67: Why Thyroid Eye Disease Is So Often Missed - The Clear Path From Diagnosis to Real Treatment with Dr. Sean Paul

I think a lot of people are looking for a shortcut when it comes to aesthetic eye treatments. And I think people really want long term results if they can get them. There's no permanent fix, but if you can reset the clock five to 10 years and it can last 10 to 20 years, I think they're pretty happy. And then creating a good maintenance plan. I think skin care goes under recognized in a surgeon's eyes. So you want to go to a practice that focuses on both the skin care and what you can do to maintain your results.

Welcome to Modern Thyroid and wellness, where we talk about all things thyroid, hormones, and honestly, anything that can help you live a longer, more vibrant life. Doctor Sean Paul, thank you so much for being here. Welcome to Modern Thyroid and Wellness.

Thanks for having me.

Yeah, so I figured we are going to talk about all things thyroid eye disease and everything related to that surgery, all the options, all the areas of expertise. But I wanted to start with just a basic definition. Tell listeners what thyroid eye disease is and how it can impact your eyes and what that looks like.

Yeah, it's a great question. So I think the most important thing to know is thyroid eye disease is really an autoimmune orbitopathy. And orbitopathy to me means inflammation of the orbital tissues. That includes everything around the eyeball and everything in the socket that is behind the orbital bones. Typically presents with some swelling on the eye or even some subtle symptoms. Most commonly, it's associated with Graves disease or hyperthyroidism. Also can be seen in patients with hypothyroidism, which is intriguing. The most important thing is chemically, it's tied to different signaling pathways that are very common in autoimmune conditions with the different receptors, such as the TSA receptor and then the IGF receptor pathways. And what we're seeing in this disease complex is, you know, we really knew about it basically based on its association with Graves disease. But we've learned over the last 170 years that it is now much more, much more detailed than just associated with Graves. It can be its own independent inflammatory pathway. So it's kind of the unsung heroes of the. Of the autoimmune conditions that may be underdiagnosed.

Wow, interesting. And in your practice, what percentage of people do you see with it with graves or hyperthyroidism versus everything else?

Yeah, I think historically we say that 80% of our patients have some sort of hyperthyroid condition. I work very closely with endocrinologists, even some rheumatologists or patients that are going to optometrists or general ophthalmologists. And the patient may present with very subtle symptoms such as dryness of the eyes, redness of the eyes, asymmetry in eyelids or brows, double vision. And that's where someone who's an orbital or oculoplastic specialist and kind of help decipher number one if they have a visual urgent issue, which could be something that could be vision threatening or something that needs basically a comprehensive team management support. And so I would say typically 80% of the patients, although that's really just a textbook number, I would say that is pretty common to what we see. Yeah.

You know, even in my experience, I've only had one ever Hashimoto's patient with eye disease, and the rest have all been graves. And I will tell you, you know, I think we've talked about this. It is the most frustrating thing for people with graves. Like they're suffering from so many symptoms, but they're like, if you can just fix my eyes, I'll be happy. I think it can be really debilitating.

Yeah. There's a lot of social isolation, cosmetically, questions from friends or family on why someone's face or eyes are changing, including the symptoms, unfortunately, with redness and dryness and eye pain, that can be there as well. And historically, there was also two categories of more of a quiet disease versus inflammatory disease. So patients who may not have the redness just have bulgy eyes. But it's challenging in that they need the correct diagnosis first. In my specialty, not only am I doing medical surgery, but cosmetic surgery with eyes and brows and lower lids and some of the fat that bulges in the lower lids and even around the eyes really can be socially isolated. So I have to kind of balance, keep my medical hat on when I visit with those patients to rule out those conditions.

Yeah. And, you know, I think what I'll do is I'll pull a photo from online to show people what this looks like, what the bulging of the eyes is so they can kind of recognize it. But I agree, people kind of isolate. They feel like they don't look like themselves any longer. You know, it's. It's super sad. Tell me you had mentioned oculoplastic and orbital surgery. Can you give me just definitions of those? So for people that maybe aren't familiar, we'll be understanding and aware?

