 60, 80 pounds, it's really hard to go into that strict diet for a very, very, a long time and then being just adjusting like two pounds at a time.

Monique Ramsey (09:18):
Yeah.

Dr. Hector Salazar (09:18):
So yeah, it does matter. Sometimes I tell my patients, "Whatever it takes. Whatever it takes you to lose weight." If you're very disciplined and you come like the patient that I was talking to you and you tell me, "I'm going to diet and exercise for two years, you'll see me back." And that's what you need? Fantastic. Sometimes some patients say like, "I don't have the discipline. I've already tried multiple times. I'm failing." Then definitely a referral to a good nutritionist and a bariatric surgeon, a weight loss surgeon, can also help them and then leave them ready to continue their lifestyle in a better weight, and now most likely to get their excess tissue removed by a plastic surgeon.

Monique Ramsey (10:00):
Now, how might it be different for somebody who's lost 25, 30 or even 50 pounds versus somebody who's losing 100 to 200 pounds?

Dr. Hector Salazar (10:12):
If we start talking about like a 20 to 25 weight loss, for sure your skin will go together. Will adapt together with your body shape. Most likely you're not going to develop any extra tissue based on that. If you're then start talking about 50 to 60, 70 pounds, then you're going to be in that gray zone that most likely you're going to start developing some extra tissue. If you talk about a 100 pounds and beyond... I'm telling you it's not a guarantee but I would say I venture to say that maybe around 60% of patients to 70% of patients will benefit from some sort of skin tightening after that weight loss.

Monique Ramsey (10:55):
So, what are the best approaches to body contouring, getting rid of the extra skin for anybody who's lost a lot of weight?

Dr. Hector Salazar (11:04):
Skin, once it has stretched, and it has lost its elasticity, there's no ability for your skin to shrink back. It doesn't matter how much you exercise, you cannot exercise the skin. So, for sure, even if you spend two, three, 10 years, I mean, it's great that they're spending all this time in the gym, but it's also important for them to understand that you can exercise the muscles but you cannot exercise the skin. And that's not going to go away. So when, whenever they're ready to undergo a skin excision procedure, I think it's good that they start looking for the advice of a plastic surgeon. You're really talking about balancing here the amount of excessive tissue that they have and exchanging that for a scar, because that's really the trade off. Are you happy without all this? And I give them a big pinch, and they say, "Yes, I'm happy."

Dr. Hector Salazar (12:06):
All right. So then I draw a line and say, "This is the scar that you are going to have. Is that a trade off that you are willing to accept?" And I must tell you 99.9% of the time they say, "Yeah. That line, I can take it. I know what to do with that line. I just need to put my shorts on top of it and it's going to be covered. But I really do not know what to do with all this tissue. Where do I put it?"

Monique Ramsey (12:31):
Yeah. Where can it go now? Now, how long would somebody need to have a stable weight prior to having a surgery like this?

Dr. Hector Salazar (12:43):
I'm going to give you two different answers here. Once they have a weight that has been stable for six months, they should actually at least start thinking about pursuing a body contouring surgery. And as you know, I mean, the doors of our practice are open just to start giving them an evaluation even before they lose the weight. I mean, if someone wants to come and talk to us, we're going to be more than glad to start educating them about what's going to happen in the different procedures that they're available. But in reality, for you to consider a surgical date, the best time to do that would be plan for it once your weight has been stable for six months.

Dr. Hector Salazar (13:23):
Now, if you underwent a bariatric surgery procedure, a weight loss procedure, a sleeve gastrectomy, a Roux-en-Y gastric bypass, the recommendation is for you to be out by one year, after that surgery, and then make sure that during that year you have a period of six months that your weight has been stable. So, it could happen one year after your procedure, if those last six months of that year you've been pretty stable in terms of weight. And when I talk about stability, I say, as I was saying right now, five, 10 pounds going up or down, that we would consider stable for massive weight loss. Because the last thing you want to do is you intervene super early, like after three months, and then turns out that they were in a very small plateau and then they started losing more weight, and then they developed more extra skin, and congratulations, we have to repeat your surgery basically. I mean, it's an investment as well for patients, in terms of time, in terms of money, in terms of recovery-

Monique Ramsey (14:34):
Yeah.

