Immerse yourself in the world of noninvasive fat treatments with “3 Plastic Surgeons and a Microphone,” featuring Dr. Sal Pacella, Dr. Sam Jejurikar, and Dr. Sam Rhee. These experienced plastic surgeons, hailing from San Diego, Dallas, and Paramus, are here to discuss the latest advancements in noninvasive fat removal technologies. In this episode, the surgeons delve into the intricacies of cutting-edge procedures like CoolSculpting.
You’ll learn about the history of CoolSculpting, how it works, and the types of patients who are ideal candidates for the procedure. You’ll also discover how different treatments compare, and what results you can expect from each. Whether you’re considering noninvasive fat treatments for yourself or simply curious about the science behind it all, this engaging and informative discussion will surely pique your interest.
Dr. Sal Pacella: Alright. Good morning, everybody! We’re back. It’s 3 Plastic Surgeons and a Microphone. We’re back. We had a long hiatus, but we’re happy to see our two additional surgeons and myself, as always, of course. I’m Sal Pacella from San Diego, California. We have Dr. Sam Jejurikar from Dallas, Texas, and Dr. Sam Rhee from Paramus, New Jersey. How are you guys doing? It’s been a long time.
Dr. Sam Jejurikar: I’ve missed you guys.
Dr. Sam Rhee: Absolutely, you guys look better than ever, though; very youthful and rejuvenated.
Dr. Sam Jejurikar: The hiatus has served us well.
Dr. Sal Pacella: That’s great. There’s been a lot of things going on in plastic surgery in the last couple of months, and in the world, so we’ll be sure to touch base on all of that. Just before we start, I want to review our disclaimer again. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based on the circumstances, situation, and medical judgment.
After appropriate discussion, always seek the advice of your surgeon or other qualified healthcare professional with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something in the show.
Fantastic, guys! And I’d like to start by saying the show’s topic will be something very interesting. I like to refer to it as A Song of Ice and Fire. Where that’s from?
Dr. Sam Jejurikar: Game why, I think of Game of Thrones.
Dr. Sal Pacella: That’s right!
Dr. Sam Jejurikar: Yeah, of course!
How noninvasive treatment works
Dr. Sal Pacella: So we’re going to be talking about noninvasive treatments, cold treatments, and hot treatments to freeze or melt your fat accordingly. So without delay, I’m going to hand it over to Dr. Sam Jejurikar in Dallas.
Dr. Sam Jejurikar: Thank you very much, Sal. Before we get started, the inspiration behind this topic is a recent news story that just came up in the last few weeks that I’ll touch upon in a few minutes, but it made me realize just how much non-surgical body contouring is actually performed. I don’t know how much you guys in your practice send people for treatments like cool Sculpting or sculpture or anything like that. Is it something you guys use a lot in your own practice?
Dr. Sal Pacella: A little bit. I don’t use it specifically in my office, but I do send out patients to some of my other colleagues that have the devices in their office.
Dr. Sam Rhee: I don’t do it in my office either. Generally, I’ll usually send people for noninvasive treatments, but more for skin-related type issues like Morpheus aid or something similar to that. I really rarely tell people about cool sculpt or some of the noninvasive. I just feel like I don’t know. I just feel like the results have never been super awesome. Although I have heard of a few patients that have gotten good results, I’ve also seen a couple of patients that had not-so-great results. And I guess we’ll get into that a little bit, and we can talk about our own experiences.
Dr. Sam Jejurikar: Yeah, well, with that, I think that’s a great way to think about it. Let me pull up these few pictures we have here, and hopefully, you guys can you guys see my screen. Okay?
Dr. Sam Rhee: Yes.
Dr. Sam Jejurikar: Okay, perfect! So we’re going to talk about both meltings of your fat and cooling of your fats because those are the traditional ways to handle fat removal when you’re not doing surgery. So let’s start with cooling. Pretty much everyone watching this podcast has heard of Cool Sculpting. It’s the technology that we’re going to talk about today that’s been around the longest.
It’s actually been FDA-approved since 2010, and it took off like wildfire ever since it was FDA-approved. And so we’ve had more than a decade of experience with cool Sculpting. Do you guys know by any chance what people thought about cool Sculpting or the story behind how cool Sculpting was discovered, by any chance?
Dr. Sal Pacella: No, but I’m sure.
