Drs. Kortesis and Bharti share highlights from the recent aesthetic plastic surgery meeting, including the big takeaways from their courses and the answers to some controversial questions from audiences which included some of the premier thinkers in aesthetics.
Topics included breast implant fatigue, breast implant illness, avoiding unnecessary surgeries, and the internal bra technique with Galaflex.
Much like this podcast, the doctors recognize that the opportunity to share their experiences with other doctors is to uncomplicate the complicated procedures they do on a daily basis.
This episode was recorded live at The Aesthetic Meeting in Miami, Florida on April 22, 2023.
Learn more about The American Society of Aesthetic Plastic Surgeons https://www.theaestheticsociety.org/
Speaker 1 (00:03):
You’re listening to Dr. Bill Kortesis and Dr. Gaurav Bharti on It’s Complicated. The podcast that uncomplicates the mental and physical aspects of life and the aesthetic surgery to help anyone committed to achieving their personal best.
Dr. Bharti (00:19):
We are in Miami right now and we’re at the American Society of Aesthetic Plastic Surgeons Conference, yearly conference. There’s legit, I mean, 2000 surgeons here, supposedly from all over the world. And uh, we’ve been here for what, how long now? 72 hours.
Dr. Kortesis (00:36):
It seems like an eternity, G.
Dr. Bharti (00:38):
We had a big night last night, so, um, you know, just,
Dr. Kortesis (00:41):
It was one of our boys’ birthdays and we had to go out. So that’s what we did.
Dr. Bharti (00:44):
Yep. And we also had, uh, got the hook up with all of our fellows here, so you know, how many people are here from our practice. It’s pretty amazing.
Dr. Kortesis (00:52):
It is pretty awesome. 20 some and
Dr. Bharti (00:55):
About eight, eight to eight surgeons. And we are involved in the meeting. Maybe a little too involved.
Dr. Kortesis (01:02):
Let’s tell our listeners what we’ve done. What are we doing in the meeting?
Dr. Bharti (01:05):
So we have done, I mean, let’s you help me with this. We had the teaching courses and, um, in the teaching course we actually work in a small setting. So we had about 70 people in a room. And we talked about the concepts of breast implant fatigue and how to manage that. And what, what’s really interesting, and you know, you tell me, is when we’re giving those talks, we’re actually directing the conversation. But the way that we roll is just open it up. So it was fun because sometimes, you know, for two hours to talk, I mean, it can be painful cuz you’ve done it.
Dr. Kortesis (01:37):
No, nobody wants to sit and listen to a lecture for two hours straight. And so the, just how we banter back and forth and make it interactive. But why do you do it? We love to educate. That’s part of it.
Dr. Bharti (01:48):
Yeah. But the selfish reason too is that there’s always comments. There’s always pearls that other people in the audience actually bring up. So by it being interactive, we gained something.
Dr. Kortesis (01:57):
Selfish reason is you like the limelight G.
Dr. Bharti (01:59):
I love the limelight. I love it. That’s not true.
Dr. Kortesis (02:02):
Real selfish reason.
Dr. Bharti (02:03):
But so let’s, let’s look at, so that, um, you know, one, yesterday we had a comment, it was, um, on how to manage implant fatigue. And so that means like what do you do when you’re tired of implants and what’s, what’s the definition of implant fatigue to you?
Dr. Kortesis (02:16):
You know, in our practice it can mean anything, but in essence it is the individual who is just ready to get rid of their implants for whatever reason. They’re just over ’em, two, they have breast implant illness, they might have textured implants, they wanna avoid that, that potential risk for A L C L down the line. And it can be in any of those things. And we see those oftentimes in our practice.
Dr. Bharti (02:38):
Dr. Kortesis (02:40):
But we don’t just do that alone. We offer reconstructive options. And that’s what the talk was all about.
Dr. Bharti (02:45):
Dr. Kortesis (02:45):
And I’m giving the same lecture tomorrow.
Dr. Bharti (02:47):
Dr. Kortesis (02:47):
Different audience. But in essence, we’re, we’re talking about what we do in our algorithm for this removal.
