January 7, 2025 • 25 mins
We’re in a new era of obesity medicine, where innovative medications are transforming weight management.
Dr. Bass shares the latest updates since our last weight loss episode, including new brands, ongoing shortages, and insights into their long-term effects, like whether people regain weight after stopping these medications.
This wave of weight loss is also reshaping the aesthetics industry. Surgical procedures like liposuction and skin removal, along with non-surgical options like RF microneedling, are becoming increasingly popular as people refine their bodies after shedding pounds.
Find out:
-
Are compounded medications safe?
-
How can you ensure your prescriptions come from a reliable pharmacy?
-
Why does losing muscle instead of fat pose serious risks?
-
How do these advancements impact bariatric surgery’s role?
-
Do studies confirm rebound weight gain after stopping medication?
-
What are Dr. Bass’ predictions for the future of weight loss medicine?
Links
- Learn more about tummy tuck and liposuction
- Learn more about Ultherapy and SculpSure
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Welcome to Park AvenuePlastic Surgery Class,
the podcast where we explore controversiesand breaking issues in plastic
surgery. I'm your co-host, Summer Hardy,
a clinical assistant at BassPlastic Surgery in New York City.
I'm excited to be here with Dr. LawrenceBass Park Avenue plastic surgeon,
educator, and technology innovator.
(00:22):
Today's episode is WeightLoss Medications and Beyond.
You've talked about this topic beforeon the podcast, haven't you, Dr. Bass?
That's right, Summer. I have.
But here we are again. So theremust be some new information.
What are the updates?
Our last episode on thistopic released in November of
(00:43):
2023,
right at the point whereFDA approved Zepbound.
Today, I'd like to update on newmedications that may be coming,
medication shortages,
and what we've learned about how thesemedications performed since our last
episode.
Okay, let's take thoseone at a time. First,
(01:06):
what have we learned about the amount ofweight loss and the stability after the
medication?
So just to back up for a second,
these are a group of medicationswhich stimulate different
receptors.
The main group stimulateglucagon-like peptide one
receptors and
(01:28):
Mounjaro or Zepboundalso stimulates a second
receptor,
glucose-dependent
insulinotropic
polypeptide
So GLP-1 and GIP for short.
So those medications, andthese are the main ones.
And we talked in previousepisodes about some of the others.
(01:51):
That main one is semaglutide.That's the generic name,
which goes by the brand name,
Ozempic for diabetes treatment and Wegovy
for weight loss treatment.
And it has specific FDA approvalsfor each of those things in certain
circumstances.
(02:12):
And the second main medicationnowadays is tirzepatide,
which goes by the brand nameMounjaro for diabetes treatment
and Zepbound for weightloss. And on average,
15% of your weight can be lost on Wegovy
(02:32):
and 20% on Zepbound in a typical
six month course of medication.So a
15% weight loss if you weigh 200 pounds,
puts you down to 170 pound anda 20% weight loss would put
you to 160 pounds. That'squite a lot of weight loss.
(02:54):
That's very difficultto do with diet alone.
But we've learned some thingsabout these medications, as I said,
since we last ran an episode,and this isn't the final answer,
but this is an update on wherethings stand now. So as I said,
you can lose up to 15%body weight on a course
(03:18):
of Wegovy, Ozempic,
but sometimes it's less thanthat. And not only that,
but about 15% of patientscan be non-responders.
So they take the medicationand they don't lose weight.
So that's the bad news.
(03:38):
The good news is people who are takingmedications for weight loss seem to do
better at losing weight than peoplewho are taking them for diabetes.
But I pointed out very clearlyon the previous episode,
and we now have more study data thatwe didn't know how much rebound we were
going to get when yougo off the medication.
(04:01):
But we now have some study datathat answers that question.
And that's a big deal because thinkabout it, when you go on a diet,
sometimes it's reallyhard to lose the weight,
but even if you succeed in losing weight,
you often rebound back to where youstarted when you go off the diet.
That doesn't happen overnight, butover a few months it certainly does.
(04:24):
And so in one study that lookedat this issue with semaglutide,
the medication in Ozempic,
in patients who weretrying to lose weight,
because that's a different study groupthan patients who have diabetes who stay
on the medication to managetheir diabetes. So this group,
on average lost the predicted amount of
(04:49):
weight on average in that 15% range.
