The central theme is a call to embrace reality and critical thinking, particularly within the medical and surgical fields, by challenging commonly accepted but often flawed practices and beliefs.
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today is Wednesday lesson of the day on
Thursday as we've continued the
tradition on Wednesday to Thursday is
pretty much me talking and the
point of this lesson of the day is that
there was a recurrent pattern of
visitors this week
who believe incorrect things and
patients who believed incorrect things
said by doctors
so the point of this is to ground
everybody to live in reality and stop
living in imagination and the problem
with really intelligent creative people
is sometimes they can stray and deviate
from reality and make up their own
realities and live in them
I was raised by a dad like this so we
need to ground ourselves when we're
looking at uh surgeons and surgery and
everything that we're doing and
um the first thing that I teach the
fellows that come and visit in the
residence is really how to become a good
surgeon is to figure out these things so
the first thing is to change the way you
look at the world because most people
look at the world very positively and
look at it as though everybody's
intelligent everybody's smart
everybody's great and that's fantastic
to be an optimist unfortunately it's
it's not reality not every surgeon is
great not every artist is great not
every Chef is great not every bus driver
is great this is the reality of the
world is that there are exceptional
people and non-exceptional people and if
you want to learn and you want to
advance and you want to be the best you
have to follow the top the top five
percent and those people so that's the
first thing I tell them is realize and I
say what's the most popular filler in
the world
they said what's the worst pillow say
what's the most popular facelift in the
world it's Mass specification what's the
worst type of facelift it's Mass
glycation so you have to understand that
the most popular is usually the worst
thing uh common sense
is common people don't get that it's
common it's not great sense it's common
sense that's what the sense that most
people would have what we're doing here
in surgery is trying to be the best what
you're doing in any field is really
trying to be the best you don't want to
be common you don't have common sense
you don't want to have common taste
common sense and common taste are
average and those things are not
impressive they don't impress me they
don't impress anybody and it just keeps
people average and the same there's no
advancement there's no change and the
way to be the best surgeon people get
confused they think it goes by patient
satisfaction that's great to keep
patients happy and I love to keep
patients happy and I care about patients
and it's important to care about
patients but that's not what makes you a
great surgeon that's not what produces
great results being selfish is what
produces great results looking at your
results and analyzing them over and over
again and always thinking that it's not
good enough that's how you become a
great surgeon so you're not doing the
surgery for the patient necessarily
you're doing it for yourself and you're
doing it for your own results to look at
your own before and after to be critical
about it and to judge yourself and say
am I good enough and if you're not you
keep getting better and you keep
improving if you do it for the patients
you're probably never going to be that
great because patients can be happy with
average results and they can come in and
say doctor thank you so much they're
like some nice people with low
expectations and they love you and they
say it's great it doesn't mean your
results are great the only way to really
Advance the result is to put the patient
expectations kind of a side that's a
whole different thing you want to keep
them happy of course but it's really to
do it for yourself and to be selfish
about the results and I tell my patients
all the time they say you know you must
really go overboard trying to do these
things for patients that's why you're so
great and I correct them I say well I'm
pretty selfish actually that's why I do
this is because I like to do it for
myself and I like to look at my before
and afters and be proud of them I go on
medical missions not because I'm
somebody who loves to give to other
people I like that it's nice but I do it
because I love going on these trips and
I love doing the surgeries and I love
playing with kids and I love doing those
kind of things and my selfish nature
helps benefit other people and the world
works out better for you when it's like
that but the things that I went through
today and recently that are
not reality
um and I want to kind of repeat this
over and over again until people
understand that just because something
is parented or repeated in the surgical
world or any kind of world does not mean
that it's true okay
um most people again have common sense
which is common it's not that fantastic
and you can you can look at our
political world and our last few
presidents and you'll understand
um yeah we we sometimes make wrong
choices and we sometimes repeat things
that we think are correct and they're
not correct so the things that I've
noticed let's talk about a few of them
one of them and this is a lecture that I
gave in San Diego recently and I
insulted everybody in the audience they
all took it kind of well fortunately was
I asked who in the audience believes in
the concept of over correction over
correction in a surgery is when you pull
something this far back and then people
look crazy and then you expect it to