Yeah, absolutely. Ophthalmology and ENT surgery were all one category together back in the early 1900s. Classically, the new York and the Harvard Eye Ear Nose stroke hospitals were all one that split off into more ear, nose and throat, and then eyes separately. But with that training, we were very familiar with the sinuses and the orbital structures and the bone around the eye. Oculoplastics is really developed by four surgeons who focus on those conditions. We have our own society, which is called the American Society of Ophthalmic Plastic and Reconstructive Surgeons. One of my mentors, Jerry Harris, was president of our society. He's based in Milwaukee, Wisconsin. He really focused on orbital disease, which was inflammation around the orbit, including orbital tumors. So general eye people don't necessarily know all the details, and certainly the ear, nose and throat people don't know all the details. Our training consisted of medical school, then the four years of ophthalmology training, then two additional years of orbital, eyelid, and also facial concerns as well. So everything around the eye. Many of us have gone on to do a mixed practice of cosmetic surgery to improve the appearance of the brows, the upper lids and lower lids, as well as a balanced practice with orbital conditions. So thyroid eye diseases really are one connection deeply to medicine? I think so, where systemic conditions can present with the eyes. Some of the most famous patients who've had graves over topically, like Barbara Bush and people who have had prominent eyes, those are people that you think of when you think of bulging eyes. And even more recently, like on TikTok and Instagram, there's patients out there who use that as a marketing thing to make it their signature look. My job is to make those patients know that we can have a plan for them. We can determine activity, status of the condition, give them options from medication, surgery, steroids, other options, radiation, even that. We can help minimize their symptoms and then also walk them through the process that can improve their functionality when it comes to double vision, dryness, or just the red eye appearance. So it's been a really unique, special to be a part of, because I feel like it's something that can a lot of times just go under diagnosed. Many patients are suffering with painful eyes, dry eyes, bulging eyes, and they don't know where to turn to. So obviously, when you have advocates for thyroid conditions like yourself or other people in the community who really focus on thyroid, it becomes really a small family of who are the experts in the world on this? And it's important to know that what I am passionate about is making sure the eyes not only look good, but feel good. And then sometimes just correct diagnosis is where you start.

Totally. That's the problem too. In the regular thyroid World as well. How did you end up so interested? And how did you end up in oculoplastics, orbital surgery, that kind of thing?

Yeah. So when I was in medical school, I went to the University of Texas at Austin and started my undergraduate training there. Went to medical school in San Antonio and thought I was going to be either a general plastic surgeon or orthopedic surgeon. I rotated through Brooke Arm Medical center, which is a military hospital. And that was right during Operation Iraqi Freedom and Enduring Freedom. So we saw a lot of patients coming in from me and Iraq with a lot of burns on their eyes and face. So I fell in love with reconstructing the eyelid, giving visual rehabilitation. You know, if you have that classic appearance of someone who had an IED or fire to their face, they have that burned appearance of this eyelid sometimes would get stuck to the eyeball, and they would deal with lots of uncomfortable pain around the eyes. And I used a lot of regenerative treatments to actually recreate the covering of inside of the eyelid onto the eyeball. And that's where it all started. My mother was an esthetician and my father was a physician. And I thought this was a good blend to also focus on the function and the aesthetics. And I kind of progressed my practice over the last 16 years to focus on both parts because I found no matter what I did medically, patients always, even if they didn't tell you directly cared about how they looked, because, you know, the eyes, obviously being the first thing that you do when you're looking at someone, you're making the eye contact. I think it's so important that you almost become a little bit of a psychologist or a counselor with these patients on how to reconnect with people because they felt so isolated for so long. So I absolutely love the challenge of making people look like they didn't have surgery and secondarily just restoring their confidence.

Absolutely. I mean, it makes you feel like a whole new person. And I've seen some of your before and afters. I'll get those from you. Because as someone that deals with people with Graves disease, people with bulging eyes, I know how just dismantling it can be. And so what I saw on your before and afters are absolutely so incredibly powerful. So I'll drop them here. I'll drop them towards the end of the episode again, so people have a couple opportunities to see them. But tell me a little bit about options for people. So now they know, hey, I've got thyroid eye disease. I have this. It's really bothering me. You had mentioned something earlier about medication. I'd love to kind of compare and contrast what is best use and what all the options are.

