The Peter Attia Drive - #13 - Brett Kotlus, M.D.： How to look younger while you live longer

00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.

00:00:10.160 The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,

00:00:15.600 along with a few other obsessions along the way. I've spent the last several years working with

00:00:19.840 some of the most successful, top-performing individuals in the world, and this podcast

00:00:23.600 is my attempt to synthesize what I've learned along the way to help you live a higher quality,

00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.000 and other topics at peteratiyahmd.com.

00:00:41.160 In this podcast episode, I'm speaking with my friend, Dr. Brett Kotlis. Brett is a New York City-based

00:00:50.060 eye and facial plastic surgeon who specializes in cosmetic and reconstructive surgery of the face,

00:00:55.660 but particularly specializing around things to do with everything with the eyes, including the skin

00:01:02.700 around the eyes. He's trained both in general oculoplastic surgery and general cosmetic surgery.

00:01:08.860 I met Brett about three years ago, and I still remember our first meeting. We met for the first

00:01:16.020 time when he just came by my office at some point, and we sat around having coffee. And as he walked me

00:01:21.420 through not just his training, which is actually quite unique, but also his particular approach,

00:01:27.380 I realized we were kind of kindred spirits in our appreciation for nuance. As you'll learn in this

00:01:32.600 episode, I know pretty much nothing about looking good and skin and eyes and all that stuff. And in many

00:01:39.580 ways to spend time with Brett is to spend time with someone who thinks a lot about how to make small

00:01:48.740 and subtle changes over time that lead to long lasting effects. And I think the reason that

00:01:54.440 resonated so much with me is my belief in longevity, of course, is that it's a compounding issue and

00:01:59.960 therefore making small but consistent changes that lead to seemingly small improvements over the short

00:02:08.220 run is actually what leads to amazing results over the long run with respect to the reduction of risk

00:02:14.420 of disease, etc. Brett's approach to cosmesis is the same way. And I suspect that my bias is probably what

00:02:22.460 has me thinking that that's really the right way to do it. And once I got to know Brett better, and we

00:02:27.500 started to collaborate and work together, and I've sent a number of patients to Brett, I was always amazed by

00:02:33.180 the responses because to me, the right way to, for example, do Botox is to be able to look at a patient

00:02:39.740 after the procedure and say, I didn't know you had Botox. And so things that we talk about here are a

00:02:44.920 bunch of things that you can do to make a huge impact on the health and vitality of your skin.

00:02:50.120 And he does get into a number of these things specifically around Botox. He also gets into a

00:02:55.620 growing list of sort of all the facial treatments and cosmetic procedures that are out there, lasers,

00:03:00.620 peels, all of these sorts of things. And most importantly, I think he also helps you as the listener think

00:03:05.740 about how to pick someone. Because again, you know, many of you listening to this might find this

00:03:09.780 stuff interesting. And sure, if you happen to be in New York and you want to meet Brett, that's great,

00:03:14.080 but most likely you're not. And so the more important question is, how do you sort of separate

00:03:19.600 the good from the great or even the great from the not so great in this space? So again, like I said,

00:03:26.160 I don't think a lot about this personally. I realize I should probably think about it more when I look at

00:03:30.260 pictures of myself today versus pictures of myself. When I was 30, I am sort of surprised

00:03:35.760 at how much I feel like I look like I've aged. And I guess part of this was a bit of a wake-up call

00:03:40.640 for me that I might need to pay a little more attention to that. If for no other reason than

00:03:44.660 just to have the optionality to look a little better when I'm 80, then I'm probably on the course

00:03:49.320 to looking. Brett does a great job here explaining why our faces change over time, what he considers the

00:03:55.540 three most important tools for skincare and rejuvenation. He gets into all the procedures,

00:04:00.360 as I mentioned, the lasers, the peels, the needles, the devices. I really enjoyed his discussion of the

00:04:05.580 right way to do Botox because I'd heard this before because of course, Brett and I had discussed this a

00:04:09.520 lot, but I'm glad we were able to sort of revisit that for people here. And he also talks a little bit

00:04:14.460 about the current trends and future trends of cosmetic and plastic surgery. You can follow Brett on

00:04:19.320 Instagram. He's drkotlus, D-R-K-O-T-L-U-S, where he puts up lots of before and after photos, especially

00:04:26.220 around the eyes, which I find particularly interesting. That's something about myself that

00:04:30.600 I've always been curious about making better. And his website has the same URL. Lastly, you can see

00:04:37.600 some stuff in the show notes here. I asked for Brett to give us kind of his recommendations on

00:04:42.660 products that he suggests that his patients get that if anyone is interested in, they'll at least be

00:04:48.020 able to sort of get that. And you can see that at peteratiamd.com forward slash podcast. So without

00:04:53.240 further delay, here's my conversation with Dr. Brett Kotlis. Well, I'd like to welcome to the show

00:05:01.800 today, Dr. Brett Kotlis, who is an oculoplastic guru and also a close friend of mine. Brett, we met

00:05:12.520 what about three years ago? I would say maybe it's two. Okay. Yeah. It just seems like we've known each

00:05:17.280 other long time. The first time we met, I remember being really impressed by kind of the nuance of

00:05:24.280 your training. Thank you. I tend to think and talk a lot about longevity, but I don't tend to think

00:05:29.600 and talk a lot about or know anything about looking younger. And you have learned an awful lot about

00:05:36.320 that. So remind me, how did you train? What was your medical training? When I was in medical school,

00:05:41.840 I was drawn to this specialized field that was sort of a cross between ophthalmology and plastic

00:05:49.080 surgery. And it's called oculoplastic surgery. I was watching this doctor do an orbital tumor

00:05:56.040 resection. And so I decided this is what I want to do. And I learned that I needed to do a residency in

00:06:05.080 ophthalmology before I can do a fellowship in oculoplastic surgery, which the field basically

00:06:11.260 revolves around the eyes and the face and plastic procedures related to that. So I found out that I

00:06:19.380 had to do an ophthalmology residency first. So I did that. And then I matched in this training program.

00:06:26.080 The match process is sort of like the medical matchmakers and you are assigned to a program

00:06:32.320 based on a ranking system, which you've been through that as well. And I matched with this

00:06:37.100 doctor in Tucson who happened to have transitioned his practice into cosmetic surgery. And so when I

00:06:44.440 arrived, I thought I was going to be doing mostly orbital tumors and tear duct surgery and eyelid

00:06:49.800 reconstruction. And that was part of what we did, but we were also doing a lot of facelifts and fat

00:06:56.880 grafting and liposuction and lasers. And so my fellowship training qualified for two different

00:07:05.740 organizations, the American Society of Ophthalmic Plastic and Reconstructive Surgery, and then also

00:07:11.940 the American Academy of Cosmetic Surgery. So when I finished my fellowship, I ended up working in this

00:07:19.120 practice in Michigan that was the largest medical spa in the Midwest. And it was an exposure to even

00:07:27.800 more lasers and more technology that was on the cutting edge of what doctors are doing for our

00:07:34.240 appearance. I remember one of the things that really surprised me when we spoke was just understanding

00:07:40.820 that basically anybody with an MD can hang a shingle and do kind of whatever the heck they want with

00:07:46.600 respect to facial plastic stuff. I mean, anybody can be injecting Botox and fillers and all of these

00:07:52.300 things. And of course, not everybody's doing this stuff well, and not everybody's doing this stuff with

00:07:57.280 the eye towards how will this look down the road. And I think your approach seemed very nuanced and

00:08:04.920 sophisticated. So I hope to certainly touch on that today, but I kind of want to start with some

00:08:10.120 just fundamentals. So I saw a picture of myself 20 years ago, meaning I recently saw a picture of

00:08:16.460 myself from 20 years ago. And I was like, God, you were like a better looking dude back then.

00:08:22.160 Why is it that at 25, I looked better than 45? And part of it, I think, is just my skin looked so much

00:08:30.820 better. So even though by most people's standards, I'm not an old guy today, clearly my skin doesn't look

00:08:38.640 like it used to. What has changed?

00:08:40.920 It's interesting because there does happen to be a double standard for men and women. And we have the

00:08:47.700 benefit of looking more distinguished as we age. So I don't think all men feel that way, that we're

00:08:53.680 looking worse as we age, but certainly our faces are changing. And there are some aging changes that

00:08:59.600 are intrinsic and some that are extrinsic, right? So your genetics, you're programmed to have certain

00:09:07.020 changes over your lifespan, right? We lose bone as we age, which happens in our faces. We are losing

00:09:15.180 facial fat as we age. And in some ways we're losing it in maybe the wrong places. And the sun that we're

00:09:23.720 exposed to over many, many years causes something called solar elastosis. So we are losing collagen and

00:09:31.160 elastin. The thickness of our skin is decreasing in many areas. And we're also gaining small blood

00:09:39.960 vessels, the telangiectasias, and we are gaining brown spots. And the combination of these things on

00:09:46.340 every layer, your skin, your fat, your muscle, your bone, the ligaments that connect the interplay

00:09:52.740 between these layers are all losing support and they're getting thinner and they're degrading.

00:09:59.360 So from the time that you're born until now, you started off with really chubby round cheeks.

00:10:07.060 So you look at your one-year-old son and it's all downhill from there.

00:10:12.020 Now, there seems to be something about the face in particular. So I used to swim a lot and I used

00:10:16.980 to swim outdoors, obviously. So I did spend sometimes six or eight hours just swimming in the,

00:10:22.480 out in the ocean. And I didn't even bother putting sunscreen on because, you know, I have dark skin,

00:10:27.240 I have olive skin, I never get sunburned. So I'm pretty used to being the guy that's getting a ton

00:10:32.300 of sun. And while I accept that that's probably caused some damage to my face, why does it not

00:10:37.520 seem to have caused that same damage to say my back, which was even more exposed to the sun when,

00:10:43.260 you know, I'm swimming in a prone position? Well, if you think about the tension at play and based on

00:10:49.720 your face and your back, I mean, they're, they're different. So your face has more movement,

00:10:54.480 but there's also, because you need to move in certain ways, there's also more areas of laxity.

00:10:59.960 Whereas your back, the skin is stretched and it's taut, even though you can certainly get brown spots

00:11:06.120 and wrinkles on your back. Think about scars on the back tend to spread. They look wide and stretched

00:11:12.160 and they don't heal well because it's under constant tension. But I think that tension makes

00:11:17.360 the back skin look different than the facial skin. But you also have different oil glands,

00:11:22.120 different parts of your body. So you have a higher density of sebaceous glands in your face

00:11:27.360 and the muscle, muscular expression. I think it affects the way that you age more than it does in

00:11:34.800 other areas. Now, I read once that, um, by about the age of 35, you've, you'll lose about 10% of the

00:11:42.420 fat in your face, which is kind of amazing to me, given that by the age of 35, I probably gained 10%

00:11:48.700 of the fat in my body. What, what is it about the face that doesn't do what the rest of the body

00:11:53.760 does, which is accumulate fat? Yeah. Well, I think there's probably local hormone effects that are

00:11:59.080 making you accumulate in other areas. And in the face, we have the fat cells come from different

00:12:05.260 embryologic origins. And for some reason, that's what's happening there. And you were talking about

00:12:10.680 very small amounts of fat. So you'll see those small differences, but think about your facial fat

00:12:17.240 as insulation. And as you lose that insulation, you start to see the structures that are underlying

00:12:23.240 the surface. And so you can see where the ligaments are tethered and you can see the places where

00:12:29.020 they're not tethered, which would be an out pouching. And so all of those tight areas opposed

00:12:35.020 and just directly next to the areas that are not tightly attached, you see these contours.

00:12:40.600 And so as you age and you deflate and you have gravity pulling down, I mean, the effect of gravity

00:12:46.340 is real. Have you ever seen a, like a slow motion video of a runner and you see their face and the

00:12:53.600 way that the face bounces up and down and there's so much force on those facial ligaments. And so you

00:13:00.640 can imagine what happens as you're just walking and running up and down the stairs and over and

00:13:04.560 you're smiling and you're doing all these things with your face. So there's wear and tear just like

00:13:09.480 it happens on our joints. It happens on our facial ligaments. Have you ever lied down on your back

00:13:14.280 and take a picture and then stand up and take a photo that lying down image that eliminates the

00:13:20.220 effect of gravity on your face. And that shows you what is gravity doing in combination with the

00:13:26.000 deflation. So that's how you take a selfie is when you're lying down and take a lying down selfie.

00:13:31.260 There's tip number one, guys, the anti-gravity selfie in longevity. I used to, used to, I still

00:13:38.020 do. And I certainly don't, don't deserve credit for this. Smarter people than me have said this first,

00:13:42.520 but the joke is the most important thing you can do to live longer is choose the right parents.

00:13:47.020 So there are lots of things that you can do to live longer, but genes really play a role.

00:13:52.600 Now in the longevity space, we have a pretty good sense of what those genes are. There are

00:13:58.420 somewhere between about eight and 12 genes that offer pretty remarkable protection in delaying the

00:14:05.740 onset of chronic disease. And therefore centenarians, people who live to be a hundred or longer tend to

00:14:11.460 be bestowed with a greater proportion of those genes. But you mentioned a second ago that genetic

00:14:17.840 factors can also influence these sort of intrinsic changes that occur. Do we have a sense of what those

00:14:24.940 genetic factors are? Clearly there are people who just have remarkable skin and they age with

00:14:30.080 remarkable skin. And, you know, you'll see a woman who's 40, who looks like she's 20 and her mom is 65

00:14:35.140 and she looks like she's 45.

00:14:37.380 Well, we know that there are some correlations between certain genetic types and certain traits

00:14:43.420 and the way we age. I mean, if you know, I see a lot of people for under eye backs and it's almost

00:14:50.540 everybody says, Hey, this is, this is genetic. Well, yes, I know it's genetic. I mean, your parents

00:14:55.500 have it. You came in with your mom and she has it too. So the structure of your face obviously comes

00:15:01.060 from your parents. But when we talk about skin types and the skin color, darker skin types tend to

00:15:07.440 have more connective tissue or denser connective tissue and tend to look better as they age.

00:15:14.620 So I mean, it's a generalization, but a lot of the Asians in my practice tend to look better,

00:15:20.900 longer, darker skin individuals, the same thing. And so the darker pigment in skin does give you some

00:15:28.900 UV protection. It doesn't mean that you don't have to wear sunscreen, but it offers photo protection.

