Speaker 1 (00:00:01):
Good evening everyone. Welcome to Hernia Talk Live. This is our weekly q and a session. My name is Dr. Shirin Towfigh. Many of you know me as your hernia and laparoscopic surgery specialist. You’re on Facebook Live right now at Dr. Towfigh. You may also be following me on Instagram and Twitter at hernia doc. At the end of this hour, we will make sure that you have access to my YouTube channel where I will be posting the link to watch all of this and share our hour. This session will have Dr. John Fischer. Dr. Fischer is a plastic surgeon, plastic and reconstructive surgeon at the University of Pennsylvania in Florida. I’ve known him through the American Hernia Society where we’re having more and more plastic surgeons be involved and we love it, which I think is great. And John’s one of our prominent ones. So welcome and thanks for joining me.
Speaker 2 (00:00:58):
Well, thanks so much for inviting me, Shirin. It was great to get the invitation and a pleasure to be here.
Speaker 1 (00:01:03):
Thanks, John. So I think we first met on the board. Are you still on the board of the American Hernia Society?
Speaker 2 (00:01:09):
Yep. Still on the board. Fortunate, fortunate to be asked to do a second term, which has been a real privilege and honor and it’s been great collaborating with you and yeah, plugged to the a HS. Really a terrific society that I think does a lot for its members and is really aiming to advance the field.
Speaker 1 (00:01:27):
Yeah, I’ve shared my story with a HS before we had Chuck Filipi, who was one of the more senior members of the A H S, and the first person I really met at my first meeting at the A H s, and he was so lovely and so kind. I told him that if he wasn’t, so he came up to me and introduced himself to me, which I thought was lovely. And I was straight out of residency, my first job, and I had presented then it really was a very warm welcome and that really stayed with me. I still remember that. I don’t think you remembered it though. And so I’ve loved being part of the society ever since, and I’ve seen a lot of fantastic advancements and so much good things that we’re doing for surgeons and patients and the advancement of hernias. So it’s great that you’re on board.
Speaker 2 (00:02:21):
Speaker 1 (00:02:22):
And so you’re a plastic surgeon. If you can just describe really quickly how that differentiates you from me, a general surgeon and the philosophy by which you are trained versus especially in relationship to abdominal walls compared to how we get trained.
Speaker 2 (00:02:42):
Yeah. Well, I think that’s a great question. I think plastic surgeons, I think have a unique way of thinking about surgical problems, whether they’re reconstructive or aesthetic in nature. And I think that the fundamental principles of plastic surgery relate to restoring form and function. I think that you could distill that down and really think about any kind of set of operations, whether it’s abdominal wall reconstruction or rejuvenating the face. And we’re really trying to maximize the way people look and feel and also really restore kind of function to whatever part of the body that we’re working on just to maximize quality of life. I kind of like to think of my job simply as to maximize people’s quality of life through surgery.
Speaker 1 (00:03:27):
I think you’re absolute absolutely right and this whole function. So as many of the people that are watching, no, we used to just patch hernias all the time. You patch a hole in the wall, there’s no function. There was no function to it in the abdominal wall. And it really wasn’t until we got to learn more of the plastic surgery literature with Ramirez and ways to manipulate the abdominal wall to be able to close the hole without it popping open that we started doing the closure of the whole primarily and then using Mesh or something to reinforce it as needed. But before we would just see a hole patch it, and that restored no function. It just prevented intestines from popping out. And I think the plastic surgery influence really helped us bring function back to hernia repairs for the abdominal wall.
Speaker 2 (00:04:22):
Yeah, I think that’s a great point, and I think it’s a lovely example of how kind of cross polymerization of ideas and knowledge I think can improve a specialty. And I think for abdominal wall reconstruction, there’s just terrific kind of cross-disciplinary collaboration between general and plastic surgeons that have, I think has served to advance the field. So yeah, that’s a great point.
Speaker 1 (00:04:43):
And so as you know, I practice in Beverly Hills. So before I used to practice in a very kind of high volume acute care hospital like LA County hospitals. So we dealt with much sicker patients than I do now, and also people at higher risk. And so the goal was to restore them to be able to go back to work and be functional. But now, in addition, aesthetics is very important. So I try and use smaller trocar sizes, smaller incisions. I work with plastic surgeons and I learn a lot about what to do. And as an example, I’d like to know your point on this. We’re going to be talking a lot about diastasis recti and so on, but people with hernias have diastasis recti, which is a separation of the muscles without a true hernia. But I feel like either they’re more at risk for having a hernia because of that thinning. Or let’s say they have a surgery, a gallbladder surgery or a prostate operation, and they take out the gallbladder or the prostate through that scar, which is through the thin diastasis, and now they get a hernia. And I’m a big fan of addressing the diastasis at the same time if possible.
Speaker 1 (00:06:02):
I don’t know if you guys routinely do that to me it’s like, oh, we should be doing this. But I don’t know that most people do that in the general surgery side.
Speaker 2 (00:06:11):
Certainly on the plastic side, I think if someone has diastasis and a hernia, I think that you really have to correct the diastasis because there’s a pathology there to it, as you pointed out. I think because of the pressure either after pregnancy or in men because of their anatomy, they can get thinning of that midline kind of fascia or that kind of area of thickening, and that can lead to some significant weakness and functional issues. So I think it’s really important to correct it as part of a, I would say comprehensive treatment plan for anyone who has a hernia. And I certainly do quite a bit of diastasis repairs as part of my practice.
Speaker 1 (00:06:48):
I feel that the diastasis is almost like what you’re doing is you’re clothes, you’re placating, or what’s the right term folding over this normal tissue over this kind of thinned out tissue. Besides it giving a flatter look, I feel like it takes tension off of the underlying hernia repair or hernia problem. So have you ever thought of using a diastasis placation as a biologic alternative to Mesh for hernias?
Speaker 2 (00:07:21):
Yeah, I think that that’s almost exactly what I do for my diastasis patients is just a application, kind of bringing rectus muscles into proper alignment to improve function and getting back to healthy tissue. I haven’t tried that for my hernia patients. I usually just rely on those techniques of releasing the abdominal wall to get the midline closed. But I think it’s an interesting idea because both kind of treatments can probably draw some principles from one another in terms of how we approach each problem.