Dr. Hector Salazar (14:34):
... and psychologically.

Monique Ramsey (14:37):
So now, is there anything that prevents someone from being a good candidate for some skin tightening after massive weight loss?

Dr. Hector Salazar (14:46):
One thing that's very important is that you lose weight but you maintain your nutrition. And remember, surgery, when we make a cut, and for this type of surgery, incisions are significant. When we make a cut and we put stitches, sutures, the sutures that we place are just to hold the tissue together while the body of the patient is actually doing the healing. The stitches are not going to maintain your body together forever. We put some sutures that are going to be dissolving because, that's what we mainly use all the time, dissolving sutures. But by the time that dissolves your body already did the healing and everything together. Everything is closed. So in order for you to heal a surgery, you need to have good nutrition. You need to have good proteins, good vitamins. I mean, lots of folic acid needed. I mean, for cell reproduction, vitamins, B12, AD, EK, all those vitamins go together with your nutrition.

Dr. Hector Salazar (15:52):
Sometimes, some of these procedures by definition, they deprive the patient of those nutrients. Just by causing malabsorption, just by causing a speedy transit in your gut and then you not being able to catch on the important vitamins. So those patients have to have very, very close nutritionist guidance in order for them to supplement those vitamins for these patients. And actually we want to make sure that the nutrition is good in these patients before they become a good candidate for surgery. Also if they're smokers, for instance, we would actually ask them to stop smoking because again, smoking prevents healing.

Monique Ramsey (16:39):
Okay. Now, let's say somebody is a diabetic, but it's controlled, are they a candidate for surgery or do they have to be under a certain A1C to be considered?

Dr. Hector Salazar (16:51):
The first thing to say is the fact that many of these patients were diabetics, then they lose the weight and then their diabetes resolves. It's a classic that they list under medical problems. When we do our HMP and patients are filling out the paperwork they'll list diabetes. And then once we're talking to them and going over all the history and physical, they say, "Well, doc, I just put it there because it's history. It's past history. Now, I'm not a diabetic. Actually my hemoglobin, as you're seeing, A1C is under control. Has been under control over the last four months."

Dr. Hector Salazar (17:27):
So most of the time that diabetes gets resolved. If it hasn't been resolved, I can assure you that the levels are going to be pretty good. We would routinely check on the glucose levels and of course, if it's out of control, we would ask them to visit with their primary care doctor or their internist to get them under control. But normally once they come to us, those levels tend to be very well controlled.

Monique Ramsey (17:52):
Now you mentioned that them, maybe seeing their primary care in certain situations, would you say with this group of patients, do you normally need them to be consulting with their primary care or is it only if there's some other comorbidity or problem going on?

Dr. Hector Salazar (18:11):
It's not a must that they go and visit. Obviously if they have an active comorbidity, an active problem, we would definitely want their primary care doctor to be informed that they're going to have surgery. And for them, I mean, we are always open to listen to their opinion. If they say yeah their patient is clear to undergo surgery, fantastic. We proceed. Or they say like, "No, no. Give us a couple of months. We need to make some adjustments in their either nutrition or their glucose management or their blood pressure or any other problem." We delay the surgery if that's the case.

Monique Ramsey (18:41):
Now in terms of a BMI, which is your body mass index, and we do have a calculator on our website, if you're curious about what your BMI number is, is there an upper limit that's too high for this kind of surgery?

Dr. Hector Salazar (18:54):
Yes, there is. And I would say for any kind of surgery. So, when you talk about patients that are after massive weight loss, normally they all come within that safety range. We also have our anesthesiologists team evaluate them and safety first, right?

