By the end of this program, attendees will be able to:
Enhance your understanding about the factors causing Split-Thickness Skin Grafts
Review clinical relevance of Silver-ORC dressings for managing Split-Thickness Skin Grafts
See Silver-ORC dressings in action as the presenter shares his case studies
um, Good morning. Good afternoon. Good evening. I know we've got a wide audience and I'm really looking forward. Thio, uh, this presentation and I hope that you find it to be informative and educational and maybe even a little bit entertaining, so we'll jump jump right in. I'm sorry, Chowdry. I'm a plastic surgeon. Essentially, I'm the chairman of plastic surgery at Christ Medical Center in Oak Lawn, Illinois, which is in the southwest suburbs of the city. It is the busiest level one trauma center in the state of Illinois. We have about 12 other plastic surgeons in our department. And don't don't let the baby face fool you. I I am seasoned enough to be here and doing what I'm doing. I hold to, uh, academic appointments at the University of Illinois as well as at the Chicago Medical School. So it's a little bit more about May I? I am a Chicago kid. I grew up in Chicago and the western suburbs. I went to a Loyola University for my undergrad education and then Rush Medical College for, uh, medical school, a Mount Sinai for general surgery and then Louisville for plastic surgery. And it's been kind of a tough year, I think for all of us going through this pandemic. But if you enjoy college sports, I think we got kind of robbed this year with the N C Double A tournament on Do the the March Madness. If you remember a few years ago, Loyola and Sister Jean the media darling, we kind of took over the whole nation as we went to the Final Four for the first time in a long time, there was a lot of fun here in the city of Chicago. Um, but jumping right. And we're going to be talking about skin grafts today and we'll talk a little bit about where we utilize skin grafts and talk a little about how we manage some skin graft donor sites. And I'm also really kind of excited to showcase and share some of my experiences in cases with you. I'm actually very proud of my cases, so I appreciate your your audience and your and your indulgence with that with my enthusiasm for them. Um, I'm a plastic surgeon. I take a lot of pride in plastic surgery. I take care of many, many complicated problems in plastic surgery and as the as the chair and chief of plastic surgery at the business Level one trauma center. I see my fair share of truly complex and complicated cases and complicated patients. Um, either it's just a sampling of the things that I see and or that what what our department takes care of on on a daily basis. And typically we meet patients that have been very challenged. They have been debated multiple times. They've been through the gamut with their surgeon, the original surgeon who operated them multiple times they've been in and out of one care centers. They're frustrated, they're referring. Physicians are frustrated as well. And so when they come to see me as a plastic surgeon that we're dealing at with a challenging situation and you know, I take a lot of pride in that and I try to encourage my residents and students and fellows to also take a lot of pride in the referral to you with a really, really challenging problem that you can hopefully fix. Um, but you know, problems and plastic surgery. We try to organize them and put them into situations or simplify them so that we can manage them. And the most common algorithm in plastic surgery is the reconstructive ladder, which starts out initially with primary closure as the most simple and basic reconstruction. Which is to say, you have a defect somewhere on the body that you can then mobilize the edges a little bit and get it to primary, close with the suitors or staples and even find white line closure at the end. That's not possible, and we try to see if we can get a reconstruction or achieve a reconstruction with the skin graft, whether that is full thickness is or suppose thickness. But that will be our next opportunity to use our ladder going up the top floor, which then proceeds to local flap reconstruction and then essentially free tissue transfer. I do do free tissue transfer. I do a good amount of microsurgery. I don't love doing it right. I try to find ways to minimize the need for that. And I also try to find ways to keep reconstructions simple, because the more simple they are, the less donor sight defects there are, the less, um, uh, donor site morbidity there is for our patients, and it's one of things that we're gonna talk about today is donor site morbidity when it comes to skin grafts. And the other thing I want to talk about today is Ah, lot of times I think about skin grafts. Not so much about the wound and the wound I'm going to reconstruct, but more about the wound that I'm going to create. I'm gonna talk a little more about that as we go through this presentation. Um, for those who don't know about skin grafts, I'm sure that I'm sure that many of you do know, but we have a pretty wide audience. We're gonna talk primarily today about split thickness, skin