settle like 20 or fail 20 percent that's
the concept of over correction over
correction for me it's one of the
dumbest things I've ever heard because
you are inherently putting into your
recipe disaster you're putting in a
little bit of failure over correction
means you're putting it this far to fail
20 30 and the thing that's wrong with
that is it's not predictable you don't
know if it's going to fail 20 30 you
know how much it's going to fail they
say it's settled but it's really failing
so you don't know how much it's going to
fail and when it fails it fails from
somewhere and it usually fails from the
incision meaning
you get scarring there because it's
pushing or pulling away from the
incision so rather than having over
correction why not figure out a better
way to do a brow lift or a better way to
do a surgery where there's no over
correction you just get it to where it
needs to be with no tension be a little
more logical about it and everything
tends to work out same as where they
pull brow lifts if you pull someone's
brow lift in the direction of surprise
so the direction of surprises frontalis
contracture this is your frontalis
muscle Inquisition surprise it's that
direction what's gonna happen when you
lift somebody in the exact same
direction as surprise
you're gonna always have some kind of
appearance of surprise it may be minimal
it may be major it really just depends
but that's the wrong direction so these
are things that people have to
understand the other thing I heard uh
over and over again was it will smooth
out meaning you're doing a surgery and
you leave a bunch of ripples on the
field and the doctor says oh it'll
smooth out why would you leave somebody
you know something to chance when a
doctor is so neurotic about every other
thing they do
everything has to be perfect in the
operating room the yellow people they
scream at people everything has to be
perfect and at the end of the surgery
they say ah that'll smooth out it's
crazy to think that you would be a
doctor whose type A personality and
everything has to be perfect yeah and
yet you say I'm going to over correct
and let it settle or I'm going to leave
Ripples and let it smooth out over time
now Ripples and irregularities they do
happen after surgery and those do smooth out
out
but if you're on the field and you've
got a dog year you've got something else
like that you don't leave it to chance
you fix it
the reason people leave things to
Chances because their predecessors told
them that it would be normal their
predecessors repeated things so many
times that they said it would be normal
there are many things in plastic surgery
that are repeated and repeated in
literature and they're interpreted
incorrectly and because they're repeated
so many times people take them as a fact
they misread statistics they misread
articles in literature they don't fully
understand them so the other
non-realistic thing is misinterpretation
of data patients come in and they say
well I heard that five percent of people
get revisions for whatever so that means
I have a five percent chance I heard
that 60 of fat survives when you do fat grafting
grafting
this is a misinterpretation of data a
doctor doing a fat grafting procedure
assuming that 60 of fat Will Survive
he will inherently or she will do an
extra 40 percent of fat assuming that 60
will survive in order to get the proper
result this is a misinterpretation of
data they read an article that looked at
a thousand patients in a population that
said the average was 60 percent survival
of fat when you did fat transfer from
the abdomen to the face
that's a population statistic it's not
an individual statistic which means if
you look at the individuals in that
study all thousand of them one of them
could have had zero percent one of them
could have had a hundred percent one of
them had 20 percent one of them had 70 percent
percent
which means the doctor's chance of fat
survival is 60 percent
the patient's chance is zero to a
hundred percent however doctors will
misinterpret that data they'll take a
population statistic which applies to
them and they'll apply it to the
individual patient they're treating
which means they'll inject the patient
with an extra 40 instead of assuming
that the patient may have zero percent
or a hundred percent so they they don't
know how to apply statistics this is the
misinterpreted misinterpretation we
always see
the other thing I hear all the time is
uh during facelifts is getting muscle
tightening or smash tightening I had
several patients come in today saying do
you do muscle tightening do you do smash
tightening I read about it and I'm like
what the are you talking about what
and it's not the patient's fault they
read this from doctors and I asked
doctors what are you talking about
muscle tightening what is muscle
tightening I don't understand like if
you could do muscle tightening I would
tighten my muscles like I I don't
understand what muscle tightening is a
muscle contracts so I don't know what
muscle tightening is is it muscle
flexing is it muscle contraction is what
is muscle tightening I've heard this so
many times yet I don't understand
conceptually what it really is because I
don't think it exists but people have
repeated it so many times that you think
muscle tightening exists it makes no
sense muscles contract they relax they
contract they relax they contract
there's no such thing as muscle
tightening then you hear us Mass
tightening smash tightening also makes
no sense this Mass which is The
Superficial musculoponeurotic system is
a system of fascia connected to muscle
how do you tighten the muscle how do you
