2727: The Surgeon Who Rebuilt a Man's Face After a Grizzly Attack! Dr. Benson Pulikkottil

30:29And the bear, you know, bent the knife. And he was shooting the bear. And there was no gun. And we're just like, whatever, dude. Like, sure. they went back years later and found the knife found the gun found all this stuff so he was he was telling us the truth and we've become really good friends so he jumps on this bear gets attacked he and his brother i think brother-in-law are there and he wakes up and he's looking at his midface that's what this portion is called your midface on the floor picks it up puts it in his pocket comes down the mountain with his brother. They get flown to the local ER and then they get flown to us.

31:08And so I'm looking at this piece in a bucket with Lily and I was going to chuck it, get rid of it and start afresh. And she's like, Hey, listen, like let's look at under the microscope and see if there's any blood vessels. And so we clean it off and there's the angular artery, which is an artery that goes on both sides right here that we see. And doing hand surgery, this is why it's a beautiful thing to have a lot of training and a lot of different, just the way you guys do different exercises, you can translate it to different elements in your life. Hand surgery, having that hand surgery fellowship was really important because on people who have arthritis of the base of the thumb, you make an incision here, get rid of the arthritic bone and fix the tendons and do things.

31:52But as you access it, there's a blood vessel there, the radial artery and the vein associated with it. So what if we took this piece and connected it there temporarily to start working on the face? So you took, hold on a second. By the way, are the hands particularly vascular? Oh, yeah. Okay, so this is perfect. So what you did is you took the part of the face and attached it to the artery here in the hand to keep it alive. Right here. To keep it going. To keep it going until we could stabilize this. Because we're working with trauma at this time. Because that was my question is how do you keep that tissue from going necrotic or bad or whatever?

32:28Is it good to put it like so, for instance, if this happens and you have access to ice, is that like the move or is it just how you transport it? That's a great question. So we give lectures to EMS all the time because in Colorado you get stuff sent from Texas. I mean I get stuff sent from Cali, I get stuff from New York. And you have to specifically tell them that let's say a finger is amputated. The way to transport that is not in direct ice. You have to put it in like some kind of gauze in a Ziploc bag over a slurry because the ice crystallizes like the cellular components of the - It destroys it.

33:06And so you won't know until you connect it and you're like, why isn't blood flowing? Because it's essentially frozen. So this facial segment, not only was it, I think it was put in ice, but it was like 12 hours later. So we had such low hope that this would work. And so we're... And what are you looking for when you attach it to the artery of the hand? Is it going to work? Is the blood going to go through? Is it going to color back to it or something? Yeah. Yeah. It's like a gray piece of tissue. And I'm sitting there. We're doing it together. I put the artery together. And having a good vein was really hard.

33:41We finally got the vein together. And there's these two clamps, one on the artery and one on the vein. We removed the vein clamp. And then when I removed the artery clamp... Let's see what happens. It turned pink. and Lily and I looked at each other and we knew that moment, our life changed. And the reason why I say that was this is a case that had never happened before. And we were so young at that time and so fresh. And we took a break at that point and we sat on his stretcher outside the room and we actually both started like kind of crying. We were like, holy crap, Lily, this worked. And now we have to figure out the rest of his face.

34:16Wow. And so the - Now back up for a second. How would you even reconstruct a face without tissue like that? Where would you get it from? Yeah, so that's the reason why. So Lily's also a craniofacial. Lily did plastic surgery, craniofacial surgery, hand surgery, pediatric surgery. So she had all these ideas and she was thinking very rapidly. She's like, listen, if we do this from scratch, this person's going to look like crap and need a face transplant. And so we have this segment, which is so hard to make. It's so hard to make a nose. Why don't we try to use it? That was her logic behind it. But if it's gone, let's say you don't have that segment.

34:54You take tissue, like you can take your rectus with the blood supply, the artery and the vein, and you can kind of stuff that. This is not an aesthetic thing at this point. This is going to be to save their life or temporize them for an eventual face transplant at one of these transplant centers. But we had the piece. And so we really wanted to try to figure out how to make it work. And so when it lit up, that's what they say, when this tissue gets blood flow, it lit up. And we went back and we were like, hey, we got to figure out the face now. So Lily did a bunch of bony work, put plates on. We washed out the face together.

35:35And we put dressings on and we just let that chill. That night, the nasal segment became purple. And so what that means is when you have arterial blood going in, that's oxygenated. Venous blood, the vein takes it away. That's deoxygenated. So the vein had some issue. So we went back and we tried to fix the vein, but it was still, there was a purplish hue to the tissue. And if you leave it like that, the tissue clots off and becomes necrotic, like you said. So this is where we go old school and we have to use medicinal leeches. And so what leeches - Because the anticoagulant effects of the - Yes, exactly.

36:12Suck it, huh? Well, no, they have compounds that prevent clots. Yeah, it's a compound that breaks clots, but also the mechanical act of removing that deoxygenated blood allows, in time, it takes about 12 days is what the studies say, for new veins to take this. So we were leeching him. nurses were like putting a leech on him every couple hours, taking it off for like 12 days. Wow. That's crazy. In the ICU. Do you just have leeches laying around there? There's a number called 1-800-LEACHES. Shut up. Seriously, look it up. Look it up. I swear. It's in my top 10. It's a real thing. You call 1-800-LEACHES.

36:51Pharmacy comes and they send you a bunch of sterile leeches. Okay, so I'm trying to envision this. Tagline, we suck. We suck. We suck hard. Okay, this guy is, I'm sure, laying in a bed, And his nose is attached to his hand the whole time? The whole time. That's wild. But now we're - I didn't know that was a thing. No, and we should look at the pictures. I'll keep them clean for you at some point, just because we're so proud of this, because it's just - Hadn't been done, right? It's incredible. It hadn't been done, but it's like, it's a husband and wife team just trying to figure this. It's just such a, it's a storybook for us.

37:25And then his face was like a big gap here. And so we got him through that first surgery, and now we're trying to figure out, what to use to close this gap to just get him stable to heal. And one of the techniques is, it's called free flap. A free flap is a piece of tissue that has an artery and a vein. So you take it off, it almost looks like an island with two tails, artery and vein. And the whole body has these all around them. Like your body is perfused and has blood flow in these different territories, and you just have to know where they are. And one of them is by the leg here. And so when people have cancer of the jaw or mandibular issues, one of the treatments for it is the ENT surgeon will take the mandible out and you need a new mandible.

