What Plastic Surgeons See After GLP-1 Weight Loss?

There are what seems to be a lot of people taking GLP-1s, and some people are losing weight faster than they expected, which can have some downstream consequences. Today we are joined by two outstanding plastic surgeons. We're delighted to have them here to talk about some of the cases that they're seeing in their practices with people who have, uh, maybe been treated in an aggressive way with GLP-1s, or just basically had the effect that was desired and now are trying to figure out how they can optimize their look from an aesthetic standpoint.

So, I wanted to kind of kick it off, guys, and talk about — first, uh, introduce you. So, we'll talk, uh, about your whole background and all that good stuff, but, uh, Dr. Rankin, you are a, uh, board-certified, uh, plastic surgeon practicing in Tiburon, California in the San Francisco Bay area. Uh, Dr. Bartholomew, you are a board-certified plastic surgeon. Uh, both of you guys are award-winning guys, by the way. That's always nice to have. Uh, practicing in the Portland, uh, area. So, Portland, Oregon area. Welcome to the show. Episode 27 of Cell to Systems. Uh, great to have you both here.

Thanks for having — great to be here.

Terrific. Great. All right, guys. So, uh, who wants to kick it off? Dr. Rankin, why don't you, uh, take us through what you're seeing with regards to this? And I know this may not be something that you guys are focused on every single day, but who knows? Uh, maybe it is something that you're seeing a little bit of, and you're seeing people coming in with what's quote unquote Ozempic face or Ozempic body. Uh, take us through it.

Absolutely. So, this is something that absolutely impacts my practice every day and people have questions all the time. I think the, uh, the good news here is that there's a ton of data. You know, if you're looking for real answers and not just expert opinion, that there's a whole bunch of data since FDA approval of the GLP-1s in 2019. And so it's given us at least something to be able to stand on when trying to give feedback and advice to these patients that are trying to figure out — well, first and foremost, that they've actually been successful with their weight loss. Congratulations. That's awesome.

You know, and I think that that's one of the things that, uh, while people are naturally concerned about, uh, new medication, one, I think we have a pretty good understanding of what the drugs are doing. Two, uh, we now can essentially, you know, sort of optimize, assuming that people have actually met their goals. So I think that's the one part that, um, that we have lots and lots of questions, but I never want to gloss over the fact that all these people are actually being successful in their weight loss, which is something that I don't think that I had seen previously in practice.

You know, if you looked at people's success in being able to actually achieve durable weight loss just using diet and exercise, it was around 5%. You know, it was not good. And so people felt like they were on this sort of just yo-yo of, um, starving themselves, you know, or getting onto some medication like, you know, fen-phen or their derivatives, in which case you had all sorts of other issues, that you actually had, you know, you had risk to your cardiopulmonary system. You know, great, you can lose weight with fen-phen, but you might have a heart attack. That's not a good trade-off. And so I think that for the GLP-1s, that while there may be some things that we need to manage around them, that overall it seems like to continue to be pretty safe, you know.

So, uh, I think that in my practice the way that this presents is, um, a lot of the times has to do with facial aging. You know, my doctor put me on this, I've had this, you know, tremendous weight loss, whatever that may be. You know, there are some people that it could have been, you know, 20 pounds was meaningful. And other people have come in — we just had a woman who had surgery last week who lost over 100 pounds in the last couple of years just using GLP-1s. You know, she didn't have to go through bariatric surgery anymore or anything like that. And she's had good stable weight loss.

So, uh, depending on whatever that is, that ultimately the way that it impacts my practice from an aesthetic standpoint has to do with facial volume. And I think this is also a very interesting time given the fact that there are, uh, there are some lawsuits out there concerning fillers, uh, that are used to be able to optimize people's aesthetics, uh, in a non-surgical way. And, um, and so ultimately one of the things that I do more often than anything else is facial fat grafting. And so it's a very common conversation that we're having with people that, you know, they don't need a ton of volume, but they feel like that they now have this trade-off, which I think weight loss has always presented — that we gave up the obesity, uh, along with, you know, the risk for diabetes and reflux and all these other things that were, you know, happening. But ultimately, we've now taken on some new things. So if it was body, you had lax skin, and if it's face, you may have laxity plus volume loss. And so for my practice, uh, I think that being able to offer facial fat grafting has been a really great way to address those concerns, um, and not have to give up, you know, the fact that they've been able to achieve their weight loss.