grafts, grasping harvest to get full thickness or split things. But we're gonna focus primarily on split thickness. Skin graft in the way we harvest skin grafts is with a device called a derma tone. In the bottom left of your every screen, there are very simply wet blades or Humvee knives, which is a knife that can shave a piece of skin off. And that's how we would do that thing. We developed a few more technologies and are able to use the either mechanical, electronic or pneumatic Dermot Holmes which I think most of us are more familiar with. Simple schematic hair diagramming. You know how we harvest skin grafts, whether they're full thickness or split thickness, skin grafts, um, split thickness, skin graft, or to take the entire epithelium as well as a part of the Durmus. Um, but not the full thickness of the Durmus. They full thickness skin graft will take the epidermis and the folder missed out of the fat. And there are different reasons to use these other types of graphs. Um, initially with a split thickness graft, depending the depth. Also, we may have a very large burn that we want to reconstruct for patient that's going to require a lot of their skin to be used. We want to use a thinner, split thickness skin graft so that we can re harvest from the same area multiple times. Um, a deeper split thickness graft is gonna have better adherence and better properties in the future for the patient on the on the wound site. But it's gonna leave our patient with mawr scarring, hypertrophic scarring and more pain. A swells, more bleeding points. At the donor site, we use some full thickness grafts because they have less secondary contracture versus a split thickness contraption. That's, uh, I think it'll be a little beyond the scope of this presentation. Um, but moving along, we harvest the skin graft, and they were able to mesh it as well. Theme meshing allows for the graft to be expanded to cover a larger area. So we have a limited resource of skin on the body. We could take that limited resource in and get more mileage out of it, so to speak. We also mesh it to allow for aggressive fluids and prevent him until mezzaroma buildup. So after harvesting a skin graft, we're left with the donor sites. And I'm gonna be talking a little bit more about donor sites and the, uh, morbidity that that leaves patients as well as I think, some of the challenges that it leaves with us as as those taking care of these patients. And we'll do that with a few cases in the future here. But I want to talk a little bit about what a skin graft means to me and how it works. So essentially we're gonna be taking a wound that we have somewhere on the body on. We're gonna recognize that that wound is essentially just devoid of skin, and we want to use skin from somewhere else in the body to close or reconstruct that wound. And so we're going to take a shade of skin as a split thickness skin graft. Reconstruct the primary wound, but we're in the process, going to create a secondary wound that we know was going to hell secondarily through episode realization. That's why we're able to use a split thickness skin graft because the that epidermis dermis will epithelial eyes from the journal appendages, and we know it's going to hell in a certain amount of time. But we are creating a secondary wound, and it's something that we have to keep in mind that it's one of the obstacles for me to use a skin graft reconstruction. That's why I think that recently skin grafts have been kind of overlooked. They people are jumping ahead from primary closure, toe local flap reconstruction and skipping over the skin graft reconstruction. So what happens at the at the donor site? We often place a lot of emphasis, a lot of stress on the initial wound that we have, whether it's on the ankle, the leg, arm, abdomen, wherever it may be. We see that to be the problem that we're trying to solve and rightfully so we see that is the issue. But then we also taking a skin graft. We take. We close that primary wound created secondary wound and secondary wound, then creates pain, discomfort, potential for infection as well as, um, opportunities for, uh so that the fluids hypertrophic scarring in a poorer overall result for the patient. Even though the initial wound is closed and finish, 1 may be closed. But you also have to figure that the secondary wound can also be problematic for patients if it's not healed in a reasonable time. Typically, secondary skin graft donor sites take about three weeks to heal. And so sometimes I look at a wound and I think to myself, Well, you know that one is gonna take about 2 to 3 weeks to heal. If I do nothing to it, it does not make sense. Then, for me to use a skin graft we constructed because the donor site will take three weeks to heal is well, so we tryto we try not to put more wounds on patients trying to create more discomfort paying operatives for infection. So when I think about doing a skin graft, my focus really actually ends up being on the donor site, and I think to myself, How can I reduce the time to epithelial ization? How can I reduce the time to wound healing? How can I reduce the opportunity for infection? How can I