38:19So we take the fibula out from here to here, a segment that doesn't really affect your ankle or knee too much. we take the bone out with the overlying skin artery and vein we cut it according to 3d constructs to match this segment and we plug it into the carotid vessels does it does it so they they then have a piece missing from there but the tibia does the job tibia does the job you lose they say there's 15 sure is what you lose but honestly we with our patients i don't really see that. And so that is in the, again, plastic surgery, it's awesome because you don't have to get so stuck in the text, the Funk and Wagnalls.

39:05You get to, if you know anatomy and you can logically think and you're creative. I was just going to say, you get really creative. You get creative. And so we didn't, the rest of his body had bite marks and cuts. So all we had was this segment, which wasn't ideal. He didn't need bone. We just needed the skin. So we took the skin with the blood vessel. We also took the bone and put it in the fridge just in case some of the bony work didn't heal down the future. And we put a big plug over his face. So he did not look human for a while. And he had this patch here of skin, two eyes, and a lower lip.

39:43And we let him stabilize the trauma team saved his life at swedish and it's a level one trauma center and those guys were amazing and now he's outpatient and now we can start taking off the the save your life hat and put on the reconstructive kind of artistic wow so that's just like a patch to to bridge to bring you have to wait till he's like okay yeah he had hand fractures he had all the stuff that needed to be taken care of how long does that take before you So how long does he look like that? So we had him, but that thing was on his arm for like two years. Oh, shit. Wow. Yeah. Whoa, whoa, whoa.

40:19His nose is attached to his hand for two years? Two years. Get the fuck out of here. 100%. So he's walking around? Or is he in the hospital the whole time? No, no. He's really funny, man. He'll be at restaurants in Pennsylvania and be like, I got to blow my nose. Yeah. What? That's crazy. He's the funniest guy, man. He's a guy you may want to have interview one day. but um so then now we went to a major conference in microsurgery the american society of reconstructive microsurgery and we found two of the the thought leaders these gray-haired guys that do a lot of this stuff and we were waiting in line to talk to them because everyone wants their like autograph or something we just had yeah i drew on a napkin our case that i wanted to present like this is where we're at this is what we're thinking.

41:09And so both of them were like, huh? And we're like, well, what do you think? Like, you guys did a good job. We have no idea what to do. And so we're like, oh, thanks. And so interestingly, I didn't mention this. He had a cleft lip and a cleft nose. So part of that lip and part of the nose had a little mark in it. And over the two years, that half got necrotic and died. So we were left with this half nose and we were like, what are we going to do with this? This doesn't look like a nose anymore. And so first things first, he needed an upper lip. And so this is a cool, this is also a cool picture.

41:49Lily found one paper that talked about putting a tissue expander, which is a balloon that expands the scalp. And over a period of three months you get, looks like an extra skull up here, a big bubble of tissue. And so - Stretches it. It stretches it. You put a little fluid every couple of weeks and you put - What's that for? Is that to use the tissue or is that for a different procedure? For the tissue because what, there's two blood vessels here, the superficial temporal artery, one here and one here. So she essentially planned out a headband flap, like a headband, drew it out put the expander underneath and then we cut it like this and just brought it as an upper lip hair was even growing down um and then in the you know plastic surgery is cool because you essentially do small moves we do a big move and then you whittle it away and so we removed the two segments and now he had this big handlebar mustache which was his scalp and he loved it he loved it I'm going to show you all this man you got to see it's amazing because he sends us a picture and we were like at this point we were like kind of hoping he didn't want to use the forearm because it's so hard we were like maybe you want to do a prosthetic and because a prosthetic you know they're awesome looking but it's a prosthetic it's like the Groucho Marx thing you're talking about but he he ultimately wanted to use that tissue so now we had to really think this through.

43:21So it's on his arm and we used the existing radial tissue, the arm tissue, and kind of created that other half with it and took the blood vessels, the radial artery and the vein with it out, plugged it on his nose and sewed it to his neck vessels. When we did that and put it the right way down, it turned blue. And so we moved things around in the neck and whatever we did, it would not stay the right color. So the only way it would stay the right colors, we had to put it upside down. And so for three weeks, he had his nose upside down. And there's a really cool video of us taking him to the OR and me releasing it and turning it right side down because it had enough time to mature the blood vessels.

44:12And so - How did you figure that out? Are you just moving it around? Oh, there it is. That's weird. You put a dopp, there's a little machine called a Doppler machine that lets you listen to the blood flow. And when you turned it, it would go away. And I'm like, damn. We have to do this for a while. Yeah. And so. How is his breathing and everything? He's got a trachea. Yeah, trachea. He's got a trachea. And so he finishes that course. He's in the ICU and he puts a picture of himself on Facebook. He's so thankful. He's like, my docs, they did this. This happened. But it looked like a big ball on his nose.

44:46And I'm looking at it, I'm like, and Lily and I are like, this is not a good nose. And so we started thinking, what if we make this the internal part of your nose? And so we went with that plan now. And we used rib cartilage, took a piece of rib to give him what's called the dorsum ear cartilage to give him the shape of the nostrils. And now he needed a cover because you're looking at innards now because we again whittled this down to the inner portion and we needed something to cover it. So again, we use that expander, we put it under his forehead. We drew out a nose like this shape. And over a period of a month, we released it, flipped it down, kept it connected.

45:35So there's blood flow going like this. And then at three weeks we released it. And so it's, it's, it's, it's amazing. it's amazing um that this works that it works that you can stay alive the whole process that like that's that's wild that i mean troubleshoot your whole way through all that in the end how long did this this whole process take for this guy probably like two and a half three years and even now like there's still little things we we tweak like every now and then he has a little thickness in his nose so he has this so one of the most beautiful experiences was we were in. He had his nose.

46:14He's sitting there in the ICU. And this was essentially, we thought, going to be functional for breathing, but he'd lost his sense of smell, we thought. And it was really for aesthetics. Because these patients, they're not trying to be on the cover of GQ, man. What they're trying to do is just get milk, get gas, and not be stared at. Burn patients, trauma patients, that's all they want to do is live a normal life. And so his wife was cutting an orange and he wasn't he was just like oh i smell an orange and everyone freaked out because his olfactory sense his smell was intact that's remarkable it was unbelievable and we didn't do anything for that that just meant that the beard didn't attack it how do you uh how do you work so burn has to be the other incredibly challenging thing because how do you get skin that was severely burned to i don't know grow back or look like it wasn't severely burned uh what what does that look like?