It was actually 17% inthis particular study,
but about two thirds of thatweight came back within a year
after stopping the medication.
So that tells us that wemay need to stay on it or we
(05:10):
may need some kind of amaintenance dose and where
we need more studies toconfirm this kind of result.
But it's been clear that there'ssome rebound when going off the
medication.
So given the shortage of thepharmaceutical manufactured product,
what are the alternatives?
(05:32):
As I mentioned in terms of thingsI wanted to put in this update,
I did want to discuss shortagebecause a lot of people in
the United States of America andaround the world have non-insulin
dependent diabetes,
and a lot of them arenow being treated with
Ozempic or Mounjaro.
(05:54):
And there are some othermedications being used as well,
but have become very popular.
And that alone has created a shortage.
And then added to that isthe need for more of the
medication for treatment of obesity.
And on top of that,
some people who are not obese butare having trouble losing weight are
(06:16):
taking the medication as well.
So there is a shortage and it canbe difficult to get a supply of the
medication. The medicationis also quite expensive.
A thousand dollars a month is atypical number can be as high as
$1500. And even if yourinsurance is covering it,
(06:36):
you may be paying several hundreddollars a month, three to five hundred,
to be on these medications.
And that's a big deal if you thinkabout that cost at the end of the year.
So one of the alternativesis to obtain the same
kind of medications, notfrom the main manufacturers,
(06:57):
Eli Lilly and Novo Nordisk,
but from compoundingpharmacies that make the same
medication, but notthrough the FDA-approved,
FDA clinical trial studied process.
Is compounding safe?
So that's the key question becauseI just said it's not that FDA
(07:22):
process in terms of everything about the
medication.
And the FDA approved medicationgoes through typically half a
dozen to a dozen clinicaltrials before it's FDA approved
and has all kinds of studies done.
And the FDA looks at everyphase of the production
(07:44):
of that medication, the distribution,
the plants that it's made in or inspected
by FDA and so forth.
So that's our best assurance of quality
compounding pharmacies orpharmacies that make medications.
(08:04):
And in particular,
this is used in circumstances likethis where there's a shortage.
So they make essentially ageneric equivalent. But again,
they're not even a genericpharmaceutical manufacturer.
They're a pharmacy and thatsimplifies who they are
because they're bigger thanyour neighborhood pharmacy.
(08:30):
But they're preparing a medication for
use by prescription
just like other prescription medications
where there's a shortage andyou can't readily get it from a
regular pharmacy.Now it's kind of a little more complicated
(08:52):
than that because if you aregetting a medication by mail order,
that may not even be comingfrom a compounding pharmacy.
It's not clear where it's coming from.
If you're getting a medicationwithout a prescription,
you should be highly suspicious thatthis may not be a legitimate pharmacy.
So there are all kinds of medicationsbecause of the popularity of
(09:15):
Ozempic and Mounjaro that purport to be
generic equivalents butare really counterfeit.
If you're being treated by aphysician in a weight loss program
in the physician's practice,
then it's their job to do the duediligence if they're treating you with the
(09:36):
medication of getting itfrom an appropriate pharmacy.
And there are different categoriesof compounding pharmacies.
So there are 503A pharmacies and 503B,
503B pharmacies are actually inspected by
FDA and FDA holds themto good manufacturing
(09:57):
practices the same way itholds pharmaceutical companies.
And so there's moreoversight of 503B pharmacies.
But given the shortageof these medications,
the compounding route offers a greater
supply to help us meet theclinical needs of patients
(10:19):
until it's more readily availableor more price approachable.
Okay. So what do you see forthe future of weight loss?
So likely,
this is me looking in the crystal ball.
And so we can never saywhat FDA is going to do.
They're going to base that on theclinical data that they receive,
(10:40):
and we can't say for sure howclinical studies are going
to work out,
but it's pretty clear thata few things are likely and
likely very soon. And when I say soon,
I mean sometime in the next year,
not talking about something that'sfive or 10 years down the line,
(11:01):
but in the next year ornext two years at the most,
we'll almost certainly have instead of
injectable medications,
because currently Ozempic and Mounjaro are
injected once a week,
we will likely have oralversions of the GLP-1
(11:23):
receptors.