Speaker 1 (00:07:53):
Yeah, I’ll tell you it’s because I’ve had a handful of women who have had in belly bone hernias or incisional hernias, and the size is over that kind of one to two centimeter size where we are comfortable not using Mesh and doing a tissue repair. So three or four centimeter defects. And they’ve also kind of, I said, you know, got a lot of extra skin here be considered tummy talk. And many of them choose the tummy tuck. And so I’m in there with a plastic surgeon. So if it were in my hands and it was purely a incisional hernia repair, four centimeters or an umbilical hernia three centimeters, I would’ve used Mesh because all the studies support that your repair will just fall apart. But then we go in and we’re doing placation with the tummy tuck, and I feel like you can close the defect and then plicate over it and there’s so loose, the tissue is so loose. So we’ve been pushing envelope up to about four centimeters of not using Mesh, and we’re following our patients now instead of using the tummy tuck as an alternative type of repair. And what so far, they’ve all done really well.
Speaker 2 (00:09:11):
Okay, that’s awesome. And that’s really in line with how my clinical practice is and some of the things that I do. I think when you talk about someone who has a hernia in kind of a sea of diastasis, even a three centimeter hernia where you typically use Mesh, I think that as soon as you close that and plicate you no longer have a hernia. And I think that some of those kind of properties that would make you want to put in Mesh, I think those conditions are kind of gone. And so the plication in and of itself I think is a great way to address it. So I’ve kind of moved away from using Mesh in most of my diastasis patients.
Speaker 1 (00:09:46):
Yeah, that’s pretty awesome. Let’s define some things. So ply, you want to explain what plication means?
Speaker 2 (00:09:54):
Yeah, sure. So if you think about the rectus muscles or the abs being separated, basically I kind of talk to my patients who present, and they’re usually postpartum women, typically patients who’ve had multiple children. It’s a separation, I kind of call it almost like an internal corset. And people really get that analogy. You’re kind of lacing up a corset, but you’re going to wear on the outside to hold everything in. Let’s say you’re going out or doing something, this is going to be an internal corset using sutures. And I typically, intraoperatively or during surgery will look at the abdominal wall very carefully, figure out where things have to be in order for them to be normalized. And then we basically do multiple layers of sutures, almost like a multi-layer corset. So you get kind of two corset on top of each other and that reduces the chance that it bulges or kind of recurs. And we’ve had a lot of luck with that.
Speaker 1 (00:10:48):
Yeah, that’s true. I really like that way. So corset where you kind of tighten it, you know, see how it kind of gathers together. That’s exactly what you’re doing with the application. I may steal that.
Speaker 2 (00:11:00):
You should. That’s a good one. People really get that. And yeah, I think it kind is a good analogy.
Speaker 1 (00:11:08):
Okay. The other term you used was releasing the abdominal wall. Can you explain what that means?
Speaker 2 (00:11:12):
Sure. So releasing the abdominal wall, what we say is a component separation or a muscle release. We typically do that for big hernias where we’re trying to get the hole in the abdomen close. And what we do is we take advantage of our knowledge of the layers of the abdominal wall. And so what we can do is we can release one of the layers very carefully and very precisely in order for us to close the hole in the defect. And the analogy that I use for this is typically when I add a patient, I
Speaker 1 (00:11:40):
Speaker 2 (00:11:41):
Notes, oh, you, you’ve probably done the same thing, but I’m a patient in the office with a really big hernia and we talk about weight loss to reduce the content, but we also talk about getting all the packaging back inside. I use a suitcase analogy. It’s an overpacked suitcase trying to get all the clothes in. And if you have one of those fancy suitcases that has an zippering button that kind of expands it, I use the analogy that a component separation basically does that. It kind of expands your suitcase so we can get all the clothes in and kind of zip you back up. And so the zipper doesn’t break from too much tension. And that’s kind of what I tell patients is that we’re using a very selective kind of releasing mechanism to expand the volume of your suitcases, basically.
Speaker 1 (00:12:20):
Oh, that’s a good one because Mo Nahabedian, who we spoke to sometime last year, used the suitcase analogy, but it was more about the suitcase inside the suitcase and intraabdominal fat. And so if you lose the weight, then we can close the suitcase, but you got to empty it out before we can close the suitcase. But the component separation or what are some terms that Rives- Stoppa or TAR transverse abdominus release, anterior components release, those are that extra zipper that expands the suitcase. I mean it does make it a little thinner.
Speaker 2 (00:13:01):
It does little area,
Speaker 1 (00:13:02):
It does little thinner.
Speaker 2 (00:13:04):
No, it may it change the shape of it. And I tell patients that the overall shape of their abdominal wall may be different, but they’re less likely to have a hernia. And you’re exactly right, it’s that expandable zipper feature that we use because we know the abdominal wall anatomy and we can do it very precisely.
Speaker 1 (00:13:22):
I like it. And just for everyone watching, almost everything we’re discussing today will be about the abdominal wall, which means around the belly button between your chest bone down to your pubic bone, and to left and right of it. We’re not really going to be talking too much about inguinal hernias unless you have a special interest in that. But most of what Dr. Fisher and plastic surgeons do that deal with abdominal wall hernias are kind of in the mid gut abdomen area. The other question is how would you treat thinning of the muscle of the abdomen or flank that has happened after Mesh removal? Have you seen that?
Speaker 2 (00:14:00):
Yeah, I mean certainly someone who has had Mesh removal, you have to assume they’ve had a Mesh repair and they’ve had surgery and probably multiple surgeries. So some patients can get thinning of the abdominal wall just from multiple operations, the scar tissue weakening muscle atrophy. And I think that if you can get healthy tissue back together, and I think this is, I’m a really simple plastic surgeon, if you can distill it down to something very simple, if you can get healthy tissue back together in a relative tension-free manner, basically not too much stress across it, I think that you’re going to derive a really good functional outcome for patients. The other thing that we routinely do, and you already alluded to this Shirin, is that we typically reinforce these hernias with Mesh. And I think that Mesh has really become a cornerstone and it’s one of the cornerstones that we’ve in our practices, and for me the biggest cornerstone I think is getting healthy tissue back together. And so that’s what I would probably recommend in that particular example is trying to use my technique to get that tissue back together.
Speaker 1 (00:15:04):
I’ve seen a patient who had Mesh removal from the abdominal wall and it looks like she had a tram. That entire rectus is pretty much gone it, it’s not technically gone. There’s like a thin layer, but it’s completely atrophied and thinned out in a segment. And I wonder, you think maybe they had a nerve injury as part of the Mesh removal? Because Mesh removal itself should not take that much tissue away, or at least those of us that do it for a living, we really try and minimize how much natural tissue we sacrifice as part of the Mesh removal process. So it just really odd to me because that one side is just atrophied. And so now she has this kind of disparate abdominal wall and I’m wondering what you think of why it happened and also now that that’s happened, how do you help reconstruct an abdominal wall where you’re missing functional muscle on one side?