reduce the pain and discomfort associated with the skin graft donor site? And that then means how do I pick the ideal dressing? And so, to me, the ideal dressing is gonna be one that is going to minimize pain, minimize discomfort, lead to more rapid capitalization and finally wound closure. I think that's what we're gonna be showing today. Using college in O. R. C and program Prisma. Um, just a simple, simple diagram here. I think it's it's what we're gonna talk about today is how to use program prisoner or risk and grab donor site. And it's very simple. You can use your your own methods, really. But over the donor site, place the program Prisma. You can use any type of, uh, foam on top of that and then either a semi inclusive, non inclusive dress on the top that to maintain the uh dressing intact and I'll show you what I dio in the coming slides here. But prior to engaging with the patient in taking on the challenge of reconstruction, whether we could talk to her cosmetic, I always think about, you know, one of my goals. One of my goals is a surgeon. One of my goals is plastic surgeon. What are my goals? Is a physician, and one of my goals is kind of a zoo, a someone in the community who is trying to trying to build a reputation, and it's always to provide the best out possible outcomes. And I don't think anybody you know in our audience today has a different goal than that secondary need to restore function for a patient. I'd like to provide aesthetically pleasing outcome for my patients, minimize downtime, minimize pain, and you know I am young and I'm trying really hard to build a reputation in my community for care, compassion and ultimately success. So, you know, with those goals, I think to myself what gets in the way of my goals while wound healing complications, getting away of my goals. DigiScents drains, Ciroma scar burden and pain. And as I go through this, we'll talk a little bit about you know, the patient experience and how valuable that is, how important that is. So I'm gonna talk a little bit about my cases. These are my cases. They are. I can't say that these air guarantee results for anybody, but I work through problems. I think pretty, um, in an organized fashion. And, uh, just, uh, show you some of the things that I dio with skin grafts and program prisma and how I think about opportunities to help my patients. So my first patient is a 66 year old lady was infected, right? Totally. Arthur Plast e. And, um, I met with the orthopedic surgery colleague and he planned to take the infected Arthur plastic out and replace it with a speaker. I'm sorry, Spacer, um, covered with a muscle flap and then a some 0.3 to 6 months later, take the flap down and place a new hardware or need for the patient. But the problem with her is when she was getting her pre op work up for her revision of all of this. She was found to have an ischemic component to her cardiac work up had to undergo stenting as well as a bare metal stent that required aspirin and Plavix. And she sells certainly also have to have this, in fact, hardware removed because she could have systemic signs of ah, bad problem if she has in fact it hardware in her undergoing a master procedure and place another stent in her in her heart. So it becomes a challenging situation. As is quite honestly, you know what I face. I face the challenges of all the challenges of plastic surgeon as the chief of department, The tough stuff comes to May s Oh, my, what big surgery colleague was able Thio, Here's the patients in the operating room. He took the implant out. I was able to do a ah muscle flap reconstruction and a, uh, skin graft. On top of all, this is well and quite you know, again we focus on the wound. We have a nice result here. We've got the donor site in here, becomes my challenge because here's a patient with a rather large raw wound. And with that is gonna be a lot of opportunity for bleeding. Using infection on does just things that are gonna be very poorly tolerated in a patient with a poor cardiac history as well as a patient has now hardware in her so on, which is an aspirin, Plavix. We have the more opportunities for leaking for bleeding and things of that nature. Um, s O, this is a great opportunity. I think that for me to use the program Prisma and I don't advocate using it just on these cases, I'm showing you some challenging situations. So good idea of what you can use it. But I take my program Prisma. I cut it to the right shape. Here it is, just after a few minutes and it soaks up a good amount of the exit dates from the wound site. I go back to my reconstruction. I use a good amount of pro Vina and individual negative pressure as well as I use the wound back to bolster my skin graft. And she got a great result here. She has 14 days later with the skin graft donor site that is fully healed fully epithelial ized, no infections and really minimal pain. And I'm gonna talk about pain a little bit further in my my presentation here, um, so moving like my my next case is an 89 year old lady with the malignant melanoma of her left arm. And she underwent a a wide local excision of of her, uh, melanoma, a swell, a split thickness, skin