Episode 37: Body Contouring in Massive Weight Loss Patient

Dr. Franco: Welcome back to Plastic Surgery Untold. I’m Dr. Johnny Franco, also known as @austinplasticsurgeon. And today’s episode is all about body contouring after massive weight loss. So we’re gonna jump into that with our special guest, Dr. Bharti in just a minute, who’s coming to us all the way from Charlotte, North Carolina. So appreciate you taking out time to join us today. But before we jump into him and all his specialties, we got our celebrity crew again. Producer Donald somehow wiggled his way into a seat since we’re doing our first tele one and probably a couple months here. So, Donald what’s going on with you? Anything new and exciting?

Donald: Oh, man, you know, I’ve been busy. Still doing the video game stuff, went over and spent some time over at Dr. G’s office, doing some dermatology work. So, you know, going through that, feeling the pain.

Dr. Franco: Oh, so you saw Austin’s most beautiful man, got a little dermatology work, and then went on a big date. So boom, boom, boom, G-Berto’s making the magic happen. That’s interesting. Damn.

G-Berto: I’m making Austin more beautiful. Just one patient at a time, John.

Dr. Franco: Women of Austin appreciate it. G-Berto, what’s going on with you?

G-Berto: You know, just getting excited for the holidays, and getting to spend some time with my family and stuff. So, just kind of winding up the Christmas shopping and kind of knocking out names off that Christmas gift list.

Dr. Franco: Yeah, we got a gift from you last week, so, appreciate it. Thank you very much.

G-Berto: Yeah, Yeah, thank you.

Dr. Franco: Celebrity, what’s going on with you? First holiday in the new house.

Travis: First holiday in the new crib, man. Just getting everything decorated, getting everything looking nice. My wife is all over it, @yourtrendytherapist. Follow her for all of your trendy…yeah, I had to… I only plugged her once last time, so I’ve gotta do better this time. I got grief for it after the last podcast.

Dr. Franco: You guys got that little stocking above the fireplace, or what’s going on?

Travis: No fireplace at the new house, except for outdoor fireplace. We got a little outdoor fire pit. You and Winston have to come by and christen the new place.

Dr. Franco: We’ll do it. We’ll do it for sure.

G-Berto: Winston likes to christen place a lot.

Travis: Oh, I heard. I heard.

Dr. Franco: Oh, he does. Oh, he does. Don’t you worry. And then Dr. Bharti, tell us a little bit about you, and I really appreciate you taking the time to join us across the country to be on our podcast. So I really feel like we’re coast to coast now. But tell me a little bit about your practice and yourself.

Dr. Bharti: Yeah, so my name is Gaurav Bharti. I’m in Charlotte, North Carolina. And I’m in practice with two other guys, Bill Kortesis and Joe Hunstad, so three of us, and we have a practice here and a practice in Huntersville, which is about 15 miles outside. And, you know, we’re busy, we’re operating a lot, taking care of a lot of great patients, and we have a unique setup in that we all practice a tremendous amount of body contouring, facial surgery, rhinoplasty, kind of really diverse practice. And it’s been an interesting time. You know, I’ve been busy with that and I got a family, I got four kids at home, all girls, so I got a house full of women and, you know…I tell you.

Dr. Franco: But you’re being way too modest, because you’re also associated with the medical school, do a lot of teaching. And then we actually initially met because we’re both on the RealSelf advisory board. So you’re on a bunch of advisory boards as well.

Dr. Bharti: Yeah, you know, Johnny, you and I met at RealSelf, and we share a lot of the same kind of concepts of… I think you’re like me, and you’re like my business partner, Bill and Joe, where we’re just not satisfied with status quo. We’re always trying to learn more, we’re always trying to push the limit, we’re trying to get better outcomes for our patients, and we’re trying to reach patients in unique ways. And so we definitely… I try to practice that every day. And we have a fellowship program at our practice where we train two other plastic surgeons every year, before they start a cosmetic practice. And, you know, it’s interesting. With those kind of tools at my side, I actually get better.

So, you know, you think that I’m the one teaching the fellows, but actually, they’re the ones kind of passively teaching me also, because everything I do has to be checked. Why am I doing this? Why do you do this? Why do you select this for this patient? What do you do if this patient has that? And, you know, we all do that. But it’s great to have that in the practice. So that’s something pretty unique that we have here. And, you know, life is good. Life’s crazy right now. You know, we’re still very busy. We’re being really careful in the office and such, and I’m just trying to be busy at work. When I come home, it’s like 10 times busier with the kids running around, going buck wild. I don’t know if you all have kids, but they change the game just a little bit.

Donald: They do.

Dr. Franco: Well, it’s interesting because the, how the world has changed. I mean, if you went back 30 years ago and said, “Hey, you’re gonna have an aesthetic fellowship, to learn how to do tummy tucks, facelift stuff,” I feel like people would have said that that was crazy talk because you gotta, you know, pay your dues, doing the ER, doing the other stuff, and not saying that, you know, those of us didn’t do ER call and do stuff like that, but it just shows how I think patient expectations, and you mentioned it, the concern for a patient to have the best possible outcome, that bar keeps getting elevated. And part of that elevation is making sure that when people come out, day one, that they know how to do these surgeries at a very, very high level. Because this fellowship is after somebody has done five, six or seven years of plastic surgery residency, correct?

Dr. Bharti: Right. Totally, man. And, you know, that’s the thing is that, I think that, you know, when you finish, and you take care of your first patient, you don’t want to just get on base, you want to round third and score and get home. And I think that’s what these fellowships allow people to do. And, you know, I’m sure you think the same way. The aesthetic space in the United States is just beginning. It’s in its infancy. What I mean by that is, the actual penetration into the public arena of actual people undergoing procedures is astronomically growing, and COVID has definitely accelerated that.

People, for the first time, I think, are absolutely more interested in taking care of themselves, in improving their overall well-being, investing in themselves. So I think this is going to be kind of the thing that is at that perfect kind of storm, perfect synergy, to really grow the aesthetic space even further. So people are going to be able to start practice now and just do aesthetic practice, and not have to do as much ER call, not as much reconstruction if they don’t want to, because the demand is here, and I don’t think it’s going to go away. I don’t know what your all’s opinion is. I do not think that we are going to have, even with economic concerns and hardships, the desire to, like, be your personal best, that’s here to stay. And I think that it’s going to get stronger and stronger.

