Episode 27: Local Lipo – Fact or Hype?

Dr.Franco:: All right. Welcome, guys. Welcome back to “Plastic Surgery Untold.” I’m Dr. Johnny Franco, also known as Austin plastic surgeon. And I have the great privilege of our celebrity cast today. So, we got some special guests and of course, our usual suspects. So, we got one “Celebrity anesthesia”…

Dr. Osborne: What’s up everybody?

Dr.Franco:: …who has been killing it on Instagram a little bit lately. So, for those of you that follow, please know it’s a NC 17 because he does not wear a shirt. But other than that, the content has been on point.

Dr. Osborne: Thanks, man. Thanks. I’ve been trying to get after it. No days off.

Dr.Franco:: Okay. And then G-Berto, thanks. A little delay again starting the day as he had to do another wardrobe change. But the flower looks on point, and you’re looking rather dapper today.

Dr. Saenz: Thank you, sir. I appreciate it.

Dr. Osborne: Dapper Dan over there.

Dr. Saenz: Yeah, My Instagram game may not be on point, but I do promise to keep my shirt on.

Dr.Franco:: Well, we’re gonna get back to this because somebody did challenge you to a bet that they said anything, correct? We’re gonna come back to this. Don’t you worry, people. We’re coming back to this. A little radio trick here, we gotta leave…

Dr. Osborne: The nugget has been dropped.

Dr.Franco:: …some good nuggets for the end. And then, we got our special guest here, Dr. Andre Levesque, who some of you may or may not know, actually we were med school classmates.

Dr. Levesque: Yeah, absolutely.

Dr.Franco:: So appreciate you joining us today.

Dr. Levesque: Pleasure. Thanks for having me.

Dr.Franco:: We’re going to talk a little bit today about local lipo, some local procedures including J-Plasma, which is one of your specialties. But before we jump into this, can you tell us a little bit about your practice, your life, what’s going on?

Dr. Levesque: Sure. So like yourself, I’m here in Austin, Texas, and solo practice. I started about almost two years ago now. And actually, we’re in an interesting situation because when I started my practice, I was sharing your office. And it’s been two years, and we’ve got a nice small staff that I really consider an extension of my family. And we do a little bit of everything. But my main focus is of course, cosmetic surgery, face, body, breast, everything. But I also do reconstruction so you may find me zipping around town taking care of trauma.

Dr.Franco:: Because you were at the university hospital before and it’s kind of your side passion, isn’t it? Some of the micro and other stuff, because you do some really, really cool stuff that I think you just don’t let go because you like the intricacies of it.

Dr. Levesque: Right. So, yeah, that was my first job out of training was at the university and got to teach residents, med students through a lot of complicated reconstructive surgery. So, you know, well trained, so I feel like I should still be doing that. And as long as my wife lets me keep doing that, I’m gonna keep doing it, so.

Dr.Franco:: It’s hard to let go of the skills you built for so long, and you’re like, “How can I just like…? You’re like, “At least let me dabble.” But it’s kind of funny, Andre alluded to it a little bit too. I was part of a big derm group, split off on my own, and then he was part of a derm group, he split off on his own. So as his office was getting prepared, he lived with us for a little bit at our office. And then, as most of you that listen to the cast, were trying to move into our new office. That’s been delayed. So, he has graciously taken us in as his foster child. And so, I truly, truly appreciate it. So, it’s been fun and it’s kind of giving me some good insight, and that’s why we decided to have him in here because he does some really cool things that I don’t do in my practice. And so, maybe I can learn a little bit or if not, at least let people know that the services are available here in Austin, which is so cool. And we talked about this on previous episodes, how many incredible sub specialists there are in Austin of just unique stuff in such a small town. But before we get into all the plastic surgery stuff, let’s get caught up what’s going on in people’s life. And we always have to let “Celebrity anesthesia” go first or he gets upset. So, please let the star bright shine.

Dr. Osborne: Do not make me take this shirt off. I don’t know if for the, you know, three people listening that don’t follow my Instagram, that was a joke. I have, like, a couple hundred followers. Not much. But this past week, my wife tasked me on…I had a full day off. So, of course, my honey-do-list…

Dr.Franco:: Oh, so like every Monday, Tuesday, Wednesday, or…

Dr. Osborne: No. Get out of here. Get out of here. I’m doing your cases on those days. You know, my honey-do-list is piling up. First thing on there is you have to take my car in to get this little oil gasket thing repaired. I’m like, “Okay, cool. No problem.” I show up, we trade cars for the day, she takes mine, she goes to see her home health patients and all that, and I pull up to the dealership and I realized that there is not a mask to be found in the entire place. So, I go back into the car, I look, Mary has taken all the masks out and put them in my car so she can see patients. The only thing I could find is a mask that she was handed when she went to the nail place a couple weeks ago, which is a faux Louis Vuitton, over the top gaudy, big LV, bright, bright, bright…

Dr.Franco:: I hope there’s some bling on it. I hope there was some bling.

Dr. Osborne: Oh, it was just barely short of being completely bedazzled, man. It was ridiculous. So I put it on because I don’t have any other option…

Dr.Franco:: How did that not make the Gram?

Dr. Osborne: Oh it did. Thanks for watching. Who is this? Oh, my gosh.

Dr.Franco:: Oh, my bad. I’m taking my bad on that one. Anyway. So I walk in and of course, I’m in this ridiculous mask. And they offered to drive me home because they don’t have a rental car available. I’m like, “Okay, no big deal.” I’m on the way home with this guy who’s probably, I don’t know, 20 years old driving me back to my place. And he’s like, “Excuse me? Is that a real Louis Vuitton mask?” And I go, “Yeah, man. Honestly, that’s $1,200.” If I felt bad, and I lied. I told him it wasn’t real.

Dr.Franco:: That’s incredible. It’s funny how this whole mask thing has taken a life of its own.

Dr. Osborne: Oh, my gosh.

Dr.Franco:: But, you know. Not to get too much in the masking. And maybe I jump leap, maybe jump in front of one G-Berto here because I feel like my life entails, you know, G-Berto’s life.

Dr. Osborne: Please. Please.

