Coast-to-Coast Confessions: What’s Next for Plastic Surgery in 2025?

Eva Sheie (00:00):
You're listening to Where Before Meets After. Today on Where Before Meets After, I've got two power houses of body contouring on the couch at the Aesthetic MEET live in Austin. Dr. Matt Ny, Dr. Franco's in my head.

Dr. Nykiel (00:14):
"Nykeel", Nykiel, Nykiel.

Eva Sheie (00:16):
Because he says it wrong.

Dr. Nykiel (00:18):
He does, but he does it on purpose.

Eva Sheie (00:18):
But he does it on purpose because he loves you.

Dr. Nykiel (00:20):
He does it on purpose because he and I trained together, as you know, we both trained underneath a pretty intense residency chair.

Eva Sheie (00:28):
Was that New Mexico?

Dr. Nykiel (00:29):
St. Louis.

Eva Sheie (00:30):
St. Louis.

Dr. Nykiel (00:31):
That's how that program director would always say my name. "Nykeel".

Eva Sheie (00:33):
Do you know who he's talking about? I also have Dr. Mark Epstein from Long Island, another giant of body contouring.

Dr. Epstein (00:39):
Oh, you're too kind.

Eva Sheie (00:41):
Is it true though? I kind of just said it.

Dr. Epstein (00:44):
That's a very big part of my practice.

Dr. Nykiel (00:48):
So Dr. Epstein actually, we've done a couple talks together on body contouring and utilizing Renuvion energy devices. He actually gives a really great talk about combining energy devices and tummy tucks.

Eva Sheie (01:00):
Do you both do that kind of work every day in your practice? Both on different coasts? So maybe let's go there. Body contouring in California and body contouring in Long Island. Same or different right now?

Dr. Epstein (01:11):
I haven't done any contouring in California, so I don't know. I would imagine it's probably pretty similar.

Dr. Nykiel (01:16):
See, I was going to say it was, and this is the fun part about having people in here. I was going to say it's different because we're Southern California, right? So we're so close to Mexico. In plastic surgery, even in our meetings now, right, there's symposiums of what's going on in South American body contouring plastic surgery.

Dr. Epstein (01:32):
Yes. I was just at that.

Dr. Nykiel (01:33):
Right. And so due to our proximity, 90 miles from the Mexican border, I just think we have a huge influx of that sort of central, Southern American body contouring. And I think we therefore are earlier adopters. Not because the east coast doesn't want to adopt it, but just because, just due to geographic spatial relationship, I think we do.

Eva Sheie (01:53):
Are you saying that there's a different look that is in demand in southern California than maybe on the East coast?

Dr. Nykiel (01:58):
I would say so. Certainly I have breast implant patients that come from the east coast, and I know when I tell 'em the sizes that we typically do on the west coast, they're like, Nope, that's too big. What would you say?

Dr. Epstein (02:09):
Oh yeah, definitely on the East coast it's a bit more conservative that way. And if you go south, it's going to get bigger.

Dr. Nykiel (02:15):
Yeah,

Dr. Epstein (02:15):
No question.

Dr. Nykiel (02:16):
And we're in the heart of big, we're in Texas right now, right?

Dr. Epstein (02:19):
Oh yeah.

Dr. Nykiel (02:20):
Where does that change, would you say, from East coast to south as far as plastic surgery trends? Where do you think that that change happens?

Dr. Epstein (02:27):
I'm not exactly sure. I think it's when you go south and people are out in bathing suits more the more exposed they're going to want to have larger breasts. I think that's a big part of it.

Dr. Nykiel (02:36):
And what about from a body contouring standpoint, like liposuction? What do you think?

Dr. Epstein (02:40):
Well, it's very interesting in my practice because I have a lot of Caucasian patients, I have a lot of Latina patients, some African-American patients, and I see definitely different preferences. And I'm also going to say even a subset of my Caucasian patients are the Jewish patients. So here's my take on that. If I'm talking about liposuction and I bring up fat transfer, if I bring it to a Caucasian patient, it's maybe 50 50 they're going to take it. If I bring it up to an African-American patient, I got a better chance. If I bring it up to my Latina patients, there's not enough fat in the county to put in, so they embrace that. Now, if I bring it up to my Jewish patients, keep that fat away from me. That's supposed to come out. Don't put it in. There are exceptions all over. But this is the trend that I see. The African-American patients love their wide hips. The Caucasian patients don't. The Latina patients also don't want to have as much width as the African-American patients have. And you have to respect and be aware of these differences when you are creating a plan.