Yeah, it usually starts with a diagnosis of status of the thyroiditis from activity level. So there's inflammatory thyroid disease and more of a quiet thyroid disease. Historically steroids were go to to calm down the inflammation. More recently, biologic immunosuppressive treatments have really gotten popular. Also historically we would sometimes use radiation to kind of fry or stop the inflammation right away. As another alternative for patients who couldn't tolerate stero. If it's vision threatening, there are surgical options actually basically to mechanically remove the fat around the eye that's causing impingement on the optic nerve or impingement on muscles or actually dimming of their vision, which if the optic nerve is that compressed, that requires an emergency surgery. Those are the overall basics of what I think about as options. What's been very popular is the biologic. So that's been really popular when it comes to what the next steps are. The brand name Topaza has really been out there. There are some newer medications coming down the pipeline. What's interesting about those medications is it's really changed the algorithm for patients who have undiagnosed disease. And it gives us an option that essentially can restore the structure and function by reducing the pathway of the way the inflammation is happening. And that really started and I was actually part of the initial study in this and we were one of the multi center sites back in 2013 through 15. But I would really say over the last three to four years it's gained a lot of speed. But there's a couple complications with topazis, particularly hearing impairment, which we've seen happen. So that used to be more of a complication. Now it's something that is called basically a side effect of the treatment. And patients are struggling with that. Sometimes they, as long as they're prepped on that, they have a comprehensive team that we can kind of intervene as soon as possible. But I'll tell you, having more options for these patients and it's such a niche group of patients that have this, it just helps their quality of life so much.

And tell me about Topeza. So tell me what that looks like. Is it oral? Is it iv? How long does it last? How many treatments do they need?

Yeah, so Topaza is an IV medication. They're currently looking at a way to get that either sub Q or oral down the road. The next wave of this patients usually have a set up guideline of multiple infusions over a certain amount of months with a lot of screening for the hearing. The big thing once we started doing Topaza, I felt that the number of surgical patients that were heading towards surgical intervention, decompressive orbits went down the eyelid. Ptosis, which is droopiness of the eyelids or the muscle bulging which led to exophthalmus or proptosis which is bulging the eye, became less obvious. So we've had a lot of great success stories. Some of those patients still need surgical intervention. But essentially if we are are reversing these pathways of inflammation that are directed toward the muscle and the fat and you're reversing the process where it starts, you're having less of those long term side effects which are like the strabismus and the exophthalmos which are really socially debilitating. Pretty remarkable that we figure that out. I just think there's going to be even more medications and there's some new pipeline ones coming down. Like there's not even a name for it yet. But I think it's Velliga drug which is another one that's coming out and that's in phase three and that's more chronic conditions. Now initially we were thinking about more patients that have new thyroid disease. Now we're able to treat the chronic phase which if we can reverse the chronic phase of this condition, I think you're going to open this up to a lot more patients.

Wow. So question for you and this might be out of your wheelhouse. So part of our approach at modern thyroid clinic is called functional medicine. So our goal is to actually reduce that immune activity in both Graves and Hashimoto's and we have some strategies. One of them is like low dose naltrexone. It will almost immediately reduce grades antibodies by 50% plus in a matter of a few months. Do you find that once people have or the beginnings of exophthalmus or bulging eyes, do you see reductions in severity of that with reductions in GRAVES antibodies or is it too hard because you don't probably check those as often?

No, we definitely check the antibodies. We check the thyroid stimulating hormone antibody, we also check the IGF1R antibodies and I think the IGF1R antibody really associated with the proptosis and diplopia. And so that's where Depositor really came into favor. There's no doubt that I guess a less holistic approach would be surgery. But sometimes when the vision is threatened, doesn't matter what else is going on you got to get in there. You need to take some of that inflammation out. Steroids, Good old steroids, as you know. I mean, those are things that just kind of like a shotgun approach. And, you know, you're getting decreased inflammations, but there's side effects. And if you're diabetic or you have other, you know, bone issues, other things, you're setting yourself up for a really rough recovery, and that's not something that's sustainable. I'm really intrigued on where biologics are heading, because if we can be more precise, and I love your idea of the if naltrexone. I think, again, it's kind of an in between these really directed antibody blockers and steroids, we're getting to the right approach. But if we can get the biologics even more in detail with exactly what the inflammation pathways are, I think we'll be able to treat the patient better from a holistic standpoint. I think it's great to have options, though, because I know a lot of patients are averse to doing an iv. They're aversive doing steroids. And I think the more options, the better. I always empower my patients. I say, by the end of the day, it's your decision. But I can just go based on my experience, which is if they look better, their vision is safe, and they're feeling better, then I think we're on the right track. And I don't think there's a cookie cutter way to address it.

I love that. That's so true. We're so individual. Let's talk surgery. So talk to me about surgical options. I know sometimes this is medically necessary because of vision threats, whatever. But also, I think people are so incredibly bothered by the physical presentation of the bulging eyes that people just want to go straight to the solution to talk with me about who makes a good candidate and even, like, what that surgery is. Recovery looks like all of that.