Dr.Franco:: You know, so, recently went to go visit my mom for her birthday, just did a little day trip, and so went out on a Saturday, came back on a Sunday. But I’ll tell you, I somehow talked to one G-Berto into coming to the land of enchantment with me to see where I grew up. And so, we got tickets on a Friday night and left I think six hours later on a Saturday morning. But traveling with G-Berto is not traveling like a normal person. I mean…

Dr. Saenz: Oh, here we go.

Dr.Franco:: No, he does baller style. So, first of all, we get on a plane, get on the plane, and they go, “Hey, I’m sorry. We’re gonna have to have you guys get off the plane because there’s a gas leak.”

Dr. Osborne: Oh, God.

Dr.Franco:: Seems reasonable, get off the plane. We weren’t gonna make our connection. We’re only going for one night. So G-Berto is like, “Let’s go to the lounge.” He’s like, “I’ll just ask my peeps.” I was like, “I didn’t know you had peeps at the airport. Fine, but okay.” We go up there. They change us airlines, get us on another flight that gets us in at the same time to a completely different airline company. And I was like, “I didn’t know they do that,” baller move number one. So then, we’re back home. And so, you know, we’re at dinner and so we took him to some place here in Old Messila, see a little old school stuff. And they have these like red piranhas. And so, G-Berto, being the baller he is, decides he’s gonna try and pet these little piranhas. And I was like, “Holy shit.”

Dr. Osborne: What could go wrong.

Dr.Franco:: I don’t think you’re supposed to stick your hand in there. And so, somehow I think he still has 10 fingers and we have to do a little count here. But he’s doing well. So then we’re coming back, you know, we took the red eye to be here for this podcast. We actually flew in today back here, boom, boom, boom, you know. We were in New Mexico this morning. We were running a little late because the flight was at 6:00 in the morning. We had to drive an hour to the airport. But so the lines out the door, he’s like, “Nope.” He’s like, “We got a back entrance.” So we go to this side thing, go right up to the front, and the lady waves us up. She’s like, “Most beautiful man, come on up here. Here’s your ticket.” Then we’re going to check into the gate in El Paso, this tiny little thing, and I’m going to the line like a sucker and all of a sudden he’s like, “John,” he’s like, “We don’t stand in line.” We go around the side, and again, most beautiful man gets waved through. It’s like, “Come on, most beautiful man. Come this way.” And I was like, “Holy shit.” I was like, “What it’s like to be Austin’s most beautiful man.”

Dr. Osborne: Traveling with Big Daddy G-Berto.

Dr.Franco:: It was. And then, we’re driving home…because I’m driving him like his personal chauffeur to his house to drop him off, you know, he’s up in the backseat, he’s like, “Hey, I told this girl that I pet a piranha, and she didn’t believe me.” And so I said, “The bets on,” and she said, “I’ll bet anything.” So I just want to see where that got left off.

Dr. Saenz: I had to show proof of said hand in the piranha tank.

Dr.Franco:: But what was the bet? I mean, I feel like you’ve left us cliffhangin’ and and you’re playing a little cat and mouse with us right now.

Dr. Osborne: You cash in?

Dr. Saenz: That’s exactly what I’m doing, John. Yeah, no, it was quite the weekend, for sure. I think the only thing I was missing was a bedazzled Louis Vuitton mask.

Dr. Osborne: That’s it. That would have sealed the deal.

Dr.Franco:: Okay. We’ll keep moving since it sounds like G-Berto is not going to tell us the epic conclusion of this story here. But let’s talk a little bit about liposuction under local anesthesia and some J-Plasma stuff. As some of you guys know, I do a ton of liposuction, but I typically need the services of one “Celebrity anesthesia.” And it’s a common question that we get in our practice, whether they have to be asleep, whether you have to do anesthesia. And so, maybe we’ll let Andre take over a little bit and kind of tell us how in your practice you decide who needs…because you do do stuff under anesthesia and you work with “Celebrity anesthesia” as well, but how you decide, who you do in the office, who you do at the surgery center, and maybe kind of pros and cons?

Dr. Levesque:Yeah, absolutely. So, you know, not everybody is going to be a good candidate for liposuction in the office versus under anesthesia. And a couple of things you look at really is, you know, what’s the anxiety level of the patient and what areas you’re gonna work on. So a lot of it has to do with mostly, you know, how much you’re going to do, which areas because certain areas are going to be a little bit easier to take care of, say, the neck, submental liposuction, easily done in the office for most patients. You start doing some of the bigger body areas, certainly things that you’re doing Johhny is, you know, Brazilian butt lifts, that’s just a lot more areas and very difficult to get people numb where they can comfortably undergo the procedure in the office compared to surgery center. So, you know, celebrity is going to help you out there. And that’s exactly the same reason that I do the procedures that…every once in a while I’m doing Brazilian butt lifts, and so celebrity helps us out there. So, you know, certain areas, back, difficult to get numb I think, abdomen and somebody who’s a little bit on the smaller side, perfect for the office, arms, segmental, you know, chest on some men would be a good place as well. So, a lot of it just depends on, you know, is the patient amenable to that? Because you can certainly offer it and they may just freak out and say, “Absolutely not. I don’t want that. I don’t want to hear. I don’t want to see, and we’re going to sleep.” And that’s fine. The reasons to do it, of course, are, number, one is safety. And if you do not have general anesthesia, then you don’t have to worry about that part of it. So no offense to celebrity there, but it is a safer option when it is going to work and you get your goals. And then…

Dr.Franco:: Can I stop you on that point please?

Dr. Levesque: Yeah.

Dr.Franco:: Safety, I think is a huge one because I think there’s some big safety benefits to not doing general anesthesia. But I think we’ve also seen people…because you’ve already alluded to some of this, that there’s certain areas that you can get better numb than others, you know, the amount of areas that you’re doing in in one setting…

Dr. Levesque: Of course.

Dr.Franco:: …because sometimes people get themselves in troubles by trying to either over numb people with because there’s a limit to how much Lidocaine, or trying to give people too much sedation in the office because you’re doing too much into… You want to guide us a little bit about how you decide, kind of your cut offs, and what’s keeping that in a good safe spot?