Dr. Franco: And don’t you think that, you know, because this is a two part question, but number one, overall, the idea that people become sub specialized into certain areas of plastic surgery has taken over. So the old days of kind of like doing general plastics, doing everything, and then, you know, kind of doing this and that has slowly gone by the wayside.

There’s some incredible hand surgeons, there’s some incredible craniofacials, you know, that can put a face together and all the broken bones, and just, now that has become true for aesthetics plastics. And I think the consumer demand wants somebody who does, you know, 200 BBL’s a year, that does 200 tummy tucks a year, because you’ve got a system. You’re very meticulous in all these things you do. Your office is very meticulous about the system of taking care of those patients.

Dr. Bharti: Yeah, I think so. And, you know, it’s a simple concept of higher volume typically will improve outcomes, shorten operative times, and lead to potentially better outcomes, because, you know, you’re doing something over and over and over again, you’re working on the process of how you do that specific thing, and then you’re adjusting it, right? I mean, that’s the biggest thing, is none of us practice stale aesthetic medicine, meaning you are using your cases and your outcomes and adjusting what you’re doing in the future, to continue to get even better outcomes. And that really is optimized when you’re doing a lot of something.

Dr. Franco: And it’s funny because the last thing, and we’ll get into the body contouring stuff, but just because you do a lot of stuff on Instagram and social media as well, do you mind giving them your handle while you’re on?

Dr. Bharti: Sure. Sure. It’s my name. It’s doctor, D-R, Gaurav Bharti, G-A-U-R-A-V, last name B-H-A-R-T-I, that’s the handle.

Dr. Franco: But don’t you think that social media in of itself has pushed physicians to be better? Because you basically have your work on display for the world? You know, and I think that it holds us that there’s… This black box of plastic surgery has gone away. And, you know, everything we do is open now, and for view.

Dr. Bharti: Oh, it’s insane, but it’s so great. You know, it’s like we’re getting more transparency. And I’m gonna tell you what, I mean, I don’t know about you all and your experience with social media, but I love it so much in the fact that, initially I had hesitation having accounts, and I didn’t have any until I started my practice. But what it has done for me is, I’m able to display, obviously, who I am, what I do, but also it is self-selected.

When the patients show up…and Johnny, I don’t know if you feel the same way or guys if you feel the same way in your practices…when they come, it’s like they’re almost self-selected and matched for you. Like, your personalities click and they are there to see you. And it’s awesome. It’s so powerful. And I think it’s been such a great change. And luckily, I know most of us here had robust profiles on social media, so when COVID hit, it didn’t change anything, rather, it accelerated it, where so many people really didn’t and they were forced to. It’s really a unique time, and I really, really, really like it, actually.

Dr. Franco: I couldn’t agree more, because you’ve already self-selected. You know, one, they see your work, they see your personality, they like that. And so when they come in, it’s a good two-way street in terms of that, because ultimately, we want patients to be happy. And if they’ve liked the majority of the work that you do, the chances that they’re going to be happy with their results are high. And so, you know, and ultimately, that’s what we want. We want people to be happy with what we do for them.

Dr. Bharti: Sure. Yeah, totally.

Donald: Also, some of the expectations that you have for your patients are already set, because they’ve watched so much of your social media and they’re like, “I know he’s gonna want me to do X, Y, and Z before I even go and see him. And I need to do A, B, and C after I go and see him.” So, many, many benefits.

Dr. Franco: No, no, I agree. And even, G-Berto does a lot of injectables, and I’ve seen him post a lot of stuff, because it’s nice for people to be realistic, like, “Hey, this person got two syringes of Voluma. This is what a realistic expectation is,” you know, with just a couple syringes of filler versus, you know, a facelift or something else.

G-Berto: Yeah, that’s an interesting conversation I have sometimes with patients is, you know, their expectations of what you can do with, you know, the tools that you have and what they see on social media. And so, yeah, it’s part of the consult, but it’s interesting to kind of see their eyes light up and like, “Oh, wow, I didn’t realize that it was gonna take that much, or you could do this with that,” you know.

Travis: I like the educational standpoint of social media. I mean, when, right there…

Dr. Franco: You’ve taken off your social media a little bit [inaudible 00:11:15]. We’ve seen celebrity anesthesia.

Travis: My shirt? Or the… Oh, social media.

Dr. Franco: Well, I think both of those.

Travis: Dude, I always say, nips get the follows.

Donald: It’s getting cold outside, though.

Dr. Franco: It’s funny, Dr. Bharti didn’t recognize you with the shirt on. He was like, “Oh, that’s who that is.” That makes sense.

Travis: Oh, that’s that guy. No, from an educational perspective, I think it’s great, because you can reach people, you can answer some of those questions that before the patient even comes to see you, before they’re logging in to set up an appointment for a pre-op or anything, they already have five or six questions that they would have for you answered already, when they’ve been watching you for two months or a month on social media, every day you’re in the OR, you’re talking about stuff, you’re going through educational things, about different procedures and what you do in each of those. I think it takes care of a ton of the back work.

Dr. Franco: Let’s jump into body contouring, because I derailed us a little bit. But Dr. Bharti, talk to us a little bit, you know, what’s unique about it and the challenges, because patients have typically gone through a lot with it, they went through a bariatric surgery, or just on their own through a diet, exercise, they’ve lost, you know, 100 pounds. What’s different about these patients than then someone who, you know, maybe just had two or three C-sections just coming in for, like, a mini tummy tuck or something like that? How do you approach them differently? And typically, it’s a process.

Dr. Bharti: Yep. You know, this concept of managing a patient after massive weight loss is definitely a little bit different than, you know, traditional mommy makeover, or someone who’s had multiple childbirths but hasn’t necessarily had massive, massive weight loss. When patients have a large, large volume weight loss, or cycles of massive weight gain and weight loss, it not only affects the traditional areas like their abdomen, or their breasts, but it affects their thighs, it affects their arms, it affects their upper back, their mid back, it affects their face.