graft, reconstruction. And I used the program Prisma for her to on. I'll explain a little bit. Why? I found it to be very valuable as I show you my my photos down the road here. But here she is, pre op with large melon ionic legion reconstruction with the skin graft. Um, and here she is after the program prison and I wanted to show this because, uh, seven days. So I did. This same reconstructive or dressing technique is before, which is to stack the prisma on the wound and cover it with a tech a dream dressing. And I want to show you here it's seven days. The technique is still clear, invisible. You consider clear to the wound bed. And I've also used the program prisoner which the wound bed has absorbed and is utilized the collagen to start the capitalization process. So I wanted to show you that I think it's a really neat way to see that. In a 12 days later, I got an 89 year old patient within friable skin with a fully reconstructed wound and it completely epithelial asking about donor site. So I think that's that's a really neat way to show how quick we could get some of these wounds to heal, considering in someone who's with advanced age, uh, to have a nicely healed wound or donor site at just 12 days when normally it takes about 21 days to get this close. So it's a big, big savings for her. Um, I had seen her in my office, uh, and then I kind of lost track of her, and I was kind of disappointed in that because she lives in a more rural area, and I was kind of concerned as to what happened to her. So I actually called her and found that she was on her farm with her son and her son had gotten so busy that hey was not able Thio, uh, bring her into the office for me to take a look at her periodically. So I told me that no problem will come out and take a look at you. So I grabbed my my nurse on. We made a little house call way, went to go see her at her home as we got there. We ring the bell and I come to the door and she's got these two large dogs that are really very active, very friendly, and they're all over over me and my nurse. And you know, I not that I don't like dogs and I just don't want them all over means we should. I don't know them. Somebody else's homed it for a medical wound purpose. So I wanted Thio just kind of put that out there. Um but I looked at her wound again. Her her donor said he really well, and her elbow excision and skin graft had healed up really well. Additionally, I wanted to showcase this. I want to show you or share my story of going to her home to see her, because you get an idea of the patient home environment when you do that. And with her having these large dogs all over her, her son not being able to work with her as much. She's relatively fit inactive for an 89 year old, but she still gonna need some help. Additionally, we typically take skin grafts from the thigh. And if you think about it, that could be an area that, with patients using the bathroom and taking showers, can be an area that doesn't always receive the best hygiene. If you couple that with pets at home challenging home environments, sometimes I really, really valued the Prisma, having the silver component to it as a topical, antimicrobial agent. A lot of times we don't know what our patients kind of home environments are. We want them to be as clean as possible in certain areas that were harvesting skin from. You know, it's hard to keep those areas clean. So if I could take advantage of an antimicrobial property of addressing for a donor site, I absolutely think I value that very, very heavily playing on my next cases. 82 year old female with a basil cell carcinoma of her scalp. Remember, I was talking to you about giving a similar talk at my home institution that I brought these three cases up in sequence, and one of the residents, you know, scream from the back of the audience saying, You know, Dr Chowdhury, you really have to get some younger patients and, you know, I I agree. I agree, but nice to take care of some younger folks as well. But this is what I get. You know, I don't get the easy cases. I get an 82 year old female patient over here on national politics, and Coumadin, who has a basal skull of her scalp that the most surgeon in their office excised. And when she came to see me in my office, this was her defect. And because she's in all those anticoagulants, an anti platelet therapy, you know, she's bleeding significantly, and so the most surgeon then cauterized all of the pere cranium on the on the wound bed. And so if you do a lot of skin grafts, you know that you have to have a certain wound bed to accept a skin graft. And on a challenging patient like this, the last thing I wanted to do is do a big flap. But if they could have just left some of the pere cranium there. I could have done a skin graft and call it a day. But I had to a local flap to reconstruct this. A skin graft. Thio reconstruct the donor defect. So here she is with a skin graft. Here is her her donor sites. And again I use my Prisma and I cover it all with it with the texture and ah lot of Ben zone around it. And I wanted to show this case over here this slide because when I've shown this the slide in the past, many people