How Cool-Sculpting was discovered
Dr. Sam Jejurikar: Yeah. Okay, well, this is really interesting. So there were physicians at the mass general who sort of recognized this phenomenon in little kids who either sucked on ice cubes or consumed a lot of popsicles where they noticed that the fat in their cheeks would actually atrophy. And that was sort of the inspiration by how they realized that you could actually cool fat, actually get atrophy of fat cells, and do so without actually damaging the surrounding tissue. So if you’ve ever heard the term Popsicle Panniculitis, that was the inspiration behind cool Sculpting.
When Cool Sculpting first came out about a decade ago, we didn’t really talk so much about staging it or doing multiple treatments. We talked about doing one isolated treatment, and I would tell people, look, you get this version of cell death called apoptosis by which it’s called program cell death, where essentially the fat cells sort of shrivel up and over the span of two to four months get reabsorbed and excreted by your body. And it worked well.
What we sort of realized with cool Sculpting is it wasn’t the equivalent of liposuction. If people wanted all of their fat gone and they had the time to recover from surgery, cool Sculpting was never going to be the right choice. But if they didn’t have a lot of time, cool Sculpting was a procedure that they could come in, get a treatment done with an applicator placed over the area in concern, and sometimes have multiple applicators set up at the same time.
Each treatment would take about an hour, and then over the span of a few months, they’d lose about 20% of their fat. As we started using cool Sculpting more, we started using this process by which we would try to get a little bit greedier. We would actually do stacked treatments where people would come in every four to six weeks and get a repeat treatment, and we would lose more fat. So in this picture that you’re looking at on the top, this is someone who just had one treatment, and I’ll say an exceptionally good treatment, not a typical treatment with cool Sculpting.
And you can see that this gentleman lost a good amount of his fat, but he still has love handles present. They haven’t gone away, but he looks like he looks substantially smaller. This patient on the bottom, if you look at this critically, they’ve had two cool sculpting sessions. And so this picture on the right was about eight weeks after the second cool sculpting session. And you can see that the overall girth of the abdominal wall is substantially less. But if you look at this critically, what do you guys think about the skin elasticity here? It looks a little wrinkly.
One of the things that you’ll see with cool Sculpting is it is specifically isolated for the reduction of fat. It has almost no effects on them. The reason I started thinking about cool Sculpting, actually, sorry, one more thing. When you look at overall patient satisfaction levels, you’ll read on the internet where people say that patients are 90 or 95% satisfied, but the only time it’s been objectively looked at in a peer-reviewed study, it’s a patient satisfaction of about 73%.
And perhaps there’s selection bias in the patients that come to see me. But most of the patients that I see that have had cool Sculpting aren’t that thrilled with their results. They typically are in my office to get liposuction. And because cool Sculpting has become so prevalent, I mean, it’s offered in a wide range of doctors’ offices, not just plastic surgeons, but dermatologists and family practitioners. There’s a cool sculpting machine on every block, it seems.
Sometimes I think the technology is somewhat misapplied, and it’s used on patients that aren’t going to get the best results. What do you guys think if you were to send someone to get cool Sculpting? Who’s the sort of patient that you think would get a good result from Cool Sculpting? Who’s the sort of patient that you think wouldn’t get a good result from cool Sculpting?
Dr. Sal Pacella: Well, so I think where I usually see it fitting in is in patients that have, say, good skin elasticity, love handles, or perhaps areas that are very spot, difficult to treat. Interestingly enough, those are areas that are very amenable to liposuction anyway, right? So it’s not really a patient who has, say, a post-pregnancy, double twin pregnancy, has excess skin and a little bit of fat and muscle laxity. That’s not a patient for cool Sculpting.
Dr. Sam Jejurikar: Yeah!
What makes a person fit for Coolsculpting
Dr. Sam Rhee: For me, the indications are really small. I would say the only way I could really see this working is for someone who has very mild or moderate, really mild fat deposition, who’s just really averse to liposuction. That’s the bottom line. Because I would say, in my experience, and I’m very biased, I don’t own a cool sculpt machine, and I do liposuction. So I understand that I’m a very biased observer when it comes to this type of technology, but for me, there are very few indications where I would say Cool Sculpt is going to win out. And that’s basically anyone who just doesn’t want to do liposuction for whatever reason. But in almost every other situation, I feel like liposuction is going to get you a better result.
