Hi, my name is Megan Gruber. I am in private practice in Tampa, Florida, and my practice is almost 100% aesthetic. And I do most of my surgery in my office with the patients completely awake. So today my presentation is going to be about using the fact that patients are awake to improve your outcomes and the reliability of surgery and also to increase patient safety. I have two disclosures, but neither one should impact any of the information in this discussion. I have a media contract with TLC Discovery Productions, and I am a consultant for Apex Renewveon. So why would we ever want to do surgery on patients who are fully awake? In the past, doing surgery on fully awake patients was the domain of the non-surgeon. We would do little things in the office and maybe some liposuction, mostly touch-ups and mole removals and smaller procedures in the office, but in general it was much easier and simpler to have somebody be asleep. These days with the changes in reimbursements and especially with cosmetic surgery and the expense of using the outpatient surgery centers, there's been a resurgence of interest in doing patients while they are fully awake. I also find there's a subset of patients who just don't want general anesthesia for a variety of reasons, whether it's nausea, vomiting, memory problems, hair loss, or real medical indications. There's just an unserved subset of the population who would like to avoid general anesthesia for whatever personal reasons. So for all those reasons, I have found that there is a large demand for patients to stay awake during surgery, and so it is up to us surgeons who could otherwise put patients asleep to bring our expertise and knowledge to this realm, which really has been relegated to our colleagues who are non-surgical. I found that patients moving can actually be a benefit rather than a difficulty. So you can get to difficult to reach areas, you can have the patients move and bend their knee to get into the inner thigh. Axilla is an area that's difficult when patients are asleep that's relatively easy to deal with by just having patients raise their arm, move to the side a little bit. And so for those reasons, I think there are benefits that we haven't explored as surgeons to having the patients be awake and able to follow commands. Another benefit is that the dermis and the muscle fascia remain sensate the way that I anesthetize the fatty areas, and this will allow me to stay in the proper plane and avoid any unnecessary damage during the liposuction portions to the skin and to the muscle fascia. Patients being able to stand up in front of the mirror and see the results really is a benefit to both the patient and the surgeon in that with lipo especially you can get a fast learning curve dealing with the loose skin. The effects of gravity are easy to learn when you can stand the patient up during the surgery and correct anything that you see immediately. Also having the patients involved and invested in the results really helps with satisfaction and realistic expectations. So the patients see how their skin is responding, they see the limitations of the liposuction portions of the surgery, and they understand why we need to make an incision, you know, in a certain place or why they need an extension of their incision, which might be longer than they were asking for. So it really leads to really good patient satisfaction levels, which is in the end what we're all looking for in our techniques anyway. So in terms of incisional surgery, I think we should try to use a more dilute lidocaine mixture than standard. And that 1% really is not necessary to provide anesthesia adequately. And if you want to maximize your surface area that you're going to be working in without general or a sedation, then you need to use more volume. So we want the volume to be less concentrated. And in the opposite way, when you're doing lipo, you can get away with using a slightly more concentrated lidocaine and less volume of it. So I don't usually do a tumescent liposuction. I just use a, probably what would be considered a semi-dry formula, where I use about a one to three volume of numbing fluid. So I don't think that tumescence is necessary to provide the anesthesia for lipo. And in fact, I think that if you use less volume, that you can maximize patient comfort while minimizing shape distortion and minimizing fluid shifts. So when patients are awake, I do think that there are a few things that you should keep in mind, and we've developed a few techniques along the way that have really helped us. So preoperatively, we carboload the patient so that they have enough energy to get through a long procedure. We do use the epinephrine in our tumescent fluid, and it's stressful for the patient. So a combination of that epi and their natural cortisol levels can make them hypoglycemic. Also because we're not using an IV, we have the patients hydrate really well the night before and the morning of the procedure. We've also found that limiting narcotics and not using any kind of sedatives has really improved patient cooperation, and it tends to make the patients more accepting of any small discomfort they might have. And finally, reassuring the patients is really important. It's important to let them know that you're going to be aware of their discomfort, should they have any, and that you will be patient with making sure that they're comfortable at all times. The prep can be very cold for awake patients, and so it's important to warm the prep solution and to dry them really quickly. Intraoperatively, we use a distraction technique called tapping, which I will show you a video of, and also we touch up areas with quarter percent lidocaine on a 14-gauge Klein needle. It's really important that you watch your own anxiety level. We're not always used to operating on awake patients and in the operating room when things go wrong or you're frustrated about something, it's not always that important that you keep your mouth shut, but when the patients are awake, you have to keep your cool at all times and make sure that your anxiety level is low so that everybody in the room feels very calm. And finally, when in doubt, 50% nitrous oxide is really useful. It does provide analgesia without anesthesia, so you don't need your facility to be accredited for anesthesia to use the nitrous oxide. And this can just allow some patients with high anxiety or low pain thresholds to get through the more painful or uncomfortable numbing portions of the procedure. So in the next video, I'm going to show how we do our standing prep. It's fairly typical. We do add in the washing of the bottom of the feet because the patients are going to be completely on the table and we want them to be able to bend their knee and move around. Also you'll notice that on the bed, there's a sterile absorbent pad. This is important if you're doing liposuction and also we use sterile drape tape for patient modesty and make them a sterile bra and panty. The next video will show my technique for wide area local anesthesia for your awake patients before doing an excisional surgery. I use a setup that's quite similar to that for liposuction infiltration, but I don't too mess the fluid. I use much less volume and I use a more concentrated solution than would be used for your typical liposuction. The recipe is shown here on the slide and I'm using about one liter of infiltrate for every three liters of aspirate. So if I'm going to take out a liter of that, I'm only using about 300 CCs of infiltration fluid. So our patient today is wide awake. Say hi. No sedation, just some Percocet, antibiotics, and a little Promethazine. So I'll show you how to do the numbing and this is with half percent lidocaine for the injection. So we're going to have the assistant come in. Tapping method relaxes the patient. The numbing half percent lidocaine. Everything okay so far? Oh good so far. Awesome. And now I'm going to just have her raise this knee and twist your body away from me so we can get to the lateral breast here along the mid axillary line. So that is the injection site for the lipo and now I'm just going to make the cannula insertion site. Any pain with this? No, not yet. So this is a 14-gauge Klein needle and I'll show you the speed of infiltration. You can just take a picture of the infiltration pump. It is at a rate of 0.6 and you can see the red line there that's extremely low. It's not even a level of one. Okay and here's what that looks like. Very slow. That's very important for not causing pain. Okay. Alright so we're going to also do the tapping at this point and this is a little cannula insertion. How's that feel? Fine. Okay so that's no numbing there just only in the skin. It's going to feel like fluid and weird. How's that? Fine. Feels okay. See this is the numbing going into the fat layer and there's no anesthetic at all in there. It's just going in and she's totally fine. Can you describe the sensation at all? There's a little