Dr. Bharti (02:53):
Yeah. And what’s interesting is that there are people that were there that didn’t necessarily understand or, or agree with the of, for example, explant, total capsulectomy and doing a lift at the same time. Cuz they’re worried about, you know, possible is the nipple blood supply gonna work? And you know, we’ve done so many of those that we know we can do it, but just because you want to doesn’t mean you need to. But for our patients, you know, we want to try to avoid unnecessary re-operation. So a lot of patients, when they have their implants out, they just want to be done. And so by able to doing it at the same time, we can avoid them in another re-operation.
Dr. Kortesis (03:27):
I mean, what’s the benefit of fat?
Dr. Bharti (03:30):
Yeah. I think a lot of times people think when you do, you’re talking about fat, you’re talking about BBL, you’re talking about something that’s artificial looking, or almost like an implant again. But it’s like the total opposite.
Dr. Kortesis (03:39):
And in our eyes, you know, when we talk about fat grafting the breast, it is about shaping the breast [inaudible]. It is not about volumizing. You know, people assume that you, you can put fat in that pocket where that implant used to live and you can get it as big as you want to get it. You can’t do that. So it’s not gonna give you that structural fullness. But fat is a, a good secondary alternative to that implant, that will help shape the breast.
Dr. Bharti (04:01):
Yeah. And like, you know, the analogy I said, which I think is the listeners may want to hear, and I I always tell patients is that you can do surgery and use fat as an adjunct. And they say what is an adjunct? Adjunct is like, uh, carrot cake.
Dr. Kortesis (04:14):
You can give your carrot cake analogy.
Dr. Bharti (04:15):
Yeah. So it’s like carrot cake. Carrot cake is amazing on its own, but carrot cake with icing is even better. So that’s kind of how I would describe fat.
Dr. Kortesis (04:23):
And you’ve seen G’s never eaten carrot cake in his life.
Dr. Bharti (04:26):
I eat it. I eat it when I need to. All right. So we, that talk was great. Any interesting or controversial things that anybody said during that talk?
Dr. Kortesis (04:32):
Yeah. They were just nervous about doing it at the same time. Yeah. But in essence, to your point, we do it all the time. We can do it routinely. We can do it safely. Patients do remarkably well.
Dr. Bharti (04:41):
One of the guys in the audience asked if we fat grafted the muscle, says that he fat grafts the muscle. And listening to that, I’m like, okay, I, I could see that. And then when we dove in deeper, the volume he put in was pretty low. So I think that’s something you could consider. It would have to be under direct visualization. Our main concern is the risk of potential bleeding or potentially embolism is the reason why we don’t use it. But I think that it probably is safe. And so those are things that we might take home and mod slightly modify our practice.
Dr. Kortesis (05:12):
One of the questions we got was, do you do muscle repair? You know, what does that ultimately mean? And how do you make that decision about muscle repair?
Dr. Bharti (05:18):
Great comment. And, and so for the listeners muscle repair after explant, what does that, what does that mean? So the idea is you take that implant out and a lot of these implants were put in under the muscle. Behind the muscles. Another word that people use, other word that doctors may use as dual plane. And after you take it out, that muscle has been released down low and the muscle kind of moves up. It, the word is called window shade. And so the idea is, you know, why don’t you put that back down? I think people are like, well I wanna be put back to where I was before the surgery. Sometimes it’s possible very easily and you just suture it down. Sometimes it’s very difficult and you have to do a significant delamination, which means separating the muscle from the breast. And so all of a sudden you’re, you’re adding a little bit of a level of complexity to the case. And then when you secure that muscle to the chest wall to do it well, you have to secure it to the chest wall. Sometimes that can be very painful and other times it could actually tear away and you can cause more damage. So I’m pretty selective if I can do it, I do it. If I think it’s gonna cause a problem, I think it’s a bad idea.
Dr. Kortesis (06:19):
I absolutely love doing it. I think it makes a huge difference if you can. But to your point, if it’s too window shaded up, it’s too high, can’t do it, it would probably be more negative than positive. And those cases definitely not.
Dr. Bharti (06:31):
All right. So then I think that was kind of a good synopsis of that course. And, and our, what we gained from our own course, the next course that we gave was on use of, uh, soft tissue, soft support, soft tissue support and breasts.
