Recover Faster After Plastic Surgery: What Works and What's Hype (Journavx, Peptides, HBOT)

SPEAKER_00 0:00

You know, it's no secret that I've had my share of orthopedic injuries. And just in the last eight months, I've been recovering from a knee surgery that is going very slowly and very frustrated with the outcome. I tried the Wolverine Stack for about six weeks. How do you think it went over?

SPEAKER_01 0:19

Um, amazing. Zero. Okay. Zero. Well, thank you everyone for tuning in to another episode of the Beauty and the Beast podcast. I'm Sam DeJuricar from Dallas, Texas. And as always, I'm joined by Dr. Sal Pachella from San Diego, California. Today we're going to have a topic that is near and dear to our hearts, and that is ways that you can enhance your recovery after surgery. And we'll kind of start off by saying that a lot of the things that we're talking about today are newer areas of medicine, some of which are more proven than others, but they're exciting and they're things that our patients are asking us about. And so, Sal, I think, you know, a few years ago in the world of surgery, we started being introduced to the whole idea of the ARES protocols or the ERES protocols or advanced recovery after surgery protocols. And, you know, the gist behind those protocols were basically ways to get people to recover faster after surgery and with less reliance on stronger pain medications. Are those principles that you have sort of adopted into your practice? And if so, what are some of the things that you're actually using?

SPEAKER_00 1:26

Absolutely. So, um, as you may know, you know, I do a lot of reconstructive surgery. So the ERUS protocol is actually something that has really been spearheaded by our hospital administration to get patients, you know, up and moving after surgery and avoid the risks of opioids and extended hospital admission. And so I think those principles are groundbreaking when it comes to patients getting up and moving after surgery and kind of getting starting their recovery. And I'm a firm believer that if your pain is controlled immediately after surgery, that makes your recovery that much easier. If your pain is poorly controlled immediately after surgery, it just means that it's extensive recovery. Okay. And that that's a bit intuitive. So I think some of the concepts are are really pretty straightforward. So the first concept really is non-preoperative, non-opioid pain medication. Okay. What do we use for that? Things like Celebrex, things like tordol, uh, preemptively before surgery. These are all really powerful pain medications that do not have a major effect on bleeding that can help to reduce some of the pain response during surgery and right afterwards. Okay. The second treatment given before surgery is aggressive anti-nausea medication. And I think one of the best medications out there is a medication, it's a pill format called emend. It's a 24-hour pre-operative uh medication that you give to prevent postoperative nausea and vomiting. And I think that works tremendously well in patients.

SPEAKER_01 3:05

Yeah. Um, amend or a prepotent, which is the generic name, um, typically is given about three-ish hours before surgery. And it's great because they've shown even in patients that have intractable postoperative nausea and vomiting, you can reduce the incidence of nausea and vomiting when you give them this medication to 0.4%. I mean, it's really a highly effective medication. Oftentimes confuses about our patients when we prescribe it to them because they get all these prescriptions pre-operatively and they get this bottle with just one pill in it, and they're a little confused and they think, oh my God, the pharmacy forgot all my other medications. But incredibly effective medication. Another principle of the EROS protocol is um hydration, um, which we've touched upon beforehand. Um, but you know, the traditional teaching was that you couldn't have anything to eat or drink at all before surgery for eight hours or so when you used to tell patients you can't eat or drink before midnight. Now we realize that if we let them have clears, even up to as soon as two hours before surgery, um they actually do a much better job of staying hydrated during their surgery, have fewer problems postoperatively.

SPEAKER_00 4:11

Absolutely. Um, and then tell me a little bit about uh your protocol with your uh the place where you operate. Um, who tells the patients, who gives them the pre-operative teaching? Don't eat or drink anything at this amount of time, and then you can have clears up to this amount of time. Is there any specialized drink that you may give them, like a high protein clear or something like that?