fullness but it's it's not even cold. I expected it to feel cold going in. And I'm going to show you just a little bit of technique how to numb the breast with Tumescent fluid. How are you doing? Wave to the camera. So it's great to put the fluid underneath the breast. You don't want to try to put it through the breast tissue so we put it underneath the breast on. That feel okay? Yes ma'am. Do you feel pressure? Yes. Do you feel sharp pain? No sharp pain. Okay you can be honest, we want this to be real, not sharp pain right now. As you can see, I'm going all the way under the breast, across, over the pectoral muscle fascia and underneath the breast tissue. Try to go through the breast tissue first, it's going to hurt a lot, right? We want to always be aware of what would hurt the awake patient. So here you can see I'm coming to the middle where there's a lot of feeling and does that feel different over there? Yeah. Or it all feels pressure. The next video will show the extent of the lipodissection that I do prior to doing the skin excision. So you'll notice that liposuction will create a very hemostatic field. Both the avulsion technique of removal of the fat as well as the use of epinephrine in your numbing solution will create a very bloodless field for you. And it's really important to use this advantage to make sure that your excision is quick. So if you thoroughly lipo your flap and don't skip the areas to be excised, you'll spend much less time on the excision because you'll be able to do it with scissor and not have to stop for cauterization of any vessels or tying vessels off. So I've finished the lipo and now we did the tummy tuck dissection completely awake, right? Yes. And wave to everybody so they know you're awake. So come on down, we'll show you everything here. So everybody knows how to do a tummy tuck already, but I'm just going to show you what the dissection looks like so you can see it's not like a mini. Come around. Alright, let's hold those up. Okay, so, right, so here's the umbilicus and this part above is all dissected with lipo. So it's very mobile, but you can see here, can you see in there? That it's dissected with lipo. You don't have to dissect it with a cautery. So then we're going to bring it all the way down and you can see she's flat and not sitting up now, but that's going to reach perfectly. Very long torso. So she's got a lot of territory here where we can make a nice flat abdomen. Once your liposuction is complete and you've been able to mobilize the flap with the lipo dissection instead of using electrocautery, you will be able to move the flap, remove the excess skin without elevating that flap off of its vascular supply. So in this way, you've created a vascular robust flap without disconnecting from the underlying fascia. And this type of flap also needs less drainage because it has connections similar to what quilting sutures will do for your flap. So you have the benefit of being able to remove the flap quickly and painlessly with scissors instead of electrocautery and also not having to drain the technique. Okay, so we have completed the skin removal and as you can see, it's basically like a regular breast reduction or breast lift. That's basically it. So we're just going to irrigate with some antibiotic solution and tailor-packaged shut. So the second breast has been reduced with lipo and she's still awake. Hey! And now we're just detaching the inferior part of the pedicle. So this portion here has been liposuctioned, you can see, and there's no breast tissue or fat on the inframammary fold. So this is the old inframammary fold and the new one's going to be up here about an inch and a half or so up. So that's the new one. Alright, so we're going to just close this up and I'll show you a little bit more. Okay, today we are doing the awake body lift. So here we have her back and I'm just dissecting the posterior flaps. Right? Can you wave for us? There you go. There you go. Okay, so she, how you doing under there? Good. Okay, so I don't know if you can see this, but hold down here, let's see. Can you see the dissection here? Yep. Basically lipo has dissected it for us and there's just tiny amounts of bleeding, really for a posterior body lift, very little blood loss at all and I'm not using a bovie yet as you can see. I'm just doing the dissection with scissors and that keeps it a lot more comfortable for the patient and comfortable for me because no smoke. But that's basically it for the posterior dissection. That took about, what, five minutes? Which is much, much faster than if you're doing it with just the bovie alone. All right, so I'm just going to show the dermis and then we'll show you the tummy tuck. Okay, so here you can see the nice dissection that the liposuction does for you, which allows you to just really painlessly come through this. So again, you can see that the point of dissection is sort of already out from the lipo and you can see it very clearly. Hey, here we are. Yeah. Are you feeling okay? Yeah. You were snoring, so I guess that's okay. No, I'm sorry. No, you're good. We like snoring. It means you're comfortable. So again, the whole dissection should be able to be done bloodlessly. Pretty nifty to do a bloodless armpit dissection, I'll tell you that much. That's a heck of a wax. That's a heck of a wax. Here is the entirety of his dissection. Can you wave to everybody? Hey! Pretty cool, huh? I think it's cool. I'll test shove here, and I'm gonna start closing it up. So we're just gonna take some stitches here and close you up. So, this side's loose, this side's tight. Alright, can you see it? You doing okay? He's smiling. It's just totally awake. Wave hi to everybody. Doing okay? Yes. And pain so far on a scale of one to ten? Zero. Zero? Oh my goodness. Are you feeling anything under there? Not at all. Zero. Just tugging, huh? Yep. That is amazing. That's it. All right. It's totally off. The skin's totally off and all we have left to do is close it up. Okay sign. Okay. With the light. Yay! So we just finished our awake thigh length. So hi. Say hi. Hi. And you can see the skin there, right? That's what we took off the right leg. All right so now we're going to get you up. Just sit on the edge for a minute because you've been laying down for a while. You okay? Yep. Wow. Much better. Looks very good. So that is how we do awake liposuction and surgery and thank you very much for watching the presentation. I hope that you learned some pearls for doing office surgery and making it enjoyable for both you and the patient. Thanks. Hello and welcome to our panel on ABCs of anesthesia and body contouring. My name is Omar Baytas. I'm a plastic surgeon in Orlando, Florida. My focus is mostly on post-bariatric or post-weight loss body contouring. I'd like to thank the Society for inviting me to give this talk. I have no relevant financial interests to disclose. So the objectives today of this panel are as follows. My focus will be to identify safe practices in anesthesia with body contouring. I do most of my procedures under general anesthetic in the OR as opposed to the other panelists here today. And so we'll have some interesting discussion afterwards. So, you know, goals after surgery, especially when talking about general anesthesia, we want patients to get up and walk early. We want a rapid recovery. We want to decrease the length of stay, whether that be in the recovery area and certainly in the hospital as that increases costs. And certainly we always want to keep our rate of complications low. And so one of the main medications that we use for post-op pain control are opioids. And unfortunately, opioids have the following side effects, which we all know, respiratory depression. They can increase length of stay. They can cause nausea and vomiting. And as we all know, again, they can cause a delay in recovery of bowel function. None of these are wanted effects. So how do we mitigate that? So we use non-opiate alternatives. So this is a quick list of medications that we can use pre-op, post-op, or pre-op, intra-op, and post-op. And we'll kind of go through all these categories here. Mainly, we'll talk about NSAIDs, Acelacoxib or Acelebrex, which is a special type of NSAID. Acetaminophen, this says IV, but we can certainly use that PO. Ketamine would be intraoperatively gabapentin. Liposomal bupivagine, which we'll focus on during this talk. And then other local anesthetics. So NSAIDs, commonly used ones, will be ibuprofen and naproxen. These will inhibit the cyclooxygenase enzyme and decrease inflammation, decrease pain. This is not used very commonly in my practice, again, because I do a lot of post-bariatric contouring, and a relative contraindication is a history of bariatric surgery due to the risk of ulcers. Other contraindications are a known allergy and pregnancy, or especially the third trimester. So Acelacoxib, as I said, is a special type of NSAID. It is a selective COX-2 inhibitor, but does affect COX-1 to a lesser degree. I