So there’s this kind of global change that you see. And the hard thing for these patients, and we’ve all seen it, is that, not only have they, you know, lost all this weight, they have changed their lives, they’re off all their medications, the blood pressure’s normal, they’re not diabetic anymore. So they’re a different person. But they’re left with this veil of tremendous amount of excess skin and some excess fat. That is like the last step. And it’s like, “Oh, my God, they came all this way.” “I came all this way. And now I have all of this.” So it’s a huge deal, because this stuff causes functional issues, it causes issues with working out, with fitting in clothing.

And more importantly, it’s a confidence thing. It really is a difficult thing to deal with. So it’s a little different too because, you know, you had hit on two things. One is natural weight loss and the other is bariatric weight loss, meaning that they’ve had a surgical procedure that has led to their weight loss. And sometimes that can be a very precipitous, fast weight loss, and sometimes it can change how they actually metabolize and absorb nutrients, so that can affect how they heal. So all those things go into play, and, that can affect kind of what and how you do. But these patients are some of my favorite, I mean, my absolute favorite patients, because they are so happy with this process and closing the book and finishing it. And also, it’s just miraculous the actual results. I mean, we’ve all seen them, and every time, I don’t care how many times I do it, it’s still so satisfying, because it’s just, boom!

When you’re done with the procedure, when they come in afterwards, they’re smiling, they have confidence on their face, they’re wearing clothes that they couldn’t wear before, they’re working out. And so it’s incredible. And there are some parallels to the things like, to mommy makeovers that you do. But there are some significant differences because typically in these patients, you’re taking off a lot more tissue, a lot more actual skin. A lot of times, we have to stage the procedures, because there are a lot of places we want to work on. I mean, you know, Johnny, when you see these patients, you know, same thing, right? We can’t do it all together, right? I mean, what’s your operative time limit, typically, when you’re doing a big combination case?

Dr. Franco: Somewhere from that six to seven tends to be the ultimate cut-off, you know. And really, if we could stay under five, that’s ideal, but six, seven tends to be my ultimate. So we do split stuff up. And then we tend to be really aggressive in terms of DVT management for some of this. We send everybody home with compression devices, we start everybody on Eliquis the day after surgery. And so those are some things we’ve done, but no question, staging.

And, kind of, you know, one of the things I tell all of our patients who come in with this type of massive weight loss stuff, because you hit the nail on the head, I think people forget it affects your face, your neck, your arms, your thighs, is that, this is a process, you know, and so it’s going to take some time to get there. And I always tell people, you know, one, what bothers you the most? Because there’s certain things that go well, combining together, and certain things that don’t, and make it a little bit more difficult, but we want to incorporate into that, you know, what bothers them the most, because it’s one thing for me to say, “Oh, let’s do your tummy, let’s do your breast or whatever.” And then completely skip, “Well, my thighs are the thing that bother me the most,” you know. And so we want to be sensitive to those needs.

Dr. Bharti: Yeah, I completely agree, you know, you hit a great concept. We do a similar thing from a standpoint of amount of time, six and a half, seven hours max. We keep people overnight. We use Xarelto, so we start that the next day. So I think DVT prophylaxis is extremely important. And also, we gotta remember to walk these patients. They have to be ambulatory, they can’t be slugs.

Dr. Franco: The days of staying in bed for a week are gone. I mean, those are gone by the wayside.

Dr. Bharti: But you hit a good point about, you know… And this is all about patient care and understanding what your patients want. And that is, we have to listen to our patients, no matter what we’re doing, whether it be breast augs, whether it be tummy tucks, whether it be liposuction, or injectables, and make sure we actually understand what they want. Because what I’ve learned in my short little career so far is that building rapport with your patients and ensuring that you’re on the same page is the most important thing. You can tell them that, “Hey,” for this massive weight loss patient, “You need a body lift, it’s a cornerstone to all massive weight loss surgery,” right, Johnny? That’s what we’re taught.

And if they, all they gave a damn about was their thighs, and you ignore that, you’re gonna have an unhappy patient. And I think that that used to happen a lot in aesthetic surgery, but not anymore. The patients are smart, they’ve done their diligence, we need to listen, we educate them. We can redirect them and say, you know, “You really would benefit from the circumferential body lift first, because it could have an effect on your thighs. So maybe we don’t have to do as significant of a thigh lift on you. But if the thigh is what you’re most interested in, then, hey, let’s focus on those thighs.”

So I really applaud you on that, because that’s so important. And that has really helped me become a lot more successful. Same thing with injectables, I mean, it’s the same thing. If a patient comes in and their main concern, just for lack of better terms, is their lips, and you say, “You know, your cheeks are really hollow. You would really benefit from this.” And the truth is, they probably do need it there. You know, there’s nothing worse than when someone’s unhappy, you get a great result, but they didn’t want that result. So I think we’ve gotta do what our patients want.

Dr. Franco: And a lot of times, what I’ll do is, is we’ll list out all the things that really concern them, you know, like the legitimate major concerns from them. And then we’ll talk about what’s most important. And then we also, I tell them, but there’s also a little bit of give and take, because some procedures go better together than other in terms of just kind of mobility, depending on positioning, length of times, you can’t have two super long procedures done at the same time, and so, trying to figure out, like, what’s going to fit in that time period, and so that we can piece it together as well, because you also don’t want to sabotage them where, you know, you’re dragging this out over six different surgeries. And so if there’s a few that we can combine, based on time and kind of recovery, then trying to help guide them in that importance too. And I feel like that’s where, you know, we can educate them in the best way to get to that end path, but ultimately taking their concerns into consideration for sure.

Dr. Bharti: No, I agree with you. And it’s nice to be in a setting, you know, where we are… We’re luckily in a setting where we have our fellows who are plastic surgeons, who are assisting me, and we have first assists, which you have also. And we can take on these big cases. So we can get a lot done in six and a half hours. And we can then do another secondary and then hopefully get a lot of these done in just two stages, which is really great.

