Big Wins and Big Losses with Semaglutide & Tirzepatide for Weight Loss

Dr. G (00:00:02):
You are listening to another episode of All the B's with me, Dr. G and my scrub tech Bri. All right everybody. It's the end of the year and we're wrapping up and to kick off our current events, it's that time of year where you get the best movies of 2024, which I don't know that there were any, but.

Bri (00:00:25):
That's a no.

Dr. G (00:00:28):
The best of or the best lists or you're wrapped. We were laughing about this yesterday, right? Because you get your wrapped on Spotify and I forget what we were Googling.

Bri (00:00:41):
I forgot what, oh, we needed our Google history wrapped from the office.

Dr. G (00:00:45):
Yes.

Bri (00:00:46):
Cuz I try and google stupid things on guests so not everyone can see it because one time it was Googling a bunch of, I can't even probably say this on the podcast. It was for work I feel like, and then they screenshotted the Google history and was like, wow.

Dr. G (00:01:06):
Yeah, our Google history from work because of work is sometimes a little whack. We would love to see that wrapped.

Bri (00:01:16):
Way better than Spotify.

Dr. G (00:01:18):
In line with that, the Forbes article, Plastic Surgeons Predict the Top Aesthetic Procedures for 2025. We talked recently about things that were important in 2024, so let's moving forward to kick it off is Lindsay Lohan's face again.

Bri (00:01:37):
Whole new face.

Dr. G (00:01:40):
Whole new face, but it's all part of that. They're guessing 2025 is more about subtle undetectable.

Bri (00:01:49):
That was detectable.

Dr. G (00:01:52):
I mean if you compare to her previous. I do see a little bit of backlash where people are like, yo, she's 38, calm down. But I mean, I think she looks good. And it's not, her face is different, but still looks like Lindsay Lohan, so I think that's part of it.

Bri (00:02:14):
It doesn't look like super, super overdone, but she definitely is a whole new bitch.

Dr. G (00:02:19):
So yeah, that is, I think the number one thing is doing tweaks or things that make you look more youthful or rejuvenated, but don't look overdone. So more is not better, which I think applies to a lot of things in 2024 and 2025. What year is this? Okay. I think it's funny that on this article there's an ad for regenerative medicine for Dr. Cohen's office and his nurse Michelle's right there. But anyway, I was like, oh, there's Michelle, I know her. But that actually is one of the trends that they're predicting, which is regenerative aesthetics, which I love, and that's doing things like PRP's not going away. PRF nano fat, which we all want done.

Bri (00:03:13):
Yes.

Dr. G (00:03:16):
Yeah. So I think you said somebody called the office yesterday asking for nano fat. Correct? Tell us about that.

Bri (00:03:23):
Yes, so somebody called and asked because they specifically wanted nano fat in their breast, which we don't do. It's generally for the face, and I tried to explain the filtering process and how you don't want, it's an incredibly filtered fat. We put it through many different systems and that don't want that in your breast.

Dr. G (00:03:48):
I mean you could do it, but I don't know what the goal would be. Right. So when you're putting fat,

Bri (00:03:55):
It's such a small amount, right?

Dr. G (00:03:57):
Yeah, it's usually a small amount. We do put it through meshes and filters that breaks up the particles so that fat's not designed to add volume. It's supposed to be adding the regenerative effects of having stem cells and all the little things that come with that fat slurry. I can talk, I can talk.

Bri (00:04:19):
This is giving me faux hawk, fox hawk vibes.

Dr. G (00:04:21):
The flat surry versus the fat slurry. Anyway, you take the fat out and we decant it. We get rid of some of the fluid that came in the tumescent fluid, so we gravity decant, and then Bri works like a little Christmas elf on the back table and pushes it through these filters that reduce the fat particles. Macro fat is just fat that has been gravity decanted. Generally what we put in the butt and in the breasts because we want that fat to stay there and become your own fat, like transplanted fat and add volume. And then you will run it through other filters to make it micro fat, milli fat. And then basically when it's just a slurry, it's nano fat and you can take the nano fat and microneedle it into your skin. You can take the slurries and inject it under the skin very much the same way you would PRP. So I'm not sure, I guess if you wanted to add it to your cleavage area, maybe to rejuvenate how people get those wrinkles right in the decolletage area, it would probably be great for that, but it's not going to add volume. So unless you want your breast skin to look glowy, I'm not really sure I know what that's going to accomplish.

Bri (00:05:49):
And for reference, I mean when we do regular fat, we put it in through 50, 60 cc syringes and this little nano fat, most of the time, 99.9% of the time I am making into a one cc syringe, which of course you can do more, but imagine just putting 300 little syringes in.

Dr. G (00:06:11):
Yeah, it would be, it would be a little tedious and I'm not sure what the goal is because like I said, it's not going to add volume. It's going to kind of just rejuvenate or restore and the image they have of that before and after is kind of what you're looking for. She's somebody who doesn't need volume, so filler is not going to be what works for her. You don't want to add volume to her face, but you want to add, soften the lines. It's kind of like a filter, honestly. It does take a little time. You don't see an immediate effect. It can take up to three months, sort of like a laser does. But I think speaking of regenerative medicine includes that, it includes anything we can do that sort of stem cell adjacent, but since we can't call anything stem cells right now. I think exosomes are huge, hugely popular. Adding that to your laser treatment, to your microneedling, all of that stuff just gives your skin a healthy glow, tightens the skin and just makes you look like you haven't had anything done, but you've had that elusive great night of sleep.

Bri (00:07:20):
I dunno what that's like.

Dr. G (00:07:22):
That doesn't exist, but that's cool. Or that you've been taking good care of yourself, which I think Lindsay Lohan has also been doing. So I mean, we're about to go into dry January, so.

Bri (00:07:33):
Speak for yourself, homegirl.

Dr. G (00:07:36):
Come on,

Bri (00:07:38):
I can. Yeah, no, I'm not going to get bullied into dry January.

Dr. G (00:07:45):
Alright. So that is one trend. Moving on, I think they had some other good options here for Forbes. They were talking about, we've talked about undetectable, we've talked about regenerative medicine, I think they mentioned blepharoplasties. So looking at that, those have been huge. Yeah, we're seeing a lot more people who want their eyes done. And then the early intervention facelift is a little controversial.