Dr. Levesque: So I think, you know, the way I look at it from a wetting standpoint, when we’re doing tumescent anesthesia, you know, typically you’re gonna inject a little bit more compared to when you do it under general anesthesia. So, I’ll typically go less than three liters, and it’s kind of where I cut it off. Now, under general anesthetic, I’m usually shooting for less than five, and those are kind of well-studied, mostly based out of Florida as far as what could be considered safe. You also have to worry about fluid shifts. So, if you are doing larger liposuction, you know, you may need to have an IV so you can give the patient some fluids and make sure you’re not getting him dehydrated. And then, you bring up the right point about, you know, we do give a little bit of medications by mouth. And so, it’s always a balance. You don’t want to give somebody too much. In a setting, in my office, you know, we don’t have celebrity there to kind of rescue us. So we’re always paying attention and we do, in fact, have all the things you need, airway, all the rescue drugs in our office, or else we wouldn’t be doing it because that wouldn’t be safe. So, you know that’s the key when you’re looking at providers that are doing this, it’s really, you know, are they ACLScertified, do they know what to do if there’s too much medication. And, you know, there’s providers that are doing some Nitrous Oxide and all these other things. So it’s more about, you know, making sure you got a good history, good physical exam for the patient so that you can give them medication just to get them comfortable. And then, once you get the numb, then it’s really not a problem. But I do think you do need to be worried about it and it’s not something you want to be cavalier in any stretch of imagination. And if you do need to be more aggressive, then definitely general anesthesia is going to help you do that.

Dr.Franco:: It sounds like you’re super selective though because especially stuff like the neck, I think that’s a great one because that’s a very isolated area. That’s not going to be a huge volume. But necks is one of these where you can do a little lipo or a little J-Plasma, Renuvion, skin tightening and make a huge difference. Even if you only take 30, 40 ccs of fat out between that and the skin tightening, it can be a huge difference. And you mainly use, you tell me, 200 ccs of wetting [inaudible 00:13:40.323]?

Dr. Osborne: Yeah, I mean, for the neck, it’ll be anywhere from 100 to 200, yeah, for a typical patient. And so that’s really not a big deal at all. You know, one thing I have found is when you do use more wetting, there’s epinephrine that constricts all the blood vessels. And so, you tend to use a little more than if you’re on general anesthesia. So the bruising is actually less. You do have to take it, you know, into account when you’re doing your liposuction that there may be a little more swelling just related to the tumescent that you’ve injected. So your endpoint may be a little different, so you take that into account. You know, we add Tranexamic acid to all of our wetting solutions. It also cuts down on bleeding and just helps with the bruising aspect. So it’s really lunchtime lipo, especially for, you know, neck. And so I mean that sounds kind of gimmicky, but that’s definitely the case for small areas like that, or arms. Arms is another great area where you can, you know, really get somebody comfortable and, you know, do the arms and do J-Plasma and tighten everything up. And I’ve certainly seen some patients in the right age range with not too much extra skin, you know, where you thought maybe you’d have to just do an arm lift, you know, you just do liposuction J-Plasma and there’s no scars. It’s fantastic. So you do need to be selective, but it’s nice to be able to do that. I will say that, you know, as a surgeon, first time you start doing this, you’re a little bit wary because you’re like, “Are they gonna feel this? Am I gonna be able to do this?” You know, worst case scenario, you can’t get it done and, you know, you just have the patient get scheduled with celebrity and then you proceed. So I don’t think you’d burn any bridges that way. It’s just a matter of, you know, selecting the right individuals. And we haven’t had any patients that just can’t handle it and freak out, but that’s part of the interview process and, you know, presenting them that option.

Dr.Franco:: And I feel like we get a pretty good sense. If somebody is just like, “Look, I don’t want to be awake for this. I don’t want to do it,” then that’s fine.

Dr. Osborne: You’re gonna [inaudible 00:15:28.923].

Dr.Franco:: And that’s easy. And that’s something that people can be up front with us. I 100% agree with you, and not to get us off tangent, but before, I’m a big fan of the J-Plasma, Renuvion as well. And before it, there was just this big gap. So there was the healthy 20-year-old that just had a little excess fat in their arms, but had great skin that were gonna be fine with just lipo. And then there was the people who, you know, had gastric procedures and have skin hanging down that are great arm lift procedures, but it’s all those people in the middle that had borderline skin, their arms were a little thick, and it’s like, “What do we do with these?” Because, you’re terrified to lipo them, and then their skin doesn’t retract. And so, I feel like now that’s a big group of people where…I don’t know about you, but in the past, I was just sending them home because I was afraid to make them worse.

Dr. Levesque: Absolutely. I mean, the scars for arm lift, you know, they’re impressive. And so, if the arms aren’t really, you know, symptomatic, it’s more of, you know, rashes and things like that after a bypass, then those scars are worth it. But in the person that is, you know, a little bit contours but the skin isn’t super tight or their 20s, yeah, then you worry about liposuction. So Renuvion and J-Plasma, you know, those are great additions to kind of help a larger range of patients. And I find myself, you know, not shying away from those patients like I may have done before where I was like, “You know, I don’t know if you really want an arm lift.” But now I’m like, “Hey, great. We can do liposuction and J-Plasma. And we can even do it in the office.” And so, you know, it’s a matter of it’s a little convenient for him not to mess around with surgery center scheduling. You know, it’s really pretty impressive, you know. And that’s not the only thing we’re doing when we would do a lot of other things in the office, but it’s all patient selection. And it’s not to say that celebrity services aren’t fantastic because they are. They really are.

Dr.Franco:: But if you can space out those visits with celebrity a little further, I see what you’re saying. Celebrity doesn’t need another Porsche. He’s on his third one already. Mary’s got her, you know, workroom. She hasn’t even gotten a shout out today. She’s doing so well. So it’s just you can tell things are rolling. Things are rolling.

Dr. Osborne: Just trying to keep up with you, man.

Dr.Franco:: Or G-Berto, like the other day, I mean, traveling with Austin’s most beautiful man has it’s perks. It’s just like you get waved on through, “Come on, come on this way.”