47:11Is that still very difficult, almost impossible? Like, how do you do that? Yeah. I mean, the cool thing about our burn unit, it's, I think, and I'm a super confident guy about this. We are the best in the world. And the reason why I say that is we're double board, certified plastic, reconstructive surgeons, four of us. We love each other. We love taking care of patients and we love complexity and really getting people back. We love when we get pictures of these patients doing the stuff that they used to do. So when you come in with a big burn, it's not necessarily the burn that kills you. It's the inflammatory cascade afterwards that gets you.

47:53So kidney shutting down, infection, lung issues. So back in the day, the way they treated big burns was if you had a big burn, like 30, 40, 50, 60, they just did wound care and everybody was dying. There was a fire, I think in the 40s or 50s in Florida, where multiple people got burned. I mean, I think maybe 100 or more. And the surgeons at that time thought about, what if we just excise the source of this inflammation, the source where the inflammation starts? So they'd cut away the burned skin and put dressings on. They noticed - Let it heal from there. Well, do that first and see what happens.

48:35The patients were living at that point. It will never heal on its own unless it's a really small burn that the skin around it can close. But if you have a big burn, you need skin from your body on it in some fashion. So fast forward to what we do now. So now if a patient comes in 20, 30, 40, 50 % burn, we stabilize them. The resuscitation, we give them fluids. We watch their hearts. And our ICU doctors are just badass. They just come in and they save people that you think would die in transport. So now it's our part. And usually the second day we go in and we essentially just take a scalpel or an instrument and remove that burn until you get to healthy bleeding tissue.

49:23Now it's about temporizing them. So we in our unit use donated human skin. And I put that in a recent post on my Instagram was holding a sheet of human skin that was like this big that gets donated. It's a gift. It's a real blessing to have this stuff. And we essentially put this on to temporize them. The body will do everything except accept it. So it'll start growing. It'll start healing. But it can't accept it because there's an immunologic barrier there. And so now, depending on the size of their burn, let's say they're like 30 % burn, you have 70 % of their body, which is not burn, that you can use to help transplant from that side onto your burn.

50:08So some cool things we do, anytime a burn over 30 % comes, we take two specimens from the groin about that big, we send it off to a company. the company takes that skin and they make a really thin epithelial layer very thin epithelial layer so they're essentially making skin but it's not full it's not like are they are they taking the stems of the cells and having no they take the epithelial they're sending it like right nope they take it and put it in culture under a hood and they just grow sheets of petri dishes oh wow and but it's like very very very thin right the thing that kills these patients is infection one of your best barriers for infection is skin.

50:50And so what we do is, and that takes about three weeks. So now we're doing, we have the donated skin and you have this cooking in the background. We start planning on optimizing nutrition, which is huge. This is what we talk about. Creatine, those kinds of things, vitamins, all that stuff really helps. Are you giving them amino acids, protein? What are the things that help grow? Okay. Oh yeah. I mean like they're on tube feeds that are optimized for protein. Their protein losses are just unbelievable when you don't have skin. Yeah, I say that because the original studies on, when you look up the old studies on essential amino acids, branching amino acids, they were all done on burn victims.

51:27It was all burn victims is where we got the data that it helps with some of the stuff. And when you think about in medicine, a lot of the advances happen in really violent and dark times, wars, big tragedies, things like that. Huge need. Yeah, and so now you have this patient, He's got, he or she has donated skin on. You bring them back, you change out the donated skin and you find the areas where they have normal skin and you take what's called a dermatome, which is essentially a, looks like a tool that extremely thin slices of skin. So you put it on the normal areas and you harvest skin off of them.

52:07You put it through a machine called a mesher, which takes that skin and puts holes in it so you can stretch it out. And then you start covering them. Right. At the same time you're covering them, you get that company to send you the thin sheets and you can sometimes put that on top to help fill in those gaps. Sometimes some. So if you don't have a lot of donor sets, let's say you're 80 percent burn when they have 20 percent of your skin available. You take the skin, you mesh it. Now there's different patterns. There's one-to-one, which is like small holes. There's eight-to-one, which are huge holes.

52:46So you have, it looks like a sheet with just lines. Now to help allow for those skin cells to close, that's when the company helps a lot with that thin skin in between because it acts like a bridge. How does the, because we met you, I met you at the Peptide Congress. Sure, yeah. So I'm assuming now you're looking at using peptides to accelerate or help us process things like GHKCU and BPC. Yeah, no, BPC, 157, GHKCU. All of these things are awesome, but medicine is slow. If you notice that that peptide conference, the people moving the needle aren't the docs necessarily. It's people like you guys talking about it.

53:33It's the people who are actually using it. And what I feel is just modern day medicine, there's so much red tape to get that stuff through. For me to even change a dressing kind of algorithm takes a lot of effort. So peptides aren't incorporated yet, but there is no doubt that that'll be the future of this stuff for healing. I mean, I used BPC, I had IT band syndrome for like two months. I did it for two and a half weeks, went away completely. And so, I mean, I'm not here to like give medical advice about peptides, but just anecdotally for me, they've helped me. And I just see the way medicine is going.

54:19So can you not, so right now you can't use it with patients? You can't. Oh, wow. Unless it was what, private? Because if it was like someone like, I'll pay out of pocket or whatever. I was just saying, are you even allowed to do that? Like, hey, I can't recommend this to you, but I've heard or seen. You can. And there's like non-uninformed people that can, that have been doing that. I mean, in my aesthetic practice, I talk to patients about the benefits of peptides after a facelift, after, you know, aesthetic surgery. Because they can go do their research and essentially if they want, buy it on their own.