SPEAKER_01 4:35

You know, that that is in that is utilized in many institutions, having a high protein electrolyte-rich solution. That is not something that we standardly do. Um, but um, but it's the pre-operative instructions are typically given by my office staff and the anesthesiologist will call the patient the day ahead of time as well. So usually there's a double whammy and we try to be consistent in what they're telling them. The thing that is most confusing is what truly is a clear liquid. Because the problem is, and you know, uh a clear liquid can be Gatorade, it can be water, it can be black coffee, but then people start adding milk, adding milk. And then those are things that can get their surgery canceled. And so, you know, the pragmatic side of me sometimes says, well, if we just tell them not to have anything, they're gonna be okay. But we know that's not in the patient's best interest. So we need people that are patient to talk to them and make sure they go over things in exquisite detail. Right, right. Now, are there any, you know, I think everyone in the United States realizes that opioid pain medications can be um problematic, you know. And the last time we had a new pain medication in the US was when we were residents. Remember when the OxyContin reps were in the hospital and giving us all their free products and their pens and all that, and it led to this crazy opioid epidemic that we've that would that's happened. And so there's a new pain medication that I'm using a lot in my practice called Gernavics, um, which is for the treatment of uh moderate to severe pain. Um, but I am being met by some skepticism by patients who are leery of trying a new pain medication. Is it a medication that you're using at all in your practice?

SPEAKER_00 6:17

Yes. In fact, I've I've learned a lot from my colleagues that are orthopedic surgeons that are using this quite a bit. And, you know, you anybody who's had any kind of bone or joint surgery, you know that that is on the level of pain that is higher than most operations. And they are experiencing a tremendous revolution and improvement of pain control afterwards with non-narcotics. I mean, you you know, narcotics are uh are a double-edged sword. They they some people they sedate, some people they wire up, right? Uh sometimes it lasts long, sometimes it does not. Um, you have side effects of nausea and you know, itching and uh hyperactivity sometimes. It's they're not great medications for what we use them for, you know.

SPEAKER_01 7:03

Yeah. So Jernavich is really interesting too, because it works on a particular aspect of sodium channels. Sodium channels are important for the conduction of nerve signals, and they work specifically on the sodium channels of sensory nerves and on and on uh pain reception on pain nerves basically. And so in their clinical studies, they looked at, they had over a thousand patients in each um in each arm. One was bunion surgery and one was tummy tuck. So one painful soft tissue operation and one was a painful bone operation. And they divided the patients up in a ratio of two to two to one. Uh, the 40% got hydrocodone, five milligrams, 40% got gernavics. And I feel bad for the one, you know, the 20% that got a placebo, uh, which is kind of cruel after a tummy tuck. And they found that hydrocodone and gernavics were as effective in treating postoperative pain. Both were more effective than placebo, but there was the same level of pain relief. When they looked at side effects, gernavics had fewer side effects, obviously, than hydrocodone, but also less than the placebo, which is which is really kind of an interesting finding. And again, it's not a narconic. It does not cross the blood-brain barrier, it doesn't go to, it doesn't cause addiction, it doesn't cause nausea, it doesn't cause uh constipation. So, what we'll do for our patients, kind of getting back to the overall theme of this, which is um, you know, enhance recovery, is our patients will preload it at the same time they take their prepotent, about three hours prior to surgery. Um, they take a loading dose, which is which is two pills, and then they take it on a cycle every 12 hours. And we're finding for facial aesthetic surgery and for breast surgery in particular, that's pretty much all the pain medication they need. Our reliance on narcotics is is going away, and we'll give them a few just as a rescue medication, but we're really finding that that can go away for our patients.

SPEAKER_00 8:54

Fantastic. This is really exciting. I mean, yeah, you know, if you can get rid of the and and it's something like a facelift where postoperative nausea and vomiting can be a can be a problem, a death sentence, if you will, to the skin. Yeah. Um, you know, you don't want your patient vomiting and causing their blood pressure to elevate that leads to hematomas and skin compromise. Um, so this is a huge advancement, I think. Exactly.

SPEAKER_01 9:17

Now, another way that we can potentially try to um control pain postoperately is by the use of intraoperative blocks. Are there any operations in which you're using blocks and there are any special medications you're potentially using for that?