Interesting. In your practice, uh, heavy emphasis on the facial side of things, and Dr. Bartholomew, in your practice, heavy emphasis on the body and breast side of things. I'm curious. I'm really curious to hear what your sort of take is on it and what you're seeing on that side. I mean, I'm sure you both are seeing both, but —

You know, I think it's revolutionary. You know, when I started in practice, uh, bariatric surgery was really the most effective way to get sustained weight loss. As Dr. Rankin mentioned, that is borne out in the literature and that was really the only way to do it. You know, uh, there were certainly folks that did it with diet and exercise, but majority of folks with bariatric surgery.

So I am seeing a tremendous number of people that come in, probably half and half, uh, that are either on GLP-1s or had bariatric surgery, that are the — we call, you know, massive weight loss patients — where they've lost 30, 50, 100 pounds and they have a lot of things, which I'm sure we're going to talk about, in terms of the, you know, the skin. There's some metabolic issues, and they're really different than the bariatric surgery patients. I think we're seeing patients lose weight a lot faster. Um, and we're seeing patients on these medicines, uh, long term.

So, what I see generally that I'm going to be doing something surgically is going to be, um, excess skin. And I think that as opposed to a more sustained, slower weight loss, we're seeing weight loss that's very rapid and there's not a lot of skin sort of retraction, so to speak. So, a lot of these patients have lost a lot of volume, like Dr. Rankin was saying, where they look kind of hollowed out even at a younger age. But, you know, the patients I'm seeing with breast and body have lost a lot of fat in their breast or a lot of volume in the breast and just have a lot of loose skin. And so, a lot of these patients aren't great candidates necessarily for less invasive energy treatments. They really need an excisional procedure — tummy tuck, arm lift, these things where, you know, we're removing that excess skin that won't retract.

So, it's revolutionary. And even the patients that I see that have had bariatric surgery, I'm seeing a number of them that are actually on GLP-1s as maintenance. And there was a study that just came out in one of the plastic surgery journals kind of looking at this and how the complications you'll see vary a little bit between the patients just on GLP-1s versus those on GLP-1 and bariatric surgery. So, we're kind of seeing this, uh, play out and I think it's interesting. We'll get more data on it and how we most effectively work these patients up and treat them. I think as we get more information on kind of this, uh, you know, group of people, group of folks. So yeah, it's really interesting.

I mean, when you think about it, we all work out, right? So we're all in the gym, we're all taking care of ourselves, we're doing those types of things. Um, and we live in these areas where that's like — we have a myriad of opportunities to do that in a, you know, just lots of different ways. So, um, there are those folks who just don't have that. Uh, I always think about the poor person who's stuck in, you know, Fargo, North Dakota in the middle of the winter and the best they can do is work out in their basement. Um, and sort of what's that going to look like.

So, you know, the one thing I do want to get into is the necessity for people to understand that maybe, uh, rapid weight loss sounds fantastic on the front side, backside might not be as great. And one of the ways it should always be worked with is the use of proper diet and exercise. And also GLP-1s kill your thirst signal. So, uh, this notion of dehydration — so staying hydrated, eating the proper amount of protein to maintain muscle, uh, doing some, you know, resistance training to basically make sure your bones stay strong so you don't have some of the issues that can be associated with that. And then also, you both brought it up, making sure that this is a reasonable progression of weight loss. Uh, we all want the quick fix. I mean, hey, I'd like to get you guys to prescribe me a pill where I grow 2 inches in height. Uh, but that's just probably not a good idea, right? So, I'm curious what you guys think about that. Uh, we'll go back to you, Dr. Rankin.