54:55And I can only tell them, I mean, I tell them the risks that it's, there's no long-term studies on this. but there's no doubt that there is benefit in in these these these peptides it's just with medicine you need to go through the randomized control trials you need to ensure that uh they're not harming patients it's gonna take a decade before it's possible yeah it's possible but uh how how hard is it to uh to reattach parts of the hand because it's such a yeah i mean there's there's there's constant movement yeah so much articulation and so much touch and so much we do with our hands and i mean if you look at the anatomy of a hand it's like good luck i would actually would have thought because isn't there's more nerve endings in the feet than there are the hands i would think the feet would be as hard or harder does that make a difference um we don't there are from from you know just hearing that you know i think there's more nerve endings just because we're making more contact but uh i'm actually not sure if that's the case but i think that the foot there's a lot more give if you lose toes that's right you're not gonna sure you're not we do things to engage in right so it's not as big of a deal if my foot doesn't look as good it doesn't move quite as good you're not playing a piano with your foot and you're not picking up a fork and so when it comes to hands now essentially the hand is skin and this is a different type of skin than the rest of your body the soles and this is called glabrous skin.

56:23There's more nerve endings. There's different, uh, architecture to it. And so it's skin underneath it. There's actually a lot of muscles, small intrinsic hand muscles. There's nerve, there's bone, there's tendon, there's, uh, on this side, same thing, skin, tendon, bone, ligaments, all of these things. When you, when you, and we, I do a lot of wide awake surgery. So if somebody comes in with the tendon cut, I'll, I'll numb their entire hand and do it while they're awake do it while they're awake so i can get the tendon to the right excursion so so you can ask them to do something i ask them to open up and if it's a little low i'll tighten it up i see and so when you're watching this this dance of extensor tendon with flexor tendon and um just motion it's hard not to be amazed it just is because it's like you said, it's so complex.

57:17And when these structures get cut, it's very, very hard to make them perfect. But recently I had a patient, she's 20 something. She was, you know, having a hard time and she tried to kill herself. She took a box cutter and went right at her wrist longitudinally so deep she cut the bone. And what's interesting is I got the call in the middle of the night. I went over all the tendons, all the arteries, all the nerves, and I put them back together, spent all this time. It looked really cool, really good repairs. Went home, went to sleep. She came back in on a Wednesday and I take care of a lot of these patients.

58:10Some of them don't even show up for follow-up because they're in their mind state. First thing she says is, I'm really sorry. So you don't have to be sorry. And she said, no, no. I heard when that year I called you, your kids were crying. And it's the first time like I've ever heard a patient say something like that. And I was like, listen, this person's different. And so to answer your question, the surgery part is challenging, but the stuff after is where it counts. So I knew this girl was different than the rest. So she was coming to therapy. all the time. And it's really important because your body is not as smart as you think.

58:46When you fix a bone, the bone heals, but it scars everything else above it. So you have to differentially move things. You guys know this when you train people, like body parts and muscles slide over each other. And if you're not aware of that - It's not exactly like a puzzle. It's not. And so the hand therapist is crucial in making sure the tendons move just enough so scar doesn't happen on the bones and additional surgeries and function isn't limited. How do you attach tendon? Is tendon to tendon or tendon to muscle harder to attach? Tendon to muscle because tendon to tendon, when you look at a tendon, this is also amazing.

59:26Look, you don't really see blood vessels with your eyes, but there are microscopic blood vessels there. And so you take a suture. So imagine a tendon and tendon in like this. You put a suture in like this, you wrap it around and you have it come out this way and you do the same format. Oh, I see. And then when you tighten it, it connects this way. And if you've seen a tendon, there's some substance to them. Whereas muscle is just loosey. I was just going to say, how do you attach a tendon to a muscle? So there are some techniques. In the muscle, you can take a baseball stitch. And sometimes if I have a loose piece of muscle like a lawnmower injures, the muscle is cut.

1:00:03You do a baseball stitch. And attach to the stitch. Attach to the stitch, exactly. Does it heal back just as strong? It can, yeah. And there's techniques you can do. You have some extraneous tendons in your body, like this tendon right here is called the palmaris. You can take that out. And use it? And use it for grafting, and I do that all the time. Why is it sometimes I see people get a torn bicep and they just leave it torn, and they don't pull the bicep back down and reattach it? Is it because it's like, eh, I waste the time? There's a couple of reasons. One is you have another muscle, the brachialis, that can do that function.

1:00:39Sometimes people are— So it's more aesthetic than anything. Well, one of the reasons it may not be possible. The tendon may be—the tendinous portion may not be enough to implant back into the bone. But a lot of times people who have that will get that fixed. It's easier than like a pec, for example. I was just going to say— A pec is really challenging to fix. It typically tears up your armpit, and that's pretty difficult. Yeah, because it's all muscle at that point. Wow. Wow, that's interesting. That's fascinating. So, yeah, to me, the hands are so fascinating because what I was told, or not taught, because it's not something I learned necessarily, but what I would hear the surgeons that I trained, and I never trained a hand surgeon, but I did train general surgeon, vascular surgeon, a lot of anesthesiologists.

1:01:28they would talk about how like the hands were just like yeah that's that's tough that's really really tough because of just all the moving parts and how intricate the hands are and how much feel there is and so that's got to be one of the more difficult areas to hand is very challenging and really the when we're on call for hand if the arteries cut you have like four to six hours before they start losing tissue and get necrotic things like that if the nerve is cut it. you have like 12 to 18 months after you repair to see if it'll come back. So the nerve is actually one of the most, like if there's an injury there.

1:02:07Resilient? No, no. It's actually if you cut like the median nerve or one of the major nerves, that's what really dictates your function. Yeah, if there's no nerves, no juice moving to the muscle. And so sensation, motion, like you said, and where you cut it makes a difference. If you cut a nerve up here, the chance of you getting sensation and feeling in your arm and your hand is much less than if you cut it here. I love asking doctors, especially surgeons, this question. What are some of the characteristics that you notice in patients who seem to do the best? Are there personality traits or characteristics?

1:02:42Or what about healthy bodies? Like when you're working on somebody who's fit and strong and healthy versus somebody that's not. But that makes a difference. 100%. And I talk about this a lot with my colleagues. I'm sure you noticed and I noticed. A lot of doctors aren't the healthiest. And it's not that they don't want to be healthy. There's something in the culture of medical school, of training, where you give everything. You sacrifice your health. You sacrifice everything. Your sleep, your health, your diet, everything. At some point, you'll get to it. I've never been that way. I've always really felt that it's a sport.