Speaker 2 (00:16:04):
Yeah, that’s a really tricky situation and I would probably venture to guess, as you suggested, there was probably some type of nerve damage or nerve injury. The rectus muscles are abs, they’re innovated by very small nerves, and if those nerves get damaged, some or a few of them, you can really see some changes in the rectus muscle. You can see bulging on the CAT scan, as you said, things can really thin out. It’s a tricky problem. I think that having a really frank conversation with the patient is probably the most important thing to do is that there’s going to probably be some long-term functional issues. My approach to those types of patients, which we often see, as you mentioned, women who’ve had tissue moved from their abdomen to reconstruct their breast mount. They can often get these types of bulges basically weakening of the abdominal wall. I tend to adopt kind of a placation type approach for these patients trying to get the rectus complex really as tight as possible, recognizing that there’s going to be some inherent weakness and then reinforcing the whole abdominal wall with a large piece of Mesh and had some great results. So basically placating and using a large piece of Mesh to kind of suspend the abdominal wall. And we’ve seen some positive results with patients.
Speaker 1 (00:17:14):
Do you do that for all your breast flaps or just the trams for a deep Mesh? So
Speaker 2 (00:17:20):
Yeah, not always for a deep flap, it really depends on the quality of the fascia, but I think for a tram we typically will put in Mesh for the women who get a bulge after the operation where they have really thinning of the muscles. I really think you got to treat it like a hernia. It’s kind of in that bucket of really severe diastasis bulge and kind of hernia and you kind of have to apply hernia principles I think.
Speaker 1 (00:17:44):
Yeah. Okay. We have a complicated question for you, but it’s something I was alluding to a bit earlier. So this lady, she has a very wide diastasis recite 16 centimeters, no hernias, and she is explaining that, so she’s had three babies, she’s explained that she feels like her, everything is wide open all the way up to her sternum. So what advice do you give her for repair to number one, regain function? Number two, help her pain because she’s really unable to do much bending, lifting, or even play for a long time with her children. And once she is repaired, is she able to go back to her more athletic lifestyle, coaching, volleyball, teaching dance, and so on? These are extremely wide diastasis. What are your thoughts about approaches for that?
Speaker 2 (00:18:39):
So first, this is a really severe diastasis, and I think that a return to normalcy I think could be achieved if you get a good repair. I think a good repair would definitely help with pain and function. I think the approach that I would consider for this might be to treat this a real hernia. When you talk about a 16 centimeter diastasis, even though you don’t have a true hernia, which means there’s a hole in the tissue, you just have a severe, and in this case, very large weakening. Yeah, I think, you know, may want to treat this a hernia and kind of take the abdominal wall apart, put it back together and add Mesh. Really, when the diastasis is above 10 or 12 centimeters, I move away from my kind of core setting with suture and start thinking carefully about adding a piece of Mesh to kind of support the abdominal wall because there’s going to be a lot of tension across the corset if you just use sutures and oftentimes they can fail. So I think in this particular situation, it might be worth treating this a big hernia and considering a formal repair with Mesh.
Speaker 1 (00:19:52):
So I’ve seen a Rives-Stoppa, a retrorectus Mesh placement for some of these, treating it like a hernia or do you plicate and then do Onlay Mesh? How is the
Speaker 2 (00:20:03):
So yeah, I mean I’ve done it both ways. I think for these big ones, and I’ve treated a few upwards of 20 centimeters. We, we’ve done a retro muscular Mesh placement typically that will involve a big kind of horizontal bikini cut or a vertical cut depending upon what the skin looks like. But I think that that’s probably the best approach for these really, really big ones. There’s just not a lot of information or evidence out there to help guide us. But I’ve, in my practice, found a lot of success in this approach when they’re this big, is to treat it like the hernia and those principles, I think that we use hernia repair. I think that they do work well in this type of problem.
Speaker 1 (00:20:50):
And what are your suggestions to people that are unable to lose their weight because they can’t be as active as they wish to be, and yet you need that weight loss to decrease attention so you can close the diastasis?
Speaker 2 (00:21:03):
Yeah, that’s a great question. I think that usually tends to be the case for some of the men that I see who have what’s called intraabdominal obesity. Not typically common in the postpartum women. I see. But I think that the first thing is, as you said, is just kind of communicate to the patient the benefits and the need to lose the weight. And I think that once you’ve gotten the same wavelength with your patient trying to motivate them to do it and then giving them information about how to go about doing a diet and exercise, we’ll oftentimes send patients to a medical weight loss specialist and then as a last resort, we’ll kind of point them in the direction of a bariatric surgeon. Yeah,
Speaker 1 (00:21:42):
I think those are all legitimate because you need help with either medications or guidance by a physician who specializes in weight loss. And then even surgery, we’re very aggressive in getting patients that help. It’s really hard to do it on your own. It’ll take you three or four years to get to where you need to go. So to expedite that, it really helps to have some physician guidance in that direction.
Speaker 2 (00:22:07):
Speaker 1 (00:22:08):
And these sutures that you place are always non-absorbable sutures?
Speaker 2 (00:22:14):
I typically, actually, believe it or not, I kind of believe in a fully absorbable sutures. And so I think the reason is actually is if you put permanent sutures in the diastasis repair, they’re never going to go away. And so every time the abdominal wall kind of activates, there’s a possibility that it could kind of pull through. And it’s almost counterintuitive, but I personally have found that the absorbable sutures actually work better for this. I typically do a multilayer kind of placation, so that just means that means multiple layers stacked on top of each other and it seems to work well. But yeah, I think that there’s still maybe some opportunities for further research in this area about which works best in which situation.
Speaker 1 (00:22:54):
That’s pretty cool. And so you’ve had good results with absorbable sutures, slowly absorbing sutures.
Speaker 2 (00:23:00):
So sutures that kind of go away over a period of three to six months? I think that there’s some evidence in the plastics literature that if you do two layers as opposed to one, you really, I think achieve a greater net strength. And that’s kind of what I do. I do really kind of two good layers of kind al, almost like a quill type suture, a barbed suture where you pull it through and it’s not going to move and it works quite well.