Absolutely. So, I mean, I think that, you know, as far as the exercise component, super important. You know, I think that the, uh, the one thing that I thought was interesting about the original studies for FDA approval, uh, was that these people were not really given a whole lot of — um, it's not like they were given, like, a you know, a list of workouts or a routine or anything like that. It was just like, you're going to inject this medication once a week and you should eat well, to whatever degree that means.

And so, you know, even though I'm being sarcastic, that I think the one question that comes up all the time pertains to — and certainly in media pertains to — loss of lean muscle mass, right? And so I think this is one area where people, you know, they seem to believe that something beyond just, you know, caloric restriction is occurring, you know. And so I certainly don't believe the GLP-1s are targeting lean muscle in a negative way. Uh, I do think that there are some more recent trials that have shown that combining exercise along with your GLP-1 therapy is able to, um — what's the best way to say this? Uh, reduce the proportion of weight loss that is lean muscle, right?

I mean, if you take a look at the bodybuilder population, this is a group of people that are absolutely very interested in maintaining their lean muscle mass. The reason that they don't maintain that shape year round is that it will begin to degrade your lean muscle mass or volume or however you want to put it. And so therefore, it just depends on how aggressive you're being. The same reason that you don't want to suddenly just starve yourself is that ultimately the proportion of muscle mass that you're losing becomes much higher.

So, I think that if people are asking me the best way to use their GLP-1 or how rapidly should I be losing weight, you know, I think that if you're somewhere around a pound a week, you know, which in most people is a negative 3,500 calories a week, that is something that is a little more aggressive than a nutritional, uh, textbook. You know, I think the traditional teachings, if I talked to the nutritionist in the hospital when I was in residency, was they want you to lose half a pound a week. That feels slow as molasses. I mean, it is just impossibly slow. Somebody could go to Chipotle and they might gain two pounds, you know. And so to be able to say that that's consistent, it's hard for the patient to see. So, I think somewhere around 4 lbs per week, uh, allows them to be able to maintain their lean muscle mass.

There may be some loss of lean muscle, but at the end of the day, I think there was a trial that said that with exercise, that of the total amount of weight loss, that you're somewhere around 18%, which is not dissimilar to diet and exercise. So again, I don't think that this is — I don't think the GLP-1 is leading to loss of lean muscle. I think that it is helping people to be able to achieve durable weight loss, and that there is some loss, you know, of lean muscle along the way because you are net negative calories. You just have to be in order to be able to lose that weight. Oh, it's a huge topic, because patients — this was a secondary effect. You know, everybody was so excited about the weight loss and then we figured out that everybody was losing a lot of muscle mass, and just because they weren't eating. And I think people have had to really focus, you know, patients that are on this have to focus on protein and exercise, as Dr. Rankin said. I think that's key.

From a surgical standpoint, what I'm seeing is that some of these patients maybe don't have the nutritional sort of money in the bank, so to speak, to heal their wounds well. And I think we're kind of figuring that out and seeing that some of these patients don't do as well with either wound healing or there's issues. So, I've started to screen for, you know, different nutritional markers that I wouldn't normally screen for, frankly. You know, and I think the GLP-1, uh, patients are not getting as strict follow-up as, say, a bariatric surgery patient, where they're going to be going into a nutritionist on a regular basis at a bariatric center. They tend to get a lot of really good follow-up, and, uh, the folks that are getting it from, say, their PCP or online are not doing that.

And so I've just done that in terms of screening because I think that we're finding out more. I'm certainly seeing these patients — they're probably still not eating enough post-op. So I have to tell them to eat enough, um, so they're not catabolic, not breaking down, you know, they're able to heal wounds post-op. And then they're eating — I always say about a gram, um, uh, per kilo per day of protein. I mean, I think they need to be at least that much to be able to heal their wounds.

So I think people are starting to talk about that in terms of how we care for these patients a little differently, because they're not exactly the same and they're not exactly the same as the patients who just had bariatric surgery. So I think, uh, we're learning a lot. I mean, this whole wave of folks that have had extra skin, they're just not exactly the same as the bariatric patients. So, I think there's a lot of nuance to how we work them up and optimally care for them. And it's going to be a process.