Dr. Nykiel (03:49):
And so that's interesting because I'd say on the west coast we don't have as, and I totally get what you're saying, and it's true for a lot, we sort of, cuz we're so close, I think to just Central America, Mexico, we have more of what I would say is a blended sort of look. I'd say it really doesn't matter. Everybody's got some type of, they want that type of central, southern American shape and sculpt. And that may be falling out for other parts of the country because I think there's a big pendulum. BBLs got real popular, making people curvy got real popular and anything, sometimes a craze gets going. And I think it was really, really big hips, a really big butt, a tiny waist to the point that it could sometimes look cartoonish. But that was so in, and now that it's swinging back to the country, it still holds a lot in California, I think. Just because just those geographical influence.

Dr. Epstein (04:40):
Yeah, absolutely. And I think with social media, patients tend to gravitate to surgeons who produce the kind of look that they're interested in. Patients want that huge big butt look, they're not coming to me. They're going to the guys who are showing that. But the complications rate with that also goes up considerably. So I like something that's a little bit more natural, but curvaceous.

Dr. Nykiel (05:02):
Times change. We all change. So we've adopted a term we call just a balanced body approach. for us, a balanced body approach still focuses on some form of curves because we can go back, I mean as far as written record, and I feel like curves are there. I mean back to where even corsets,

Eva Sheie (05:19):
The Venus de Milo.

Dr. Nykiel (05:20):
Yeah, that's right. Venus de Milo. I mean it's just there. So I think, and that's what we decided to do. We recognize change. We say, okay, there's always going to be some form of the feminine shape. And to us, we kind of think, okay, if we have that as the ideal, how do we balance the body to get more in line with that ideal sort of feminine shape? And it's been very beneficial. I think it's really helped us deliver a better body contouring result and experience for people.

Eva Sheie (05:48):
I have a butt question. Are there patients now who've lost a ton of weight who maybe previously would've never considered having an aesthetic procedure to reshape their butt who are now in that market. Is it a completely different person than the butt patient of the previous decade, maybe?

Dr. Epstein (06:09):
I think it is a different patient because the tissues are often very compromised, very damaged. A lot of them who are coming in for surgery are having surgery because they've lost so much fat that they now have all this extra skin. And some of 'em don't even have enough to harvest to make that adequate butt and the scaffold, the infrastructure to the butt, it's just not there. It's not what it is in the other patients. So you're not going to get the same results.

Dr. Nykiel (06:37):
I would add onto that, I'd say in general, when we're talking about body contouring, rebalancing the body, we have one to two problems. We either have too much fat or we have too little fat. And it is interesting, right, to see that shift with the GLP-1s that we're more and more coming into the issues of now we have too little fat, right? We're needing to add fat back. We're needing to give volume back to help balance that body more towards that ideal shape that we're going for. And that's a huge change from four years ago. Four years ago, it was we need to take away as much fat as we can to then almost like taking a stone. How do we carve that stone into a final statue? And now it's very different. Now it's like more to Dr. Epstein's point, a rehabilitation reconstruction. We've got the finished statue, it's just parts of the stone have cracked off. We've got figure, how do we add it back on?

Eva Sheie (07:30):
So there are people who have just enough fat, but they're not coming to see you. They don't need to have more or less fat.

Dr. Nykiel (07:37):
And that's a good point. Right now you can have just the right amount of fat, but what if it's not in the right spots? I think one of the best examples even in this GLP-1 era is bra rolls, right? I think bra and back rolls have become a much bigger issue for people because you can cut your weight down to almost anything, and you're still, if you had a back and bra roll there. It's very hard for it to go away with diet, exercise, and loss. So

Eva Sheie (08:03):
Why is that?

