Monique Ramsey (00:02):
Welcome everyone to the La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey, and today I'm joined with plastic surgeon Luke Swistun. He is board certified in plastic surgery, and we're today going to talk about what is life going to be like after 360 lipo or maybe any kind of lipo, but talking really about getting back into life, what to expect. But we're also going to talk about the emotional, psychological, mental stuff that you might be going through and what's normal. So welcome Dr. Swistun.

Dr. Swistun (00:33):
Thank you. Thank you, Monique.

Monique Ramsey (00:35):
So talking about recovery, there's many facets to it and I know that it's different for every patient. I think we got to just lead with that, that all of us recover differently at different ages in our life, different than my sister or my daughter or my mom. So we can't necessarily set expectations around other people or even what we might have gone through in the past. But then also I think every doctor has different advice, right, about what you might want your patients to do versus what another doctor, what might give them instruction. So I do want to sort of preface this episode by saying that things aren't always exactly the same for every patient or for every surgeon, and what those directions might be.

Dr. Swistun (01:20):
That's correct. I mean, there's a lot of things that are technique dependent and depending on whether certain surgeons use drains, certain don't. There's going to be small variations in the recovery process and the recommendations. But overall, I think the themes are the same. If we're talking about a 360 liposuction, that is a major transformation that usually entails liposuction of the entire trunk, and sometimes we add arms to that, sometimes thighs, and sometimes we do fat grafting, classically, a BBL, Brazilian butt lift, liposuction of the entire trunk and fat transfer to the buttocks, sometimes even the breasts. So the take home point is that this is a major transformation. So there is going to be a pretty involved recovery process associated with that, not just physically and physiologically from the surgery, but also emotionally. Patients do go through a major experience. Everyone I've spoken with in the long term after has basically definitely said that it was worth it in the long term. Would you have done it again? Yes, I would have. However, there were some ups and downs or actually questioned that decision, "should I have actually done this?" And that's usually very early on, first week or so, it's like, "oh my God, why did I put myself through this?" But then you talk to that same patient six weeks later is like, "oh my God, definitely worth it. New confidence in life and the way I look now is spectacular."

Monique Ramsey (02:36):
I can really relate to what you're saying because now here's a good example. Somebody who, when I was 24 or 25, I had liposuction sort of from my waist to my knees and all the way around, and I'm sure techniques are better today than they were then, but that emotional psychological part, and even though they told me I might feel funny the next day, the next day I literally was on my couch thinking, "why did I do this? I felt great yesterday. Yesterday I was fine and now I'm not fine." I was so upset and it's so funny because here I'm working in that world. I understand the world of plastic surgery, and yet I still as a patient had this crazy, what have I done moment? But then, yeah, at the end of it I was so happy that I did. But even if you just know what to expect, I think that helps us. You're not looking down a dark tunnel with no idea what's going to come at you. And so what would you say to patients who are in that first few weeks, how to sort of prepare themselves emotionally?

Dr. Swistun (03:53):
Well, I'd say have your support system in place. Obviously this is an elective surgery. This is not surgery you have to have. So everybody goes into this surgery knowing that there's going to be a little bit of a setback in their lives and not necessarily that there needs to be. So having family in place to take care of the kids and pets and basically you're going to be restricted. You have to to take time off of work and be comfortable with that and just have these basics covered so that this is not a stressor. And then after that, just be ready for the fact that this is a major transformation, but there's a little bit of a cost involved in that recovery. There is a lot of factors that are going to feel like they're off at first because of swelling, because of the way the garment is fitting, because of lots of different factors, even the way you sleep or which side you sat on that day. And that's going to change the shape and that shape is going to be very variable early on as the body, the swelling goes away and as everything kind of evens out, but in the long term, things just kind of fall into place.

Monique Ramsey (04:55):
So how long might somebody be under anesthesia and what are they going to feel like in that first 24 hours? What could they expect there?