We will likely have medicationsthat target other receptors besides
GLP-1.
And the biggest thing that Ithink is going to be the focus
of obesity treatment in the future
is it's going to beabout fat loss more than
(11:45):
weight loss.Currently,
these medications are demonstrating intheir clinical studies that when someone
stands on the scale,
the number goes from a higher numberto a lower number, you've lost weight,
and that's a good thing. We alwaysfeel happy when we lose weight,
but what we really want to lose is fat.
(12:10):
And there's a lot of reasonswhy we don't like fat.
We don't like fat because we don'tlike how we look in clothing.
We can't get into the clothing that weused to get into maybe if we've gained
weight. Fat also,
metabolically drives illnesseslike hypertension and
diabetes,
which are two massively common chronicillnesses in the United States.
(12:34):
So there are a lot of reasonswhy we don't like fat,
but we'd like to keep ourmuscle. And in reality,
when we go on a diet, forexample, and lose weight,
we lose some fat and some muscle,and we're hoping it's mostly fat,
but muscle is hard toget back, and as you age,
(12:55):
we naturally lose some muscle anyway.
This is a condition called sarcopenia,
which just means a low amount ofmuscle because we're losing it with
aging and we don't want toamplify that as part of weight
loss programs.
So likely in the future there'llbe a focus on figuring out
(13:19):
how to help people lose fat and preserve
muscle.
Where does all this progress withpharmaceuticals leave bariatric surgery?
So we discussed on the last podcast
that a few years ago,
the indications for bariatricsurgery were greatly expanded
(13:43):
and there was a refinementand how bariatric
surgery was done many years agowhen this was mostly converted
about 20 years ago,
a little more to being donelaparoscopically instead of with
open surgery.
So that was a big growthand expansion for bariatric
(14:05):
surgery and to finallyredefine definitions of who was
appropriate for bariatric surgery.
That hadn't changed sincesometime in the 1990s,
but at this time,
these non-invasive pharmacologic options
(14:26):
really despite some side effects,
and we talked about thoseon the last podcast,
still don't have the major life
impact of having a surgerylike bariatric surgery.
And so these seemingly,despite any disadvantages,
(14:48):
are much more popular bothwith physicians and with
patients.
So there's likely to be areduced role for bariatric
surgery, althoughcertainly not eliminated.
And currently the amount of weightloss typically with bariatric
surgery remains greater than theamount of weight loss that could be
(15:12):
expected on averagewith these medications.
Despite that there's a reboundrate with bariatric surgery,
just like with these medications.
So you don't keep a hundredpercent of the weight loss off,
but
we don't tend to see asmany non-responders as you
(15:36):
see with something like Ozempicwhere we said there was that
15% non-responder rate.
Now that you've explainedbariatric surgery,
where does that leave plasticsurgery options like liposuction?
So okay,
now we get to go back to myfield where we're talking about
(15:56):
beauty and plastic surgerybecause it's important to
realize that weight loss is about health.
It's not about body contouring. Of course,
if we lose a lot ofweight or smaller thinner,
we like that shape better.It contributes to our beauty,
(16:17):
but it's really a healthissue in these medications or
our proof for treatment of obesitywhere the amount of excess weight
is at a level where itimpacts health and wellbeing.
So there's a lot of
(16:37):
lessons in body contouringthat have grown out
of the bariatric surgery past 20 years.
So
we treat people who'velost a lot of weight
with a range of plastic surgerytreatments because there are
(17:00):
unfinished business, so to speak,
even after you've lost amassive amount of weight.
And all of the plastic surgery options are
still appropriate,
preferable for certain body shaping
applications.If you're already at a normal weight,
(17:21):
if you're at a normal or maybeeven an ideal body weight,
you don't want to lose a lot of weightbecause now you're losing muscle
and not much fat with it.
So that hurts you more than it helps you.
And there are certain areas of the bodythat just tend to have bulges that are
formed by fat that don'trespond well to diet and
(17:44):
exercise. Love handles,
the outer thigh area orsaddle bags are two typical
areas that just don't dietand exercise off very well.
So even despite being at ideal weight,
there are many people with fatty contoursthere that they don't like and that
don't show well in clothing. So that'sideally what liposuction is for.
