Enhance Your Practice Podcast
Enhance Your Practice Podcast
EP77 WPS Remix Edition: Weight a Minute
Host: Rukmini (Vinaya) Rednam, MD, FACS
Guest Speakers:
Patricia Mars, MD
Beth Collins, MD
The views expressed by hosts and guests are their own and do not necessarily reflect the official policies or positions of ASPS.
Welcome to the WPS Remix Edition. This is the Wait a Minute panel. Today, I'm joined by some talented surgeons Dr Patricia Mars and Dr Beth Collins. Welcome, ladies. Thank you.
Speaker 1:Hi. So let's talk a little bit about our panel. This was a great panel. We talked about everything from surgical, bariatric, post-bariatric procedures to weight loss medications, and I know that both of you really focused quite a bit on that. So, dr Mars, once you get us started off, let's introduce yourself, tell our listeners a little bit about yourself, and then we'll get into chatting about the topic.
Speaker 3:All right, great. So my name is Patricia Mars and I'm a board-certified plastic surgeon practicing in Tucson, Arizona. I have an all aesthetic practice and I've been in practice this year will be 28 years, ladies, so a very long time and I've been running a semi-glutide program in my practice for two years this March actually was two years, and so my topic was exactly that you know, running a semi-glutide practice and how I do it and how I take care of the patients and just kind of the ins and outs of that experience.
Speaker 1:That's wonderful, dr Collins.
Speaker 2:Hi, I'm Beth Collins. I'm a board certified plastic surgeon in Connecticut. I have two offices, one in Guilford, connecticut, and one in Mystic, connecticut. I specialize in I kind of have a dual specialty in body contouring and also facelift surgery. But I have been recently become very interested in lipidema, which is a newly classified disease with a brand new CPT code, so we're really recognizing it for patients and actually letting them get their care. So we've almost after the WPS meeting there was an opportunity to join an IRB study at UVA. So we're really going to start to look into surgical corrections of this very debilitating illness.
Speaker 1:And we're definitely going to talk a lot about that because you just had some amazing insights with it. And to introduce myself, I'm Dr Vinaya Rednam. I'm a board-survived plastic surgeon in Houston, texas. I moderated the panel and I loved moderating it because my practice is largely post-bariatric and post-weight loss patients, so this was just right up my alley. Derek Hollins, I loved. You know you talked a lot about Lipidema and one thing that I found very interesting is the point you brought up with the GLP-1 medications and Lipidema. Could you discuss that a little bit?
Speaker 2:Yeah, I mean, I too run a GLP-1 clinic out of my office and when I started to work with these Lipidema patients, the common theme is that they try all sorts of weight loss, just like anybody who suffers from obesity, and oftentimes they will lose weight every place else but the areas affected by the lipoedema, so typically their lower extremities and even up into their upper extremities.
Speaker 2:So they may lose weight every place else except for in those places. But because what we're starting to see with lipidema and it's becoming a little bit more clear that there may be an inflammatory component to the disease, I thought that perhaps putting them on a GLP-1 medication would help not only with weight loss and cravings but also with the inflammation, since we have such good track record with those medications with inflammation. So while we're waiting for our insurance company approvals, I started people on a course of the GLP-1, and I found that they, for the first time in their lives, were actually losing weight in those lipoedema affected areas. So it was making my surgery a lot less difficult, less volume for the liposuction, and it was really a win-win. And now I'm starting to look at keeping them on for maintenance of their surgical results.
Speaker 1:Is this something that you kind of discovered? Is this something you read about that had been published elsewhere?
Speaker 2:No, I just started doing it. I don't think really anybody's looked into it. We are at the very beginning of elucidating what the actual pathophysiology is of the disease. That's still very much in theoretical discussion right now. The newest theory behind lipoedema is that it could be a subclinical compartment syndrome, creating a vicious cycle of ischemia followed by pain, ischemia followed by pain, followed by inability to shrink fat cells, because the metabolic demand well, I guess blood supply is not great, so you don't get the the metabolic benefits of, of whatever weight loss you're doing into those particular fat cells. There's a genetic component to it that we're starting to figure out, so no, so everything really that's going on right now in that whole field is brand new. Although the disease itself was recognized back in the 1940s, there are probably most physicians worldwide don't even really know what it is.