Dr. Epstein (08:04):
Because the skin is bound to certain fixed points like the ribs. That's what creates the roll. The fat expands the skin between two fixed points horizontally and that expands the roll. And then now that the skin has been deflated, it's just like a sagging breast after pregnancy. It doesn't have the recoil. So now you have all this extra skin and lipo isn't going to help. And if the extra skin is beyond the point of radio frequency, skin tightening, then you're faced with doing a back lift.

Dr. Nykiel (08:35):
Do you do many back lifts?

Dr. Epstein (08:37):
I wouldn't say many, but I do do them. And when I do do them, the patients are very, very happy. But it takes a lot to push me to do one because it's a big operation and it's a big scar, albeit you can hide it with a bra. It's usually massive weight loss patients where they don't care about scar, they're just more interested in the contour.

Dr. Nykiel (08:55):
Other thing, I'd like to jump back on that and just say in those people that we're talking about sort of just enough fat, whether or not diet and exercise, whether or not that's just how they were born or whether or not they're post GLP-1. I think, and GLP-1, for anybody listening, semaglutide, tirzepatide, although I feel like now you can just say GLP-1 and anybody that's listening probably knows, right?

Eva Sheie (09:14):
Yes, thank you to the pharma companies for forcing us to call it by the category name.

Dr. Nykiel (09:21):
The bra roll, you'll always have a little bit of posterior flank fat no matter what you try to do to get rid of it. So we can just take those areas and balance that down to whether that be the hips, the hip dips, maybe a little bit of upper buttock volume that got lost. And those subtle changes, I think just really restructure somebody. We're not trying to do what we were doing five years ago where it was just such the bigger, the better. You know what I mean? The curvier. It's just how do we balance you back no more naturally, aesthetically appealing.

Dr. Epstein (09:48):
Yeah, you can talk in generic sense about all the different options we have, but it really comes down to when you see that individual patient, ask 'em what it is that they want, assess their tissues, look at the quality, how much extra skin, how much fat they have, what are the options? And there's oftentimes more than one thing that you can do. You present the options to the patient and let the patient decide based on what you tell them, what is best for that patient.

Eva Sheie (10:12):
Close out the fat thing, I have one last question there.

Dr. Nykiel (10:15):
Oh, I got some for you on fat too.

Eva Sheie (10:16):
Oh, throughout your body, the fat is not the same everywhere. Is it accurate that you could take fat from one part of your body and you probably shouldn't put it in the face because it's not the right kind of fat or.

Dr. Epstein (10:27):
Well with the face, the fat in the face is of different size. Call it different parcels. And as you go, more superficial, the parcels get smaller and smaller. So when you're harvesting fat for facial fat graft and you can take it from the abdomen or the inner thigh or the flank, and then you put it into a device called the lipo cube or an equivalent device that cuts it into different sizes. So when you harvest the fat, it'll come out as what we call milli fat. The particle size is one size, then you can cut it into micro fat and then you can even make nano fat. So in the face for structural things, you can put in the milli fat and then as you get a little more superficial, put it in some micro fat. And then the nano fat actually has regenerative capabilities, so you can inject it right into the dermis and reverse the aging on the skin.

Dr. Nykiel (11:15):
Mark stole my thunder there. That was my,

Dr. Epstein (11:17):
Oh, I'm so sorry, Matt.

Dr. Nykiel (11:21):
That was when we talked about new things with fat. Fat and we went to the synthetic fat and that's what I said. There's actually some cool things going on with fat itself. Nano fat is obviously one of it. And that was my first branch there. And then the second thing I think is cool, again, coming out of South America is they're taking, now when they do their tummy tucks, et cetera, they'll actually take some of that fat from the lipo and as they're doing the tummy tuck, they will repair the tummy muscles to bring them back together, but they'll actually inject a little bit of fat under direct visualization into the actual tummy rectus muscles themselves. Not to create a big steroid, like huge bulky muscle, but just to give it a little bit more bulk. And it's really cool actually to see how that plays out postoperatively because now when we're sculpting trying to form three dimensions, we actually have a back base of muscle that gives a little bit more push and we're getting a little bit more shape. So I think that's a really cool thing that's honestly going on with fat in another application of fat that we're using.