Bri (00:08:18):
Is that like 30 year olds trying to get this facelift?

Dr. G (00:08:21):
And I think that's always been around, at least in Hollywood. So the number of younger celebrities that have had facelifts. One of the more famous people for facelifts, Mike Nyack is in St. Louis, Missouri and he has some great educational videos that I watched and I was shocked when I watched one and the patient was in her forties, but she really needed it. So I feel like if you're not in an area, maybe in the Midwest, they don't take care of themselves. I dunno, she just looked older than 42, so I agreed that she needed a facelift. So at face value, I would say 42 seems a little young, but if you've had a lot of maybe weight gain and weight loss or had some other things in your life that made you maybe age a little faster, maybe that is something you need to do. I don't know.

Bri (00:09:20):
Your forties is the new sixties.

Dr. G (00:09:24):
Yeah, it seems like a lot because, you know facelifts don't last forever, so you're going to need another one. But if you have that disposable income, by all means go for it.

Bri (00:09:36):
Will you always need a second one if you get one done when you're 30? I'm like, where can I?

Dr. G (00:09:40):
No. Yeah, I mean think so. People who do it in their fifties often come back in their sixties and seventies to get a second one. So I mean if you do want a decade, that's like a lot. Every time you go back in too, you're revisiting those planes and some scar tissue and run the risk of having a nerve injury.

Bri (00:10:02):
There's so much harder, let me tell you.

Dr. G (00:10:06):
When it's a secondary facelift. So I don't know. One of the arguments we're doing 'em early is that instead of pumping your face full of filler and doing radio frequency microneedling and ultrasound therapy like Ultherapy, the concern is that is creating scar tissue as well, which can make the facelift harder to do. But I think having a facelift makes the facelift harder to do so. Neither is a great option. Maybe we just need to sleep upside down.

Bri (00:10:38):
I guess so.

Dr. G (00:10:41):
Or on your back, which is impossible. I did have a patient that I did a facelift on and he looked great and then we did some microneedling afterwards, radiofrequency microneedling to his lower neck and chin, and then I was taking the after photos and I was like, damn, it looks really good. He's been aging, I've been treating him over the last five years. And he's like, oh, I started sleeping on my back.

Bri (00:11:08):
But he had moved out from the couch or moved out from his bedroom to the couch and was like, oh yeah, I don't sleep. I was like, you just left your partner and you're just sleeping on the couch, but it works.

Dr. G (00:11:19):
Okay. Then post weight loss body procedures, I think we're going to talk about that, which is on brand with our topic today, which is to talk about GLP s and our office experience and our experience in general treating patients with GLP-1s. But yeah, I think as people are losing weight, they're realizing that now they need to deal with the extra skin or want to deal with any ptosis they might have either with their breasts or their face. So I think having post loss body procedures is going to be a big deal.

Bri (00:11:57):
Yeah, it's definitely spiked, I feel like the end of 2024. Actually kind of a lot of 2024, but it's been pretty big recently.

Dr. G (00:12:08):
And it's not going away. So that is our trends for 2025. I'm excited to talk about the next article that made it to Yahoo. I went to the wrong guy to put my face back together. Seven male celebrities who opened up about their cosmetic surgery regrets.

Bri (00:12:30):
It's that Santa?

Dr. G (00:12:32):
That's Kenny, Kenny Rogers who is what everyone thinks of when you think of bad male plastic surgery because whoever did his eyes needs to be fired.

Bri (00:12:45):
He looks like the Santa, the plastic version in Santa Claus 2 where they duped the original Santa and he came out and nobody knew it wasn't really Santa, but he was made out of complete plastic and his eyes were like up here. Can we pull up a picture of him? I'm sorry, Santa Claus 2 plastic Santa and just put it next to each other.

Dr. G (00:13:11):
Poor Kenny Rogers. Yeah, I mean I think he had a surgery around the same time that the Donnie Osmond, who I'm sure you don't know who that is, either had surgery and I will say one of the common themes in all these celebrities is the most common area for men to have done is eyes and noses. And both of those are really hard. You don't want to feminize.

Bri (00:13:40):
See?

Dr. G (00:13:40):
Plastic santa. Okay.

Bri (00:13:45):
They're one and the same. Come on.

Dr. G (00:13:48):
Alright, I'll give you that. So yeah, unfortunately for Kenny Rogers, it's all about the eyes and I think Brad Pitt had an amazing facelift that he just showed off, but his eyes aren't done.

Bri (00:14:08):
Oh really?

Dr. G (00:14:09):
Yeah, and so he looks good and I think when you start messing with men's eyes, you get in trouble because more is not better there. You want to do a very conservative, both upper and lower blepharoplasty because Kenny Rogers ended up with beady and it's a very unnatural, a tight round eye with no overhanging upper lid just looks weird. It looks weird on most people. It looks even weirder on a guy. And then who was our next celebrity? Yeah. See, Brad Pitt's face looks great, but he still has a squinty little eyes because they were smart to not mess with that. That's what he looks like.

Bri (00:14:55):
He does look good. I did not realize he had a face lift.

Dr. G (00:14:59):
Yeah, he looks great, but his eyes were always kind of like that and if you did it, it would've made him look different and weird. So yeah. Yeah, props.

Bri (00:15:09):
I like it. Good job.

Dr. G (00:15:11):
I think our second person, you'd have to biggify the screen for us somehow.

Bri (00:15:17):
I'm trying to pretend like I know who all these people are.

Dr. G (00:15:20):
We're going to get to some people you know I think. Is that Mickey Rourke? I believe so.

Bri (00:15:26):
Looks like straight out of Yellowstone.

Dr. G (00:15:28):
Okay, so Mickey Rourke is famous for having a ton of surgery that allegedly addressed his facial injuries from boxing. No one believes that.

Bri (00:15:40):
Very overfilled with filler.

Dr. G (00:15:43):
Yeah.

Bri (00:15:44):
I don't know.