SPEAKER_00 9:30

Yeah. So essentially in every single operation, I'm doing some sort of block intraoperatively. So in facial surgery, um, I have a specialized mixture that I give patients that I use um as a not only a local anesthetic, but a tumescent solution. Um that is a medication, that is a pre-u-mixed um cocktail, if you will, with lidocaine, which is a local anesthetic, fresh epinephrine, which is a vasoconstriction uh agent, which controls the amount of bleeding and makes the lidocaine last longer. Um there's some markane in it, which is a longer-acting local anesthetic. And my favorite medication now of all time is a medication called transacemic acid TXA. And that is a medication that stabilizes clots. And there's something to be said for post-operative swelling, postoperative uh bleeding, which leads to much more pain. Okay, so so I use that routinely in the face, nasal surgery, et cetera. In the body, uh I'm oftentimes working with my anesthesiologist to do um, they do uh what's called pectoralis blocks. Okay, so they use an ultrasound guided needle, they inject the two major nerves in the pectoralis muscle, which can really help with postoperative pain control. And variants of using uh some long-acting local anesthetics. There's expiril, which is a um, you know, long-acting markane, if you will. Marcane is a little shorter acting drug than expiril. Um, and so I think all of those work really well. The other thing I tend to use quite a bit in tummy tucks is I like a very old school pain pump, believe it or not. So when I'm um when I'm plicating the muscles in the abdomen for an abdominal plasty, I actually snake in a catheter behind that muscular repair, uh, two catheters, actually. These are metal catheters, and then they hook up to a little device that looks like a bulb that has marcane in it that secretes that medication on a regular basis over the next three to four days. And I think that is a tremendous way to help localize control because in abdominal plastys, that's the area that's the most painful.

SPEAKER_01 11:44

Yeah. And I think what's key is how you're how you're inserting your catheter. You're you're making a point to put it in with your muscle placation and not freely floating. And I think that's why it works so well for you. Um and you had touched upon XPRL. I think that is an exciting medication that people are using in all areas of the body. I use it most commonly in tummy type patients. Um, but expirel, as you touched on, lasts for about 72 hours. Um, it's bound to what are called liposomes, which are little fat um lipophilic or fat-loving particles that basically hold on to the bupivacaine or markane, and it allows for slow release over about three days. And I find that to be really effective as well. You know, the next thing that could be very interesting to talk about, but isn't as well studied in the world of medicine and plastic surgery are peptides. And um most of the information that patients seem to be getting about peptides come from social media. So I guess my question is: what are your thoughts about peptides, injectable peptides, um in regards to peroperative recovery, preoperative preparation, postoperative recovery? Is there any role for peptides in your practice, both theoretical and realized at this point?

SPEAKER_00 13:04

So great question. Um, you know, so what are peptides? Really, they're they're short chain proteins, if you will. And so these have these are proteins that are manufactured or or found inside the body uh that may have been discovered for in the animal population to have uh a beneficial effect. I think the important thing to understand is to date, no human study has shown efficacy of any peptide in the body. Okay. I disagree with that.

SPEAKER_01 13:36

There's two. I'm sorry.

SPEAKER_00 13:43

I mean, I mean the peptides like the the joint recovery peptides. I mean the if you're you're lumping in GLPs into peptides, which they are peptides, I guess.

SPEAKER_01 13:53

And then this is well, you know, you said none, so I but then the second one is SRMOLIN. Um SRMolin, which is in the category that you are thinking of, has been proven, but it's been mainly in a pediatric population where they looked at growth hormone deficiency, and it's actually FDA approved in children for FDA for growth hormone deficiency. Um, and then it's been studied particularly like in the 90s, early 2000s in adults as well. So I think SRMOLIN might be in a different category than the other peptides, but in general, I agree with you that they're not well studied.

SPEAKER_00 14:25

Okay, so let's talk about studied and FDA approved. So which are FDA approved?

SPEAKER_01 14:32

Well, let's go back because it SRMOLIN has been studied and is FDA approved. They're all, they're all sort of in this, what is it, class? I forget the class name, but they're all in some nebulous category where they're not banned by the FDA and and don't have specific indications, but compounding pharmacies aren't supposed to make many of them. And now there's some new loosening of that regulations or speculations that there will be. You know, I think we're in a time right now where government approval of medications may or may not have a different level of uh you know validity to to physicians and patients, but Sir Moralin has been studied. It just hasn't been studied in a long time.

SPEAKER_00 15:13

Right. Okay, so let's let's talk about that for a second. So I'm gonna I'm a b if I'm a believer in peptides and I'm gonna start using them, um where do I get them from?