Eva Sheie (12:20):
What's driving all this development in the fat category?

Dr. Nykiel (12:23):
It's really interesting to go back to it, cuz for the longest time, fat was just kind of not paid attention to. We looked at more,

Eva Sheie (12:30):
It was discarded.

Dr. Epstein (12:30):
It was medical waste.

Dr. Nykiel (12:31):
In plastic surgery we had the idea, we couldn't even use it. It's blood supplies too delicate. You can't transplant it, you can't do anything with it. And then probably early two thousands, wouldn't you say is when the idea of stem cells, and I'm blanking on the very famous man's name.

Dr. Epstein (12:45):
Michael Longaker.

Dr. Nykiel (12:46):
Longaker. And then who was injecting the fat in the people's hands?

Dr. Epstein (12:49):
Oh, uh.

Dr. Nykiel (12:51):
Sidney Coleman, right?

Dr. Epstein (12:52):
Yes. Coleman.

Eva Sheie (12:52):
Coleman.

Dr. Nykiel (12:52):
Yeah, Coleman. I mean these people, again, just pioneers willing to try some things.

Eva Sheie (12:57):
Who looked at the fat and said, why are we throwing this away?

Dr. Nykiel (13:00):
Who heard a complaint from his patients that they were loving his plastic surgery was doing, they hated when people were taking photos of their rings, it gave away their age of how age their hands look. And he thought, well, I take some of this fat and start to spin it down and give that back. And would that make the hand look better? I mean, it's just crazy.

Dr. Epstein (13:19):
Yeah. When you get away from the paradigm of just remove, remove, remove, and as Matt said, it's body balancing. It's filling in the peaks and the valleys and creating the contour that you want. You have to have something to do volumization.

Eva Sheie (13:34):
You both mentioned Renuvion at some point. For those who don't know, what is it? And to me it sounds like it's almost become universal. This is something we're all relying on. Is that accurate?

Dr. Epstein (13:45):
Yeah. Renuvion is skin tightening using radiofrequency and skin tightening is the last hurrah in plastic surgery. When you solve that, you solve a whole bunch of problems. And I've been doing radio frequency skin tightening for about 12 years now. This is the third system I have. And I would say the first one that really works and very, very, very little risk and complication.

Dr. Nykiel (14:08):
And I think to answer your question, we both mentioned Renuvion, it's a radio frequency and plasma, it's basically energy delivery system to help tighten up our skin. For me, I usually get about a third. And the way I look at this product is very similar way, I looked at Vaser ultrasound. When Vaser ultrasound came out, it was a new product. People were kind of like, oh, is it Vaser? And now it's just called ultrasound, right? Vaser still has a brand name recognition, but it's ultrasound. And when you look at most individuals I think that do good body contouring in any part of the world at this point they use ultrasound. And I think you're seeing that same sort of revolution with the ability to tighten skin because with ultrasonic liposuction or Vaser Lipo, we're able to reduce loss and we're able to free fat up easier. So many of the risks and complications from lipo of blood loss start to fall out or at least decrease when using ultrasonic lipo. Would you say that's fair, Mark?

Dr. Epstein (15:02):
Yeah, there's less blood loss, less trauma too, because you're emulsifying the fat before you're even removing it.

Dr. Nykiel (15:09):
Absolutely right. Now, as body contouring experts, it's not can we remove the fat? Well, what are we going to do with all this skin? And that was the main rate limiting step. And then with that addition of radial frequency, Renuvion is not the newest one and I'm sure there's going to be other ones after it. It worked quickly. The other devices would literally take an hour to work and it's you don't have an hour in an operating room to do just one portion of the procedure. It would become, and when I say an hour, that's to do both arms. I mean that's not even the torso. It would be not feasible from a safety standpoint.