I want to introduce something to the — you just said something about, you know, the protein ratios. Uh, I'm a big believer that it should be a gram per pound of body weight in total. That's because I'm a little bit older and I have age-related anabolic resistance, uh, which can lead to sarcopenia if I'm not careful. So, um, you know, I'm going to push the protein maybe a little bit harder than, uh, the other person just to make sure that I'm getting my leucine threshold met.

Um, the reality is that it can be targeted towards lean body mass. One of the ways that we can do that is understanding what our lean body mass is. You can do that in a couple different ways. Use a DEXA scan or an InBody. So the DEXA — for the listeners who are out there, DEXA scan is basically a form of an X-ray that goes through and takes little slices, looks at all the different fat mass, muscle mass. And then the InBody uses, uh, electromagnetic ability to go through the body and take a look at that. And they're all within degrees of accuracy of each other. Um, some people like, you know, I think the practice is like the form factor of the InBody. Um, but the reality is I think that's a great place for people to really start to understand, hey, what am I really working with?

And one of the things I love about you guys is that you really always look at patients holistically. Uh, whereas I think one of the things I'm concerned with just from being all these years in healthcare is that these GLP-1s are going to wind up — when we know about the neurocognitive benefits, we know about insulin sensitivity, we know about — I mean, the list goes on. The GLP-1s just have a lot of benefits beyond just the immediate side effect of weight loss. There's a thought process that I have, uh, around this — is eventually we're going to see PCPs, primary care providers, just sort of prescribing, uh, GLP-1s just like a statin. So we now look at — you know, you look at statins, you know, we're not really looking at, you got an HDL, LDL, and they go, oh, we — total cholesterol, you need a statin. But we're not looking at ApoB and all the other things that you might need to know, and sort of like what are the sizes of the particles. So I kind of broke that into two different things. We can respond to it two different ways.

Couple of things. So, uh, I think you're absolutely on the right track, and two, I think from PCPs prescribing GLP-1s, we are there. I mean, the number of people that I meet that, you know, I went to see my doc — and so I think really, for, you know, I don't like to see insurance be the gatekeeper for anything, or the one that, you know, dictates what is good or not good for our country or our patients. But, uh, at this point I think the PCPs are more or less on board and prescribing it a lot. And so every once in a while people come and ask me if, you know, it's something that we offer, simply because their insurance company paid for it for the first 90 days and then decided to cut them off, you know, or that their copay was significantly higher.

But that being said, I'd love to actually jump backwards for a second. Uh, Sam, you had made a comment about ordering different labs than you normally would in preparing somebody for surgery. I've got to imagine, no different than the bariatric population, that I like to see stability in weight, you know, for six months before you're going into an operation. So, I'm curious to hear what labs you're ordering, or if even with stable weight, if we're still seeing deficiencies.

Yeah, most of the bariatric patients tend to be pretty worked up. I'm starting to get prealbumin, honestly, because I'm worried people are still potentially losing weight even — and I'm the same way, six months, which is tough to hear as a patient because people want to just get moving. I think you get better results. So six months. But I'm starting to get, uh, some vitamin D levels too. I think there's patients that are deficient in that. There's some, you know, data to show that can affect wound healing, but, um, really — and albumin as well.

So where I wouldn't normally be as concerned about this, or these patients already have the workup from their bariatric center, I'm starting to get these because I'm concerned. Or even, you know, a CBC in an otherwise younger person, that's going to look at their blood count and potentially for anemia, because I'm just trying to pick up some of these potential, you know, in some cases maybe small deficiencies that are going to affect their ability to heal from an elective procedure. So that's really the only thing different. I haven't seen any strong, you know, protocols come out, but I mean, it's kind of on my radar because I'm just wondering if there's other things.

I mean, I think about that. I mean, I'd be curious to know if you're doing anything differently or looking for other vitamin deficiencies or anything to work these patients up. Um, because I think that, you know, they just get prescribed these. I don't think anybody's following up, honestly, or at least in terms of the nutrition. I know that that's not normally part of a, say, a PCP's protocol. They're not getting regular labs. So, you know, that's why I'm a little more worried about this population coming in and maybe being nutritionally deficient in some way that I may not even be aware of.