Monique Ramsey (19:12):
Mm-hmm(affirmative).

Dr. Hector Salazar (19:13):
And definitely patients above a BMI of 40, they would be falling into a higher comorbidity, around the surgery perioperative, around the surgery problematic patient. So then those patients we protect them and we ask them to continue losing some weight. Definitely we are always open to talk to them, to tell them what potential surgeries they can benefit from. But then at the same time to start planning and really planning their surgery, then they probably need to wait a little bit longer.

Monique Ramsey (19:45):
Okay. Now, you mentioned when you were talking about the young man that lost all the weight, you talked about doing his surgeries in a couple different settings, or stages, let's call it. So, do some people, are they able to have surgery all at once?

Dr. Hector Salazar (20:03):
So let's take it a little bit to an extreme. So let's say we have a patient, she's 60 year old female patient that lost probably 150, 160 pounds. And she did it through bariatric surgery, let's just say that. When she comes and visits, we sit down and listen to what her concerns are because that's the most important thing. What concerns the patient has. It's not what we could do here because yeah, what we could do, we could do 3000 different things. Not because we can do it, we should do it. We always like to listen to what our patients want.

Dr. Hector Salazar (20:42):
Let's say literally we do a little wish list that we are going to be writing down and saying, "Okay. So she has skin in her face, in her neck." The cheeks actually tend to drop a lot when patients lose weight and then they look empty in the mid face. Then skin on her breast, her breast also they've gotten deflated. The next thing is her lateral chest wall, the sides of her breast. I mean, they also develop a lot of extra skin. The same thing on her arms, the skin is hanging there. The belly, the abdomen has like now three, four folds of skin.

Dr. Hector Salazar (21:27):
Then another area, it's the mons, just above this patient's intimate parts that we're talking about. Then there's also some extra skin hanging there. Inner thighs. Outer thighs. So as you can see, we're talking about multiple areas with this nice lady. So in reality, if she wants to address all those areas, then we go and we start listing all these different procedures per area. So yes, she would benefit from a facelift. She would benefit from a neck lift. She would benefit from an arm lift, which we call brachioplasty. She would benefit from a lateral chest wall or side of her breast incision. What we do is we do an extended brachioplasty, so we extend our incision into the chest. And that's a long incision.

Dr. Hector Salazar (22:18):
Then if we are talking about the breast, benefit from a breast lift, sometimes they have lost so much volume that they actually benefit from an implant. So you're talking about an augmentation of the breast and a mastopexy, which is a breast lift. Then abdomen. You're talking about an abdominoplasty. And sometimes patients not only need a traditional abdominoplasty with a single horizontal incision that's as low as we can get it, but sometimes they have excess skin in two different axes and that's like the horizontal and the vertical. So now they also need, what we call a fleur de lis abdominoplasty or an extended abdominoplasty. Or even a body lift going all the way around the waist. Then you're talking about a medial thigh lift. Sometimes it has to be an extended thigh lift. It all depends on how much skin they have.

Dr. Hector Salazar (23:15):
So at this point, I mean, I'm already tired, Just by naming the different procedures. So imagine if you start adding hours and hours and hours, you're talking about like 28 hours of surgery, 24 hours of surgery. This elective surgery. It has to be safe. We cannot compromise the healing process. We cannot compromise the breathing ability of the patient. It has to be a nice experience. No complications moving forward. And the patient's smiling every time the patient comes back to the office.

Dr. Hector Salazar (23:50):
So in order for us to have that, we have to limit the time of our surgeries. In order for us to do that, we definitely have to sit down. Now when we have the list, let's start prioritizing. Okay, why don't we group this one with that one? I mean, that carries us into five hours. Why don't we limit and we say, "First let's take care of the trunk. Then let's talk about the extremities. Why don't we do and leave the face for last or no? You know what? The face is what I show the most. Why don't we start with the face. Let's do the face first, and then let's, little by little, work on your body." So, definitely it's something that that's important that we talk to our patients, understand what they dislike the most and let's get going. Let's get started.