But no surgeon should ever be concerned about separating and breaking things apart. And I think that’s an important concept, because if you’re a single surgeon doing this and you don’t have help, and you try to do a circumferential body lift, and you’re doing arms and breasts or something like that, eventually, it’s just too much. And so, segmenting these is an important thing. It ensures better outcomes and lessens the risk of complications.

Dr. Franco: And it’s funny because on one of our previous episodes, we were talking about the business of plastic surgery and how you set up a good system in your office. You know, people like you that have a efficient OR that does a lot of these with your team, you know, a lot of that helps with that too, because the entire OR team knows the system, you know, runs really flawlessly. I don’t think people realize how much time you can cut down, that doesn’t affect patient care per se, other than shortening the time by being very efficient. So you’re not hurrying, but you’re being efficient in your moves in the operating room.

Dr. Bharti: Great concept. You know, it’s funny when patients, and you guys probably get this too is that, you know, when a patient says, “Are you doing…” I had one patient last week ask me, “So, when you do my case, are you doing any other surgery that day?” I’m like, “Oh, yeah, I’m doing lots of surgery that day” She’s like, “Well, are you going to be tired? How are you going to do it?” And I told her, I was like, “Number one, it’s an interesting thing when,” and I’m sure all of y’all feel this way, even when you’re tired. When you’re in your element, when you’re taking care of patients, it’s like everything is blinded to you and you’re in your zone.

But also, then I talked about this concept of efficiency and this concept of working in a very diligent, quick fashion, but that’s very methodical and calculated to where you can go fast when you need to, you go slow when you need to go slow. And so that’s that ability that, you know, we all have that we know when we can be a little bit more aggressive and move fast. Or when we’re turning over changing positions, we have the whole team all hands on deck boom, you know, you can do a big position change in a matter of a few minutes, where let’s say you’re doing it at the hospital. I mean, guys, you know how long it would take at the hospital to do a position change.

Travis: Might as well go get lunch, man.

Dr. Bharti: Right?

Dr. Franco: Here’s a question for you is, how long after they’re… So, someone who had a bariatric surgery, and after they have gotten to a stable weight, how long do you make them wait till they have their surgery?

Dr. Bharti: You know, my number is usually six months of stable weight, ideally, after something like that.

Dr. Franco: That’s what I do. I tell people, “You need some time for your body to kind of get right.” You know, when you’re losing that weight, your body thinks it’s starving. It’s just not in a good place. So I agree. And I feel like I get a lot of pushback, so I just wanted to make sure I wasn’t alone out there in making patients wait.

Travis: Especially when patients are losing, you know, 100-plus pounds. I mean, that’s a big weight swing, that’s a huge percentage of their total body weight. You need that to level off.

Donald: I was also going to ask, I wanted a follow up to Johnny’s question, like, what other, like, pre-surgery things should patients consider before going to see you? Like, other than the weight loss are there any kind of like special labs or things like that, that they need to have done?

Dr. Bharti: That’s a good question. I think that, you know, coming up with a consultation is never a bad thing. A lot of times, these patients who have had bariatric surgery need to be followed by their bariatric providers, and just to make sure that everything is okay. And the things that we look out for are nutritional deficiencies, potentially, and also anemia. You know, if some patients when they have specific bypass type of procedures, where their GI tract has been rerouted, that fundamentally can cause some issues with nutritional status, which means wound healing could be compromised, or they could become anemic. And obviously, when you do a surgical procedure, you typically lose a little bit of blood, so if they’re anemic at baseline, then that could be a problem.

So having stable labs and normal function is important. A lot of times, you obviously will get those checked, but you have to be careful for these actual bariatric patients even more so, that they are optimized. You know, the one thing about what we do from a plastic surgical standpoint is that, you know, all of us here are taking care of people who should be very well. These are all elective procedures. So the goal is really have these patients as tuned up as possible. And then we’re going to take them to the operating room and inflict this big trauma on them, then they need to heal. So it’s upon us and everyone to try to ensure that they’re as safe as possible and can endure the procedure that we’re going to put them through.

Dr. Franco: What would you say is the most common, like, maybe top three or four post-bariatric surgeries that you do? You mentioned circumferential body lift. What else are very common ones that you do?

Dr. Bharti: So, I’d say body lift, number one. And a lot of them have the fleur-de-lis component, which is a vertical incision in addition to a horizontal incision. And then, you know, one of the most popular ones now that’s gaining a lot more traction is kind of the posterior torso lift, i.e. the bra line back lift, because a lot of times, this is really interesting because…and you guys all probably know this, but I want to just illustrate it or describe it to the listeners and viewers. When you do a body lift, like for the abdomen, it’s always black and white, you know you gotta get rid of all that extra tissue. You can kind of grab it just like that, you know it’s gotta go.

Now, for the posterior part, meaning above the butt, in that lower back, if you grab that tissue, and you pull up, it pulls the buttock up, but it doesn’t do anything for the upper back rolls. And some of these patients have a tremendous amount of laxity there. So the bra line back lift, which is a lift in the bra line, where you grab all that tissue and lift it up, can be very powerful. And so, sometimes I’m doing that procedure, and a fleur-de-lis abdominoplasty together, because it’s basically taking care of the whole entire torso all around. And then the next most common would probably be brachioplasty or thighplasty. They’re very similar procedures, so dealing with that extremity. What’s your order? Is it similar to that?

Dr. Franco: It’s similar, and I think the bra line one is a super important concept, because, you know, I do a lot of butts in my practice, and I get so many patients that come in, that want to just liposuction that. And it becomes, you know, our job to educate them that that’s a skin issue and me liposuctioning that is going to have very little effect for them if they just have a huge amount of excess skin, you know, and they’re going to be disappointed.

I think the other thing that’s kind of interesting, because I think I get a little bit of a slanted view, just because I do so many butts in my practice is, unfortunately, when people lose all this fat, a lot of times they lose their butt, too. And so, some of these procedures, like the circumferential body lift, and any type of these lifts, spiral lifts, some of these other things that they go more around the back, because they lift that skin, unlike a breast lift, they actually tend to flatten the butt a little bit…

Dr. Bharti: A hundred percent.