Speaker 1 (00:23:25):
Yeah. What are your thoughts on Mesh sutures? Have you ever used those or
Speaker 2 (00:23:32):
Haven’t used them personally, but I’ve seen them in person. I think it’s a terrific idea and perhaps a great indication for diastasis where we have a problem that really I think is of tissue and oftentimes sutures can pull through that thinned out tissue. And so I think it’s a very innovative concept and hopefully it’s something that we have in our toolbox to be able to treat these patients someday.
Speaker 1 (00:23:58):
Yeah, very good. The next question is more of a philosophical question, which is, when you approach someone with a hernia, how is your thought process different than a general surgeon? Is it you have a wider understanding of the anatomy or is it like the type of scars you place or can be different, your technique, maybe different since you do work with general surgeons and you know, hang out with some of us, how do you compare your kind of evaluation thought process to be different?
Speaker 2 (00:24:34):
Well, I think it’s not too different. I bet it’s largely the same as someone who does a lot of hernia to myself, frankly. And I think the things that might be a little bit different are related to my surgical approach. I tend to not be, I’m afraid of making a bigger incision to really, I think achieve I think a better kind of more functional or more aesthetic result because I’m very comfortable with closing tissue and contouring. So I think that’s kind of one thing that I have in my toolbox and as part of my training and background is that I’m very comfortable countering the skin and taking apart things and putting it back together. And so that may differentiate me a little bit, but I think for those of us general and plastic surgeons alike who do a lot of complex hernia, I think that our mindset and our philosophies and our approaches are I think pretty much the same. I think.
Speaker 1 (00:25:34):
Are you more or less likely to use alternative meshes, biologic meshes hybrid, or are you more on this kind of standard Mesh use?
Speaker 2 (00:25:45):
Yeah, so I think I try to individualize it to each patient and talk with each patient. I definitely have had a lot of success with biologic and biosynthetic meshes, but it’s really kind of an individualized decision to talk with the patient. What are they comfortable with, what kind of amount of support does the abdominal wall need? So I’ll give you an example maybe. So a 35 year old comes into the office who has excellent tissue, is going to live for 40 or 50 years on average. The decision between putting a permanent piece of material into the abdominal wall if they have healthy tissue and a fixable hernia, I think the risk benefit shifts more towards using something that’s going to go away over time because of the conditions. If you have someone by contrast sixties or seventies who has a thinned out abdominal wall just from aging or weakness or obesity and their life expectancy is much shorter, I think that putting a permanent synthetic in makes a ton of sense and there’s kind of areas of gray in between all that. So I think that it’s an individualized and tailored approach, but I think that, yeah, that’s kind of in a nutshell what I think about.
Speaker 1 (00:26:55):
Okay, cool. And what kind of biologics do you use or absorbable meshes do you use?
Speaker 2 (00:27:00):
I’ve, so I’ve used a lot of different types of meshes. I’ve used poly four hydroxybutyrate, which is aphasic, Mesh, pH Mesh. I’ve used enform Mesh, which is a fast absorbing. Yeah, I’ve used a various number of different biologic meshes you now, a lot of them are sign biologic meshes, so made from pig tissue and ultimately manufactured to be able to be used in humans. And I use those in really, really high risk complex cases. And then I’ve used standard synthetic meshes, whether it’s polypropylene or P T F E.
Speaker 1 (00:27:40):
And do you feel that the biologic meshes the key is to, I mean, there’s a trick to them because can, when I first started the county, it’s a huge burn center, so we had a huge amount of skin available, synthetic, not skin, synthetic like cadaver skin. So our contract was lifestyle, which was the main producer of these cadaver skin cells was great. And so I had access to this new product called AlloDerm, which had just come out and I, we had, it was so easy to be access, so I was using a lot of it in these Mesh infected patients and so on. And we learned fairly quickly you can’t use it like regular mesh. You need some type of scaffold for it to grow on. You can’t just bridge. So we’ve changed our techniques since then and most of us have not used, I think we overuse the biologic absorbable meshes and now we’re kind of tailoring it to appropriate use. But do you agree with that or do you use it as a bridge as wild?
Speaker 2 (00:28:47):
It’s a great question. I really try to, so when you say bridging, you basically mean that the tissue doesn’t get closed, which we had said was the really important thing in hernia. I think that if I can avoid bridging, I usually always do. And it’s very, very, very, very once in the blue moon, rare that I ever bridge anyone just because of how aggressive I am with my releases and my techniques. If I have to bridge, I think you’re right. I typically am using biologic for whatever reason, just so complex. If that’s kind of what ultimately gets used. And I think you’re absolutely right is Mesh does better when it’s up against healthy tissue. It incorporates better, grows in better and it becomes stronger. So yeah, that’s where I
Speaker 1 (00:29:29):
Use it supports the repair. It supports the repair as opposed to being the repair.
Speaker 2 (00:29:33):
And I use a lot of human AlloDerm in the breast. That’s what you refer to AlloDerm, which is great and been used a lot breast. So I’ve used that for breast.
Speaker 1 (00:29:42):
Yeah. We have a question about abdominal wall release or what we often refer to as component separation. Is there blood vessel and nerve trauma that can increase in complications and infection rates? And what is the risk of either the nerve or blood vessel trauma and also the impacts rate risk with these operations?
Speaker 2 (00:30:02):
Yeah, that’s a terrific question and I’ll, the short answer is yes, there’s, there’s a risk and I think that that’s got to be part of the conversation with patients. That risk in my personal hands is pretty low. When you precisely release the intended layer of the abdominal wall, it’s a pretty nice dissection. It’s basically what we call an anatomic dissection. It basically means we’re separating layers that can be easily separated and there really shouldn’t be bleeding or nerve injury. With respect to the risk, I think it’s important is because the benefit of doing one of these releases is that you’re more likely to close the tissue, which means you’re less likely to get a hernia recurrence because the tissue got closed. And so that’s the upside. The downside is oftentimes you have to dissect and take apart, which introduces risk. It creates a space where fluid could fill up or the risk of infection could occur.
Speaker 1 (00:30:58):
Yeah. Do you perform Mesh removal? And if so, is that something that most plastic surgeons are comfortable with or No?
Speaker 2 (00:31:10):
So most of my most complex hernias are done in collaboration with one of my partners. It’s a general surgeon, especially if we’re going to have to be doing a bowel resection or going inside the abdomen to do something kind of more on the general surgery side. But the answer is absolutely, I think as part of my practice, I see lots of patients who either have infected Mesh or painful Mesh or some type of Mesh issue, and I certainly remove a fair amount of Mesh.