Monique Ramsey (24:34):
Now, let's pretend in our example patient, that she really is bothered by her tummy the most or all the way around, but then also wants to do her breast and arms. How long would you wait in between those two surgeries?

Dr. Hector Salazar (24:52):
You're giving a great, great example, Monique, of someone that we would really like to take our steps one at a time, or grouping two, three surgeries only at the most. Two, three different areas. I would say around three months would be the ideal time to wait. I mean, if you want to be advancing quickly, do we have to do it at three months? No. By no means. If you want to wait up to six months or a year after then come back and do the other part, you can as well. Some patients say, "You know, what doc? What I want to do is I want to be ready as soon as possible. Let's March every three months." And then that's fine. We're living in a world that we want immediate results and we all live it.

Dr. Hector Salazar (25:36):
But what it's important here is to tell the patients, I give them an analogy. I said like, "When I take my car to the dealership for service, and if the car has other things that they can fix while the car is there, change the wipers, go and adjust the tires and go and align it. Whatever scheduled service that it needs, that makes sense. Because I'm going to drop my car and I want one recovery, that's it? No more." Right? But the thing is, our bodies are living tissue. They are not cars. It's not that, "Since I'm here, you should do everything possible to my body before I get released, and I am only going to have one recovery." That's not safe.

Dr. Hector Salazar (26:16):
So definitely it's breaking it into different surgeries. Grouping as many procedures as we consider safe and within a certain amount of time in the operating room, and making it efficient for the patient, time wise and economically wise also, because that's very important, and expedite their care. And then this will be a very, very nice experience in which it's only going to be about looking at the results, looking at the improvement, being happy about how things are taken care of.

Monique Ramsey (26:48):
Now, you mentioned a tummy tuck and an extended tummy tuck and a body lift. And we do have an episode about tummy tuck specifically, but just a quick difference of what those are.

Dr. Hector Salazar (27:01):
So, when we start talking about interventions for massive weight loss patients, maybe there's some candidates to undergo a regular abdominoplasty, basically the incision will go from side to side, from hip to hip. And yeah, it is a significant incision but will for sure eliminate all that horizontal X skin. If there's more excessive skin, what you can do is extend that incision. So carry it into the back because if you imagine the patient's laying on his or her back at the operating table. So the limit for you to stop the incision is actually that table, because you cannot go beyond that table. And then what you do is you can flip the patient carefully. You can turn the patient in the operating room and then extend that incision into the back. Of course, maintaining it as low as possible for them to be able to cover it with like a two piece bikini or underwear. So that's a tummy tuck or abdominoplasty. And then if you extend your incision into the back, then that's considered extended.

Dr. Hector Salazar (28:07):
Then you have a circumferential abdominoplasty. What that means is that that incision is going to go literally all the way, not only extended, but have that incision meet at the back. There's another intervention that's called a fleur de lis abdominoplasty, and that's one of the most powerful operations in plastic surgery. What you do is you do an abdominoplasty incision, which is from hip to hip, as low as possible in the front. And then you do a vertical incision right in the midline. So what that does is really, really creates an external corset for that patient because you do an abdominoplasty. Basically you lift up all the skin and fat, you divide it by half and then you crisscross those tissues and you pull down and that literally generates an external corset.

Dr. Hector Salazar (29:02):
So that's a very powerful surgery indicated for patients that have a lot of extra skin in the horizontal, as well as the vertical axis. And this is such a powerful operation that it starts recruiting tissue from the back. So even if they have extra skin rolls in the mid back, pretty much a little bit below that bra line, in the case of female patients, you see how all that tissue starts improving and you have never touched the back.

Monique Ramsey (29:33):
Because you're kind of bringing it around to the front.