Dr. Osborne: But to touch on what Dr. Levesque said, I think he hit the nail on the head. It’s all about patient selection, surgical, you know, selection site, the volume of lipo that you’re doing. And then, you know, to me, the only absolutely 100% contraindication to do that is if a patient refuses, doesn’t want to be awake and they’re refusing, you know, that local anesthetic, then, of course, “Yeah, we can go to sleep for it.” But I’m a minimalist, and I believe less is more. And I think that sometimes that is the safer thing to do, like you did touch on. And I don’t think that general anesthesia is unsafe, but, you know, with anything, it does carry risks.

Dr.Franco:: One hundred percent agree because…and we’re talking about, and you can correct me if I’m wrong, Andre, but you’re not talking about the people like our BBLs who were doing five liters a lipo, 1300 ccs of fat transfer. Like, that’s not an office procedure.

Dr. Levesque: Right. No. And you’ll see me right there with you doing it with Celebrity. So I mean I’m not doing that in my office. And, you know, it could be that you stage it. You know, maybe somebody wants their abdomen done and you can do that in the office and then you’ll break it up and do the flanks, you know. So it’s a matter of how much you’re doing at one time. And it’s the same with general anesthesia, you know. If you have a patient on the table for 8, 10, 12 hours, you know, that’s adding risk, you know, risk with anesthesia, with DVTs, PEs, all those things. So, you know, it’s just being safe, you know, not being a cowboy about it because, you know, we’re doing elective surgeries and we can’t have any complications, honestly.

Dr. Osborne: That’s right.

Dr. Osborne: It’s a lot of pressure. You know, I love the whole neck lipo J-Plasma under local because in this day and age of Instagram, Facebook, Zoom, webinars, I mean, you know, I feel like we’re not on a webinar or YouTube, you know, “Plastic Surgeon Untold,” Austin Plastic Surgeon, you know, podcast, any of those are great places to see yourself, but, you know, if you’re looking for something. But it’s interesting because we’re our own worst critics and it’s interesting if you don’t have to go the surgery center, if you don’t have to get a clearance because, tell me, if you’re doing it under local, do you still make them get a cardiac clearance, a clearance from their PCP, those type of things, or not necessarily?

Dr. Levesque: Really not. And the way I see it is this, you know, we’re not giving them an induction agent, which really drops their blood pressure, which can stress the heart and cause issues. So, you know, really, we monitor their blood pressure, you know, we’re talking with them the entire time, and we’ve got pulse oximetry. So, you know, if they get a little deep, we just say, “Hey, how are you doing?” And if we’re getting too deep, then you have ways in which you can augment their airway, or reverse the meds so that you can get them back into safe place. So it’s really about paying attention and just all hands on deck when we’re doing it, you know. With general anesthesia, your celebrity is taking care of that. So it’s just one more thing that, you know, you’re paying attention to with a dedicated person on your team. In the office, you’re still doing that, but the medications we’re giving are nowhere near as strong. So I don’t stress about it. I still do, you know, worry about some of the medications, you know, the blood thinners, things like that. You don’t want to have any bleeding. But it’s definitely a different level of anesthetic where I don’t worry about stressing the heart.

Dr.Franco:: Celebrity anesthesia and I have talked on multiple episodes here about like the whole ERAS protocol, getting people started on Celebrex, Gabapentin, some of these other things ahead of time. You know, I’d like to get you and celebrity’s opinion on that. Is that something that you still do with the local cases in the office or not, you haven’t found that as necessary?

Dr. Levesque: I have. I still do that for the larger procedures that we’re doing. So, you know, I do facelifts as well in my office under the same circumstances. So for those patients, I’ll definitely have them with the Tylenol, Gabapentin, Celebrex. Celebrex, I will sometimes hold off on the open neck procedures that we do just for a fear of increasing bleeding risk. But I think that’s all important, especially if it’s given beforehand as it’s supposed to be done. Then, before I’m even injecting, the patient’s already in a very comfortable place. It’s all about, you know, not having a painful stimulus where the brain will sense that something’s off. So, you know, if you can get to that place where they’re numb, they’re just going to have so much better experience and the blood pressure is not going to go up, which means you’re not gonna have as much bleeding, less bruising, easier recovery.

Dr. Osborne: And when you’re given meds, you know, correct me if I’m wrong, but your main goal for those procedures is anxiolysis…

Dr. Levesque: Correct.

Dr. Osborne: …or decreasing this patient’s anxiety because that local anesthetic is theoretically taking care of, like you alluded to, the blocking those pain pathways. So that brain is not even understanding that you’re cutting on the face, or cutting on the neck, or anything like that because those signals aren’t being transmitted. But if you need to give them anything, you can give them a Benzodiazepine or something at a lower dose so that they are comfortable and you’ve decreased their anxiety.

Dr. Levesque: That’s right. Absolutely. That’s the biggest medication that we’re giving is the anxiolytics, the short acting Benzodiazepines, be specific. And that’ll just get patients in a comfortable, compliant, you know, place so that you can go ahead and get them numb. And once they’re numb…you know, we’ve had patients wanting to watch the procedure and things and say, “Hey, can I film that?” or, “Can you film it and let me watch?” And I’m like, “No. I don’t want to be distracted with that. So no.” But, yeah, technically, they could totally do that. And I’ve done other procedures, you know, just hand surgery where people are literally watching me put their tendons together. So, it’s certainly, you know, impressive when the medications are given what we can do. You know, I can’t imagine the times before we had these medications. I mean, imagine Civil War times, like, this is crazy.

Dr. Osborne: Half a bottle of bourbon and bow it, you’re sawing somebody’s leg off.

Dr.Franco:: But tell me, you can still do a lot of the things that we do under general anesthesia because you still do some small fat transfer, like you’re doing fat transfer with your facelift, or to the lips, or something like that?

Dr. Levesque: Oh, yeah.

Dr.Franco:: You could still use, like, the PALs, the power-assisted lipo if you wanted to and so forth, correct?

Dr. Levesque: Absolutely, you know, pretty much. Things I think you can’t do effectively in that situation are your tummy tucks, or your deep muscle work, breast implants, under the muscle. That’s just gonna be a little bit too nauseous. And trying to get the patient numb at that level is incredibly difficult.

Dr.Franco:: I feel like the gauntlets been thrown down. Come on, celebrity anesthesia, you know, challenge accepted. We’ll see.

Dr. Osborne: Let’s do it.