Speaker 1 (00:31:36):
And what’s the reason for removal as infection or pain or recurrence or reaction?
Speaker 2 (00:31:43):
Yes. So I think if I had to kind of break it down, I would say two thirds, it’s in the setting of recurrence. And I think the point that you made earlier I think was such a insightful remark about trying to remove the minimal amount of natural tissue. And that’s kind of my philosophy. If harm is going to be done from removing it, that exceeds the benefit of removing, I won’t. But usually the Mesh gets removed because of recurrence. Then less frequently is it removed for a Mesh infection or kind of chronic pain. So yeah.
Speaker 1 (00:32:15):
Yeah, it’s less of a problem. So in your specialty, you’re aware of breast implant illness. You may recall back in the, I think nineties or early two thousands, there was a lot of issues of maybe silicone is causing autoimmune disorder. So silicone breast implants were taken off the market by the F D A, the company, I forget the name, starts with a, went out of business or stopped making it. And then now there’s a resurgence of implants. But there is also an understanding of the ii, which is called Stands for Breast Implant Illness. In the hernia world, we’re a little bit slower to accept, maybe we should call it m i dunno, Mesh implant illness. We call it Asia syndrome or Schoenfeld syndrome, which Asia is an acronym. It stands for autoimmune or AUTOINFLAMMATORY syndrome induced by adjuvants. So it includes any type of implant reaction and it’s usually a syndrome of systemic symptoms. It could be anything from rashes and random areas and joint pain and swelling and so on. So what do you know about with the breast implant illness or even Mesh implants and what are they seeing in your specialty about this problem? Because I think it’s still not grasped by most practicing surgeons.
Speaker 2 (00:33:46):
Well, I think it’s a terrific question. I think that our society, the American Society of Plastic Surgery, which is our key society, I think is doing a lot of research in this area. Breast implant illness I think is a real thing. It’s a constellation of symptoms, a lot of research that’s kind of needed to further help us understand both what causes it, what are the kind of key symptoms and what are the best treatment options for patients. I think an important kind of disease state that’s kind of right up against B i is something that’s really known to be associated with implants and textured implants is called Anaplastic large cell lymphoma or A L C L. Yes. Which has recently kind of emerged as an associated disease state that’s related to textured implants, which is very, very specific. That textured surface on these silicone or saline implants causes inflammation over time. And that’s something that we’re learning a lot about and treating more and more and counseling our patients on. So I think we’ve learned a lot about that more to go. But B I think is a real thing and it’s certainly something we have to focus our research efforts on.
Speaker 1 (00:34:53):
Yeah, absolutely. And do you see a lot of patients in that respect?
Speaker 2 (00:35:00):
We do see a lot of patients with breast implant illness, and I think that after working patients up for autoimmune issues and really understanding their symptomatology, the treatment outcome that we predominantly offer is complete implant removal with removal of the capsule too. So on block capsulectomy and yeah, implant removal, send it to pathology. And oftentimes patients just have a tremendous relief of symptoms. And it’s hard to know if a component of that is the removal of the scar tissue or a component of that is the psychology of it, which I think we have to acknowledge is very important potentially in impacting the way patients feel after the implants removed. So yeah, that, that’s kind of been my approach.
Speaker 1 (00:35:40):
And have you ever seen anyone get autonomic dysfunction or a POTS like syndrome after due to implant illness
Speaker 2 (00:35:50):
Or No, I honestly, I haven’t.
Speaker 1 (00:35:53):
Haven’t either. Yeah. But I just spoke to a patient with that, so we’re trying to figure it out. I’ve seen people with pots, which is a postural orthos, orthostatic tachycardia syndrome. It’s like you drop your blood pressure and constantly have to hydrate and it’s a horrible problem in some patients. People who have pods I’ve seen are more likely to have an implant illness or Mesh reactions. I tend not to put Mesh in those patients if I know they have pods, but I’ve never seen the reverse where the implant illness creates a pot pots like syndrome. I guess it can. Do you treat patients with ehlers danlos syndrome?
Speaker 2 (00:36:37):
Treated a few, yeah. Very unique population with the genetic collagen apathy. That’s basically a fancy term for, they have kind of a genetic or a gene-based issue with how their collagen works and functions. Very tricky patients to fix a hernia. And definitely seeing some patients, cause we have a big Ehlers Danlos center at Penn typically when fixing those patients, I will use permanent Mesh in those folks. That’s kind of definitely a subgroup of patients that I would put permanent Mesh in to support them because of their known healing issues.
Speaker 1 (00:37:12):
So one of my tricks is for groin hernias, they often come in with pelvic floor dysfunction and they have a groin pain and they have either a hernia or a direct hernia or laxity or some combination of those. So instead of treating ’em like a regular inguinal hernia pair where we patch the hole, I do like a tummy tuck of their groin. I do a placation of their groin first and then I put the tissue repair, I put the Mesh repair because they need that extra tightness to get rid of their symptoms. It works really, really well. It’s like my trick on how to deal with. That’s awesome. Ehlers Danlos, I assume. Oh, do you have any tricks too for how you handle that? Well, so
Speaker 2 (00:38:02):
Not really. For the abdominal wall, I typically apply kind of my standard techniques, which is get the tissue closed. Usually if they need a release, they’ll get a release and I just put in permanent prostatic match and typically do kind of a wider Mesh overlap. So usually that would mean I would be doing a tar, as you mentioned, or a transverse release or releasing the backside of the abdominal wall and putting in a big piece of prostatic Mesh.