Dr. Hector Salazar (29:35):
Exactly. It's like when you have a nice jacket, if you're pulling it to make it super tight on the back, then you have extra in the front and then we remove the extra. And then lastly, you were talking about a body lift. What that means is that you do an abdominoplasty, or it tends to be extended, or circumferential. And then what you do is you undermine the tissues below that level, below the level of where your incision is, into the thighs, particularly the lateral thighs or the buttocks. And then in addition to excise the excess tissue from the abdomen, from the lower back, you're also going to be pulling up the lateral thighs or pulling up the buttocks.

Monique Ramsey (30:21):
Ooh. And lateral thighs are the outside of your thighs?

Dr. Hector Salazar (30:25):
The outside of your thighs, yeah.

Monique Ramsey (30:26):
And then you talked earlier about a medial thigh lift, which is your inner thighs.

Dr. Hector Salazar (30:30):
Which is your inner thighs, right.

Monique Ramsey (30:32):
Okay.

Dr. Hector Salazar (30:32):
I mean, unfortunately for those, they have to be addressed separately because of the amount of excess skin.

Monique Ramsey (30:39):
Well, and that tissue kind of in the people's inner thighs is sort of not fabulously... I feel like it's not that elastic or something. It's that kind of hangs there.

Dr. Hector Salazar (30:50):
Yeah. It kind of hangs in. Because normally if you feel your skin from your inner thigh, you can see that it tends to be a little bit on the thinner side. It doesn't have good elasticity, so with time gravity, it starts stretching. If you add some weight and if you stretch it because you have a lot of subcutaneous tissue in there or fat, then you realize that it's going to be hanging and then you lose that fat and then it's going to hang even more. And then you add the factor of age and also it's going to hang more. So definitely it's something that it's amenable to be excised and again, it's all a trade off. You're going to trade that better contour for an incision.

Monique Ramsey (31:32):
Now, what would somebody expect their body to look like afterward? And sort of let's think about where the incisions are and how long they might be read or when you consider them healed.

Dr. Hector Salazar (31:49):
So, for any of these procedures, I would say that it's important for patients to understand number one, how do we perform them? We explain to them how we excise the skin and how we perform the closure. The way we like to do it is we like to do it at multiple layers and that's really important. It takes a little bit longer to do it in multiple layers. But what that gives you is it decreases the amount of tension for scarring, because scars are going to be present. They're going to be significant. They're going to be long because of the nature of this type of procedure.

Dr. Hector Salazar (32:20):
So then what we have to commit to our patients is to do them as thin as possible. So in order for us to be able to do that, it's important to decrease the amount of tension. How do we do that? We use specialized sutures, thin sutures, the smallest that we can use. We pulled, as much as we can, but then we decrease the tension by doing the closure and layers. I would tell you the day after surgery, that line, we leave it pretty, pretty thin. Very, very thin and fine. Patients take over at that point in time, and their recovery, and then healing starts happening.

Dr. Hector Salazar (32:58):
So, we like to follow up our patients very closely. We follow them the next day, the next week and three weeks, and six weeks, and three months, and about six months and then a year. And we are following them to follow those scars and if there is a need to intervene, so we can actually do it at their appropriate time.

Dr. Hector Salazar (33:19):
So, even though we tell them and we show them that very thin incision the next day, as the recovery process takes place, that scar, it's going to look much better day one than it's going to look at about three weeks or six weeks. And then at about three months, it's going to look pretty red and we call it angry face of the scar, because it's very red and purple. And then the scar starts tuning down and then we're seeing how it gets better and better. And at about a year, it matures very nicely. And then little by little, it starts to become less and less visible. I would be lying to you if I would tell you that the scars go away.

Dr. Hector Salazar (34:03):
Plastic surgeons were good at hiding scars because we love to hide scars in places that you can't see them, or it's really hard to see them. And we like to create nice looking scars, but we're not magicians. It's not about making the scar disappear. So, it's really important that patients... I show them scars on other patients, I mean, they see them. It's like, "Oh absolutely, that's acceptable. Let's go ahead and do it." And it's going to look better and better, but definitely there is some process and there is some time that they have to adapt to those scars.