do tend to use this in weight loss patients. Certainly a short course, I found it's well tolerated. I do generally touch base with the bariatric surgeons before prescribing this, and most have been pretty open to 10 to 20 tablets for patients. Again, it's a short course, and we've not found any incidents of increased complications. This has not been studied, so anecdotal data. Again, contraindications, pregnancy, or allergy to sulfonamide drugs. Our next class will be neuropathic agents. These are medications like gabapentin or pregabalin. These will inhibit neurotransmitters, and so they can have epileptic properties, but we certainly are using them for their anti-nociceptive or anti-pain properties. Really very minimal contraindications. It's a known allergy. Gabapentin can be sedating. I'll cover that a little bit later on, especially in older patients and especially at higher doses. So that is one to be a little bit careful of in older patients. Next, we have our muscle relaxers. Commonly used muscle relaxers will include methocarbamol, or Robaxin is the brand name. Another one is cyclobenzaprine, also known as Flexeril. So these will block transmission at the neuromuscular junction and help with muscular pain. I find this very useful, for example, in a tummy tuck. Not so much for the abdominal symptoms, but more so for the back when the patient's hunched over for the first few days after a tummy tuck. I find that that can be helpful for some of the back spasms that patients can get. Somewhat of a long list of contraindications, but again, for the most part, pretty well tolerated. Generally be careful in patients with cardiac issues. So again, this will be what my talk is focused on to a large degree, is liposomal bupivacaine, or Expirel. This is delivered using a multivesicular liposomal compound. It does come in two vials, or two sizes, the concentrations being the same. Once the first vial is a 10 cc vial, this is usually a small surgical site. Generally for plastic surgery operations, we'll be using the larger vial, the 20 cc vial, which is 266 milligrams of bupivacaine. So what is a multivesicular liposome? Essentially, it's 20 cc's will have 750 million liposomes. These liposomes will release the medication over an extended period, and the way to get analgesia is to obtain full coverage of the surgical field with the liposomes. So the 266 milligram version can be expanded. You can use normal saline, or lactated ringers, and you can do that using a volume of 280 cc's for a final mix of 300 milliliters. You can also mix it with plain bupivacaine. You just have to make sure that the ratio of plain bupivacaine to Expirel does not exceed one to two milliliters. So keep in mind that Expirel 266 milligrams has 300 milligrams of bupivacaine, so when you do your calculations, that means you can only put in plain bupivacaine in a maximum of 150 milligrams. So if you're using a quarter percent mixture, that's 60 cc's. If you're using a half percent mixture, that's 30 cc's. I'll generally use 30 cc's of a quarter percent mixture, so that keeps me at about 75 milligrams. So again, how do you use it? You're going to dilute it in your mixture of choice. You can inject it several different ways. You can do a field block, a specific nerve block, or you can do a subfascial or regional block, and I'll go over those. The nice thing is it's an intra-op injection and no need for any pumps or catheters like the On-Q pump. So you want to inject one to two cc's per site, and you want to inject in small areas a couple of centimeters apart to cover the whole area. You can inject above and or below the fascia. You can inject into the subcutaneous tissue, and generally the recommendation is to use a 25 gauge or larger needle to not damage the liposomes. So in the breast, generally what you want to do is do a PECS1 and a PECS2 block. A PECS1 block is performed by infiltrating between the PEC major and the PEC minor. A PECS2 block is performed by infiltrating between the PEC minor and serratus anterior. So we're going to inject x-perl into the breast here. I've diluted this in 230 cc's of saline for a total of 250 cc's, and here I'm doing essentially a PECS1 block. I'm injecting between the PEC major and PEC minor. I'm staying parallel to the chest wall. I'm using a large bore needle. I like a spinal needle because I don't have to stick patients as many times and I can reach a little bit farther with that. And generally in the chest or breast I will do 20 cc's in that PECS1 plane and then right here I'm putting five cc's into the serratus to do my PECS2 block. So in this diagram you can see the various types of blocks you can do. You can do a classic tap block which will be T10 to L1. That's the yellow outline here. Subcostal tap T6 to T12. That's this smaller longer oval. You can do a bilateral four-point tap block. That's the blue semi-ovals here along with a larger semi-circle here. Rectus sheath block is going to be this gray diagram here. And then the quadratus lumborum block which is the kind of larger oval in purple. Generally I'll do kind of a rectus sheath block and I'll show that in a minute. You can do this under ultrasound. The nerves typically lie between the internal oblique and transversus abdominus muscles. If you are only doing an abdominoplasty you could do this in this technique and then just flood this plane with your expirale. So this is the same patient we've done the breasts on. Again we've diluted the expirale with 230 cc's of saline. So I've got 200 cc's left to use on the abdomen. I'm going to use again that same large bore needle. I'm going into the fascia. I typically inject on the withdrawal and the goal again is to get one to two cc's every one to two centimeters and flood the entire subfascial plane. I like to do this before I placate. I think otherwise you don't get the entire fascia and I feel like it gives better pain control post-operatively. So the benefits of expirale improve pain control, decreased opioid use, decreased post-operative nausea and vomiting, and shorter length of stay. For me this has really revolutionized my practice whereas in the past I might keep a patient overnight for that first 24 hours to help with pain control. My patients now go home the same day. So the patient who we just watched the videos for went home on post-op day zero. You can see here liposomal bupivacaine versus plain bupivacaine versus the on cue pump versus controls. Expirale or liposomal bupivacaine came in at significantly smaller doses of outside narcotic use compared to all three other groups and they were all statistically significant. A few quick warnings. You have to be careful and use it with other local anesthetics. So I will tumesce the abdomen and then use lidocaine in my tumescent, but you can use that 20 minutes later. And again also you know you're tumescing the subcutaneous space whereas you're injecting the subfascial space so in theory they're not exactly the same site. And then this is metabolized by the liver so use cautiously in patients with liver disease. So multimodal pain therapy. We'll go through that somewhat quickly. Pre-op again we talked about NSAIDs or silicoxib in bariatric patients. Intra-op we can use our bupivacaine, liposomal bupivacaine. And post-op again we can use a whole variety of drugs. So this is our patient from two days. She's post-op day two. Same patient I injected. And tell us about your pain. My pain level is like five. Okay and what medications have you been using? Gabapentin, Robaxin, and Tylenol. Great. You can see the bruising here. Have you taken any narcotics? Have you needed any narcotics? No, not yet. Okay. And pain's been pretty tolerable? Yes. All right. If you had to point to the place where it's the worst, where would you point? Right here. Right there. Okay. All right. And to the sides. And the flanks where the liposuction. Okay. All right. Great. Thank you very much. Thank you. So again a whole long list of adverse reactions. Many of these are pretty typical post-op and in general. So I don't think there's really any fears about using this. So again we talked about ERAS slightly earlier. And so really this was developed to develop to create a patient-centered protocol that's multimodal, multidisciplinary, and evidence-based. And so I encourage you if you're at a hospital or operate at a surgery center to get a group together. It typically takes five to seven people. And these may be, you might only have one surgeon, one anesthesiologist, or CRNA depending on where you operate, and then a nurse in each of these sections. But it's good to sit together regularly and discuss, and sorry, discuss processes and outcomes and how we can improve post-op pain. So again this is an example of an ERAS protocol. We do allow patients to drink clear fluids up to three hours before. And sometimes we'll allow them to even have a drink the evening of and then the morning, or the evening prior and the morning of surgery. Again this is all