look at that and say, you know what? That's six day photograph really looks, Doesn't look so great. Doesn't look so healthy. It's really dark. And we don't like to see dark components to any riel area in wound care. We don't like dark. Anything we like. We like black when I like dark purple. We don't like dark anything. So, um, I wanted to show this because what this is showing is a fluid filled taken er that is not leaking that has been partially absorbed by the program. Prisma. Um uh it's good to see that I also like using a semi inclusive dressing like this because I can see through it. I could see the wound, and here we are 11 days now. Keep in mind. Typically, wounds take about 18 21 days to heal. And the donor says healing up here in 11 12, 13 days, which I think is is remarkable, especially for patients that have kind of advanced diseases medical call mobility's as well as on certain medications that may impair their wound healing. And there, uh, cloud formation. My next is another totally author plastic on a 17 year old gentleman who had similar co morbidity and complications, and I won't go through that too much. But here is you could see his bare metal, uh, in the operating room that we need to ah, flat reconstruct. And here he is with skin graft. Here's donor site, and I put the prisma on there as well as with a large target. ERM, here he is a day four, and I wanted to show you this, because again it's dark stained. There is no riel leaking, and I think it's what I want to show here is that for those of you who have may have taken care of skin grafts, in the past and donor sites. I remember taking down dressings on day one at by day one day two, they have leaked. They filled with fluid. They no longer have the semi inclusive properties that we like to see e m taking it down. But I want to show this because so long as the dressing is intact is not leaking, not over filled with fluid. I leave it alone. And I found that a lot of times I've been successful with only one, uh one dressing change throughout my whole you told the 14 days of dressing therapy for a patient with the with the skin graft and again a day 12 fully healed, fully up with allies. Don't recite Onda patients ready to kind of go live their life. We talked a little more about paying towards the end of my presentation, which I think is also very important component to it. Taking care of patients. My next patient is unfortunate 44 year old gentleman who was a construction worker and had a bulldozer back up over his leg and D glove his posterior aspect. It was ankle his Achilles and his plantar aspect of his of his healing and mid foot. So how you presented to me in my office? Um challenging, challenging problem. I was really nervous about losing that plant our skin because it's a tough area to reconstruct. Also very nervous about losing the, uh, skin covering the Achilles again. Tough area to reconstruct. Um, but it took him to the opening room and debris did him serially. And I'm gonna show you that on this slide here a little bit out of order cleanse choice dressings, which you may or may not be familiar with. But three honey combing and the macro and micro strain on a wound I think is really very helpful to get a really good clean wounds that are going to support skin grafts. And one of things I like to do with negative pressure is develop a wound, but that will support the skin graft really in a very healthy way. So here's my my mood prepared. Here is my skin graft donor site. Slightly different technique over here. As I'm sure many you can see, I use the program Prisma I cover my wounded in its entirety. You know, this time all season, Cara, phone which is a really nice absorbing foam and a bio inclusive against semi permeable. I'm sorry, semi inclusive cover dressing and here I've got a fully reconstructed footman. It's not a pretty foot, but it works for him and sometimes you have to do the best you can. And I tell ah, lot of my residents and fellows that, you know, just to someone who has nothing, a little bit of a lot. So because Mrs is not our our our foremost concern here but functional foot, then he gets to keep is a big deal for us. And again, at 14 days we got fully healed, epithet realized, non painful donor site where he can start to rehab and move forward. Visit with his life. Um, unfortunate young man over here, 21 years old, who had a compartments in what was his left arm, who was had fashion items performed on guy used again. Use the back vera flow and cleanse choice to clean the wound up getting prepared for a skin graft. And I use, um, my skin graft to reconstruct his arm and again here program Prisma Cara foam and a bio inclusive, semi inclusive dressing Thio treat the donor site And here we have again. I think if you can see that here. But this is at day six. I believe with a a donor site that is not leaking, um is not accessible to the patient. And what I what I want to mention here for this patient as well and it's unfortunate, but he is a patient that had a drug abuse. Uh, problems fell asleep on his arm and caused the compartment syndrome. He also had multiple lacerations on him in the past, and he also had