Monique Ramsey (34:38):
Now I know it depends on what procedure they're having, but you mentioned, it's going to be a longer surgery than a breast augmentation, let's say. But about how long would you say they would be under anesthesia?

Dr. Hector Salazar (34:53):
It varies, and it varies depending on the combination, but you would say that it can range anywhere from like three hours, two and a half hours for a more to discrete abdominoplasty tummy tuck to about five and a half up to six hours to do like a breast lift combined with an implant placement and maybe an abdominoplasty. A good range would be from three to six hours on average.

Monique Ramsey (35:17):
Okay. Now, do the patients get to go home after this? Or do they go somewhere postoperatively?

Dr. Hector Salazar (35:26):
So, for our shorter versions of surgery, in terms of if we're talking about a combination that allows you to stay within three, four, five hours, I would say that patients recover after surgery here in our recovery area of our surgery center until they're ready, they're ready to go home. We also have some patients that decide to stay overnight at a hotel or because either they come from out of town or they prefer to do that, or they actually go back right into their house.

Dr. Hector Salazar (35:56):
But for those surgeries, it's completely, completely fine. We're not invading deep cavities in your body. We're operating on skin and subcutaneous tissue, skin and fat. We actually see them before they leave. We evaluate them before they leave our facility. We call them later that night. We stay in touch overnight, if we need to have a conversation over the phone or FaceTime, or we need to see them in our office, or we need to, God forbids, go back to the operating room. All that is available.

Dr. Hector Salazar (36:27):
When patients go over five and a half, six hours, then we always consider having postoperative care for our patients to be watched and monitor a little bit more closely. And again, we stay in touch with them the same way that I told you about. We always see the patients the next day and always, we personally see those patients. And I think that's also important for patients to understand that they're going to have a close, close monitoring from their doctors. The other thing is that in the preoperative visit, in the visit that the patients have to be educated, what starts to happen is they literally go over every single stage of their recovery, so they know what to expect. They know how to react to it and they understand and learn what are the signs that are important for them to watch after surgery.

Monique Ramsey (37:16):
So we talked about recovery a little bit. When, maybe would you clear them to go on a walk, or give us a quick picture of maybe what that recovery looks like?

Dr. Hector Salazar (37:27):
So with this specific surgeries, actually we like our patients to walk right away. We like our patients to start ambulating, to start walking the same night. That same night that the patient had surgery, we want them to walk. How much? At least to go to the restroom. Stand up, walk, go to the bathroom, come back, have a sit in a chair and then go back to bed.

Dr. Hector Salazar (37:55):
We want them to be active as soon as possible. We don't want them to be redecorating the room or rearranging a closet. Because patients tend to have extra time that they plan for their recovery and they sometimes become creative and they want to do more. So that's what we're here for and we tell them, "No. No, you gotta take it easy. Watch, binge some Netflix series that you're running behind or read a good book or call some friends."

Dr. Hector Salazar (38:20):
But in terms of exercise, depending on what procedure we're talking about, we ask them to stop exercising anywhere from three to six weeks depending, depending on if we're tightening some muscles or we are just addressing the skin, it can vary. But for someone to undergo the surgery, they're probably going to feel fine around a week to 10 days. They're going to feel fine.

Monique Ramsey (38:43):
Okay.

Dr. Hector Salazar (38:44):
The only thing is they still have to take it easy for about another couple of weeks.

Monique Ramsey (38:49):
Okay. Now, what would happen if they were to gain weight after surgery?

Dr. Hector Salazar (38:56):
Can they gain weight? Yes, they can. Remember that what we did is we removed skin and the subcutaneous tissue, the fat that was underneath. And that's important for us to clarify it because patients sometimes they imagine that you only remove the skin. Well, no. Underneath even though they've lost a lot of weight, they still have some fat. So we've removed skin and fat. So now that we've, in a way, hit the reset button, so now they have a new body with fat corresponding or matching to skin, if they gain weight, they can gain weight. They're going to start developing a belly. They're going to start developing like a chubby arms. I mean, can they do that? Yes.