Yeah. So three major surgeries that you see with thyroid eye disease. Number one, orbital decompression. That can include fat decompression or bone decompression. So from a surgical standpoint, this is your biggest surgery that's directed toward treating orbital pathology. Now, the bone decompression, the bone technically is not changing as aggressively as the fat. The fat's what's going to cause the vision problems. If it doesn't cause vision problems. What you see with patients are bulgy eyes. And some patients will do a cosmetic orbital decompression if they know they have the symptoms. And they don't meet medical guidelines for the decompression. Other patients will do a more medically indicated procedure. In rare cases, we're doing urgent orbital decompressions. If there's a vision threatening issue there, your big things there. Recovery time can be anywhere from one to six weeks. It depends on and how inflamed the orbit is. Rarely does it. It used to include a hospital stay if there was vision threatening. Usually do it in the hospital, sometimes in an outpatient center. If there's less inflammatory tissue. There's very commonly that we're putting people on either antibiotics or even some steroids afterwards. We don't want to keep that on as we don't want to keep the steroids on if essentially you're removing the inflammation, but you will get some rebound inflammation certainly after the procedure. The second surgery is a strabismus surgery, which usually done by either an adult strabismologist or a pediatric ophthalmologist. And they usually work with the muscles themselves. And that's the position of the eye. So there's very common patterns of certain muscles that pull the eye down. With thyroid eye disease, and that's usually the inferior rectus and the medial rectus. So those are muscles that live underneath the eye and toward the inside corner of the eye. So you commonly see patients not able to lift their eye up or not able to pull their eye out because those muscles are so thick and fibrous, fibrotic, and they kind of pull the eye in and down. That's what we see. Once the condition is stabilized, whether it be pesa or steroids or orbital decompression, you typically perform the cerevision surgery. Second, very commonly you may see multiple cervis surgeries to kind of correct it, or you may add in prism in the eye glasses to help align the vision. Obviously, you know, it's not always fixed the first time because thyroid eye disease may not always be controlled. So multiple surgeries. And also we may have to, if you're wearing glasses, cover one eye with like some scotch tape just so you can see clearly as that's healing up. And then the last part is the eyelid position. So commonly with thyroid patients, you're going to see a peaked upper eyelid or what's called eyelid retractions. One of the telltale signs that you might have an early stage of thyroid eye condition. If you don't take a good history, you'd fix an eyelid retraction without addressing the thyroid. That's going to typically recurring and so the way that's done surgically is an incision usually along the eyelid crease, and you kind of relax the muscle there that lifts the eye up to bring the eye in a more normal position. Historically, we were trained back in the day to do these surgeries in sequence. What you're seeing now is with stable disease, you can do some of these surgeries combined at the same time. And so I think that's going to continue to evolve. And it's important that you actually work with multiple specialists to do the surgeries if you can, at the same time, particularly with oculoplastic surgeons. We're doing the orbital portion and we're doing the eyelid portion. We typically do not do the cerebusiness portion. So we usually could work with a person that we trust, or we go back and forth with them. We refer back and forth as that patient's going through that healing process. But those are the three major things I'd say all the surgeries, typically you're looking at about one to two weeks of downtime when it comes to bruising and swelling the visual portion on how you're actually going to end up. It does take usually three to four months to kind of see how bulged the eye will look after the decompression, if you still have a double vision or not, and the eyelid position. And we're just fighting good old inflammation. So when you're talking about inflammation, if there's any adjuncts you're doing, whether it's medications that you recommended or anything else, like, we need to know. So even like herbal supplements, selenium is a big one that we talk about in our field. We just want to know what you're doing to decrease inflammation, because you can get rebound inflammation as well, and that can affect surgical outcome. So we, in an ideal world, we would like to at least three to six months of stability before we do a surgery. And in the orbital world of its vision threatening, we move a little quicker.

Interesting. While I have you here, I kind of want to pick your brain on just general things as well. I'd love for you to tell me if you're seeing any kind of trends in the cosmetic world for eyelids, but also just for facial rejuvenation, like what's on the horizon? Because this is always such a fascinating topic for me, but for my listeners.