00:15:34.040 And I, I theorize that UV exposure from sunlight causes fat atrophy over many, many years.

00:15:42.840 Wow. What do you base that hypothesis on?

00:15:45.540 We use heat and we use laser procedures in a very highly focused way. And we know that it destroys

00:15:51.780 fat cells. So these externally applied devices that are available now, and they effectively remove

00:15:58.820 subcutaneous fat. And I believe that UV radiation does the same thing over a long period of time.

00:16:05.740 And if you've seen people that have always protected themselves from the sun, they look

00:16:09.900 like they have white porcelain skin, they have less wrinkles, and they have younger looking faces. I know

00:16:15.780 we're moving away from the genetic question you're asking me, but I think you can often overcome many of

00:16:21.440 the genetic things just like with chronic diseases or with your lifestyle modifications. But I think

00:16:27.880 that there is also an internal drive that we have to perpetuate our gene pool. We each have our own

00:16:35.140 internal motivation to do that. That's just our evolutionary goals. And I think some of the more

00:16:41.740 favorable genes become selected over time. And so I think there's a genetic motivation for people to

00:16:49.820 want to look good, because they want to present themselves in their best possible way to a

00:16:55.220 possible mate, kind of like a peacock. We don't have feathers. So one of the things that I'm sure

00:17:01.820 anybody listening to this, and certainly I've always found a little bit, I don't know, worrisome is

00:17:07.180 God, if I had a dollar for every time I saw someone walking down the street, and who'd looked like

00:17:13.080 they'd had a million procedures done, and you just feel bad for them, you feel like God, something went

00:17:18.360 wrong there. You don't look natural or normal. And I think for many people, it becomes off-putting,

00:17:24.680 and they think, well, gosh, like I don't want to do anything. So it begs the question, are there

00:17:29.760 strategies that one should take to consider gracefully aging in as much as one cares? I mean,

00:17:37.240 look, I think in the end, some people are going to say, I don't care about any of this stuff. But

00:17:41.020 presumably, if someone is still listening to us talking now a few minutes into this, they probably care.

00:17:45.540 Right. How do you think about this? And maybe how does that differ from what other docs think,

00:17:49.900 or what would be a traditional point of view? Think about all the people that are walking by

00:17:54.880 on the street that have had work done, and you don't notice it because it's done well. So I think

00:18:01.600 you're seeing that every day, but you just don't know it. Yeah, I only see the numerator. I don't see

00:18:07.260 the denominator. And what are the reasons for the unnatural appearance? Why do people get to that

00:18:12.740 point? I think in some cases, maybe it's unlimited access or unlimited resources. I think there are

00:18:19.380 forces that push people in that direction. Your appearance is a very emotional subject. And I think

00:18:28.640 we tie ourselves to that, maybe an age that we feel like that was our best age. Think about the

00:18:34.820 actress that everyone knows for the role that they played when they were 20 years old. And

00:18:41.020 in our minds, we think of them as that person. And it's almost hard for us to imagine them aging,

00:18:46.500 and you see them and you're like, oh, look how old they look. And I think it's a natural tendency to

00:18:51.320 think that because you're remembering that favorite movie that you saw them in. But think about the

00:18:55.340 pressure they feel in that situation. Like my career is based on my image. And so if you try to hold on

00:19:03.400 to that 20-year-old version of yourself, at some point, you're going to cross the line into an

00:19:10.400 unnatural, distorted look. So there's probably a rough guideline. Your goal should, you know,

00:19:17.540 if you want to look your best, maybe I'd like to be look a little like seven years younger than where

00:19:22.340 I am now, or 10 years. But if you go beyond that, it's a little too much. That's one part of it.

00:19:28.640 I think the images that we see around us, if you look at some of the, this is part of like what I

00:19:35.080 call the Instagram effect, where you're scrolling through and you see these photos of celebrities

00:19:40.620 that have blown up their lips, and their cheeks are over the top or whatever it is. And some of it is

00:19:47.460 Photoshop, but some of it is from medical augmentation. You start to think that that's

00:19:52.940 the new normal, but it's overdone. And that exaggerated appearance, it's people around you

00:19:58.880 in your circles might be doing some of these procedures. And so you all see each other like

00:20:03.240 that. And then you want to get a little bigger and just push it a little more. And then before you

00:20:08.060 know it, you've gone too far. And it can be a slippery slope. So I think people start to lose sight of

00:20:14.120 where they started and what their goals were. Your goals maybe change. And maybe you've found a

00:20:19.900 provider, there's a doctor or a nurse injector that said, okay, you know, let's take this a little

00:20:25.460 further, a little further. And then they say, you know, I think you're good here. Let's stop it. But

00:20:29.120 you want to go further. So you'll find somebody. And so you'll, you'll get to another provider and

00:20:33.060 they'll do it. I personally feel this way. If someone comes into my office and they've had something

00:20:37.120 done, I think I can fix them. But maybe you can't, or maybe it's time to say, okay, let's put the

00:20:42.320 brakes on. So I think there's different reasons why people get to that point. But the technical

00:20:48.080 reason that someone looks unnatural is when you either try to enlarge something beyond its natural

00:20:54.520 dimensions, there's only a certain point is how far the skin will stretch before you start to lose

00:20:59.240 the contours. And we say like, you can't have light without dark. So the goal of your face, the goal of

00:21:06.600 a natural looking face is not to be totally smooth and to have no curves and no shadows and

00:21:12.600 no lines. When you smile, you're supposed to, you see my brow elevate and you see some lines in my

00:21:16.820 forehead. You know, I'm, I'm, I'm conveying expression. I'm conveying a message to you that

00:21:22.380 I'm surprised or that I'm angry. And so if you lose those expressions, if you lose the shape of your

00:21:27.600 lip, you have a cupid's bow where it looks like it dips down in the middle, or you have two pillows in

00:21:32.560 the lower lip. And if you distort that by just blowing past all of that and filling it up. And so

00:21:37.680 you have a sausage now for your lower lip. I mean, your eye will pick up on that very quickly that

00:21:42.280 that's not natural. You might not know how to describe what is natural, but you know, it isn't.

00:21:48.140 And so you distort the natural dimensions and pulling will achieve the same type of distortion.

00:21:54.040 If you go too far facelifts, when they're pulled back too tight, because someone is being too

00:21:59.880 aggressive on the surface of the skin, you see the windswept look, those type of things where,

00:22:04.960 you know, you see it in older actresses or even actors, maybe they feel like, okay, I can spend

00:22:10.660 this much money to look like this version of myself. Well, there's no amount of money that will

00:22:16.000 make you look naturally 30 years younger than where you are. You know, if you compare, I think,

00:22:21.940 people's bodies today to people's bodies 30 years ago, based on augmentation, there are some

00:22:27.380 inevitable trends. Now I don't have any data to back this up, but I can only imagine that breast

00:22:31.360 size is larger today. I think breast augmentation must be more common than it was 30 years ago.

00:22:36.600 When it comes to facial augmentation, what are the trends? And I'm not talking about the,

00:22:42.320 just the extremes where people have like gone too far, but it would seem to me that people tend to

00:22:47.660 have fuller lips these days. Is that, would that be true? I would say yes. And for good and bad

00:22:54.440 reasons, I think we recognize now more and more that global volume loss is something that's happening

00:23:00.880 to our faces as we age. And that includes the lips. So lips can be reinflated because they've lost

00:23:07.960 volume in a natural looking way that you wouldn't know about. I think that there is a tendency now to

00:23:13.660 focus on these areas. So look, when you come into my office and you say, Hey, look at my face,

00:23:18.660 what should I do? I'm probably not going to just say like, okay, you should do this, this,

00:23:22.180 and this. I'm going to focus on what you're seeing, but I might point out certain things like,

00:23:28.480 you know, you've lost a lot of volume in this part of your face. And I know you're focusing on

00:23:32.660 your, your brows for something, let's say, but, um, but I, I see, you know, I want to maintain a

00:23:38.720 balance. So it's been popular to fill these nasolabial lines next to the lips, you know, the

00:23:44.680 lines that go from the corner of your nose to the outer corner of your mouth or to inflate the

00:23:49.520 cheeks, but we have to look at the neighboring areas. Like you're a car guy and you get a scratch

00:23:54.500 on your car where you have to paint the panels next to it in order to make it look good. And so

00:23:59.580 a good provider, a good physician will look at you and say, okay, your concern is your,

00:24:06.140 your nasolabial lines. But I think we should also just at least consider your lips because

00:24:11.300 let's look back at your photo from 10 years ago and look what your volume status was then.

00:24:16.580 And let's look at it now. So I think in a good way, people are focusing on lips, but also I think

00:24:21.900 the negative is that, uh, there's always going to be some people that are over the top. And I see it

00:24:28.160 a lot when, you know, when you have a lip injection, you know, typically we're using hyaluronic acid

00:24:32.080 fillers, which is something that's a constituent of our skin to begin with. So these are very safe

00:24:37.680 in terms of that. They're not, they're biocompatible. There's no allergic reactions to them in general

00:24:43.560 and they're reversible. So we have an enzyme that can take them back. If there's something

00:24:48.320 that doesn't look right, or there's an issue, but with these gel fillers, they tend to be

00:24:53.700 hydrophilic, meaning that they absorb water. And for the first two or three days after you do it,

00:24:59.340 your lips look like that person that you're trying to not look like they get pretty big. So most people

00:25:06.260 for about two days, they're sort of like homebound or they're freaking out. They're wondering if they

00:25:10.840 overdid it. Yes. But it's almost a hundred percent of the time, the first time someone does lip filler

00:25:17.200 and they come back and I said, okay, you were pretty swollen. I bet for the first two days. And

00:25:21.500 they say, yeah, but I sort of miss some of that swelling. And so the next time around we do a little

00:25:27.200 bit more and that's sort of like where you have to determine that's, that's, um, it's a personality

00:25:34.340 thing. It's a personal decision in terms of like, what is good. And, and it's a discussion between,

00:25:40.280 you know, myself and my patient. And, and we don't always agree. Like my patient might say,

00:25:44.940 you know, I hear what you're saying. You're telling me this is natural. I want to go a little

00:25:49.460 further. And, you know, I'm open to that. Now that's something that doesn't like a facelift.

00:25:54.300 Once you get a facelift, you're kind of stuck with it, right? I mean, a redo procedure there is going

00:25:58.940 to be cumbersome. It depends on, you know, what the reason is for doing you can, there's a big,

00:26:03.420 I think role for revision facelift surgery, but you're right. When you take something out,

00:26:07.900 right. Or you over reduce the nose or you overstretch someone that can be very difficult

00:26:13.180 to, um, to repair. But obviously the hyaluronic acid doesn't last forever, right? Right. So if

00:26:19.380 someone is doing, whether it's an extreme or incremental strategy of filling, how often do

00:26:25.060 they have to do that? It depends on the area. So, you know, lips tend to not last as long as other

00:26:30.180 parts of the face. Like I, I do a lot of under eye filler under your eyes. You don't have a lot of

00:26:35.240 movement there, even though you're blinking under eye filler lasts, you know, a year, two years. I've

00:26:39.780 seen it last four or five years in some people, whereas the lips, you're always talking and

00:26:44.200 pursing your lips and eating maybe six to eight months. Now you have a very interesting technique

00:26:49.800 of doing the under eye filler, which I've sent a number of patients to you because I've been

00:26:54.680 so impressed by just how amazing it looks and how minimally invasive it is. What, what do you do

00:27:01.320 different there? So this is sort of become my niche in my practice. And I probably do that one procedure

00:27:09.740 more than anything else. And it wasn't by design. I didn't plan for this to happen, but it was

00:27:15.640 definitely an interest of mine. And, you know, when you look at someone's face, the first thing

00:27:20.860 that starts to age would be the eyes, because that's where we have so much movement. We're

00:27:26.500 blinking all the time and we have the thinnest skin in our body and combine that with the fat pads under

00:27:32.480 your eyes, which can enlarge with time because they have a different embryologic origin and we're

00:27:37.480 losing fat in our cheeks and the upper part of our cheek, which that groove where you get that shadow

00:27:42.960 is called the tear trough, which I don't really like that term. It makes me think of like pigs eating

00:27:47.840 at a trough, but that trough would be, if you were to cry, it would sort of spill down that kind of

00:27:52.780 slide in the inner corner of your eye. This is what makes people look like they have almost a black

00:27:56.800 eye sometimes from the shadow. Right. And people think, you know, everyone says I'm tired, but I'm

00:28:01.260 not. And so when you combine the puffy under eyes with the tear trough area, you look tired and you

00:28:07.860 might not be, or maybe you are, but you just don't want people to know it. So what I do with fillers,

00:28:12.440 I use a hyaluronic gel filler and I inject it there, but with a cannula. So a cannula,

00:28:19.340 what's a cannula for people who don't know it's like a needle, but the tip is dull. It's a blunt

00:28:24.860 tips needle. So what I do is I approach that area from the cheek. We make a little needle hole in the

00:28:30.460 cheek, and then I introduce this cannula through that little needle hole. So you have no needles under

00:28:35.440 your eye and I can use that cannula in a very accurate way. And at this point I know exactly where my

00:28:41.880 tip is all the time, even though I don't always see the tip, I know where it is. And when I'm doing

00:28:47.480 this, I'm, I'm imagining the surgical procedures that I do very frequently, which is blufferplasty.

00:28:53.100 And so, because I know the, so that's a blufferplasty just means that modification of the eyelids

00:28:59.020 through surgery. And so cosmetic blufferplasty is often either removing the fat pads, the bags,

00:29:05.580 removing skin from the upper lids or shifting the fat, whatever I have to do to make your eyes look

00:29:10.680 younger or the way that they used to look. So I do a lot of blufferplasty. And because of that,

00:29:15.340 I know what it looks like inside. And so I imagine that in my mind when I'm placing the filler and

00:29:21.860 I'm placing this gel that takes up space and it's replacing the fat that you've lost, or it's also

00:29:29.620 disguising the fat pad that might be bulging. And so by putting it in the right place and using the right

00:29:35.340 filler, because there's certainly, there are hyaluronic gel fillers that are incorrect for that area

00:29:39.980 because they just have the wrong properties, the wrong stiffness, the wrong amount of water

00:29:44.220 attraction, but placing it in the right area and the right amount.