Dr. Swistun (05:03):
Sure. I guess we can focus on the details. Obviously the day of surgery, everybody's a little bit nervous, which is appropriate. You're going under anesthesia, but we take it very seriously. If you are not nervous, I would be nervous. That's not normal. However, everyone's nervous and we all acknowledge that and that's the appropriate way to be. We mark you. Typically, the way I like to do it is I mark the patient in the mirror so that she and I can be on the same page as far as exactly what we're going to do. And if there's any little tiny areas of focus, we acknowledge those and definitely point attention to that with the markings. And then the patient basically goes to the operating room and we typically, for a 360 lipo, we do a standing prep. So we basically have the patient stand, keep them warm, and then we prep their entire body as they're standing so that we can paint with, prep everything that we need to do so that when they lay down on a sterile field, they're already able to be turned in multiple directions to what we need in order to do the surgery appropriately.

Monique Ramsey (06:02):
And let me ask you, what do you mean by prep? Does that mean with the Betadine wash or something like that?

Dr. Swistun (06:08):
Correct, correct. Basically the antiseptic solutions that we clean the skin with for surgery, and it's an unusual situation to be because typically when you have surgery, you go to sleep and that's done after the patient's asleep. In this case, the patient's actually awake for that part. They're standing and they're cooperating while their entire body is getting cleaned so that then they can lay down on the sterile operating table and then go on their anesthesia after that.

Monique Ramsey (06:30):
Do they start face up or face down?

Dr. Swistun (06:32):
Well, they always start face up. They're basically laying on their back, and the anesthesiologist then makes sure that the patient's comfortable and warm and we get their airway secured after they're given general anesthetic. So obviously the rest of the process is just basically very standard. And after the anesthesiologist is very comfortable with their steps that have been taken, then the surgeon sort of takes control of the situation and then we do the procedures and depending on exactly what we're doing, the positions can change. My standard 360 lipo typically starts when the patient is on their back and I would liposuction the entire front and the flanks, maybe the thighs, and then I would turn them to the right side and then to the left side. And on each side we address the entire flank again and the back, the side and the back and sometimes the arms of we're also doing the arms, and then any sort of fat transfer to the buttocks can be done at that same time.

(07:31):
The position on the side really just gives me the best view of the contour, best control of the shape of the waist and the lateral thigh and the buttock at the same time. So I find that to be the most efficient position, even though it requires three positions rather than two, another way to do it's basically prone supine, which means patient is on their back and then just flipped over to the front. Two positions are pretty good, but it doesn't allow me to, at least in my hands, it's not as accurate to sculpt the waist line as well. So I take the extra step of using three positions, but I think it turns into a better result.

Monique Ramsey (08:05):
Now when they wake up in recovery, what are they wearing? What do they go home in?

Dr. Swistun (08:11):
Well, the good news is they don't have to worry about it because everything is put on before they wake up. So after the surgery is done, I typically do use drains for these patients. Typically there's a drain in the front and the drain in the back, and then we put on a garment, basically a gentle compression garment and some padding of gauze in certain areas just to catch any fluid that may be sort of seeping out early on. And then we transfer the patient after they get extubated and woken up from anesthesia, they get transferred over to the gurney and we transfer them to recovery, and then we take all the time we need in order to make sure that they're comfortable before they go home. So it's a process where they wake up and we basically titrate their pain medication according to what we need to do and make sure that they're awake and alert and comfortable.

Monique Ramsey (08:54):
Now, A, when is the first post-op visit? And B, where are they emotionally at that point? Are they sort of zonked out or are they pretty with it? And what would you say in general is sort of their emotional state?

Dr. Swistun (09:09):
Typically what I would do is I would call the patient the next day after we set expectations of what I'm going to be asking. And if everything is good, the patient doesn't necessarily have to come into the clinic that next day. If everything is going as expected, I'm assuming their pain is well controlled, the drains are working, and these are all things that they know how to look for. We teach that in advance, and then we typically would see them in person the day after that, just give them 24 hours to sort of recover and take it easy. And without stressing them with a trip to our clinic, usually just not necessary. If it is, we can certainly see them that day if there is a concern or a problem, but that's very rare the next day when we do see them in person, it really varies. There's some patients that were very much ready for this, certainly patients who had a previous surgery kind of know what to expect, and it's like, "well, yeah, it's sore, but that's exactly what I expected. It's good to go." And then there's some patients that are a little bit surprised. They are saying like, "wow," kind of like you said, Monique, "I was healthy yesterday and now I'm sort of sore all over. Why did I do this to myself?"

Monique Ramsey (10:07):
"What's wrong with me?"