tighten this mask this mask the fascial
components are a hydratory layer with
fat and fascia and water it's a cushion
layer that provides support and volume
under the skin
it supports it so when you heat it you
don't tighten it like this you shrink it
like this it deflates
so everybody says smash tightening smash tightening
tightening
they don't even I don't have no idea
what smash tightening is how are you
going to tighten this mask you can only
shrink a smash deflate this mask
hollowess mask dehydrate this mess
shrink the fatness mask you cannot
tighten this mess it doesn't exist it
cannot happen now why are they confused
because during surgery they'll sit there
and they'll start cauterizing this area
Your Shopper is calling me cutting off
my my signal here so because of that
they assumed that the contracture that
they saw with their own two eyes
represents a true contracture and
tightening of tissue in real world which
it does not so what are they observing
what are they seeing when they think
that it's doing that what are people
seeing when they do a laser of CO2
around the eye and they see the skin
shrink and they think that that's real
collagen tightening they misinterpret
the data what do they think they're
seeing is they think that they're seeing
true tightening what they're actually
seeing is called explosion they are
heating up water and they are
evaporating it and when you vaporize
water you shrink the entire tissue now
that area is going to get rehydrated and
repaired at some time it doesn't stay
tightened it doesn't do that if anything
it only deflates so the same Doctor Who
is doing all this deflation over here by
my definition their own definition is
they're doing smash tightening but
realistically they're just hollowing
this area we'll go do a smash
application where they Hollow the rest
of the face and then they'll background
the entire face so they Hollow this area
then they go preach fat grafting and
volumization because you lose volume
with age and they volumize the rest of
the face so it's a little
counterintuitive and a little
contradictory that you would Hollow it
and then add volume so these things are
misinterpreted misunderstood
the other thing I've heard is to improve
skin quality during
a facelift you have to go past the last
wrinkle and Elevate the skin more and
pull on the skin more now we've clearly
proven this wrong with deep plane
surgery you see deep plane surgery where
we leave all the skin attached and the
support system to the skin is the
hypodermis and this Mass we leave it
attached to the support system you get
less problems anytime you lift the skin
off the support system it starts to
retract you automatically produce
tension on it
and we've noticed that doesn't help so
people have accepted we're going to go
over to deep plane a little bit more and
the same doctors that have slowly
accepted this with force and repetition
of our results being better because you
look at our photos and they're better
still resist on some point where they
say no no well here's deep playing but
down here you need to elevate all skin
in order to get rid of wrinkles
I always compare this to like religious
people who uh they're like no we have to
keep kosher and we have to do this that
but then they have like premarital sex
so they choose like one part of the
Torah or the Bible and then they ignore
all the others I don't care which one
you do but it's a bit of hypocrisy or a
bit of convenience for them the same
exists in surgery where they will
conveniently believe in one thing yet
ignore the other thing so whether it's
hypocrisy or whatever it is or
self-contradiction you can't Hollow this
area and then just be like I want to
volumize the face you can't say I
believe in deep plane here but then not
believe in it down here deep plane
exists everywhere and well not everyone
but you get that one
skin quality problems are very different
than skin excess and most surgeons
believe that there's a ton of skin
excess that's formed I haven't met one
person in the world other than
hyperelastosis patients who really
develop a bag of skin over age it may
look like their skin is excessive but
what happens is their skin used to be
tucked up here and it would have to
travel around the jaw down here over
there around all these Contours so the
surface area was longer and it would
wrap around all these areas and the skin
would look healthier because it was
wrapped around all these areas it had
some volume under it had some fat under
it then you lose some of that volume and
you blend everything and now it's a
straight line from here to here so now
you have all this what appears to be
skin excess but you improve the Contours
again you tuck everything back up the
skin has to travel a longer distance
again and it looks better automatically
so you don't have that much skin access
now they they don't believe in this
somehow for skin but they believe in it
for platysma they say okay yeah I
believe the platysma when we redrape it
it needs to travel longer distance so
they do my auto Meats in it but somehow
they don't believe in skin that it
exists so a matter of uh belief of
convenience so
um that's another thing that just for
the surgeons who need to understand look
at my results look at my results go look
at my face results I don't dissect skin
past here and I get improvements all the
way down along the clavicle more so than
somebody who elevated the entire face
and neck so every time we have this argument
argument
with surgeons and I try to explain to
them you don't need to elevate that much
skin just improve your Contours more
they go look back 20 years in their
photos and they find one photo to prove