evidence-based. So the ERAS Society is a non-profit society. It helps develop programs. It is again evidence-based. And a lot of the things we just went through now, like I said, carbohydrate drinks, minimally invasive approaches, managing fluids pre, intra, and post-op, and then early mobilization. So in general, we want to improve overall recovery with decreased use of narcotics and decreased post-op nausea and vomiting. This does lead to increased patient satisfaction, decreased length of stay, and then as I said before, XBRL can be a very useful adjunct and can be an integral part of ERAS protocols. Here are my references. Thank you very much for your time. We have to take questions and have a discussion later. Hi, good morning everyone. This is Spiro Theodoro from New York City. We're going to talk about Brazilian butt lift under local anesthesia. These are my disclosures. So we published Brazilian butt lift under local PRS with Chris and myself, and it took us a long time to develop this, but it had mostly to do with the way that we numb up things. What's important to bring up here is that considering all the issues with safety and injecting the fat into the muscle versus not, we figured that safest way to do this, to do a Brazilian butt lift or fat augmentation would be under local anesthesia, and we'll describe to you our technique and how we did it. Obviously everyone knows that, you know, the number of Brazilian butt lifts has gone on dramatically. It's not that Brazil actually was invented in California by a plastic surgeon there, at least the name was. So that's sort of what we're talking about. Now here is a patient of mine in which she comes in for a butt lift, and I think it's important to delineate, she's explained the reasons what bother her, it's important to delineate that not Brazilian butt lifts are not necessarily large volume for fat grafting. There's a lot of women that are completing apoptosis that just wants a little better shape is what she's saying, she's Brazilian, and we're going to help her with that. So a little better shape, a little better sort of shape and lift, and not all Brazilian butt lifts are large fat grafting. That's really important. Now why is it important? Because every patient that walks in your office that you're doing liposuction now, if we utilize this technique, are possible candidates for, instead of throwing away that fat, giving them a little lift or a little better shape with it. This is very easy to do since we're doing it under local, so here is what this patient looks like. Okay, she has a kind of square looking butt, but as you can see, she doesn't want a large butt, she just wants a shapelier butt. And there's your infraglial crease. Younger patients have a shorter infraglial crease as they get older. The infraglial crease extends as longer because it shows the ptosis of the buttocks. So here is her sort of the markings. A lot of the things related to Brazilian butt augmentation we learned from our friend Dr. Delvecchio. So here are the markings for a Brazilian butt lift under local. So the majority of the fat is going to go laterally, as you can see right here, and to give her that rounder shape that she likes. And of course, as you know, aesthetics, taste changes over time. Women nowadays want to be a little curvier, and you can call this the Kardashian effect, of course. A little curvier versus the 60s, for example, that women want to be sort of flatter and more on hips. So here's the fat where I'm taking it from. Again, flank fat is probably the easiest access and the best fat and it gives you that advantage of making a smaller waist. Now whenever we're looking in the buttocks, you can't look at it in isolation. You have to look at it as part of the rest of the body and how it conforms and how it moves in and how it looks with the rest of your figure. And in this case, you want a smaller waist, right? Everyone looks better with a smaller waist. It doesn't matter how much fat you can take off. You want a smaller waist. And even if you just did that, you just did a smaller waist without the fat, it would look better. The buttocks would look better. Now, this is an area right there, super gluteal, people forget to do it. It's right over the coccyx and there's usually a little fat pad there and I suggest you take it down. All these things help improve the appearance of the buttocks. Now, again, you see Brazilian butt lift, but at the end of the day, it's recreating that infralateral support to give a push of the buttock sort of flap to go higher up. So it's not just, you know, if you have a little of a lady of a person or a patient who's older, you know, after childbirth in the 30s or 40s, they're going to have some melanobacteriosis. So it's not just important to putting it where I'm describing but if you have to, you could always put it in the infraglial crease from lateral to medial to give you that support as well. So typical patient, young, just wants better shape and of course, you want to remove the abdominal fat for sure and put in that place as well. So here we'll go with our technique. So here is what's important to see. As we move along, right, I put them in the lateral decubitus position. Why? Because in lateral decubitus position, this butt flap right here actually falls towards them with gravity. If it doesn't fall, it's actually really young patients. But what that does is it opens up the space for us to come in and inject, put local anesthesia right over the muscle. As you can see right here, now we have direct access. So why over the muscle? Because there's no nerve endings. The nerve endings, majority of the nerve endings are aborization happens over the skin. So if you go deep right off the bat and you inject the base right over the muscle and you let hydro dissection or the actual tumescent anesthesia to sort of flow through, it will help tremendously with numbing the buttocks up. So here's the case. This is how we do it. The different area zones, we start off and finally the last part we do is the infralideal part and we numb them up. It's important here to explain that we're not doing tumescent here. So what you're doing is you're putting a little fluid to numb it up. You're not completely tumescent like it was liposuction. You're doing just enough to actually have a couple hundred cc's per side, just enough to give us some numbing effect. And then you proceed to go ahead and do your actual liposuction. So here's the numbing methodology and how to do it under local anesthesia. As you can see, I'm right above the actual muscle and I'm injecting fat using the expansion vibration liposuction to free the Dr. Del Vecchio, popularized. And here's the best news. While I'm doing this, if I hit the muscle, the patient will jump off the table. So the patient, it acts as the best neurological sort of alarm that we cannot get through the muscle because if you hit the muscle, patient jumps off the table and stop the operation. So we're staying the fat all the time across, over the muscle, injecting in this plane. So the question is, if you can put fluid in, does it distort the actual result? The truth of the matter is no, because you're putting a little fluid in, then you're proceeding to go and do your liposuction part, harvesting your fat. And once that's done, then you come back and you inject the fat in the patient. By the time that's done, most of the lidocaine effect is still there, but most of the fluid is gone because it's about an hour and a half later or an hour later. So depending on how fast you are, at that point, you have the numbing effect, but you don't have the distortion effect from the fluids. It doesn't really matter. This is how, you know, sort of we do it. Now, here's the methodology we use this for local anesthesia, just same issue right here. Chris and I developed this over the years. We go superficial, inject, and here the Greenland is your superficial fascial system. So as you can see, the majority of the nerves, the tree trunks are based on here, and then the majority of the arborization happens at the level of the skin. So then we go into scissors, and here is a live patient. I like doing this one incision. We usually don't use a scalpel. We use, we inject deep just like we described. And then we use a 14-gauge needle to make the incision and proceed. But again, the patient is in a lateral cubitus position while we're injecting the patient for local anesthesia. No poudre orange. Try not to make a wheel because that hurts. Here's a 14-gauge that goes in. The nice thing is that this heals a circle. And so things in nature heal, the circle heal a lot better as opposed to a line. Let's spread a little bit over here. Once you're able to do this, you can do any operation. That's the important thing here. And here we go. So here are the superficial nerves. We go on with your injection cannula and go past the FSFS. You'll feel a little pop when that happens and you'll drop in and you inject most of