Speaker 1 (00:38:27):
Yeah, I feel like these patients are so loosey-goosey and stretchy that you have to tighten them much more when a normal patient would not tolerate that much tightness, but they would. So I have a personal patient question. So I have a patient with Ehlers Danlos and Mesh reaction. So we’ve tried everything every time she had Mesh in her, she had a horrible reaction, rashes, itching, joint pains, a lot of other symptoms. You take the Mesh out, she does great, but then her hernia comes back. So now she has incisional hernia, al hernias. My thought was to just do a huge application of everything, tighten her all up as a tissue repair. The hernias are not so big that she needs any component separation, but almost like a placation of everything and me, but I don’t feel comfortable doing that in a patient with Ehlers Danlos without putting some type of Mesh in her. But she’s reacted to every Mesh, so maybe it would have to be a biologic Mesh, even though I’ve had patients react to biologic Mesh too. So can
Speaker 2 (00:39:47):
You help me? It’s an interesting, yeah, it’s situation and obviously kind of a complex clinical situation. I like your idea. I think that when I think about hernia as a disease, I think that the most important thing, the determining factor I think is getting that tissue closed. And so I think that if you can get that tissue closed and get an attention free state, I think you’re going to really get the most bang for your buck in terms of what’s going to be most impactful in terms of the outcome you want. So I would say that might be the way to go is get attention free application and see how the patient does because not everyone needs Mesh. I think we’ve gotten so accustomed to putting Mesh in everyone because we’ve got great data that supported, but many people that get Mesh maybe don’t need it is we just don’t know. I mean that that’s just me being totally honest is that we do things because we have data, but maybe some people get meshed that don’t need it. Maybe some people that don’t get Mesh needed. It’s kind of still an area where we need kind of more, I think, knowledge.
Speaker 1 (00:40:51):
So she’s failed tissue repairs. But I wonder, at least for the incisional part, I wonder if a tissue repair with application on top using her own tissue as her biologic Mesh would work. Would you feel comfortable doing that in a Ehlers Danlos patient?
Speaker 2 (00:41:09):
I mean think it’s for the try. I think again, it’s going to be a function of your relationship with the patient, kind of talking them through. And it sounds like you have a wonderful relationship with this patient and you could talk with him or her. Yeah. Yeah, I think that it makes sense to me. I think it’s reasonable.
Speaker 1 (00:41:28):
Yeah, she’s been through so much. Okay, well eventually fix her and then we’ll have to celebrate going back to component separation there. So is the rate of surgical infection higher or the same than other hernias with component separation? And then do they need more complicated surgery for that or treatments for that than regular? That’s a question being asked.
Speaker 2 (00:41:56):
Yeah, it’s a great question. And I kind of alluded to this before, Shirin. I think that it’s really relates to can the necessity of doing the component separation I think basically signifies or it means that the patient has some type of complicated hernia. And so I think those individual patients are going to be higher risk for having complications. The act of doing the component separation when you kind of break it down involves releasing more tissue, taking things apart. So there’s some intrinsic risk to that. And so I think that the short answer to the question is that yes, it probably does increase the risk of complications to my knowledge. I don’t know that it actually increases the risk of an infection or what’s called the surgical site infection or SSI, but I think it does increase the risk of having events or issues with healing or fluid. Does that require more surgery? Not often, at least in my hands. And I think that the data and the literature really doesn’t have a clear answer because there’s not a trial where you compare complex hernias where you did or didn’t do it, at least to my knowledge, because I think it’s kind of become our standard. There’s not a randomized trial looking at do we do a release or we don’t do a release if the patient might need it. So we don’t have the answer.
Speaker 1 (00:43:16):
I have a question about belly buttons. Sure. Often I see patients that are told, oh, we can fix you, but then your belly button’s going to be gone. And I’m a big advocate of saving the belly button and that everyone should deserve to have inny. So it’s like my thing. But what are the situations in which you lose the belly button, even in your specialty? I’m sure you probably spend more time trying to save a belly button than the average general surgeon because you’re an aesthetically inclined. So for example, the lady that we presented the 16th centimeter diastasis recti, is she going to lose her belly button?
Speaker 2 (00:43:54):
A hundred percent.
Speaker 1 (00:43:55):
Speaker 2 (00:43:56):
Yeah. But why? What? So that’s a great question. Why? And I think that in order to reestablish the integrity of the abdominal wall, it’s basically fancy plastic surgeon talk for get her tissue back together. So she has normal function, you’re going to have to release tissue. She probably has, I mean this patient I have to imagine does not have an inny, I mean with that much diastasis, there’s probably total disruption of the features of the belly button. So for someone like this, if she came to my office, she would most likely get a full abdominalplasty with a Mesh based repair of the diastasis, and I would do what’s called a neo umbilical plasti. I would create a new belly button. The old one is just not going to be suitable. I often tell these patients that when you have to tighten the muscles that much, you’re kind of creating these competing forces. When you think about it, you tighten this much, the belly button gets kind of pulled in. Yes. Then you got to pull it back to the skin. So you create all these adverse factors affecting the blood supply to the belly button. I said, I typically say is it’s going to either have a healing issue or get infected. And so we typically just make a new one, which I think it’s not perfect, but I think that it still kind of recreates what you want to see.
Speaker 1 (00:45:16):
Yeah, I’ve seen those. They look okay if done correctly. There’s these different tricks. Yes, but okay, so is that because of belly buttons kind of floating or it’s because when you do the plication, the center of that placation will be so deep that you don’t really have a stalk to give you much of a belly button?
Speaker 2 (00:45:36):
Well, so there’s a couple of reasons. Can definitely, if you’re doing a vertical cut for this individual who has the big diastasis, you could leave the belly button attached to one side of the skin. The issue would then become after you raise the skin up and you tighten this, or maybe you’re doing this robotically, I’m not sure. All I can tell you is that if you placated, you’re going to have so much loose skin in the midline that it’s just not going to look right. You’re going to probably want to have to size that.
Speaker 1 (00:46:04):
Yeah. And you recommend, let’s say that, let’s say it’s a patient with a large incisional hernia and some loose skin. Do you recommend a two-stage of operation? Let’s get a good hernia repair done and then in a second stage see how you heal and then come back and we’ll take off all the extra skin or do do ’em both at the same time?
Speaker 2 (00:46:27):
We typically do ’em at the same time. And I think there’s a couple of reasons. Usually for most of my patients who have hernia, a lot of this is through their insurance company. And so we typically kind of bundle them together and rather than doing two different operations, insurance will oftentimes let us do them both at the same time. And then for the patient’s convenience, we typically do ’em at the same time. It does introduce a little bit of risk though because yeah, it’s two operations at once and so we tell patients there’s a higher risk of having a wound healing issue basically because of the cut that we’re going to make where we’re taking the skin off, which is more healing to do. And so we kind of tell patients that, but I really haven’t, at least to my knowledge, met a patient who has regretted doing, if I recommended it, the skin removal with the hernia repair people I think uniformly are very satisfied.
Speaker 1 (00:47:13):
Yeah, sure. No, I get it. I, I’ve liked to do that because I think that seems to be the right thing. The literature, like you said, does show that there’s a higher risk of complications, wound complications in doing, and I hate wound complication.