Dr. Franco: …and don’t give you that kind of bulge lift. Like, you know, we cone the breast, it doesn’t cone the butt, and I think that’s a misconception, and sometimes, trying to educate patients about the options there, in terms of what effect it’s going to have on their butt. And I’m not saying they’re bad procedures, but don’t want to mislead people that this is going to give them a plump butt. It may get rid of some of the skin, but it’s not going to round that butt out.

Travis: Sure.

Dr. Bharti: Johnny, you’re so accurate. And one of the things that I started to do on all the buttock lifts that I’m doing, or the posterior component of a body lift, is suctioning the absolute daylights out of the resection pattern, suctioning out the hip rolls, and just doing an autologous fat transfer right then. So everything that is removed to put that in there, and it’s made it better, and it’s lessened the flattening appearance, and I always counsel them all that you will have buttock flattening, and if you don’t do any simultaneous fat grafting, it’s gonna be significantly flattened. So I really agree with you on that. And I try to fat graft every single one of those patients. Even the massive weight loss, where you think there’s no fat, there’s always fat. There’s always fat in the resection pattern. So suction it out. And what I do after I suction it out, I do an avulsion technique. So after it sectioned out, just tear it off. There’s no bleeding, there’s no seroma. I do it for the arms too, and it’s a good tool, in case you haven’t tried it.

Dr. Franco: I love that, for the arms and thighs. I absolutely love it. I just recently started doing my thighs that way, and I wish I could go back in time. I feel like…tend to get better results. It’s easier for me. And it’s funny, because this goes to your point about being efficient, right? You know, patients are getting better results, and it’s easier for us. So, [inaudible 00:28:23]

Dr. Bharti: Man. And the other thing is, you know, is the dreaded lymphocele, you know, vertical thigh lift. Guys, if you get a lymphocele on the vertical thigh lift is such a nuisance, and, like, these patients have to have these things drained for, like, weeks and months, and I haven’t had that happen, so it definitely makes it better.

Dr. Franco: I knocked on wood for you.

Dr. Bharti: The hard thing… There you go. Listen, you know what I always tell my patients? I say, what is the likelihood of getting a complication? I tell them, “It’s super small,” or if it’s 1 in 1000, whatever. And, you know, I tell them, “But I’ve had it, because I do enough to get it.” And the thing is, it’s almost like you want to get that complication as a surgeon, because it keeps you on your toes. Like, I mean, everybody here knows, you know, if you’re operating, you’re doing injections, you’re taking care of patients, you are going to get a complication. You’re going to get issues. The key is how we manage those.

And that’s why it’s almost a gift to be in practice a little bit longer, to take care of patients, to see more, so that you can just know you’re going to handle it. And all of us here on this call, in this video, really care about our patients and are going to be there for them and take care of them. So I think complications are a thing that I’d love to talk about a little bit about with any surgery, but with massive weight loss body contouring, where you have literally just hundreds of centimeters, of inches, of incision line, you’re going to get some degree of complication. Usually it’s typically just some wound healing complications. But I wanted to talk a little bit about that and your approach to potential complications in these patients.

Dr. Franco: A hundred percent. I couldn’t agree with you more, and some of this is the reason that people do a fellowship with you, because the hope is that you’re going to learn how to manage some of these complications, how you prevent some of these, as many as you can. It sounds like you and I are both super aggressive, trying to prevent the most dreaded complications, i.e. DVT, you know, PEs, those things. I know that we’ve talked in the past… I don’t want to get us sidetracked again, but there’s even special things we do for the fat transfer, in terms of avoiding muscle, stuff like that, to prevent fat emboli.

You know, and so there’s a lot of things we do to prevent it, but even then, some of the small stuff, like the skin issues, especially… If you’re doing a circumferential body lift, there’s just no way you’re not going to get some little small delayed wound healing areas. And sometimes I don’t even like to call those complications, because I tell people, “You’re going to get it somewhere. I can’t tell you where, but you’re gonna get it somewhere.” If somebody has a breast that their nipple’s all the way down to their belly button, and we’re getting them up and high and tight and right, you’re gonna get some little T, little wound healing issue. We just can’t move your nipple, make your breast that high and tight without some little stuff.

And so, I think this is some of the part of us managing expectations, like, “Hey, you’re gonna get some little stuff, bumps are along the road.” Inner thighs is one, I think right in the groin crease. That’s hard to not get a little something, you know, but we’re gonna take care of you throughout the process.

Dr. Bharti: And, you know, the great thing is, is, I always tell these patients, because like you said, you made your list of everything that’s important, what they want to tackle initially, is that most likely, you’re going to have a second stage. And at that point, I always, you know, offer them any area that I kind of know I can improve, you know, let’s touch up that area, and it’s an opportunity just to really supercharge your result. And so that’s another great thing to always let our patients know that, you know, we want a better result than they do, and so we’re going to do whatever we can to get them there, but sometimes, we need to do a little tweak at some point.

Dr. Franco: And I think this also comes to why there’s a limit, you know. There’s always the question of, like, tummy tucks, lipo, body lift stuff, and, you know, it’s funny because, you know, you’re very strategic and smart about how you’re lipoing, you know, you’re lipoing the areas that you’re going to resect, and you can lipo while other areas. But there’s so many things that go through our mind in terms of, like, being smart about how we’re attacking this, what areas we’re doing because of trying to protect that blood supply and different stuff for this.

Dr. Bharti: One hundred percent. I think that’s the thing, is, we have to be very thoughtful in what we do. And at the same time, we don’t want to be wasteful when we… Now, it’s like every time you lipo…

Dr. Franco: Want not, waste not, you know?

Dr. Bharti: …you can’t throw it away. It’s that liquid gold. I know you believe it. I mean, this guy loves some fat. We’re bringing fat back.

Donald: I got a question for you. So, we kind of went into this and we started talking about the different procedures, different pre-surgery things and stuff like that. Like, who’s a good candidate for this? Right? So, like, personally, myself, I’ve lost over 130 pounds. And, like, is that enough for, like, one of these big massive surgeries or, like, do I have to be, like, in a 200-pound loss range? Who’s a good candidate?