Well, here's one way that — uh, I mean, admittedly, I'm probably a little bit biased. My wife, uh, works for a company called Function Health, and so I feel like this has been a very, uh, popular, uh, addition to your health screening, uh, in terms of people come in, they're interested in surgery, uh, assuming they meet certain criteria. You know, I think that there is plenty of people that, um, that if you look at the American Society of Anesthesiologists, say that they don't need an EKG and they don't need a lab workup, uh, before they get certain types of surgery.

Uh, but in this case we're almost in this area where we are trying to figure out what to do with, uh, over-information. Like, we just have too much data to go through. Because — well, I love the — I'm kind of a gear head, whether it comes to like cars or bicycles or otherwise, that I just like data, you know. I like all the little things because it gives you all these different ways to be able to manipulate, you know, your patient or optimize them or otherwise. But, uh, going from having, you know, 13 to 20, you know, biomarkers to a panel of 160 has certainly increased, um, the number of levers that we can pull. Uh, and so I think from that standpoint, yeah, I think there's still plenty of them that for me it still remains to be seen how those impact our pre-operative and post-operative management.

Um, you had mentioned prealbumin. That's one that I've always loved because of the short half-life, you know, that it's something that instead of — like, I know patients hate waiting six months once they've reached their weight, but at the same time, prealbumin is one that you can turn them around in a couple of weeks, you know. That if you educate them and get them on the right nutritional package, that you can see that bump with just in a couple of weeks and get them on the road to surgery, recovery, and, you know, happiness and health and all that good stuff.

You mentioned Function Health. I mean, I use Function Health personally, uh, for a variety of reasons. One of the reasons being is that I want to have all of those things in sort of like, hey, I want to see where the smoke signal was on anything, like C-reactive protein was here and now it's up higher over here. So, I'm tracking things, uh, just in my own data set. Um, but I love Function Health and that's what I use. So yeah, however you order the labs, whatever you guys are doing, I can see why you'd want to do that. Uh, trying to make sure the patients heal up correctly and also they're getting the right macro and micronutrients. Also, I'm curious how much, um, counseling are you giving patients with regards to hydration?

Well, I mean, I generally just — I would say nothing more than usual. I mean, to stay hydrated. I mean, I don't prescribe GLP-1s personally, so I'm not involved with that kind of the hydration. And I know that was a great point earlier about these patients aren't taking enough free water. Um, you know, I just make sure they have adequate amounts post-op. I think that's important because if they're not, they're going to get dehydrated or have kidney issues. But, uh, I don't have them usually go too overboard. You know, especially for a lot of the big body surgeries I do. Actually, if you have a tremendous amount of free water, a lot of times that goes into the surgical site, or if I have drains in, it's going to come out the drains because it's just extra water. So, there's definitely a balance.

I agree. Uh, I think that my thoughts about the hydration status, I think, have more to do with — if they're on a GLP-1, I know that one of the biggest reminders for me to drink water — I could probably drink more on a regular basis — is a meal. If you sit down to a meal, you go to a restaurant or something like that, that they're going to offer you a glass of water. Without that trigger, without that reminder to say, oh, I'm going to have some water — or certainly just eating something that's dry or savory is certainly going to trigger that as well.

So, I agree with Sam. I'm not of the mind that I've got a specific volume of water that my patients need to drink after surgery, but the recommendation I have for them is that it should be within arm's reach. In those first couple of days after surgery, people struggle with their appetite. They're not super hungry. And so, without that reminder, they tend to struggle a little bit with maintaining hydration. Because those tissues are leaky, they tend to be relatively dehydrated. And so I tell everybody to have, whether it's, you know, water, Gatorade, or a little protein shake at the bedside. And basically whether or not you're thirsty, they should be sipping on that throughout the day.