SPEAKER_01 15:24

Yes, that is that is the fundamental problem. And I and then that's a very leading question. What you're trying to get me to say is I don't really know. Because what you're doing is you're having to go on the internet, finding a pharmacy, the purity of what you're getting could be fantastic, or it could have no purity, or you could be injecting something completely differently into your body. And so, you know, it requires a lot of trust in where you're in where you're getting it from, which is clearly not something that you should do if you're randomly getting something off the internet, and injecting it into yourself daily or multiple times a day, right? Yeah. No, but there are some, you know, compounding pharmacies that people may have relationships with. Um, I definitely do, where I do believe that the purity of what I'm getting is is is what I'm told. Beyond that question, though, the question is is it harmful? Because there these aren't really well studied. So I think I put Surmoralin in a category by itself. There are things like um BPC 157 and uh TB500, which I don't know what the long-term, you know, both of those basically are thought to promote healing. Um BPC-157 is thought to be more of a local response, TB500 is thought to be more of a systemic response. But they but they both basically work by creating angiogenesis. Angiogenesis is the formation of new blood vessels. Theoretically, that sounds like that would be amazing around the time of surgery. It also sounds like over long-term units that could cause cancer. And so I don't recommend these to my patients because I don't know enough about the long-term amplifications of the case. Right.

SPEAKER_00 17:07

So let's talk about those for a second. So the two of those compounds mixed together are commonly referred to as the wolverine cyclound, right? Wolverine stacked, yes. Yeah, and uh, you know, from Michigan, wolverine. Um but and and I think the name comes from the X-Men character, right? So who had as a regenerative uh power, superhero power. Um so I will say, you know, it's no secret that I've had my share of orthopedic injuries. And uh and just in the last eight months, I've been recovering from a knee surgery that is going very slowly and very frustrated with the outcome. I tried the Wolverine stack for about six weeks. How do you think it went over?

SPEAKER_01 17:48

Um amazing. Zero. Okay. Zero. And and um where did I get it from? Where did you get it from and where did you inject it?

SPEAKER_00 17:58

Okay, so good question. So where did I get it from? I got it from a recommended pharmacy from at least three people who independently recommended that to me. And so I can't remember the name, it was out of state. But when I went to search for this compound, under the fine line it says not for human use for research purposes only. Okay. Yes, I'm researching on my own body. Okay. Um where did I inject it? I injected it right near my knee joint, okay. So locally to the area.

unknown 18:29

Okay.

SPEAKER_00 18:30

And you know, the the compound comes in a a small bottle about that big, and you know, one bottle, maybe two or three injections. Um there's a question of stability, what you use to inject it with. Um what's the right dose? Yeah, what dose because you're experimenting on yourself. Yeah, and and these are and and so getting back to what I said at the beginning of the podcast, you know, we believe in evidence-based medicine, right? And it's the ethical side of me says, you know, can I recommend these to patients? And and that answer is probably no. Am I certainly willing to try them on myself? Sure. Yeah, but I'm a believer that it didn't really do anything for me.

SPEAKER_01 19:12

Well, I'd like to share my experience with uh with the Wolverine stack on myself because I have chronic rotator cuff injury, and for about two months, I injected it around my shoulder, and I had the exact same experience as you. Um and the way I got it was the same way the warning on the label was the same. So yeah, I've come to the same conclusion as you, and I believe in evidence, evidence-based medicine as well.

SPEAKER_00 19:40

No, let me say this too. I have a I have a very good friend who um is a smart guy who is a massive believer in peptides. In fact, he when we were first talking about this, he said to me, you know, I have injected over myself over 1200 times with you know various peptides. And we were talking about the wolverine stack, and he was telling me about this. This is how I first kind of got the information about it. And he said, But if you have cancer, I wouldn't inject it. Yeah. What if you've got undiagnosed cancer? Well, I asked that question. Yeah, and he said, Well, I get my labs checked every three months. Oh, you get checked for every single cancer out there. Right. You know, so I, you know, and I think I I think a lot of this is a placebo effect, wanting things to work. And, you know, I'm a I'm a skeptic, uh, a secretic skeptic at heart.

SPEAKER_01 20:32

Well, and so so the only one that I'm not as skeptical on is Sumoralin. Yeah.

SPEAKER_00 20:37

So Tesimorlin, too, right? And some moralin, yeah, exactly.

SPEAKER_01 20:41

Because they because they are analog to promote growth hormone. Right. Both as a patient and in the studies, I've definitely seen an increase in lean muscle mass with that and better quality sleep. So my stake on peptides with my patients in terms of enhanced recovery, because I get this, a lot of my patients are on them, and I'm sure it's the same with you, is I make them stop all of them except Surmoralin, intestamoralin, or epomorlin. I let them take continue to those throughout the time of surgery. I don't prescribe any of them for anyone. But it's an exciting hot bud time, and a lot of patients are putting themselves on them. Like I will see patients that are that are going to the internet and doing it to try to recover from surgery. And so I'm nervous about that. I don't actively recommend it for people, but I am seeing it more in our patients. And it's important that we touch on it for sure.