Dr. Franco: G, go ahead. I mean, I think everybody’s different. Like, some people have loose skin after 20 pounds. Some people, you know, have great skin after even 50 pounds of weight loss. It’s very individual. And what body parts it affects is a little interesting. I have some people that lose all this weight, and they lose it all in their face, and they need a neck lift, but their tummy actually still looks great and vice versa. I mean, it’s hard to predict.

Dr. Bharti: I couldn’t agree more. I mean, this is the great thing about this field is that everybody is so different. And the manifestation of massive weight loss on two people can be totally different. And most of the time, it’s going to be driven by the patients. And I think that, you know, 130 pounds versus, like Johnny was saying, you know, 20 pounds, it is very variable how that’s gonna present, how it’s gonna affect the individual. But, no, I mean, congratulations. That’s a massive amount of weight. That’s a whole person of weight that you lost, you know, when people [inaudible 00:34:05]

Donald: That’s a whole Johnny.

Dr. Franco: Maybe.

Dr. Bharti: There you go. But you look great, your face looks great. So, no, we can’t tell. So, you know, you’re one of those people who has done it very gracefully. And figuring out who’s a great candidate just depends. I think that that’s why we’re at a very unique position that anybody can potentially be a candidate for certain things and addressing it. The keys is, the operative plan is going to be very customized to each patient.

Dr. Franco: Dr. Bharti, I don’t know if you guys do some of this in your practice. You guys do so much body contouring. One of the things that’s been interesting that we’ve incorporated in our practice, because it was a huge kind of, like, area, and I don’t if, like, concern’s not the right word, but a place where patients left lacking and I felt lacking too, in some of these patients who’ve lost 130 pounds and we’ve done a tummy tuck, you know, overall, their body looks great. When they stand up, you know, it looks really good, but they just had this loose texture to their skin that drove them crazy.

And a lot of those patients now we’ve started going back and staging them and coming back and doing like a J-Plasma Renuvion. I know some people do BodyTite. Do you guys do anything like that with any of the massive weight loss patients? Because there’s a difference between taking out skin… At some point, there’s no more skin to take out, but trying to change that skin turgor, you know, that tightness of the skin, which, you know, we try to be very upfront, if you got stretch marks going all the way up, there’s a limit to how tight we’re going to make that, especially when they sit down or those type of positions.

Dr. Bharti: Yeah, you know, you’re totally right. That skin inherently is, for lack of better term, damaged, or it just behaves very differently, right? And so, what you want to do is you want to try to really pep up that collagen synthesis or reorganization, and pep up the production of elastin and hyaluronic acid. And so, we do things very similar. And adding energy, RF-type energy, using things like you mentioned, Renuvion, or using things like BodyTite, are things that we have done in our practice, and continue to do, in addition to that, adding some transcutaneous, or, like, RF microneedling as well, so you…

Dr. Franco: Oh, cool.

Dr. Bharti: You know, somewhat the concepts are… And we do a lot of vaser too in our practice. And again, that’s a different device. But one of the ideas that we talk about when you’re addressing skin is, you know, you have skin that’s here, you can address the under surface of the skin with, you know, probes like BodyTite or Renuvion. And then you can do transcutaneous, which are needles delivering energy into the skin, into the dermis. And then what we’ve done on some patients is then doing super low dose laser therapy, like using, like, something like a Halo laser, or even like a very, very low setting CO2 laser. And the idea is to do this multi-laminar treatment of the skin, and basically just took what we were doing in the face, and, like, why aren’t we applying this to the body? And I think it’s very important. [inaudible 00:37:08]

Dr. Franco: This is why I love talking to you. I learn something every day. These are jumping nuggets.

Dr. Bharti: But it’s true. And it’s funny, like, think about all of us, you know, and what we do for patients on their face, and how much money people spend on their face to keep yourself looking youthful. And we don’t really advocate that enough for the body, and we should. We’re doing a better job. Like, one thing that we started using for all of our patients are some of these body firming agents. I like Revision Bodifirm.

Initially, I used to use the Nectifirm. And anything that I recommend I try to use, and the Bodifirm is another agent. So we’re putting all of our body contouring patients post-op on Bodifirm also. And listen, it’s not going to be, like, a earth-shattering change. But the fact is, they’re going to actually be taking care of that skin, they’re going to be using an agent that will help that skin at some level than it was before. And I think it’s an important thing to just to try to remember to do.

Dr. Franco: It’s funny how many of these other factors go into it. And again, when they see somebody like yourself, like, you’re not telling them they have to do these, but like, “Hey, let me give you the full track of what it takes to get where you want to be.” And they may not do all the things at once, but at least, like, “Hey, here’s the simple stuff you can do. Here’s, you know, a Bodifirm that costs 50 bucks or something. Here’s some other treatments you can do down the road,” but at least that way they can plan and they have realistic expectations of what you can and can’t do in each procedure.

Dr. Bharti: Yeah, and you know what else is really important is that, I tell patients, and you all probably say the same thing. I’m curious what everybody says here. You know, when you provide a treatment or a surgical intervention, you don’t just get it and you walk away. You are becoming a part of that practice. Like, in our practice, we say, “You’re becoming a part of our family,” and that we’re going to take care of you before your procedure, after your procedure, and then we need to address all of your aesthetic needs.

We need to address your facial aesthetic needs, we need to stress your body aesthetic needs. And we want to maintain everything we’ve done, because you’re going to invest all this effort, all this capital, into whatever change you’re trying to gain. And then we need to hone it in and protect it and address all the other things that you have. And I think you probably do a great job of this. But we really try to focus on this, because that’s the way I think you can really ultimately get the best outcomes, the happiest patients, and you also get stability for your business also.

Dr. Franco: And it’s funny, because sometimes patients forget there’s some simple things they can do, like a good sunscreen, a good moisturizer. It doesn’t have to be crazy expensive stuff to really take care of themselves. And G-Berto probably knows a lot more about that stuff than I do, but, you know, there’s some simple things you can do, especially if you start when you’re younger, that’s gonna pay dividends over the long term.