Dr. G (00:15:45):
He looks distorted. His face lift is feminizing. I don't know what they did with his rhinoplasty. And then in 2017, this was him in 2017.

Bri (00:15:55):
No, Brad Pitt.

Dr. G (00:15:55):
When he got his nose redone, but it's too late. So yeah, very, he has a very feminizing look. And then Simon Howell was noted for having too much filler where he overshot that and looked crazy. He looks ridiculous. His eyes are sucked into the back of his head because there's so much surrounding filler. It looks bananas.

Bri (00:16:24):
His, he has no, it's cheeks, chin, all of this is all one

Dr. G (00:16:31):
One big unit.But again, with filler, I'm unlike with implants, you can just dissolve that, which is what he did. I just think that these are people who have a little bit of power and clout and I think maybe their surgeons or dermatologists or whoever's doing it doesn't have, they come in and they want more and it's hard to say no sometimes that might be what's going on. I don't think the aesthetic person taking care of them's like this is a good idea. I would hope not. I just think these people demand more and more and they're like, okay.

Bri (00:17:07):
I'm going to give it to you because otherwise you're going to go elsewhere?

Dr. G (00:17:11):
Right, exactly. And then this is such an unflattering picture of John Stamos, but I don't know, he talked about his decision to get a nose job. I think what was interesting is for all these people, they did not like the way they looked on TV and I think they got on TV based on how they look. So it's a little depressing that even celebrities hate how they look on film.

Bri (00:17:41):
Which is crazy.

Dr. G (00:17:44):
I know. So he thought his nose was distracting from his performance and so he had a rhinoplasty and then he hated it. It looked kind of pushed up like Peter Pan, which we all know is that again scooped up, feminized nose that Yeah, it doesn't look right on a dude. You have to be subtle.

Bri (00:18:06):
He also looks like he's had a lot of upper face work, maybe, I don't know, a brow lift or a cro ton of Botox, but then his neck is completely forgotten.

Dr. G (00:18:17):
I think he's just in an awkward position.

Bri (00:18:21):
He looks like a John Stamos Ken doll.

Dr. G (00:18:27):
Yeah. But in this one, which I think is after his Peter Pan nose job was corrected, I think he looks better. I actually never noticed his nose one way or the other. But the thing about rhinoplasty, which Dr. Chao does is that it's on the center of your face, so people who have rhinoplasty are appropriately obsessed with what it looks like afterwards. Doing it again, every time you do a rhinoplasty, you create scar in a very tiny space and so having to do it again is a fraught with problems and ends up you really, really need someone talented to do revision rhinoplasty. It's complicated and it's not me not doing it.

Bri (00:19:19):
I am ready for my rhinoplasty. I'm waiting. I came in yesterday ready to get some bone shaved down, a little tip work.

Dr. G (00:19:30):
You've helped on a couple now with Dr. Chao and you're like, I know what I need done.

Bri (00:19:35):
I know. I was like, let me tell you what I need. you can do, shave a little here, shave a little here, bring this up. Easy peasy. I just need time off work.

Dr. G (00:19:47):
I mean I feel like you could work with that splint on. It'll be fine.

Bri (00:19:50):
See, that's what my boss would say. You're fine. You're back the next day.

Dr. G (00:19:55):
Yeah, just

Bri (00:19:56):
I definitely could though.

Dr. G (00:19:57):
Don't breathe. Just, you don't need to breathe.

Bri (00:20:01):
We need a rhinoplasty podcast and I need to share my journey, so that's why I need to get it done.

Dr. G (00:20:07):
Okay.

Bri (00:20:08):
But you do. A lot of people tell me, I don't need it done, but when you're like, I focus on my nose.

Dr. G (00:20:15):
Yeah, it's hard. Yeah, because it's like I said

Bri (00:20:18):
It's on your body.

Dr. G (00:20:19):
It's right on the center of your face. So then there's another rhinoplasty down on this list, but Flipping Out's, Jeff Lewis decide to dissolve his decades old lip filler. Finally, a dermatologist refused to do anything until they fixed his lips and he said filler from 20 years ago, I'm like, okay, migrated on both sides of my upper lip and created two balls. I didn't know it was filler, it thought it might be silicone. I haven't liked it, but I thought they're going to have to cut open my lip and take it out, which is a fair assessment if it's silicone, but it wasn't.

Bri (00:21:04):
How do you not know what you have in?

Dr. G (00:21:06):
Come on. People don't know, especially

Bri (00:21:10):
That true.

Dr. G (00:21:12):
We see people who don't know what size implants they have all the time, but the amount of time people can't remember when you're like, okay, well, so you're interested in a facelift. Have you had anything done before? No. And then they come in for a consult and you start examining them and you're like, these scars back here from,

Bri (00:21:32):
What are these?

Dr. G (00:21:33):
Facelift? Oh, I mean I had a mini facelift. Okay. And the incisions, I mean I had that bleph 20 years ago.

Bri (00:21:42):
It doesn't count.

Dr. G (00:21:43):
The incision in your forehead. Oh yeah. Also brow lift at the same time. You're like, okay.

Bri (00:21:48):
Always better to know.

Dr. G (00:21:51):
Okay, so then there's actor Zahid Ahmed opened up about his nose job, which so you're starting to see the trend of men unhappy with their noses and then unhappy with how it turned out.

Bri (00:22:08):
2025 is going to be all about the man. I'm telling you, all these men, they're like, oh, it's okay. All these women are getting plastic surgery. It's so accepted, it's fine. It's just going to be, we've even had a pretty big influx of men at our office in the last, I would say month or two. It's accepted. Men are ready, they're ready to take on their stay-at-home dad roles. Their getting plastic surgery roles. They're ready for their wives to be the breadwinner.

Dr. G (00:22:40):
Great. Okay, so speaking of terrible nose jobs or people unhappy, this guy, the modern family actor, reviewing, starting at 19, he began getting multiple cosmetic procedures, chin and cheek implant with four different doctors and then each procedure would cause a new problem and I'd have to fix with another procedure. This screams body dysmorphia, sorry.

Bri (00:23:08):
Yes.