Dr. Hector Salazar (39:35):
But the best thing about this is that not only they've already done the tough job of losing the weight, and demonstrating that they're disciplined, through whichever route they follow, but they've already showed a good amount of discipline. Then in addition to that, now they see their new body. So it's really, really rare that they gain the weight back.

Monique Ramsey (39:59):
Yeah. I bet it's like an incredible moment for them to see their body maybe for the first time. Can you remember anything people have said or kind of what that emotional experience is for them?

Dr. Hector Salazar (40:10):
Oh yeah. I remember a patient saying like, "Oh, I'm a Renaissance man." I mean, in reality it's like a Renaissance period in their life, in which now they're not only healthier and more focused on a better nutrition, they lost all this weight, solved some of the health issues, as we were talking about like diabetes, hypertension, high cholesterol. Now they have a new body image at the moment that we go and do that for stressing change and they don't see all that at extra skin.

Dr. Hector Salazar (40:38):
Obviously they look bruised and they are swollen and all that, but they can start seeing through that part of their recovery. And I mean, yeah. You can see their eyes and they look surprised and they're amazed by the result. And the good part that we could tell them is, "This is only the beginning. It's only going to get better because all the bruising is going to resolve and then all the swelling is going to go away."

Dr. Hector Salazar (41:00):
And that's another important part. After this procedures, the compression that we provide for patients, the compression garments, the molding of those results, it's also really, really important. And we talk to them about it during their first visit and their preoperative visit. Because it's really important that they follow our advice after the procedure for those results to keep on improving and improving and improving.

Monique Ramsey (41:26):
So, I read a review from one of your patients that I just want to share.

Dr. Hector Salazar (41:32):
Oh, thank you.

Monique Ramsey (41:32):
So are you ready?

Dr. Hector Salazar (41:33):
Yeah. Absolutely.

Monique Ramsey (41:35):
Okay. Dr. Salazar provided amazing detail when explaining the process and listened to all of my concerns and wants. He hit it out of the park.

Dr. Hector Salazar (41:45):
Oh.

Monique Ramsey (41:45):
He stayed true to his word and the results are amazing. The confidence I've gained from the procedures I had done is life changing. So, that's kind of a wonderful little... Does that make you feel good?

Dr. Hector Salazar (41:58):
That's very touching. That's actually what keeps me going every day. Thanks so much for sharing that with me, Monique. Well, yeah. No, I'm very, very happy for this patient.

Monique Ramsey (42:08):
Yeah. And I think for those of us who aren't doctors, how can we measure-

Dr. Hector Salazar (42:13):
Absolutely.

Monique Ramsey (42:13):
... our happiness? It's in words and in pictures, maybe. So in those words, you as a prospective patient can read different reviews from patients and what their experiences were. You can look at before and after pictures, but then Dr. Salazar, from your point of view, why should someone feel confident about coming to you for post weight loss, body contouring or any kind of surgery?

Dr. Hector Salazar (42:38):
Well, I mean, it's hard to say good things about me. But I would say that my background, I'm a board certified plastic surgeon. We have plenty of experience. This is something that, for patients, the unique ones in a lifetime experience, and that's the way we treat them. That's the way we make them feel. But for us, it's something that we do every day. So that you want to go to someone who's well trained, who has the volume, who has the time to sit down and listen to your goals. That's imperative for us to listen to what our patient wants to, to what their goals are, we prioritize together. And then we guide them and we do not make the decisions for them, but we protect them and we guide that decision for them to establish an educated plan.

Monique Ramsey (43:34):
So sounds more like a partnership.

Dr. Hector Salazar (43:37):
Exactly. It's working together.

Monique Ramsey (43:38):
And a dictatorship.