Speaker 1:Yes, I agree with you. I think that a lot of people think you're just pronouncing it incorrectly when you say lipoedema.
Speaker 2:Yeah, you're exactly right. I've been in the embarrassing situation of way back. It was probably when I was in residency. A patient said I have lipoedema and I, you know, very smugly corrected them, say you mean lymphedema. And little did I know that I was the ignorant one in that conversation. So it's good that people are starting to recognize it. It's a very frustrating disease for the patients. There's a lot of eating disorders associated with it because they go. These patients go from doctor to doctor saying you know, and the doctor's saying, well, just get on a diet or lose weight, and they can't. So it's frustrating, it's cumulative, it gets worse as they get older. So I think we're starting to see pretty good options, with one of them being the GLP ones, the other ones being surgical correction, because we're we're seeing great resolution of symptoms with surgery. So all of those things are promising.
Speaker 1:Well, it sounds like there's a lot we have to learn in that area, Um, but it's good that we're we're going, we're headed in the right direction to help with these individuals.
Speaker 2:Absolutely, and they're some of the happiest patients. Very, very gratifying work for me.
Speaker 1:Well, dr Mars, when your talk you talked a lot about like how to implement JLP1s into your practice. Could you kind of give a general overview of some of the basic things you feel like someone needs to do in order to have a successful integration in their practice?
Speaker 3:Of course. So I think you know the kind of the steps that I outlined in my talk are, of course, you know, doing a little bit of research. You know about the GLP-1s and you know knowing how they affect patients, knowing what the risks are, knowing what the side effects are. I think a little background in that my talk didn't really discuss all those things, but we can briefly talk about that as I go through kind of the steps of the program. But I think you need to have a basic knowledge about GLP-1s and you know how they work and the major studies that brought them on and you know the amazing things that they can really do for patients. So I think the first thing that you need to do when you know that you want to bring on a program is that you have help. You know you're going to need help doing this program. So you can either have a nurse practitioner, an RN, an MA if they can do injections, but it gets pretty busy. So you have to identify a staff member who is really going to be that key person to talk, discuss with. You have to identify that role in your practice who's going to be following the patients and seeing the patients and kind of troubleshooting along with you. The second thing that you need is a good pharmacy and you know a compounding pharmacy that will provide you with the medication, and there's a lot of, of course, compounding pharmacies available. When we first started, we probably interviewed around five to 10 different compounding pharmacies, just asking you know, of course, the basic questions what is the cost? How long does the compound last? What is in the compound? Because when they compound it, of course you can't have it the exact formula. It needs to be altered and usually you know B12 is in it. You know that's kind of a common thing, so that it's not exactly like the original formulary, and you need to know how long that's going to last Some of them last 30, 60, 90 days how they're shipped, what the shipping is, what the cost is and how, of course, you inject it into a patient and what the units are. Most of the pharmacies use it on a unit basis instead of like a milligram dosage. Like the original formulas are a milligram dosage. These are usually in a unit dosage, so you have to know how to deal with that. Then, once you have your compounding pharmacy and you know you have, you know, a good agreement with them and you feel supported by that pharmacist and that pharmacy, then the next step, of course, is designing the program.
Speaker 3:So what I did, what I decided I wanted to do is I really wanted to be a doctor first. So I take a look at my patients, of course. We weigh them, we get a BMI and then I do labs on all of my patients. I really want to know their health and we do, of course, a physical examination, we do a background history on them, and then you have to have your do's and don'ts like the people you will or will not treat. I'm not comfortable treating type 1 diabetes or type 2 diabetes. I don't want to mess with someone's. You know primary care or internist and what they're being treated on. So you have to have you know kind of an idea of you know what type of patients you want, what BMI limits. You know upper or lower. I mean, you know you wouldn't think there would be a lower one, but some people come in and you know they're very thin and they still want to lose weight. So I think you have to have, you have to be, you know cautionary about that, and then you know go ahead.