Dr. Kortesis (06:44):
And, you know, very interesting topic, slightly controversial because you hear the word mesh, mesh ,mesh. Is mesh good, is mesh bad, but
Dr. Bharti (06:52):
Dr. Kortesis (06:53):
Mesh is mesh, very messy. But, and it’s one of those things where I think in the right patient it works remarkably well. And so the, the, the topic was on Galaflex.
Dr. Bharti (07:05):
Dr. Kortesis (07:06):
But there, is that Galaflex the only mesh that’s available?
Dr. Bharti (07:08):
No. There, there are multiple other mesh constructs available. But in the aesthetic or reconstructives plastic surgical space, the one other product that’s available is called Durasorb. And then in within the uh, Galatea brand, there’s also a GalaFLEX light. And so basically what these are, let, let’s talk
Dr. Kortesis (07:26):
About what, what is mesh? Is this a permanent material? Is it something that goes away? You know, will will the patient feel it? And when, when do you use it in your practice?
Dr. Bharti (07:34):
Yeah. So mesh, the connotation that you get from mesh is the scary stuff that you see on the TV lawsuit ads about mesh. And really what we’re talking about is something a little bit different. It is a mesh. So mesh literally is a construct that’s used for added support in soft tissue on the body. Historically it’s for hernia repair, like inguinal hernias or ventral hernias which are hernias of the abdominal wall. And a lot of those old meshes were permanent material like nylon or Marlex or other materials that would be there all the time. And that could potentially erode and potentially cause horrific complications. So the products that we are actually talking about are very different cuz they are absorbable meshes or bioresorbable meaning they actually integrate to the soft tissue and go away.
Dr. Kortesis (08:18):
And so in layman’s terms, they’re just like suture material?
Dr. Bharti (08:21):
Dr. Kortesis (08:21):
Just any other suture material that you would end up using in the breast or in the body to close things. It’s the same. It’s made of the same thing. And what is the purpose of that? Like? Why is it called soft tissue support?
Dr. Bharti (08:33):
Well the purpose is that things stretch. Things uh, loosen up. For example, in the breast, when you lift something up and and tighten it, the tendency is over time gravity always wins and things can fall and, and you can lose sport. And the idea or the theory is that if you can strengthen that soft tissue by adding this material there that you will it.
Dr. Kortesis (08:56):
And do you think that’s real? Do you think that placing this material in whatever capacity you want will allow it to stay there forever? I mean we, we just said that it’s absorbable, it’s gonna go away. So does that strength go away as well or does it that strength last?
Dr. Bharti (09:14):
I think it is a little bit of verdict’s still out into a certain extent. The data that we’ve seen from a lot of the users is that it’s pretty long lasting depending on where and what has been used. Cuz there are now different products that go away fast. And I think more than anything things can be very complicated and that to uncomplicate ’em you have to have a reason for use and a reason for every action that you have. Especially with us in the operating room, we don’t just do anything just because you can do it.
Dr. Kortesis (09:44):
Right. Cause it’s always an added risk. Yeah. When you add something, it’s an added cost to the patient and so you ultimately, you have to make the right decision for, for that patient.
Dr. Bharti (09:52):
Exactly. And then I think incorporate the patient in that decision, like I sure as hell am not gonna be like, you need to use mesh and this is what’s gonna be used in the case. I would rather say you could potentially benefit from the use of mesh. Here’s why, here are the added risks and with this product, they’re pretty low risk. I think it’s pretty amazing. But I, we don’t just say this is how I do it.
Dr. Kortesis (10:12):
So how do you use it? Now our colleague that we did the teaching course with pretty much uses it on every breast case. Which I think is great. His results are absolutely phenomenal. Do you use it on every case?
Dr. Bharti (10:23):
You know, I don’t, I’m very selective with it and I know you are too. And I think that I use it for revision cases. So in situations where you’ve done something and it’s failed, you bring in something new so you’re not repeating the same thing. You know, the other times is that if I know there’s gonna be a need for it or if the patient actually fundamentally wants it, patients are smart. And this is why I think that what separates us at HKB and hopefully other premier providers is that you have to empower your patient with all the knowledge possible. And once they understand what the purpose is, once they understand why you would use something like that, the pros and cons, then I think ultimately they can be the decision maker. Cuz somebody always says, do I, do I need it? And I’m just kind of like, the truth is no. I mean,
Dr. Kortesis (11:09):
Most of the stuff we do, nobody needs. Right? It’s all, it’s all a want or desire. And you know, it’s interesting you said that, uh, a lot of our patients come in asking for it, right? They want this insurance policy. They want that,
Dr. Bharti (11:21):
It’s like travel insurance for the, for the breast. Right. Or or somewhere else.