Dr. Hector Salazar (43:39):
Totally. Totally. It's very democratic. But definitely sometimes we have patients that they come and they say like, "No doc, I just want to listen to what you have to say because you're the expert." Say like, "Well, I fully agree with that, that I'm the expert, but let's say that I'm not here and just out loud what you want pinch on what you don't like in your body, and say it in your own words then I'm going to tell you what do I think, and then together we can make decisions and establish our plan."

Dr. Hector Salazar (44:07):
So for all those reasons I would say that other than the reviews, as you were saying, and our results and pictures that we have and experience, that would be a very good reason and all together. Another very good reason is the experience that our center has, the excellence that they're going to find right off that very first phone call, that first contact with our center. And obviously like the state of the art surgical facility that we have together with our premier group of anesthesiologists, real doctors, real board certified anesthesiologists that are taking care of our patients. So, while I'm only concentrating in performing my surgery, they're really watching closely the patient and that's why we practice in a very safe environment.

Monique Ramsey (44:58):
And actually for everybody, I recorded the podcast yesterday with Dr. Steven Saltz, who is Dr. Lori Saltz's husband and he's an anesthesiologist who's been in our group for many years, almost 30 years and is going to be a really interesting podcast. So I encourage y'all to listen to that because that really does help you understand things from the anesthesia side of things, and sort of in or while you're sleeping, what's happening-

Dr. Hector Salazar (45:24):
Exactly.

Monique Ramsey (45:25):
... while Dr. Salazar is working and what else is going on, there's a lot going on. So, last thing I just want to say is that, if you're looking for information on prices, everything is on the website. Financing information it's on the website as well, and like I mentioned, we have a podcast about that. But reading reviews online, that really helps a lot. And we have thousands of reviews right on our website all from patients, which is important. So the first step that somebody would do would be, if they want to come see you for consultation, and let's say if they live locally, we can set up an appointment, but say they're from out of state or out of town, can you coordinate that with them?

Dr. Hector Salazar (46:10):
Yeah, absolutely. If patients are coming from out of town, I mean, this is one of the things that COVID has taught us actually, is that doing a Zoom initial visit, it doesn't take away a lot in terms of meeting that person, understanding their goals. We perform virtual exams as well, and that gets things going. We never operate on anyone. As I told you, safety comes first. So we never operate on anybody that we have not actually performed a full physical examination because that's even, again, that would be very risky. But it's important to start the conversation, for patients to understand our philosophy, for us to understand what their goals are, and once we establish that we can come up with a nice plan.

Monique Ramsey (46:56):
Well, this has been so informative. Thank you so much, Dr. Salazar. I just want to ask our audience for a special favor that if you love The La Jolla Cosmetic Podcast, if you've learned something from it, that's helped me. You make a decision, tell your friends, write a review of the show on Apple Podcast or Good Pods or wherever you're listening. We love seeing reviews and we want to hear from you.

Monique Ramsey (47:19):
And then if you have any questions about scheduling or financing or photos or anything, check our show notes for links, and you can find information there as well as before and after photos, Dr. Salazar's biography on our... Not your biography, but your bio, yeah.

Dr. Hector Salazar (47:36):
Thank you.

Monique Ramsey (47:36):
You haven't written your book yet. I haven't written a book about you and you haven't written your autobiography yet.

Dr. Hector Salazar (47:43):
Comes in the 32 volumes and is the authorized version.

Monique Ramsey (47:47):
That's right. But you can get all that good information on our website and then of course setting up your appointment is super easy, so we're happy to help you with that. So thanks again, Dr. Salazar, we appreciated you coming on the podcast.

Dr. Hector Salazar (48:00):
Thanks so much Monique for the invitation and as you can tell, I really enjoy these conversations with you.

Monique Ramsey (48:06):
Thank you.

Dr. Hector Salazar (48:07):
Thank you.

Speaker 1 (48:13):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego freeway, in the XIMED building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram at ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, theaxis.io.