the fluid down deep. And slowly allow the fluid to rise. By the time it gets to superficial nerves, the patient's numb and the whole process does not hurt. And here's what this looks like. So, as you can see, the injection, down deep, salivation, let everything slowly, not shoving the cannula back and forth. And the only other advantage of this is most of bruising happens during injectional local anesthesia, doesn't matter where in the body. So, you can go nice and slow. And here we go. As you can see earlier, she's in a lateral decubitus position and I'm putting some local and not a lot, just to numb her up a little bit and make the process less painful when we decide to come back for the fat grafting portion. So, you see I'm not shoving it, not pushing it. She's awake. Right? As it'll pull socks, you can put a blood pressure monitor. She said she's good. And this is exactly how we want her to feel when we're doing the things under local. This is the hardest part, is to make this part comfortable because that's what they forget. And you're not shoving it back and forth, you're just slowly advancing as you move along. And that's the plane that opens up in this position. Here we go. Now, we're sucking out the fat. You can use any cannula type you like. You're using micro right here and a four millimeter cannula. All our cannulas are double Mercedes, a little faster. You can do vaser before if you'd like to sort of loosen things up. It doesn't affect the fat transfer, you're the right energy. And here we go. And this is the technique we learned from Dan. Why is it important? Because you're done very quickly, right? No needles, no syringes. You're using expansion, vibration, lipofilling. As you can see here, we're using exploding cannula and we're injecting the fat in the buttocks. And it's important that the pain is, remember, most of the fluid is gone at this point, but the numbing effect is still in process. And in her case, I'm putting the majority of the fat laterally because she wants a better shape. She doesn't want a bigger buttock. She just wants a little rounder on the side. And these are perfect candidates for BBL. And remember, there's not a lot of fat that's being put in here. You can put 300 a side, 500 a side. You're not doing a large volume fat grafting. BBL is not synonymous with large volume fat grafting. It can be about shaping. So now that the patient comes in, she's had one valium, one of Vicodin, nothing IB, she's chilling out. It's important to start looking at patients that are coming into your office as all of them potential candidates for fat grafting because it's so quick to do, easy to do. This adds another maximum 15 minutes to the operation. This part's fast. Remember, she's under a local. So safe. If I hit her buttocks, she'll jump off the table. And here's her result immediately afterwards. As you can see, she's a little rounder, waist is in. So doing the waist is just as critical. Everyone, a lot of people fuss about, you know, where to put the fat, how to put the fat. But at the end of the day, it's just as important to be able to take down the rest and frame the fat accordingly, the butt accordingly. In this case, you see she went from square to round. Here's another patient, 500 a side. So that goes to show you that you can really do a lot right after surgery. You can make her waist smaller and give her buttocks a better shape. Here's another patient, 350 a side. Again, not square, long waist. Here's another one that's been operated two or three times in the past. The cellulite has bad results from prior surgery. You can see her incisions from a, you know, sort of the lift. Again, weight loss patient, all those elements. And again, all you have to do is just reposition the fat and she'll look better. Here's another patient, same cellulite problems and in bad shape right after, 400 cc's a side. And you can see the differences of the wonderful things you can do with fat. In this case, she also, of course, had a little ptosis on her buttocks. So we're also putting fat below and rebuilding her infrared gluteal crease relationship. Now, here's a skinny patient, really important because again, this patient would have never dreamt to have fat done, but you see her infrared gluteal crease. You see the buttock ptosis because of her age and what she wants is a, you know, better shape and a little lift. And if you put the fat in the right place, you know, crisscross the infrared gluteal crease, obliterate it, make it shorter, all that loose, the youthful element. So just this time, I won't show you immediate post-op. So I'll show you some long-term results just to make sure that everyone knows that, you know, what we're doing is we look at very critically. Look at 24 hours. Look at one week. There is minimal of any bruising here and that is for three reasons. Reason number one, 1.5 epinephrine. Reason number two, we use vaser or some energy-based device that doesn't kill the fat. So you have less trauma and bleeding. The reason number three is slow numbing and using Tumescent not shoving it back and forth fast, nice and slow and the block that we create doesn't cause any bruising. See her one a week, two weeks, and one year out. As you can see, she's maintained her shape, the fat's still there. And you can see here's the other side. Again, 24 hours, one a week, two weeks, three months, and one year post-op. So very, you can have patients like this that want a BBL. They're not major fat grafting and the only limiting factor to do large volume fat grafting under local is the amount of local you give. And believe it or not, you can actually segment that, which probably helps anyways because you have a lot of fat loss at once. So you save more fat, come back two weeks later, two months later, do the second part of it if you like. So here is our patient, the one you saw earlier. You know, I think, I don't know what happened when we took this video. Maybe it was one of those mornings. So anyways, but you can see in the video that, you know, actually she looks good. Here is another patient, same situation pre-op, two years post-op. You see the fat maintains all under local anesthesia, same tattoo, same location. I like to tattoo patients for demonstration because it actually shows, you know, different elements that were there. And here she is again. You see the ptosis you had before and you see her result two years post-op. Looks much, much better. So again, look at it as an adjunct to lumbar suction. Don't look at it as large-volume fat graft. You can look at it as, instead of throwing away the fat, giving a little better shape, offering it to her at the same time. And since it's fast and quick and we use UVL for it, and you do it under local, all those elements do not increase the amount of surgery time tremendously. And most importantly, they're safe. So thank you very much. So safe subcutaneous bladder augmentation under local anesthesia. I appreciate you all being with us. Dr. Bates and I are going to be discussing some of the questions that we get most often. Your pre and post-op regimen for Celebrex and Gabapentin. So can you tell us a little bit about the dosage and when to administer, you know, an hour before or so before you take the patient back? Yeah, great question. So generally for Celebrex, we do a 200 milligram dose. Generally, like as you said, about an hour before in the pre-op area. And then for Gabapentin, somewhere between 100 and 300. We also tend to hold that for older patients over 65 or so because combined with anesthesia that can sometimes make for a very drowsy patient, you know, who can, we've had a few cases where they're breathing in the PACU. They're just not really waking up or responding to commands. And so we've cut that dose down or completely made away with it with older patients. And when going away from the narcotics, you know, what should we expect? Do we still give them the narcotics prescription in case they don't respond to this? Do we tell them to up the Gabapentin? You know, what are some of the pearls if somebody hasn't used this combination that you might suggest? So we still do give narcotics. We generally give 12 pills. I like to, generally if I'm dispensing narcotics, I use a number that ends in two. That's always been what I do that way. If someone is writing for 10, 20, 30, some typical number you would see. I know I didn't dispense that. I've had some patients issues with fraud in the past. So I think pick a weird number and stick to it. That way, you know that you wrote it. It's a lot less likely now with electronic prescriptions, but it can still happen. So we give a dozen. The vast majority of my patients say they take none of those that do. They say they take, you know, maybe one the first night, maybe one the second night to help them sleep. But most patients don't even go through the 12 pills that we give them. So maybe even 12 is too much. But I would do, you know, if someone's starting this, I would say the pearl