Dr. Kortesis (11:24):
Yeah. They, they’re wanting it or their friend had it. Can I get it? Can I get it too? But I think it’s all part of this informed consent process where we have to tell patients, Hey, this is the advantage. This is what we can do. Does it work? Does it not work? Can we, can we use it and let them ultimately be a part of that decision making process. For us I would say routinely we use it for implant malposition. Yes. I think in those revisionary cases that extra support goes a very, very long way. And then on primary cases we use it judiciously, depending on the type of soft tissue that the patient has, if they have a recurrent posis over time in those scenarios, it does play an important part.
Dr. Bharti (12:03):
Yeah. I agree. And I think that’s the key and uh, is to use it selectively, but also to make sure that y it is, I think every surgeon should know how to use it. It’s like, you know, if you’re gonna build or create a masterpiece, you need to have everything in your disposal to create a uniqueness to that piece of art. So I think it’s a valuable tool. I think that it’s gonna continue to be used in different novel ways and sometimes we, I think we, we use it for even like in a, a tummy tuck where someone has a super stretched out abdomen and we wanna, we do that tummy tuck, we worry that their fascia is not strong and it might actually cheese wire through or they could have recurrence. We can reinforce that with that mesh. So what it does is it, it’s like a, a time that allows the body, it kind of helps the body form the scar in a very purposeful, logical way. And I think that can be really valuable. So I think that was a good conference as well.
Dr. Kortesis (12:53):
And you know what I, what I realized is the participants, the other surgeons, our peers, they really wanted to know how we would address certain problems. Right. Those case studies that we went through, they’re like, oh, you did a conversion from on top of the muscle to underneath the muscle and then use mesh.
Dr. Bharti (13:08):
Dr. Kortesis (13:09):
And so those concepts are foreign to a lot of people.
Dr. Bharti (13:11):
Dr. Kortesis (13:12):
And I I love that part of it. Don’t you? Like they be able to kind of showcase some of your results and say, okay, we did it this way and this is how we did it.
Dr. Bharti (13:20):
Yeah. And sometimes listen, I think the most powerful thing, which I just want to be real and I think that people learn the most from is you can show actually a result that maybe actually didn’t turn out how you intended or wanted it to be, but you showed what happened and then what you did. I think that’s kind of fun to do. And then also to kind of get input from others. Would you guys have done anything differently? What would you do? And um, sometimes you can get incredible ideas from that because you know, you’re having it look, looked at the lens of 60 other people at the same time. So I think that that was really fun. How about anything else interesting that you’ve gained so far from the meeting? What’s your favorite part about coming to an event like this?
Dr. Kortesis (13:58):
Seeing my colleagues that have not seen in a really long time. We just literally on the way over here saw a couple of our friends from, from South America. Yes. Hadn’t seen a long time. They embraced us, gave a couple hugs.
Dr. Bharti (14:08):
Yeah, we just saw Javier Soto. I mean this guy is incredible. He’s an amazing surgeon, but his um, visibility on social media is probably unrivaled from a plastic surgeons standpoint. I mean millions of followers. And the level of engagement is so high and the content is just, it’s just uniquely him. It’s uh, it’s really amazing.