Dr. Swistun (10:08):
There is definitely that moment, and a lot of patients sort of say that, and maybe there is some patients did express guilt to me and it's like, "well, this is a selfish thing. I have kids, I should just be taking care of them. Why did I do this to myself and take myself out of action for a week or two or three and now there's all this hoopla around my recovery and extra people have to get involved just so we can run the family still." And that's I guess a valid question. However, basically I think you deserve it, especially if this is, a lot of patients do this after having one or two or three children and then devoting themselves to raising them and really sacrificing a lot of time and effort into their family. I think it's once they're done with childbearing, it's fair.

Monique Ramsey (10:57):
To feel well to feel like themselves again. I think it's just restoring yourself back to whole, whatever that means for you. Everybody's a little different, but I think that you bringing that up, that mom guilt, I'm sure dads have dad guilt too.

Dr. Swistun (11:14):
Dads are actually the most supportive people and whenever we have the family visit for a post-op, mom feels guilty about being in an absolute position and dad's like, "no, we got this. We're doing this for you. We got everything. Don't worry about it." But it's just difficult to take that guilt away. I think we're all born with it.

Monique Ramsey (11:32):
Right. Well, and how would you say to people listening in the audience who might be thinking about having this done, what's the best way to maybe prepare your spouse, your significant other, your mom, whoever might be taking care of you, that support person? How do you prepare them to be the best support person that they can be?

Dr. Swistun (11:53):
I suppose they can be in the consult and sort of ask those questions prior so that they know what to expect. If you know anybody that went through the process, that really helps tremendously because they can probably weigh in not just on their surgical part of the recovery, but how their family took it and what was needed in order to get through the whole process comfortably, not just for the patient but for the whole family.

Monique Ramsey (12:14):
Now, do you recommend that some people might not go home, that they might go to a hotel for a day or two or in what cases and what have you heard of your patients? What are the choices that they sort of make in that first, let's call it two days?

Dr. Swistun (12:31):
So a lot of patients sort of anticipate that. Some patients make that choice consciously and by themselves. They're like, "well, my home is just too busy. I have two dogs. They're very big. They're going to attack me as soon as I walk through the door. I don't want that." Or some patients say, "I have three kids, but I have the grandma and grandpas over for the next week or two, so they're going to take care of them, so I'm going to just take it easy and focus on my recovery. Let's go to a hotel that's nearby." And if the procedure is extensive enough that it goes over like let's say close to five or six hours, we're expecting a lot of fluid shifts. A lot of times we'll actually recommend that you do something called aftercare, at least for one night, we'll send you to a hotel with one of our specialists who basically deals with who can help you through the initial recovery that somebody who's done this multiple times and knows exactly what to expect and how to take you through that initial 24 hours. And also they can report to us directly, check the set of vitals and make sure that you're doing well and remove a catheter if necessary. There's little things that they can do that really help out early on.

Monique Ramsey (13:35):
I actually love that idea because having surgery later in my life when my kids, I don't know, they were like five and seven or something when I had a surgery and when I came home, the grandma and grandpa were there and they were cooking dinner and I was in the bedroom and my husband was taking care of me, but the smell of the food made me want to just die. Things I didn't expect. And I was like, I wish I was not here right now. It sounded like chaos. It was too much. And I think allowing yourself and maybe building in depending on what your situation is, but building in maybe a night somewhere else, depending on, again, you, might be a good idea to plan it in the budget and maybe with like you say with a nurse or a support person who really knows what they're doing, so you're not, I think we tend to pull the stress on ourselves like, "oh, can he do this and can he also take care of the kids? And is everything okay? And I hear somebody crying and it's too much." It's too much.

Dr. Swistun (14:38):
But you're right. So that's a perspective that I'm glad that you're sharing. I didn't even think about the food in the house being an issue. That's the first time I'm hearing every, but it makes all the sense in the world. Yeah.

Monique Ramsey (14:48):
Yeah, it was pretty bad. It was too much. It was too much. All of it was, I think sort of sensory overload in a way. So speaking of kids, and I know all kids are different ages when we moms decide to go do this to ourselves, what would you recommend how to have those conversations with your kids or how have you heard some of your patients talk about how did they tell the rest of the family or specifically their children?