Dr. Bharti: And that’s really interesting, and I actually, you were about to chat, I was gonna ask you, I’d love to hear how you handle that with your patients. How do you handle a patient who’s going to come in, let’s say for example, who just comes in for a filler or a neurotoxin consult, but really kind of opening their eyes to what they actually need to be doing, you know, so that they have this, you know, lifetime result?

G-Berto: Yeah. So, I think a lot of it goes into establishing that rapport with the patient and kind of telling them, “Hey, I know you’re here for this particular procedure that brought you in initially, but let’s talk about all these other things that are going to be really important in not only, you know, maintaining what you’re going to get from this procedure you’re coming in for, but also is going to benefit you in the long run and it’s going to pay dividends, you know, in terms of skin care, you know, improvement of, you know, skin laxity, you know, all these different things that come with, you know, a good foundation of, you know, skin care.”

Which I usually tell my patients, you know, the good foundation for skin care is, like, like Dr. Franco mentioned, is going to be a good sunscreen, a good moisturizer, a gentle cleanser. I try to put all my patients on a topical retinoid, or retinol, depending on what they can tolerate. And then all the other things that come with that, like the Nectifirm, like the Bodifirm, like vitamin C serum, those are just kind of like the cherries on top of the sundae. And, you know, overall, we want to try and help them, I guess, address things that maybe they didn’t even know needed to be addressed from a holistic standpoint, you know, just kind of looking at the patient as a whole and trying to, you know, take care of all their needs, not just what they wanted to come in for that particular day.

Dr. Franco: Dr. Bharti just because…

Dr. Bharti: I love that. I didn’t mean to cut you off, but the reason why I love it is that, I’m glad that you’re seeing this and you use the word holistic. Like, listen, what’s interesting about what we do as aesthetic providers is, we actually care for the patient almost from top to bottom. And like, that’s the things we gotta realize is that there’s more to it. We are really trying to take care of that patient, you know, in every way.

Obviously, there are some things that are out of our ability to address for them, but we’re not just trying to get them to have surgery, we’re not just trying to get them to get, you know, five vials of this. It’s about we want to get them to a place that they are just, they are at a level and an overall sense of well-being that they are just happy to be at.

G-Berto: And I think if they feel cared for in that way, they’re gonna keep coming back to you, because they know that you are taking care of them and you’re looking out for them in the long run, not just someone who wants to come in and just get a couple units of Botox during their lunch hour. Someone who actually cares about, you know, what your end results are and, you know, trying to get you to that point where, you know, you feel comfortable in the skin that you’re in, you know?

Dr. Franco: And that’s why people like yourself break up surgeries. If all you cared about was the check, you’d be like, “Fine, let’s do everything in one day, because I don’t want you to…” You’re not worried about them coming back, because you know they’re gonna have a good experience, you know that you’re gonna do the best job possible. They’re gonna come back because they’re gonna be like, “I’m so happy with this first procedure. I can’t wait till I can do the second one.” You know, if you didn’t care, you wouldn’t say, “Hey, you gotta wait six months till your body’s right before we do this surgery.” I mean, those are the type of things of when you’re finding a physician, you want somebody that cares more about your overall success and health than you just trying to book a surgery with them.

Dr. Bharti: Listen, you know, I don’t know if you’ve seen it, but I have, and it happens more often than not…or not more often, but it does happen. Meaning that I see a patient, I tell them, “Actually, I don’t think I would do this, I would do this.” And it may not necessarily jive with them, or there’s some sort of thing where they don’t think it’s a good idea and I’ll voice it. And they’ll go somewhere else, they’ll undergo that procedure and come back, “I should have listened to you, Dr. Bharti. I needed you to fix this.”

And, you know, what’s hard at that point is, we never, like, as surgeons, we don’t want that. We don’t want to be like, “I told you so.” We never ever would wish that on anyone. But you feel bad in a way, because they had that procedure, they invested in it. Now they gotta come to you and invest back into you, and they have to have this double procedure. Now, afterwards, when you get them to where they need to be, it’s great. But it is really incumbent on us to protect those patients, try to let them know, and really, really, really do their diligence, because sometimes if they do make not the right decision, then unfortunately, they might have to have a secondary procedure to fix what happened at the first time.

Dr. Franco: And sometimes it’s hard to fix.

Travis: Yeah.

Dr. Bharti: Oh, yeah.

Donald: I know that Johnny’s about to, like, wrap things up. And I really wanted to touch on recovery, because in some of these procedures, like you were talking about the circumferential body lift and things like that, like, just how long is the recovery for some of these procedures? I’m imagining they’re, like, pretty long.

Dr. Bharti: Yeah. So, it’s a good point. And it’s very important, you know, from the get-go, that first consultation, to really lay out there. And I’m pretty aggressive about telling them how things… I always tell them, you know, day one in the recovery, you’re gonna feel pretty good. A lot of the numbing solution’s going to be on. Day number two is when you come in and you hate me, you don’t like anything. And from then on, you’re at this peak of how horrible it could be, and then you do this undulating sinusoidal pattern of up and down…

Dr. Franco: So true.

Dr. Bharti: …and then you improve, and then you go up, and then you go down. And then, patients have pretty significant blue days sometimes too, and they need to know, their families need to know. But I’m pretty aggressive about getting people up and moving. And I don’t know how you guys feel about it, but I say after about four weeks, and if they’re stable, then I want them to actually start working out light and going to the gym. So, four weeks is my number. But for that first little bit, it’s hard, and they’re walking around in a bent-over position typically, they have a lot of compression garments, they have to potentially manage drains, they have lots of incisions that have to have tape dressing changes, and lots of follow up visits, to assess them. But it’s definitely an intense first four weeks, is what I tell patients. What about you, Johnny?

Dr. Franco: Yeah, I typically tell people three to four weeks. And what’s been interesting, and I know I’m supposed to be wrapping stuff up, but I feel like this is why stuff has changed a little bit during the COVID time, because a lot of people are working for home. I feel like they’ve been able to shorten that time off work a little bit, because if you’re on your recliner, on the computer, those type of things, they have a little bit more flexibility than when they needed to drive, go and sit in an office for 8 to 10 hours. Because if they’re at home, if they needed a little 15, 30-minute break, they’re gonna be fine. They’re not having to drive, they’re not having to do some of those things that kind of kept us from letting them go back to work, in that they could be in that good position that we want them to be in. So, in my practice, I’ve seen people be a little bit more accepting of that time over the last six months than I did previously.