As well, yeah, I would say cosmetic eyelid surgery is very, always been very popular. It was the number one procedure in 2024 and 2025 for the American Society of plastic surgery eyes. Once we had Covid and we got a really refocused on the eye situation after everybody's wearing masks, we saw a real big boost in the number of requests for eye bag surgery or upper lid surgery. We've also seen a trend toward people being more open about what they do with their listeners, Especially if you're visible on social media or on YouTube. And patients are much more open to do something that lasts a little bit longer. Historically, people were doing lasers and neurotoxins or neuromodulators, and I think talking about surgery is becoming the norm. We're seeing patients, I would say average age of surgery is getting a little bit younger because patients want to enjoy the results a little bit longer. And also some of the maintenance treatments they're doing doing just may not be getting the results that they want. So I think there can be room for both surgery and for lasers and neuromodulators to be definitely in vogue. We are seeing some patients shy away from some of the aesthetic fillers, Particularly in the mid face, which is an area below the eye bag. So whether you have thyroid eye disease or you have just an eye bag, genetically, we're seeing less and less patients get filled in that area. Some patients are opting toward fat transfer, or they're opting toward surgical taking of the fat, doing a skin pinch, or moving the fat into a different area. Now, you have to be careful. You have to have a good history, because if they have old filler in the fat or they have something like thyroid eye disease, you don't want to move inflammatory fat to an area where it could cause chronic swelling. So I've kind of worked on that project just kind of independently as I've done surgery over the last 16 years. I think it's important to know that fat is beautiful and that it has stem cells and can be used toward your advantage. And so you can take fat from the tummy or the belly or the. Sorry, the tummy or the thighs or the. Or somewhere else, and you can place it in the mid face. And as you spin that down to nano or progenitor cells or micro, it can really become a nice way to volumize and also rejuvenate the skin. But if you take some of that locally around the eyes, that may already have some of those inflammatory cells from either thyroid or may even be fibrotic, too, as the thyroid progresses, or if it has filler or something else in there, then you can be sure not to put it somewhere else in the face. So again, I'm just super passionate what I do. But most important thing to me is like I'm always a student, I'm always learning. I'm also just talking to my patients. And I think a lot of people are looking for a shortcut when it comes to aesthetic eye treatments. And I think people really want long term results if they can get them. There's no permanent fix, but if you can reset the clock five to 10 years and it can last 10 to 20 years, I think they're pretty happy. And then creating a good maintenance plan. I think skin care goes under recognized in a surgeon's eyes. So you want to go to a practice that focuses on both the skin care and what you can do to maintain your results. I think we're also not seeing overdone surgery as much anymore. Like overly aggressive, lifted up brows, really overdone mid faces. We're not seeing that as much right now. It's called like the natural is the new plastic surgery. And I think patients are more accepting of that too. I think plastic surgery has such a bad connotation. Oculoplastics really came in as like the cleanup crew, which is where we kind of started our specialty, which is we were fixing plastic surgery work that maybe the patient didn't love or that may have not thought about some of the functional aspects of how much skin you leave behind around the eyes so they can close the eyes, not taking out muscle around the eyes that help the eyes close. And now we're seen as like the world's experts in eyelid surgery because it's all we do all the time and we like to fix it. And the patients are becoming so much more knowledgeable due to social media and their own research on chat, GPT and everything else that you can find some of the best people in your neighborhood. You don't have to go to New York or LA anymore, which is really nice. So we've seen a major influx of patients traveling them to Austin to see me here, which is really humbling and awesome. But I think you have to keep your medical hat on, still not miss things that could be missed. So a good medical history, a good understanding of what they've done is very important. And when your patient walks away, that's, that's your. They're going to be your best advocates and they'll tell their friends or people that ask. But also you want to be proud of your work and make sure they look like themselves. They don't look totally different where it's really Noticeable?

Absolutely, absolutely. Tell me some of your favorite skin treatments, whether it's lasers, whether it's skin care. Tell me your top three favorite things that you've all have been doing lately to help rejuvenate skin.