(18:06):
And to a lesser extent, the nonsurgicaloptions. If the area is small,
things like CoolSculpting and SculpSure
can knock down those areas a little bit.But the weight
loss patients likewiseare still going to need
(18:27):
some shape adjustment.
There may be residual shapeseven if they lose weight going on
Ozempic or Ozempic-like medications.
So there's still a role forliposuction, and in fact,
if people have gotten goods, theyoften want to finish the job.
(18:47):
And so in fact, on some level,
it amplifies the volume ofthose procedures going forward.
The other issue that ariseswhen we start to think about
significant weight lossis loose skin and the
skin will tailor to an extentwhen you diet and when you have
(19:10):
liposuction. But ifyou lose enough weight,
there is substantialextra skin. And again,
this is a lesson that was known,
but that a great deal of experiencewas gained after bariatric
surgery became more mainstream.
And many patients who have hadmassive weight loss need skin excision
(19:32):
procedures, skin removed from arms,
tummy area, chest, waist, thighs,
and sometimes again withmore modest weight loss,
that can be dealt withwithout actual surgical skin
excision.But with energy devices like RF
(19:55):
microneedling, Ultherapy, TempSure,
things that sculpt,
things that put energy intothe skin and stimulate some
smoothing, tightening,remodeling of that skin.
And there are even injectabletechniques like Hyperdiluted Radiesse
where a very diluted filler that is what's
(20:18):
called an active dermal matrix filler,
one that stimulates collagenproduction in the skin,
can help stimulate a littlesmoothing of skin that's
modestly loose.
So all of those thingsare also part of what's
needed after weight lossand also as a part of aging,
(20:42):
and that is going to havea growing role as these
medications become more popular.
Before we wrap up this episode,
can you share any important takeawayswith our listeners, Dr. Bass?
We're at the dawn of a new erawhere pharmacologic approaches
are at the forefront ofobesity medicine as well as
(21:06):
the forefront of weight management.Even for non-obese individuals,
diet and exercise are not done.
They're still an importantpart of health and wellbeing.
And bariatric surgerylikewise, is not done.
However,
every time there's a paradigmshift or a major new innovation,
(21:30):
all of the options most ofthe time stay on the table,
but the pie gets slicedup a little differently.
The role for each optionshifts and adjusts.
So all of these thingsare still important.
A multimodality approachprobably gets you there best.
(21:50):
That's very clear with theseGLP-1 medications that using
the medication incombination with some dietary
management and an active lifestyle greatly
improves the chances that you'regoing to achieve your goals.
So body contouring and skin treatments,
(22:12):
the plastic surgery sideof it are not really weight
loss themselves.They're part of the beauty or appearance
side of it, but they'regoing to play an increase,
not a decreased role tofinalize and perfect the
changes that are startedby the weight loss,
(22:33):
whatever modality you're pursuing,
and that's the same as it ever was.
We've already seen this in the massiveweight loss patients after bariatric
surgery.
And the same will be true with themore moderate weight loss that's
seen with these new GLP-1 medications.
(22:53):
The biggest unknown is the mixof surgical and nonsurgical
treatments for chasing theseresidual unwanted shapes.
The bulges of fat and the love handles,
the saddle bags and the loosercrepey skin that remain after weight
loss. So this was theoriginal role of liposuction,
(23:14):
contouring unwanted shapes madeof fat in people at ideal body
weight,
but it's in recent yearsplayed a growing role
in people after weight loss as well.And both
categories,
the surgical and nonsurgical are going to
(23:34):
have a role in these post weight loss
patients again, however theymanaged to lose the weight.
So selecting the best optionrequires that relationship with an
experienced plastic surgeon who's upto date on the latest capabilities and
technologies and can put togethera program for you to get to
(23:57):
your best appearance after weight loss.
As you can see, this areais undergoing rapid change.
We're learning a lot ina short amount of time,
and this will continue to evolveas we look increasingly at
muscle maintenance and restoration,
both in aging patients andin patients who have lost
(24:21):
a lot of weight.
The future is going to befocused on fat loss with muscle
maintenance.