Speaker 2 (00:47:30):
Well that makes two of us.
Speaker 1 (00:47:34):
Another question, going back to Mesh reactions are mean, are immune suppressants ever considered for patients like that? For those who have reactions to Mesh, the very first paper that I remember reading was maybe 20 years ago or 25 years ago, about someone who may have had a Mesh reaction and they gave the patient cyclosporine, which is a very old school, very strong immune suppressant with so many risks to it. And I’ve seen other patients be on Humira and having good response to Humira for the immune Rives response against the Mesh. But that’s so much just take out the Mesh usually. So much more complications.
Speaker 2 (00:48:24):
What do you think? I would tend to agree with you on that. I think that the benefits of being on immunosuppression, I don’t know if they’re there for kind of what you’re talking about. Yeah, I’m not totally sure.
Speaker 1 (00:48:38):
So one question I get a lot is, so how do I know that my plastic surgeon is going to do a good job? They’re great in doing boobs and maybe a nose job, but in Beverly Hills, theoretically all the plastic surgeons here can do abdominal wall reconstruction. In fact, there’s a handful where they ask me to do the umbilical hernia as part of the tummy tuck. They don’t even want responsibility for the umbilical hernia part. And I do most of the abdominal wall hernia reconstruction in our hospital. It’s not done by our plastic surgeons. And part of it is they’re just busy doing other things. And so when our fellows go and interview, I remember one of our fellows when I interviewed and said, oh, so you do abdominal wall reconstruction? He’s like, yeah, and who doesn’t? And it’s like, Dr. Towfigh, I’m, she’s not a plastic surgeon. Why aren’t your plastic surgeons doing it? So it’s a little bit of a turf battle. But how does a patient know if they should be choosing a plastic surgeon or a general surgeon for their pre repair, how could they tell if the right surgeon to seek consultation with? What are your recommendations?
Speaker 2 (00:49:55):
Great question. I think that 90, I hate to say it to all my plastic surgery friends listening. I think it’s unusual that a plastic surgeon would be focused on or do a lot of hernia or complex hernia. Yeah, I think that one of a few people that as part of their practice does both regular hernia and complex hernia. That’s a plastic surgeon. That’s just kind of one aspect of my reconstructive and aesthetic practice. But I think for the most part, hernias are fixed by general surgeons and fixed quite well. I think that as we touched upon some of the benefits of having a plastic surgeon involved, I think that we kind of bring that aesthetic orientation to the fold. But I think your point’s a great point. The one that you just mentioned, Shirin, is that, you know, come in and fix the belly button hernias for some of your plastic surgeons. There’s such great opportunity for collaboration kind of across disciplines because we bring different skill and backgrounds and what’s better than having people with different backgrounds collaborate? I think it works
Speaker 1 (00:50:57):
Great. Oh, I love it. I love it. I work with all different surgeons. I love going the plastic surgeons and I actually, so I don’t just pop in, do the belly button leave. I stay for the entire operation. Oh,
Speaker 2 (00:51:08):
I love it. Oh, that’s
Speaker 1 (00:51:08):
Great. Love learning. And lemme tell you, one of my favorite plastic surgeons I trained when he was a general surgery resident, so he was my resident. He was a great resident and I think he’s so good that I refer a lot of my patients to him. And so we operate together. He is so obsessive compulsory that he won’t let me put any sutures in. Usually if you’re sharing a case, I’ll do one side. You do the other side at the end or something like that? No, I’m allowed to cut suture, that’s it. Oh
Speaker 2 (00:51:42):
Wow. Remind him who trained him. Yeah,
Speaker 1 (00:51:47):
Exactly. Exactly. I was the one who was his professor at one time, but Oh, that’s funny. That’s just a sign of a plastic surgeon that’s really kind of loves what they do and really good at what they do. But I love the collaboration. I stay for the entire op. They keep telling me, you can leave now. Nope. I love to stay for the whole thing and watch and see what you guys do. And I see some amazing stuff that you all do. The new belly button, different ways of making the belly button look good for a tummy tuck. Definitely. This whole idea of not using Mesh if you’re going to do a tummy tuck anyway. And then the breath stuff is really cool. Making the nipple smaller and breast lifts and all that. Very cool stuff.
Speaker 2 (00:52:33):
Speaker 1 (00:52:34):
Yeah. I work a lot with urology and gynecology too, and so didn’t used to understand a lot of what they did before. But you know, kind of learn and it helps you when you talk with your patients, oh, well this is what they’re going to do. Or most likely this. Or if they come to you and they say, yeah, I went to my plastic surgeon. They said X, Y, and Z. I’m like, okay, that does not sound right. Get a second opinion.
Speaker 2 (00:52:57):
Speaker 1 (00:52:59):
Speaker 2 (00:52:59):
It’s, it’s cool. It’s cool. It’s cool that you’re getting able to see what other specialists are doing because oftentimes we’re driving so fast in our own little lane and we don’t get a chance to look around and kind of see what’s happening with our colleagues around us. So I think that that’s such a useful thing to do. And I agree. I think it can bring some things into your practice that you can use to help your patients. I think it’s
Speaker 1 (00:53:24):
Terrific. Absolutely. So agree with that. And as a practicing surgeon, you often look as a resident, you operate with 50 different attendings, you learn 50 different ways of doing the same thing. And you pick and choose what you like for your own practice eventually. And that’s really a great way to learn when you’re in your own practice. Once you’re graduated, it’s not common to be in someone else’s operating room. So I do enjoy the collaboration with other surgeons. And I also, when I’m in between cases, I kind of peek into other people’s rooms, mostly for social visits. I say our or is like a country club. I go from room to, Hey guys, what you doing? Oh, what are you doing there? Oh, look at that. Or whatever the situation is. But I also like to see what other people do because you lose that interaction.
Speaker 2 (00:54:21):
That’s great. The be you’re like the buzzing around, cross polling, all the flowers. No, that’s great. That’s awesome.
Speaker 1 (00:54:28):
Although if they’re doing hernias, sometimes I don’t go in the room cause I feel like they think I’m peeking in their critiquing or something. So I try to be respectful. I don’t do that too much.
Speaker 2 (00:54:39):
Oh, that’s funny.
Speaker 1 (00:54:42):
Okay, we have more questions. It’s an honor and privilege to hear two great knowledgeable professors during this. Thank you so much. Okay. How do you, thank you. Yeah, that’s very nice. How do you decide whether to use monofilament or braided suture? One’s softer, one has less infection risk. These are amazing actually.