Dr. Epstein (15:43):
The beauty of the Renuvion is that it brings the tissue up to the temperature 85 degrees C where you see really good tissue tightening. It does it for a blink of an eye 0.4 seconds, and then the tissue cools. So you don't have risk of a thermal injury, but you get 3,500 times the ability for the skin to contract, then you do with something like BodyTite, which struggles to bring the tissue up to 65 degrees and there's more risk for thermal injury for having burns on the skin. So for me, once I got my Renuvion, the BodyTite machine has been parked in a corner.

Dr. Nykiel (16:18):
I feel like in full disclosure, we both need to just say we're both KOLs teachers for Renuvion and just for other people listening, I'd love the product, I think it's a good product just as we're,

Eva Sheie (16:27):
I don't think either of you would even be a KOL for them if you didn't believe in it. I don't think neither of you is the type.

Dr. Nykiel (16:34):
I don't think we would either, but I just want, just in case anybody's Googling as they're reading, they're like, oh, this guy, they talk for them and we do. One other point about the skin tightening thing that I think is super interesting is, the skin tightening is also another piece that we don't often think of in that body balancing. When we talk about the back bra rolls, when we talk about the waist, that ability to tighten that skin up, for me, I usually tell people it's about 30%, but by getting that skin to snap back by about 30% just gets that little bit more shape. It shows a natural definition. I think there's a lot of debate about how much definition's, too much definition for the most part, everybody wants some definition. Everybody wants to look like they at least go the gym. They may not be like the bodybuilder, but they want to be like, Hey, I'm eating healthy, I'm working out. They would love to have a shape that looks like that. I don't think anybody's going to be against that.

Dr. Epstein (17:24):
There's very few people that have just one problem, loose skin or excess fat. It's usually a combination. So I explain to the patient, you have two problems. We have two technologies, two solutions. Lipo doesn't take care of loose skin. Renuvion doesn't take care of excess fat. Put the two together and it's an incredibly potent combination to get a better result.

Eva Sheie (17:48):
So in this progression of RF devices that we've been seeing over really 20 years, right?

Dr. Nykiel (17:54):
Yeah.

Eva Sheie (17:54):
This one requires you to be under general anesthesia. Is that because of the heat or can you do it without anesthesia?

Dr. Epstein (18:01):
No, I've done 'em under local.

Eva Sheie (18:02):
You can.

Dr. Epstein (18:03):
What matters is the total area that you're putting the local anesthesia because there's a limit to how much lidocaine you can give before it's toxic. So when someone is asleep, I'll put 0.04% lidocaine in my tumescent solution. Technically you don't need to put anything in because they're asleep, but I found that when I use 0.04%, the patients wake up far, far more comfortable than when I didn't. And then if I'm doing someone awake, I use 0.1%, so it's two and a half times the lidocaine concentration. So there's a limit to how much you can give before you reach a toxic level. So that's the rate limiting factor more than anything.

Dr. Nykiel (18:41):
And like anything when you're talking about awake versus asleep, I think it's also just an important point for people I listen to just that it really depends on who you are. Some people are totally fine seeing things being pushed in and out of you ,hearing noises, smelling smells, and other people are like, absolutely not. I do not want to see that at all. So I think that's a big portion of whether or not you could tolerate really any procedure awake versus asleep. Some people do breast augmentations awake, and if you find the right patients in that they can tolerate it and they'll remain calm, then it's good.

Eva Sheie (19:13):
What's on the horizon? I heard yesterday that there's some really interesting things happening with fat in terms of products that are filler that are made from fat.

Dr. Nykiel (19:24):
Were you talking my boy, Dr. Johnny Franco? Was he in here talking about that product?

Eva Sheie (19:27):
I think it was Adam Clay.

Dr. Epstein (19:32):
AlloClae?

Eva Sheie (19:32):
Yeah, alloClae.

Dr. Epstein (19:32):
Yeah, alloClae is a product by Tiger Medical, and what they do is they take cadaveric fat, they process it and it looks like fat, like you're ready to inject it and it comes in syringes. It's sterile, it's not immunogenic. Totally safe to inject, but the advantage to it is if you have small areas to augment, you can use this as an alternative to doing a surgical procedure where you have to use liposuction to harvest fat and then process it and then inject it. So for small areas, it's easier on the patient and may even be cost effective.