Wow,
those are really interesting points thatI didn't think about when looking at
the number on my scale.Thank you, Dr. Bass,
for sharing your expertise andupdating us on this rapidly changing
subject. Thank you for listening tothe Park Avenue Plastic Surgery Class
(24:45):
podcast. Follow us on Apple Podcasts,
write a review and sharethe show with your friends.
Be sure to join us next time to avoidmissing all the great content that is
coming your way. If you want tocontact us with comments or questions,
we'd love to hear from you,
send us an email atpodcast@drbass.net or DM us on
Instagram @drbassnyc.
Welcome to Park AvenuePlastic Surgery Class,
the podcast where we explore controversiesand breaking issues in plastic
surgery. I'm your co-host, Summer Hardy,
a clinical assistant at BassPlastic Surgery in New York City.
I'm excited to be here with Dr. LawrenceBass Park Avenue plastic surgeon,
educator, and technology innovator.
(00:22):
Today's episode is WeightLoss Medications and Beyond.
You've talked about this topic beforeon the podcast, haven't you, Dr. Bass?
That's right, Summer. I have.
But here we are again. So theremust be some new information.
What are the updates?
Our last episode on thistopic released in November of
(00:43):
2023,
right at the point whereFDA approved Zepbound.
Today, I'd like to update on newmedications that may be coming,
medication shortages,
and what we've learned about how thesemedications performed since our last
episode.
Okay, let's take thoseone at a time. First,
(01:06):
what have we learned about the amount ofweight loss and the stability after the
medication?
So just to back up for a second,
these are a group of medicationswhich stimulate different
receptors.
The main group stimulateglucagon-like peptide one
receptors and
(01:28):
Mounjaro or Zepboundalso stimulates a second
receptor,
glucose-dependent
insulinotropic
polypeptide
So GLP-1 and GIP for short.
So those medications, andthese are the main ones.
And we talked in previousepisodes about some of the others.
(01:51):
That main one is semaglutide.That's the generic name,
which goes by the brand name,
Ozempic for diabetes treatment and Wegovy
for weight loss treatment.
And it has specific FDA approvalsfor each of those things in certain
circumstances.
(02:12):
And the second main medicationnowadays is tirzepatide,
which goes by the brand nameMounjaro for diabetes treatment
and Zepbound for weightloss. And on average,
15% of your weight can be lost on Wegovy
(02:32):
and 20% on Zepbound in a typical
six month course of medication.So a
15% weight loss if you weigh 200 pounds,
puts you down to 170 pound anda 20% weight loss would put
you to 160 pounds. That'squite a lot of weight loss.
(02:54):
That's very difficultto do with diet alone.
But we've learned some thingsabout these medications, as I said,
since we last ran an episode,and this isn't the final answer,
but this is an update on wherethings stand now. So as I said,
you can lose up to 15%body weight on a course
(03:18):
of Wegovy, Ozempic,
but sometimes it's less thanthat. And not only that,
but about 15% of patientscan be non-responders.
So they take the medicationand they don't lose weight.
So that's the bad news.
(03:38):
The good news is people who are takingmedications for weight loss seem to do
better at losing weight than peoplewho are taking them for diabetes.
But I pointed out very clearlyon the previous episode,
and we now have more study data thatwe didn't know how much rebound we were
going to get when yougo off the medication.
(04:01):
But we now have some study datathat answers that question.
And that's a big deal because thinkabout it, when you go on a diet,
sometimes it's reallyhard to lose the weight,
but even if you succeed in losing weight,
you often rebound back to where youstarted when you go off the diet.
That doesn't happen overnight, butover a few months it certainly does.
(04:24):
And so in one study that lookedat this issue with semaglutide,
the medication in Ozempic,
in patients who weretrying to lose weight,
because that's a different study groupthan patients who have diabetes who stay
on the medication to managetheir diabetes. So this group,
on average lost the predicted amount of
(04:49):
weight on average in that 15% range.
It was actually 17% inthis particular study,
but about two thirds of thatweight came back within a year
after stopping the medication.
So that tells us that wemay need to stay on it or we
(05:10):
may need some kind of amaintenance dose and where
we need more studies toconfirm this kind of result.
But it's been clear that there'ssome rebound when going off the
medication.
So given the shortage of thepharmaceutical manufactured product,
what are the alternatives?