is keep doing what you generally do. We did start to track how many narcotics patients would take. Just a quick questionnaire or, you know, you can just have your PA or if you're seeing them post-op. Hey, how many did you take in the first week? And then as you start to start that process, then you start to cut down. If you see that patients are saying, oh, I took three. Well, maybe then you can just start to give, you know, eight, nine, whatever that might be. So. Okay. So on to your questions about your Xpirel use. Basically, you know, if again, if no, if someone hasn't done this before with the Xpirel and we wanted to start, you know, I think most people want to start with tummy tuck. That's where we've heard, you know, good use of it. If you're not injecting directly into the rectus, if you want to try the tap block, where do you think is a good resource to learn how to do that? Or is it simple enough to, you know, watch a video and do it yourself? When I started, I had some of the anesthesiologists do tap blocks. Unfortunately, you know, I work for a big hospital. We have hundreds of anesthesiologists who cover, you know, our surgery centers, like 10 of our hospitals in the area. So I had someone different each time and sometimes patients did well and other times they did terribly. And then, you know, I do multiple body areas at once. So I might be doing a circumferential body lift. And so a tap block just wasn't enough. So ultimately it made sense for me to just do it myself. You know, I think if you have someone who's with you consistently in the OR, like if you have a private small group or just one or two anesthesiologists, and again, you can, I think tracking those outcomes is important, right? I mean, if you don't know if it worked or not, and that in this situation, it would be the anesthesiologist being able to track or you being able to go back to them and say, hey, on the last two patients you did, it didn't work. We need to do something different. Then I think that's fine. In my case, like I said, I do a lot of body parts. I had someone different every time. So I decided it just made sense for me to do that myself. So I don't do a true tap block. I just do kind of a rectus sheath block. Okay, that's a good segue into the question of if you're doing, you know, something to do with breast, pec, you know, submuscular UGG and a tummy tuck. How do you dilute and how do you separate, you know, how much goes into each area? Good question. So, as I said in my talk, the max you can dilute to is 300 CCs. So that would be your, you know, expiral comes in 20 CC. So you can add 280 CCs of saline or you can mix in some amount of marcaine if you want. I find that kind of pointless for long cases because the expiral will have taken effect anyway by the time the patient wakes up. So 300 CCs and that's basically what you have to play with. Generally, I try to put 25 in an arm or a breast or a thigh per side. So, you know, 50 if you're doing two arms, 50 if you're doing two breasts. I generally try to use 200, give or take, in the abdomen because it's the largest area that we're working on. And I kind of go from there. I mean, I've played with it a lot, you know, sometimes if I have 300, I'll put it all in the abdomen. Then I started working my way down to where I feel like if I do 200, patients are still pretty comfortable. And it can be pretty interesting. I mean, I would ask my patients at the one week or sometimes like a three-day visit, like, where does it hurt? And sometimes if you miss a spot, they can tell you like it hurts right here. And then, you know, you can say, well, maybe I just missed that spot or didn't put any there or, you know, kind of inject it around it, but sometimes they can point to one very specific area. And then I would say the other interesting thing I found is when you do lipo, and I might take some tips from your talk about maybe using like a hyper lidocaine solution, but generally if I'm doing like a tummy tuck with lipo, they hurt in the flanks where I did lipo. They don't hurt in the in the anterior abdomen. So it seems like the X-PRL works really well, but then the 2-method's not working as well. So. Right. Yeah, I think lipo just hurts more in general. It's not as, you know, precise a technique. I guess there's collateral damage, so to speak. Correct. It seems to hurt more for my patients too. And then, you know, of course, there's always the question, how much does it really cost? You know, how have you handled the cost of X-PRL and that, you know? Yeah, I believe because at one of the surgery centers, they wanted to charge for it. I believe it's $300. I'm pretty fortunate. The hospital just rolls it into their facility fee, so we don't charge extra for it. Certainly, if you are, you know, running your own practice, you want to include that in the cost of your surgery. So if you're going to use it, you might just want to add an extra, you know, I don't know if people generally want to make a profit on it, but $300 to $500 extra to make up for that cost. Still cost less than a non-Q-Pump, I guess. I believe so. Again, I don't know the numbers exactly, but I've heard when we were looking at doing it at a surgery center that it was $300. And I don't know, this is maybe like two years ago. So this, you know, it could be even cheaper at this point. All right. Well, that's all the questions that I have. We can move on to questions for my presentation, if you'd like. Yes, let me ask you a couple. I know we had some interesting differences in how we do things. So one of the questions probably you get asked is what are the limitations of awake surgery? So what can you do? What can't you do? Or maybe won't you do from previous experience? Right. So I've found that the most limiting factor is the patient, you know, tolerance for laying on your table. So about four hours is about all people will tolerate and then they just start getting annoyed and antsy. So it's not really about pain. It's not really about lidocaine limits. It's you need to be able to do what you're going to do in four hours. Most of my procedures do not involve muscles. So no submuscular odds, no repair of muscles. Not that I couldn't do it. I probably could. I can definitely do a platysmaplasty under local only. I don't even have to add extra numbing to the platysma itself. It's just so thin there that when you to mess, you know, into the neck, it just anesthetizes the platysma pretty well. And I think we know this because we do the smash and and that with local and so that muscle is an exception. I never go into the you know peritoneum or do anything deep. I can't imagine doing that. But otherwise, even very big surgeries. I will do, you know, a full length I live like a spiral type side lift, I do one leg, and then they rest for five days to a week and then I did the other leg, mostly for fatigue, it's really not because I can't do it it's just you know it's too much for a patient to lay there, and you don't want them getting up and down and you know how to use the restroom and stuff like that. So, we do sometimes use a like a depends underneath not for legs but you know for arms and face, so they don't have to get off the table, but, you know, when you're doing thighs you definitely want to like get in and out of there. It's not a problem for most patients to do one side and then come back and do the other side, everybody's been pretty happy with that. Okay, interesting. And then I think we'd seen this in your video you say that you will basically prep the patient standing and then have them lay on a sterile or table. You know, and you mentioned also I think that patients sometimes can get up and you'll watch, you know, have them look in the mirror and see how they like the result. Yeah, to reprep them I mean are they touching anything like if they have to go to the bathroom Do you have to start that whole process over again. Right. So in general, I'll get through the light bulb, and then I'll stand patients up, and when you stand them up for the light bulb, I put, you know, sterile sheet on the ground so they just, they're not touching anything not there so they can get down without contaminating anything. When they need to use the restroom and we can't, you know, let them just use a depends, or a chucks. Then we do repress the whole, whole thing, but it's pretty it's pretty quick, you know, they, I have the patients do to chlorhexidine washes, just like regular surgery so they really like pretty, pretty prepped and then you know you're in sterile we have So we do prep them, you know, again, but pretty quickly. Okay. And then I think at one point in your talk you mentioned lidocaine and upper limits which what limit do you use for your upper limit by body weight. Right, I always put on the board 35 milligrams per kilogram, and then I also do put 50, just in case I ever go above 35 but it's very rare that I do I'm always around 25 to 30 at the max. I don't plan to do the surgery, if the