Dr. Swistun (15:17):
Well, I mean a helpful resource for a lot of patients are their daughters, believe it or not. In fact, I had one of the surgeons that I used to work with in Beverly Hills that was very first question that he would ask the patient if she was going to undergo a major surgery such as liposuction, 360 liposuction. He is like, "I'm interested in how many daughters you have and what are their ages because you have an older daughter, she's in their teens and stuff. She will be probably your best help through this process of recovery." And that seems to be true. But beyond that, I think everyone has their methods of explaining it to their kids. But usually it's just like mom had a medical procedure and she just needs to recover. And it's just as simple as that. And as long as the rest of the family is supportive, then it's not really a big stressor on the kids.

Monique Ramsey (16:02):
I think having that support system, not only going into surgery, but then so when you're coming out of it that you feel safe, I don't know if that's the right word, but that you know, everybody's sort of on your side. What's your advice? Do you have any advice about that or thoughts?

Dr. Swistun (16:21):
I think that's all important, yes, but I would also say that you really just are doing this for yourself. Bottom line is you deserve it. You're doing this for yourself, don't do it for anyone else. And you only live once and you're only going to be in your 24's, 25's once, and if you wait until you're older, that's just, I don't know, a waste of a couple of years of looking the way you want to look while you're living that life. I mean, that's a lot of patients related to that. It's like, "well, when am I going to do this? When I'm 40 or 50? I want to go to the beach now." So yeah, the bottom line is I suppose do it for yourself and then find the support network that supports you in that decision.

Monique Ramsey (17:01):
Yeah. Well, I think people talk about the lifetime value of something. Well, the longer you can amortize it, the better, right? If it costs you $10,000, but you can amortize it over the next 40 years versus the next 10 years. And like you say that having that feeling that you've done something for yourself and that's okay, we can do things for ourselves and then to have those happy years. So getting into, okay, after the first week or so, what kind of things are they the patient's going to expect in terms of, I hear about these garments and the fajas. What is it to faja or not to faja? What is it? What is it and what are these little pads that people put in and at what point, and do you have suggestions of what they should do prior to surgery so that they're set up later? What are your thoughts around just that first maybe three weeks?

Dr. Swistun (17:59):
Well, I mean the intent of the garments that we put on patients is just so that they heal without any major fluid collections. We need a little bit of compression to control the swelling. But in addition to that, if you think about it, we are doing major liposuction, so we are basically removing the fat layer between the skin and the muscle, sort of all around the torso. So there is an empty space in there where that fat used to be and that needs to adhere back down to the tissues. And I accomplish that with the use of drains, which actively remove any oozing from those raw surface areas and basically evacuate that fluid immediately so that the skin and the muscle are together so they can heal. But in addition to that, we use compression basically just keeping that tissue, the skin compressed against the muscle wall so that the healing takes place.

(18:45):
Drains also take care of the swelling more to some extent. The compression garments also do that so that it's a combination of all these factors that contributes to the final result. It really takes about three weeks for that tissue to really seal up. In my experience, before you're sort of off the hook for a fluid collection under the skin, the drains don't usually stay in that long, but we do tell patients to just take it easy and don't do too much, don't raise their heart rate, their blood pressure with even longer walks or things like that just so that fluid loss or oozing in those raw areas is down to a minimum. Drains typically come out one or two weeks afterwards, and then we really rely just on the compression and the patient's activity level to let the rest of the healing take place. After three weeks of 24/7 compression, we basically can ease off and say, "well, now you can just wear the garment only when you're active, but you don't have to wear it 24 hours a day."

(19:43):
Most patients are still more comfortable with the garment on for much longer than three weeks, and that's a preference thing. It's important to find a comfortable garment. I've actually never found the perfect garment. We've gone through lots of brands and lots of shapes and sizes and things like that, and ultimately everybody's a little bit different. So each garment is going to be just a little bit too tight here, just a little bit too loose there and stuff like that. So the padding that you mentioned, this sort of fills in some of these spaces. The more padding and the more complex the garment is made, the more inconvenient that becomes to change it out and things like that. So we try to keep it simple and we usually get it close to where it needs to be. Keep in mind, the garment will also change to some extent because patients are most swollen about 24 hours after the surgery when the tissue swells the most. So the garment needs to be loosest, maybe even a size larger. And then as the swelling goes away and as they recover, we actually downsize that garment. So typically it's the same one that we use that we just make tighter and tighter, and eventually we actually switch 'em to a smaller garment a few weeks out. But again, that's individual to every patient and we see them on a regular basis to that.