1:03:19And for me to perform in the operating room, I have to be mobile. I have to be strong. I have to be able to. And so I train every morning at 4.50. I train today. And so I think that when I have a patient, I try to convey the importance of that. Part of it is, hey, listen, you're going to get through this and you're going to crush therapy. You're going to get your function back. You're going to be able to hold your kids. You're going to be able to work. Here's what I need from you. I need you to think positively. Like I'm a scientist when it comes down to it, but I'm also very holistic. Like my family is generations of Ayurvedic medicine, things like that.

1:03:58positivity, what you think manifests itself. Like there's so many times where I'm like, you know what, this is going to be okay. And it's okay. Have you seen the correlation between depression and autoimmune disease? And they've actually been able to see that the depression leads to more autoimmune disease, not necessarily. Interesting. Yeah. And I'm wondering if the immune system responds because of this, like, you focus on how much you hate yourself so much. I wonder if the immune system starts to react. There's some truth to that. So when we do these big cases, like a piece of tissue here, put on somebody's neck.

1:04:31We're actually doing a huge one on Friday, covering somebody's brain with their latissimus muscle. Me and Lily are going to do that. What we do is the scientific portion is the surgery, which goes really well. Then all the other stuff, no chocolate, because after surgery, there's a risk of chocolate causing vasoconstriction, which is the blood vessels shut down and close up. coffee, there's some risk of coffee causing that. We put them in a room with the window so that they can have a circadian rhythm. We make sure that their family isn't like stressing them out. We don't want epinephrine in there to shut down those blood vessels.

1:05:07Sometimes I'll give them a book and I'll say, hey, they'll find out what they like to do. Do you guys use PDE5 inhibitors for blood flow during surgeries? Like which one? Like Viagra, Cialis, would those help? So we do some medications like lidocaine, for example, and papaverin. These are medications that take out what's called vasospasm. When you touch a blood vessel, there's a nervous system on every blood vessel. That's how we do a cold plunge or a sauna. That's how you dilate and constrict. This can be harmful when you're doing these surgeries because it can all of a sudden constrict. And then your whole flap is the piece of tissue is clotted off.

1:05:47So putting these medications gives you a temporary window where you can sew it and allow for blood flow back and forth. And yeah, I mean, there's a very holistic approach to this too, besides the scientific part. Patients who come in that are positive, I've seen somebody that has a horrendous injury with a positive attitude do really well versus somebody who doesn't have such a bad injury but has a negative attitude and doesn't feel like they're going to succeed, do poorly. And it's with work too. Like if there's a study with hand, if you're out of work for like something like three weeks, the chance of you going back to work is like single digits.

1:06:28Do you have any favorite partners that you work with? Like, you know, do you need to work? Do you work closely with other practitioners like, you know, other doctors that aren't doing what you do, but you're like, Like, hey, you go to this guy because I work very well with them and we work together. Well, part of plastic surgery, which is really cool, is a lot of the work we do is somewhat unpredictable. And we'll be on call and the orthopedic surgeon's like, hey, man, can you come to room four? And you come in. Hey, we took out the tumor and there's a lot of tibia exposed. Can we figure out a plan?

1:07:02Oh, right. So they call you in. They call us in. So neurosurgeons, when they do spinal surgery and they put a bunch of hardware in, instead of just closing up, they'll call us in to use the muscles to cover the hardware. So if any infection gets in, it doesn't cause a hardware infection. So routinely we'll get called, hey, we're unable to close over the scalp. Are you guys available to just one of you guys? And there's always an on-call one of us. Right now it's Lily. Can you come by to room eight and just see what needs to be done? and so we'll figure something out. Is there a typical time frame?

1:07:38Because I remember when I, just out of high school, we went for our senior trip to Hawaii, my friends and I. It was the beginning of the week and my buddy gets drunk and gets in a fight and this dude split his lip all the way from the bottom of his nose, flayed it wide open. And we had to rush him to the hospital and they actually had to wake up a plastic surgeon and fly him in or something like that to come do the work like in the middle of the night is there certain body parts or certain types of injuries that you've got a small window that you've got to attack it if you're going to save it or be able to reconstruct it like or is there different or is it kind of universal like ever you got a certain window pretty much anything if you want me to be able to save that that limb or part or yeah so so with nerves that are motor so there's sensory nerves yeah you touch something you feel it and then there's motor motor nerves when they're cut you really want to get to them within a couple of days like soon because once they're cut the end point so your nerve is like this there's an end point that accepts the signals the end point's like i'm not getting signals it shuts off it shuts off and it starts turning into scar over time so you don't want that to happen like in your hand and stuff like so that's if somebody tells you hey this guy came in with the samurai cut to his wrist He has no function of his hand.

1:08:56We're taking that to the OI that night. We're going to fix the nerve, the artery. Artery is another thing. If blood flow is not there, we're going to fix that right away. But like a lip, for example, that's often done emergently. At least we do it because if you wait too long, the swelling is so hard to really approximate and get it to line up just right. Okay, that's why they were so… So we'll often do that like at the time. But that can wait. That's something that you can wait on. Like as far as health and survival, but for aesthetic reasons, that's why they did it. Because yeah, I remember the next day his shit was like this.

1:09:31Yeah. I mean, I'd never seen it. It's so swollen. It's really hard. And at that point you have to go back and try to align. It's just logistically it's easier and it's better for the patient. Nobody wants to sit at night. Because I didn't think it was like a life or death thing, but it's like, man, it was very urgent. They flew someone in. It was a big deal. Any interesting new technologies in what you're doing? Because I know you, I see articles and I'm sure it's years out, but they're like, you could grow you know from your own stem cells or your own this or your own that like is that all kind of on the horizon a lot of it's on the horizon one of the cool things we do um is when we take skin you know there's the creation of skin where in that you know a company that like i talked to you about sends it back in three weeks but you can also take skin and scrape off some of the cells, like the epithelium, and put it into a solution that we do at the bedside, not in the operating room, but we're kind of making it with saline and things like that.

1:10:30And for facial burns, for example, a common burn that we get is the older person who is on oxygen but decides to smoke a cigarette. Oh, lights it on fire. And they have a facial burn. It happens every week. Oh my God. Yeah. And so that skin, it's very superficial often. And so that'll come off. And when you spray this solution, it can help regenerate to the point where there's new data coming out that for people like me who have melanin, it can restore melanin into some of these burns. Because that's one of the things that if I had to burn, I'd lose my melanin. Some of the skin grafts and things like that.