Dr. G (00:23:09):
And I know actually of someone who operated on him and he did not, it did not go well. Not because the procedure didn't go well, but because him as a patient is just, he has some insane body dysmorphia. So that is, in plastic surgery. There's an acronym for the person you don't want to operate on, especially with regards to facial aesthetics and the acronym is called SIMON and he fits all of those. So he's single, immature. I'm not saying he's immature now, but when he started at 19, everyone's immature at 19. Male.

Bri (00:23:56):
Definitely male, always male.

Dr. G (00:23:59):
Out of proportion to the defect. So they're obsessed with their nose, but their nose looks fine or he thinks he needs cheeks, but he doesn't really need cheeks. You think the problem is a lot bigger than it is. And then narcissistic, which again, he was an actor, he's on tv and so he fits all of that. So he's the classic SIMON, here to help.

Bri (00:24:20):
He had the discussion in the OR a little bit yesterday. Dr. Chao was seeing a patient that was a little bit younger and she and I were discussing psych exams. And at first I was like, you know what? I would be offended if my doctor was like, let's make sure that you have a psych consult before. But then at the same time it's like that's a really good way to go about it. Then people, you can weed out the patients that you don't think you should maybe performing surgery on. This patient specifically was super young, so there could have been a lot of other variables into play. So you know what? Somebody asked you to get a psych consult before having surgery, just do it.

Dr. G (00:25:02):
I think he was our last celebrity that had issues. So we can move on to our topic of GLP. So I will admit I was slow to get on the offering weight loss medications in my clinic.

Bri (00:25:24):
I could have been skinny like months ago.

Dr. G (00:25:28):
I think I just was trying to align it with what our goals are, but I think plastic surgery is becoming more about overall wellness and not just one thing. And so that plus the ubiquitous nature of weight loss medications and how great they are turning out to be for most people. I agreed to bring them on into the practice and so we do offer weight loss medications. We started with some semaglutide and tirzepatide back in August, but tirzepatide is hands down, just a superior product, has less side effects, is associated with better weight loss. So we essentially just offer tirzepatide at this point. Nobody wants to pay a little less for the medication that's going to make you feel sick.

Bri (00:26:27):
Super sick.

Dr. G (00:26:29):
Yeah.

Bri (00:26:29):
I don't think anyone in the office tried that one either, did they?

Dr. G (00:26:33):
No one wanted to try it.

Bri (00:26:35):
Yeah. I have some friends that are doing it and I've heard some not so great things about it, so I was like, I do not want to feel that way. I don't want to be nauseous. I don't want to be absolutely exhausted all the time, although I'm chronically tired.

Dr. G (00:26:50):
Right? We're already there.

Bri (00:26:52):
At this point, what's the difference?

Dr. G (00:26:54):
Right? Yeah. So the demand I think will only go up as people lose weight. They're saying, oh, I'm going to have one big, this happens all the time and I have one big blowout before I start losing weight with the new year and make all your resolutions. So I think we will see an uptick in patients willing to try it because that's just new start all that stuff to get going on it. As it becomes more and more prevalent, more and more patients are asking for it and interested in it, appropriately so. And then next we had the swimsuit model, Brooks Nader admits she really liked Ozempic. We also had an unrelated patient come in for a different procedure who was super skinny and in the kind of profession that you need to be super skinny maybe in the adult entertainment industry who was also on Tirzepatide, right?

Bri (00:27:57):
Yes.

Dr. G (00:27:58):
She was tiny.

Bri (00:28:00):
Very tiny

Dr. G (00:28:01):
Guessing that she uses it to maintain that. Yeah. So let's not kid ourselves that if you're a supermodel or a Christina Aguilera or whoever it is, it makes it so much easier to lose weight or maintain your weight.

Bri (00:28:27):
A hundred percent.

Dr. G (00:28:30):
She's mad that somebody ratted her out and that it's not just green juice and Celsius I guess.

Bri (00:28:35):
And horseback riding like Martha. Everybody needs to just come to terms with that. That should be 2025's goal is to just be real. All of this, everyone is doing it, whether they tell you it or not, it's all accepted. And get rid of the friends that don't want you to be skinny.

Dr. G (00:28:55):
That's right. Tell 'em to kick rocks. It's interesting the shame that gets put against it because I think if you were doing Octifest or what was that nonsense, slim fast or what was Anna Nicole Smith pushing back in the day?

Bri (00:29:16):
Cocaine? Just kidding.

Dr. G (00:29:18):
I mean, no one's jumping on these models when they're doing heroin and amphetamines, right, because they don't have to talk about it. So you're insane if you don't think they're chain smoking and not eating.

Bri (00:29:32):
Right. Adderall is all the rage, but for some reason because it's prescribed for them, it is fine. This is also prescribed essentially, so what's the difference?

Dr. G (00:29:43):
Yeah, everyone's like, you don't need to do this. You don't need, it's insane that a 27-year-old model thinks she needs to lose weight. It is part of her job description to be that skinny. So if she can do something that makes it a little bit easier to accomplish that goal, why the hell not? It's certainly better than chain smoking cigarettes and doing a little heroin on the side. Either way, no one's eating. That's a model period.

Bri (00:30:10):
Exactly. And I think a huge debate, and you can touch on this a little bit, has been people that actually need, I know there's certain different medications like Ozempic specifically, for diabetics and then other drugs specifically for weight loss, is when it first came out people were all upset that it was being prescribed to people who didn't need it causing shortages and stuff like that. So what are your thoughts on that? I feel like that's what kind of gave it initially the bad rap.

Dr. G (00:30:44):
Yeah, so no one was stealing from the diabetics. Let me just.

Bri (00:30:50):
You heard it here first.

Dr. G (00:30:54):
They were getting prescription medication that was straight up, just not enough of it was available. And that is a name brand. It comes in the little clicky pen. You have to jump through 8,000 hoops with your insurance company for it. That was still going to people who met criteria that most insurance companies and systems like Kaiser had definitely multiple things you had to hit before you could even consider being on it. You had to meet with the nutritionist, your A1C needs to be this, they were gatekeeping it just like they gate kept and continue to gatekeep bariatric surgery. You have to meet certain criteria before you get bariatric surgery. Now can you go down to Mexico and get a lap band? Sure, but that's on, you're not depriving somebody of bariatric surgery by going to Mexico and getting a lap band.