(05:32):
As I mentioned in terms of thingsI wanted to put in this update,
I did want to discuss shortagebecause a lot of people in
the United States of America andaround the world have non-insulin
dependent diabetes,
and a lot of them arenow being treated with
Ozempic or Mounjaro.
(05:54):
And there are some othermedications being used as well,
but have become very popular.
And that alone has created a shortage.
And then added to that isthe need for more of the
medication for treatment of obesity.
And on top of that,
some people who are not obese butare having trouble losing weight are
(06:16):
taking the medication as well.
So there is a shortage and it canbe difficult to get a supply of the
medication. The medicationis also quite expensive.
A thousand dollars a month is atypical number can be as high as
$1500. And even if yourinsurance is covering it,
(06:36):
you may be paying several hundreddollars a month, three to five hundred,
to be on these medications.
And that's a big deal if you thinkabout that cost at the end of the year.
So one of the alternativesis to obtain the same
kind of medications, notfrom the main manufacturers,
(06:57):
Eli Lilly and Novo Nordisk,
but from compoundingpharmacies that make the same
medication, but notthrough the FDA-approved,
FDA clinical trial studied process.
Is compounding safe?
So that's the key question becauseI just said it's not that FDA
(07:22):
process in terms of everything about the
medication.
And the FDA approved medicationgoes through typically half a
dozen to a dozen clinicaltrials before it's FDA approved
and has all kinds of studies done.
And the FDA looks at everyphase of the production
(07:44):
of that medication, the distribution,
the plants that it's made in or inspected
by FDA and so forth.
So that's our best assurance of quality
compounding pharmacies orpharmacies that make medications.
(08:04):
And in particular,
this is used in circumstances likethis where there's a shortage.
So they make essentially ageneric equivalent. But again,
they're not even a genericpharmaceutical manufacturer.
They're a pharmacy and thatsimplifies who they are
because they're bigger thanyour neighborhood pharmacy.
(08:30):
But they're preparing a medication for
use by prescription
just like other prescription medications
where there's a shortage andyou can't readily get it from a
regular pharmacy.Now it's kind of a little more complicated
(08:52):
than that because if you aregetting a medication by mail order,
that may not even be comingfrom a compounding pharmacy.
It's not clear where it's coming from.
If you're getting a medicationwithout a prescription,
you should be highly suspicious thatthis may not be a legitimate pharmacy.
So there are all kinds of medicationsbecause of the popularity of
(09:15):
Ozempic and Mounjaro that purport to be
generic equivalents butare really counterfeit.
If you're being treated by aphysician in a weight loss program
in the physician's practice,
then it's their job to do the duediligence if they're treating you with the
(09:36):
medication of getting itfrom an appropriate pharmacy.
And there are different categoriesof compounding pharmacies.
So there are 503A pharmacies and 503B,
503B pharmacies are actually inspected by
FDA and FDA holds themto good manufacturing
(09:57):
practices the same way itholds pharmaceutical companies.
And so there's moreoversight of 503B pharmacies.
But given the shortageof these medications,
the compounding route offers a greater
supply to help us meet theclinical needs of patients
(10:19):
until it's more readily availableor more price approachable.
Okay. So what do you see forthe future of weight loss?
So likely,
this is me looking in the crystal ball.
And so we can never saywhat FDA is going to do.
They're going to base that on theclinical data that they receive,
(10:40):
and we can't say for sure howclinical studies are going
to work out,
but it's pretty clear thata few things are likely and
likely very soon. And when I say soon,
I mean sometime in the next year,
not talking about something that'sfive or 10 years down the line,
(11:01):
but in the next year ornext two years at the most,
we'll almost certainly have instead of
injectable medications,
because currently Ozempic and Mounjaro are
injected once a week,
we will likely have oralversions of the GLP-1
(11:23):
receptors.
We will likely have medicationsthat target other receptors besides
GLP-1.
And the biggest thing that Ithink is going to be the focus
of obesity treatment in the future
is it's going to beabout fat loss more than
(11:45):
weight loss.Currently,
these medications are demonstrating intheir clinical studies that when someone
stands on the scale,
the number goes from a higher numberto a lower number, you've lost weight,
and that's a good thing. We alwaysfeel happy when we lose weight,
but what we really want to lose is fat.