1:11:17But yeah, I mean, aside from that, there's cool things happening in surgery, like the robot. I'm sure you've heard of that. They're using robotic surgery for head and neck, for different – they're trying to incorporate into different aspects of plastic surgery. I mean, AI is pretty cool. you know i know it's just with how would you use because obviously the the skill of the the hand for you to do so many things i think and then the real time pivots human is so important but i got to imagine there's got to be ways that you could you know plug something into ai and like if we do this what are the potential outcomes if we do this and then like yeah do you use it like that already or will you like what do you see not yet i mean to for for surgeons to say that ai won't replace them is, I think, ego.

1:12:07And the reason why I say that is because for a product to do well, you probably need it to be good like 80 % of the time. Now, when you have surgery with me, I'm going to treat you like a family member. I'm going to give you every drop of my brain and sweat and hands to make sure that the outcome you have is the best. Now, is that necessary for you to be functional. I don't know. Now, this is where AI may come in and say, hey, you know, what he does, that extra 20 % is not necessary for me to be functional. Health insurance pays this. And so that's what I'm a little worried about. But at the end of the day, there are nuanced things that we do that I just don't know how, based on this, I'm reacting this way.

1:12:52I don't know if that's something that AI can pick up. Maybe. I mean. Interesting. Do you, because I know you're, in medicine, you do, you have to be so specialized. You have to, you have to know it's so deep. And sometimes there isn't like that cross communication. When it comes to like the face, do you work, do you ever work with neurologists with like, when people have things like trigeminal neurologia or pain, and then do you guys work together and kind of learn from each other? Like, what does that look like with you guys at that level? Do you guys all sit down and go, all right, Let's talk about these things.

1:13:26We do. I mean, we have, not with the neurologist, but like part of the burn team is every Wednesday we have a multidisciplinary team rounds. Okay, cool. So on that rounds, we talk about every patient, sometimes 50 patients. And the people there are case managers, social worker, trauma, ICU, dietician, pharmacy. Oh, wow. And it's long. And everybody says something. Oh, wow. And then we get really great care that way. And that's why burn units are really important, because not just a surgeon doing some skin grafts, it's multidisciplinary approach. But an example of that is we work with neurology in the sense that there's a cool surgery that we do for headaches, where neurology, there's, for example, occipital pain, they're injecting Botox.

1:14:23They're injecting steroids and there's no relief. And so we get them as kind of a last resort, put some lidocaine into that area. And if their pain is resolved, we know that maybe there's an option for surgery here. And so we'll make an incision down the middle of the scalp. We'll raise the tissue up. And there's three nerves here, the occipital nerves and the third occipital nerve. and the greater and lesser occipital nerve and the third, they're kind of like this, three on each side. And all we do is we find them and we free the compressing tissue over them. Sometimes it could be from a trauma whiplash.

1:15:04Sometimes it could be a blood vessel that's pulsating on it. That's got to be life-changing for somebody who suffers from chronic headaches all the time. I had a patient once that I did this procedure on. she had the procedure. I'm operating another room and the nurse is like, hey, you need to go talk to that patient. I'm like, oh no, what's going on? I go back and I'm like, hey, what's going on? And she's like, this is the first time I have zero pain. I don't know if you know, but I was so suicidal. So, I mean, that gives you a lot of just satisfaction. And it's a challenging surgery, but it's not like putting a face back together.

1:15:46And this thing that you kind of think you're on the next case, it's made such a difference just releasing tissue on a compressed nerve. Do you get more? It sounds like you do. I think I already know the answer. But do you get the harder the case is, is it like the more exciting for you? Are you like, okay, this is a tough one. Like the challenge, yeah. This is going to be interesting. I think that, yeah, I think that that really is, as much as we get older, you know my family's my number one priority and when we didn't have kids that's all i wanted was the hardest case be the biggest badass and tell everybody like this is what we do because we were trying to build a name for ourselves and i'm still that way i still want challenging cases but what you start noticing is what is a big case to you is a big case for anyone undergoing surgery whether it's a carpal tunnel.

1:16:45Sure. For them, it's always. Yeah. They're not sleeping. That, you know, it's like the headache person. Like that's life change. She was suicidal. You saved her life. Or a trigger finger. Like I think it takes one, two minutes to do a trigger finger and people come back and like, now I can like move my hand. Now I can hunt. Now I can fly fish. Now I can do all these things, you know? Wow. It's cool. Yeah. That's great. How do you guys balance family? Because you're both surgeons and you got kids. What does that look like? It's hard, man. It's, it's, it's, I don't think there is balance like in life as much as I want to say I you know everyone wants to get balanced I think there's points in your life where you're focused on certain things and points in your life where you're not and I like I said I had this I don't want to say it's unhealthy this just drive to be the best resident be be the best technically figure out all about surgery until my first son was born.

1:17:41I saw him and it's just like, I was like, things got to change now. And I remember the moment I'm holding him and I'm like, I got to make sure like you're okay. Doing what you do, would you encourage your sons to go into the same field? Or because sometimes people will do something that's very challenging. They're like, I love it, but I don't want my kids to do it because it's just a lot. So I used to say, I don't want them to do it because the pathway was so hard. It's not just the years of schooling. You lose friends. Your parents are like, hey, we're having this event. You can't come. Or I remember Thanksgiving where I had the day off.

1:18:20And I'm at Thanksgiving. And I'm a resident. And the resident who was there was sick. And the attendant's like, dude, you need to come in. So you just go in. And there's a lot of sacrifice to that. So unless you truly love it, and I'm going to gauge that with my kids, unless they like really love it i think it's uh i think it's a there's other ways to to be successful in life and you really have to i i feel very fortunate because i'm friends with a lot of doctors and i love what i do i love it i love it to the 10th exponential whatever a lot of my friends they don't love it they're burnt out they're trying to get out they're looking for side hustles that are doing all this stuff.

1:19:05At its core, surgery and plastic reconstructive surgery and aesthetics, I love it. Now, do I like notes? And do I like the healthcare system? And do I, no. But the job itself, it's amazing to go meet patients, talk to them, hear the changes you can make. And ultimately like share that with your loved one. Like my wife, we talk about this stuff. I'm like, what's a date like? now it's not as much like back in the day before the kids we'd we all you talked about yeah i mean the or used to when we got to our hospital the or was upset because they'd hear us fighting and we're not fighting we're like arguing about family like lily we should go to the facial artery she's like dumbass go to the thyroid artery it's bigger and better and the or is like oh my god they're fighting we're just we're just like talking it out communicate on another level yeah And we're like looking at each other like this over the microscope.