Dr. Kortesis (14:29):
It’s all about education. Right. And that’s one of the main reasons we’re doing this podcast, is to be able to educate patients. You know, the very first meeting that we took or or talk we had, it was very interesting. It was on the business side of of life and our colleagues wanted to know what we’re doing with HKB. They’re blown away with our expansion. And they were like, what are you guys up to? Why? I know we this in one of the other podcasts, but it was pretty interesting to give them a taste of HKB, at the national level,
Dr. Bharti (14:58):
It was interesting. And then to really understand how unique what we’re doing and what we’re trying to do. Because not only do we want to provide our patients with the best outcome and the best experience and we’re working to continually improve that. We have a long way to go and we just, we’re never gonna be satisfied. But that we actually have a responsibility here. Like our, our space needs this, they need us and we have gotta do right by our colleagues, our fellow plastic surgeons and the other aesthetic providers that are within our network because there’s lots of things happening in medicine and if we aren’t doing what we’re doing, I think it’s gonna affect the way that aesthetic treatments are provided to patients. Cuz it really was an aha moment for me also. And I think the entire audience that was in there, which are like some of the most premier, you know, thinkers in our space worldwide.
Dr. Kortesis (15:55):
I think they were in awe of HKB and what we’re, what our mission is. Which is to, to give people their best. And to be there for every one of our employees, every one of our patients. It’s pretty remarkable.
Dr. Bharti (16:07):
Dr. Kortesis (16:08):
Are you looking forward to anything else in the meeting?
Dr. Bharti (16:10):
Yeah, you know, I think a couple things we have, we’re gonna speak, um, tomorrow, you and I both are doing some different things on the main stage. So the main stage is a little different. That’s kind of the, the big mega room where there 2000 people were there, hundreds of people in there and you know, your face is enormous. But my, my discussion is gonna be on augmentation mastopexy in the massive weight loss, uh, patient. And you know, to us, to you and me and to our practice in the massive weight loss patient is incredible. You know, going on a little tangent, you know, this concept of losing a person or two people from a weight standpoint, a patient who’s journeyed so far, whether they had surgery or a lifestyle modification or both, which is usually what has to happen. They’re then left with this, you know, significant deformity from all the excess skin. When you look and focus on the breasts, they have a significant deformity. You know, it’s a almost a functional deformity, not just an aesthetic deformity. So what we do is not just skin deep. I mean these cases are incredible, but they’re very challenging.
Dr. Kortesis (17:07):
These are some of the best patients.
Dr. Bharti (17:09):
The best Oh incredible.
Dr. Kortesis (17:10):
They’ve done all this hard work to get to where they’re at. And then you come in last minute, always say that we’re running a marathon, they’ve done the first 22 miles and we get to run the last few with them.
Dr. Bharti (17:20):
Oh it’s, it’s amazing the finish line and you know, when I, when I’m gonna give this talk, it’s gonna be real because what I say in this talk, and this is so important.
Dr. Kortesis (17:26):
That you are the best.
Dr. Bharti (17:27):
I’m the best.
Dr. Kortesis (17:28):
You going to tell everybody that it’s gonna be perfect.
Dr. Bharti (17:30):
Best breasts by Bharti. BBB. So no, for real. Well what the thing is that that case, we typically do it together, meaning if we’re gonna add volume to the breast and we’re gonna do it if we’re gonna do it together. But one, one thing that I clearly say is that in the massive weight loss patient, you’re not only gonna be taking care of the breasts, typically you’re gonna address other areas and you’re not gonna be able to do it all together cuz it’s too long of a surgery. So in that situation, I typically, you typically can get them an outcome that they’re proud of and that we’re proud of together. But every once in a while I might need to tweak it. So I always kind of set the stage that you’re gonna get a result that is satisfactory, but that it might need secondary intervention.
Dr. Kortesis (18:07):
Why’s that? Let’s, let’s tell our audience why, you know, why in those cases would you say that there is a potential need for something else in the future?
Dr. Bharti (18:15):
Here’s the deal. So that person was literally another person in the past. So when you see that the, the change that their body’s undergone,
Dr. Kortesis (18:22):
But in their, their eyes are like, I lost weight, I’m healthier, my body should respond better now. Is that, is that the case?
Dr. Bharti (18:30):
What’s happened is that skin, that soft tissue can’t be exercised, it doesn’t snap back. And so it fundamentally behaves differently than an individual who never had that mega weight shift. Okay.
Dr. Kortesis (18:43):
And a lot of the patients just don’t really truly understand the nuances of what that’s like until after they’ve lost the weight.