Monique Ramsey (20:47):
Now, one of the things I remember vaguely was if you're in the garment and you're sitting in bed or if you lean, I don't know, I felt like when I would take it off to wash it or to switch out to a different one, I would have a crease. And do they need to panic if they have a crease or not panic? Is that normal?

Dr. Swistun (21:09):
Yeah, I mean that's sort of unavoidable. And the good news is that crease is usually on the outside of, basically on the very surface of the body. It's basically a skin crease and not much more than that. And if you just let the swelling go away without doing anything else, that crease will disappear over time. The best way to try to avoid that is, you obviously want to avoid a crease, a permanent crease in a certain area all the time. And this is where we say, "okay, this is where we start massaging. This is where you take off the garment off, adjusted it in certain areas, but try to keep it straight." But a lot of patients will notice some asymmetries, some creases, some little different things like that early on. And that's basically emphasized or scaled up by the fact that there's just swelling in the tissues and that does not manifest into their final result at all.

Monique Ramsey (21:57):
So you were talking about trying to keep the swelling down, keeping the heart rate down, and so a longer walk, say somebody is at two and a half weeks and they're like, "I'm feeling pretty good and I could go walk on the beach, maybe I won't go fast." Is that okay? Or do you just say literally nothing until I tell you to?

Dr. Swistun (22:17):
Usually the way I say it is that usually it's, it's a little bit of a gamble. Once three weeks goes by, I think everything is sealed enough that we can start increasing the levels of exercise, but some patients feel much better after one week and after two, and then they start increasing their distances, increasing their activity. Maybe they just have to get back into work sooner and things like that. And I say, well, I recommend against it only because if you do it, you're just gambling just a little bit of every time you do it. As in you may walk a few blocks here and there and then you don't really see a complication, you don't see a result, but then you feel comfortable doing it because you get away with it once and now you're going to extend it a little bit and at some point it's too much. And then the patient comes back with a fluid collection under the skin, a seroma, which we then have to drain with a needle through the skin and things like that. And then what happens then is that their recovery just gets a little bit extended. It's not a disaster. We'll obviously take care of that, but their recovery now is going to be just one or two weeks longer than it would've otherwise been. Right.

Monique Ramsey (23:19):
So you kind of set yourself back. By trying to maybe do a little too much thinking, you feel good.

Dr. Swistun (23:25):
It's also natural for patients to just want to get back into the regular activities just so that they're not, especially if they're feeling like they're a nuisance on the rest of the family because everybody's taking care of them, and most patients are not used to that, so they almost desire to come back as soon as possible. But that will actually result in if they have a complication that's actually going to be counterproductive, they're going to be out longer.

Monique Ramsey (23:47):
That makes sense. Now, the lipo incisions are pretty small, right?

Dr. Swistun (23:51):
Yeah, the cannula is about four millimeters, the ones that I use, so that technically the incision is about four to five millimeters, which is like...

Monique Ramsey (24:00):
Tiny.

Dr. Swistun (24:01):
this long, and then we close it with deep stitches, so that typically it looks like a little line, a fine line.

Monique Ramsey (24:09):
Oh, so are there any care instructions, I guess do the patients need to do anything at those incision sites at any point?

Dr. Swistun (24:18):
Yeah, typically we recommend scar massage once they're completely healed. So typically once they're out of the garment, but three weeks out, we recommend lots of different massages just to get the best result. There is lymphatic massages that we can talk about that we refer patients to, especially after a 360 lipo or a major surface area liposuction. Those really help. Then for scars themselves, a focal massage of the scar also helps, and that's something that we ask them to do maybe twice a day for about a minute.

Monique Ramsey (24:44):
Okay. So that seems easy. Are there any specific activities, let's talk before we move past the three weeks sort of in that three week period, are there things you don't want them to do other than exercise but or positions that you want them to be in or not be in?