patient's really, you know, tiny, I don't plan to do a lot on them. And if the patients are bigger of course we're limited in Florida by our four leaders so you don't have to put that much lidocaine in them anyway you can't do their whole body in one session anyway. I have one of the other questions I had, and I'm in Florida too so how does that change, you know, and then earlier just now in the q&a you mentioned that you will sometimes do one time and then bring them back into the other day so if you feel like you might do more than, you know, let's say for let's say you need to do five liters or six liters on a patient you do one side and then have them come back a week later and do the other side or how do you address that. In general, I stay underneath the one liter of lipo with the tummy tucks, but with something like a thigh lift, I'm really doing the lipo, mostly only on where I'm removing the tissue. So, I, I think it's, you know, reasonable to argue that you're taking the fat out whether you're cutting it with a scalpel, or removing it with the lipo, I understand that there could be fluid shift questions, but we don't use an IV, so we're not overloading anybody And I also use, you know, very dry technique. So, maybe one liter in a, in a four liter thigh one liter fluid in the four liter thigh lipo section it down, basically, right along the lines that I'm, you know, going to cut on down to very little. And that's primarily so I don't have to use a bovie a lot. It's not because I love to liposuction it, it's really you don't have to use the bovie and then it's much more hemostatic so it really gets the patient in and out, better to liposuction it down. So, I feel confident that if somebody asked me, you know, do you think this is breaking the rule I don't, I do, I am very careful with the tummy tuck stuff, because that has a very specific role for, for very specific reasons. So those people I do what's called a like a lipo 300 instead of a lipo 360, I stopped short of the rectus right there in the middle I leave it on liposuction, so that it's mobile, and so that I don't have to do more than a liter of lipo. And I guess my other question was does that rule apply if a patient's not under general anesthesia and I mean this is kind of more of a legal question I guess I don't know if you know the answer but I was curious, I think it would apply. It does pretty clearly state that it's a tummy tuck, and it's not in a hospital. So I think it does apply and that's why I'm pretty careful with it. Yeah, I would be too but yeah. Oh, and then my last question, well my, I guess two questions is, do you do everything awake like nothing under general or IV and then since you if you if yes or no. How long does the local typically last on those awake patients. No, I do. I do patients under anesthesia, all the time. It's just after I had this discovery TV show. I'm getting just more and more requests for doing it away. That's what people kind of know me for now but yeah, I sometimes prefer pages to be asleep, especially the very big cases. But I use a mixture of lidocaine and republican and really I'd say it lasts about eight hours. It really lasts a long time. I use 1.5 milligrams of epi per liter and the standard is one milligram of epi per liter. The extra epi makes it very hemostatic, and it just I think it sticks around longer, you know vessels are constricted and my patients usually tell me that they can feel it wearing off when they go home around like 8pm to 10pm. So, you know, we get started I have a strange schedule but I get started on 11. Most days, and it lasts pretty long. So then who, I guess, this leads me to another question then sorry I lied. Who is the patient who comes into your office and says I want this done awake and you say, absolutely not. One of the very most common ones is somebody who needs, you know, breast implant capsule changes placations, I'm not going to sew in there against the rib cage and try to, you know, tack anything to the ribs while somebody is awake that's just way too intense. Same thing like and black capsule like me something that, you know, takes a lot of like hugging and not so ergonomic and sticky mess and stuff like that and I'm not going to want to do that I have gotten into that. Not on purpose but I don't I don't like it. And then of course anybody with any kind of like abdominal issue small hernias or, you know, very, very big guy stasis, stuff like that I don't do, I don't do the placations with patients awake. Have you ever started a case and awake and then realize this was the wrong patient or we've got to abort and do this with this patient asleep or any of those situations. So there were two times that I stopped. One was before I even started the patient had a panic attack. So thank goodness we hadn't even started she just laid on the table was like I can't do this. So that was one. I had done lipo and I was gonna do the VBL, and she was like, you know what, I, I think I'd rather do this under anesthesia. Luckily she had plenty of donor site. So we actually did stop that we didn't do the rest of it and I took her to the OR on another occasion, which she needed anyway because she had more than four liters to remove. But sounds like maybe she had a real apple shape and just nothing in the bum, like it was all in the upper body. So, she did great though. That's great. Okay, so questions I had for you. Great. We are going to have a separate taping with Dr. Theodorou, and so we'll go to that next. Thank you so much. Thanks. Oh, Dr. Theodorou and I both gave presentations on doing surgery on completely awake patients. And I think we get the same question sometimes you know what's the difference between the asleep patient and awake patient and how do you deal with those differences. So one of the questions I wanted to ask you is how you deal with your sterility, when people need to get up. Do you let people use the bathroom, how do you deal with all of that during a longer case. Megan that's a great question. Usually, I prefer they don't get up. But if they do and have to go pee for example, we just bring them back and we tell them we reprep and redrape the whole area again. That's basically it like just like as if he walked in the first time. Right. So we do segmental areas as you know, so I'm not doing that. So it's the flanks and thigh or, you know, for example, that's an easy area to reprep and redo so it's not a full body prep. It's all segmental and as far as sterility is concerned, you know we do wear gowns gloves all that sort of thing just like a regular operative case I know it sounds very obvious but I have seen a lot of physicians just wear gloves and a mask and. I think we're old school about that. Yeah, the last thing regarding that is the room. I definitely keep it warm. I've been trained, you know, Jerry Pittman taught me to keep it around 80 degrees and I think it helps the patient. But people tend to pass out at that, but it's a it's a good workout for us. I can't even imagine. Imagine in an 80 degree room that would be. Wow. But having said that, knock on wood. We published a couple series of over thousands of cases and our infection rate is, you know, under 1% as expected. So, have not seen any issues with that. Another question I had for you. I also do awake BBL and I also believe that it is, you know, at least emotionally, a safer, a safer procedure because you know you're not going through the muscle I mean that you just aren't that the challenge that I've had here and there is with patients with tight buttocks, especially the sort of violin deformity, the hip dip, trying to get that numb, but also not increasing the volume there with your to mess in. So, can you tell us a little bit about, I know you said you put the in and let it to mess but what are the volumes you're using there. No, that's a really good question. So, it's the same technique as we do for awake light though the only difference is I'm not to messing those areas. I'm putting away less. So, in an area where I would normally put 400 or 500 CCS for example to mess it. I'll just put 200. Not so not not full to mess it you don't want to tend to everything, because at some point I'm going to have to go back and put fat in. And I want that most of that fluid to dissipate. So if I'm doing the lateral thighs, or doing the buttocks, and they're on their butt that the pressure from that positioning actually helps the fluid get absorbed even quicker. So if I'm doing the right side and I put some fluid in to 300 CCS, not to mess completely. That's enough to get them numb and by the time they've moved. They sat on that side since I'm working on the other side they put pressure on it, that helps dissipate the fluid, so it's less fluid. And when you come back to it. It pretty numb. I always tell them that, look, it might you might feel a pinch here there it's not exactly like the regular light bow, so be prepared for that but usually works pretty well. To your point about