Dr. Levesque: Let’s do some blocks, you know, the decent implants.

Dr. Osborne: I’m on my way.

Dr.Franco:: I mean, if I just listened to this, I feel like, you know, we’re gonna have to help celebrity anesthesia write his indie profile, you know, what other skills do you have, celebrity, that you could do? I mean, you’re a photographer, you’re a limo driver. I mean, there’s…

Dr. Osborne: That’s right. I’m my wife’s manager, all that good stuff. She manages my account now, so it’s great. It’s great. You can find her at @trendytherapist. There it is. There it was, plug number 3,860.

Dr.Franco:: How have you found the recovery has been for your patients? Without the anesthesia, do you feel like they get going and get back up a little bit? I guess it’s twofold. I guess the procedures tend to be a little bit smaller, which is helpful for them, but also not some of the anesthesia effects.

Dr. Levesque: Yeah, definitely. You know, with a general anesthetic, there’s a sense of a fatigue. I’ve personally experienced that with my own surgeries. But, you know, you get a little fatigue, a little bit off.

Dr.Franco:: His calves are on point, for those of you who are wondering. You look good.

Dr. Levesque: Yeah. So, you know, I’m really, you know… So, absolutely, the patients recover fast. I mean, honestly, if they didn’t have Benzodiazepine, they could literally drive themselves home, which we don’t let them do that, of course. So they can go home, and after the Benzos are off, they feel great and the bruising is minimal. So the nausea is also a big deal. So, you know, patients are not having nausea like they would in patients that just are prone to that from a general anaesthetic. So all good things. You know, I feel like I’m just bashing anesthesia. That’s not the case.

Dr. Osborne: Oh man, more chest pain.

Dr. Levesque: Yeah. So I mean, you’ll see me there just as much as I can. So it’s not I don’t not do general anesthesia, but, you know, I think for the right patient. It’s a powerful tool to kind of get you the results that, you know, patients are looking for. And there’s definitely a fear just of many patients of going to sleep. I’m sure you’ve come across that too is, you know, people are just scared of anesthesia.

Dr. Osborne: Half of my job is talking to people in the pre-op area, you know, doing some education and talking to them about the real risks and what is associated with general anesthesia, “The fact that I am there the entire time, I am not doing anything else, I don’t just put you to sleep and then walk out for the, you know, six-hour case and come back and you wake up. That’s not how it works. I’m there for the entire time holding Franco’s hands.” So it’s…

Dr.Franco:: I need a lot of help, a lot of help here in these procedures. G-Berto used to be part of these procedures. And he said that his back got hurt, you know, from helping me the entire time, so.

Dr. Saenz: It’s more about me carrying you, John.

Dr.Franco:: And then you alluded to a little bit, Andre, before. So, you know, lipo is definitely a big one and kind of the focus of today of, you know, things that we can and can’t do at the surgery center. But you do a lot of other cosmetic procedures there and stuff like you do some upper eyelids and things like that as well.

Dr. Levesque: We keep expanding that, honestly, because of our experience, you know. The patients have done so well and we’re more comfortable doing it. So, you know, I started doing my facelifts probably about two years ago, when I started the practice. And I haven’t done facelift under general anaesthetic, Sorry, Travis, in that time. so it’s been in the office. And the reason you can do that is, you know, on the face, there’s specific nerves that can be blocked very easily and very predictable areas. So that’s a very easy thing to do. You know, I think you got to have the patience to kind of learn the technique and also understand that you’re going to be speaking to the patient. There’s plenty of surgeons that, you know, prefer not to speak to the patient while they’re working, and that’s fine. So there’s nothing wrong with that, so.

Dr.Franco:: And PAs they prefer not to [inaudible 00:28:09.923].

Dr. Levesque: But yeah, facelifts, we do our upper eyelids, lower eyelids, you know. Those are the big things. We’ve done arm lifts in the office, liposuction, all sorts of things and just looking to expand that, not go to the surgery center, but just to give more options to patients.

Dr. Osborne: And I think, you know, every anesthesia professional that’s listening to this podcast is just cringing when I’m going to say this, but I actually agree with you. I think that at the end of the day, it is all about what’s best for the patient. And if it’s better for that patient’s budget, if it makes that patient more comfortable to have a small area worked on at a time instead of doing five liters of lipo under general anesthesia, maybe that is the best tool for them, and maybe that is the best, you know, path of treatment for those patients. So, I totally agree with you, man. I think if you have them comfortable, which you always do in your office, and you’ve got a good protocol, and you’re following all those safety measures like you all do, I’d say hats off to you. That’s awesome.

Dr.Franco:: And I think this is where it goes back to the initial consultation. And we’ve talked about this on so many topics here in terms of, you know, what are the patient’s goals, you know. If they’re thinking that you’re going to get five, six liters of lipo, you know, that this isn’t the case. If they come and say, “Hey, it’s just this little bulge here that drives me crazy, you know,” then you’re like, “Oh, this is a great candidate for some stuff like this.” And so I think trying to find a good, happy spot and this is where, you know, you’d be like I do, where, you know, we have people come in and just talk about, “What are you hoping to achieve?” and so we can be on the same page about what’s real, what’s not. And maybe for them, they’d rather come in three separate times to lipo different areas and then do it little by little. And if that’s what’s best for their life, then great, then that’s probably a good place, you know. You know, we get the other trim sometimes where people want to do 42 procedures in one day. We have to be like, “That’s it. No more procedures. No more add ons. No more one more thing. Nothing and nothing. We’re at the limit.” And it’s our job to help guide people and keep them safe one way or the other.

Dr. Levesque: Yeah, absolutely. Absolutely.

Dr.Franco:: G-Berto, I think I throw you off a little bit about your anything bet. But I’m just trying to see if you’re still with us, and what’s going on, and just catch us up here. I even took a little Instagram picture of you right now to post it.

Dr. Saenz: Oh yeah?

Dr.Franco:: Yeah, just this awkward moment of silence. What’s going on? Some thoughts?

Dr. Saenz: No. This is all really interesting. I’m curious, like, you know, you mentioned submental fat liposuction and skin tightening. You know, could the same be done for other areas that are trouble spots like…I know I get some patients come in that ask, “You know, what can you do for this little pocket of fat where my bras at that kind of collects?” I mean I would imagine that’s something that could be done in the office as well would you say, Dr. Levesque?