SPEAKER_00 21:24

You know, the other interesting thing too is with some of these wolverine stack compounds and some of these other things. You know, we um my son's a high school athlete, and you know, he comes home constantly and tells me, Hey, I heard from such and such that they're on these peptides, and you know, their father gave them this and this and that. And it's it it's uh that's uh dangerous. It's a dangerous, slippery slope to think about here, you know.

SPEAKER_01 21:51

Yeah. And it might be in twenty years, these are well studied and and I certainly hope so hope that's the case. And we did and we decide that they're they're beneficial and not harmful. The getting the evidence is important. Final thing that I'd like to touch on in terms of talking about enhanced recovery, which is near and dear to my heart, is hyperbaric oxygen therapy. Hyperbaric oxygen therapy, we have used for years in the world of wounds and reconstructive surgery to treat problems. And I'm sure you have had considerable experience with that. But now there's a movement more to use it to try to prevent problems. What I'm seeing a lot of in facial aesthetic surgery was kind of where I saw it the most is that facelift patients of mine who started on their own going to hyperbaric chambers, seemingly anecdotally, this is all anecdotal, but their swelling went down a lot faster and they look socially presentable much faster.

SPEAKER_00 22:47

Have you noticed anything like that in your patients? You know, I've I've had a handful of patients go independently to hyperbaric chambers, and I think it's phenomenal. I mean, I think I am a, you know, as an old school plastic surgeon like you, um, you know, we've seen the benefits of those in patients with uh vascular disease, healing wounds on their toes, et cetera. And, you know, if it if it works in patients like that or can work in patients like that, healing radiation injury, et cetera, you know, it's going to work phenomenally for patients that are healthy, um, and particularly where the blood supply is or the blood flow is good. And so, so how does it work exactly? Well, reduces the pressure and sends you into a lower pressure grade externally, which preferentially delivers or higher pressure, excuse me. Yeah, which preferentially delivers a higher percentage of oxygen to your cells. So you're you're changing the ambient pressure around you, which preferentially pumps more oxygen into the cells. And, you know, there's there's a lot to be said for that because, you know, one of the things we do with patients that are hypoxic is give them oxygen, right? And so this is yet just another way of delivering oxygen to the local tissues.

SPEAKER_01 23:56

Yeah. In some ways, I feel a little hypocritical when we're talking about this because we just talked about evidence-based medicine for peptides. In the world of hyperbaric oxygen to try to enhance recovery, I use it a lot for my patients, but there isn't the same level of evidence. But I think we all sort of believe intuitively that more oxygen when you're healing just makes sense. And it's not some giant mystery. And it's the two factors that you're talking about increased atmospheres of pressure and increased oxygen that we think promotes that increase, you know, promotes that extra healing. Here's what we don't know though. Um in the world of hyperbaric oxygen therapy, you know, when you've had a chronic foot wound and gone to a chamber for 20 treatments, you go to a hospital grade chamber where you're getting typically between two to three atmospheres of pressure and a set protocol. What's not well studied in the world of plastic surgery is what's the right atmospheres to go to. I've seen many patients go to little zip-up, you know, um oxygen um chambers where they're only getting 1.3 atmospheres, which is not considered medical grade. Um, I send most of my patients to chambers that are 1.5 to 2 atmospheres, two is where it becomes meets the threshold of being hospital grade. And there are benefits to lower pressures. It's less trauma to the ears when that's happening, particularly in facelift patients who have a tendency to get this buildup of fluid in their ears afterwards. It can actually be better tolerated. What we don't know is if it is efficacious. So, any other things that you can think of? I mean, I think we've touched on a lot of different things: ways to reduce pain, ways to reduce nausea, peptides, what they may or may not do, hyperbaric oxygen. You know, I think it's an exciting time in surgery where, you know, everything we can do to make the recovery better is just gonna make it more appealing to people.

SPEAKER_00 25:49

Any last thoughts? Um, I think, you know, it's an exciting discipline to be involved with. And I think, you know, I think the next five to 10 years are gonna really be the test of time where the rubber hits the road.

SPEAKER_01 26:01

So thanks again to everyone who's sat through another one of these episodes, and we hope you make it through some more.