Dr. Nykiel (20:05):
In the problem, we're trying to body balance people. Either we have too much fat or we have too little fat, and sometimes if we're really strapped for fat, this is a great option because there have been times where you say, if we're trying to target, maybe get a rounder hip, get a rounder hip dip, I don't think implants are a great option for that. And there'd be many times where we just said, look, in the US we really don't have a good option for you. I wish I could offer you something, but it's just not here yet. And now it seems that that is at least becoming more of an option. I think the important point about alloClae too is just to point out it is FDA research approved. We're actually going to be one of the people that are going to be able to offer it early also, but we have that conversation with people too. Hey, this is FDA research approved. So when people ask you what are the negatives that could happen, I just very honestly and bluntly say, that's why we're testing it. I know, you're give me that look, right? It's a little bit of a moment.

Eva Sheie (20:54):
It's early.

Dr. Nykiel (20:55):
Yeah. Yeah. It's a little bit of a moment. You kind step back and you're like, oh, wait a minute, that's why I'm getting this tested on me. Do I want to go through that? And some people just like any risk, do you put all the money down on black on roulette or do you not? Do you let it ride or not?

Eva Sheie (21:08):
I'm so old, I had a friend get Restylane in her lips before I even had heard the word Restylane. So I mean what year was that? 2003?

Dr. Epstein (21:16):
Yeah, well go back to about 1965 or so. It was a very brave woman who got

Eva Sheie (21:22):
Breast implant.

Dr. Epstein (21:22):
The first breast implant.

Eva Sheie (21:23):
Lindsey.

Dr. Epstein (21:24):
Yeah, that's right.

Eva Sheie (21:24):
I've written about her many times.

Dr. Nykiel (21:26):
Crazy, right?

Eva Sheie (21:26):
She's one of my heroes.

Dr. Nykiel (21:29):
I stop and I think about that and it's just so interesting. Then you think there are businesses that will fly you up into a plane and push you out of there with a parachute on and you sign up for it. So it's just amazing the will of human beings to try things that could potentially have very adverse complications and we are all better because of it. Pretty wild.

Dr. Epstein (21:48):
But the thing is to do it in a controlled and safe fashion.

Dr. Nykiel (21:51):
There is one other thing on the horizon I think for body contouring and that is sort of the next level and if we kind of think about this skin, we've been removing it, fat we've been liposuctioning it now, we've been giving it back. Muscles, we've been figuring out ways to augment it either by adding a little bit of fat in or putting implants in, and so the next portion in trying to body balance is actually the bones and there have been some developments or there's been some work, again mainly out of South America and Central America of seeing can you safely, and that's the key word, reposition or basically control break people's ribs to reshape them and it's ongoing. I don't think you could give it the thumbs up that it's fully been vetted a hundred percent. I'd say it's been looked at pretty heavily for the past, I'd say two years, three years, and again, you've got some people willing to pioneer in that space and you've got people willing to be tested on in that space.

Dr. Epstein (22:44):
This is a revisiting of an older idea where people would actually remove lower ribs, the entire lower rib, which is a radical procedure and not a benign procedure.

Dr. Nykiel (22:54):
That was the main issue is that there was severe consequences, cuz you could frequently get into lungs, like your ribs have very important structures behind them. I mean obviously, but that was the issue with it.

Dr. Epstein (23:05):
As plastic surgeons, we do procedures with great frequency and skill, but we also are very well-trained as surgeons to know what lies on the other side of where we're working. You're doing a breast augmentation, you're doing a capsulectomy, you got to know not how to get into the chest, things like that. We're very trained for this and we know what to do if things happen as well.

Eva Sheie (23:29):
Where is that headed? Where are we going with the rib thing?

Dr. Nykiel (23:32):
I don't know. I have been going to the talks throughout the world and it is seeming that as the individuals are doing them more and more, it's becoming a more reproducible and safer procedure, but love to hear Mark's opinion too. But there is that point where you say like, well, each time we push that envelope and we start doing on bigger and bigger changes, the negative to that is there's just bigger and bigger possibilities for complications that are much more grave. And I think that's kind of where we're at right now. I think that's where the general consensus of this is just, Hey, wait a minute. I get it. You've gotten it now to a point that's pretty, that's reproducible and seems to be relatively safe, right? Based on current data.