Dr. Swistun (25:04):
Depending on what we did, but typically just regular normal movement is fine. If we did fat transfer, let's say to the buttocks or to the breasts, obviously you want to avoid putting pressure on the areas that were fat transferred. So the patient usually knows exactly where the fat went and depending on where it is, that's the area we avoid pressure on. So a lot of times with fat transfer to the buttocks, the patients will actually sleep on their stomach or sleep on their side to offload the pressure from that area. Once they're sitting, then there's little pillows, little devices that we can recommend in order for them to sort of sit more on their thighs and let the buttocks sort of be suspended in air so that there's not direct pressure on there. Ultimately, a short time of pressure is not a big deal for a couple of minutes. If you push down on that area that we fat grafted, it's not going to displace fat in the different places or it's not going to kill it. But you want to avoid long sustained pressure on the area that we fat grafted as in more than 45 minutes for the first six weeks. I would recommend critically for the first two weeks for sure, but I recommend even be cognizant of it, being cognizant of it for at least six weeks after surgery.

Monique Ramsey (26:14):
And what are the complications? So you talked about fluid buildup if they start exercising too quickly and they could get a seroma. What are the other things that might happen during a 360 lipo recovery?

Dr. Swistun (26:28):
Yeah, I think the seroma is by far the most common one. Again, because of what we did, we just opened up that space and we allow fluid to kind of collect in there if we're not careful. And that's an easy treatment. I mean, they are a complication, but they're more of just a nuisance. They're not very dangerous. I've rarely seen infections. I suppose every time you have surgery, that is another complication that we can see. But obviously the patient gets antibiotics during the surgery and afterwards as long as they have drains typically. So that's not really an issue. Occasionally whenever we close wounds, there is one of the stitches can turn into a little stitch abscess like a spitting stitch, which is also a small nuisance that we treat very easy. That's very rare, but that can happen. I guess the major complications that we also want to avoid, which is why we risk stratify everybody, is something like a blood clot in their legs or things like that, or maybe some sort of a cardiac event. So that's where we really do our homework beforehand and make sure that the patient's healthy enough to undergo the surgery, undergo six hours of anesthesia, undergo major fluid shifts.

Monique Ramsey (27:31):
So let's say you're back to work, you're back to the gym, but when is that final result? Where are they really going to see sort of what you would call their final result? How long does that take?

Dr. Swistun (27:43):
Yeah, I would say about six months is they're close to their final result. They're like 95% there, and at that point, everybody's healed and back to regular activity. Early on, a lot of patients see results within even the first couple of days, even despite the swelling and everything, if there's some obvious areas that we address that were always bothersome, patients see that right away. But the good news is that they continue to shrink and tighten up, and as the swelling goes away, I typically tell patients it takes about six weeks for about 80% of the swelling to go away and about six months for 95 plus percent of the swelling to go away. So at six weeks, they're definitely seeing a result. Six to eight weeks, they're already recovered. They're usually trying on new bathing suits. They know it's not the final result, but they're already seeing a big difference.

(28:26):
And then there's definitely a very positive difference even between six weeks out and six months out because that last 10, 20% of that swelling really makes a difference. The waist just gets that much tighter and the back just shrinks in just a little bit more. And that's when they're really happy and that's when they all come back and realize, "you know what? This was actually worth it. And I remember that first week when I was like, why did I do this? This is why I did that. There's dresses in my closet that were hanging there that I used to just put on. And right now I'm not just wearing that dress. I'm actually rocking that dress." It's a very big difference mentally. They just report all this new confidence every day in every situation, everywhere they go. And that distance, that time distance from surgery allows them to sort of have that mental gratifications like, all right, this was definitely worth it.

Monique Ramsey (29:13):
Yeah, you just got to get there. And that's I think the hard part. And our society is so instant gratification that sometimes it's like, "oh, I got to wait six weeks or I got to wait six months. What do you mean?" Because we're not ever waiting for anything and got to give yourself some mental space to say, "okay, I need to be patient. It's going to be okay." And we've got this whole support system for you. You've got Dr. Swistun, you've got all the nurses, you've got the whole team of people who know what they're doing, have done this for a long time, and who can help you when you're having those doubts or you're having a panic about, what about this? Call us, we're going to answer the phone. And I think you're bringing up a great point with the thought of not just what am I going to look like or when is that final result?