1:20:00And they're getting uncomfortable. Are you guys ever like in the middle of the OR, you're doing something, you look up, you're like, I love you, honey. Absolutely. Great stitch. The crazy story about Lillian, I mean, she's beautiful. She's a double board certified surgeon. She's an amazing mom. so when she was pregnant she worked until like nine and a half like nine months right she calls me i'm in a flap i'm doing this big procedure she's covering somebody's brain and she calls me and she's like hey i'm like what's up lily she's like my water broke mid-surgery mid-surgery shut your face she was doing surgery still and so i'm like i didn't even know what that meant because we're he's five weeks early oh he's early that's why okay and so i'm like oh my god what what do i like i'm you know going from being a married guy with no kids to that moment i know this is happening i'm like lily i'm in the middle of a case she's like don't worry i'm gonna drive myself i'm like no no you gotta you gotta find somebody so she drove herself gangster and has a C-section the next morning.

1:21:13Kid is fine. And we have to take our hand boards. We were supposed to have like this later, but the timing of the kid made it so that she had just gotten the C-section and two days later, she's taking her hand boards and she's on pain meds. She's on all this stuff. And I'm, we're in the Prometric Test Center. I there's a computer here and a computer here. And I look and I get up during the break. She's asleep. I kick her chair. I'm like, get up. Like, and she comes up to me. It's like, you know, I left 10 blank. I'm like, holy crap. You know, cause I felt decent about it that I passed it. And I was like, man, hope she doesn't like not pass it.

1:22:01Cause this is not fair. She'd do better than you. 10 points. 10 points. Hold that over you forever. Yeah. That's great. Any hobbies outside of work and family? Absolutely, man. Fitness has been huge for me. I remember fourth grade, I was kind of chubby, and I had a cousin, Basil, this kid, just a beast, just an athlete from the get-go. He, August 15th, fourth grade, 6.30, he taught me my first sit-up. I remember the time because I looked at the clock when I was doing it. I couldn't even do it. He was pulling me up. And so I just started really getting into, at that time, it's like muscle fitness and, you know, you're watching Predator and Rambo and all of these idols that don't look like the people now.

1:22:50But that's who I wanted to be. And in the Indian community, it wasn't like normal to play sports. Like none of, I didn't know anyone. Basel ran track. I played football. I worked out. He worked out with me. And I remember doing push-ups and doing push-ups. And finally, like my cephalic vein came. And I was like. I got a vein. I got a vein. Yeah. And so it was huge for me. I mean, all throughout high school, we opened the first real gym in our high school. I mean, and I'll give them a shout out, Sean Leonardo and Harold Riggs. These were high school, but they are high school buddies of mine that we'd come, I mean, in high school at 530 in the morning to just work out.

1:23:30And then college playing football, that was awesome. And training is a huge part of my life. How much of an advantage? Again, I trained a lot. At one point, I trained a lot of surgeons, and they would tell me how that would make them better at their job. 100%. Yeah. How much of an advantage is it? It's night and day. We'll talk about that. Why? Why? Because especially if you're a surgeon, especially if you're new, the schedule can be crazy. Yeah. And so the thought is, I'm going to take time out to go work out. I'm so fried, or I don't know. Like talk about the advantage of being fit for what you do.

1:24:07I mean, I used to do the evening workout and then I realized I was missing out on kid time. So we make our life at that time. Now we don't need this nanny. We had a nanny come at five in the morning so I could get to the gym downstairs. We built a gym. 450 in the morning. I'm doing, I sit in the, we have an infrared sauna. I'd sit in there, just kind of loosen up, then do like a pretty powerful push pull workout. And I've always tried to sprint at the end. And part of it is when you go to the operating room, you're contorting your body in a lot of different ways. And it's not unusual for surgeons to pull their back doing something stupid and be out or they hurt their neck.

1:24:55And so for me, part of it is that, but it's a mental edge too. Cause I also do cold plunge and sauna. I've done that for 27 years, cold plunging. And that really, uh, when you do that in the morning, the rest of the day is easy for me. You know, I'm starting out with something that sucks, something that, yeah. Embrace the suck, right? Like, so if you do that, the rest of the days is it gives you a mental edge in surgery. It lets you think clearer. Um, I typically don't eat breakfast because I found that if I eat a big breakfast, I'm a little bit shaky. Sure. Yeah. And so I like to be super stable.

1:25:34Don't eat breakfast at around 11 or 12 or 10. I'll take a huge protein bolus and then I'll keep that going for the day. What's the longest you've been in the OR where you're working on somebody? 43 hours. 43 hours straight? 43 hours straight. So hold on a second. So this is stuff that always blows me away. And the first time I understood this, I was training a general surgeon who had done a Whipple procedure. And she was in the hospital. She was in the OR for hours and hours and hours. And my question is always like, what if you got to go to the bathroom? Like, what do you do? You take breaks.

1:26:05Yeah. Okay. So that's what I was going to say. How do you do that? Do you go take a nap? Because it's 43 hours. No, never. So this was a very unusual case. That will never happen again. How many Red Bulls are you drinking? Like, what do you do? I don't. Because you don't want to shake. Oh, that's right. And so this was a case that I was the chief resident and there was an attending there. And it was a mandibular reconstruction, same like this leg was being used and very detailed attending. It took a long time to get this leg out and put it on one side of the neck. The vessels didn't work. Then tried a different vessel, didn't work.

1:26:41And then now you're like doing the other leg and finally it worked. And it took, I'm not kidding, it took 43 hours. And so in between, I took like, I don't know, five or six breaks, not long, ate something, came back. And then there's residents that are coming in between. And you're not sleeping? No. I don't know. That's crazy. The adrenaline keeps you a heart. There was also like a long time ago. That's like 2015. Well, hold on. So I'm going to ask you a controversial question. Doing a carpal tunnel, falling asleep. This might be a little controversial, but I know that now when you're a resident, when you're out there, you're trying.

1:27:18Sure. They now have limitations on how long they'll let you work and stuff. I've heard arguments on both sides. One side says, yeah, yeah, we're going to put limitations because there's only so much they can learn and there's a lot of mistakes. The other side says, you got to go and go through the crap because sometimes you'll be in the OR for hours and hours and hours. Where do you stand on it? Do you think that they've made it too easy? So I went through the older pathway where my first year there wasn't any restrictions at all. Yeah. And my residency was a little bit slow to keep the restrictions in the beginning.