Speaker 1:Are these patients all patients who are going to become your surgical patients, or are you doing general patients, helping them with their weight loss as well?
Speaker 3:Yeah, it's both, you know. So some patients want to lose weight and some patients want to lose weight and then have. Of course, I love it when they want to have something done. I mean that, you know, ultimately is the goal is that they lose enough weight and then, you know, they cross over to the surgical side. I'm very happy to welcome them from our med spa side over to the surgical side. But you know this, you know, just like you know Beth said, you know her patients are her lipoedema patients are very happy.
Speaker 3:These are some of the most happy patients you know that have struggled with weight loss. You know either their whole lives or you know they've gone through menopause and it's been very difficult, or they've had, you know, a child and they just can't get out of that cycle. Restriction and exercise, sometimes metabolically, that just isn't enough and this really kicks, you know, kicks, into gear. I think something that's missing and it really is very, very effective. And you know all the major studies. You know when it first, when you know semi-glutide GLP-1s first came out, there is about a 10 to 12%, you know, ineffective rate.
Speaker 3:So the patients who do not, you know they just don't respond to the GLP-1. So I have seen that We've used both semiglutide and terzepatide. We cross over to terzepatid when patients are resistant. So that's one of the things that you'll see when you're, you know, using this. A lot is that some patients you know are they're just resistant even to semiglutides or GLP-1s in general. But anyway, so those are kind of the steps and then monitoring patients, seeing them back, you know, taking care of them along their weight loss journey, getting them to their goal weight and then kind of weaning them off. Those are kind of the steps of the program.
Speaker 1:Do you, does your staff or you teach them how to do the injections themselves, or are they coming in for their injections each week?
Speaker 3:You know, I think there's so many spas in town that just hand them the medication and say see you later that they don't really get good follow-up. So I call my program a concierge program because we see them every week. Now if someone's going out of town we'll give them a couple of doses, you know, to go home with after they've been on the program for a while, and I kind of trust that they know what they're doing. But you know my go home with after they've been on the program for a while, and they I kind of trust that they know what they're doing. But you know my RN or MA injects them, sees them weekly, weighs them, you know, talks to them about how they're feeling. You know if they're having any side effects or any issues or problems, we address them right away.
Speaker 3:I think it's just a different way of, you know, treating a patient. It's a little bit more personal. I like it. I like that kind of control. Guess what, I'm a control freak, so I do like seeing them back. Plus, they get to know my staff. They see what's going on in the office. They become like part of our family. They get comfortable with my staff. It's more likely that they'll cross over to skincare and Botox and fillers and all the other wonderful, lovely things that we do. So that's kind of the other reason why I like them there on a weekly basis. They see what our specials are, they see, you know, like whatever is new in the office that we're kind of promoting, you get, you know, some, you know some good crossover with that weekly follow-up.
Speaker 1:That's great, and it helps you stand out, too, from a lot of these places that are providing this, but without all of that concierge type service.
Speaker 3:Yeah, that's what we think too is like it's just a step above. I don't want to be like you know the average, you know med spas in town that you know that you know like patients will come to us and they'll switch to our program because they're like I just felt like I wasn't. You know that they had no guidance at all and so we're there really to provide guidance and follow up and care and like you're doing great and you know that kind of a thing.
Speaker 1:Yeah, dr Collins, do you do something similar with your program?
Speaker 2:Yeah, pretty much exactly the same. I feel very validated whenever I hear Patricia talking about her program. But the one thing I have a question for you what are you going to do in? I mean, I know that in the next couple of months the FDA has kind of put a moratorium on the compounding pharmacies. Do you have a plan for that?