Speaker 2 (00:55:03):
Yeah, that’s a really insightful question. So braided suture is great because it handles really well. The two braided sutures that I’m familiar with that I use are Vicryl, which will oftentimes close the soft tissue with, or the skin and fat layers. That’s kind of a suture that’s braided. That kind of goes away pretty quickly. For the most part. I use monofilament suture, as you mentioned, slow absorbing monofilament suture is kind of what we use for fascia closure. That’s basically a suture that slowly goes away over time as your body gets stronger is kind of how I explain to patients. And that’s kind of what I use for the most part, for closing these hernia defects.
Speaker 1 (00:55:46):
Yeah, I agree. I feel that the more, the closer you are to the skin, the more lack I am to use the berated sutures so that they don’t feel the knot or the stiff end. But I do prefer the monofilament for the reasons. Explained. This question, I don’t understand too much. It says for component separation, do you need to dissect the intimate fascia under the anterior rectus sheath? And how does that compromise abdominal wall function?
Speaker 2 (00:56:19):
I dunno. Fascia is, yeah, yeah. I’m not totally sure, but maybe you
Speaker 1 (00:56:24):
Can explain how it compromises abdominal wall function when you start releasing different components.
Speaker 2 (00:56:30):
So I think that this is kind of emerging maybe as a theme is that, yeah, that you have to do a very precise release. And I think that in going to a surgeon, if you have a complex hernia, you really have to make sure he or she has the background and skillset to be able to do an advanced or complicated repair. And so when you do the release, you have to avoid what we call the neurovascular bundles are, that’s basically fancy word for the blood vessels and kind of nerves. And if you disrupt or injure any of those kind of sensory or motor nerves to the rectus muscle as you’re doing the release, so you’re in the wrong layer and you’re in the layer where the nerves are, you could potentially compromise the innervation or the signaling to the muscle, the rectus complex, which could lead to weakness or even a bulge or a change in the way the abdominal wall looks. Yeah. And we’ve seen examples at our meeting of patients who have ultimately had complications from component separation. So it’s a known risk, but I think going to someone who’s got good technique and a good skillset, I think is probably your best bet.
Speaker 1 (00:57:40):
Yeah, I totally agree with that. We’ve seen some botched component separations and redoing those are really difficult, especially if there’s nerve damage. There’s very little to do with denervated muscle. You can’t reverse it. Actually, let me ask you this. Can you reverse it because there is some nerve transfers that are done by plastic surgeons.
Speaker 2 (00:58:06):
Yeah, that’s a great question. So as an example, if you injure your arm and you severe your nerve, there’s so many different nerve techniques that you can use. You can repair the nerve, you can sew a new nerve to it to stimulate it. The issue with the abdominal wall is it’s not one nerve. It’s so many small nerve. And so when you disrupt multiple nerves, it would be a significant task to kind of coapt or bring back together all those small disrupted nerves. Now, I think to my knowledge, it hasn’t been done or hasn’t been done successfully. And there’s also kind of a critical window where the muscle, when it loses its nerve supply, undergoes these kind of structural changes where it’s no longer going to work after a period of time. And oftentimes there’s a big separation between the inciting event and then when you see the patient. And so it would be very difficult to do that. And it kind of brings me to this other point, is that what you’ve been talking about is that you go from a hernia problem to a dysfunction of the abdominal wall, which is almost like an unfixable problem. Now you might be able to get it so they don’t have a big bulging deformed abdominal wall, but there’s going to be a fundamental loss of function because of what’s, and so that’s got to be a conversation you have with your patients.
Speaker 1 (00:59:24):
Yeah, I agree. All right. This last question is intense, and I think it’s the most appropriate question to end on. Where do you think the future of abdominal wall reconstruction is going? Is it more robotics, more minimally invasive, or engineering of different Mesh materials?
Speaker 2 (00:59:41):
So this is a multiple choice type question. I pick
Speaker 1 (00:59:43):
One. What were your thoughts?
Speaker 2 (00:59:45):
Well, so I think that I’ll, I’ll be totally honest with you. This is going to be kind of a cliche answer, but I will tell you of those choices that I think about. But let me just answer. What I really believe in my heart of hearts is the right answers is us understanding what works best for each patient in which circumstance. I think learning over time, kind of what approach is going to get the best result for the patient. And that is such a broad statement that I mean to say is that will some patients be better served with a minimally invasive repair? Do some patients need a placation only in no Mesh? Do some patients really fundamentally benefit from having the skin removed? I think we’re not kind of really yet there with our evidence to understand this is the set of operations each patient should be offered.
Speaker 2 (01:00:32):
I think that robotics, I think, is here to stay. I think minimally invasive surgery is really super important to the field, and this is coming from a plastic surgeon who does basically everything open. And I think that technology has had a huge impact on the field. So I think we have to acknowledge the impact of robotics. Admittedly invasive surgery, it makes the recovery better. I think it can reduce pain. So many great things. The future of customized meshes could be a big deal. Kind of tailoring the Mesh for the individual patient and making it printing customized. Exactly. Making the Mesh for the patient. But I really do believe, I think that the biggest thing for the field is going to be to continue to get evidence or information that helps us make better decisions.
Speaker 1 (01:01:19):
Awesome. Yeah. I think we’re doing more better for patients. I
Speaker 2 (01:01:28):
Dunno. I think so. I think so too. I think do doing better for each of our patients than in any way we can. And I think that I’m always humbled by talking with other surgeons and kind of seeing other people’s approaches because what I realize is there’s so many different ways to get great results. That’s kind of a thing that I say when I talk to folks is that there’s not one way to do it. There’s not necessarily a right or wrong way. I think there’s a lot of good ways to get good results. And what’s fun is hearing other people’s perspectives.
Speaker 1 (01:01:56):
So true. Well, I really enjoyed this hour. Thank you for donating your time to this. We learned so much. We had tons of questions coming through. Thank you for your time. This ends Hernia Talk Live this Tuesday. I’ll make sure that I post the link to the YouTube so you can watch it again, share it with whoever you’d like to share it with. Thanks for those of you that joined us on Zoom and on Facebook, Dr. Towfigh. Follow me on Hernia doc at Hernia Doc on Twitter and Instagram. And again, thanks Dr. Fischer. It was great. Thank you so much. I appreciate. Take care. See you later or see you soon. Bye-bye. Take care. Bye-bye.