Dr. Levesque: Yeah, sure. I mean, if you can think of an area that Kybella markets do, you could do the same thing. So, I mean, it’s definitely the upper outer part of the breast, you know, you got the lower portion of the buttock, banana roll areas. The smaller areas are just easy to do. And you can use even smaller cannulas than we’re using in the surgery centers so the scars are really a non-issue. So it’s definitely just, you know, getting the word out that, “Hey, these are areas that can be treated Kybella. It could be treated with liposuction. This is really just how you want to get there.”

Dr.Franco:: Are you guys Kybella fans? Not to put you on the spot here, Andre, and then we’ll come to you G-Berto.

Dr. Levesque: Oh, go ahead.

Dr.Franco:: Anyone want to take a bet on this? It’s fine. Don’t upset Al again.

Dr. Saenz: Well, for me, it’s the only option I have, you know. I’m not trained in liposuction, so that’s the only option I have. I think it does an okay job. It’s clearly not as good as, you know, having a full liposuction procedure. But, you know, for those patients that maybe are a little surgery averse and want to just give it a try, I think they do… You know, it’s for a specific patient, I think. But I do see some improvement.

Dr.Franco:: Andre?

Dr. Levesque: I mean, for me, personally, I’m going to lean more toward liposuction just because I know I can get faster results with pretty minimal downtime. I consider it to be pretty close because, you know, Kybella does create a pretty substantial response in a lot of patients. That’s my preference. That’s not to say I haven’t done Kybella, it’s just I do liposuction.

Dr.Franco:: I mean, I get some people that they want it, they just don’t want a procedure, and I get that and that’s fine I think. With Kybella, just really being upfront with people about how much volume it actually takes. It takes, I think, more product than most people think.

Dr. Levesque: In a few sessions.

Dr.Franco:: In a few sessions, agree, spaced over time.

Dr. Levesque: Over months.

Dr.Franco:: And so, I think, you know, if you’re looking for a quick fix overnight, you know, it’s not a magic bullet. So, it’s just trying to be real with people about that.

Dr. Saenz: I probably refer more patients to Dr.Franco: for localized liposuction, than I do Kybella to be quite honest. I mean, I’ll do it, but like I said, it has to be a specific patient type.

Dr.Franco:: It’s like everything. You know, it’s figuring out what their goals are, what they’re trying to get to, trying to be up front about budgets. And I think it’s something that everybody else wants to skirt around and not talk about. But I mean, there’s always some cost involved, you know. And for those of you that know celebrity anesthesia, he’s not cheap. He’s not. And so, you know, this could be cost saving for people…

Dr. Saenz: Like Johnny Manziel.

Dr.Franco:: … along with the convenience. I’m sorry, G-Berto?

Dr. Saenz: Oh, no…

Dr. Osborne: I did my Johnny Manziel shot. In the spirit of football season. We’re finally back.

Dr.Franco:: What other big kind of points would you say in terms of if people are trying to consider whether to do something, you know, liposuction under local anesthesia because even here in Austin, there’s several practices that do a lot of liposuction under anesthesia, some that don’t. I’ll give you my two cents, and I’d love to hear what your thoughts are. I think it’s just all about what your goals are and being very realistic about that, you know. And I think, unfortunately, from a downside, I see people who got BBLs under local, and they tend to just feel disappointed that they didn’t get enough fat out, they didn’t get enough fat transferred in. And I really don’t think the surgeon did a bad job. I think there wasn’t a clear, you know, course of action between them in terms of, “Hey, look, here’s really kind of the limit of what we can lipo for you under local anesthesia and what we can transfer.” And I think that that’s somehow it just got lost in the communication and it wasn’t like that they didn’t do a good job, if that makes sense.

Dr. Levesque: I’ve certainly seen that as well. And I think today’s age with Instagram and, you know, favorable positioning of photos, the demands for…

Dr.Franco:: That’s a very kind way to say that.

Dr. Levesque: The demands for our results just get, you know, tougher and tougher. And so, you know, I think if you’re going to be aggressive, I think you got to have general anaesthetic. At least, that’s been my personal experience as well, you know. If you’re really looking for that snatched waist, you know, and Instagram famous, you know, you’re probably going to get a more aggressive result if you’re asleep. And so, that’s how I kind of approach it, you know. It’s what’s the specific anatomic part, you know, am I going to be aggressive enough, and how’s the patient gonna handle that? So, you know, you certainly don’t want to be in a situation where you’re just not able to deliver the result that the patient wants because of the anesthetic that you’ve chosen. So, I do feel that that’s the biggest part of it is really just kind of picking and choosing, you know, what the results are going to be and what the expectations are. But that’s just plastic surgery in general.

Dr.Franco:: And social media has made it…you know, I’m a big fan of it, obviously, and any of you that follow celebrity have seen that he’s become a big fan of it over the last two weeks. And so, it’s been pretty amazing how it’s been able to take the black box out of plastic surgery. But on the flip side, you know, a friend of mine in LA does this fake versus reality because it’s just amazing how many pictures are photoshopped, angles, airbrushed, and don’t realize, like, you know, trying to help patients be like, “Hey, that’s not real. That’s not doable.” I mean, there’s so many times people bring pictures and I’m like, “I can’t do that.” And they’re like, “What do you mean?” I was like, “I just can’t.” You know, I don’t really know what else to say other than I can’t.

One of my all-time favorite is somebody brought in a picture of something who’d had a BBL. And this was done outside of Austin. So it wasn’t one of the incredible plastic surgeons here in town. But someone who had Photoshop their pictures didn’t realize that they had striped walls behind the patient. So when they edited the picture to make their waist smaller and their butt bigger, the striped walls were curved too, which was absolutely phenomenal on the before and after. And it’s just kind of like, “Oh, okay. That does not help in the world.”

Dr. Osborne: I didn’t realize how far down the rabbit hole we’d gone in these filters and everything until me and Mary were in the car the other day, and she’s doing an Instagram story, @yourtrendytherapist. And she turns it over to me, and I look over her at a red light and I am the tannest I’ve ever been in this photo. I’m just like, “How did I get that tan?” “Oh, it’s my favorite filter.”