Speaker 3:I know this is really scary and frustrating. So for now what we're doing is trying to just stock up as much as we can. We were using triseptide in our practice and that has been squashed completely. So we don't have access to it and we use about three different compounding pharmacies and we couldn't get it from anybody. They're just like no, that's completely cut off, and so it's a good question. We're kind of like faced with that right now, beth, and I think you know the options are.
Speaker 3:We are very close to Mexico. That may be an option for us is to obtain, you know, prescription medication from Mexico. It's exactly the same thing. You can get prescription medication down there relatively inexpensive, for just about anything, much less over-the-counter costs than you would pay in the United States. That's an option. I know some people are going to probably look towards Canada and getting it from Canada. I mean I'm not really sure what we're going to do. We're just starting to discuss it with patients. Like I can provide them with prescriptions, they can, you know, get you know the medication and those locations too. I don't know what we're going to do, do you? I mean this is kind of our plan, but right now we're kind of stockpiling. That's my plan for right now.
Speaker 2:So I think that I want to get in touch with Eli Lilly and Novo Nordisk, because I think that, instead of the pens that are preloaded, they may be switching over to selling vials that are multi-use for a patient, and in that case you can be the provider who follows them, and I think that those vials may be less like, more affordable for the weight loss people.
Speaker 3:Okay, well, that's another good option then.
Speaker 1:In that case, that would be sent to the provider and the provider then dispense. You know, I really don't know.
Speaker 2:So this is, this is something that's also up in the air the, the compounding pharmacies, may still be able to compound some agglutide with other things like, but I don't know how long that's going to fly. But my plan was to get in contact with the reps from Eli Lilly and Novo Nordisk to see what we can do about being the actual providers of that care, because still, I think a lot of the family practice doctors are not comfortable prescribing the medication at all for weight loss. So we still may be able to be the the providers for that, but using on-label medications and you know your services would be you know you wouldn't be selling the medication, you'd be selling your medical care, right, I mean, that's a that's.
Speaker 3:You know, maybe that's a good transition. I don't know. We're this is kind of all active right now. We're kind of like what are we going to do, you know?
Speaker 2:I mean. There's a third agent coming out from Eli Lilly now that has, so it's the Terzapatide, which is DLP1 and the GIP. They added Ducagon to it. And that's their newest offering that's coming, coming to a theater near you.
Speaker 1:Well, I know that one of the company firms we use is actually very actively fighting because they're being sued and they sent out an email to all of us, basically being like we're staying strong and they're still providing the medication. So awesome, yeah. So I mean, we'll see, because, unfortunately, a lot of people who don't quite fall into the insurance approval you know what they would need can still benefit from these.
Speaker 2:Yeah, absolutely, I mean it's. It's crazy that insurance doesn't cover these medications, because the health benefits are just undeniable.
Speaker 3:They really are.
Speaker 3:And the other thing that I've seen and I'm I'm sure you know, you've seen this, vinaya, and you too, beth is that I see so many patients that are obvious, obvious, you know.
Speaker 3:They would be like, hands down, insurance should cover their, you know they're obese and they have, you know, you know, secondary issues because of that and they have secondary issues because of that and their health is affected and they can't get access to it. They're like, no, my primary care physician won't write it for me or no, my insurance won't cover it. And it's like this is ridiculous, because I mean, in the end, what they're doing is preventing all the subsequent illnesses and problems down the road by treating the patient and getting them to lose weight. It really makes sense to me. I mean, it's like a no brainer that these patients should be on the medication as a whole and saying I want to reduce your future risks for so many things we can, you know, rattle off you know, you know 10 diseases that it would prevent in the future for these patients, but why are they not getting covered? They're obviously candidates.
Speaker 1:Well, and it's interesting when you say the primary care doctors. I, you know, recently had a patient I've become her primary care for that because she needs this medication and a primary care doctor just doesn't really feel like that's what he wants to discuss with her, and she's the perfect candidate for it. So it's in that situation, like you said, that I've decided to be doctor first here and I'm going to help her.