multiple other wounds where he was using heroin and injecting his wound sites with heroin. I think that those of you who take care a lot of wound patients, that's not an unfamiliar story. Um, what I like about this dressing type is it's not painful, and it kind of prevents the patients from accessing their wound. Eso if compliance is a concern, and I think it is for everybody. Um, having a wound or a dressing that really seals in locks in or bolts in the compliance for a patient, I think is really, really valuable because, you know, those of us to take care a lot of wounds, take care of patients. We know that you know, they're counting on us to deliver a result and we are also have to partner up with them. Thio achieve results as well and those must take care a lot of wounds. We know that our method or technique is built on details and everything that we're trying to do is really trying to make sure that we get the best outcome. We have steps and stages that we go through and if those fall apart along the way, we have a setback or problem. And so I think that if we can lock in the compliance bolted in and prevent patients or other providers from interfering with what we're trying to achieve, we have a better chance of success. So here he is to get reconstructive wounds and, um, really great reconstruction of his of his donor site as well. So I want to talk a little about about what I used to dio and what I used to deal with and the impact that this has had on my practice. And many of you, I'm sure, have taken care of skin graft. Owner cites many of you have done skin grafts and you know, a lot of times the primary wound is not the problem. I mean, it really is not the problem, especially if it's gonna be reconstructed with the skin graft. I look at it at a wound that just needs skin. I look at that. Oftentimes, patients have been depleted, been through wound care centers and met with other surgeons, and they've had the wound for sometimes weeks, if not months. I look at a wound that needs a skin graft and look at that and say, You know what? I can have that closed in 30 minutes. I can have a healed in five days. That's how great skin grafts work. They are a low run on the reconstruct, a ladder for a purpose for a reason. They're there to reconstruct the majority of skin only defects right that cannot be close. Primarily, that's a lot of wounds, but the problem is it's the donor site. I could get the initial wound healed in closed in 30 minutes, and the wound healed in five days. But now I have a donor site that is painful present for sometimes 21 days to three weeks to four weeks that leaks that can be infected. And that's what I used to deal with. And because of that, I used to look at wounds and think to myself, You know, if that wound that I'm looking at can heal secondarily in, say, three or four weeks, I'm going to ride it out. We'll do local wound care. I'm not gonna draft it. I'm not gonna close it because the donors, that could be difficult. So what I think about with with skin, only ones that need to be reconstructed and then what ends up happening is I give it two weeks. I look at it, it's not close to being closed, and I think, Wow, hi needs just two more weeks. So I'm not gonna draft it two more weeks ago. By now, about four weeks is getting close to fully healing. But I say, you know, it's two more weeks, so I'm not gonna draft it next time. I was 6 to 8 weeks. It's healed secondarily with potential contracture issues and epithelial ized with stuff that's not skin. It's just scar. Um, but I've wasted six weeks and I've got a reconstruction that is less than ideal scan graph. Reconstructions are good reconstructions I don't want I don't want people to think that's not the case. They're great reconstructions. It's autologous tissue and it works really, really well. But I guess what I'm saying is that if I can get donor sites to hear reliably within 12 to 14 to 15 days with addressing type, that is, that is that is also gonna be painless. Um, that eyes going to be not very messy, not cumbersome. The tip of my patient. It puts the skin graft reconstruction back into my toolbox. It puts it back into my armamentarium. It allows me to take care of patients appropriately. It allows me to take care of more patients. It allows me thio, um heal wounds quickly, and I think that's a really, really valuable, really valuable tools. Um, you know, patients used to complain a messy, leaky dressings or addressing that were painful that were irritated and infected, and I would see it, and I have debated skin graft owner sites and after I'd to breathe them. Now I'm having to do a skin graft reconstruction of a skin graft donor site. It all comes down to the dressing right. Things are gonna happen. We can't guarantee anything. But if I can't minimize theory risk of complication with my donor site, it really is becomes a very powerful tool for May. The other thing I want Thio mention is that I always try to keep my goals in mind, right. My goals are going to provide the best possible outcomes, restore function, provide the best aesthetically pleasing outcomes, minimize pain, minimize downtime and again build a