(12:10):
And there's a lot of reasonswhy we don't like fat.
We don't like fat because we don'tlike how we look in clothing.
We can't get into the clothing that weused to get into maybe if we've gained
weight. Fat also,
metabolically drives illnesseslike hypertension and
diabetes,
which are two massively common chronicillnesses in the United States.
(12:34):
So there are a lot of reasonswhy we don't like fat,
but we'd like to keep ourmuscle. And in reality,
when we go on a diet, forexample, and lose weight,
we lose some fat and some muscle,and we're hoping it's mostly fat,
but muscle is hard toget back, and as you age,
(12:55):
we naturally lose some muscle anyway.
This is a condition called sarcopenia,
which just means a low amount ofmuscle because we're losing it with
aging and we don't want toamplify that as part of weight
loss programs.
So likely in the future there'llbe a focus on figuring out
(13:19):
how to help people lose fat and preserve
muscle.
Where does all this progress withpharmaceuticals leave bariatric surgery?
So we discussed on the last podcast
that a few years ago,
the indications for bariatricsurgery were greatly expanded
(13:43):
and there was a refinementand how bariatric
surgery was done many years agowhen this was mostly converted
about 20 years ago,
a little more to being donelaparoscopically instead of with
open surgery.
So that was a big growthand expansion for bariatric
(14:05):
surgery and to finallyredefine definitions of who was
appropriate for bariatric surgery.
That hadn't changed sincesometime in the 1990s,
but at this time,
these non-invasive pharmacologic options
(14:26):
really despite some side effects,
and we talked about thoseon the last podcast,
still don't have the major life
impact of having a surgerylike bariatric surgery.
And so these seemingly,despite any disadvantages,
(14:48):
are much more popular bothwith physicians and with
patients.
So there's likely to be areduced role for bariatric
surgery, althoughcertainly not eliminated.
And currently the amount of weightloss typically with bariatric
surgery remains greater than theamount of weight loss that could be
(15:12):
expected on averagewith these medications.
Despite that there's a reboundrate with bariatric surgery,
just like with these medications.
So you don't keep a hundredpercent of the weight loss off,
but
we don't tend to see asmany non-responders as you
(15:36):
see with something like Ozempicwhere we said there was that
15% non-responder rate.
Now that you've explainedbariatric surgery,
where does that leave plasticsurgery options like liposuction?
So okay,
now we get to go back to myfield where we're talking about
(15:56):
beauty and plastic surgerybecause it's important to
realize that weight loss is about health.
It's not about body contouring. Of course,
if we lose a lot ofweight or smaller thinner,
we like that shape better.It contributes to our beauty,
(16:17):
but it's really a healthissue in these medications or
our proof for treatment of obesitywhere the amount of excess weight
is at a level where itimpacts health and wellbeing.
So there's a lot of
(16:37):
lessons in body contouringthat have grown out
of the bariatric surgery past 20 years.
So
we treat people who'velost a lot of weight
with a range of plastic surgerytreatments because there are
(17:00):
unfinished business, so to speak,
even after you've lost amassive amount of weight.
And all of the plastic surgery options are
still appropriate,
preferable for certain body shaping
applications.If you're already at a normal weight,
(17:21):
if you're at a normal or maybeeven an ideal body weight,
you don't want to lose a lot of weightbecause now you're losing muscle
and not much fat with it.
So that hurts you more than it helps you.
And there are certain areas of the bodythat just tend to have bulges that are
formed by fat that don'trespond well to diet and
(17:44):
exercise. Love handles,
the outer thigh area orsaddle bags are two typical
areas that just don't dietand exercise off very well.
So even despite being at ideal weight,
there are many people with fatty contoursthere that they don't like and that
don't show well in clothing. So that'sideally what liposuction is for.
(18:06):
And to a lesser extent, the nonsurgicaloptions. If the area is small,
things like CoolSculpting and SculpSure
can knock down those areas a little bit.But the weight
loss patients likewiseare still going to need
(18:27):
some shape adjustment.
There may be residual shapeseven if they lose weight going on
Ozempic or Ozempic-like medications.
So there's still a role forliposuction, and in fact,
if people have gotten goods, theyoften want to finish the job.