Dr. Sam Jejurikar: I would agree with both of you guys 100%. Liposuction is always going to be the gold standard for fat reduction. And particularly Sam’s point, people that don’t want liposuction, I, for instance, as a surgeon, always generally recommend liposuction to people that are in my office. But I, as a patient, don’t really have the time to recover from liposuction. So Cool Sculpting might be something I would consider because there’s no downtime really associated with it. The other two indications that I would say in terms of patients that get good results, you can’t be too fat if you’re morbidly obese.
The applicators actually just have a hard time sucking up the fat, and the results tend to be very unimpressive. And if you’re super thin, I think we’ve sort of seen over time that in patients that are really thin, it’s harder to cool the fat because of the proximity of the fatty tissue to the underlying muscle, which is a little warmer, and the results don’t tend to be as good. So you can’t be too skinny, you can’t be too fat. You have to basically be okay with results that are going to be improved but not perfect and stacking treatment. Sorry, go ahead.
Dr. Sal Pacella: So you mentioned something very interesting. You said clue sculpting has very little effect on the skin. So if given a patient that is a Cool Sculpting candidate, you did regular, traditional power-assisted liposuction, and in my experience, those patients get really pretty decent skin retraction, right? If given the same patient for Cool Sculpting, are you saying there’s less skin retraction?
Dr. Sam Jejurikar: I think so because I think it’s rare for any of us that are talking here to just do liposuction and not at least think about the skin. Although what we typically tell patients is that liposuction is geared towards fat removal. We all have things that we do during the surgery itself to try to promote skin retraction. When you’re talking about power-assisted, there’s usually a step at the end of the operation where you’re doing fat redistribution with your cannula to basically smooth out the fat, and in the process, you traumatize the under the surface of the skin, which I think can promote some new collagen formation over the ensuing months.
I typically use an energy modality, which I’ll talk about at the very end of this, in combination with patients who I don’t think have great skin elasticity. Obviously, if someone has great skin elasticity, as you had sort of mentioned in your indications, for someone that’s going to do well with Cool Sculpting, they’ll get skin attraction, but if they have poor elastic, I think they’ll have extra skin or their skin will hang. Does that answer your question? Perfect!
So here’s what got me thinking about Cool Sculpting. And I don’t know if both of you guys saw this. I imagine you would. It was a big news story, but Linda Evangelista, the supermodel from the 1990s, put forth an Instagram post and simultaneously announced a lawsuit against Celtique, which is the subsidiary of Allergan that owns Cool Sculpting. And in it, she developed paradoxical adipose hyperplasia. This is not Linda Evangelista’s Tummy in this picture. Just going to put that out there.
I haven’t seen what it looks like, but this is a patient that’s at Cool Sculpting, and you can sort of see this block in the lower portion of their abdomen, which is PAH paradoxical adipose hyperplasia, which happens. And I’m going to use air quotes rarely after Cool Sculpting, and I’m using air quotes because nobody really knows how often it actually happens. The first time it was really reported in the literature was in 2014. They said it happened one in 20,000 times. The manufacturer says in their own literature that it happens about one in 4000 times.
There was a letter to the editor of Plastic and Reconstructive Surgery in 2016 where the authors said when they were using a large applicator to treat the lower portion of the abdomen or the flanks, they saw it in one in 138 cases. And they talked about some modifications that they did where they would use smaller applicators that kind of distribute the cooling a little bit different with the use of multiple smaller applicators and that they thought reduced the frequency.
And probably the most comprehensive review was published just last year in the Aesthetic Surgery journals; they surveyed over 2000 patients from Canada, and they said that the incidence was probably about one in 2000. So it’s definitely a thing that I’ve seen multiple times and multiple patients who have come to me probably eight to ten times in the last five years who have developed this for treatment. Have you guys seen this at all?
Dr. Sam Rhee: I’ve seen two. And the worst was someone who had a bra, like the behind-the-back bra area. And it was quite amazing how hypertrophied the fat was there. It looked almost like those blocks that you just showed in the belly, but it was around the back. And the thing that concerned me about it was if you have a complication with liposuction and listen, you can have a complication from any aesthetic treatment. We know that a lot of it is really operator dependent, right? In fact, all of it really is operator dependent.
You find someone who’s as experienced as you possibly can be with any treatment, and you’re going to reduce the risk of complications. And I would say I don’t know the exact statistics, but I would say in an experienced physician plastic surgeon who knows how to do liposuction; I would imagine the risk of complications is going to be relatively low, definitely lower than 1 in 130. It might approach 1 in 4000 or 1 in 20,000, and it’s my guess. And you’re never going to get more fat resulting from liposuction; let’s just put it that way.