Speaker 2:Yeah, it's not complex. I mean, the side effects and risks of it are pretty minimal.
Speaker 3:They really are. I mean, just over the two years I have seen very little side effects and I've treated I don't know, you know hundreds of patients.
Speaker 1:Yeah, well, there's still a bias because of the disease it's treating, because we have no problem putting people on blood pressure medication when their blood pressure is not okay. Well, yeah, and cholesterol medication and everything Diabetes for diabetes.
Speaker 3:They seem to be okay with that, you know.
Speaker 2:I mean yeah, yeah, you know the only thing that I sort of differ a little bit with you, Patricia, is that I'm not really looking to wean people off. When I start them on it, I tell them that it's very likely to be a lifelong medication.
Speaker 3:Yeah, I do. I do agree with you in many respects. I tell patients that to look at this as a at least a year to two journey of weight loss and that I will try to wean them off. I have successfully weaned off patients, but many patients I have not. I have them on a very small dosage, or they're taking it every other week or they're taking it every three weeks, but they're not getting off of it.
Speaker 3:And I'm like I'm saying the same thing that you know. You just said, vinaya, like you know, you don't take patients off their blood pressure once it's under control, when their diabetes is under control. You just said, vinaya, like you know, you don't take patients off their blood pressure once it's under control. When their diabetes is under control, you don't withdraw the medication. So it you know. If I tell them if you need to be on a small micro dose for the rest of your life, where is the harm in that really Right? So I do agree with you, but I have been able to get patients weaned off. Some patients can do it, but I would say that's the minority.
Speaker 1:Yeah, yeah. Have both of you, as a result of increased use of these medications, felt that you've seen patients coming in for procedures that maybe normally wouldn't have? Maybe they're not massive weight loss patients, but they're losing more weight rapidly because of these.
Speaker 2:Yes, I've had a lot more body contouring people who have lost lots of weight, who had been on it through their family, doctors.
Speaker 3:Yeah, I agree. I mean I see patients, of course, from my own clinic, but I don't think a week goes by that I don't see a patient that has been on, you know, a GLP-1 and has lost weight and now it has subsequent. You know, like you know abdominoplasties and fleur de lis and you know brachioplasties older than you know you probably would think because you know it really bothers them, but you know, and they're still, they're now in really good health and it you know. I mean we're living longer and we're more active longer, and so I feel like I'm seeing those patients. Like you wouldn't think, people in their sixties, you know, late sixties, maybe even early seventies, are wanting body contouring, but after you know, finally losing weight, they do want it.
Speaker 1:Well, people, if you're living longer, they want their quality of life to be just as good, and this is part of it. Yes, well, thank you both for being on. It was so wonderful being on this panel, and I feel like everybody learned so much. What's one take-home point that each of you has for somebody who might be interested in incorporating this into their practice?
Speaker 2:interested in incorporating this into their practice. Well, I like the idea of people going to actual doctors to get their medications, so I love that Patricia is doing this, and in our practice we're really following our patients. We're following up with labs to see that we've got improvement. We're keeping an eye on people, making sure they don't have complications and we're being their doctor, so I think that's super important.
Speaker 3:I'm just going to you know kind of reiterate and agree, I mean like taking a holistic approach. We try to do that, you know, with everything that I think that we're doing now in surgery. You know taking care of patients. You know before surgery, getting them healthy, getting them ready for surgery. You know taking them through surgery, trying to really support them, and then, of course, you know really good postoperative care. So I think, if you're going to do this program, kind of take that same approach, really take care of your patients before, during and after weight loss.
Speaker 1:I agree with both of you and I think that you know a lot of people may say plastic surgeons are not the people to do this, and I think that we might be exactly the right people to do this. We have long-term follow-up. We make really important relationships with our patients, so I think this is an area that would make sense for us to continue in, and I guess we'll just have to see how things continue to go with compounding pharmacies and the future.
Speaker 3:Yeah, yeah, very interesting to see what happens and thank you very much for the discussion.
Speaker 2:Thank you so much.