(00:31:54):
Are you going to be successful? Probably not. We just had this conversation. So before Ozempic and GLP-1s, bariatric surgery was really the only solution for those who had obesity or morbid obesity. And my husband was saying that on one of the Facebook groups for these patients, I mean it's a misconception just like with the GLP-1s that you can just do this and that will solve all your problems. So especially for bariatric surgery, you have to make lifestyle changes, you have to make dietary changes, you need to exercise, you need to watch your nutrition, all of those things. And the more successful patients on these big surgeries are ones that meet with the nutritionists and do all the things. And so he said there was a whole group of them on there that called it Get your sleeve and leave.

Bri (00:32:54):
Wow, that's great.

Dr. G (00:32:56):
And I was like, yeah, these are the same people who decided to get the little lap band but then never filled the band. Why bother if you're not going to do any of the work, you can eat through your bariatric surgery and you can't eat through Ozempic easily, but when you come off of it, you could rebound if you don't make those changes. So I think that's going to be the next wave is either, everyone's just going to be permanently on these medications or you have to make some changes so that you can maintain your weight loss. That being said, there's medication, the shortages with regards to those who meet insurance criteria and are trying to get it through the pharmacies, going to CVS, have Kaiser or Blue Cross, that's where your shortage is. So compounding pharmacies started making their own version of the medication.

(00:33:54):
And I think the real issue here is that now it's being marketed to everyone and that does not impact the shortage. What it does impact is Eli Lilly and the other companies that make the product. Because if I don't want to deal, we have had Kaiser patients that are like, they want me to meet the nutritionist, they want me to do this, then they want to put me on Metformin, which if that was such a miracle drug for weight loss, it's been around forever, no one's using it. No one never been like, oh, I took Metformin and lost all this weight. It's a great medication for controlling your glucose in pre diabetics and then the next step is usually insulin or whatnot, but it's not ever been bantered about as a weight loss drug. But they want you to do that too. So six months later you've just proven that you're now ready for Ozempic or mounjaro and they're like, I don't feel like waiting. Just can we just go?

Bri (00:35:03):
And then that kind of stems into getting, getting it from a reputable place.

Dr. G (00:35:09):
Oh yeah. Well, right. So then, okay, so rant over about this gatekeeping. I do think there's Eli Lilly just said there's no shortage back in October and then the compounding pharmacies sued to put it on hold because if there's no shortage, then compounding pharmacies are not authorized to make the medication, which is a problem for all of us that are using compounded meds. But also part of the argument for not having the compounding pharmacies provided is because as soon as it seemed profitable, new compounding pharmacies are sprouting up and they're unregulated or they choose to be regulated or not, but unregulated pharmacies can exist. And then what are you injecting? What are you getting? Is it clean? Is it sterile? Is it processed correctly? Is the dosing right now you're, who knows?

Bri (00:36:07):
Right? Don go in an alley and get Ozempic shots from anyone. I feel like I heard that as a story. Obviously can't facts, not facts, but somebody going into an alley. I feel like at some point I heard that and got Ozempic shots and then they died or something, cuz it was in fact not Ozempic shots.

Dr. G (00:36:27):
Yeah, I think like anything else, you want to go somewhere accredited, somewhere you trust somewhere, you know that they're not diluting your Botox, they're not importing Canadian Botox or counterfeit Botox. If it's too cheap, if it's too good to be true, it usually is.

Bri (00:36:50):
Our office specifically compared to other clinics, what makes us different? I know a lot of patients have said that, oh well I can go to a med spa and get it for this and I don't need any lab work or this or this. I can just get it right off the bat. So why is it important for patients to either get lab work or go through screenings first to make sure they're good candidates for this medication?

Dr. G (00:37:14):
Well, it's a medication. It's prescribed and so any medication has potential side effects and I think having some baseline labs is a responsible thing to do as a physician. It's more about making sure we're offering the right thing and safely for our patients versus just trying to make a quick buck off of something. And Azella our RN screens, the patients tells 'em what labs we need to have to make sure your baseline healthy before you start on this medication, checks in with you weekly and then monthly have in person check ins. If you want to phone it in, get on HIMSS or whatever and buy it online. I guess HIMSS and hers, yeah, whatever the online pharmacies are that are offering it. Because I think again, you need a little bit of support. You need somebody that's there to tailor the dosing for you. It's not a one size fits all dosing, all of that. Or you can just pay maybe a little bit less but then be figuring it out yourself. And TikTok is not a medical resource. Just going to put that out there. Med talk.

Bri (00:38:25):
It's a resource but not a medical resource.

Dr. G (00:38:29):
Med talk is not it. So yeah. Okay. Well let's talk about some of the benefits of Ozempic and its kin. It doesn't have family. There's evidence that it can have cardiovascular benefits. So definitely it's reducing the risk of heart attacks, strokes and cardiovascular death, which is amazing. There's some interesting anecdotal that it helps with lipedema. Interesting trials that show Alzheimer's might.

Bri (00:39:10):
That's why I started it because that runs in my family.

Dr. G (00:39:13):
Prevent it or delay the progression of the disease. That would be amazing. Then we could keep drinking our diet Coke.

Bri (00:39:21):
Amen. Sister.

Dr. G (00:39:23):
Yes, cuz per med tok, that probably causes everything.

Bri (00:39:26):
Speaking of Diet Coke, I got her a Christmas gift this morning.

Dr. G (00:39:31):
Yeah, we can segue here. Let me show you. Please hold.

Bri (00:39:36):
This was really important. You might have to unplug the back.

Dr. G (00:39:39):
I'm just going to hold it up.

Bri (00:39:40):
She's like, I already know. It is a Diet Coke mini fridge. So she doesn't even have to get up and walk to get a Diet Coke.

Dr. G (00:39:47):
All the way to the break room to get it. No.

Bri (00:39:51):
And it has a car charging port so she can take it with her in the car and have a crack a cold one while she's driving.