You’ll never have more fat than when you started with. And if you do have complications with liposuction from liposuction itself, it’s probably going to be relatively minor. You can’t even tell who are the patients that are going to have paradoxical hyperplasia, can you? It just happens randomly. So that’s a little concerning that you can’t actually even predict who’s going to get complications from cool Sculpting.
Possible Complications from CoolSculpting
Dr. Sam Jejurikar: The only thing I would say to that is I think you’re right to a degree. I do think that the incidence of paradoxical adipose hyperplasia has increased as more and more physicians have gotten aggressive with stacking the treatments. There’s a lot of thought process that as people have started to try to get more and more and more fat removal as opposed to just doing one treatment, the incidence of it has increased.
And then again, as I sort of mentioned, changing the way applicators are used, I think, as, for instance, instead of treating the lower abdomen with one giant applicator, treating it with two smaller ones has been shown to probably result in less of a likelihood of getting this PAH, which, by the way, is also called a stick of butter. It looks like a stick of butter, which is why this butter is. I realized there was a reason why I put a picture of butter on this slide, but that’s how patients sort of identify what they have.
Dr. Sal Pacella: Throughout this discussion, I think I’ve just seen staring at a block of butter.
Dr. Sam Jejurikar: I was like, why did I put that butter there? Oh, yeah, that’s why.
Dr. Sal Pacella: Can you treat this with regular liposuction to remove it?
Dr. Sam Jejurikar: Yes, maybe. Sam said yes, and that’s the way I’ve always treated it.
Dr. Sam Rhee: I was just about to say Zeltiq will reimburse the patient for liposuction treatment if they get PH if you submit all of your documentation. So I imagine this happens more often than the company is letting on because they have a very standardized procedure of how to deal with PAH or paradoxical adipose hyperplasia. They have this whole formalized procedure, and as you wrote there, it’s not more cool Sculpting. The way to treat it, in Zeltiq’s mind, is with liposuction.
Dr. Sam Jejurikar: Yeah, two things that kind of add to that as part of the reimbursement thing. There is an NDA that patients sign. So yeah, we don’t actually know how many patients have done that. Linda Evangelista refused to sign all that, which is why I think I got so much publicity. The only definitive way to really get rid of it is actually direct excision, though most people have had very good success using an energy modality, whether it’s power-assisted life or a VASER and liposuction removing it.
I have had one patient that recurred after I did VASER and liposuction; I had to have a second treatment. So it’s not foolproof, but it is definitely much less morbid than directly exciting. But yeah, it’s a real thing. I guess my take message with Cool Sculpting is I still think there is a place for it. I think it’s certainly a very cost-effective treatment at this point because it comes to supply and demand. And the supply of Cool Sculpting machines out there is quite high, and the demand has gone down as there are newer technologies that we’re going to talk about.
But you can still get pretty good results with it, is what I would say. But you have to watch out for these complications. And if you are unwilling to take those risks, this is a complication that is unique to Cool Sculpting and nothing else we’re going to talk about.
Dr. Sam Rhee: Again, I think one of the biggest problems with this is that Zeltiq marketed to every physician out there. As you said, it was on every corner, and I was constantly bombarded with ads to get to purchase one of these machines. And I think once you throw five Bazillion machines out there with people who may not have a whole lot of experience managing aesthetic body contouring, you’re going to get problems. As you said, they’re trying these machines in ways that are probably not really indicated. And the rash of complications ensues just like with many other aesthetic treatments that we’ve seen out there.
So I feel like some of the blame actually lies with Zeltiq, to be honest with you, and the fact that you just have to find providers that know what they’re doing in general. Just like with every other aesthetic treatment, whether it be Botox or something that’s supposedly safe or noninvasive, the person who administers it and does it does matter.
In 2015, FDA approves first device for removing fat
Dr. Sam Jejurikar: I totally agree. Let’s move on to the next technology because we spent plenty of time on that. So in 2015, the FDA approved the first device for removing fat by heating the skin, which has affectionately been known as warm Sculpting. But that was actually a sculpture, which is not what we use in our practice, but it was the first FDA-approved device. And it was a similar process. As opposed to gently cooling the skin, you gently heat the skin, and much like you get programmed cell death like you do with cooling, you also get programmed cell death over several months by heating the skin.