(18:47):
And so in fact, on some level,
it amplifies the volume ofthose procedures going forward.
The other issue that ariseswhen we start to think about
significant weight lossis loose skin and the
skin will tailor to an extentwhen you diet and when you have
(19:10):
liposuction. But ifyou lose enough weight,
there is substantialextra skin. And again,
this is a lesson that was known,
but that a great deal of experiencewas gained after bariatric
surgery became more mainstream.
And many patients who have hadmassive weight loss need skin excision
(19:32):
procedures, skin removed from arms,
tummy area, chest, waist, thighs,
and sometimes again withmore modest weight loss,
that can be dealt withwithout actual surgical skin
excision.But with energy devices like RF
(19:55):
microneedling, Ultherapy, TempSure,
things that sculpt,
things that put energy intothe skin and stimulate some
smoothing, tightening,remodeling of that skin.
And there are even injectabletechniques like Hyperdiluted Radiesse
where a very diluted filler that is what's
(20:18):
called an active dermal matrix filler,
one that stimulates collagenproduction in the skin,
can help stimulate a littlesmoothing of skin that's
modestly loose.
So all of those thingsare also part of what's
needed after weight lossand also as a part of aging,
(20:42):
and that is going to havea growing role as these
medications become more popular.
Before we wrap up this episode,
can you share any important takeawayswith our listeners, Dr. Bass?
We're at the dawn of a new erawhere pharmacologic approaches
are at the forefront ofobesity medicine as well as
(21:06):
the forefront of weight management.Even for non-obese individuals,
diet and exercise are not done.
They're still an importantpart of health and wellbeing.
And bariatric surgerylikewise, is not done.
However,
every time there's a paradigmshift or a major new innovation,
(21:30):
all of the options most ofthe time stay on the table,
but the pie gets slicedup a little differently.
The role for each optionshifts and adjusts.
So all of these thingsare still important.
A multimodality approachprobably gets you there best.
(21:50):
That's very clear with theseGLP-1 medications that using
the medication incombination with some dietary
management and an active lifestyle greatly
improves the chances that you'regoing to achieve your goals.
So body contouring and skin treatments,
(22:12):
the plastic surgery sideof it are not really weight
loss themselves.They're part of the beauty or appearance
side of it, but they'regoing to play an increase,
not a decreased role tofinalize and perfect the
changes that are startedby the weight loss,
(22:33):
whatever modality you're pursuing,
and that's the same as it ever was.
We've already seen this in the massiveweight loss patients after bariatric
surgery.
And the same will be true with themore moderate weight loss that's
seen with these new GLP-1 medications.
(22:53):
The biggest unknown is the mixof surgical and nonsurgical
treatments for chasing theseresidual unwanted shapes.
The bulges of fat and the love handles,
the saddle bags and the loosercrepey skin that remain after weight
loss. So this was theoriginal role of liposuction,
(23:14):
contouring unwanted shapes madeof fat in people at ideal body
weight,
but it's in recent yearsplayed a growing role
in people after weight loss as well.And both
categories,
the surgical and nonsurgical are going to
(23:34):
have a role in these post weight loss
patients again, however theymanaged to lose the weight.
So selecting the best optionrequires that relationship with an
experienced plastic surgeon who's upto date on the latest capabilities and
technologies and can put togethera program for you to get to
(23:57):
your best appearance after weight loss.
As you can see, this areais undergoing rapid change.
We're learning a lot ina short amount of time,
and this will continue to evolveas we look increasingly at
muscle maintenance and restoration,
both in aging patients andin patients who have lost
(24:21):
a lot of weight.
The future is going to befocused on fat loss with muscle
maintenance.
Wow,
those are really interesting points thatI didn't think about when looking at
the number on my scale.Thank you, Dr. Bass,
for sharing your expertise andupdating us on this rapidly changing
subject. Thank you for listening tothe Park Avenue Plastic Surgery Class
(24:45):
podcast. Follow us on Apple Podcasts,
write a review and sharethe show with your friends.
Be sure to join us next time to avoidmissing all the great content that is
coming your way. If you want tocontact us with comments or questions,
we'd love to hear from you,
send us an email atpodcast@drbass.net or DM us on
Instagram @drbassnyc.
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