Dr. G (00:40:00):
Oh, that's so problematic. There is an association with alcoholism and addiction, so people are starting to see that in addition to all these other things that we've mentioned that there might be that addiction habit or urge is reduced and I do feel like I don't need my Diet Coke as much as I feel like I generally do.

Bri (00:40:32):
Same.

Dr. G (00:40:34):
And also my interest in wine went down quite a bit after starting that. So it's starting to get to the point where you name it and GLP-1s are going to help

Bri (00:40:50):
Except for cheese. I have kind of the same thing. Diet Coke, I don't have a daily diet Coke anymore. Wine is hard to drink because you have a glass and you feel like you are already hung over by the end of the glass. But cheese, I have craved cheese. So I started back in August, the end of August. You started early September and ever since then I need daily baby bell or daily sharp cheddar cheese. We had to order cheese from Costco.

Dr. G (00:41:29):
Had to.

Bri (00:41:30):
Yes, had to. That has been the only real craving that I've had since starting it that I have noticed. Have you had any of those? I am just like anything cheese. I'll put a slice of cheese on anything I possibly can.

Dr. G (00:41:49):
I have not had cravings, but I think everyone's different. And I remember with pregnancy, people definitely like to talk about what they craved and I never had any cravings there. Things there were definite things that I could not stomach and it was different with each pregnancy and also it usually did not return after I delivered. I was like, nope.

Bri (00:42:16):
How interesting. My first child, I craved lemons, which I know is not good for your teeth. And I ate a ton of lemons, just straight lemons. And it's really funny because my son, also not good for his teeth I know, is obsessed with lemons. He eats straight lemons as well. He is a fruit baby. My second, I craved waffles. I mean this chick will put down a whole chicken, a bag of waffles, some pancakes.

Dr. G (00:42:44):
She loves her carbs?

Bri (00:42:45):
She loves her carbs and he loves his fruit and salads and lemons and I think it's really interesting.

Dr. G (00:42:53):
Oh my gosh. Okay. I mean there's no science to back that up either. But yeah, so the thing about the studies on these, so the GLP-1s, semaglutide and Tirzepatide, those clinical trials are expanding. In the meantime, these companies are racing to come up with other weight loss medications that are in that same category. And again, there initial clinical trials, they're going to be based on weight loss in people who are obese. So we're not going to know if they have the same protective effects or it's just going to be a while to see how all this pans out. But so far it's been very encouraging for multiple other things in addition to just losing weight and preventing the progression of diabetes or reversing that or any of the downsides of obesity. So there has been a decrease in bariatric surgery because people are on Ozempic, which is great.

Bri (00:43:58):
What side effects personally from your, we of course had to start it because we can't suggest things to patients that we don't know what we're talking about. I also implement that with my surgeries. I have to have surgery so I can give the full patient experience and tell them how it's going to be after. But what is your experience side effects since starting to take this medication?

Dr. G (00:44:22):
Yeah, so I think the last person in the clinic to try it at the time because first of all, I don't want to get hate because everyone's like you don't need it. Ironically, Bri and I weigh exactly the same when we started. Yes, we didn't know until we weigh in. And we both lost the exact same amount of weight, but we are at a healthy weight, a healthy BMI to start with. We're just trying to lose that elusive 10 pounds that we're always trying to lose or maybe lose and gain, lose and gain. Anyway, my nervousness was starting the medication besides people giving me grief

Bri (00:45:02):
I bullied her into starting it.

Dr. G (00:45:05):
Was nausea. So everything makes me sick to my stomach. Just thinking about getting nauseous, talking to patients about post-op nausea, watching a Lord of the Rings movie makes me nauseous. Everything makes me nauseous. I get motion sick so I cannot be the passenger in a car and look at my phone. I get sick. Everything makes me really sick. I would've made a terrible astronaut because even zero gravity makes you nauseous or motion sick. Well, motion sick, but then motion sick translates into nausea. Anyway, would've also made a terrible heroin addict because again, side effect of nausea.

Bri (00:45:48):
Same.

Dr. G (00:45:50):
So anyhow, I tried it and I was a little nauseous at the beginning, just a tiny bit, not enough, not crippling like in the tiktoks. And I think I took the second week I was on it, I took one Zofran one morning and that's been it. I was okay. I just needed to drink more water and sometimes I would just take a walk and deep breathe and it went away. I mean I was nauseous again last week, but it wasn't dose related because I got a cold. So yeah, I was apprehensive about trying it. I didn't want to be sick. Went with Tirzepatide, had minimal side effects and then lost I think I lost a pound the first week or no, I lost four pounds the first week, which I think was water weight.

Bri (00:46:49):
I gained a pound the first week,

Dr. G (00:46:53):
Then I just stayed there. So you don't want to lose too much weight too fast. First of all, it's probably anytime you start a diet or start to eat less, mostly water weight. So you know that's bs. And then just lost a pound or two every couple of weeks. We've been on it for a while. I've kind of leveled out at that 13 to 15 pound range of weight loss, which I was only trying to lose 10. So super happy about where I am. It helped cut out wine for it, changed my affinity for coffee. I still drink it, but I like it black.

Bri (00:47:35):
Same.

Dr. G (00:47:35):
And I just eat less or certainly when you first start on it because all the food noise is gone, you have to remind yourself to eat. That goes away after a while you'll still get, now I get hungry. I was super hungry this morning, but if you pay attention, you need a lot less to feel full. Again there is a potential to eat through all of this, just like anything else. But if you do, then you feel Thanksgiving full. So hopefully that reinforces your overeating. But you can blow past it, right?

Bri (00:48:15):
I did that yesterday. I ate ever since I started it first week, gained a pound after that, I slowly lost a pound of two pounds a week. I also lost a couple pounds more than I wanted to and I was pretty good about my portion sizes before I started this. And now my portion sizes are definitely smaller, but if you overeat, it hurts. Like yesterday morning I ordered Starbucks, they got my order wrong, so I got extra Starbucks and so I had two things and I felt kind of sick the entire day. My stomach hurt. If you overeat, you will feel it. I definitely drink a lot less wine. I mean I didn't drink a lot of wine from the get-go, but you really only have a glass and you're, that's it. You feel like you've had two glasses, three glasses personally. And I thought I'd be super, super nauseous and there's only one time where I ate something super sugary where I was like, I think I'm going to throw up. I didn't. But that was the only time where I was super uncomfortable. I think I probably consumed a 5,000 calorie crumble cookie or something.