(30:03):
What am I going to look like? How am I going to enjoy that, but who am I going to be? And you're speaking to that more confident self rocking that dress versus just having it in a closet or being able to go shopping in a way that you weren't able to, it wasn't even fun maybe. And now it's like this whole, like you said, a whole world of possibilities sort of opens up. What I keep hearing, and I don't know if you've heard this, but the one thing people keep saying is, "I wish I would've done this sooner." Do you hear that a lot?

Dr. Swistun (30:33):
I do. I do. Yeah. "Why did I wait? I could have been in this situation years ago had I just moved forward." Yes.

Monique Ramsey (30:42):
How long will their results last? Do they last forever? What might people expect in the future?

Dr. Swistun (30:50):
I guess what we're doing with this transformation is that we're sort of resetting the clock and we're changing proportions for the better. So there is some permanency to that result, barring major weight gain or major weight shifts and things like that. Even a little bit of weight gain, even still preserves the contours, preserves the proportions that we have instilled because we basically moved fat around, we changed the proportions of where the fat lives do. I always think about it. I explain to patients that patients are typically born with pretty much all the fat cells that they're ever going to have in their lives from head to toe. And when they gain weight, all the fat cells get bigger, and when they lose weight, all the fat cells get a little bit smaller. And liposuction just rearranges those ratios, those proportions. If we remove a bunch of fat cells from the waste, the waste now has that many less.

(31:36):
And then if we transfer that fat into the buttocks for instance, then the buttocks have that many more. So in the future, when you gain or lose weight, the waste gains a little bit less or the buttock gains a little bit more. Obviously with massive weight gain after a procedure does these proportions tend to get distorted and they sort of go away. And there are patients who sort of come back after a couple of years and it's like, "I had a great result for a while, but then I had a breakup with my boyfriend and I went into a depression state and I was just down for a year and then I gained about 25, 30 pounds. And can we reassess the situation?" And even then they look better than when we started. But there's a little bit of changes, maybe a little bit less favorable, and then there's a couple of little areas that you can focus on and just bring them back. That's not a very common scenario, but I've seen it on occasion. But in general, the proportions sort of stay.

Monique Ramsey (32:28):
Yeah. Let me ask you a question about overall pain. At the beginning, if somebody says, "okay, I'm having 360, we're going all the way around and we're going to do my arms and let's put some fat over here or over there." I guess the more areas that are being operated on, does that magnify the pain that much more?

Dr. Swistun (32:53):
I suppose the more areas you address with any given procedure, the more difficult it is to find the comfortable position, I think is the way to think about it. It's not like every area is super painful or any given area is super painful. Typically everything is just sore, but if you just sore on your abdomen only then you can sort of isolate that and just position yourself in the way that you minimize the sore of the abdomen. If you're sore in the abdomen and the back and the arms and the buttocks and the flanks and the thighs, it becomes that much more difficult to find that comfortable position. Nothing is outrageously bad and we certainly have medications to control that, but I think that's the frustration. Sometimes I just can't find a comfortable position and obviously that's temporary and obviously there's medications that we can titrate to effect so that the patient becomes comfortable, but that's sort of the challenge.

(33:39):
My strategy with pain control is typically for the patient to just stay on something that works all the time. So I typically schedule them on medications that are safe to take for a long time. So usually something like Tylenol dosed at maximum doses that are safe for the patient, but I asked them to take that around the clock. And in addition to that, we use Celebrex now, which is an anti-inflammatory. It's assisted to ibuprofen that we also take. At the same time, these are safe medications that can be taken for a long time, and if you take them around the clock, they actually do a really good job suppressing the vast majority of the pain, and then the patient still has other options on top of that if they need it. So most patients are after a few days, pretty comfortable with just the non-narcotic pain medication regimen, which is very safe. We want them to have good pain control because if they are struggling, there are patients who basically refuse to take a lot of medications, but then they're uncomfortable. Their heart rate is higher, their blood pressure is higher. They're actually probably a little bit more prone towards getting sort of a bleeding event or a seroma or something like that just because their system is so stressed. If your're comfortable, the recovery is a little bit smoother overall.

Monique Ramsey (34:47):
That's interesting. And when you said that, I remember hearing that that pain actually raises your heart rate, is that right?