Dr. Bharti (18:50):
And, and, and listen, that goes back to the, the most important thing about what we do in every, every talk we give. Even when you become a big shot busy surgeon, you have to remember, bring it down, engage with that patient, make sure they understand what the significance of where they’re starting, where they’re going that report so they, they know what it’s gonna take. But that’s the key. And it’s funny, if you can anticipate all issues with a patient there ends up not being a surprise. Even if something difficult or bad happens, they understood it. They knew it. Not only did they sign a consent, but they heard you say it. And then more importantly, you just address it. You stomp it out. And I think that’s like this piece about, you know, we’re not to call this customer service, but it kind of is like you have to like be there for everything and everyone, whether it be your patient, whether it be for people on your team.
Dr. Kortesis (19:39):
You’re not, you’re not just a technician are you?
Dr. Bharti (19:41):
No. You can’t be. And I think if people know that and they’re taken care of, well people understand that things happen, complications happen. It’s about how they’re taken care of and how they’re addressed. And I mean, that’s the whole entire mantra and foundation of this podcast. But it is so funny how that every single thing that we have boils down to that is how do you, how do you plan, do and execute something and then how do you address it when things aren’t how they should be?
Dr. Kortesis (20:05):
Isn’t it pretty amazing? Every one of our talks was about how complicated the procedures were were doing are, and how we try to uncomplicate ’em.
Dr. Bharti (20:13):
Dr. Kortesis (20:14):
It’s come in full circle.
Dr. Bharti (20:15):
It’s amazing. And then we have another thing, which is another massive weight loss panel that we get to do with some of our, uh, incredible colleagues. And we’re excited about that. And what’s really interesting too is sometimes the discussion of what you bring to the podium obviously valuable, but sometimes the most important thing is the discussion that happens on stage. Meaning there’s a moderator and then there’s the discussions and sometimes these presentations and you know, I want, I think we wanna plug our, our great friend Simeon Wall when we did our, um, talk on Thursday where Bill had a talk and I’m not supposed to be on stage and he literally makes me come on stage with him, which was great. But
Dr. Kortesis (20:56):
We do everything together. It’s like a package deal. But in essence, you know, the, these discussions really, it’s really good to get differing perspective because it’s not a single way of doing anything. We, we typically end up, there’s a couple roads that get you to the end point and sometimes one road is better than the other road.
Dr. Bharti (21:14):
You know, one of the amazing things that we get to do here too is we get to have our yearly fellowship event where all the prior fellows who have trained at our program that, you know, Joe Hunt said initially started, I mean oh, 20 years ago. And so now we have, I mean, how many fellows? I don’t even know. It’s, it’s a massive number. And these, these surgeons are all over the country. They are all,
Dr. Kortesis (21:35):
They, they’re our age, but we always say they’re, they’re like our kids and you love to see how damn successful they are. Not, and when I mean successful, I’m not meaning financially, I’m just meaning in their careers.
Dr. Bharti (21:48):
Dr. Kortesis (21:48):
They’re able to help so many people. They’re really great surgeons and they’re just really good, good people.
Dr. Bharti (21:53):
Yeah. It’s, it’s great. And it’s just nice to see each other and, and commiserate about the past and talk about their times as a fellow and then what they’re doing now. And, and like you said, they’ve all achieved wild success in all corners of the, of the country. It’s pretty amazing.
Dr. Kortesis (22:13):
Overall, great meeting.
Dr. Bharti (22:14):
Great meeting. Exhausting, I’m not gonna lie cuz you’re just running, running, running. I think, um, next year I’m gonna plan some more downtime, some chill time.
Dr. Kortesis (22:23):
I want it to be poolside right now, but G made me do a podcast.
Dr. Bharti (22:26):
Speaker 1 (22:30):
Links to learn more about anything mentioned on today’s show are available in the show notes. To learn more about Dr. Bill Kortesiss and Dr. Gaurav Bharti and the entire team of HKB Cosmetic Surgery, just go to hkb surgery.com or follow HKB on Instagram at hkb cosmetic surgery. Subscribe to our newsletter for key takeaways from each episode, links to any resources we discuss and promo codes or giveaways from HKB and our partners. If this show has helped you in any way, if you learn something, write a review on Apple Podcast and share the podcast with a friend. Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more. It’s complicated is a production of The Axis, the axis.io.