And so typically, people would see 20% to 25% fat loss over several weeks. But one of the differences, which people sort of kind of noticed at the time, was that you could have some secondary benefits on the skin. So when you use radio frequency over the ensuing months, you can get increased production of both collagen and elastin in the skin, which helps profoundly with skin elasticity. And so, when you looked at patient satisfaction scores a few months afterward, they tended to be higher with radio frequency techniques.
What we use in our practice is a treatment called Evolve, and it just sort of illustrates some of the things that you can do with heat that you can’t do with cooling. Not only can you get fat removal, but you definitely can also see some tightening of the skin. And then you can also start to see some muscle development. They’ve very cleverly marketed as tight, trim, and toned as the different treatments, but they’re all using different benefits of radio frequency to get results on not just the SAP but also on the skin and the muscle.
So here’s a patient who underwent one cycle of treatment. And what we typically will do with one cycle of treatment is come in weekly for six weeks to get a relatively quick 20 minutes treatment with any Evolved probes; there are four or six of them hooked up at a given time. So it’s a quick treatment, but you have to do them staggered over the span of a few weeks. But this is one cycle of treatment when you sort of see that after a few weeks have gone by, after the treatment, there’s an overall, again, not all the fat is gone, but the abdomen is substantially smaller. And you can tell that the skin has tightened somewhat with this treatment.
Wouldn’t you guys agree that, unlike the cool sculpting picture, you can definitely see the skin is a little bit tighter? There’s not the same sort of wrinkles that you might have seen. And this is someone that I would look at who’s getting liposuction that I would be afraid of, would have some excess skin. Now, I think we would all agree this isn’t the same result we would get after liposuction, but for a no-downtime procedure, I think the results are pretty.
Another patient here, really similar, where they’ve undergone a cycle of evolution. They’ve had this gentle heating of the skin, and then after several weeks, they lose a good amount of fat, and their skin has tightened down without having a lot of loose skin. I think in both this picture and the one I showed you before in both of them, if I were to objectively look at this, the same problems that they had before the treatment exist, but it’s just better, right? This patient still has extra fat in the entire abdominal wall, but it’s better.
So if that’s the sort of treatment that sort of results that a patient is going to be happy with, I think using a radio frequency noninvasive treatment like sculpture-like Evolve is going to give you results. They’ll be happy with it. If they’re looking for the flattest best result they can. That’s when it’s time to see a plastic surgeon and have liposuction.
Dr. Sam Rhee: It’s pretty impressive, actually. Does this work safely for all skin types or all ages, or are there any sort of limitations in regards to the patient population or suspension skin types?
Dr. Sam Jejurikar: Not really any limitations – all ages. I think you and all three of us would agree that as patients get older, their elasticity isn’t as good. So in older patients, I tend to be much less impressed with the results of radio frequency treatments. As patients in their fifty s and sixty s, I don’t tend to see these quality results from a skin tightening standpoint in patients in their thirties and forty s that haven’t lost massive amounts of weight and haven’t developed a bunch of stretch marks from pregnancy. Yeah, I think it can get really good results.
Dr. Sam Rhee: I mean, I don’t want to be the CrossFit a-hole here, but a lot of these body concepts…
Dr. Sam Jejurikar: Just to be clear, when you say CrossFit and you start talking about it, you are automatically an A. I know.
Dr. Sam Rhee: I understand.
Dr. Sal Pacella: What you meant to say was always to talk about.
Dr. Sam Rhee: Alright, so I’m going to be the CrossFit a-hole here, and I’m going to, but let’s face it, a lot of aesthetic body contouring these patients would benefit a great deal from lifestyle changes. Right? They would do better if they nutritionally improved if they improved their fitness level, all of these things.
Dr. Sam Jejurikar: I think you have this confused with your other podcast. Dr. Rhee just forgot where he was for a second. We forgot there were three plastic surfaces talking about treatments.
Dr. Sal Pacella: A vegan across Fender walks into a bar and stops talking.
Dr. Sam Jejurikar: Exactly.
Dr. Sal Pacella: Before I get canceled, I just want to reach out to my vegan colleagues. I’m also on a plant-based diet.
Dr. Sam Rhee: Okay, so you’re going to apologize to the vegan guys but not the CrossFit guys out there.
Dr. Sam Jejurikar: I actually fully back Dr. Pacella on that.