their point but I go back and look at
their other thousand photos after they
send me their one photo and I see
that they're all trash but this is how
people justify what they do and then
they spread the LIE they keep repeating
it repeating it repeating it and they
keep getting average results yet there's
people who excel in the fields of facial
Plastics and they are the ones or
Plastics and they're the ones who are
getting the better results and they're
doing different things than everybody
else so always believe in that top five
percent another fallacy or another lie
that's been repeated over and over again
to Residents is the concept of
redistribution of tension or tacking
sutures where you would take human
tissue which has turnover meaning it
reproduces itself at a given time you
pull it up you put it with tension
somewhere and then you say okay that's
gonna be my tacking Stitch and then I'm
going to cut all the skin out and then
everywhere else it's going to
redistribute attention
this is not reality reality is tension
is tension and if you don't get rid of
tension tension is always there whether
it's in a deeper layer or a superficial
layer deep tension
or putting tension on a deep layer
doesn't get rid of tension on The
Superficial layer there's tension
everywhere still which is why your
results fail which is why they're not as
big which is why you use scar more so
that whole concept is a lie now
residents come and visit and it's hard
for me to explain all these things in
one day
and I try to tell them I go please don't
believe everything you've heard it is
not true and they say what do you mean
have you heard of redistribution of
tension they say yes it's a lie it
doesn't exist it's not real what do you
mean I say well if you have tension in
the face it's got to be there no matter
what you do on a deep layer superficial
layer and at some point your tension
holding suture is going to grow cells on
the other side of it they call that
cheese wiring and they think it's just
stretching against around the tissue the
microscopic cells don't stretch they
grow on the other side and they grow
more cells so it's hypertrophy so they
end up growing more cells but they're
growing it and pulling away from your
Stitch that you use to tack everything
up so those things aren't real I had a
patient comes in today and said well the
doctor did some fat grafting around my
cheek and some filler and use the
cannula and pass it around everywhere
using a subcision technique to release
the ligaments and I'm like what are you
talking about in her cheeks and I love
her to death She's like I've known her
for eight years and she's wonderful so I
hope you don't mind that I'm giving you
as an example I won't use your name ever
and she's so beautiful so pretty but now
her cheeks are overfilled and
um one doctor believes that they were
releasing uh ligaments when putting fat
around them and getting rid of
indentations on the face whereas the
other doctor me I'm like what are you
talking about how do you release a
ligament because I'm a surgeon I've been
in there so I don't know what they're
talking about when they say really
ligaments I don't understand what they
mean when they say smash tightening I
don't you know I live in reality I don't
understand these things
and in his mind or her mind they are
releasing ligaments and improving
Contours in my mind they are flooding
muscles they flooded the muscles of the
face and the muscles of the face don't
work anymore can't smile there's muscles
that come all the way across over here
now they have all this fat and filler
around them with the intent of releasing
some ligament that I don't even know
exists or how you'd release it but I
don't understand it fully but in reality
what they did was they flooded the
facial musculature so their intent was
to lift the face
and improve Contours the result was that
they got the face fatter worsen Contours
and it will now accelerate aging and
drooped it so that's the reality of what
happens with these things
so yes we have good intent but unless
you live in reality you end up doing the
opposite of what you want which is why I
tell everybody that I teach or talk
about I say just live in reality like
you don't have to say Sculptra produces
collagen to people that's like a stupid
thing to say why would you say that
sculpture does produce collagen but it's
misleading because people think collagen
is always a good thing they don't know
that collagen can be a bad thing they
don't know that keloids are collagen
they don't know that hypertrophic scars
are collagen they don't know the
fibrotic tissue is collagen they don't
know that all the adhesions around their
ovaries after surgery are collagen
unless you tell them that way so when
you put sculpture in the face you're
depositing collagen but you're doing it
with scar tissue formation and I like
Sculptra I use it
just because I say these things doesn't
mean I don't like it I like Sculptra but
I'm realistic about it and because I'm
realistic about it my results will be
more reproducible than somebody who just
believes in their fantasy that is
producing healthy collagen and they go
injected everywhere into the skin
thinking it works like a laser and they
go put it underneath and they think it
works like a laser and it's like putting
vitamins in the skin and they get
nodules sometimes they get
irregularities sometimes whereas when I
use sculpture I never get problems
because I understand what it does and I
accept that it's forming scar tissue and
I put it down deep in the cheek to form
bulk it's a bulk former that's what I
use it for I use other things for other things
things