Yep. So Alloclade came along and FDA approved now, right? And you can use that. So that's, um, something you use in your practice, Dr. Bartholomew. Uh, Dr. Rankin, I'm not sure if you do or not. But Alloclade for those when you're doing fat grafting that just don't have any fat, they just don't have any to work with or not enough to pull from, whatever. I guess you could explain more about how you do that.

Yeah, I think it's a tremendous option. I mean, it's allograft fat. It's from a human donor. It's been processed in a way that's a little different than it has been historically, and we can get bigger volumes from it. So, I've been pretty cautious with it. I know that there are, you know, when it's been out for about a year, maybe a little less, uh, I inject into the breast, sometimes the hips or around the bottom area just for contour. Um, you know, in my practice, it's not a substitute for a breast implant. It's typically for patients who are very thin and either don't want liposuction to do fat grafting, or that just don't have the fat. Frankly, they just don't have it.

Um, but I've been pretty cautious in terms of the volumes. You know, I think that the downside of it is potentially get what's called fat necrosis, or you can get little lumps or bumps where the fat doesn't survive. And I've been fortunate not seeing that, but, you know, I'm usually kind of a slow adopter of these new technologies in terms of being safe and trying to start out. Because, I mean, you can put massive volumes of this stuff in, but I think that's where you're going to run into more problems. So, I'm seeing more subtle results. It's nice. Patients come in the office and it's a nice option to offer them in lieu of an implant.

I think for our population here, we — I think we both live in areas that are incredibly health-conscious. People here are very active. They lead these tremendously outgoing lives. And so I think the frequency to which I find people that do not have sufficient donor sites is pretty high. And so I think that's where this has created a good opportunity for people, particularly as we get in the last 20 years this increase in, um, we'll call it a South American, uh, aesthetic, you know, that there's a greater desire for having, you know, a rounded backside and decreasing hip dips and things like that. Hip dips are a very natural occurrence for somebody who is physically fit, and particularly for, you know, my runners and, you know, cyclists and stuff like that, that the just the amount of, like, gluteus medius that you build up that's going to add to that hip dip is there.

So it's — I totally agree with Sam that I am not an early adopter of really anything. I think that if somebody is feeling like, oh, I'd like to address this a little bit, I get it. I think doing a ton of it is not in line with my experience at this point. Uh, I think that the smaller volumes, uh, for body contouring and Alloclade have been great for the face. Renuva, I think, has also been — it's a similar product but a little bit different in the sense that, um, that is injected then almost like Sculptra. They really don't see a whole lot of the volume, and over the course of three months their body actually responds by creating its own fat. Um, so I think that's an interesting, uh, difference between the two.

Um, still struggling to understand the, uh, I guess the biochemistry with, uh, with the Alloclade that allows this. I mean, it was real tissue, it does not need to be vascularized, and but somehow does not get broken up, or, uh, so far we're not seeing any, like, granulomatous, uh, results or anything like that. So, uh, like I said, I think that it's promising. It certainly fits a need. Um, but again, I think just, uh, proceeding with caution is usually the, uh, the best approach.

Yep. All right. Well, we are right at that time where it's time to wrap up, guys. Uh, the quick question I have — I know you both have busy surgical days, so I got to let you go. Uh, the question I have for you: if you are a patient, if you're a person and you have used a GLP-1, you've lost a significant amount of weight, you're not satisfied with how you look, what's your first step? What do you do? And how do you make sure you're talking to the right person?

Well, I think the important thing is your weight should be stable for about six months. So I'll often see patients when they're kind of all along that journey, but you want to have a goal in mind, and patients' weight needs to be stable, for my practice, for six months. Get better results, more consistent, more skin retraction, less recurrence of that elasticity.

And I think, you know, a general rule of thumb for patients is if you're standing and that skin is kind of hanging down and it's a little excessive, chances are you're going to need an excisional procedure. There are rare exceptions where you can do a little Renuva or you can do a little Renuvion, which is an energy treatment. I do some liposuction. But frankly, if there's a lot of extra skin, that's going to need a little nip and tuck, it's going to need a little surgical removal. Um, it's always good to look at different options, but, uh, you know, I will say, you know, you can give things time. You know, sometimes people will go six months to a year and you'll get some retraction. But I think at that point, if things have not, uh, retracted significantly, you're going to get a more satisfactory outcome with surgery or some other treatment. And that's what plastic surgeons like myself and Dr. Rankin are here for, to help those patients out.