Yeah, I think that you're going to see more and more regenerative treatments when it comes to collagen stimulation. I think you're going to be seeing more Erbium and CO2. We go back and forth on what we like around the skin. IPL works fantastically in conjunction with Erbium. Some of the brand names are like Halo and the Cytong brand, have done a good job of creating a very safe laser that does a good job of resurfacing and not only building your own collagen at the same time without the major downtime of a full ablative laser. So I think that's going to be something you're going to see more and more patients continue to do. I think combination treatment. I think you're going to see that the high aleuronic acid alone fillers will slowly merge into combined high aluronic acid with regenerative or biologic fillers. I was in Vienna, Austria, two years ago, and I saw what they were doing in Europe and Brazil and South America, and they brought all these at a conference over there. And I think that America is always a tad bit behind on what's the most innovative way to add volume without looking overdone. There are certain countries, such as Korea, Brazil and some places in Europe where you always have kind of that shiny, beautiful skin without looking, being overfilled. So I think it's gonna be really important that we focus on education for people that are using the needle to inject into the skin. Certainly the hot topic is always stem cells or biologics such as exosomes. And, you know, I think the jury's still out on some of those treatments, on how they're going to treat with how they're going to work with the skin. So I'm always keeping a close eye on those two treatments as well. But I would say lasers, micro filler treatments are a great option. Neuromodulators are tried and true because they relaxing wrinkles. I think those are just totally underutilized still with a lot of patients who don't want surgery. So I think they're a great option. But I would say the number one thing is actually health. I would say health and diet and nutrition. I think that, like, you can't just walk into a clinic and assume that a needle or laser is going to fix what you're doing. Same concept. When you're going to the gym, just because you're working out, what do you put in your belly when you go home? I mean, I think that there's going to be a blending hose of the wellness and the health aspect and the aesthetic aspect in the next 10 years, and we're seeing that with our patients. With the advent of GLPs, weight loss, we're seeing the effects of weight loss on skin quality, laxity of facial skin, neck skin, tummy skin, breast skin. Everything starts to end. So we can surgically fix a lot of that, but the skin still may not look the way that you want. So I would say that's what's going to be the next big frontier is how do you blend the whole package of. Of what am I putting in my body, what am I doing to repair, and then how much am I preventing it? So it's a really, really cool time to be in my industry. And it's crazy that it all started with just doing reconstructive surgery at a military hospital, but I think it really keeps in mind that even back then I was doing regenerative treatments around the islet tissue. It's going to keep happening, and I'm glad it's becoming more mainstream now that this discussion is open. And I think patients appreciate a doctor who's staying at the forefront of all these changing things.

Absolutely, we do. Heck, yeah, we do. Well, tell listeners a little bit about where they can find information about you, your practice. You mentioned you're located in Austin. My neighbor, but Phyllis, and even social media tell us where people can find out more.

So our practice name is Offset Face and Body. It was founded by me in 2015. We're based in Austin, Texas. We have three major locations in Westlake and Austin, downtown Austin and Round Rock. We also see patients in New Braunfels and some of the other peripheral cities on the website austinfaceandbody.com and then on social media, we have a very active social media that focuses on education. So not only everything is in orbit, but it's quite a bit of everything from breast and body, women's health, face and neck lifting, deep plane, facelifting, all the things aesthetic. And that's primarily on Instagram, Sonface and Body. And my handles, rShopaul. We have a group of surgeons that absolutely loves what we do. We're all super specialists in what we do. So you're going to see quite a variety of people, not just one doctor, talking about everything you're going to see different doctors and nurses and estheticians talking about our entire process. Very comfortable seeing patients from out of state and even out of the country. We've dealt with a lot of that. I think that's awesome that patients really connect with us. And so if you want to get to know more about me or my team team, we'd love to see it.

Can people do virtual consults?

Absolutely. So I started doing virtual consults actually back in 2019, and that was because we had so many patients from Oklahoma, Louisiana, South Texas that just wanted to get to know us kind of again. Pushed me to post more on my social media and obviously during COVID it was very, very important and of course we'd love to see you in person, but even today we had an inquiry from Pennsylvania and last week I had a patient from Mississippi. Like that happens where if you find the right person who you feel comfortable with, just, you know, reach out to them. I know that virtual consultations is really the best way to break the ice and get. Just make sure that doctor you're going to work with understands you, understands what you're looking for. We do typically see our patients in also for a pre op, in person once the virtual consultation is completed and then we do the surgery after the that we do have requirements depending on the surgery of you to stay in town, but we do have our own accredited facility for surgery and we're very proud of it and we, we really focus on quality.

I love it and I'm going to eventually recruit you to come to TikTok because it's the best place to be. So if y' all are on Instagram, that's great, but you need to come.

We actually do have a TikTok too. It's called the TikTok Face Talk. So if you want to find us on there, we can. I still have one video. It was like 1.6 million views back in 2019 or 20, but that's my claim to fame there. But it's the TikTok face talk on TikTok. But yeah, it's. It's all the doctors now who are on there. And Tick Tock has been awesome. I mean, for education wise, been great. But you know what's been crazy on Tick Tock is patients have tagged us of their journeys after surgery, which has been the coolest place for that. So that's been really fun to see.

It's such a powerful place to like share information, experiences, great doctors, surgeons, all of it. So I'm glad you're over there. I'll check you out over there after this. Well, thank you so much for taking the time to share your work and brilliance with my listeners. And, yeah, thanks for coming on the podcast.

You're welcome. Thanks for having me.