Dr.Franco:: Wait, you’re crushing my world. Mary does a filter?

Dr. Osborne: Only for tan.

Dr.Franco:: What?

Dr. Osborne: Only for tan, not for snatch twit.

Dr.Franco:: Right now, my world has been shaken. I thought Your Trendy Therapist was just like that.

Dr. Osborne: Just naturally sunkissed all the time.

Dr.Franco:: You just gave away all of our free secrets.

Dr. Osborne: I know.

Dr. Saenz: I’d rather you guys do use a filter than actually try and get tanned, from a dermatology perspective.

Dr. Osborne: That’s for you, man. We’re doing it for you.

Dr. Saenz: Thank you. I appreciate it.

Dr. Levesque: Hashtag no filter. It’s one of your movement.

Dr.Franco:: What other take-homes would you like for us to take home for people out there listening and trying to decide, you know, how they want to go about their liposuction, or J-Plasma Renuvion treatment? You know, what are a few key points or questions you would have them ask their physician or to think about when they’re trying to decide, whether this is something they want done under local, under general? And at some point, I think you have to find a physician you trust and kind of go with them because having somebody do something they don’t do on a regular basis is probably not a great idea either, maybe if you can touch on all those things.

Dr. Levesque: So I mean, I think, number one, you know, you got to make sure that, you know, the surgeon you’re going to is board certified in what they’re professing to do. And so, you know, there’s a lot of different providers that are capable of doing cosmetic surgery, but there’s certainly some providers that are maybe not entirely honest about their credentials. And so, you start there, do your research. The good place to find it is just the Board of Medical Specialties and see what kind of certification they possess. And then really, it’s about, you know, what the experience is with the consultation, you know, are you comfortable with that surgeon, are they going to take care of you if there’s a complication? You know, I think that’s number one is really just a feel. You know, if you feel comfortable, everybody knows what it feels like to be sold to. And so, I think that’s one of the things where you got to just kind of, you know, make sure that the alarms aren’t going off. And don’t worry about the price or anything. That can all be looked at later. It’s really about the comfort and is the surgeon really going to be able to deliver the results I’m looking for and safely because, you know, you do elective surgery, this sort of stuff is not cheap, and it gets more expensive if there’s complications to try to correct that. So, you know, looking at what their results are, what the reviews are, all that goes into the research. And then, certainly if somebody is telling you that they expect that, you know, I can achieve these results in a general anesthetic and you’re pushing him to go do it under local, maybe that’s not going to be a good fit because, you know, we’re all going to suggest what we feel most comfortable doing. And so, you don’t want to put somebody in a position that they’re not comfortable, certainly when they’ve got a scalpel in their hand. So, you know, I think there’s plenty of providers that can do it, you know, under local anesthesia. I also like to see the providers that can do it under general anesthesia as well, rather than the folks that only can do it under local anesthesia because maybe they don’t have privileges in a surgery center. But that’s another topic.

Dr.Franco:: If the only tool in your toolkit is a hammer, you’re gonna get a hammer, you know. And so, it’s nice to be able to see some other options and get some perspectives and so forth, you know. And so, interesting in terms of that. So I think the point about, you know, making sure people are credential, whether you’re doing this under anesthesia or locals is super important, very, very important. Celebrity, any take-home points from you?

Dr. Osborne: I mean, not more than, you know, what we already kind of touched on, just make sure that if you are going to a place to have stuff done under local anesthesia, a local, at most times, does not mean that you’re just getting one injection of Lidocaine. That means that you are also going to get either some version of conscious sedation, or you’re going to take some oral sedation. So just because it says local anesthetic doesn’t mean that you won’t have some type of sedation or anxiolysis. The other thing I would say, just make sure if you go to a place, if you are going to go somewhere where local is performed, where Dr. Levesque talked about, his office has a plan for emergencies. They have a crash car, they have, you know, admitting privileges to hospital. So, you know, just go to a place that you vet and that you feel comfortable with.

Dr.Franco:: And I think both you and Dr. Levesque brought this up that, you know, just because it’s called it local doesn’t mean that it can be benign completely. And so, there’s a healthy limit and we all know, you know, here’s the limits of Lidocaine based on your height, and weight, and BMI, and those type of things because there’s specific milligrams per kilogram that people can get and depends whether you do Epi and depends whether you do Temesa, beyond the scope of this. But those are things that we calculate ahead of time to know where we can get to, and that’s why he has some general rules about what he does and doesn’t do is for those. And we adjust those.

Dr. Levesque: Yep. And to add to that, there’s also at least in Texas, I know there’s a certification that you have to sign up to be doing this legally, which is office-based anaesthesia, and there’s different level categories. So, when you’re doing oral sedation, you know, that’s a level two, if you’re adding IV sedation, you know, level three, general anesthesia level four, and those all have different requirements. You know, you need to have an AAD, you need to have somebody trained in ACLs, you know, rescue drugs. So, you know, those are all things that, you know, certainly you could ask that at the time of consultation, and if somebody gives you a straight answer, and says, “Yeah, you want to see my crash cart? It’s right here.” And you know, if somebody is dodging that question, then maybe that’s a sign that, you know, hey, look somewhere else. So, you know, those are all things that are a little bit uncomfortable, you know, asking somebody what their credentials are, but I think it’s totally legitimate.

Dr.Franco:: I mean, like you and I don’t mind. If somebody asked us if we’re board certified in plastic surgery, I mean, that doesn’t offend me…

Dr. Levesque: No.

Dr.Franco:: …at all. I’m sure it doesn’t offend you either.

Dr. Levesque: Absolutely not. I think that’s only smart for prospective patients to really be, you know, checking.

Dr.Franco:: G-Berto, anything to add or questions that you might have might have thought of here?

Dr. Saenz: No. I just feel like I learned a lot about in-office procedures. I do some in-office procedures, but it’s nothing like what you guys do. I’m usually excising moles or I’m excising skin cancers, cysts, like benign stuff, and that’s done under local anesthetic. But this is on a totally different level. And it’s really interesting to see what you guys can do.