1:27:58Now it's very regular. Now here's what I have to say about it. There's literature that shows when you're tired, you are essentially drunk. Right. Yeah. And you can't be that way. Right. But at the same time, not everything happens between nine and five o 'clock. A lot of stuff happens in the middle of the night, at this time, at that time. And so I think we have to find a happy medium because there's an extreme where you're in the hospital 43 hours, which is not, I don't think that's right. Right. But then people are being pulled out of a case that they're in because they're over hours. So what I tend to find is a lot of these newer surgeons that have problems are finding people like myself and sending patients to us because we've had that experience and we have that.

1:28:50It's almost like a discipline. Here's my, I have an opinion. I would love your thoughts on this. I think that there are people that are not like the average person that can operate better than the average person under a lot of sleep restriction or stress. And I feel like you kind of want that process to whittle down to the people that can do that. And maybe that's what it serves. Maybe that's kind of what it serves because there's going to be situations where, hey, I know when you went through residency, we had all these regulations and rules. But out here, there are going to be times when you're sleep deprived.

1:29:29Yeah. And you've got to be able to perform. And we don't want the people who can't perform when they're under that stress. It's hard to know yourself like that. I'm one of those people. Like I feel like I've, my entire life, I've really, when I like something, I love it and I focus on it. And in the operating room, when you're there, it's, you're in flow state. You are, all that matters is you're going to get this patient, that right outcome, get them off the table. They're going to be alive. They're going to be safe. And you don't remember, you don't like sit there and an hour pass. Yeah, you're not clock watching.

1:30:05No, you're getting it done. And afterwards, that's when you're like sitting at the computer trying to finish the note and you're out and dead. And so I think that there is truth to that. I think that you have to know the kind of surgeon you are. Are you the surgeon that wants to do five or six small cases and be done? Or do you want to be the person that is the end of the line that if it doesn't work, this person gets an amputation? And that's kind of the mentality I am. And so to hone that and do that, it's not just being in the OR. It's some of the jobs I've worked in. I used to do an inventory job that I would work 24 hours straight.

1:30:46I used to, you know, like study for hours on end. All of those things build muscle, this discipline muscle. And this is something that I really believe about surgeons. You can't be a sloppy person and be expected to be this neat, awesome surgeon. You can't be a bad person who cheats on certain things and then be a great surgeon. Because your natural tendency is to fall back into that when stress happens. So if you're a cheater and you have a corner to cut in surgery, human nature is to cut that corner. So I really feel like when you talk about training, when you talk about family, You talk about finances.

1:31:33They're all interrelated. You have to really think about them in the same way. So I think that type of surgeon, it's a little taboo to promote that this day. I knew it was controversial. But that's who I want as my surgeon. I want the guy or girl that has seen it all. is, you know, by being in the hospital, by working hard, by reading, by understanding the pathology, they have the experience and they can adjust. Is this where the reputation, you actually said it earlier, the surgeons were kind of like these jerks that walked around like that. Is that where that reputation comes from? Because they're like so focused.

1:32:10And so if you don't understand that, they can seem like they're just. I mean, it was brutal residency for, I mean, I had it tough, but even further back, it was harder. Like they call it residency because you lived there. Oh, yeah. And so these people were, there was no attending, and none of this is right. There was no attending supervision for some of these people. They were operating on people, trying to figure things out on their own. They're having family strife. And so this gets manifested in being mean to a medical student. I trained a woman who was a general surgeon, but she was, so this was 15 years ago.

1:32:48she was already in her early to mid 60s. And so, and the other surgeons would talk about her because they're like, you don't know. They're like, when she went through, back when she did, it was much harder and it was harder for a woman to go and do what she did. And that's why she's such a badass. And so they would just talk about this woman like she was, and she was, she was incredible. I mean, I see that with Lily. Like, you know, it's a very male dominated sport, even now. And in her training, And she was in one of the roughest places in Newark, New Jersey. And she's this amazing surgeon, but she always dressed up.

1:33:25She never looked sloppy. She always was positive. And if she ever acted assertive, they said that she was being a B. You got to be, though. Yeah. And you have to control your own destiny. You have to make sure that who's going to advocate for you more than yourself. So she really was a proponent for herself. And that's why she got, she was successful, but that's, you know, swimming upstream. And so I think it's harder. Have you seen that translate into her being a mother? I bet she's a bad-ass mom. She's an amazing mom. She, and we have two boys and they're crazy boys. They're like four and seven.

1:34:09and they do things that, you know, I fly fish. I've been doing 15 years. Lily got me into that. She was doing it for 30 years, but I never grew up doing that stuff. And my seven-year-old, he catches trout on three flies. He skis blacks. I never skied until two years ago. And so she's really big on giving them these experiences. If it's up to me, they'll like, you know, they'll hang out with me, I'll do the stuff, but I won't be thinking about, okay, let's go on a Disney cruise or let's go to Costa Rica and visit the Osa Peninsula with the boys. It'll be nice for them to see birds of prey, things like that.

1:34:49And so she's a badass mom. I mean, I've heard about your wives and they're similar DNA amongst them with high-functioning husbands. That's great. Well, I appreciate you making the time to come over here, man. I know you're real busy. Yeah. It was really awesome meeting you at the Peptide Congress. Yeah, absolutely. Yeah, this was an interesting, fascinating conversation. Yeah, man. Appreciate you coming on, my friend. Absolutely, man. I'm really honored. And let me know if you guys ever have, you guys can get my cell number if you guys have hand issues. I hope we never have to call you. No, but if you do, you're the man I'm calling.

1:35:22Something happens. I got my number for sure. No, but the cool thing is like who you see on the billboards is not necessarily always the best person for things. And so doctors are connected with who they would go to. So take down my cell number if you guys have a lot of friends and family out in Cali. And so if you have issues or if you're worried about something, let me know. Thank you. Appreciate you. Appreciate it. Thank you, man. Thank you, guys. Thank you for listening to Mind Pump. If your goal is to build and shape your body, dramatically improve your health and energy, and maximize your overall performance, check out our discounted RGB Super Bundle at mindpumpmedia.com.

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