Dr. Epstein (24:11):
Yeah, it's risk and benefit, and you have to see how you can do it in a safe manner that you can teach to other surgeons who can reliably do it safely. If you just have a handful of surgeons who do it well and do it safely and other people are doing it and getting into trouble, then it's not a good operation.

Dr. Nykiel (24:28):
I'd like to piggyback off that because I think the other issue slash concern is there appears to be a learning curve with it, right? Anything in life, there's learning curves. Anything we do, the question is just what are the negative complications during that learning curve? I think that's really where we're at right now with the ribs, with the ribs remodeling, restructuring, is just how are we going to be able to get people to learn and educate in a way that we can avoid these major complications during the learning curve? What would you say that's fair, Mark?

Dr. Epstein (24:57):
Yeah, definitely. Absolutely.

Eva Sheie (24:59):
Let's go somewhere fun for the last question.

Dr. Nykiel (25:02):
I love that.

Eva Sheie (25:02):
Totally unrelated to, maybe not totally unrelated to body countouring. Okay. When you're on an airplane and the flight attendant gets on and says, is there a doctor on the plane? What do you do?

Dr. Epstein (25:13):
I've had that happen three times.

Eva Sheie (25:16):
What do you do?

Dr. Nykiel (25:17):
I've had that happen four times.

Eva Sheie (25:19):
Really? Four times.

Dr. Nykiel (25:19):
Yes.

Dr. Epstein (25:21):
Yeah. I always pony up and I volunteer. The last time it happened was the most significant one. It was a couple years ago. I was coming home from Morocco. We were somewhere over the middle of the Atlantic, actually little closer to Spain than the mid. A gentleman in coach I was sitting in first class with my wife, was going into urosepsis and he was getting shockey.

Dr. Nykiel (25:44):
That's a real problem.

Dr. Epstein (25:46):
We were in the middle of nowhere, so this was air Morocco. So I asked if they had a blood pressure machine and they brought one out with the batteries, the dead batteries taped to the back of it. There was no pulse oximeter, but someone had an apple watch. We did manage to get 'em to take fluids orally, and we needed antibiotics. And by the way, there were two urologists and an internist who also put their hands up, but they weren't being very active. So I was kind of taking the lead. I realized if we can get some antibiotics into him, we might have a shot. Flight attendant in English, Arabic and French requested people bring up their medications. So we were looking through the medications because we all had antibiotics with us, but they were in our baggage. I was like, oh, thank you, sir. No, Viagra is not antibiotic, but someone actually did

Dr. Nykiel (26:37):
But to him it's as important.

Dr. Epstein (26:38):
So someone did have some cephalosporin. We got that into him. Meanwhile, I was meeting with the pilot regularly in the cockpit, and we were plotting where we could divert, and she pointed to some little numbered islands in the middle of the Atlantic that don't have a name. They have numbers. I think they were part of the Azores as a possibility. And fortunately the guy was able to rally and we made it to JFK where he got medical attention, and I spoke to his family the next day and he was fine. And I spent most of the trip in coach, so.

Eva Sheie (27:11):
Did you get wings for that?

Dr. Epstein (27:13):
Actually, it's funny. I gave air Morocco my email.

Dr. Nykiel (27:17):
They never.

Dr. Epstein (27:17):
My phone, everything.

Eva Sheie (27:18):
They did.n't do anything.

Dr. Epstein (27:20):
They were very appreciative on the plane, but as a corporation, they completely ignored me ater that.

Dr. Nykiel (27:25):
I've had it called four times and I've gone back to help, and on three of those times it's nothing. And then one time it was someone that basically from Vegas that was basically partying a little bit too hard and they were just hung over and they passed out. We got some fluids and they did great. But it's very interesting because sometimes when you stand up, when they ask, I'm happy to help out. You get up and you walk back and I get it, it's a stressful situation for everybody involved. I think as surgeons in that specific stress, we handle it well because we're just used to that type of stress. But I've had the flight attendants snap back at me and be like, go sit down. We have enough people there. I'm like, okay, I'm the surgeon. I'm the doc. You guys asked if there was anybody help. I'm here.