Dr. Swistun (34:56):
And your blood pressure and your basically entire...

Monique Ramsey (34:57):
Which is so interesting. So yeah, you're not really helping yourself out. You think you might be... interesting. Okay, well, that's a nice little gem. In terms of, you touched on massage, and I'm sure you have people do some themselves, but if you want them to go see a lymphatic drainage specialist, how does that help and what should they expect and what's normal in that realm?

Dr. Swistun (35:26):
Yeah, I think the bigger the surface area of the body that we address with surgery, the more important the lymphatic massages. And early on they really help. It really depends on when the patient can tolerate the massage. I've recommended it as early as 24 hours after surgery, 48 hours after surgery when I was in Beverly Hills, they actually had masseuses that would come into a recovery area 24, 48 hours afterwards and perform the first massage, assuming the patient can tolerate it. Lymphatic massages are actually very gentle, and if done by a proper, a very well, well-trained specialist in them, they're very helpful. I typically recommend one or two or three prior to when the drains are removed because at that point, the massages really take the swelling out of the soft tissue and sort of push it into those empty spaces, and the drain picks up the swelling, the fluid and the swelling just is dramatically reduced early on.

(36:15):
So they get a little bit ahead of the game with doing that. And then even after the drains are removed, continuing the lymphatic massages really allows for the swelling to continue to go away. And as the scars form underneath the tissues, the scars are not tight. They're basically loose and relaxed, and that allows the skin to redrape most favorably over that so that the scar does not tighten and take control over that shape. So lymphatic massages early on, in general, most patients get them maybe two to three massages prior to the drains coming out, and maybe two or three more after the drains come out. So that's a total of six, maybe a couple of days apart. There's also a very big learning curve in how to do it. A lot of the lymphatic masseuses that we work with actually teach the patients how to do it properly. And as the patient is more and more comfortable with it, they sort of take over. And that's a very valuable time spent.

Monique Ramsey (37:04):
Well, and I think we have a group of people that are vetted that are where as the surgeon, yes, I can pass the patient to this person who isn't going to undo or create damage because there's people out there who might say that they're a lymphatic drainage specialist, but they may not be. And I think at that point, listening to the experts at La Jolla Cosmetic who will say, "here's a list, here's who we recommend, here's who we know understands this from a medical and safety perspective," because there's some scary stuff out there. So yeah, I think the last thing I was thinking about was sort of the attention that we might get after surgery, like positive attention. How are we mentally ready for that? And I don't know, what have you heard from patients about what people say?

Dr. Swistun (38:07):
Well, in general, it's a very positive experience. I keep my results really natural. I know that there's some extremes that are out there that whenever patients think about Brazilian butt lift, immediately they think of an oversized hind and a very thin waist, and these extreme contours, which are just not natural. And there are some patients that prefer that, but that's very rare. I rarely have a patient ask for something like that. Most patients just want to look natural, "make me look like I looked when I was 16, when I was 18, when I was in my prime" and stuff like that. So that's where most of my focus is. A lot of patients say, well, they can't really pinpoint what I did. It's not like I lost weight. It's not like I weigh any different, but the proportions are just more favorable now. So in that sense, it's positive. It's not like "what have you done to yourself?" But just like, "oh, you look better. I don't really know why, but you look better."

Monique Ramsey (38:58):
And if it's done right, you're just feeling really great. You're dressing to your new body and to show off your new body, and people are just going to pick up on that confidence, not necessarily like why it's there, but just that you have that kind of newfound vigor for life because you feel great. In the show notes, we will link to, we've had a patient on skinny BBL who talked about that. We have had you talk about 360 lipo in the past where we really get into the procedure more deeply and about skinny BBL. So we'll put some resources in the show notes so that you all, if you're more interested in this procedure, you want to have a little bit deeper knowledge, you can jump in there and take a listen or take a watch. Well, thanks Dr. Swistun. This was fun.

Dr. Swistun (39:49):
Thank you, Monique. Thanks for arranging this. Yeah.

Monique Ramsey (39:51):
Alright, thanks everybody, and check those show notes and we'll see you on the next one.

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Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the XiMED building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram at @LJCSC. The La Jolla Cosmetic podcast is a production of the The Axis, T-H-E-A-X-I-S.io.