so because I'm realistic my complication
rate goes down my issues go down my
success rate goes up whereas the other
people just kind of blame it on
complications that happen
and say oh well yeah you know there's a
one in a million chance that this
happens there's a one in a thousand
chance that this happens a 100 000
chances a lot one in a hundred chances a
lot you know injecting uh Kenalog every
single time for a pimple on somebody
without severe cystic acne it's probably
not a good idea you're going to get more
problems that you can't fix so use
something else if you're realistic about
what this stuff does
um so that's my my wrap for today is
it's very difficult uh
trying to retrain surgeons who visit
especially the younger ones who look up
to everybody who have heard these things
so many times they think it's reality I
would advise you not to believe what
most people think 95 of the world has
not Advanced the world they live in the
world they can be your friends five
percent of the world one percent of the
world are the people who Advance things
so you have to look out to see who are
those people it could be somebody who's
never contributed anything in their
lives and they do come up with something
so it's not always the person but you
have to find that one percent of ideals
one percent of reality that is better
than everything else and then that's how
you Excel so I struggle a bit because
things are parroted and repeated and
people think because it's repeated it's
real this is not true it can be repeated
a million times and it may not be real
it can be published in a peer-reviewed
journal and it may not be true or it may
be misinterpreted so
um that's all before I run out of breath
I hope that the residents visiting can
watch this video and just hear those
things so I don't repeat them every time
sound like a repeating I don't
like repeating myself I like to say
things once I like to originally create
things I don't like to say things over
and over again because I don't feel
original I don't like to tell the same
joke twice I don't like to cook the same
thing twice that's why I like to change
surgery all the time and keep improving
it if I Plateau on a surgery I get bored
and I don't want to do it anymore it's
not creative it's not fun for me so we
did this with like the Nano fat PRP
stuff I did hundreds of these and got it
to the best point it could possibly be
at and I plateaued and then I kind of
lost interest in doing it and that's how
I'm with some procedures but I am like
that with every conversation I like to
always be original always create
something so hopefully if I just put
this out there maybe I'll make the
residents watch it before they come visit
visit um
um
do appreciate you guys listening to my
little rants we have one question here
by fadia Jafari can you fix mailer edema
unrelated but why not uh I have heard
many fallacies about Miller edema and
people try to do crazy things to fix
malar edema one is they try to fill
around it so that makes sense so Miller
ID mess everyone's aware is an area over
here on the zygoma where we call this
the malar region there's a mailer um
um
Basin where the fluid has to drain
around here and go there before it goes
down it can't gravitate inferiorly so
male edema happens and people with
either allergies a higher salt intake
higher alcohol intake poor lymphatic
drainage over filled faces because they
can't drain surgery in the past in some
cases where they disconnected too many
things but that's uncommon but all these
things can lead to malaria demos how do
you treat it most patients in LA are
treated for melodyma by dissolving their
filler and you just dissolve it and it
goes away about like 50 or something the
other ways to treat malar edema are
scarification or citrization where you
try to go actually just kill the Dead
Space there and this can be done with
sclerosing agents like doxycycline
tetracycline bleomycin I wouldn't but
those are kind of inflammatory and
unpredictable you don't really want to
use those things there or you could do
it with radio frequency treatments which
tend to be a little more predictable
sometimes CO2 might help
the thing is most people don't
understand which layer this is occurring
in so and I fully don't know which layer
it occurs in it tends to look like it's
in the superficial spongy layers but
it's really hard to tell so when people
treat these areas they do radio
frequency deep too superficial and there
used to be about a 50 success rate with
fragatora and then now with Matrix and
Morpheus this is actually success rate
it's a little bit higher we have Dr
honig I think does a profound mixed with
CO2 laser a few treatments and he's got
a very high success rate so there's a
bunch of ways to treat it most people
just by avoiding high salt intake uh MSG
Chinese food red wine and those things
that tends to get better or by sleeping
with their head a little bit elevated
you don't want to sit flat
so let's see any other questions here
fantastic all right wonderful so I will
head home out tomorrow
my friend and I are going to be
performing profound
radio frequency skin tightening and PRP
for the hair together so I've done two
hair transplants I've done PRP to
maintain it I wish I'd started it sooner
but we're going to do that tomorrow so
I'm not going to film his but I'll film
mine uh you see as can watch to see what
I look like in pain and just so you know
everybody in the office has uh
volunteered to stab me in the face so uh
I guess I'm I'm likable you know uh they
just they want to help me
so everyone else have a fantastic night
and I will post this in case you guys
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