00:29:48.900 Is Restylane a hyaluronic acid paste filler?

00:29:51.240 That's one of the fillers that I use. And it's also amount of, it's having restraint. So

00:29:56.220 I understand at which point that this will become puffy or look unnatural and that's where we stop.

00:30:02.380 And sometimes we stage it, but this procedure will brighten up people's faces who look like they

00:30:08.880 have bags and look like they're tired. And it's really gratifying to see people's reactions to

00:30:14.380 this when they look in the mirror, especially when you do one side and you look in the mirror and then

00:30:17.680 you see the difference. It's pretty remarkable. And so it's one of the things I really enjoy doing.

00:30:23.440 And I think that there's a lot of doctors that sort of stray away from it either because they're not

00:30:26.980 comfortable with the idea of injecting under the eyes. There's risks with everything we do.

00:30:30.960 So to me, that's not a high risk procedure, but I think it's perceived as one.

00:30:35.880 I think part of it too, is this gets back to your unique training. I mean,

00:30:39.860 you trained first as an ophthalmologist, which, you know, if I think about it, like I trained in

00:30:45.060 general surgery, like my, my scope of what I needed to know was so broad. But when you look at

00:30:51.080 someone who's training in ophthalmology, like you get to focus five years on like two inches of a

00:30:56.840 person's body. So your knowledge of that anatomy is, is, is unparalleled.

00:31:01.760 Right. I was narrow to begin with. And then I became,

00:31:03.740 and then you become even more narrower. So it seems to me that the advantage that you have,

00:31:07.360 and this is certainly why I've always felt very comfortable sending people to you is I know that

00:31:11.860 people who understand the anatomy because they've operated, they've actually been beneath the surface

00:31:16.860 can do exactly what you describe, which is there's sort of, they know what the art is.

00:31:21.740 Put it this way. When I was in residency, there was never any confusion that I would go into

00:31:24.760 plastic surgery or when I was in medical school. Like I just don't have that artistic

00:31:28.160 capacity, but I would say, you know, at the same time, you know, I like to talk about my skills,

00:31:34.380 but I, I don't, I think there's like a political part of this conversation where the question is

00:31:39.380 like, who do you go to and who's the right kind of provider? If you want to do something like this,

00:31:43.240 I don't think it has to be a certain person or a certain kind of person. I think that there are

00:31:49.200 good injectors and bad injectors. I think there's good doctors.

00:31:52.300 How can people distinguish? So if you're, if someone's listening to this podcast and they're

00:31:56.700 saying, well, you know what, these bags under my eyes are driving me crazy. Let's say they don't

00:32:01.120 live in New York so that you're coming to see you wouldn't even be an option.

00:32:03.960 Well, people come from other places or countries to see me. But I think when, if you're looking for

00:32:08.580 a provider for anything, obviously everyone, everyone says, oh, I did my research.

00:32:12.900 Put it this way. If your wife needed a procedure and you decided, you know what,

00:32:16.720 I don't want to be the one to do it because there's an emotional connection to this person.

00:32:20.240 And how would you pick the person that would do this to your wife or your mom?

00:32:24.260 I think you have to find out first, what are the organizations that certify people

00:32:28.920 for my field? And let's say talking about blepharoplasty, I think there's a handful of

00:32:34.680 specialists that would be competent. You could be a plastic surgeon, a facial plastic surgeon,

00:32:41.040 an oculoplastic surgeon. I have, I'm biased towards oculoplastic surgeons because that's

00:32:45.940 a big part of what we do. I would look at that first. References like referrals from other people,

00:32:53.100 obviously, you know, look, if you wanted to find out the best surgeon in your, in the hospital,

00:32:58.020 you'd probably ask the nurses or the scrub techs and say, tell me, or the anesthesiologists because

00:33:03.320 they have firsthand knowledge. So I think referrals go a very long way. And if you know somebody that had

00:33:08.480 a great result or you know someone who's done something, but you have to meet with a few people

00:33:13.340 because you might have the best surgeon or the best under eye injector or lip filler person.

00:33:19.880 And that person could also be a physician assistant. It could be a nurse. I mean, I've seen some

00:33:23.600 amazing physician assistant injectors that I would have inject myself, you know, without hesitation,

00:33:29.280 but it's like, are, do you have a good rapport with that person? Do you think you're on the same page?

00:33:34.340 Do you have the same goals and style? So it's almost like an interview when you go for a consultation,

00:33:40.080 sometimes you have to pay for a consultation fee, but I think it's worth doing that at least for two

00:33:45.680 or three or four doctors to meet with someone and say, I get the wrong feeling here, or this office

00:33:51.920 seems frantic, or the doctor just didn't even really look at me or listen to me. I mean, those things I

00:33:57.280 think are all really important. So I know doctors that are family practice doctors that are exquisite

00:34:03.880 Botox injectors. And so I think it's wrong to fall into the political trap of you have to have this

00:34:09.340 label next to your name, or you have to be this kind of like training. I think that a lot of the

00:34:14.880 training that I've done was post post your formal training. And some of the training is there are

00:34:20.620 things that I developed on my own, but for blepharoplasty or eye procedures, I recommend looking at the

00:34:26.280 oculoplastic organization, but for things in general, I think you should look, you look at photos of

00:34:31.860 people all have their galleries online, they're going to show you their best work. So you look at those

00:34:35.560 pictures, and you say, Oh, those look good. Or some, I look at some well known doctors and surgeons, and I

00:34:41.220 look at their photos. And I think this does not look good to me at all. I don't think this is natural. And

00:34:46.400 they're promoting it as their best work. There are a lot of things that I see around the eyes where, you know, I

00:34:51.780 preserve fat, and sometimes I'm often adding fat, which a lot of people don't like to do, because they

00:34:56.920 don't maybe have the same philosophy that I do. But I see hollowed out eyes.

00:35:01.860 And people are pushing that putting that forward is that this is my best blepharoplasty. Maybe for

00:35:06.460 someone that is maybe that's the look they're going for. You should want to ask how many procedures

00:35:10.340 the person has done? Is there a certain number above which you sort of hit that threshold of okay,

00:35:15.840 now I've really, you should ask all of these questions, like how many procedures I mean, look,

00:35:21.040 I've done well over 1000 2000 of under eye fillers, buffer plasties, like, it's 1000. So,

00:35:28.340 but in early in my career, I did lots of procedures, and it was probably hundreds. So

00:35:32.720 you should ask and your doctor shouldn't be defensive about those questions. You can say,

00:35:37.940 hey, can I talk to somebody who's had this with you? And we do that all the time. We connect

00:35:42.120 patients with previous patients who are, who are open about it, and say, hey, what was your

00:35:47.040 experience? Or can you say, well, tell me about the complications you've had. And if I get one of

00:35:52.020 those, what are you going to do for me? How do you how do I manage that? Do I have to pay

00:35:55.040 to fix the complication? Those are questions you should be asking.

00:35:58.000 That's such an important thing in medicine in general. It's amazing how easy it is to gloss

00:36:03.500 over consent forms. And you just sort of list a whole bunch of generic complications. But you

00:36:09.180 don't actually talk about what probabilistically or expected complications could look like. And to

00:36:14.560 your point, what are the next steps? So for example, you know, with breast augmentation,

00:36:19.380 I know a woman who had these really horrible contractures develop. And I was like, God,

00:36:25.920 I'd never even heard of that. You know, I didn't even realize that was a complication. Obviously,

00:36:29.580 I'm not in the loop in that space. It's actually a common complication.

00:36:33.200 Yeah, it's about 3% I've learned. I think it could be even higher depending on the type of

00:36:37.680 implant and the placement. So those are things that surgeons should be saying to every patient that

00:36:43.100 3% is a relatively high rate. Yeah. And you're right. It could be, I mean,

00:36:46.920 it depends on the implant. So if you're using the different textured implants, it could be as high

00:36:51.140 as 5%. I mean, 5% complication is, is really high, right? One in 20 people who do this is going to

00:36:58.620 have this. And a lot of times on redos, it still happens, which is not to say one shouldn't have an

00:37:05.280 augmentation, but boy, I'd, I'd be very upset if someone I cared about had that procedure, wasn't

00:37:10.980 told about that complication and then developed it, especially if they required redo, redo.

00:37:14.780 Of course. And so that going into it, you know, let's say this busy surgeon's doing 20 breast

00:37:19.140 dogs a week. And so one, one patient every week is going to have potential reoperation. So going

00:37:25.200 in, you should know, Hey, I might have to do something else. And that's what I think any

00:37:29.100 procedure, the risk is relatively low with, with many of these things. Sometimes we're talking about

00:37:34.580 one certain complications might be one in a million. And so you don't have to put that as like,

00:37:39.540 this is likely for you to have, but yes, that's part of the discussion.

00:37:43.400 So let's go back to Botox for a second. I think about like six years ago, one of my good buddies

00:37:48.500 from residency, who's a plastic surgeon, I was just hanging out with him. We were just sort of

00:37:52.700 playing patty cakes one day and he was like, Hey dude, why don't I throw some Botox on your

00:37:56.500 wrinkly forehead? And I was like, all right, fine. So I like sat down in his little chair and he whipped

00:38:01.560 out some Botox and put like what felt like 3000 injections into my forehead. And, uh, and I put

00:38:08.000 an ice pack on it, went home. Classic mistake though, I think is what you're starting to describe

00:38:13.320 treating your forehead directly. Well, let me tell you, Oh my God. I don't remember how long it took

00:38:19.680 to wear off. I think it was about two to three months, the most miserable two to three months of

00:38:25.120 my life, because this was at a time when I was a very active cyclist and I didn't realize it until

00:38:31.480 of course I lost the ability to do so, but not being able to lift my brow meant I had absolutely

00:38:37.660 no way to keep the sweat out of my eyes, even when I was wearing my kind of do rag under my helmet. So

00:38:42.780 I couldn't believe how miserable I was not being able to lift my eyebrows.

00:38:48.020 Yeah. So it's uncomfortable. And then it's also a dead giveaway. So when you look around,

00:38:53.360 let's say you're watching the Oscars on TV or something, and you want to know which people have

00:38:57.940 had poorly done Botox and it's a lot, it's when the frontalis muscle, right? Which is the only...

00:39:03.700 So where is that for the people who are listening?

00:39:05.480 That's the forehead muscle, right? Okay. Between the eyebrows and your hairline. Okay.

00:39:10.620 Okay. So for some of us, it's further back than others, but the frontalis muscle is the only muscle

00:39:15.760 that raises your eyebrows. So you get those transverse, those horizontal lines across your

00:39:21.440 forehead and your instinct is like, Oh, I should do Botox to get rid of these. Well, if you inject

00:39:26.140 the frontalis to the degree, the degree where you smooth those lines, because those lines are formed

00:39:31.960 by the muscle contraction. So your muscles don't contract anymore. And I said, they're the only

00:39:37.300 muscles that raise the brows. So now you can't raise your brows. In fact, they drop, but your

00:39:41.240 forehead will be shiny smooth. So if you see somebody and they can't raise their brows at all, you just

00:39:45.280 see smoothness. They were over Botoxed in their forehead. And we say Botox as a generic, it's actually,

00:39:52.140 that's a trade name. And there's other Amgen product, right? That one is Allergan.

00:39:57.280 Oh, it's Allergan. Okay.

00:39:58.140 Currently FDA approved his Botox, Xeomin and Dysport. So those are all types of botulinum

00:40:04.800 toxin type A. There's slight differences in the molecules, but they all have the same effect.

00:40:09.480 So the mistake that was made for you was going after the horizontal forehead lines.

00:40:14.180 And in fact, what...

00:40:15.920 Which seems like a common mistake given on the frequency with which we see this.

00:40:18.900 Yeah. I think people know a little bit more about it now, but still, I think they use too

00:40:22.620 many units up there. So the unit is the strength of how much is being injected. But what would have

00:40:27.540 been better would be to inject the corrugator and percerous muscles, which are the ones that are

00:40:31.020 just at the top of your nose, but the ones that furrow your brow, you treat that. And then just a

00:40:36.180 light sprinkling in the forehead. So you can still elevate your brows, but you weaken that muscle

00:40:40.640 contraction. Then over time, if you do it a couple... It'll last you about four months. And then over

00:40:44.940 time, as you repeat it, then those lines will soften because you're not making as much of that

00:40:50.280 contraction.

00:40:51.320 So if somebody comes to you and says, Brett, when should I start doing this stuff? Let's say someone

00:40:55.220 takes the long view, right? Someone says, look, I'm, you know, whatever. I'm 40. I'm 30. I don't know

00:40:59.940 what the age is, but I want to know that when I'm 70, I look more like I would otherwise when I'm 50,

00:41:06.780 they want to take that view, which is... I'm not trying to look like I did when I was 16,

00:41:10.220 but I want to really take a long view of plenty of iterative interactions.

00:41:18.180 Are you looking at a magnitude of wrinkling or are you saying, you know, we start with very,

00:41:23.940 very small, for example, just looking at that area that furrows the brows, but not touching anything

00:41:28.120 on the frontalis muscle above it. I mean, how do you think about this from that standpoint?

00:41:32.500 I think we have to think from the beginning that you don't have to do anything, right? Nobody has to do

00:41:37.520 Botox. Nobody has to even spend this much time thinking about their appearance, right? People

00:41:44.180 do it because it's important to them. And what's important to you might not be important to someone

00:41:49.100 else. So with that aside, let's say your goal is to look your best as long as you can. You should

00:41:55.540 probably first start focusing on the preventive things, which can include neurotoxins like Botox,

00:42:03.440 but it should start with sun avoidance at a young age. You should do Botox or something like that

00:42:11.080 before you start to get etched lines. Is an etched line one that means when your forehead is relaxed,

00:42:17.020 the line still shows? Right. And I think it's okay. You know, I have some etched lines and

00:42:20.820 horizontal etched lines in my forehead, and I think it's acceptable for me and I'm okay with it. I mean,

00:42:26.040 look, there's a range of what's acceptable. I used to look at Bill Clinton on TV all the time and I'd

00:42:30.380 see his big eye bags. And when I was in my training, I'm thinking, oh, I would just die to be able to

00:42:35.820 take out those nice juicy fat pads, but he doesn't care about them at all. Right. And so it's meaningless

00:42:41.500 to him or maybe he thought about it, but you know, he obviously didn't pursue it. So it doesn't really

00:42:47.140 matter if it doesn't matter to you. And I think, you know, what's interesting at the root of all of

00:42:53.400 this is, you know, why do we do cosmetic procedures and why do some people think it's so important? Why

00:42:58.240 do people think it's nonsense? It's about your confidence. It's about how you feel about yourself,

00:43:03.360 your self-image. And I think that there are some people that will chase after confidence and may

00:43:10.680 never be able to achieve it. And it's because of what happened to us in our childhood, our upbringing,

00:43:16.160 the, I guess, the stability that we had when we were growing up. And it's being able to experience

00:43:20.520 love in your family, experience acceptance, people that were proud of you. People can say that they

00:43:26.660 love you, but if you didn't experience that, it's much harder to be self-confident and to have

00:43:32.800 a good self-image. And so I think it all goes back to that. I think there's a healthy way to do it. And

00:43:39.840 I think it's not something that we should frown upon. I think it's becoming more accepted in our

00:43:44.600 society to, to have a focus on how we look and how we project ourselves. And I think the best way to do

00:43:50.620 that is to have a healthy attitude about it in terms of, look, I'm doing this for me. I'm not

00:43:56.140 trying to impress somebody. I'm not trying to fit in with somebody. And what's amazing is sometimes

00:44:02.940 a little tiny thing that you wouldn't even know you wouldn't notice it. But I see people walk out of

00:44:07.600 the office with a different gate or they're smiling when they weren't before. And we barely even did

00:44:13.720 anything, but it's a little shift in the way that they were thinking about themselves. And so it's

00:44:19.080 not so much exactly what you do, but how you help somebody to feel better. So in terms of doing

00:44:25.280 like a neurotoxin inject, like doing your first Botox injection, if you're looking at your parents

00:44:29.500 and you see these lines and you think, I don't really want those lines. So you do it before they

00:44:33.840 start to become fixed lines, those etched creases. You do it before you get that. So there's not really

00:44:39.500 an age. I mean, I've, I've injected people in their twenties. I've injected people in their eighties.

00:44:44.020 I think it's never too late, but there's certainly times where it can be too early.

00:44:48.480 Now, have you ever found yourself in a situation where you felt it was unethical to participate in

00:44:52.720 the care of a patient because you felt that they were just being too neurotic or they were asking

00:44:58.160 for something that you felt was too much? I mean, did you find yourself in that situation all the

00:45:02.000 time, all the time? I think that's the nature of what I do, right? It goes along with it. And so

00:45:08.200 the way that you look is tied in very closely to your emotions. And when you, especially when it's

00:45:15.580 your eyes and I see people all the time that have had poorly done procedures and they're tearful when

00:45:21.220 they're talking to me. Um, and I see people, I think they're unrealistic and I try to guide them.

00:45:27.140 I, I, my goal is to be on their side all the time. So in order to sort of focus on overall wellness,

00:45:34.840 not just appearance, but, but there's, I think there's a connection between appearance and wellness.

00:45:39.680 And if you seem to me like, you know, there's something else going on here. Why are you chasing

00:45:45.960 after this, this one line when you look, anyone who would look at you objectively would say, oh yes,

00:45:51.520 you look younger, you look more relaxed, you look refreshed. Like what are we really talking about

00:45:56.780 here? Well, maybe there's something else to talk about. So you're almost having to try to be a

00:46:00.860 psychologist, psychiatrist at the same time. In a way, I mean, maybe it's also my,

00:46:05.020 my wife is a therapist. And so some of that probably, um, has brushed off on me in terms of

00:46:11.100 how important it is having somebody to talk to that's outside of judgment. And so, um, I think

00:46:18.040 sometimes people need to, maybe it's not just one thing, it's both. It's having someone to talk to.

00:46:22.800 Maybe there's some other issues going on and, um, you know, what is your goal in doing this?

00:46:28.820 Let's go back a little bit further. Let's say someone's listening to this and maybe this is a lot

00:46:34.220 of people and they think, look, it's really good to know that there are people out there like you

00:46:39.140 who can do the most nuanced, complicated grafting, injecting techniques above, below the eye,

00:46:47.820 the forehead, et cetera. But what if they say, look, I don't want to do anything that I can't do as the

00:46:51.800 patient myself, meaning lotions, potions, behavioral changes. Let's start. You, you alluded

00:46:59.840 to son, let's start there. I get asked all the time and I'm kind of embarrassed because I just

00:47:04.660 don't know the answer. And I have to say, I have no clue. I get asked all the time, Peter,

00:47:09.200 what sunscreen should I be wearing? Like, I feel like it's easier for me to answer, like,

00:47:13.980 how would you solve the, uh, Iran nuclear missile crisis or, you know, before, like,

00:47:18.360 I don't have a clue what sunscreen to wear. It's a complex marketplace, let's say, because the way

00:47:24.380 that sunscreens are marketed, the way that the labeling is done can be a little bit confusing.

00:47:30.760 And there are technologies that are being employed now that are newer, that we don't fully understand.

00:47:37.620 So let's talk about. So let me start with the first question, which is,

00:47:40.720 there are some people out there who say sunscreen is horrible. You should never wear it. I'm assuming

00:47:44.860 you don't think that that's the right approach. It's absolutely untrue. I mean, I can't feel strongly

00:47:49.120 enough about, look, I see a lot of, uh, skin cancer and I treat skin cancer and it's, uh, it's obvious

00:47:56.080 and it's been well scientifically proven that there's a correlation between UV radiation and skin

00:48:01.820 cancer, right? So I have to reconstruct people's eyelids, their faces, their noses, because they've

00:48:08.920 had basal cells, which basal cell carcinoma, which is related to sun exposure. My wife has had

00:48:14.720 several Mohs procedures where, which means a dermatologist with special surgical training

00:48:19.560 has to remove pieces of skin and then that has to be reconstructed. And, you know, I don't think

00:48:25.380 anybody wants to go through that. I look, the recommendations, the American Academy of

00:48:29.720 Dermatology is to protect children from sun. And there's recommendations about levels of sunscreen.

00:48:35.860 So you can get your vitamin D even if you're using sunscreen.

00:48:39.820 So when we talk about UV, they talk about UVA and UVB, and you'll see these things on sunscreen.

00:48:48.500 Can you explain what UVA and B are?

00:48:50.520 Traditionally, UV, you can think about it as, um, UVA, the A might stand for aging and the UVB

00:48:56.440 is for burning. UVB is what's responsible for your skin turning red. Okay. They're just different

00:49:02.020 wavelengths of ultraviolet light. And when you're looking at SPF, they're talking about UVB.

00:49:08.720 The way that they determine SPF is they will take a subject, they'll do it probably, I think you

00:49:14.920 need to have 10 subjects. This is just done on a person. It's not like a laboratory test that

00:49:19.680 works well for this. They still use it on people. So they would put you under a light in a laboratory

00:49:24.860 with UVB and they would wait and see how long it takes for you to turn red. And then an SPF,

00:49:31.000 so that's UVB radiation. SPF 15 means what do we need to put on you that will make you turn red 15

00:49:39.580 times longer? It'll take 15 times longer to turn red and 30. And this is my silly question, but

00:49:47.740 is there an objective metric for what redness is? Like there's a color, you know how like you can

00:49:53.460 define colors by the percent red, green, blue. You can measure the redness.

00:49:57.000 You can measure the color. Got it. It's a purely objective measurement. So it's interesting. SPF 15,

00:50:02.000 which seems like very mild sunscreen still gives you 15 more times. So if it takes you 10 minutes,

00:50:07.740 this is going to take you to, you know, what, 150 minutes is like two, two and a half hours,

00:50:13.340 basically. If you look at the difference between SPF 30 and SPF 50, you're getting a difference of,

00:50:20.480 I think it's like a 96 or 90, 96% protection against UV during that time versus a 98% protection.

00:50:28.160 So it's, it actually becomes less of a difference in protection from those rays as you go up higher.

00:50:34.860 So over 30, you don't get that much more benefit. So, but you should be using at least a 30,

00:50:41.380 but that's talking about UVB. If you want to protect yourself from UVA and UVB, which you should,

00:50:47.680 you should be using a sunscreen that says broad spectrum.

00:50:51.240 Okay. And that's still the same SPF system.

00:50:54.000 Well, no, SPF does not apply to UVA. It doesn't measure UVA. In fact, there's no measurement of

00:50:59.280 UVA. So if you buy a broad spectrum sunscreen, it will not have an SPF number on it, or if it does

00:51:05.460 SPF, but it relates to UVB. Okay. Got it.

00:51:08.340 Because UVA doesn't cause redness. So you can use that test.

00:51:12.560 Which of the two is more responsible for vitamin D synthesis?

00:51:17.680 That's a good question. I don't have the answer for you.

00:51:20.280 All right. We will, we will find out the answer to that question at some point that should be known.

00:51:24.440 Mike, I, my intuition is it's UVA, but I, I, uh, I don't know.

00:51:29.520 But, um, both are responsible for skin cancer.

00:51:32.960 Got it.

00:51:33.680 So UVA is, can, can lead to melanoma.

00:51:36.280 Now I remember reading that. Yeah. I mean, I've read so many things like you should always have zinc

00:51:40.420 in your sunscreen. You should never have zinc in your sunscreen.

00:51:42.700 So there's other divisions of sunscreen types. And so there's something called organic and

00:51:49.080 inorganic, which we also more commonly is termed chemical versus physical. So the inorganic

00:51:57.060 sunscreens are physical and those typically use zinc or titanium, which are metals as a reflective

00:52:03.900 agent. And it just reflects the rays of sun. So those are the ones that you think of like Baywatch

00:52:09.680 and you're have like the white under your eyes, but they don't look like that anymore because now

00:52:13.840 they have micronized versions of those zincs and they have nanoparticle. All right. So smaller

00:52:19.680 particles mean that it looks clearer. You still get a little bit of that lightish. I didn't give you

00:52:23.960 one of my sunscreens before it. You get a little bit of a whitish hue, but it's not like a pasty white.

00:52:30.140 Those are the ones I recommend because it reflects the light. Now there are some newer chemical

00:52:35.220 sunscreens that are thought to be safe, but there are some issues with the, so the way the chemical

00:52:39.580 sunscreens work, which are considered the organic sunscreens, they absorb the UV light and they

00:52:45.480 convert them into heat, which disperses locally in your skin. So if you have melasma, those type of

00:52:51.320 sunscreens could potentially worsen your melasma. Tell us what melasma is. Sorry. So it's also a term

00:52:56.800 like the mask of pregnancy. You see darkness or hyperpigmentation on the cheeks, the upper lip,

00:53:02.560 the forehead, any dyschromia or brown spots can be made worse by heat, which is why

00:53:08.660 I recommend against some of the chemical sunscreens. I wouldn't say it's a blanket statement. Some of

00:53:14.960 the chemical sunscreens also have hormonal disruptive effects, which is why they're not

00:53:19.880 recommended for children, but I wouldn't recommend it for myself either. So what are some, maybe what

00:53:25.800 we'll do in the show notes, we'll link to like brands that you really, really like versus brands

00:53:31.000 that people should really avoid. If you're sitting there at the CVS and you're trying to get some

00:53:35.300 sunscreen before you go to the beach, are there any ingredients that are red flags that you should

00:53:39.680 avoid? So, you know, I don't like octanoxate, which is a hormonal disruptor. I think it's debated

00:53:45.000 and you know, how much dose do you need in order to really disrupt hormones, but I don't really need

00:53:50.580 that at all. If I, I just would look for physical sunscreen that has broad spectrum and at least an

00:53:55.460 SPF 30. And that's pretty simple. Some of them say they're waterproof versus not waterproof. Is that a

00:54:00.520 gimmick or is that the real deal? It's hard to measure the waterproof effect, but you, they do

00:54:04.700 that the same test, but they're spraying you down with water in the lab. And then they're waiting to

00:54:09.380 see how long you turn red. I think the, the key is that you have to apply enough. Most people don't

00:54:13.920 put enough sunscreen on. I'm guilty of that as well. I mean, I was in Florida a month ago and I'm still

00:54:19.560 sort of tan and I was wearing a wide brim hat and I'm applying sunscreen, but it obviously wasn't

00:54:24.740 enough. So, and you apply every couple hours. I mean, every two hours you should probably reapply.

00:54:29.360 Interesting. I know people don't do it. I don't do that either. But if you care about how your face

00:54:34.940 looks, then at least focus on that. And maybe your hands too. And maybe your chat, we call the

00:54:40.600 decolletage, like your chest. Those are the areas that are going to be exposed. And if you want to

00:54:45.180 look your best, don't forget about your hands because when you're 70, you'll have brown spots

00:54:51.280 and you'll have wrinkly skin on your hands. If you don't protect yourself, your face, you don't want

00:54:56.280 to get wrinkles. All right. So put on sunscreen, wear a hat that has a wide brim. And then particularly

00:55:01.860 for women, or if you wear a low cut shirt, or you're wearing a V-neck t-shirt, then put it on

00:55:06.680 your chest. Are there certain moisturizing creams that people can apply that have sunscreen in them,

00:55:12.640 but they're primarily like, they're not necessarily sunscreen per se. Like CeraVe is a product that I

00:55:18.220 have used from time to time. It's not a very high SPF. It might be a 15, but I really like it because

00:55:24.100 it's odorless. Like I think part of the thing I hate about sunscreen is I can't stand the smell of

00:55:28.520 it and the greasiness of it. But the CeraVe, I really, I'm like, yeah, I can actually wear this.

00:55:33.840 Yeah. I think 15 is probably low. Look, if we're here in New York city and you know, you're walking

00:55:38.560 from your home to your office and you're probably getting a blast of sun on your face. I put on a 30

00:55:44.000 in the morning. You can do a trial in there. You go to your cosmetic store, you go to, you know,

00:55:48.900 your dermatologist's office and you ask to try a couple of them and you feel in your skin. I mean,

00:55:53.040 the technology is getting better and the scents are, I think it have a wide range to appeal to a

00:56:00.860 wide range of people. You'll find something that will suit you if you look for it.

00:56:04.920 What brands do you like?

00:56:06.600 I don't necessarily want to promote a specific brand because I think that there are so many

00:56:11.080 good products out there. If you look at the medical grade brands, which are sold in doctor's

00:56:16.840 offices, but you can find them also online. You can find them on some of the online vendors.

00:56:20.960 There's Elta is known to be a good brand. MD Solar Science. I like Replenix, SkinCeuticals. You'll find

00:56:28.740 a long list of potential products. I don't mean to leave any out or focus on those, but yeah.

00:56:36.240 Okay. So then the next thing I want to talk about as far as just sort of nuts and bolts

00:56:39.780 maintenance stuff is something I've heard quite a bit about and also have tried from time to time

00:56:47.180 is retinoic acid. So first of all, what is it and why does one use it or how does it work?

00:56:51.920 Well, so we're talking about a form of vitamin A and it acts like a hormone in the fact that it works

00:57:00.620 in the intracellular, in the DNA level. So it's affecting transcription of particular genes. It's

00:57:08.840 promoting collagen synthesis. It's increasing the turnover of skin cells. It's one of the few things

00:57:15.560 that's proven for anti-aging, but also for acne. So there are a wide range of forms of vitamin A,

00:57:23.040 but it's one of the top three things I would recommend for everyone to be using if they

00:57:29.600 are interested in having a skincare regimen that's effective.

00:57:33.120 Now, retin-A cannot be bought over the counter or can it?

00:57:37.380 You can get over the counter retinols. Okay. So the retinol is a less potent version of what you're

00:57:45.020 referring to, which is tretinoin. And do those over the counter versions, which are obviously less

00:57:51.020 potent, do they have the same efficacy or do you have to apply them more frequently?

00:57:55.460 They're not as potent, but they have less side effects. So if you have not used one of these

00:58:01.320 products before and you're looking primarily for anti-aging or for anti-wrinkles, you want your skin to

00:58:06.000 look younger. So it helps that you have less wrinkles. It helps reduce pigment in your skin.

00:58:11.440 Someone who's been using retinol from their twenties on, they, they always look better.

00:58:15.640 How often should one use it? This stuff can dry your skin out, right?

00:58:18.940 Yeah. So it's less drying when you're using the over the counter retinol type products.

00:58:24.520 I would start with something like that if you haven't done it before. And often those have

00:58:29.520 moisturizers or hyaluronic acid or other things in there that avoid some of that drying.

00:58:34.880 If you do get dry from that, then you can just use it every second or third day,

00:58:39.880 or you can do sort of a pulse treatment where you put it on and then 10 minutes later you wash it off.

00:58:45.080 So you've sort of gotten a short exposure. If you can tolerate that, and that's primarily

00:58:50.840 recommended for nighttime. And there's a myth that retinol is making you sun sensitive. I mean,

00:58:56.660 it's possible because your skin has less pigment in it and your skin is, looks younger, but, um,

00:59:02.900 it's more that the retinol breaks down from sun exposure, right? So it becomes ineffective.

00:59:08.980 I always assumed it was for what you said in the first place, which is you'll get more burned if

00:59:13.800 you use it. And that's okay. It's not necessarily true, but it is recommended. You know, we use it

00:59:17.840 at nighttime. I use it every night. Now, if you can tolerate that, then you can talk to your doctor

00:59:22.800 about getting a prescription for a higher strength. And that's usually like 0.025% or 0.05% or 0.1.

00:59:29.900 So I'm up to 0.1 now and I do it every night and I have no side effects, but I use just the generic

00:59:35.680 0.1% tretinoin. Yeah. That stuff ain't cheap. Yeah, no, I know, but it's, and there's newer

00:59:41.520 generations that also have less side effects, but the traditional tretinoin works nicely, but a little

00:59:47.340 bit goes a really long way. I mean, you can use one of those 45 gram tubes can last you several months.

00:59:52.620 And do you put it all over your face? Yes. The other myth. So for guys, so someone like me,

00:59:57.960 who's got kind of a beard, am I also supposed to apply it over the bearded area?

01:00:02.000 That's tough to do. The nice thing as someone who shaves every day, that area, when you're shaving

01:00:08.260 it, you're basically giving yourself like a microdermabrasion. So you're mechanically

01:00:13.700 abrading the outer surface, the surface layer of your skin, which also promotes skin turnover.

01:00:17.880 So you're probably a little bit protected there, but I would apply it to your whole face and include

01:00:22.520 your eyelets. A lot of people say, don't put on your eyes that there's a myth. I think that

01:00:26.700 you have skin on your eyes, right? On your eyelids. So that skin, if anything, it's more

01:00:31.340 effective because that skin is thinner. So you might not use it as often there, but I close my

01:00:36.780 eyes. I apply it to my upper lids. I applied it all the way up to the eyelash line. So if we're

01:00:41.260 going to do, we've got two things in our toolkit so far, we're going to put sunscreen on in the

01:00:45.600 morning. We're going to put retinoic acid on at night. Is there anything else that you

01:00:51.580 recommend as part of a kind of overall maintenance plan? So like vitamin C would be the third part of

01:00:58.020 the trifecta. Vitamin C is also... Vitamin C, which most people think of as like a vitamin you

01:01:03.220 take to avoid getting cold. So that seems to be kind of bogus. So topical vitamin C, and this one

01:01:08.600 might be a little bit more controversial. I mean, it's not thought to be controversial because

01:01:13.420 every skincare line promotes their vitamin C. And the question is what type of vitamin C is

01:01:20.460 effective. But think about vitamin C deficiency, right? What happens to your skin?

01:01:24.920 Yeah. Well, you'd get scurvy, you get collagen deficiency.

01:01:27.500 Right. So we know that lack of vitamin C is a problem for the way you look in your skin.

01:01:32.060 If you're healthy, does vitamin C help your skin? Well, we know it's a very powerful antioxidant. So

01:01:38.140 it's scavenging free radicals. So it's protecting you from UV damage in that way. It also is a cofactor

01:01:44.980 for collagen synthesis. It turns out it does work better if you have it with vitamin E,

01:01:49.540 but here's the thing. A lot of the products that are out there, they oxidize. Vitamin C oxidizes

01:01:55.300 very easily. And the L-ascorbic acid, which is meant to be, it's thought to be the form that

01:02:00.100 penetrates the best and is the most effective once it's penetrated, it needs to be stabilized.

01:02:06.260 And so there's different patents that are developed by these companies. And they sort of

01:02:10.900 have these patent wars, like whose patent is better for vitamin C, and they try to protect

01:02:15.220 their technology so other companies can use it. You'll find a lot of stuff out there. And if your

01:02:20.860 vitamin C can oxidize over time in the bottle. That's why they always tend to, these things come

01:02:24.860 in very dark bottles, right? And you keep it in your cabinet. Sun damaged skin tends to have lower

01:02:30.500 vitamin C levels. And I think vitamin C is effective in those cases. Why can't they just add vitamin C to

01:02:35.580 sunscreen, for example? I don't know if it interacts well. Isn't there something about iron that they put in

01:02:40.720 this as well? I think the one that you're thinking of, that product, which is the CE ferulic. So the

01:02:45.620 C and the E we know are synergistic. The ferulic acid is just another antioxidant. So it's just

01:02:51.460 another form of antioxidant that's added into the mix. But the issue is, and what I've seen in the

01:02:57.620 literature, is that if your serum levels of vitamin C are high, then your skin doesn't absorb topical

01:03:04.040 vitamin C very well. So we don't know if applying vitamin C topically is preventing you from

01:03:10.520 developing sun damage. We know that if you already have sun damage, that it helps to reverse it.

01:03:15.020 And you put this on in the morning or in the evening? I typically do in the morning,

01:03:18.180 but you could do two times a day. But I use vitamin C in the morning and I do retinol at night.

01:03:23.060 And then the sunscreen goes on top of the vitamin C? Yes. But I don't want too many steps. If I tell you

01:03:28.840 you need to do 10 things, you're going to stop doing all of them. So, but if you can do these three

01:03:33.340 things, which I think that's pretty easy. Like, you know, you just have to think about your

01:03:36.320 C and your sunscreen in the morning and your vitamin A in the evening.

01:03:38.980 You have to separate the time between the sunscreen and the vitamin C so they don't

01:03:42.220 interact. I like the serums, the C serums. So I usually wait a couple of minutes and when it's

01:03:46.520 dry, then I apply my sunscreen. And look, this isn't a universal plan for everybody. We all have

01:03:51.000 different skin needs and, but in general, this is a pretty good plan for most people.

01:03:56.480 Yeah. If one does this kind of stuff, right? They say, look, I'm going to put the effort into

01:04:01.320 what I do with respect to sunscreen with topical vitamin C retinol. As you, you know, you alluded

01:04:09.460 to earlier, I'm going to take greater care to care for my skin by wearing a hat, that kind of thing.

01:04:15.380 What percentage of the benefit is someone getting in terms of an anti-aging regimen? Is that like

01:04:20.220 half the battle right there? It will go a really long way. I've had patients where we didn't touch them

01:04:25.340 with a needle. It's been no surgery. It's just been recommendations and a directed skincare

01:04:30.680 regimen. And look, I'm not a dermatologist, but I, a lot of what I do is skincare using these

01:04:37.240 powerful basics. I've seen amazing changes. And so when you combine that sometimes with some other

01:04:42.520 concerns, some directed treatments, then it's synergistic. It's even better. It sounds simple,

01:04:48.820 right? But it's, it's powerful. I mean, I think that makes sense. I guess anybody can do those

01:04:52.900 things. You do need prescriptions for at least the retinol, but I think everything else you,

01:04:57.100 but only for the prescription, only for the high grade. Yeah. Right. So kind of going back to

01:05:00.800 something we talked about earlier, what are some of the trends that we're seeing now? I mean,

01:05:04.800 we alluded to at least one of them, which is lips getting a little fuller. Botox has certainly been

01:05:09.580 around for quite a while now. Are we seeing people using Botox in ways today that they weren't doing it

01:05:16.080 10 years ago? Well, yeah. I mean, there's many more indications for Botox. We, you know,

01:05:20.340 we have non-cosmetic indications, bladder spasms, vocal cord spasms, torticollis, migraines,

01:05:27.680 axillary hyperhidrosis. Botox is being used for so many different things. And I think we've

01:05:33.580 developed a more nuanced approach to how we treat people with Botox. I hope so. I still see people,

01:05:39.500 I even know Botox injectors that have these like Spock brows. You know, if you've seen that,

01:05:44.900 where did you get the overarched? Nicole Kidman sort of had that appearance for a little while,

01:05:48.880 not to say that she doesn't look good or, you know, I don't know anything about how she was

01:05:52.780 injected or treated or not, but that look is often not desired, especially if you didn't have that

01:05:58.380 look before. So I still see a lot of those, what I would consider like amateur mistakes or maybe just

01:06:04.360 not, the field has progressed and most of us have kind of gone along with it, but there's sort of a

01:06:10.440 pressure, I think, for a lot of physicians to move into the cosmetic realm because the world of

01:06:16.020 insurance doesn't reimburse as well as it used to. And so we're seeing a lot of new providers in the

01:06:20.860 marketplace and some of them have more experience than others. But we do have better ways of using

01:06:25.640 Botox, using it in smaller amounts, spread out over a larger area, using different facial muscles.

01:06:31.480 We can turn up the outer corners of the mouth so you don't look like you're frowning as much.

01:06:35.200 We can reduce a gummy smile by injecting above the lip. I can treat the lower eyelids so that you

01:06:41.520 can look like your eyes are slightly more open, or we can reduce some of the squinching wrinkles

01:06:46.160 that happen under the eyes. There's, there's a lot of ways that we can use this that we didn't

01:06:50.740 use them, you know, 15 years ago or 10 years ago. We've talked about some of this stuff in the past.

01:06:55.040 And one of the things that I think I've taken away from those discussions is that

01:06:58.680 if you're going to have this kind of stuff done, you really want the person who's doing it to

01:07:03.280 understand the anatomy because you can see the wrinkle on the surface, but you have to understand that

01:07:09.040 the wrinkle is the product of changes in musculature and connective tissue and fat.

01:07:15.760 And I'm sure when you look at a face, you actually are almost doing so with x-ray vision, right? Like

01:07:21.980 you're not, you're seeing beyond the skin, you're seeing everything that's underneath it and knowing

01:07:25.380 that, well, look, if I actually want to reduce that wrinkle, I, I don't necessarily inject into

01:07:31.100 the wrinkle. I'm injecting obviously where the muscle is. Yeah. And it's not just looking or

01:07:36.080 understanding. It's also asking the patient to move. I say, okay, I want you to frown for me

01:07:40.100 and I can touch them. I can see where the muscle is pulling. And there's a variation in the way that

01:07:45.740 we're built. And so your muscle might come up at an angle and might be different on the two different

01:07:50.120 sides. So it's important to look at those little differences and to see what's happening, not just,

01:07:58.100 and people say, look, I like to avoid a cookie cutter approach. Everything's personalized. It's easy to say

01:08:01.900 that. Everyone markets themselves as like, oh, we offer personalized care, right? Every doctor says

01:08:07.820 that that's what they do, but do they, you know, are they really like giving personalized? I know

01:08:12.500 that in your practice, you're giving personalized care because you're diving deep, right? And you're,

01:08:17.300 you're looking at things. You're not just ordering. You don't just call the lab and say,

01:08:20.700 hey, give me a CBC and a chem seven. And then I'll tell a patient what he needs to do.

01:08:25.600 You're diving deep. And so that's truly personalized care. And when you're looking at

01:08:31.880 patient and if I have a fellow following me, I sort of have to answer to what, you know,

01:08:36.640 someone who's training, I sort of have to answer to him too, in terms of what I'm doing. And if he

01:08:41.340 sees me or she sees me doing the same procedure in the same place in every patient, they're going to

01:08:47.760 ask me like, why did you do that same thing? You know, I don't because, and I feel that scrutiny

01:08:53.000 for myself as well, that your treatment is going to be different from the other person's because you

01:08:57.980 look different and your body's different and your muscles are in different places. And,

01:09:00.980 and you have different concerns. I mean, so that's, that's what personalized treatment is.

01:09:05.360 It's not just saying it on your website.

01:09:07.820 One of the things I get asked about a lot by patients, and this is why I'm really glad I know

01:09:11.420 people like you, because I obviously don't know the answer to any of these questions is my friend

01:09:17.160 got such and such a laser treatment on his or her skin. And I want to do that. And all these

01:09:23.940 different types of lasers and these things, can you give us the kind of the one-on-one on laser

01:09:28.480 treatment for skin?

01:09:30.040 I think lasers are effective in many ways, right? And the lasers are getting better.

01:09:33.920 The technology is getting better. There's fractional technology. There's different types

01:09:37.740 of energy. And it's confusing though, to consumers, because you don't know, are you selecting a doctor?

01:09:44.300 Are you selecting a device? Anyone can buy a laser. If you have a certain amount of money

01:09:49.160 and you have a certain amount of patients and how much of the work is being done by the laser

01:09:53.920 by itself, you just turn it on and it just happens. Or is it the provider selecting the

01:09:59.460 right patients and changing the settings? So there's a lot of variables. There are some devices that

01:10:04.980 doesn't matter who does it for the most part, like the cryolipolysis, right? Coolsculpting.

01:10:10.880 It's a device that suctions your fat and it freezes it at a certain temperature. And it uses,

01:10:16.280 you know, an algorithm to figure out what temperature it needs to stay at for how long

01:10:19.500 to adequately cause apoptosis of those fat cells, right? And so basically someone just has to say,

01:10:26.740 okay, this is the area where we're going to do it. And they stick the machine on you.

01:10:29.500 There's a little bit of, you know, understanding and training that goes into it,

01:10:32.740 but once you turn it on, it's done, right? You sit there and it happens and then you...

01:10:36.800 And is this CoolSculpt procedure effective?

01:10:39.380 It's effective. Yeah. And there are other ones too. There's other types of the sculpture.

01:10:43.320 Sure. There's other devices that also effectively, non-surgically can reduce fat. And, but they don't

01:10:49.620 require a lot of, it's not an operator dependent for the most part, right? So you turn them on and

01:10:54.860 they're good. And so you can probably go to most places and they'll do a good job for that.

01:10:58.620 There's a procedure where they use heat and then there's a procedure where they use

01:11:01.540 cold. What is more effective? They're both effective. There's a lot of devices, but the two main

01:11:06.780 leaders in the market are both effective and they're probably equally effective. They work in

01:11:11.500 different amounts of time, but usually you get about 20% of subcutaneous fat reduction with that

01:11:17.300 course of treatment. So if a person wants to take a little bit of fat off, presumably you do this on

01:11:21.800 your belly or you can do it legs? Even your flanks. Anywhere you can pinch fat, you can do it,

01:11:26.140 right? So it's subcutaneous fat. It's not visceral fat that's under the muscle, but it's the

01:11:29.780 subcutaneous fat. And it works well. As long as you can apply the applicator, there are some

01:11:34.420 limitations, but they both, the main devices have FDA approval for next as well. So those devices

01:11:40.840 doesn't really matter so much about who's doing it. You want to go to a reputable place. You want

01:11:45.560 to make sure it's the real device. There are like, there are Chinese knockoffs that are not FDA

01:11:49.420 approved. So you want to get the real one. You know, you can go to, there's like cool sculpting

01:11:54.040 is an FDA approved cryolipolysis device, but I've seen fat freeze or something. And it's, and then

01:12:00.320 you look into it and you say, oh, this wasn't even approved by the FDA for marketing. So got it. So

01:12:05.360 at least make sure you're going with an FDA approved procedure or device. There are lasers that work on

01:12:10.860 skin. There are lasers. Yeah. What are the skin laser? Like people talk about like getting their

01:12:15.620 face lasered for skin. I've had a chemical peel once a little while ago. I was really, I mean,

01:12:21.880 this has got to be, it's gotta be about five or six years ago. I was amazed at two things. First of all,

01:12:26.660 how quick and easy it was to, for this dermatologist to apply this stuff to my face. That's the first

01:12:32.200 thing. The second thing that amazed me was how red I was for like five days and how I had to like

01:12:37.600 lather myself up in aquaphor. And then third, I was just amazed at how many sunspots vanished.

01:12:43.380 Yeah. Well, I mean that procedure can be very effective. There's lots of different types of

01:12:47.580 peels. There's phenol peels, which can have more risk, but more benefit. In fact, for a phenol peel,

01:12:54.520 you have to be connected to an EKG. So you don't, so you're monitoring for arrhythmias.

01:12:58.860 There are TCA peels, which can be also equally strong. There's a lot of experience that goes

01:13:05.000 into selecting the type of peel, how they're, how it's being applied, how many layers, what you're

01:13:10.040 seeing that that is a very operator dependent procedure. So is there a chemical peel that you

01:13:16.320 would say is if you were going to have one tomorrow that you would preference? I wouldn't say

01:13:21.400 that. I think it's, that's more of a, depends on your skin type. There are certain things that are

01:13:26.580 not safe for darker skin types. So that's a very specific treatment plan for each.

01:13:32.620 So what questions could people ask the provider to know that that, because really what you're

01:13:37.840 saying is you have to rely on the provider's judgment to know that.

01:13:41.040 Very heavily. And you can get a burn and you can get a scar.

01:13:43.860 So how do you screen out for who the right person is?

01:13:46.400 Well, it's asking, you know, how many of these have you done? Can you show me examples? And is

01:13:50.720 this safe for my skin type and what are the risks? So chemical peels are essentially using an acid

01:13:56.680 or a chemical to burn away the outer layer of your skin. That's why you look so red.

01:14:00.780 And they go at different depths depending on how many layers of chemical are being applied

01:14:05.180 and what type of chemical and the strength. So I can use a 10% TCA peel on you and you'll look

01:14:11.220 slightly red and you'll, you know, look a little better. I can use a 35% and you'll,

01:14:17.120 your skin will peel off like a snake. Um, so there's a wide range and, and might not be safe

01:14:22.760 for all skin types.

01:14:23.900 So let's look at me right now. I'm kind of a olive skin dude. I've probably got,

01:14:28.660 I don't know where I would rank on the sun damage scale, but I,

01:14:31.460 I would say for you, either you're looking at a, let's say you want to just do a skin rejuvenation.

01:14:36.500 You want to look smoother, less wrinkles, improve texture and brown spots. So we would either talk

01:14:42.320 about a chemical peel, like a, maybe a TCA peel of 20% and I might recommend three treatments,

01:14:47.620 or we would talk about a laser. So the laser does the same thing that the chemicals do,

01:14:53.980 except it's using energy to burn the surface. Most lasers today are fractional, meaning that

01:14:59.980 they're not taking away everything like a peel would, right? The liquid from the chemical peel is

01:15:04.540 going to take off all of your skin, at least the outer layer in a continuous fashion. Whereas the

01:15:09.960 fractional laser is creating dots and leaving some normal skin in between. So the most common

01:15:15.600 lasers for resurfacing would be erbium and CO2 carbon dioxide. And again, with, within those,

01:15:23.300 there's different levels and different energy settings and certain patients are not candidates

01:15:28.980 for those. And some are. So that relies heavily also on the experience of the provider. Now there's

01:15:34.720 some very safe lasers that are very low grade, like a laser, like clear and brilliant, very low risk

01:15:40.140 at causing a problem for most people. And doesn't always have to be a doctor performing the procedure.

01:15:46.320 It can, depending on your state laws, can be an esthetician or a nurse.

01:15:50.380 And are these painful procedures? Do people need some sedation for them?

01:15:53.660 Usually no. I mean, it depends on your pain tolerance. The heavier duty lasers, the more

01:15:57.980 powerful are going to require some type of anesthetic, whether it's an injection, topical

01:16:02.860 anesthesia, sometimes sedation. And often we do them in combination with surgery. So my patient's asleep

01:16:08.040 while I'm lasering them, we're doing one thing and then we're lasering another. That is something

01:16:13.280 where you need a consultation and someone to evaluate your skin type and say, okay, this is my

01:16:19.140 recommendation for you based on my experience and my knowledge, my training. But there are also,

01:16:24.420 I think when you, what you would also lump into that, that category would be the energy devices

01:16:29.500 that are now becoming more rampant. And these are designed for facial rejuvenation in terms of

01:16:35.820 tightening, not the skin surface. So the first generation were things like Thermage that use

01:16:41.180 radio frequency, or today you see all therapy, which is a focused ultrasound. You're seeing more

01:16:46.620 plasma devices. The idea is heat is stimulating collagen synthesis and contraction and tightening.

01:16:55.960 And for the most part, I'm underwhelmed with these technologies. In a way, it's almost like,

01:17:01.780 you know, I kind of referred to like the emperor wears no clothes, right? Where the doctor has invested

01:17:08.120 a lot of money in this device. And so they have some stake in it working, whether it does or not.

01:17:14.100 And the patient is investing a substantial amount of money potentially for them. And so you don't want

01:17:19.200 to feel like you're a sucker and you've spent a lot of money on something that doesn't work,

01:17:22.520 but you have to look at the before and after photos. And if you have a hard time telling which

01:17:27.520 is which, then you're not going to see a lot. Is anybody doing anything with PRP in terms of facial

01:17:33.080 rejuvenation? PRP, platelet-rich plasma has obviously achieved, you know, some success,

01:17:39.520 although I think it is still somewhat questionable, but at least anecdotally, there are people who are

01:17:43.740 certainly reporting success in the periphery, for example, treating orthopedic injuries with it.

01:17:49.980 And it started out, I think, in the dental realm for dry sockets. I mean, I think they sort of

01:17:54.620 pioneered PRP in a lot of ways.

01:17:56.620 Oh, I didn't know that.

01:17:57.260 And I think, you know, here in New York, I feel like you can get PRP on every corner now.

01:18:02.840 It's become so widespread in medical spas and cosmetic practices because it's so accessible

01:18:09.280 for providers to perform this.

01:18:10.860 And it's always autologous.

01:18:12.040 Yes.

01:18:12.560 Okay.

01:18:12.840 Yeah, of course.

01:18:13.300 So what that means for people is it's your own. They take yours out, they spin it,

01:18:18.000 they return it versus aloe, which would mean you could use it from a donor. So what do they,

01:18:23.140 what do people do in skin with this?

01:18:24.320 I think you probably feel the same way as me. Whenever there's something is like touted as

01:18:28.660 like a, as a cure-all, you have to be a little bit skeptical, right? Can PRP help your joint pain

01:18:35.340 and can it make your skin look smoother and can it replace your hair? And is it going to heal all

01:18:40.340 your wounds?

01:18:41.520 Enhance your erections.

01:18:42.700 I know. So I think it's a nice thought to think that we have, that the magic that we were looking

01:18:47.840 for all these years was inside of us, right? It's like a, it's like the end of a Disney movie,

01:18:52.200 but is it true? I mean, I'm skeptical. I've had PRP injected in my head, my scalp for prevention

01:19:01.500 of hair loss and I'm underwhelmed, but I mean, think about, all right, so let's talk about for

01:19:05.940 hair loss. The mechanisms that are causing hair loss in men, the androgenic alopecia are still

01:19:12.840 happening, right? Whether I do an injection or not. So how often are you going to have to do it? If

01:19:17.060 let's say it does work, right? You're creating, what does PRP do? I mean, there's, you're talking

01:19:22.180 about the platelets in your blood, which are, what is their purpose? They're, they're there to

01:19:27.640 help with injuries, right? They, they clot, they send out signals saying we have an injury here.

01:19:33.500 So send more growth factors. Let's heal this injury. There's, um, angiogenesis,

01:19:40.180 neocollogenesis.

01:19:41.200 So let's explain those terms. So angiogenesis means recruiting more blood vessels. Yeah.

01:19:46.620 Building more collagen, more collagen. We're trying to create a scaffolding and a framework

01:19:50.340 to heal a wound. So when you have a cut on your arm and your platelets go to that, that area and

01:19:55.060 they create a clot. They send out chemical signals to also do those other things.

01:19:59.240 Right. So we do heal ourselves, right? And if you're an animal in the woods and you get a gash in

01:20:03.800 your leg, then you'll get a clot there and it'll contract. And hopefully if you don't get infected,

01:20:08.080 then, um, you'll just have a scar. So for hair growth, if you inject it in your scalp,

01:20:13.840 then I think there's probably a role for the ideas that you're creating an environment

01:20:18.660 that will help to stimulate the existing stem cells that lie within your hair follicles,

01:20:24.160 maybe creating more blood flow to allow for more hair or prolong the cycle of hair growth,

01:20:30.420 right? So the hairs grow longer. So you have more of them and they become potentially thicker,

01:20:35.720 but we still have the hormones of five HT is still in that area and it's still fighting in

01:20:42.700 the opposite direction. So if you do have a benefit and let's say you do three treatments a

01:20:47.560 month apart and you look a little bit thicker, then how often do you have to repeat it? Like

01:20:51.840 every four months or every three months or, wow, that's a lot of work. And for me, it was

01:20:56.560 uncomfortable. I mean, look, you can do a ring block. You can, you can numb the area by injecting

01:21:01.460 all the way around your head. I drew my own blood, but then I had my dermatologist friend

01:21:05.180 inject it for me. But by the time I did that, the anesthetic that we injected had already worn

01:21:09.340 off and it was uncomfortable, but I tolerated it. And I don't think it was, I didn't get a great

01:21:15.280 result. I think it's known to work better for females, but the literature is not very, it doesn't

01:21:21.240 support it very strongly. I think maybe it will eventually. We just don't have good studies on it.

01:21:25.520 And do you stratify by, you know, patients that are taking five alpha reductase inhibitors? So

01:21:30.220 a drug like Propecia or Avodart that block the conversion of testosterone to DHT, the hormone

01:21:36.780 that's responsible for hair loss. And then you can also apply these topical things like minoxidil.

01:21:42.380 I mean, you can go all in and that probably is better. Or if you're having hair grafting,

01:21:46.200 right? Like transplants, then it's often done at the same time you do PRP. So I think I haven't seen

01:21:52.780 any negative to it other than sometimes I think it's ineffective. And I think it's one of those

01:21:58.840 things also like these skin tightening lasers, the facelift lasers that I think it's oversold.

01:22:05.020 And the same thing with facial rejuvenation, you know, it's very popular to do this thing called

01:22:09.760 vampire facial. What's that? So that's taking the PRP, which is your, you know, from your own blood.

01:22:15.560 That's where the term came from. This was like a, I think it's probably like a Kardashian.

01:22:19.420 How much, how much blood do they need to do a PRP treatment?

01:22:22.600 Typically if I'm so, and I offer this treatment, I don't oversell it, but I offer it in my practice.

01:22:28.660 I'll draw, let's say 10 vials, eight CC vials. So a total of, let's say 80 milliliters and we spin

01:22:35.880 it down. I do a double spin method. And then we extract the platelets from, we separate it from

01:22:41.980 the platelet poor plasma and the red blood cells. And then we, I activate those platelets. That's also

01:22:47.420 controversial. There's a lot of different methods of creating PRP and there's a lot of variety. And

01:22:52.980 so that's one of the problems with the studies that are out there that there's inconsistent methods

01:22:57.320 and not everybody is also quantifying how much PRP are they collecting. Some doctors have counters in

01:23:04.960 their offices and they can say, okay, this is the concentration I'm delivering, but there are

01:23:09.300 different methods. And so you don't know what you're getting. Some people are injecting platelet poor

01:23:13.040 plasma and platelet rich plasma together and calling it PRP, but it's not necessarily.

01:23:18.060 So if you're going to get PRP done, you should confirm that the person doing this has a way of

01:23:23.260 counting the platelets. Not necessarily. I think you just have to have a proven method of concentrating

01:23:27.900 the platelets. They have to know exactly what they're doing. I used to have a lot of experience

01:23:31.260 with apheresis when I was back in the lab and this was super complicated. I mean, at the time we were

01:23:37.180 identifying, we were trying to extrapolate or rather identify lymphocytes. So you would put a huge 14

01:23:42.820 gauge needle in one arm, draw a bunch of blood out, run through the apheresis machine and basically

01:23:47.140 return everything except the lymphocyte. That's serious business. Like you've got to know exactly

01:23:53.560 what you're doing. It seems that PRP would be similar, wouldn't it? Especially because the

01:23:58.460 platelet and the red blood cell are the same color. So you can easily be confused by color contamination.

01:24:03.320 No, but you can see what the difference is when you spin this down.

01:24:06.360 Yeah. The density should separate them.

01:24:07.880 The red blood cells are all, that bottom section is all red and I don't want any of that. But

01:24:12.180 when I first started doing it, I did send the samples into the lab and we got an emergency call

01:24:18.020 in the middle of the night. Your patient has super high platelets and I said, oh, it's okay. We were

01:24:22.180 just checking it. But I did quantify it initially. I don't quantify it every time because I'm still

01:24:26.900 using the same method. But then the question is, do you activate the platelets or do you just put them

01:24:31.820 there and hope that they're going to activate? And what do you activate them with? You can usually use

01:24:35.440 some form of calcium, like calcium gluconate or calcium chloride. And so you just...

01:24:40.980 And you dilute the platelets, obviously, before you inject them? Or do you inject them in that

01:24:45.460 concentrated... So I go from that 80 cc of initial blood draw and I end up with about 8 cc total of

01:24:52.280 PRP. And that's fully concentrated platelets.

01:24:54.360 There's a little bit of platelet-poor plasma in there, but I've gotten rid of most of that platelet-poor

01:24:59.300 plasma. So it's platelets suspended in plasma, but it's highly concentrated. And many fold more than

01:25:05.080 what you'd have in your serum. So the vampire facial, what we're doing is taking microneedling

01:25:10.320 pen, which is a pen that has 12 needles at the tip that are surgical, small needles. And these are

01:25:16.460 not reusable. They're per patient. So it's a sterile setting. This pen has a motor and it's going up and

01:25:22.260 down, driving the needles in and out of your skin. That sounds really pleasant.

01:25:26.040 At a selected depth. It actually doesn't hurt like you would think it does. You come in and I'll do it

01:25:30.660 in just some time. I might pass on that. But I can do it at a depth of a millimeter. I can do 1.5

01:25:37.120 millimeters, 2 millimeters. The deeper we go, the more you bleed. It doesn't hurt like you think. We

01:25:42.300 numb you first with a topical anesthetic. But as you bleed from those channels, the face looks sort

01:25:48.740 of bloody. And I think that's where the term vampire facial came. But then we're using the PRP

01:25:52.520 on the surface, but also applying it as we're doing the needling to drive the PRP into those channels.

01:25:58.300 So this is a hollow bore or solid bore? Solid bore needle. Solid bore needle creates the trauma.

01:26:02.700 And then how do you get the PRP into it? So this is variable among doctors and providers,

01:26:07.320 but you apply, you can apply it to the surface and then needle over it. The idea is that you're

01:26:12.040 driving it into the channel. You can apply it to the channel and assume that's going to absorb

01:26:16.080 because you have now like more porosity. And you can also inject it directly under the skin

01:26:21.080 like a filler. I'm not a major proponent of this procedure. I mean, besides infection,

01:26:26.860 what are the other big risks of this? It's actually a pretty low risk procedure.

01:26:30.940 I think the biggest risk is financial loss. How much does this procedure cost?

01:26:35.680 I would say on average, it's about, you know, let's say $800 to $1,200 a treatment

01:26:40.940 for the PRP with the microneedling. You can spend a lot of money trying to look good, huh?

01:26:46.140 Yeah. And, you know, it's recommended to do it every couple months or do it every six months. I mean,

01:26:52.160 so I wouldn't say, I'm not saying I'm against this procedure, but I don't think it's well proven

01:26:57.620 because look, it's marketed for wrinkles, for acne scarring, for hyperpigmentation, for anti-aging

01:27:05.100 most of the time. So again, look at the before and afters because everyone's going to put their

01:27:09.240 best workout. So if you look at the before and afters that I've seen, like type in Instagram PRP

01:27:15.560 facial or microneedling facial or PRP injections and look at the acne scarring pictures. And it's

01:27:23.440 very hard to find good results that are not the result of differences in lighting, right? You have

01:27:30.160 a shadowy picture before, and then you have a front facing light in the after. And I would say

01:27:35.440 the majority of the time, any benefit that you're seeing is from that. There's some evidence. There's

01:27:41.340 some evidence that it does help. And on a histologic level, yes, we're building collagen,

01:27:45.240 but it has to be significant enough to be observable to the people around you. Otherwise,

01:27:52.180 are we just like making ourselves feel better? Or are we just jumping onto the bandwagon? Or is it a

01:27:57.520 money grab for a doctor's office? I mean, I'm not criticizing anyone for doing this, but I don't

01:28:02.240 think it's been fully vetted. And so I think because it's a relatively safe procedure, I think it's overall,

01:28:09.160 I don't think it's detrimental, but let the results speak for themselves, you know?

01:28:13.740 Is it safe to say then that these are three broad categories of facial rejuvenation? You've got the

01:28:19.500 chemical peels where you're like physically applying a chemical to the skin and burning it.

01:28:23.860 You've got the laser peels where you're fractionating and selectively burning. And

01:28:28.460 then you've got this whole PRP vampire trick. And microneedling, there's radio frequency needles. I

01:28:33.860 mean, there's a huge realm of devices and there's a lot of money in this industry. So there's

01:28:40.260 definitely a drive that's motivated financially for companies to come out with the next thing

01:28:45.620 and they have to sell the next thing to the net, to the doctor's office.

01:28:49.700 What is the typical FDA approval process? I mean, a drug typically takes more than 10 years

01:28:54.280 to get approved.

01:28:56.020 It's not that lengthy and it depends if there's a predicate device.

01:28:58.580 So if there's something that's a similar energy, it's much easier and you can usually get it based on

01:29:03.180 the previous device. A new device can take longer. You know, it depends, but it could be,

01:29:08.440 it depends what it is. If there's an IRB study that's been already done, it could be six months,

01:29:13.840 it could be a year, it could be two years. But you also have to have an understanding that

01:29:18.460 because something's FDA approved doesn't mean that it's effective. It just means that it's safe.

01:29:22.220 Safe, yeah.

01:29:23.160 So there's lots of devices that I think are bogus and I see them all the time. And you have to look

01:29:29.000 at what's really going on here. Is it that this industry needs to make more devices? And I hate to say

01:29:34.660 I'm not trying to criticize my friends and my colleagues that are in the industry. But I think

01:29:39.720 we do have to step back sometimes and look at this and say, who are we serving? You know,

01:29:44.740 are we serving ourselves? Are we serving our patients? If I do a treatment on you and it's

01:29:49.000 not that effective, are you going to come back to me? I mean, you might, but if I do it again and again

01:29:55.180 and patients are walking, you know, that's not the foundation of my practice. And hopefully it's not

01:30:00.000 like that for everyone, but everyone has different motivations. And I would say I wouldn't do something

01:30:05.260 on you that I wouldn't do on a family member. And hopefully that's how most people are. And it

01:30:10.480 probably is. I think most physicians, most providers have good motivations, but it's not

01:30:14.380 universal. And so I think you have to be careful. If you look for a device or a treatment, it's probably

01:30:20.000 better to look for a provider that you trust than to look for the device. I mean, devices, you can find

01:30:25.440 the same devices in most cosmetic offices, but how are they being used and who are they being offered

01:30:31.360 to? And are they being selective? I mean, there's a treatment that I do now that's called thread

01:30:37.120 lifting, right? It's a dissolving thread that has barbs in it. And we sort of lift the skin

01:30:42.320 non-surgically and more than half the people that come in asking for it, I turn them away because I

01:30:46.900 think they're not candidates. And I think it's effective in a very select group of people and

01:30:52.920 everyone else. I have to say, I'm sorry, but I don't want you to walk around saying that it did

01:30:57.440 it and it didn't work. So it's interesting. When I was in residency, I remember one of the

01:31:01.120 attendings saying something that I never forgot, which was he said, you know, your reputation as

01:31:06.960 a surgeon is going to be much more about the patients you choose not to operate on than the

01:31:11.320 patients you choose to operate on. Yeah, I think that's true. I didn't really understand it at the

01:31:15.200 time, but it certainly has made sense later on down the line, which is effectively what you're

01:31:19.380 saying. You know, if you, uh, you only need a couple of times where you've done something on

01:31:24.660 someone who shouldn't have had it done and it can out outweigh the benefits of the, you know,

01:31:30.080 the hundreds of people who responded well. Yeah. And those are the ones you stay awake thinking

01:31:34.780 about, right? We stay awake thinking about the mistakes. Yeah, it's true. And hopefully you learn

01:31:39.180 from them. I mean, the other phrase that you hear a lot is like to the hammer, the world's a nail,

01:31:45.460 right? And so how that applies to this field is when you go into someone's office, are they,

01:31:51.880 are they willing to refer you to somebody for something that they don't do or that they don't

01:31:55.960 think that they're the best person to do? If someone comes to me and they want tattoo removal,

01:32:02.240 you know, I might have a laser that can do tattoo removal, but it's not the best one.

01:32:07.120 If I'm not going to do it on my wife, then, and I'd rather, you know, I'm going to send her to my

01:32:11.500 dermatologist friend that has the Pico second laser, then I'm not going to push you into that

01:32:17.000 box. So you, I think you have to be wary too. If you're looking for a solution, you have a problem

01:32:22.900 and you want a solution and you go to somebody, are they giving you the solution they have? Are

01:32:27.480 they giving you the solution that you need? So that could be another good filtering question

01:32:30.740 for patients, which is when you meet with a doctor, say, Hey, Dr. So-and-so, what are the types

01:32:35.680 of procedures you typically don't do and you refer out? And depending on their honesty with that,

01:32:40.560 you may get, you know, better insight into, you know, who they are.

01:32:43.720 Yeah. Or if there's a procedure, let's say there's a problem that you have and you say,

01:32:47.120 what is your solution? And say, are there other solutions that are out there that you can discuss?

01:32:52.260 So in my area of interest, which is longevity, I spend a little bit of time, not a tremendous

01:32:59.200 amount of time, but maybe 10% of my energy goes into thinking about the future. What are the step

01:33:04.920 function changes? What are the things that are out there that are not a part of what I do today?

01:33:10.760 Cause they're not ready for prime time or they're still very theoretical, but they're the things I

01:33:16.080 want to keep enough tabs on because I hope that within the next decade or, or maybe beyond they

01:33:20.820 become relevant. What fits that description in your field? What are the things that maybe aren't ready

01:33:26.660 for use yet, but show promise?

01:33:28.760 It sort of makes me shudder to think about the future because I imagined myself 20 years from

01:33:34.040 now, hopefully I'm still practicing and I'm going to look back and think like, wow, you know,

01:33:40.240 we were in Plato's cave at that time. Like we were seeing the shadows on the wall and not seeing the

01:33:46.940 true objects. Right. And I think we are in a sense, right. I mean, what is our, how limited is our

01:33:51.900 understanding and the things that we, we don't know that we don't know them yet. And so I think there

01:33:57.760 are things, the things that we're doing today that I don't fully understand, like things like fat

01:34:02.680 grafting, I use it. And I think there's some predictability to it, but we don't fully understand

01:34:08.900 why it works and how it works. And I think some of that relates to the stem cells, the stem cell

01:34:16.020 effect. And you hear a lot about stem cells being used for all types of medicine. And it's the same

01:34:21.600 with cosmetic procedures. And I do some procedures.

01:34:23.920 I think of stem cells. Like I think of Chevy Chase describing ball bearings and Fletch, you know,

01:34:28.980 that scene when he's like, uh, you know, that's all ball bearing. And the guy's like ball bearings.

01:34:33.320 He's like, that's all ball bearings nowadays. And it's like, that's like stem cells and ball bearings.

01:34:37.240 It's just the same thing to me.

01:34:38.460 It's the cure-all. It's the PRP of the future.

01:34:41.720 Which remains to be seen how viable it is, right?

01:34:44.120 It's the PRP of today. I think, look, there's something there. We know there's something there.

01:34:48.440 We just can't exactly understand. We can't put our finger quite on it. And there's some good

01:34:54.280 science there now, but I think there's definitely going to be something. And I have colleagues,

01:34:59.340 I have friends that are doing a lot of stem cell treatments, whether it's intravenous,

01:35:03.180 direct injections. I'm in a sense using nanofat as a stem cell. You know, our fat is a rich source

01:35:09.620 of stem cells.

01:35:10.640 Yeah. This is counterintuitive, isn't it? People have always considered fat to be a totally inert

01:35:14.500 tissue, but it's actually an endocrine tissue.

01:35:17.220 That's true, right? And then why are we going to bone marrow for stem cells when it's closer to

01:35:22.180 the surface? It's right there. And it's abundant in a lot of people. When I do procedures with fat

01:35:27.820 grafting, and I'm thinking, hey, I'm injecting fat, and these fat cells are making them look younger,

01:35:32.760 but it might be that the fat cells are not, none of them are surviving.

01:35:35.580 It might be none of the fat cells at all. It might be the adipokines or the cytokines.

01:35:38.400 Maybe it's a combination. Or when I do what I call nanofat, which is the stromal vascular fraction,

01:35:43.300 or the soup that's in between the fat cells, and now I inject that with the fat, am I supporting

01:35:49.360 my fat grafts with these factors? Maybe. I mean, I'm seeing results, and we sort of look at the

01:35:57.040 literature, which is limited, and we look at large-scale studies, which are also limited.

01:36:02.180 We're looking for answers in doing these things, and we try to stay safe. But there's definitely

01:36:08.240 a lot to learn when it comes to that particular area, right? We know that. We look at other types

01:36:13.880 of growth factors. I've seen some promise with fibroblast growth factor, which is also an

01:36:19.080 injectable. I consider that a biologic therapy.

01:36:21.900 And in FGF world, which is the abbreviation for fibroblast growth factor, there are so many numbers

01:36:26.800 to them. Are you talking FGF 21? Well, this is something that's not approved in the US. We

01:36:33.400 don't have it here. There's been studies in Asia. Actually, I don't even know which version. I probably

01:36:40.720 have it in my notes here, because I haven't been able to do it. But basically, are they harvesting

01:36:46.060 autologous FGF from an individual? No, these are laboratory-derived.

01:36:52.140 Got it. So they're basically making FGF as a growth factor and just injecting it.

01:36:56.960 Correct.

01:36:57.320 And is this done in Europe?

01:36:59.180 It's done in Asia.

01:37:00.120 And what's the indication?

01:37:01.740 Volumization, facial volumization. And it seems to have long-lasting results.

01:37:06.360 So is the FDA evaluating this stuff now?

01:37:08.700 I'm not clear about that. I don't know. I haven't heard of any studies. I don't know if

01:37:12.260 anyone who's part of an IRB. But it seems to hold some promise. I think customization, like what you do

01:37:18.620 in your practice, and you're going to get down to the specific gene level eventually,

01:37:24.840 right? And hopefully, we'll be able to have a full map of everything. And each person will know

01:37:29.140 exactly what drug is going to work well for them. And we'll be like that, I think, with cosmetic

01:37:33.980 procedures, right? How is your skin going to respond to this laser? And what energy setting is

01:37:40.180 appropriate for you versus this other person based on what your genetic screening told us?

01:37:45.060 I think that's definitely in the future. I think customization in terms of 3D printing,

01:37:51.320 bioprinting. So let's say there's something you don't like, you want to change your ear,

01:37:57.480 we'll probably be able to print ears. We'll be able to print organs. I mean, there's no question

01:38:01.220 that bioprinting is in the future, and we'll be able to replace blood vessels, organs, skin.

01:38:06.640 That just seems so far out. I mean, as an interesting aside, I remember once being in your

01:38:10.900 office, and you showed me a bunch of surgical instruments that you designed yourself and

01:38:14.420 had 3D printed, and they were just perfect, right? It was like you knew exactly what you

01:38:18.560 wanted, and you were like, well, this doesn't exist. I'll just make it.

01:38:20.860 Right. I mean, in the past, you would have to go to a manufacturer, and you'd have to convince

01:38:24.800 this industry person of what you want to make.

01:38:27.880 Right. Make a fab.

01:38:29.000 And then they're going to say, well, how many people are going to buy this, and how useful?

01:38:32.840 Well, I don't know. It's for me. It's useful for me. But then they're not going to make

01:38:36.480 an injection mold for me based on, you know, let's say the 300 eyelid surgeon specialists

01:38:41.300 in the country. That's a limited market. So with a 3D printer, I just draw what I want,

01:38:47.440 and I have it translated into a digital file, and then I print it. There's a place in Long

01:38:53.320 Island City, Queens, and they make it in stainless steel, and then it comes to my office, and I'm

01:38:57.840 using them every day. And I've sent them out to my friends and that kind of thing. But in the

01:39:02.520 future, we'll be able to make what we want. Imagine a box that is connected to your computer,

01:39:07.180 and whatever you can imagine will be in that box. And it doesn't have to be just like in

01:39:11.800 silly, like it doesn't have to be a Hello Kitty made in plastic. It can be made out of multiple

01:39:16.400 materials. And so you can have, imagine your phone. I mean, I'm not trying to promote 3D

01:39:22.420 printing, and it's not my, my practice isn't 3D printing, but let's say just you pay on Amazon,

01:39:27.960 and then you press the button and then it prints the phone in your box. And then you have the new

01:39:33.520 iPhone. I mean, I think that's conceivable in the future. I mean, it's, it's, it's easily

01:39:38.560 conceivable. And so the same thing with organs, I think there's a big, see, I didn't realize we

01:39:43.060 could go beyond, I mean, I've certainly seen amazing things in 3D printing where you're dealing

01:39:47.960 with something that's homogeneous, but a phone is like a completely heterogeneous thing.

01:39:52.980 Well, you can print circuits. You can print in different materials right now. You can print in

01:39:58.600 different thicknesses and rubbers. So you can have a soft rubber inside of a hard rubber. So you can

01:40:03.840 print a, let's say you can print a silicone breast implant, right? And you can make it exactly your

01:40:08.400 shape. So I would scan your body. Well, I don't know if you want a breast implant. Yeah, I'll probably

01:40:12.160 pass, but maybe you want a pec implant though. And I would scan your body. Are you saying my pecs are

01:40:16.520 inferior? You just, you can use a little bit of bulk. I know you did the Joe Rogan

01:40:22.700 podcast. So maybe you're thinking you need to be a little beefier. Yeah. I took a lot of heat for

01:40:27.320 looking too scrawny on that, but I could scan your body right with a 3d camera. I would probably get

01:40:32.940 some CT scans of you as well to look at your bone structure. We would design an implant that was,

01:40:39.240 and you'd have, you know, maybe your left pec needs to be a little bit higher and your right one

01:40:43.460 needs to be a little more projection and it would fit your body exactly. And it would be, let's say

01:40:48.440 soft on the inside and a little firmer on the outside. So it feels like muscle, but when you

01:40:52.840 press on it, it's kind of squishy like muscle, but why stop there? Why not just make it out of muscle

01:40:57.240 cells, right? We'll create a scaffolding and that scaffolding will populate with cells that we

01:41:02.940 cultured from your muscle in a lab. And then we populated it onto the scaffolding and we grow it over

01:41:07.960 a week or two. And then we just use a small incision and we implant it in you. Yeah. It's

01:41:12.460 interesting. When I was in medical school, my very first summer, the first lab I worked in was the

01:41:18.520 lab of an ENT surgeon and he was interested in growing septal chondrocytes. So taking these

01:41:25.680 chondrocytes, these cartilage producing progenitor cells and growing ears. And at the time, a very,

01:41:33.380 very popular paper by, um, God, I'm trying to remember the name. It was Langer and Vacanti,

01:41:37.380 two very famous guys in this space from MIT and Harvard. And they grew, they grew the ear in the

01:41:42.540 mouse. Yeah. And we had that picture up in our lab and, you know, we were trying to replicate it.

01:41:47.600 And of course the challenge at the time was coming up with biodegradable scaffolds. Yeah.

01:41:51.660 It has that. And of course I haven't paid attention to this problem in 20 years, but

01:41:54.580 there are scaffolds now there's people that are printing blood vessels. Look, but I think it's a big

01:41:58.440 regulatory obstacle. I think for me, what, what I was always interested in was printing in materials

01:42:04.220 that are already approved, right? Like silicone. And I think the living cell printing will be there,

01:42:12.120 but think about the regulation of if you're in the operating room and you want your tissue printing

01:42:17.560 device, you have to approve it for every indication. So you have to approve it for making this thing for

01:42:24.820 this procedure and you have to, it's, it's a, it's like an endless permutation. So the FDA now is

01:42:29.840 looking at 3d printing and they do have new guidelines and regard to that. And they're

01:42:34.720 recognizing that this is the future and that medical 3d printing is growing, but it's definitely

01:42:41.180 going to happen. There's been use of 3d printed implants in university of Michigan for infants

01:42:47.740 with tracheomalacia. It's actually considered to be 4d printing because these implants change over time.

01:42:54.420 So the implants can grow with the patient and eventually can reabsorb. But someone with a baby

01:43:00.280 with a narrow trachea, they were building 3d printed cages and suturing the trachea to the cage to hold

01:43:06.800 it open externally. And then as the patient grows, the cage enlarges and then eventually it can absorb.

01:43:12.920 So the application here goes far beyond cosmetic surgery and it will be unbelievable. And I mean,

01:43:18.260 it is believable to me, but I can talk about it for another two hours. It's just,

01:43:22.580 it's mind blowing and it's exciting and it's frustrating because I want the next step and

01:43:29.660 where it takes money, it takes time and it takes people that are interested. But if somebody's

01:43:35.360 listening and wants to talk to me about developing 3d printed materials for surgical procedures,

01:43:41.860 I mean, I have something specific in mind. I've been trying to do that for a while. I have,

01:43:46.000 I have non-disclosures with a lot of large companies, but it's hard to get someone to invest money

01:43:51.560 in something that doesn't give you a return in the next two years. Right. That's, that's one of the,

01:43:57.240 I think the struggles. Well, speaking of people contacting you, I follow you on Instagram because

01:44:01.660 I just love looking at your before after photos and how can people follow you? What's the best way

01:44:06.640 to follow you on Instagram? It's at Dr. Kotlis, C-R-K-O-T-L-U-S. You can look me up on my website.

01:44:12.540 I have some videos and procedures. And what's your URL? It's Dr. Kotlis.com, D-R-K-O-T-L-U-S.

01:44:19.900 But yeah, I share a lot of my stuff on Instagram. I think that's kind of fun because people can give

01:44:24.100 me feedback and my, I've seen my audience grow and I'm, I'm following you on Instagram too,

01:44:28.860 with your race cars and your, your, my nonsense. Yeah. It's fun. I think, um, you know,

01:44:35.000 Instagram has connected me with a lot of people that I probably wouldn't have met otherwise. I mean,

01:44:40.000 the, the internet and social media has, has made the world a smaller place in a way. Look,

01:44:45.300 there's a lot of garbage to wade through, but it's not all bad. I don't think there's anything I do

01:44:49.960 clinically that is really relevant to Instagram. Well, it's not visual, but it is right. I mean,

01:44:54.660 I think people are interested in seeing what you're doing in your day. I'm interested in your

01:44:59.480 routines. I'm interested in like, Oh, what is he eating? What is he, what is that indwelling device

01:45:04.940 that you have that's measuring your blood glucose or what's going on in your lab? You posted that

01:45:08.680 picture on your whiteboard of your, like, it looked like your Einstein theories of longevity.

01:45:13.840 I mean, it's actually very poignant breakdown of your longevity approach and I've seen you working

01:45:19.940 on the whiteboard. So I'm imagining you writing that and sort of like constructing your book that

01:45:25.180 everyone's waiting for. But I think people are looking for insight into your life and into your

01:45:31.800 philosophy. And it doesn't have to be, I mean, for me, it's a little bit easier maybe because I can

01:45:35.160 show a before and after, but that's not, I think the before and after is not the important thing.

01:45:40.360 The important thing is like the story behind the before and after. Like this is a teacher and she

01:45:44.880 came to me because she was recently divorced and she's thinking about finding a new partner maybe,

01:45:50.760 or maybe just feeling better about herself because she's surrounded by younger teachers.

01:45:55.320 Those kinds of stories to me are the powerful things. And what's important, like what I love about what

01:46:00.660 I do is that people bring me into their lives in many ways, not just for an injection, but to tell me

01:46:07.780 about why they want to do it. Yeah. You have a video on your website that you produced, right?

01:46:14.280 Right. Yeah. So that was just, I think, trying to convey my philosophy in a way that I thought was,

01:46:20.260 you know, more powerful about the stories of people who are seeking my help or my advice.

01:46:25.760 And so, um, I'm always thinking about the next one. I think I could do it better,

01:46:29.120 but that was a fun project. Well, Brett, I can't thank you enough for this. I've learned a lot from

01:46:33.920 you over the last couple of years. And I feel the same way, but I appreciate you taking the time to

01:46:38.480 sit down today. I hope that people get something out of this. And again, it could be as extreme as they

01:46:44.260 know that they want to do some of these procedures. And now they feel armed to scrutinize the

01:46:48.960 providers out there and make sure they're getting the best care possible. And alternatively, it may

01:46:52.140 be, I don't want to do any of that stuff, but boy, if I can just do these three things, you know,

01:46:56.420 put my sunscreen on, use some retinoic acid and maybe a little topical vitamin C that's going to

01:47:01.600 make a 10 year Delta. Well, thank you for inviting me to do this and for leading the way for many of us

01:47:06.940 in terms of searching for the answers and, and also sharing those answers. It's great to see you.

01:47:13.100 And I will, uh, we'll, we'll continue this discussion. I'm sure. All right. See you.

01:47:18.960 You can find all of this information and more at peteratiamd.com forward slash podcast.

01:47:24.520 There you'll find the show notes, readings, and links related to this episode. You can also find

01:47:29.640 my blog and the nerd safari at peteratiamd.com. What's a nerd safari you ask? Just click on the

01:47:35.640 link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my

01:47:39.660 subjectively non lame once a week email, where I'll update you on what I've been up to the most

01:47:44.340 interesting papers I've read and all things related to longevity, science, performance,

01:47:48.980 sleep, et cetera. On social, you can find me on Twitter, Instagram, and Facebook all with the ID

01:47:54.340 peteratiamd. But usually Twitter is the best way to reach me to share your questions and comments.

01:47:59.480 Now for the obligatory disclaimer, this podcast is for general informational purposes only and does

01:48:04.100 not constitute the practice of medicine, nursing, or other professional healthcare services,

01:48:08.580 including the giving of medical advice. And note, no doctor patient relationship is formed.

01:48:14.400 The use of this information and the materials linked to the podcast is at the user's own risk.

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01:48:23.960 diagnoses, or treatment. Users should not disregard or delay in obtaining medical advice for any medical

01:48:29.360 condition they have and should seek the assistance of their healthcare professionals for any such conditions.

01:48:34.440 Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my

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The Peter Attia Drive - September 03, 2018

#13 - Brett Kotlus, M.D.： How to look younger while you live longer

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