tight about tight and so young patient. That's not as the flap or is not as malleable I understand exactly what you're saying. You just have to go slower and and make sure you're in that plane that plane is matter how tight the patient is that plane is a is an easy plane to go into. And it's. If you're not too messing you're just numbing, then you're putting way less fluid it's fine. So you'll put less fluid and they actually need. As you know, because there's not a lot of plastic surgeons that do a white lipo so I certainly applaud you for doing it I think we're very few of us do it. But having said that we usually put more fluid than you would be under the patient is sedated. But, but I didn't put the same amount of fluid whether it's a date or not, just because it's a habit. And it helps them at the end of the day it helps them with the blood loss. I put 1.5 of epinephrine in versus one. And I think that works great a PA taught that to me one day it was like, let's bruising let's see she so I learned that from them, no issues with heart rate. And I'm sure you saw the same thing so I think the combination of of 1.5 of that be slow to mess it because as you know most bruising happens during to mess in or during putting like an anesthesia no matter where you are. I'm worried if you're adding an adding an energy based tool like laser for example, or body type the heat from that also helps with it so I see that the bruising is very minimal after these operations. Yeah, the big selling point I'm sure Megan you saw the same thing. Yeah. I also add more lidocaine to mine and I add real pivoting because I do you know for our cases where I'm also doing the tuck at this at the same surgery as the lipo. Are you using a one milligram. I mean sorry, a 1000 milligram per liter lidocaine what's your lidocaine amount. So it all depends on what areas or how many areas I'm doing because I still want to stay under the recommendations of the society. Right. So, we can use sometimes we'll use either 50 cc of 2%. If we have to. So that's more than 1000 milligrams, obviously, but it depends on how many areas, I don't push it. Once I know that I estimate ahead of time I tell them look, if you have three areas to be done chances are we can do to safely and then the third, you come in the next day and usually Friday Saturday no one says no to that, or a week later. So it's important to understand that with those lidocaine levels, you have earlier peaks, so they tend to peak at 12 hours, the serum levels. So you got to keep that in mind. So 24 hours gives you plenty of time for the to wash out their system. I also stage things for patients, the recovery is so quick. I usually can, you know, sell them on that you can go back to work and, you know, two or three days. And so I say you know like two shorter periods of recovery is is better than really one long one. So, you know, and it becomes a treatment right me again it becomes a treatment becomes a treatment versus a big operation or something like that. And in Florida, we have pretty strict rules about volumes and four liters doesn't give you much when you're trying to do a 360 on someone, sometimes so. Right. But you also in New York is 500 cc of aspirate, the fat, actually. So fat is what you're allowed to do. If you have a non accredited facility. That's the limit. So, if you have a credit facility like, like we do, obviously it's not an issue. But those are that's what New York State has put in effect. So 500 cc of pure fat is could be about, you know, 1.2 of 1.3 of aspirate. Oh, that's really low. Okay. Yeah, but that's for people who don't have the credit facility. Right. I understand in Florida the constraints are a little different. Yeah, they've, they're trying to prevent the surgery mills, you know, but it affects us as well. Right, right. Um, I think there were some other questions about monitoring, you know, what I remember you saying that the, you know, the brain and the alert oriented times three is your best monitor and I agree totally. I did see a poll socks there and and wondered what, what you're monitoring. Yeah, so I just use a poll socks for purposes demonstration. You know, just to show that everything is fine for people to understand that they're not being cowboys about it. But typically I don't use any of that, any of those, those things. And the reason is I don't use an IV. And, and, and the patients alert and talking to me and breathing that's my best monitor and I would say that initially we were a little concerned about it but we slowly start removing these things, not because they're not necessary. But after you after the first 1000 cases, you see that them talking to you and breathing and responding and alertness is probably your best indication. Obviously we have, you know, we pick our patients as well right, you make sure if you have any, any doubt that there's some medical history that's an issue. You know you got a clearance you do all that, even if we're awake, we get that if we have to. And usually when they have medical history awakes even safer anyways. So, it's a good thing no matter what. I've only had one case where a patient had exhibited signs of laticane toxicity. And it was a case that I did three areas back to back three different days, which was probably in retrospect quite foolish, but it was funny because the first thing they exhibited was perioral numbness or tongue tingling, and they told me about it immediately. So we kept an eye on them kept them you know of course around and, you know, there's not much you could do anyways, but just kept monitoring them they define, but that is one case in, I'd say easy about 5000 cases that exhibit and that was my mistake just trying to make a person happy so what I learned. Don't try to make people everyone happy, you know, stick to your stick to your stick to your rules and guns and you'll be alright. So, yeah, I find the same exact thing. Try to give people a week rest, just so they can you know be energetic enough to go through it again that's one of the things that I found limiting is people's energy level. And with my open surgeries you know I try not to go beyond three or four hours, because they just get tired it's not even the pain or the laticane. It's just sort of like their internal metabolism just says no more. Thank you. I'm done. Three, four hours. Yeah. Well, so, um, you have a couple of papers out on awake BBL, do you have any other resources people can look for out there. We published our initial publication awake life a section was on a laser lipo suction cases the first thousand. Then we did another series of another thousand so that's out there. That's all awake BB awake lipo in general. So those are good resources. We published another paper with Dan Del Vecchio together on post up monitoring using nanotechnology and SJ for BBLs. So, there's a company that makes this vest. It was still a prototype at the time that measures all your vital signs everything post up with non non invasively. So, title volume heart rate blood pressure everything positioning. We published that paper in SJ last year in 23. So that's a good resource for people to look at. But what we found is we put this vest on, you look on your phone and monitor this patient remotely. This is the new sort of way things are going is wearable technology. Yeah, and we found that patients you know we're so strict oh you can't sit after your BBL you can't do this you can't do that. Well, the truth of the matter is, everyone does whatever they want. So, we saw that all those patients only one slipped on their on their on their tummy, the rest slip anywhere there once so whatever retention rates you're looking at 60 to 70% for BBL which is true about everybody. So, important myth to dispel because you go into this BBL clinics and you see people like standing up on all fours. So, that's not necessary at all even though theoretically doesn't make sense because of pressure as we know, but at the end of the day, that just dispelled one myth. So that's a cool paper to look up. Yeah, about artificial intelligence and nanotechnology post-op monitoring, I think there'll be the future for at least are bigger cases like tummy stuff like that. Sounds great. I just also wanted to say that we're going to have a paper out Dan Lalonde and and I and a couple of colleagues about awake surgery so fully awake. Open surgery. So we'll have some resources out there for everybody who may want to start looking into this avenue of our practice. Thank you. Megan Thank you so much. I appreciate you having me and wish everyone good luck with everything. Thank you. Appreciate you too.

Aesthetic

Body Contouring

cosmetic

Anesthesia

Patient Safety

pain management

Perioperative Care

awake surgeries

aesthetic surgeries

local anesthesia

Dr. Megan Gruber

outpatient surgery

general anesthesia

real-time results

patient preferences

Brazilian Butt Lift

Dr. Spiro Theodorou

distraction techniques

preoperative preparation