Eva Sheie (28:06):
Are they judging you by the way you look and thinking you're not a doctor?

Dr. Nykiel (28:09):
O don't know. I just say, okay. I mean, they've got some people there. This is a good question. It's always like, well, who are the individuals that are helping? It's great if you've got a first responder there, of course you want their help. But at the same time, if that individual who's needing help, if they heard there was a doc on board, would they like to at least hear the doc's opinion? I would think yes.

Dr. Epstein (28:26):
It's very true.

Dr. Nykiel (28:27):
Yeah, right?

Eva Sheie (28:28):
Yeah. Wouldn't you rather have a team than be going at that alone with no resources on a plane? I would think so.

Dr. Nykiel (28:33):
No. And I've got one other strange thing to just tell you about that. So I was not on the plane, but my wife was on the plane and a gentleman actually had a heart attack on the plane, and luckily there were some medical people on board, and it's piggybacks off of Mark's story about how contacted corporate and they didn't help out. It was dire for that individual. And does anyone have epinephrine? My daughter who has actually a very severe allergy, did. We say, okay, and the doc was like, we need it all. And we're like, you want to help people out? So we did. We gave it all, but at the same time, now there is that risk of what happens if there's some type of weird cross food contamination. The people on the plane were very appreciative. They asked for my wife's number, Rosie's number, any of it. Never contacted either Mark. They never contacted.

Dr. Epstein (29:17):
Well, it's interesting you bring that up about epi. What happens if the surgeon is the patient? So I was giving a talk for Venus a few months ago. I had a bit of a cough, and one of my friends who works for the company gave me some little teselon pills, which I've had before to suppress my cough, and she gave it to me. It was on a Friday night before the meeting, and I took it, no problem. And then when I got Saturday, I got there one hour right before to give my talk and she gave me one of those little things. I took it and within minutes I felt my throat, I'd never experienced this before closing up, and I said to myself, oh my God, I guess this is what anaphylaxis feels like. So there's a room full of a couple hundred people. They're giving presentations. I'm due to go on in 45 minutes. I go up to my friend, I say, Sabina, sorry to bother you. I think I'm having an anaphylactic reaction. We go into a back room and there was a doctor there who was I guess medical director or something or another. It was a medical meeting, and I needed some epinephrine. They had called EMS, but EMS wasn't there yet. Someone who was in the audience happened to have an EpiPen,

Dr. Nykiel (30:27):
And are you getting worse at this time or what's going on?

Dr. Epstein (30:29):
Well, they gave me some Benadryl and stuff, so it was already starting to stabilize. It wasn't a bad attack, and I did the EpiPen and then I felt great. When EMS came, we just sent them away. 30 minutes later, I did the only thing I could do. I gave my talk on schedule.

Eva Sheie (30:44):
That was my next question. You gave the presentation.

Dr. Epstein (30:46):
I gave the presentation.

Eva Sheie (30:47):
Did they give you wings?

Dr. Nykiel (30:50):
Maybe talks a little fast from all the epi in your system. It was

Eva Sheie (30:52):
Just really got it done.

Dr. Nykiel (30:54):
Those pens, the one I got is the one that talks to you in instructions like an AED and a pocket size. It's $600. So I made sure that the company made that donor, I don't know who it was, whole, because that is not a cheap drug.

Eva Sheie (31:10):
It's a great place to end. Thank you both. All right give me your Instagram, your website, and where to find you.

Dr. Epstein (31:16):
Epsteinplastic surgery.com. And our Instagram is Dr.Mark, MARK, Epstein. You can find me on Long Island in Hauppauge. It's in Suffolk County.

Dr. Nykiel (31:27):
And I am a SoCal plastic surgeon, Matt Nykiel, in Newport Beach.

Eva Sheie (31:31):
Thanks for listening. I'm your host, Eva Sheie. Follow the show and submit questions for our experts at wherebeforemeetsafter.com. Where Before Meets After is a production of The Axis.