reputation for current success. In my practice, in my community, I do a good amount of cosmetic surgery. Also in my institution. I take care of a lot of other physicians and nurses and staff in the hospital for reconstruction as well as for cosmetic purposes. The majority of my cosmetic practice is built on word of mouth and referral, and a lot of times it comes from from my reconstructive patients as well and the experience that they have and experience that the nurses have taken care of them in the hospital. And so I give this example where, you know, I could have a really well heeled skin graft and donor site. Have it all hell within 14 to 15 days. However, if the patient experience is not ideal or if it is poor, which is, say they have pain, they have a setback. They have leaky dressings. It feels messy or dirty to them. That has a big reflection on on me. And if patients in the hospital tell they're they're carrying nurses that my procedure caused pain. The, uh you know, the next step there is that Dr Chowdhury causes pain or plastic surgery causes pain, So I don't wanna have a breast augmentation because it causes pain. I don't want to have a tough time because it causes pain, or I have a painful experience with so and so with Dr Chowdhury. That's how it happens and how it works. So if I can, uh, you know, minimize the pain discomfort for my patient keep in mind. Also, every time the patient has pain requires narcotic. Nurse has to go take care of that. She has to do addressing change. She has to address it. It takes her away from taking care of patients that might need her more or him or right. So I think that's that's really important to keep in mind. However, if you have patients in the hospital recovering from a skin graft, that is really, you know, on minimum medication has minimal needs. It makes it for an easy patient to nurse or care for, which I think is important as well. We want smooth, easy processes. Additionally, if I have patients that are calling my office for paying issues or leaky dressings, I've haven't come into my office, examine them, evaluate them, and I'm happy to take care of that. But if I could minimize that, I am now liberated to take care of other other patients, and I could take care of more patients and I can. I can provide better outcomes for essentially more people, which I think is the goal as well. Um, so the overall experience, the the other thing I keep in mind also is, you know, it's, uh it is a social media world out there. It is a review world out there, and if you're reviews aren't all five stars, it's gonna be tough. It's tough to grow. It's tough to build is tough toe to be a part of a community, and the way I I think about This is the, um, patient who has a a tummy tuck or a face lift, or a patient who I'll put it like this. Ah, patient. Anybody who is involved in any type of online retail. Let's say you buy a device by microwave. You communicate with the online vendor. They communicate really smoothly with you. The microwave arrives at your home within three days, just like it was promised. It runs perfectly. It's in perfect condition. However, when it arrives at your home, it's got a tear in the box or broken box. There were some people they're going to say. I had a good experience with shipper. Everything went well. I got my device that works well. There's something to say. Well, you know, my create works well, but you know, there's a The box was broken. And so here's a three star review for the for the vendor, and it's unreasonable is not fair, right? But that's what we deal with. I have a beautiful result for a patient, but if they have a pain issue or they have an issue somewhere with addressing, it doesn't work that well. That's what goes into reviews. That's what goes into building your reputation, the great stuff. It takes a while for people to go out and tell you other people how great your work is. But if you have a bad experience with someone, they tell people immediately. So I think it's good to keep in mind. It's It's more than just wound healing. It's more. It's patient experience because keep in mind, wounds heal. I think anybody takes care of wounds for a long time. Those wounds do hell, but we want to provide a better outcome, a better experience and getting the hell quicker. So can I. I think that if I, um when I look at once, if I wanna go from here, you know, to hear I keep my goals, you know, or if I wanna go to defensive if I want to read knee reconstruction, my goals can remind remain the same and try to keep those in mind for my patients and try to the same outlook the same approach, so I can really keep those consistent and be set and be successful in what I'm trying to achieve. Eso, my experience and observation with program prison have been that I have improved pain management, improved drainage, exploited capitalization. We also have a paper that that shows that there has been almost minimal to no narcotic pain requirement. Using a prominent prisoner was grabbed on her sites. It's been an absolute pleasure meeting with all of you. Andi, I hope this educational and it was little entertaining. That's great. Too nice to meet you are.