Dr. Sam Rhee: Alright. The last preachy thing I’m going to say about this is I do talk to all of my aesthetic body contouring patients, especially if I ask them, listen, do you think you could do better with your lifestyle, with what you’re doing in terms of what’s going on? And if you feel like you can, you should do it before you get an aesthetic procedure.
And I think holding our patients accountable to a certain degree is really important because some of the changes they don’t like about themselves, where they come in to see us, are in large part due to things that they might be able to improve on their own as well. And so I’m not saying no to aesthetic body contouring, but I’m saying it’s synergistic with the stuff that you can do in your life to make yourself better.
Dr. Sal Pacella: I’m going to start recommending popsicle therapy. So for facial theft?
Dr. Sam Jejurikar: Exactly!
Dr. Sal Pacella: Cosmetic world.
Dr. Sam Jejurikar: You just have to make sure they symmetrically apply the Popsicles inside of each cheek. And now that I’m done abusing Dr. Rhee, he’s 100% right. Any procedure we talk about, whether it’s surgical or non-surgical, is not a substitute for a healthy lifestyle, which includes both diet and exercise for sure. But, you know, sometimes, and I think you would agree with this, Sam, that the two go hand in hand. Changes in lifestyle and simultaneous body contouring procedures together just give a synergistic result that sometimes you can’t achieve with either alone.
Dr. Sam Rhee: I agree. And I’ve seen that.
Dr. Sam Jejurikar: Yeah, for sure. So then, now I’m going to talk about something that these guys will have an easier time getting behind, which is liposuction. Yes, liposuction is the gold standard. The treatments that we talk about are best for people that either just don’t want to have surgery because they’re afraid of surgery or don’t have the time for surgery. But with liposuction, if you want to talk about the gold standard for fat removal, it’s still going to be that. Because we all know we can remove a lot more fat with liposuction.
And a lot of times, we can do things better. Whether it’s related to skin, whether it’s related to the muscle with liposuction, and using things like radio frequency or ultrasound, which is commonly known as body tight or J-Plasma or VASER, all of which I use body tight and I use VASER a lot in my practice. You guys may use other things, but using energy modalities in combination with liposuction can, to some degree, help with skin elasticity as well.
So I think you can also get more precision in terms of the results. So here’s a patient that had liposuction. You can accomplish so much more in terms of developing the underlying abdominal wall structure, making the overall abdomen look smaller. Here’s a lady who probably didn’t even need liposuction. She looks like she’s in great shape, but you can just shape the body much more precisely when you do liposuction. And the fat that you take out with liposuction, you can use in other places.
So in this patient, we take out fat from her love handles and her abdomen, put it in her hips, and make her look curvy. And so, liposuction is still going to be the gold standard by which you can get great results. So that’s all I really have to say. I don’t know what closing thoughts you guys have on this topic. I know you guys do a ton of body contouring as well, so I don’t want to hog the spotlight.
Dr. Sal Pacella: Oh, great presentation. I think this just reiterates in our world, what I think makes us unique among aesthetic providers or cosmetic providers, as board-certified plastic surgeons, is you can be assured that when you come in to see us, you’re going to get a bespoke or tailored treatment, not when you’re a hammer. The whole world is not a nail. So we’re going to give you what you’re going to, what’s going to be best for you, or at least talk about the options for you.
Dr. Sam Rhee: Yeah, I completely agree. We see more patients of all types. Mild lipodystrophy to significant lipids, tons of fat, and we know how to deal with it. And I hate to say it, but it’s true. As Sal said, being a board-certified plastic surgeon just gives you every tool at your disposal. The other two things I was going to say is one is I do love the fact with liposuction, you can recontour and actually change proportions, which is very powerful, especially when you’re looking to redistribute fat. And then my last one is sort of facetious. Did you put all those ovals on? Because for the dude, that oval went down about like two-thirds of his thigh. And I just wanted to know.
Dr. Sam Jejurikar: He’s a powerful man. This is Texas. There’s a saying we have down here; everything is bigger in Texas.
Dr. Sam Rhee: I’m glad. You know what? I’m very impressed. I’m very impressed with the men of Texas. That’s nice!
Dr. Sam Jejurikar: Yeah!
Dr. Sal Pacella: Awesome!
Dr. Sam Jejurikar: Well, on that note, gentlemen, always great to catch up with you guys. Enjoyed this conversation a lot. And until we see each other again, take care. Bye!