Dr.Franco:: But you do some of the same too because there’s a limit to how many benign or how many excisions you’ll do in one setting because, again, it goes to the limit of, you know, how much local you can use, how much people tolerate beans, you know, Lansedil [SP] for a certain amount of time. And so, you guys have protocols in your office too, though?

Dr. Saenz: Absolutely. Yeah. I mean, personally, I try to limit procedures to maybe one excision at a time, even if a patient has multiple skin cancers that need to be removed. I may schedule them to do it, you know, couple weeks apart from each other, when we’re doing suture removals for, you know, one previous procedure, we’ll do the next excision for the next skin cancer, and so on and so on.

Dr.Franco:: I think this has been super interesting because I think it affects people in their daily lives among lots of things, whether it’s getting a skin cancer removed, whether it’s a little neck lipo, whether it’s, you know, a facelift, so definitely more stuff to come. And, Andre, hopefully, you’ll come back and talk about some more, either facelift or eyes under local. That would be another great topic for us.

Dr. Levesque: Always happy. No, it’s a pleasure.

Dr.Franco:: But before we wrap up today, we got a few quality sections here. So we’ll do a little fact or fiction. Andre, we’ll start easy, fact or fiction, we were med school buddies together.

Dr. Levesque: That’s right, fact.

Dr.Franco:: A fact or fiction because I feel like I remember this that we ended up rooming together on the interview trail during med school and ordering Imo’s Pizza in St. Louis when we got into midnight for our interviews the next day because we were delayed 16 times.

Dr. Levesque: That one I don’t know. I think I’m gonna fiction that one. I got one for you, which may date us but, what years were we at medical school together?

Dr.Franco:: Oh, we were there in ’05…2002 to 2006.

Dr. Levesque: Yeah, it’s been that long. Wow.

Dr.Franco:: Damn. Damn. It’s been a little while. Well, we do a section that we like to do called Behind the Bovie. Can you tell people what’s one thing that nobody kind of realizes or sees about office-based procedures that’s kind of a cool little nugget that they would never know but you’re like, “Damn, this is kind of interesting.”

Dr. Levesque: You put me on the spot here, but you know, I think the cool thing is…honestly, the coolest thing I think is doing say like a facelift. Yeah, totally. One medication with some Xanax and local, and having the patient talking to you while you’re doing it. That was probably the coolest thing that I’ve incorporated in my practice in the last couple of years. And honestly, it was from my experience in Birmingham, and I got to train and work with some awesome faculty there as my mentors. And Louis Vasquenez [SP] was taking this in Birmingham, as well as many other impressive things. And they’re not the only one. You know, Mustoe over in Northwestern, a lot of people have done aggressive plastic surgery under local one. So, you know, I think you get out and you’re a little tentative at first, and as you do more and more, you get a little bit more comfortable. And the first patient I offered it on actually was a patient that had a facelift already and said, “You know what, I want another facelift, and I’m totally fine with you doing under local anesthesia.” So it’s really that patient who was like, “Go right ahead. Worst case scenario, you can’t do it, then we’ll go to the surgery center.” And so after that, it’s been no looking back.

Dr.Franco:: If I can do his revision facelift, that’d be good.

Dr. Levesque: And the variations of the facelift techniques over the last few years has also gotten to a more deeper plane, which I thought was really very difficult to do actually. It’s a little bit easier because of the plains of the face. So that part’s pretty cool. So I’ll probably do a little video so I’ll be happy to have folks take a look at that but coming up, actually in two weeks, so.

Dr.Franco:: Awesome. That’d be exciting. And the for anyone who listened to Episode 26, there may or may not have been a belly flop on the quote of the day. So I don’t know if G-Berto is going to redeem himself or if he’s lost privileges and Celebrity has taken over. PS on that.G-Berto had to do it because Celebrity forgot.

Dr. Osborne: Oh, come on. Come on.

Dr. Saenz: I can try to redeem myself. I think I got a good one.

Dr. Osborne: That was building confidence.

Dr.Franco:: Is it in anything one or we’re going with that?

Dr. Saenz: It’s certainly much better than the last one. I’d tell you that much. It’s much more comprehensible.

Dr.Franco:: Okay, let’s hear it. Let’s go.

Dr. Saenz: All right. So I don’t know if you guys know who Lee Jun-fan is. He’s also known as Bruce Lee. But Bruce Lee once said, “A wise man can learn more from a foolish question than a fool can learn from a wise answer.” Really?

Dr.Franco:: No. I mean, I just…

Dr. Osborne: That was the thing?

Dr.Franco:: Can we just go back to how can the sky be the limit when there’s footprints on them?

Dr. Osborne: There we go.

Dr. Saenz: That was my golden nugget. That was like my little fixing the hole.

Dr.Franco:: I feel like you came strong too fast.

Dr. Osborne: I have one that is in the spirit of first NFL Sunday of the year, Lou Holtz said, “Virtually nothing is impossible in this world if you just put your mind to it and maintain a positive attitude.”

Dr.Franco:: Oh, that’s what I’m talking about. That’s what I’m talking about, G-Berto, just like that, just like that.

Dr. Osborne: Sorry, man.

Dr.Franco:: Well, Dr. Levesque, thanks for coming on. I appreciate it. I think this was super, super helpful because I think people have thoughts about this. I know we get questions about it all the time. So it was kind of nice to dive in a little bit deeper. Celebrity cast, I appreciate it as always for you guys taking a little time of your weekend to educate the world. So thank you. Feel free to download us on iTunes or wherever you get your favorite podcast. You can also find us on YouTube. So check us out, The Plastic Surgery Untold or under Austin Plastic Surgeon. So, Andre, tell us your website and your Instagram handle just for people listening.

Dr. Levesque: It’s just @drlevesque, you have no way of knowing how to spell that, but certainly it’s L-E-V-E-S-Q-U-E, and it’s like levesqueplasticsurgery.com.

Dr.Franco:: Oh, there it is. Thank you, guys. The greatest podcast in the world as voted by us, “Plastic Surgery Untold.” Thanks. See you, guys.

Dr. Osborne: See you.

Dr. Saenz: Thanks.

About The Author

Dr. Johnny Franco
Episode 26: Who Doesn’t Want More Hair???Episode 28: Injectable Treatments You Have Never Heard of, But Should Have!


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