So yeah, and I think the one thing that's really interesting before we move on to you, Dr. Rankin — uh, Dr. Bartholomew, you know, the thing we've talked about it extensively — the notion of the closures are just so good now that you can have those kind of, uh, nip and tucks. And it's almost — I mean, sure, there's going to be some sort of always a scar, right? But you made them so they're so good now that it's, uh, kind of an interesting time to be doing that.

Dr. Rankin, uh, what do you have to say about — patient says, "Hey, I love it, lost all this weight." You said, "Hey, good on you." Um, and they say to you, "Listen, I just want to get this loose skin," or "I want to fill this in." What should — who should they be looking for? Uh, and how do they go about it? What's the endgame here?

Jock, Dr. Bartholomew, uh, stable weight. Make sure that you have reached a plateau, because in that way you're not catabolic. Uh, and ultimately you're just going to have a way better outcome, right? You don't want to be dealing with wound breakdown and stuff like that.

That being said, look for somebody who is a board-certified — you know, if it's going to be face, board-certified plastic surgeon or board-certified otolaryngologist that just does this. You know, I think that everything that we do is going to be based on certain procedures, but there's also an artistic element to it. And I think one of the things that might be the coolest element of what social media and the internet has done for our industry is simply the ability for patients to be able to see, is this particular doctor's aesthetic in line with what I want? Right? That if you were to go to Scottsdale, Miami, New York City, that the way that they're going to address a neck lift might look different than the way that I address a neck lift.

And so I think that a lot of the times you want to make sure that the patient and the surgeon are on the same page. And at the very beginning of that relationship, you have to be able to make sure that, one, you can communicate. Every single patient encounter is trying to figure out, can we work together? It's a partnership. You know, if it weren't for my patients, I'd be sitting around here just twiddling my thumbs doing nothing. And if it weren't for me, they wouldn't be able to have that opportunity to be able to achieve their goals. And so, as long as we can work together, that ultimately I think that we can achieve some really wonderful outcomes, assuming that it's very clear what their goals are and ultimately we set expectations. And so, essentially, as long as you've met those criteria with whoever it is, that ultimately I think that patients are going to be very, very satisfied.

And I think the last thing I would say is, while there are minimally invasive ways to address changes in your body and your face, that being able to talk to somebody like myself or Dr. Bartholomew, who's going to level with you and say, look, I've got a lot of experience in this setting, and just because you don't want to have this type of incision doesn't mean that's the right surgery for you. And so it doesn't happen very often. My staff does a lovely job of educating patients. But sometimes if the expectations are not aligned with reality, you just say, you know what, someone is going to be able to take care of you, but I don't think I can make you happy. And so I think just being honest and real with people is the best way to be able to take care of them.

That's one thing's for sure. You guys couldn't have been as successful as you've been in your careers — um, you know, Dr. Bartholomew, you voted 12 years in a row by your colleagues as the top guy in your area. Um, and Dr. Rankin, uh, winning, uh, awards as well. What I would say is you guys couldn't have done that without building solid relationships. I think that notion of really connecting to the patient and telling them exactly what they're dealing with is the key. Relationship, patient experience is just so, so important.

So, I want to thank both of you so much for taking the time to come on the show. We really came to that point in time where we've covered a lot of GLP-1 content and we needed to talk to the people who see these patients at the end of the line, when they've actually had the result and maybe they want to make some changes. So again, can't thank you enough for joining us here on Cell to Systems, and I hope you guys will come back at some point in time. We can talk about some other things.

Oh, it'd be great. Thanks for having me, Jock.

Great seeing you, and, uh, maybe we come back and talk about peptides and recovery, Jock.

Yeah, we can definitely do that. Love it. Yeah. All right, y'all. Take care.

All right, guys. Thank you.

Thank you, guys.