(00:49:40):
But other than that, I was actually pretty surprised based off social media, how sick people were, in the bathroom all the time, this and this, and that was a hard thing starting too. I was like, I also don't want to be in the bathroom all the time. I don't want to be sick. I don't want to be extra tired. And I think that's why all of us opted to do tirzepatide over the, we didn't want the side effects. And I have pretty much been, I ordered off of Zofran and I don't think any of us have really had to use it. But you've definitely eat a lot less and I think as long as you're a lot more mindful about what you're eating, don't go eat a bunch of cheese unless you have to. Yeah, it's definitely about,

Dr. G (00:50:30):
I think it's about, it helps, it's a great booster. Like I said, I think last night I went to eat dinner and we had some naan bread and I went to go put it in the toaster and then I ate my little bowl, little veggie chicken bowl or whatever. And then later on that evening I was cleaning up and I was like, oh, like I forgot about the bread completely. It didn't even occur to me. So for me, I don't generally have cravings and I forget pretty quickly if something's available. So it makes it even easier to be like, yeah, I'm busy. If I'm distracted I might even feel a little hungry. But if I get distracted then, and part of that is just our job description. No one cares if you're hungry in a four or five hour case.

Bri (00:51:26):
No.

Dr. G (00:51:26):
You just have to push through that you're, can't imagine.

Bri (00:51:30):
Can't make someone get you a Diet Coke.

Dr. G (00:51:33):
I can't imagine scrubbing out for a snack. That's embarrassing.

Bri (00:51:37):
No, I think neither of us would ever live it down if one of us did that. I would hear about it forever.

Dr. G (00:51:46):
So I think if you're accustomed to you're hungry and you maybe say, I'm hungry, my nose itches, and then you operate for two more hours and you're like, oh, I forgot. Because you can't possibly be fixated on being hungry or your nose itching or whatever it is while you're in the OR and can't do anything about it. So I mean I think we're pretty adaptable to that. We've had our anesthesiologist lost 30 pounds.

Bri (00:52:15):
Yes.

Dr. G (00:52:16):
His wife has lost 20 pounds. She was actually prescribed it through insurance and then they changed her insurance and she was told no. So I think she had done it for a month and then got denied. So this works out for her perfectly. Now she can get the medication that she knew she wanted. Our nurse has lost 20 pounds. So it's been really, really impressive actually. Everyone's been very happy with the results. Our patients are also equally excited about their results. They're losing 10, 15. Did you find out who lost the most weight? Is it what's our biggest weight loss? I mean we've only been offering it since August.

Bri (00:53:00):
I have not. I only looked between you and I for a competition and I lost one more pound than her not to brag.

Dr. G (00:53:12):
So we've had our patients have lost a significant amount of weight and have been happy with it. It is slower than the branded medications, but I think it's good because if you don't make those changes then, we've had one patient was a little bit resistant and we kept increasing her dose. She's finally losing weight. But again, you have to make some lifestyle changes or it's not going to stick.

Bri (00:53:38):
So once people have lost the weight after taking these medications and they're to their goal weight, what do you suggest patients do to either maintain, keep it off?

Dr. G (00:53:52):
And I think because the medications are so new that we're still figuring that out to some degree. So again, I think it's super important that you make the lifestyle changes that we've previously discussed. I have continued to work out. I think that's one of the things people are concerned they're going to lose muscle. Well don't stop working out. Or maybe now's the time that you're feeling better to work out, feeling better that you lost the weight. You're more motivated to do the things that maybe you didn't feel like you could do before. So making sure that you're maintaining those lifestyle changes and then at your stable weight, they're now thinking that you might need to stay on the medication when you've reached your stable weight for three months, six weeks, nobody knows and then maybe taper off. So I think that's probably the most effective way of dealing with it is to taper off the medication.

(00:54:50):
So there's two ways to do that. You can microdose, which is a little controversial. We're not sure if that's the best way to do it, but that would be taking smaller doses more frequently or stretch the dosing out, which I think is probably the easier way to do it. So I think that that is what we're recommending to our patients. So let's say you're on a dose of, I don't know, you're on the medium-sized dose, but anyway, instead of taking that injection every week, you do it every 10 days and then every two weeks and then maybe every other week until you're off of it. So it is like a taper because we know the drug as you have it, there's a peak and then right about the time you're due for your dose, again, you can tell you're getting a little bit more hungry. You can tell the difference between the first couple of days you're on it and the last couple of days. So if you can stretch that out, then we think that's probably the best way to maintain your weight loss. So you can kind of adjust to not having it onboard and not having food noise or whatever, those distractions come back and being able to manage them.

Bri (00:56:08):
I know, and in my personal experience, when I started losing weight, I was like, oh, I'm losing weight, I don't need to go to the gym. I don't need to do anything and that is not the way to do it. You still want to be active and that just kind of made me even more tired. You still have to, whether it's just walking or being a little bit active, you don't want to lose all of your muscle. So definitely the opposite.

Dr. G (00:56:31):
I kept working out.

Bri (00:56:32):
Yeah, she's not a normal human. She is kind of insane. She works out every single morning without fail. Vacation doesn't matter. She's going to find a class.

Dr. G (00:56:48):
I love to work. I live for that little endorphin rush. So I do like to work out and so I maintain that. And in my mind I'm losing weight, but you know how you can do sit-ups forever and if your diet isn't good, you're going to see, you will be stronger, but you're not going to see your abs, because a lot of that is the diet. I think it just encouraged me to work out more because now I can see the results of lifting weights, of doing all those awful burpees and ab exercises. It's positive reinforcement in my mind for the exercise. So you just have to find a way to trick your body into thinking, I just want to move. This is helping me get to a healthier lifestyle. I'm going to eat more protein, I'm going to drink more water, I'm going to eat less crap and I'm going to work out and move forward.