Dr. Bharti: Yeah, same thing. And one thing that we forgot to mention, too, is, you know, when we’re doing any kind of muscle work, is using Exparel. Exparel has really, really helped recovery, and removed that agonizing pain.

Dr. Franco: I love it.

Dr. Bharti: Oh, yeah, that’s right.

Travis: We use that a lot down here.

Dr. Bharti: Are you guys using it at all on the soft tissue, not only in the plication?

Dr. Franco: Mostly in the plication. I haven’t used much of it in terms of for the soft tissue. Some of the things that Celebrity and I have been looking at is doing some muscle, or doing some nerve blocks with the ultrasound ahead of time. And so, something Celebrity and I have been exploring a little bit doing some [inaudible 00:47:16], other stuff. Celebrity?

Dr. Bharti: I like that. That’s good stuff.

Travis: Yeah, we were talking about some tap blocks, and ES, erector spinae blocks as well, to hit some of those areas. I think the rectus sheath block, when you’re on either side of the plication, is great, too. You know, you touched on a bunch of things. Me and Johnny are huge advocates of getting these patients up, out of bed, night one, like, they need to be going to the bathroom, they need to be moving around. And we’ve jumped on the ERAS protocol train.

We do a lot of our cases with minimal to no narcotics, using other opioid adjuncts. So these patients are not, you know, gorked out of their mind for the next two weeks. They feel good, they feel lucid, they feel clear-headed. They’re not having the constipation and the things that come with the sequela that come with the opioids. When they need them, we give them, but we really try to reduce that as much as possible.

Dr. Franco: I think this has been absolutely fabulous, and probably on me for trying to do body contouring in one podcast. So I’m gonna put you on the spot here and ask you if you’ll come back, because I feel like we didn’t talk enough about arms, thighs, and we didn’t even talk about face and neck, which is another huge part of after massive weight loss. So maybe if we can lock you down here in the spring and steal you for another episode, we would absolutely love it.

Dr. Bharti: Let’s do it, gentlemen. I really, really appreciate it…

Dr. Franco: Well, you’re not off the hook yet. You’re not off the hook yet. I’m just putting you on the spot.

Dr. Bharti: Oh, Got you, got you, got you.

Dr. Franco: So we do a little section called “Behind the [inaudible 00:48:46].” What would you tell patients, if there was one kind of like nugget that people don’t realize or don’t see? If there was something you could tell them kind of a behind the scenes, something that you think is important for them to know, what would you say? Is there anything that you would want people to know?

Dr. Bharti: Yeah, you know, one thing I would say is, I don’t know if they realize how much we care and how important it is to get the best results, and how we agonize. We agonize over everything.

Dr. Franco: I agree. Everything.

Dr. Bharti: When the blood pressure is low, and the heart rate is high, when there’s a little bleeder, or… I mean, it’s just, we agonize over every freaking thing, and everybody in that OR, I know you guys are the same, the team is so behind getting the best result. And it’s a unique thing that… And it’s every case, and I don’t know if that’ll ever go away. I hope it does. And if it does, I’m not going to work anymore.

Dr. Franco: I agree. The day it stops is the day to just hang up that coat, you know? And then it’s just time to move on. That’s such a good one because I couldn’t agree more, such a good one. What about a little quote of the day? Can we get a quote of the day? I know…

G-Berto: Yeah, yeah. I got one that I think applies to today’s episode. So this one’s from Dr. Martin Luther King, and it says, “If I cannot do great things, I can do small things in a great way.” And I think that that’s kind of a nice little piggyback on how we were talking about staging, you know, some of these procedures, you know. You may not be able to do everything all at once and have, you know, just knock it out of the park, home run, one time, but, you know, doing these procedures in serial, you end up with the result that you’re really wanting. I know that I sometimes take that approach with my injectable patients, where, you know, they may want all these things, but either due to finances, or time off, or whatever, we have to kind of do things, you know, in stages. So I kind of like that quote for this episode.

Dr. Franco: I love it.

Dr. Bharti: I love that quote. And I just want to follow you on what you said about injectables. In addition to that, you know, a lot of industry has really propagated getting people to correction in single settings. And a lot of times, that’s a lot of syringes. When in truth, a gradual transition, having people come in… I have some patients come in weekly, and then you kind of just work them, or even every two weeks. And you get more precision. And so, like you’re saying, I think you do get great things by doing them in smaller segments at times. Very nice. I really love that quote, by the way.

G-Berto: Thank you. Thank you.

Dr. Franco: Dr. Bharti, before we sign off here, can you tell people one more time, your website and the name of your practice if they want to check out your information a little bit more or message your office with more questions?

Dr. Bharti: Absolutely. So the name of our website is HKB Plastic…oh, I messed up my own website.

Dr. Franco: You see, when you’re world famous, you don’t even need to know your own website. People just find you. That’s what I’m talking about.

Dr. Bharti: It’s hkbsurgery.com. And my Instagram handle again is @drgauravbharti. And this has been a lot of fun. This is a good crew right here.

G-Berto: Thank you for joining us.

Travis: [inaudible 00:52:06]

Dr. Franco: I appreciate having you. This was fabulous. And so, sincerely, we’re gonna rope you into coming back again. We got so many more topics to cover here. And so, thank you for taking time out of your day in this busy holiday season, and I know you’re working like a machine every day, so thank you. I’d like to thank all of our listeners for listening in to the greatest podcast in the world as voted by us. Download us on iTunes, Pandora, Spotify, iHeart, wherever you get your favorite podcasts. We’ll see you guys. Bye.

Dr. Bharti: All right, guys. I will see you in Austin. Hopefully soon.

Dr. Franco: Yeah.

Travis: There you go.

About The Author

Dr. Johnny Franco
Episode 36: Building an Empire – The Synergy Way


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