Bri (00:57:40):
You have to make a bunch of good changes for sure. And then for the patients that experience, I know some worries from people are, oh, I'm going to have all this loose skin. I'm going to look a certain way. What do you suggest doing after or during to help patients feel more comfortable or is there a way to minimize that?

Dr. G (00:58:04):
Yeah, so one of the things to do is to lose the weight as slowly as possible. So you don't want to lose five pounds a week. That's crazy. You're going to, the faster you lose the weight, the less likely you're going to maintain any lifestyle changes and the less time your skin has to respond to that changing body. So especially if your excess fat is external, if it's internal, if you have intra abdominal fat, it probably isn't going to matter. But that external fat is what causes your skin to sag. And so there are some things you could do as you're losing weight. If it's maybe 10 or 20 pounds, you could do radiofrequency microneedling or Emsculpt or some sort of therapy, external therapy to try and keep your skin as tight as possible. But really it's just get to your goal weight, see what you got. And that is one of the benefits of having a plastic surgery office be managing it because then we can talk to you, we can segue into, okay, this is extra skin now and you need a tummy tuck or you're a good candidate for a lower face and neck lift after losing 25 or 50 pounds. So how to address that lost weight.

Bri (00:59:23):
You can suggest to certain patients in an appropriate manner to take these medications prior to surgery? Say if you're trying to get under a BMI or of some sorts.

Dr. G (00:59:35):
Yes. So we tend to shy away from doing elective cosmetic procedures on patients whose BMI is over 35. There's a little wiggle room there depending on what it is. But for example, breast reduction surgery, a lot of insurance companies will have a cutoff of a BMI of either 30 or 35 at least in Southern California. And so those patients have large breasts, they have a hard time working out and they're trying to get to that goal weight so that they can be eligible for their breast reduction. I think that's one aspect of how these could help hit that weight and then see is that weight coming off your breasts? We know from experience that a lot of times they're still going to need a breast reduction, so it's chicken or the egg in that situation. Like do they need to lose the weight first then get the breast reduction or do they get the breast reduction and now they can buy sports bras off the rack and exercise and then subsequently lose weight and lead a healthier lifestyle. But we know what the insurance companies have decided and that's lose the weight first because usually that's hard to do.

(01:00:49):
So with a tummy tuck, you definitely want to be within 15 pounds of your goal weight. We don't want to take off that extra skin and fat just to have you lose another 20 pounds and then have more loose skin. So that is another reason we like to encourage that weight loss before and most things, having the weight off first is the way to go before you commit to surgery.

Bri (01:01:15):
But what should somebody do if they would like a consult with you regarding weight loss medications?

Dr. G (01:01:21):
So there is some information about it on our website and then call the office or send us an inquiry. Ava, our excellent patient coordinator, will briefly talk to you and she will set up a screening phone call with you with Azella, our RN. And then Azella will set up this 15 minute phone call to talk to you about what your goals are, whether this is a good fit for you. We are not currently treating patients that are outside of San Diego. We're not HIMSS or hers. We're not mailing a prescription that needs to be cold and on ice. So we're not that kind of distributor. We really just want patients that are local to us because we're more of a boutique weight loss clinic and not an online situation. So anyway, so Azella will reach out to you, let you know what labs we would like to see first, what the reasons for those labs and assess your goals.

(01:02:26):
Then Azelle and I meet and talk about the potential patients and she arranges for an in-person appointment. And then you come again, I meet with you. We go over some of the things that we've talked about on this podcast and then you can start your medication the day you come in because we've already done all the checking in advance. So we have you start your dose, that first injection is done in the clinic, and then we send you home with three weeks worth of medication. So three doses and a little ice pack and Azella goes over how to self-inject. And then we check in with you weekly and see monthly to adjust dosing, make sure you're tracking correctly. You can always call and chitchat with us if there are questions. And then we get your monthly weigh in. So it's pretty streamlined. But yeah, we've had people call from out of the city and we're like, no, we're not shipping it to San Francisco or wherever.

Bri (01:03:31):
Our afraid, our anesthesiologist is so funny because he is such a baby and he does not want to self-administer. So any suggestions, can patients come in weekly if they're afraid to self-administer their own injection? Like the big baby male population?

Dr. G (01:03:47):
Yes. They can come in and we're happy to do the injection for you.

Bri (01:03:51):
Hope you're not watching this.

Dr. G (01:03:55):
We can ice the area, but it's a really teeny tiny needle.

Bri (01:03:59):
So small.

Dr. G (01:04:00):
It's so much less than the flu shot. Most patients, we haven't had anybody besides our anesthesiologist, require somebody else to do the injection.

Bri (01:04:13):
What are the most common injection sites?

Dr. G (01:04:16):
Mostly abdomen, but anywhere there's a little bit of subcutaneous tissue. So arm is also an option.

Bri (01:04:24):
I do mine in my arm.

Dr. G (01:04:25):
Yeah, because you're hoping it'll work there.

Bri (01:04:29):
Make my arms small.

Dr. G (01:04:31):
Yeah, I think it's going to be the wave. I think GLP-1s are here to stay and we're excited to be able to offer it to our patients.

Bri (01:04:38):
Yes. Come on in. Get skinny.

Dr. G (01:04:42):
Get skinny with us. We're excited for the new year and on our upcoming podcast because Bri is going to be finally taking a vacation. We're going to be talking to Dr. Chao or I will be. So that'll be really something to look forward to in 2025.

Bri (01:04:58):
Yes. Happy New year. Happy end of 2024. Happy beginning of 2025.

Dr. G (01:05:06):
Bye.

Bri (01:05:06):
Bye.

Dr. G (01:05:08):
We do the worst closing.

Bri (01:05:09):
It's the new. We need a good closing. That's going to be our goal for 2025 is to find a good closing. Peace out Girl Scout.

Dr. G (01:05:20):
If you're listening today and have questions, need info about scheduling, financing, reviews, or photos, check out the show notes for links. Restore SD Plastic Surgery is located in La Jolla, California. To learn more about us, go to restoresdplasticsurgery.com or follow us on Instagram @restoreSDplasticsurgery. If you enjoyed this episode, please share it and subscribe to All the B's on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts.