The Peter Attia Drive - #355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance

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

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00:01:04.340 My guests this week are Dr. Tanuj Nakra and Dr. Susan Obaji, two highly respected physicians in

00:01:11.360 aesthetic medicine. Tanuj is triple board certified in facial and ophthalmic plastic surgery, faculty

00:01:17.480 at the Dell Medical School, and the director of the Cosmetic Surgery Fellowship at the TOCI

00:01:21.900 and Face Institute in Austin. Susan is double board certified in dermatology and cosmetic surgery.

00:01:27.920 She is an associate professor at the University of Pittsburgh and the director of the UPMC Cosmetic

00:01:33.340 Surgery and Skin Health Center, where she leads advancements in cosmetic and laser surgery on a

00:01:38.580 global health scale. In this episode, we talk about the biology of facial aging, how hormonal changes

00:01:44.880 impact facial bone structure and skin integrity, and the critical role that hormone replacement therapy

00:01:50.740 plays in preserving a youthful appearance. We talk about what makes a face attractive from an

00:01:55.740 evolutionary perspective and a psychological perspective, and how modern media and social

00:01:59.420 media filters are warping and distorting those standards. We talk about the troubling rise in

00:02:04.240 cosmetic procedures among teenagers and how physicians can navigate ethical decisions around

00:02:09.100 these things. And then we really get to the substance of this podcast, which is we talk through a

00:02:14.280 practical and science-backed approach to skin health, including the essentials, sunscreen, retinoids,

00:02:20.220 and vitamin C, and many more things. We talk about mineral sunscreens and why they are likely

00:02:24.800 superior to chemical or organic sunscreens, how to use retinoids correctly based on skin type and

00:02:30.680 sensitivity, what a personalized morning and evening skincare routine should look like, including

00:02:35.480 cleanser type and application order, the medical management of acne, especially cystic acne,

00:02:41.040 the psychology behind aesthetic consultations, and why trust, motivation, and emotional readiness are

00:02:47.320 critical before undertaking procedures. And finally, and perhaps most importantly, at the end of this

00:02:52.100 podcast, we turn the tables. I'm the patient. I'm sitting across from them, and I'm asking them

00:02:57.880 to be as brutal as they need to be and offer an assessment of what would be truly possible if someone in my

00:03:05.520 shoes wanted to take all the steps of aesthetic medicine and apply them to their own appearance.

00:03:10.660 from the neck up. This was the most illuminating discussion, and while I realized that listening

00:03:16.380 to it, it might sound like they're being overly harsh or critical, you have to understand this is

00:03:21.140 exactly what I wanted. I wanted to understand these things, and honestly, I came away from this

00:03:26.300 realizing there was more quote-unquote wrong with my face than I ever imagined. Again, will I do

00:03:31.880 anything about it? Truthfully, beyond the new skin regimen, I have adopted probably nothing,

00:03:37.340 but nevertheless, I was intrigued by this, and I think that many of you who have been thinking about

00:03:43.180 these things as well will come away either deciding maybe there are things you want to do from an

00:03:47.660 aesthetic standpoint, or at a minimum, just taking care of your skin might be the right thing to do,

00:03:51.760 and clearly, you'll come away from this with a great regimen for how to do that. So, without further delay,

00:03:56.480 please enjoy my conversation with Dr. Tanuj Nakra and Dr. Susan Abadji.

00:04:06.580 Tanuj, Suzanne, great to have you here both. You're obviously in Austin. You traveled from

00:04:12.480 Pittsburgh, right?

00:04:13.320 Yes.

00:04:13.940 Awesome. Well, this is a topic we get asked a lot about, and sometimes when we get asked about topics,

00:04:20.220 I already know quite a bit, and this is absolutely an example of the opposite of that. This is a topic

00:04:28.160 we get asked about a lot, and I would argue that my knowledge is even below that of the general

00:04:33.080 public. I can't think of a time when I've done a discussion on the podcast on something where I know

00:04:39.360 less than all things related to the health of one's skin and appearance. And so, yeah, thank you very

00:04:47.280 much for both being here, and thank you for helping me even think about how to structure a discussion

00:04:52.280 on this topic. Maybe before we jump into it, just give us each a little bit of your backgrounds.

00:04:58.020 I think it was helpful to have not one but two experts here because you guys have sort of a

00:05:03.260 different specialty. Obviously, within medicine, you have a different specialty. You overlap in things,

00:05:08.680 but obviously do some things different. So, tell us a little bit about your training,

00:05:11.280 your background, and what you focus on.

00:05:13.460 Yes. Thanks for having us, Peter. It's a pleasure to be here to talk about

00:05:17.260 something I'm quite passionate about, and I know it's very confusing for a lot of listeners

00:05:22.460 to understand aesthetics, and we'd love to demystify it a little bit. So, my background,

00:05:27.640 my core specialty is oculofacial plastic surgery. I trained in eye surgery and in facial surgery,

00:05:33.920 mostly at UCLA.

00:05:35.500 Do you train in plastic surgery first?

00:05:38.180 My original background is ophthalmology, and then I did fellowships in ophthalmic plastic surgery,

00:05:43.940 and then another fellowship in facial cosmetic surgery in addition to that.

00:05:48.140 My practice is limited to eye and face plastic surgery, basically. That ranges from reconstruction

00:05:56.640 of children, cancer reconstruction for elderly, and all the cosmetic surgeries that we can perform

00:06:03.280 on the face.

00:06:04.140 Including nose, neck.

00:06:06.020 Including nose and neck, yes.

00:06:07.660 I moved to Austin 16 years ago after training at UCLA, joined a large group here, and we're also

00:06:14.620 all in the faculty of the Dell Medical School. So, we are actively involved with academics,

00:06:20.080 teaching, residents. We have a fellowship program, two fellowship programs in our practice.

00:06:25.020 It's a real pleasure to be involved in academics because it's the cutting edge of science,

00:06:28.720 and we'd like to perform clinical research. And in the academic community, which is how I know

00:06:34.780 Susan, there's a lot of collaboration among specialties, and we have an opportunity to

00:06:39.640 dialogue and further the specialty that we care so much about.

00:06:43.920 Awesome. Okay. And Susan, you are a dermatologist by training?

00:06:47.000 Yes. And then I did a cosmetic surgery fellowship, and I am in academic medicine as well. I'm at the

00:06:52.560 University of Pittsburgh. I've been there about 24 years. So, I got to see the evolution of this

00:06:58.060 entire field, starting with what we used to do at the time was surgeries, and then maybe a few

00:07:03.660 collagen injections. And now we have the plethora of all these tools at our disposal. And I train

00:07:09.800 residents, medical students, and I have visiting physicians from all over the world that come in.

00:07:14.840 And I love the multi-specialty collaboration that we have because we both belong to the American

00:07:20.580 Academy of Cosmetic Surgery, and we hear a different approach from different specialists,

00:07:25.600 maybe on the same procedures. In my practice, I focus on everything with regards to skin

00:07:31.400 rejuvenation, peels, lasers. I also do a lot of fat grafting. We do body liposuction,

00:07:39.360 mini facelifts, eye lifts. But everything, when it comes to the face, is about really enhancing the

00:07:44.900 appearance of the skin first, because my feeling is that's the most important thing that everyone

00:07:49.560 sees. So, when a patient comes in like you, who has not had anything done or doesn't know about the

00:07:55.920 field, I actually like that because I can take that opportunity to really educate them and pick the

00:08:00.760 right things for them. I appreciate you noticing I've had nothing done. We were talking before the

00:08:07.340 podcast, but it's worth me stating this now, again, for everybody to hear. There is something about

00:08:12.720 this field of medicine that I have such a block in my brain to understanding. And Tanuj and I have

00:08:21.740 met before. Tanuj helped me with a scar. So, Brett Kotlis, a friend of mine who's actually been a former

00:08:26.840 guest on the podcast, introduced us. I face-planted one morning due to some hypotension and sustained a

00:08:33.780 pretty nice scar here that I think, for the most part, is largely invisible today, probably in part

00:08:39.600 because my face is leather to begin with, but I think in part because we did some 5-FU microabrasion,

00:08:46.220 we did a whole bunch of stuff, and I was actually pretty diligent about staying out of the sun for the

00:08:50.740 period of time after it, etc. So, I think we've also done a Botox treatment, which it's certainly

00:08:57.680 reduced the wrinkles. Obviously, it's long gone, but I'd love to talk about that. My wife and her

00:09:02.660 friends, it's almost like they've done fellowships themselves, the way they talk about this stuff. And

00:09:08.540 maybe that is just true of women in their 40s, but the way they go on about these techniques,

00:09:14.500 it must sound like that when I talk about cars in front of them. It's so foreign. So,

00:09:21.920 as I was saying earlier, I have taken a strategy towards my appearance that is probably illogical,

00:09:31.020 which is I'm just going to ignore it because I don't understand it, and I'm going to focus on

00:09:36.000 things I understand. I would view it as an enormous win of this podcast if, in a few hours,

00:09:42.860 I decided to do something that was sustainable and going to help me look a little better at 62

00:09:51.100 than I should look. I'm 52 today. I looked at a picture of myself 10 years ago before this podcast.

00:09:58.100 What a difference 10 years has made. I look so much worse today than I did 10 years ago.

00:10:03.840 I guess that's not uncommon. I would guess 42 to 52 is a big reduction in appearance, but it also made

00:10:10.040 me realize, wow, the next 10 years, that reduction will probably be greater if I don't do something

00:10:14.960 proactive. And to just make one final point about my abject laziness on this topic, I can't even bring

00:10:21.540 myself, this is going to sound so disgusting. I can't even bring myself to wash my face before bed,

00:10:26.700 which my wife is like, you are so disgusting. Just wash your face. But I'm like, eh, it's not like

00:10:33.500 I'm that greasy. Who cares? She's always buying products for me. I just can't bring myself to do

00:10:38.640 it. So you guys have your work cut out for me because if I can be educated on this, you can

00:10:44.180 change the world. I was about to say that, 10 years. We have our work cut out. Let's start a little

00:10:49.620 bit with the biology of the aging face. And again, we're going to limit our discussion today to the

00:10:55.760 neck up. Not that there isn't other things that are completely relevant around cosmetics, but

00:11:01.380 that's just a big enough topic. I told you that when I looked at myself 10 years ago,

00:11:06.040 I couldn't believe how much better I looked. But I'd have a hard time telling you why. I can't put

00:11:11.180 my finger on it, but I bet you can without me showing you those pictures. Why did I look better

00:11:16.640 at 42 than 52? That's exactly how my patients come in. A lot of times they'll come in and they'll say,

00:11:22.320 I feel like I look tired. I don't know exactly what's going on, but I feel like I look tired.

00:11:27.440 And I have these beautiful diagrams in my office and I show them the face of someone who's 20,

00:11:35.020 the face of someone who's in their late 60s, and I walk them through the changes.

00:11:39.100 And the first thing I do is we show them the diagram with the skin peeled off.

00:11:43.380 And you see about 11 different fat compartments in the youthful face on each side of the face that

00:11:49.520 are plump, they're robust, they're giving volume, and they're giving a padding between the skin

00:11:55.620 and the muscle and the underlying bones. And then you look at someone who's in their late 60s and

00:12:01.560 you peel the skin away and you see a dramatic atrophy in all those fat pads. A few might increase

00:12:08.140 in size, but the vast majority undergo atrophy. And then in addition to that, I show them what the

00:12:14.020 bones are doing at that age too. So we look at the bony vault of a 20-year-old and the opening around

00:12:20.020 the eyes are nice and tight. The cheekbones are nice and wide. The jawline has a really good

00:12:25.540 definition. And then you look at someone who's in their 60s and all of a sudden the opening around

00:12:30.460 the eyes are wider. Really? Cheekbones are less wide, jawbones less wide, less height. And so now

00:12:37.140 you've got that scaffolding that's diminished and all the skin looks like it's just hanging.

00:12:42.140 And that's what's happening, but it starts early. So what I see on most of my patients when they come

00:12:47.800 in and say, I look tired, and you said it.

00:12:50.020 You look at your pictures 10 years ago and you look now and you don't know what's different.

00:12:53.760 The first change is around the eyes. And I'm sure Tanoosh can add to that. But basically what's

00:12:58.880 happening is you're getting more bone loss around the eyes, more fat atrophy around the eyes. So

00:13:04.200 you're starting to see the underlying anatomy, which was padded before.

00:13:08.160 So first of all, this is completely news to me. Is this loss of bone comparable to what we would see

00:13:16.160 in the reduction of bone density in a person's hips as they age?

00:13:20.200 So a lot of it is hormonal. A lot of it is hormonal. And you see it, especially in women,

00:13:26.820 if they start to see the aging changes, they'll start to identify that in their early 40s.

00:13:32.220 So this, in other words, is probably another reason why women would benefit from hormone

00:13:36.380 replacement therapy, because maintaining estrogen levels would maintain bone health.

00:13:40.580 Absolutely. And actually, that's something we need to stress more and more to them,

00:13:44.400 because it starts in their probably early 40s, and then it just accentuates over time. But by the

00:13:50.700 time they hit 50, all of a sudden, now if we're looking at them cross-sectionally, a group of 50-year-olds

00:13:55.960 compared to guys who are 50, the men are holding up pretty good. Their facial bone structure is good,

00:14:02.180 their fat volume is good, their muscle thickness and skin thickness is good. But from 50 to 60 or 70,

00:14:08.780 women will age about 20 years faster than men, in the lower face especially. They will get so much

00:14:14.560 atrophy in the mandible. That's why women start to say, I hate my neck, and I hate the loose skin in

00:14:19.640 my neck. Because if the mandible is retracting, the neck becomes looser. Yes. Again, this is

00:14:24.920 remarkable, because if you're bringing it back to the one thing I know about bone, it's when you

00:14:29.900 look at men and women aging from a skeletal system, they're both going through a comparable decline

00:14:36.480 starting in their 20s, because we both peak, both men and women peak in the early 20s. But at about

00:14:42.440 50, women fall off a cliff, whereas men just continue a linear decline. And so the gap really

00:14:48.420 widens. Interesting to realize that the exact same thing is happening in the face.

00:14:52.220 That's exactly it. And that's why women come in, the first things they say when they're 50 is,

00:14:56.600 I hate my neck. And I think we jump to try to surgically correct it or to augment it with

00:15:02.320 fillers or neuromodulators to keep the muscle from pulling down. But I think we have to have a talk

00:15:07.140 about hormone replacement. You have to catch those women before they're far along into menopause.

00:15:12.740 Again, I'm blown away by that fact. And if I could hop in for a second, I love the direction of this

00:15:17.200 conversation, because I don't know if people realize how much science there is about the aging

00:15:22.820 process. There were some seminal studies by Rorick and Pessa in the 90s and 2000s that delineated a lot

00:15:31.240 of what Susan's talking about, where they looked at CT scans of the same individual over time.

00:15:37.600 I think some of those studies had a 15 to 20 year span. And there was quantitative calculations of bone

00:15:44.280 density and bone projection of the mandible, the maxilla, the frontal bone. And these bone structures

00:15:50.540 all recede with aging. And the bone is the foundation for the face. And so when we're talking

00:15:56.680 about youthful fullness of a face, a lot of that is the bone structure. And then as Susan said,

00:16:02.160 of course, the fat compartments are a critical component of our facial aesthetics. And as we lose

00:16:07.280 all that volume, the reason why people start to look more skeletal as we age, one of the most common

00:16:13.020 areas that I see in my practice is people talking about their under eye bags and their lines that

00:16:17.900 are showing up in their eyelids and their cheek area. It's because we have ligaments that attach

00:16:22.560 the skin down to the bone. It's called the osteocutaneous ligamentous network of the face.

00:16:27.360 And those ligaments are the same for every single individual, no matter what your ethnicity is. Of

00:16:32.760 course, there's variations on the theme, but the orbital retaining ligament, the malar ligament,

00:16:37.980 the temporal ligament, the mandibular ligament, the masseter ligament, these ligaments are always

00:16:43.280 present. And then as we lose that facial volume from fat atrophy and the bones move backwards,

00:16:50.580 these ligaments are tugging on the skin and these deep lines start to show up. And that's,

00:16:56.640 I would say, one of the fundamental changes we see with aging of the face.

00:17:00.440 What I guess I don't understand is the following. Again, I'm just going to use myself as the example

00:17:04.600 because I think I'm probably reflective of many people. 10 years ago, I was less fat than I am

00:17:13.000 today. Same body weight, by the way, almost to the pound. I'm the same as I was 10 years ago,

00:17:18.960 but I would bet my body fat was two or 3% lower. In other words, I have accumulated fat in my body.

00:17:27.360 Why am I losing fat in my face? What is it about facial subcutaneous fat depots that atrophies

00:17:36.040 when for virtually every person, the opposite is happening when they age. They're actually

00:17:41.540 adding adipose tissue subcutaneously and unfortunately, often viscerally.

00:17:47.560 If I may answer that one, it's interesting because I talk a lot to my patients about that. Now,

00:17:52.220 the vast majority of my patients are female. So they'll come in and they'll see me and I can look

00:17:58.380 at their face. Let's say they're in their late thirties, early forties, and I can guess how many

00:18:02.660 kids they've had. Because what happens is you gain weight in pregnancy. It doesn't have to even be a

00:18:08.540 lot. But then most people, if they're fit, they lose that post-pregnancy weight.

00:18:13.240 I've had none, by the way, just in case you were wondering.

00:18:15.940 That's good to know. And then they lose that post-pregnancy weight. And what happens is they go back to

00:18:21.020 being the same weight that they were before they got pregnant, but their face is thinner.

00:18:25.440 Second baby, more so. By the third baby, it takes a significant toll on the face,

00:18:30.940 that weight gain, weight loss. So you can tell looking at a female face almost how many times

00:18:35.940 they've gone through that weight gain, weight loss. And so what happens, the facial fat pads are very

00:18:40.980 unique metabolically. Like I mentioned, most of the time they're just atrophying as we age.

00:18:46.060 There are a couple of compartments that might in time get thicker, such as the nasolabial

00:18:50.980 fat compartment, which is why some people have that deep fold. But for the most part,

00:18:55.580 they atrophy. And so if you go through this yo-yo change with your weight and you're progressively

00:19:00.300 getting thinner and then getting some weight back, it doesn't go to the face. It goes to parts of the

00:19:04.280 body we don't want. But the face continues to undergo that weight loss or the volume atrophy.

00:19:10.700 But do we know biologically, because it's almost like a lipodystrophy,

00:19:13.900 where the fat cell becomes defective and can't reaccumulate triglyceride or whatever it is,

00:19:20.540 whatever form it's going to store it in?

00:19:22.160 Like so many things in medicine, there are things that we know and a lot that we don't know.

00:19:26.580 Yeah. So we know that it's happening. We don't actually know the biochemical

00:19:29.240 mechanism necessarily.

00:19:30.360 We know some. I think we're just starting to understand the individual receptors and specific

00:19:38.020 nature of different areas of fat. So for example, even in the eyelid region, when we're doing

00:19:42.420 surgery on the face, we're doing surgery on the upper eyelid, we will see that the fat pads have

00:19:48.180 different colors. So the medial orbital fat pad is lighter substantially compared to the much

00:19:54.220 yellower and more orange lateral fat pad. And that color will be different than the buccal fat pad.

00:19:59.700 And one of the differences, there's beta-carotene differences in the fat pads. And that's probably

00:20:05.600 just one of maybe a hundred that we'll eventually find out is contributing to the differences in the

00:20:11.340 fat population. So we know that facial fat is different from abdominal fat, which is different

00:20:15.580 from lower extremity fat. And we know this also practically speaking, because when we're doing

00:20:19.980 fat grafting procedures, the source of the fat can have a different long-term effect when it's

00:20:25.400 injected into the face, depending on what the source was. So we know that fat is not the same

00:20:30.740 throughout the body and it's not the same in the face. There is a general consensus that beta-carotene

00:20:36.720 is an anti-inflammatory mediator. Higher concentrations and lower concentrations of

00:20:42.740 beta-carotene can have some effect on the metabolic health of fat, especially how it

00:20:48.320 responds to stress. And so in the world of longevity, there's a lot of discussions about

00:20:53.700 managing cortisol levels. Sleep is helpful. Having lifestyles that reduce your overall stress

00:21:00.460 level is good for your overall health in numerous ways. That's also true for the fat

00:21:06.600 and the skin of the face. Because again, a lot of this is not fully explained, but we're

00:21:12.180 starting to get more and more details as basic science progresses in this area, that these

00:21:17.540 fat compartments and the skin, which we can talk more about, is exquisitely sensitive to

00:21:22.920 stress that the body is experiencing cumulatively over time. So a lot of times people feel like

00:21:28.620 they're really aging in their 40s. People have midlife crises. They're probably experiencing

00:21:34.020 the maximum stress in their life at that stage typically. And I'm just generalizing here, but

00:21:38.780 people will have a busy career. They've got kids. They've got financial worries. And so people are

00:21:44.520 under a lot of stress in their 30s and 40s. And that contributes to some of the more rapid

00:21:50.660 facial volume loss changes, some of the skin aging changes with elasticity, collagen, elastin changes

00:21:57.640 that occur over time. And so that's where I think that this conversation really plugs in quite well

00:22:03.860 into the line of education that you're providing your followers in terms of longevity benefits,

00:22:10.160 because it overlaps here with cortisol stress and inflammation.

00:22:15.040 And what's interesting is that chronic elevation of cortisol in the body is actually anabolic to fat.

00:22:22.580 You accumulate fat. It's catabolic to muscle. Muscle decays, fat accumulates. It sounds like you're

00:22:28.740 saying, okay, that's true from the neck down, but above the neck, chronic elevation of cortisol might

00:22:34.300 have the opposite effect. It might actually be catabolic to fat and therefore it accentuates the

00:22:40.180 fat loss. Am I hearing you correctly in that? Yes, I believe that's correct. Just yesterday in my

00:22:44.700 clinic, I had a perfect example of this. I had patients back to back. One was 68 year old woman who

00:22:51.400 has lived a very comfortable life. She comes from affluence, hasn't really had to work too hard in her life

00:22:59.000 and has maintained things. Of course, she's used skincare products and she's had a little bit of

00:23:04.160 fillers and Botox, but no surgery. And she looked 10 years younger than her stated age because of

00:23:09.980 the kind of life she's been living. And then the next patient I saw was from rural Texas, has been in the sun,

00:23:16.680 has never been taking care of her skin, was working kind of a blue collar job, difficult life,

00:23:23.520 couple marriages failed. She looked like she was 10 years older. And this is common. I'm sure you see

00:23:28.600 this all the time as well, Susan. So lifestyle stress factors clearly have an effect. And one of the

00:23:34.940 reasons why, Peter, perhaps this is not an area that you've delved into in your vast experience in

00:23:41.380 medicine is because the quality of science and aesthetics has historically been pretty poor.

00:23:47.120 You're giving me way too much credit. I wish I could say that was, I have delved into plenty of

00:23:51.360 things where the science is poor. There is some other mental block I have. It might be that I'm

00:23:56.500 not smart enough to understand it all, but we'll continue. And I appreciate your...

00:24:00.980 And another reason why it becomes very murky to sort through the science, and I'm sure this exists in

00:24:06.840 other areas of medicine too. But a lot of the individuals, corporations, forces that are

00:24:13.580 delivering science to the masses and to physicians who are eating it up and regurgitating it to their

00:24:18.700 patients, these sources are questionable. They're profiting, as you I'm sure realize, the aesthetic

00:24:24.760 industry is a very, very lucrative industry worldwide, especially in the United States. There's a lot of

00:24:32.720 forces where those that are delivering the science have a vested interest in receiving monetary benefit

00:24:39.300 from what they're pushing out. And that makes things murky.

00:24:42.780 But I think going back to the fat compartments, think about it with our patients in general.

00:24:47.580 The role of the fat compartments in the face are to allow muscle glide. So the muscles can move over

00:24:52.380 each other when you smile, talk, eat, chew, all of that. And I don't understand why they should undergo

00:24:58.480 such atrophy over time for such an important function. But then we look at the metabolic

00:25:03.440 activity of the fat in other areas of the body, and it's very different. So when we do fat grafting,

00:25:09.120 for example, and we take fat from the abdomen, which has the highest concentration of stem cells,

00:25:14.640 pre-adipocytes there, and put them in the face, the fat starts to behave more like the fat from the

00:25:19.820 abdomen when you put it in the face.

00:25:21.660 So it retains its source.

00:25:22.920 Yes. And then when they gain weight, you have to tell your patients specifically,

00:25:27.540 don't try to gain more than a few pounds because it will hypertrophy like it would in the abdomen

00:25:33.100 if they gained weight.

00:25:34.760 Interesting. Is there an evolutionary explanation for any of this? I mean, I don't know if aesthetics,

00:25:40.440 if you think about this through an evolutionary lens, but I mean, historically, we didn't need to

00:25:45.180 look good beyond our 20s if the purpose of looking good was to attract a mate. So none of us sitting

00:25:51.820 around this table need to look good in Darwinian terms because we're not reproducing. Do you think

00:25:56.960 that factors into any of these observations?

00:25:59.760 A hundred percent. Yes. And so I think it's also good for the sake of the overall podcast for us to

00:26:05.820 talk about the evolutionary aspects of beauty for just a moment, which could be a whole separate

00:26:11.360 podcast. You could invite Nancy Etkoff from Harvard to come talk to you about the psychology of

00:26:17.720 beauty. She wrote the definitive book on it and summarizes all of evolutionary beauty science. I

00:26:24.740 have all of my fellows read her book because I think it's just a beautiful compendium. The evolution

00:26:29.940 of beauty is a fascinating topic because when you think back to the evolution of humans, why do we even

00:26:37.360 care about beauty? The interesting fact is that we're actually genetically hardwired to appreciate

00:26:44.060 beauty. And so there's this famous study from the University of Texas in the 1980s. Judith Langlaw

00:26:50.340 is sort of a well-known name in psychology. She did what's called a preferential looking study of

00:26:56.160 infants. I don't know if you've heard of this study, but it's fascinating. She took newborn infants who

00:27:00.940 were literally weeks old, barely able to see six inches away from their face. She showed them pictures

00:27:08.300 that are considered beautiful, faces that are beautiful, and faces that are less beautiful. And these

00:27:13.380 newborn infants who've not yet been influenced by society preferentially were looking at the

00:27:19.240 beautiful faces. And so that natural drive for us to appreciate beauty is present even at birth.

00:27:27.680 Does that suggest that there is a definition of beauty that arcs time? Because I was actually going to

00:27:35.600 ask a question, which would be a great detour for us to take after this point, about how much is the

00:27:41.180 definition of beauty changing? In other words, if you took Matthew McConaughey and transported him

00:27:46.700 back 10,000 years ago, would he still be a hunk is sort of where I was going? I would say that the

00:27:52.200 answer is generally yes. There's two layers here. The first layer is the genetic biologic drive that we

00:28:00.200 have to appreciate beauty in men and women. And then, of course, there is a societal impact that conditions

00:28:07.340 us to appreciate certain versions of that beauty. But the fundamentals have been studied in the 90s.

00:28:14.920 And the fundamentals are that all humans across ethnicities all over the world have been studied,

00:28:21.340 and they appreciate certain features of beauty. So there's symmetry of the face, facial proportion,

00:28:28.900 and then they also appreciate sexual dimorphisms. Those are kind of the three categories. And so

00:28:34.380 symmetry, when a face is symmetric, it sort of connotes if you're out there in the reproductive

00:28:40.780 world looking at the pool of your options. Symmetry means that this individual most likely has had

00:28:46.860 good development and nourishment and is most likely going to have good genetics for me to potentially

00:28:53.400 connect with and pass on genetics together with. Facial proportion is similar. In fact, to go a little

00:28:59.780 deeper into that, averageness is really what people are looking for. On the surface, that doesn't sound so

00:29:05.680 attractive to be average. But if you take 100 faces of men, 100 faces of women, and average them all down to a

00:29:12.320 single composite, you will average someone who has a little bit of a big nose or a small jaw, or some aspect of

00:29:20.220 their forehead shape. And all that gets averaged down into a composite that is considered universally

00:29:26.160 beautiful across cultures. And again, that sort of unconsciously in the mating pool from an evolutionary

00:29:32.580 standpoint is connoting healthy genetics to be able to pass on your genetics with. And then the third

00:29:38.700 area, which is sexual dimorphism, we're talking here about strong jaws in med, full lips or big eyes in

00:29:46.160 women. These tend to connote either higher estrogen levels or higher testosterone levels, depending on

00:29:52.900 whether you're looking at women or men. And again, that's fertility, that's subconscious communication

00:29:58.000 of fertility. So those are the genetic absolutes that exist in all of us on the planet. And then on top

00:30:06.720 of that, as you're bringing up social media, in this culture, this particular way of wearing your hair is

00:30:13.840 considered beautiful. Those are conditioned upon us based on society, but it overlaps on top of that

00:30:19.900 underlying genetic basis that we all have. And how much can those things override? Again,

00:30:24.360 I'll just use examples that we can all appreciate. I was talking with my daughter about Cindy Crawford,

00:30:29.420 and I was like, look at a picture of Cindy today. Look at a picture of Cindy in the mid-1990s. I mean,

00:30:36.240 there's simply no way to describe beauty in any other way. It doesn't matter what your type is,

00:30:41.980 everybody would acknowledge Cindy is absurdly beautiful. And so you're saying she is hitting it

00:30:48.640 out of the park on those three things, independent of what the in vogue look of the moment is.

00:30:55.640 If it becomes the case that blondes are really attractive, it doesn't matter. Cindy will override

00:31:00.820 that. If it becomes the thing that women who weigh 30 pounds are attractive, it doesn't matter. Cindy

00:31:05.780 will override that. Is that kind of what you're saying?

00:31:07.880 If you look at even different races, a beautiful person in each of those, they actually all have

00:31:13.800 similar measurements. So there are these masks that you can superimpose onto any image and really

00:31:19.900 dissect down every single angle, whether it's the cheek angle, the jawline angle, the shape of the

00:31:25.840 nose, the eyes. If you look at that across different races, they all have that same kind of measurement

00:31:31.680 that they hit. Talking about those symmetry, the upper third, the middle third, lower third,

00:31:36.340 the face, the fifths going across the face. All of that, if you look at a beautiful person,

00:31:41.560 no matter what race they are, they all kind of hit those measurements. Now, then there are nuances.

00:31:46.420 Like you said, you change your hair, you change your makeup, you can transform yourself. But if you

00:31:52.340 take someone without makeup and just look at them that way, they all kind of conform to those

00:31:56.320 measurements. Doesn't this imply that over time, beauty should be one of the most preserved,

00:32:03.780 concentrated traits of our evolution, given presumably the difficulty in acquiring a mate

00:32:11.100 absent beauty? In other words, does it suggest that if you compared what we as a population look

00:32:16.600 like today in 2025 to what we looked like 2,000 years ago, 10,000 years ago, 100,000 years ago,

00:32:23.960 are we monotonically getting more attractive as a species?

00:32:27.800 You would think so.

00:32:28.900 Because the selection should be ramping it up.

00:32:30.960 Exactly. So we should be marrying someone that looks better or mating with someone that looks better

00:32:35.540 and having our progeny look better. But what's different is our diet. Go back 100 years, 200

00:32:42.220 years, 1,000 years, we had to chew a lot more to really digest our food. We were working our

00:32:48.660 masseters, we were working our jawline, our palates were not as high, our jawline was a lot wider,

00:32:54.260 our teeth were stronger. And then as we have changed our diet and everything is cooked and we don't have

00:33:00.880 to make as much effort to chew it, you actually get more crowding in your teeth, your jawline is a

00:33:06.300 little bit less strong, your palate changes, more people become mouth breathers as opposed to nose

00:33:12.020 breathers. That changes the shape of your face. And that has been measured anthropologically.

00:33:18.440 And so it's interesting because there's a whole book on breath and they go through the anthropology of

00:33:24.680 all that and the changes in the skeletons that they've gone back and studied. And so that does

00:33:29.640 fundamentally change. Now we have kids that have to have teeth extracted or we have to have palate

00:33:33.800 expanders now because we realize when we extracted teeth before we made the faces more narrow. And so

00:33:39.920 now the thinking is let's preserve the teeth, expand the palate when the child is 10, allow those teeth

00:33:46.300 to come in so there's less crowding, and then that face will be better and a stronger jawline. So it is

00:33:53.760 something that we've changed. And then just to head into the area of sociology for just a moment,

00:33:58.940 10,000 years ago, if you were born in some place on earth, Peter, the genetic pool that you'd be

00:34:05.500 interacting with was tiny. There's some fact that I'm probably going to misstate, but somewhere around

00:34:11.520 1900, most people on this planet had not moved within 10 miles of where they were born. And now

00:34:18.100 it's totally different. And with social media and the way that we can connect with people around the

00:34:23.800 world, not only because we can fly all around the world, but we're also seeing people on screens,

00:34:28.920 the apparent genetic pool of faces that we're looking at has exponentially blown up into this

00:34:35.380 very strange world that we're living in in 2025 compared to where our evolutionary biology has taken

00:34:42.000 us. And I wonder also at what point in our development did other, I don't want to say higher

00:34:49.140 order, but other things became priorities in finding a mate. All of us, I think when we were

00:34:53.680 looking for our mate, appearance was probably not the top of the list. It was one of the factors you

00:35:00.020 had to be attracted to the person, but I would guess for all of us, it was, will this person be a

00:35:04.100 great spouse? Will this person be a great parent? Does this person share my goals and values and blah,

00:35:08.800 blah, blah, blah, blah. It's hard to imagine our ancestors had the luxury of maybe thinking about

00:35:14.300 those things. So yeah, all of this is to say it's way more complex today. It is to hear you guys

00:35:19.880 describe this. It's entirely fascinating to play the thought experiment of transport a hyper-attractive

00:35:26.220 person today back in time, 10,000 years. And I would just be so curious as to how they would react to

00:35:32.840 that individual. I think it's a fascinating thought experiment. And I think that if they meet those

00:35:36.980 criteria that we're defining, they would be considered a hunk or a beauty. Yeah. One last thing,

00:35:43.040 and then we can certainly move on to the next topic. But in terms of timing, it is important for

00:35:48.900 us to be evolutionarily attractive, historically, not in the modern era, until you're about 20 or 25,

00:35:57.460 because we weren't supposed to live this long. One of the issues that comes up with longevity and

00:36:04.480 trying to maximize our health span is that we were not really supposed to be living this long and

00:36:10.760 healthy this long. And so evolutionarily, Mother Nature is not helping us with our appearance.

00:36:16.980 Our appearance was supposed to carry us through until about 20 or 25, at which point most people

00:36:23.100 were procreating at 14. And then at 25, their kids were at the point where they were getting ready to

00:36:28.840 procreate and then led out to pasture at that point, basically. So evolutionarily, what we do every day

00:36:35.160 with our patients is we're really fighting biology. We're fighting genetics. We're fighting unnatural

00:36:42.560 existence that we have as a luxury of being born in this era.

00:36:47.480 How much do you see, even just speak about it through the length of your actual careers,

00:36:53.380 how much do you see trends that dramatically change what people are asking for? In other words,

00:37:00.820 Susan, 25 years ago, did men or women come into your practice significantly looking for something

00:37:08.620 different in terms of an appearance and an outcome that they wanted you to shape?

00:37:14.620 Yeah, I would say that's such a loaded question because 25 years ago, if we think back, there was

00:37:20.320 no social media. Television was very basic. Maybe there was some shows that had live people on there

00:37:28.680 on different shows where they would talk about beauty or fashion, but you had to actually tune

00:37:34.800 in and watch those shows to be able to see the trends. Magazines came out, and that was the extent

00:37:39.680 of it. Now you have social media and various channels on social media, and then you have what we now know

00:37:45.920 as influencers. And they're changing what our patients are seeing and what's driving them. And the biggest

00:37:51.680 one that I can talk about is basically that very well-known family in California that has monetized

00:37:57.880 their appearance and set a lot of trends, for better or for worse. It's great to see that they're

00:38:04.260 making it okay to talk about enhancing your appearance or fixing something that bothers you. But where I draw

00:38:10.280 the line is when they start putting out their transformations. And this trend now is something that

00:38:17.060 everyone wants to emulate. And you're talking about young women changing, physically changing their body

00:38:22.560 drastically to conform to what you said is a trend, which is exactly it. And trends, as the word says,

00:38:29.180 are not permanent. So what happens when that trend ends? The celebrities have the money to go to the

00:38:35.980 doctors and reverse all that. Now it will take surgery, and they will have scars to show for it or hide from

00:38:41.900 that. But the patients that follow them, these young women, don't have all of that income to go back and

00:38:48.200 then re-transform their body. And they don't know the implications of that. We have a duty as doctors,

00:38:54.820 definitely, to try to educate our patients about not following trends so strongly and look beyond the

00:39:01.340 monetary aspect of it. And so from that standpoint, I try to really educate my patients to stay away from

00:39:07.280 things that are trending and really do things that make them look and feel better but natural for

00:39:11.780 themselves. Because I don't know in your practice, but I know people want to come in for the enhanced

00:39:16.660 buttocks, Brazilian butt lifts, and the small waist. And that's something, again, that's being undone by

00:39:22.740 that family now. And you're going to see a whole trend that's coming out that doesn't look like that.

00:39:27.860 What are kind of the top above the neck trends? So what I see as I look around is I see lip size being

00:39:36.100 something that's getting bigger, smaller, bigger, smaller. Where are we today, by the way, in lip size?

00:39:40.500 So just to continue Susan's line of thought there, we're in this, again, unusual era where the

00:39:47.920 influencers that are affecting society are much more in our faces than they have been historically.

00:39:54.260 And they're affecting young people at a much younger age, which is why we just let my 16-year-old

00:39:59.540 daughter have a social media account. And that influence of these influencers is quite powerful

00:40:05.360 because what happens is on social media, which is the primary exposure that people are receiving

00:40:11.520 these days about beauty, the images that are being posted are not real. They're filtered.

00:40:16.700 They're unrealistic exaggerations of some of those three original factors that we're talking about,

00:40:23.000 the symmetry, proportion. People will photograph themselves in such a way where they

00:40:26.560 look more proportionate. They will pull their jaw in a certain way to make their proportions look

00:40:32.340 better. Someone has to teach me how to do this because anytime I see a video of myself,

00:40:37.980 I'm like, that is the worst looking thing I've ever seen. Like, I need to learn these tricks.

00:40:42.220 You need a 20-year-old.

00:40:44.440 And a lot of this is subconscious posing. That's a term that I have used for this concept where people

00:40:50.740 are subconsciously posing. Like, for example, a lot of people, when they walk past a shiny building,

00:40:56.180 will stop and look at themselves and kind of like adjust themselves a little bit.

00:40:59.380 Is that new? Like, in other words, did our ancestors walk by a stream where the water was

00:41:04.720 still and look at themselves? I mean, not that we can know that, but...

00:41:08.480 Possibly, I think so. But I think it's becoming so much more exaggerated now to the point where we

00:41:14.020 can confidently state that social media influencers are selling exaggerated forms of beauty ideals,

00:41:22.640 like the sexual dimorphism. So we talked earlier about larger lips or bigger eyes. One of the most

00:41:28.180 popular procedures in Northeast Asia is surgeries to make the eyes wider. You actually cut into the

00:41:34.440 canthus and perform ptosis surgery to make the eye look bigger. And then, of course, this trend to have

00:41:40.060 bigger lips. Fillers are being used left and right, unfortunately, to overdo lip volume and plump up

00:41:45.880 lips. Because the social media influencers are posting it, it's becoming more exaggerated because

00:41:51.840 these exaggerated gender traits are becoming normalized. And so the family that Susan's

00:41:58.100 mentioning in California, they normalized overdone lips to the point where people come in asking for

00:42:04.500 it and we have to say, no, I'm sorry, this is not a good direction for us to take you in.

00:42:08.700 I was talking to somebody yesterday where I said, one of the marks of a great surgeon is a person who

00:42:15.440 is happy to say no, is happy to say, I'm not going to do this because I'm so good that I don't need your

00:42:21.300 business. I can be as selective as I want about what I do. That allows two things. That allows

00:42:26.980 the right patient selection to get a good outcome. So the discussion I had with a patient yesterday was

00:42:31.540 about an orthopedic surgery issue. And the doctor said, yeah, I think it's time to do the surgery.

00:42:36.860 The patient was saying to me, well, he does sort of have a vested interest in doing the surgery.

00:42:41.080 After all, he's a surgeon. I said, yes, but I can speak about this surgeon in particular.

00:42:44.960 I've watched him say no to a hundred patients because patient selection is the most important thing for

00:42:49.680 him to drive amazing outcomes. He'll say no until it's time. In the cosmetic world, you add another

00:42:55.860 layer to that decision. And clearly you guys are both on the spectrum of, you're both the top of

00:43:02.100 your field. So you don't need an incremental patient. You're happy to say no. There's also,

00:43:06.340 it sounds like an ethical reason for you to say no. Where I'm going with my rambling question is,

00:43:11.140 where do you think the field is on the whole? Are you guys the outliers or are you guys the majority?

00:43:17.500 Is there a handful of bad actors out there that will take any money from any 17 year old who's

00:43:24.860 being duped into thinking this is the way they need to look? I'm trying to get a sense of the scale

00:43:29.860 of this problem. I would say the vast majority of physicians are ethical. I do think there are some

00:43:36.660 out there though, where it is something that's monetized. So they will mask treat patients. Their goal

00:43:43.000 is to have surgery after surgery coming in and basically letting the patients make their own

00:43:48.120 informed decision about it to an extent. But I always look at it akin to managing hypertension or

00:43:54.820 diabetes. We never let the patients determine how much insulin to use or how much antihypertensive

00:44:00.800 medication to take. And I don't think we should let the patients say that they want to transform

00:44:05.940 themselves to some completely different person. I just ethically think that's wrong. I think that

00:44:11.820 brings to mind a whole bunch of other psychological issues that might be playing there, including what

00:44:17.660 we call social media dysmorphism, where people come in with pictures of themselves with a filter and say,

00:44:24.760 can you make me look like this picture?

00:44:26.840 By the way, is that a recognized diagnosis in the DSM-5 now?

00:44:30.020 Oh, in the DSM-5, I don't know if it's made it that far, but it is something that is mentioned

00:44:34.640 at different meetings now. So I don't know that it's made it into the DSM-5.

00:44:39.840 If not, it'd probably be in the 6th.

00:44:41.600 If I could chime in, I think that Susan's obviously a very ethical, outstanding surgeon and physician.

00:44:49.020 I do have to say I'm an optimist. I have to say that I think the situation's worse than what

00:44:54.620 you're saying. I think that there are, unfortunately, financial incentives for physicians, nurses,

00:45:02.080 and the broad spectrum of people that perform aesthetic treatments, including Botox and filler

00:45:07.880 injections. It's very poorly regulated. There are tons of people out there, ranging from hairdressers

00:45:16.180 up to surgeons, who will be happy to take your money and find a place to put the syringe or filler

00:45:21.740 because they know it's going to be money revenue into their practice. And so I don't want to be

00:45:27.080 overly negative, but I think this is sort of a cautionary warning to people who are listening

00:45:31.900 to this podcast that when you're delving in the area of aesthetic enhancement, you have to

00:45:38.900 understand that there's an overlay where the person that you're seeking out advice from has a

00:45:44.620 substantial financial incentive to treat you. I think it's a real issue.

00:45:48.200 Yeah. I'll tell you, one of the things I always caution patients toward in my world is you need

00:45:55.920 to be really careful when you're seeing a quote unquote longevity doc who is selling tests and

00:46:03.400 selling treatments for the results of that test. When you go to see somebody and they're selling a

00:46:09.460 biologic clock whose treatment is this supplement and they're monetizing those two things, I just don't

00:46:17.620 see how you can trust that individual. I don't see how even a person with good intentions can't get

00:46:24.400 conflicted there. And I guess I never thought of it until you said that, but the entire aesthetic

00:46:29.100 industry is effectively that because you're not just selling a procedure, you're often selling a

00:46:35.580 treatment. You're getting paid on both ends.

00:46:37.800 And what's happened is like Tanuz was saying, the providers have changed. So before it used to be

00:46:44.480 only dermatologists that would do the injectables and then it became dermatologists and plastic surgeons

00:46:49.160 and then it became the RNs and the physician assistants. And those are still all medical providers,

00:46:55.480 including dentists who are very well-trained can do that. But then you get in certain states,

00:47:01.280 lack of regulation. So you're seeing unqualified people who are not medical providers doing

00:47:06.880 injectables and laser treatments that they may not be trained for. And all of a sudden you start

00:47:12.820 to open up a whole Pandora's box of complications there. And this is a shame because patients might

00:47:19.080 not know enough to ask about qualifications. They might see that it's a nice storefront, the person's

00:47:24.120 wearing a lab coat, they look professional. So from that standpoint, they might go in trusting that

00:47:29.580 this person has their best interests. There might not be a physician overseeing everything.

00:47:34.220 We feel very strongly in our practices that there is a physician overseeing every treatment,

00:47:39.040 whether we're doing it, our nurses or our PAs are doing it. We're overseeing all of that to make sure

00:47:44.620 that if there's a complication, that complication is ours. No matter what, we're going to take care of

00:47:48.780 that patient. So it is a shame. And I do warn a lot of young residents coming into the field

00:47:54.720 to enter the field if they truly love the field and are passionate about dermatology,

00:48:00.380 ophthalmology, oculoplastics, all of that. Because if they're going into it thinking they're going to

00:48:05.320 be the next glamorous doctor on social media, then they're not going to have a lot of treatments that

00:48:11.180 they can offer. Because at that point, all these other providers are doing those treatments.

00:48:15.760 They're going to have to find a niche for themselves to make a name for themselves

00:48:18.540 doing something differently. So it's really fascinating right now, the times that we're living in.

00:48:24.720 And do you see a change in residents today? So when I was in medical school, which is almost

00:48:29.940 30 years ago now, the people, and maybe that's such a small sample that it's an irrelevant

00:48:34.940 statement. But when I think back to everybody I knew that ultimately chose plastic surgery,

00:48:40.040 they all had a very artistic bent to them. I'm not going to say that they didn't pick it because

00:48:44.220 it was also a lucrative field and things like that. Maybe if plastic surgeons made 50,000 a year,

00:48:48.580 they wouldn't have done it. But I never got the sense that that was their primary motivation.

00:48:53.220 When I think back to my friends in medical school that went into plastics, they were artists.

00:48:58.880 They really took an interest in the art of this. Do you still see incoming residents largely

00:49:05.780 of that philosophy where they're interested in the aesthetic component of it, the underlying

00:49:11.100 physiology of it? In other words, are they cut from the cloth you guys are cut from? Or do you see

00:49:15.480 a trend towards, no, this is literally a cash machine? And as reimbursements are going lower and

00:49:23.220 lower and lower across the entire field of medicine, it is clearly more attractive to be in specialties

00:49:28.360 where reimbursements either remain very high and or it's mostly cash.

00:49:32.520 I'll take a more optimistic tone here. I think that those who are coming into residency and

00:49:37.520 fellowships in the world of aesthetics, I think really still have that same artistic mindset.

00:49:42.640 People who are painters or musicians, they have that artistic mind. And it's something we

00:49:48.000 actually look for in our fellowship when we're considering candidates because we know that they

00:49:52.700 have that right brain mentality of being able to handle medical problems. But the reality is that,

00:49:59.420 as you said, medical reimbursements are going down. The lucrative nature of aesthetics is high and

00:50:05.520 getting higher as time goes by. And so someone can go through all the training and then when they see the

00:50:11.100 dollars come in the door, they're just going to want more of that. It can distort their ethics and

00:50:15.100 they may not even realize they're doing it. I'm not saying that there are physicians out there who

00:50:19.460 are knowingly duping patients into having treatments, but I think it just becomes this unconscious drive

00:50:25.180 because of the finances.

00:50:26.820 We were talking about that earlier. And I do think it's a challenge because here we go again,

00:50:31.520 Medicare just got cut again in terms of reimbursements. And that's sad because we're talking

00:50:36.580 about in our university practices, there's a huge push for doctors to see more patients

00:50:42.780 because reimbursement is dropping. And so the only way that the medical centers can compensate is to

00:50:48.640 increase the volume. There's only so many patients though in a day that we can see and offer really

00:50:53.580 good care. So Tanuj and I have a very unique practice because most of our patients are self-pay.

00:50:59.840 So we have the luxury of time. We can talk to our patients, get to know them to the point that a lot of

00:51:06.240 our patients come to us seeking medical advice and opinions on other advice that they've gotten

00:51:11.240 from other physicians and we can help them decipher the facts. Whereas there are other physicians may

00:51:16.680 be fabulous, but they have to see 30, 40 people in a day. And that's a shame. That's the detriment

00:51:21.680 now that the physician's market is in because we're burning out a lot of really good physicians who want

00:51:27.760 to give good care, but find themselves having to see more and more patients so they can only spend 10

00:51:33.340 minutes a patient. And that's really unfair. And that's not why all of us go into medicine.

00:51:38.600 And for both of us, we entered our fields before all of these devices and treatments existed. So I

00:51:43.560 think we did come into it with a passion for what we love, but we both have an artistic bent to our

00:51:49.480 personalities as well. So we kind of gravitated towards this.

00:51:53.020 I want to put a bow on the social media thing for a moment. What is the most concerning trend

00:51:58.080 or what is the most concerning request you are getting from people that you believe is

00:52:03.480 unique to the social media phenomenon?

00:52:06.420 What I'm seeing a lot more are teenagers now coming in, asking for fillers and neuromodulators

00:52:12.620 in their forehead, fillers in their lips. And that's sad.

00:52:16.340 Would a neuromodulator do anything when you're at that age anyway?

00:52:19.600 No, but they're now being told that even 18, for example, it's okay to start preventative Botox.

00:52:25.140 You don't need that until you're a lot further along in age.

00:52:28.880 So that's just an abject lie that they're being told.

00:52:32.020 Yes. Unfortunately, they're also being made to feel very poorly about their shape of their lips.

00:52:37.740 They're being inundated with images. And like Tanuj was saying, these are highly filtered images.

00:52:42.760 We know a lot of people who will take in their waist, take in their thighs, all of that,

00:52:46.900 change the proportions, and then post that image. What I try to tell patients is that what you see in

00:52:53.340 terms of images that are on social media, A, are filtered, B, are taken with certain angles of the

00:53:00.100 camera to enhance someone's appearance. And we will never, at least in my practice, take someone's

00:53:06.420 photo that they took on their phone and then try to enhance them to look like their photo, because

00:53:11.040 what's happening is that you're going to make them look very different in life, in real life.

00:53:15.740 You're only going to photograph beautifully if you're the most symmetric person.

00:53:18.880 And that's why even the most beautiful model in a photograph, if you look at them in person,

00:53:23.940 they're very pretty. But you wouldn't think that they're supermodels sometimes. But when they

00:53:28.480 photograph, they photograph beautifully because of their symmetry. But for us, with our forward-facing

00:53:33.800 cameras that we point at ourselves to take our selfies, they're going to distort our face. If you

00:53:39.240 tilt one way, you elongate the face. Tilt a different way, you shorten the face. And patients get hung up

00:53:44.580 on that. That's really sad, because in real life, they look fabulous.

00:53:48.880 Now, is this a 95.5 female-male problem that is arising from social media? Or are there,

00:53:54.240 I guess from the purpose of this discussion, I would guess it's mostly female. My guess is the male

00:53:58.300 issue is probably much more on anabolic steroid abuse and things that young men are being influenced

00:54:03.160 by. Is that safe to assume?

00:54:04.900 Yeah.

00:54:05.660 What is it that you see, Tanuj, that is most disconcerting? Is there a particular product or

00:54:09.540 particular procedure that is showing up that would have been unheard of before social media?

00:54:15.620 I would say two areas. One is because fillers are non-surgical, relatively accessible price points

00:54:23.980 and low risk and are ubiquitous. You can find a clinic within one mile if you live in a major city.

00:54:31.000 I think overfilling is a serious problem. Whether it's the lips or the cheeks, overvolumization has

00:54:37.520 become an epidemic. It's a serious problem, not only because it looks exaggerated and distorted and

00:54:43.960 strange, but even when as a facial surgeon I go in to perform surgeries, I will find that filler has

00:54:50.820 disrupted normal anatomy. And so decades later, the companies will tell you that filler only lasts

00:54:57.220 one year in the face and then you have to refill it. That's definitely not true. I have patients

00:55:01.540 coming in who don't mention that they've had fillers in the past, but then in surgery, I will see

00:55:05.960 filler in their cheek or in their face because they had it eight or 10 years ago and it's still there.

00:55:11.680 And it's stretching the ligaments, it's changing the structure of the tissues. It actually makes

00:55:15.880 routine surgical procedures later more challenging.

00:55:19.800 And by the way, are there biologic features of the individual that would make that more or less

00:55:23.680 true? Are there some people in whom fillers go away after a year or are you saying that for the

00:55:28.140 most part they last longer?

00:55:29.140 That's also another whole complex topic is the metabolism of hyaluronic acid. And

00:55:33.600 some people are higher metabolizers, some are slower metabolizers. And we actually don't have

00:55:38.940 a good sense of that. We have some general concepts just based on experience, but there's very little

00:55:44.320 science on that. We can't really predict.

00:55:46.140 So one doesn't know.

00:55:47.460 One really doesn't know.

00:55:48.540 Okay. And I'm sorry, you were going to get to a second point.

00:55:50.300 Yeah, no. The second point is from a surgical standpoint, there is a trend right now where people

00:55:55.500 are asking for this high arched brow effect where it's a hyper exaggerated, the tail of the brow comes

00:56:01.300 up very high. It's called a snatched look. About once every week or two, I've got someone who seriously

00:56:06.900 wants to have their face distorted with a surgical procedure with me. And I have to say, I'm sorry,

00:56:11.700 we're not going to do that.

00:56:12.620 Is it safe to say that anyone who walks into a physician's office to do this needs to be able to

00:56:20.220 be over 18 to provide consent? But is it safe to say, or is it the case that people younger than

00:56:27.140 18 can do this in less reputable places without parent consent?

00:56:32.360 It should be 18. It's like any other medical procedure. You have to be 18 years of age to

00:56:36.760 consent. There are rare instances where I will treat someone who's 16 or 17 if the parent is there.

00:56:44.560 And if it's for something, for example, a patient has a hump on their nose that they don't like,

00:56:50.220 but they're not ready to commit to a rhinoplasty. So I can use fillers in a creative way to help

00:56:56.060 reduce the appearance of that. But that's very far and few in between.

00:57:00.060 The parent is there.

00:57:01.060 Yes, absolutely. I did have a very interesting incidence where I had an 18-year-old though

00:57:06.820 come in. She had just had a rhinoplasty and was coming to see me for fillers and for neuromodulators.

00:57:14.560 I asked her, I said, you're 18. Is someone here with you from one of your parents? And no,

00:57:19.560 nobody was there with her. And the interesting thing is though, she is 18 thinking that she's

00:57:26.260 an adult, but she's only a junior in high school. So I was very conflicted. I kept referring back to

00:57:32.940 something along the lines of, you need to talk to your parents. You need to tell them what we

00:57:37.300 discussed here. That really bothered me for a long time that here's this 18-year-old who's still in

00:57:43.460 high school that wants to do things. And I don't see a parent there with her.

00:57:49.020 But I think it's not a huge problem probably across the board that people under 18 are getting

00:57:53.580 treatments, but they're getting fed all of this societal pressure. I like to use the term beauty

00:57:59.440 pressure, like peer pressure. It's beauty pressure that's now more extreme because of social media.

00:58:04.780 They're getting all this beauty pressure at a very young age, 12, 13 onwards.

00:58:08.880 And so by the time they get into their 20s, they've been thinking about this for years and

00:58:14.660 years and years and they're ready to dive into it. Now, there's probably not a lot of people in

00:58:18.280 my audience that are particularly young, but maybe we can start the discussion through the lens of

00:58:25.480 preventive care. So we can talk about preventive care and then move into maybe where I am now,

00:58:31.900 where I missed the boat on pure prevention and I now need to start being active. So for the person

00:58:36.720 who's listening to this who's still in their prime from an aesthetic perspective, so I guess they're

00:58:41.600 in their 20s, maybe even in their 30s, depending on their genes, the only thing I know is wearing

00:58:48.120 sunscreen is a net positive. So I understand enough to say that UV damages skin. Is it damaging

00:58:55.120 elastin? Is it damaging collagen? Or is it purely just these sunspots that it creates? What is it that sun

00:59:01.480 is doing that is damaging? Quite a bit. I'm glad you mentioned sunscreen because if anyone's going

00:59:06.820 to come in and say, what's the absolute minimum thing I should use on my skin every day, it would

00:59:11.400 be sunscreen. And in fact, there was a four-year study out of Australia that followed people for

00:59:17.140 four years and either they wore sunscreen or they didn't. And the ones that did aged better.

00:59:21.640 Was it randomized?

00:59:22.560 It was randomized.

00:59:23.220 Okay, good.

00:59:23.680 They aged better, fewer lines, fewer wrinkles. And that's in a country that has a lot of sun.

00:59:29.080 So that shows you the power of using sunscreen. Now, I'll take it a step further. I tell my

00:59:35.080 patients they have to use mineral sunscreens as opposed to chemical sunscreens because I'm not

00:59:40.000 convinced of the safety of avobenzone, oxybenzone as hormone disruptors. I do think there are some

00:59:46.360 scientific studies that suggest maybe they play a role in infertility. You can measure them in the

00:59:51.160 bloodstream, especially if you're putting them over the entire body. The skin is a great portal for

00:59:57.000 chemicals to enter into the bloodstream if it's the right size chemical. So there have been already

01:00:02.000 studies done that show a huge spike in the amount of these in your bloodstream after application.

01:00:07.120 After saying this for 15 years, I think the FDA just a couple of weeks ago finally told the

01:00:12.080 companies they must do animal safety studies. It's about time.

01:00:15.920 It's very late. Yeah, so late in the game.

01:00:18.440 It's very late.

01:00:18.920 Sorry to interrupt. I'm so on board with you about the problems with chemical sunscreens because

01:00:23.780 the other problem it creates is that patients think they're covered and then the chemicals that

01:00:30.240 are actually protecting against the UV damage become inactivated over time.

01:00:34.400 Because you still have the film on you.

01:00:36.020 You have the film on you and you don't know at what time of day you no longer have any solar

01:00:40.360 protection.

01:00:40.780 It's within an hour. You put a sunscreen SPF 70 on, go outside. If it's strong sun,

01:00:47.220 it's going to be deactivated within an hour. People will burn on SPF 70, SPF 100. There should

01:00:53.360 be nothing above an SPF 50 mineral.

01:00:55.760 What is the use case for the chemical sunscreen? Are they less expensive? What was the rationale for them?

01:01:01.600 They blend in. They blend in very easily. People love it because there's no white film when they put it on.

01:01:07.200 A mineral sunscreen takes a little bit more work to blend it in or it's going to cost more because

01:01:12.780 you're going to have to get a micronized formula of zinc oxide or titanium dioxide.

01:01:16.280 So my Elta MD 30 to 50, I think I have one of each. I'm pretty sure that's a mineral sunscreen.

01:01:23.380 You have to work to put it in.

01:01:25.060 Yes. And some of them, Elta makes some mineral and some chemical ones. So just double check.

01:01:30.220 And they make it confusing on purpose, by the way. So you have to go out of your way to actually find

01:01:35.660 formulas that are primarily mineral because the companies want to sell you both products and they know that

01:01:41.880 customer satisfaction is higher with chemical. And this doesn't have anything to do with this conversation

01:01:48.320 specifically, but Susan has created skincare and so have I created skincare. So we've really dived into this

01:01:54.780 world of skincare and the marketing of skincare can really mislead consumers. Companies that are

01:02:02.660 creating skincare are motivated by sales. They want people to be happy with their SPF. When it's a

01:02:08.220 chemical sunscreen, they're going to be happier with it because it doesn't have that white pasty

01:02:11.700 effect, but it's just not as effective. And the other thing that happens, if you look at the amount

01:02:18.320 of skin cancer in the U.S., it's increasing, including melanoma. So why do we have generations now of

01:02:25.360 people from the late 90s on up who say they use sunscreen all the time and our skin cancer rates are going up?

01:02:32.660 I think it's twofold. I think it's because A, like you said, Tanush, the sunscreens degrade very

01:02:38.400 quickly when they put on a chemical sunscreen. And I'm going to take it one step further. When those

01:02:43.260 chemical sunscreens absorb those harmful rays, whether it's UVB or UVA, the chemicals absorb them

01:02:49.720 and they neutralize those rays, but they cause reactive oxygen species. And those reactive oxygen

01:02:55.280 species damage the DNA of the cells, which then accentuates the damage that you're getting from

01:03:00.280 whatever other UVA gets through the sunscreen. So you're really causing more damage and probably

01:03:05.680 causing these cells to become more atypical over time. By the way, you know that there's a group of

01:03:10.560 people who argue, and I don't agree with this at all, that argue that sun and UV rays have no causal

01:03:18.060 role in melanoma. And the argument they put forth is sunscreen use has been increasing, and yet we see

01:03:25.160 a significant increase in the incidence of melanoma. So they're pointing at the same observation. They're

01:03:30.460 offering a different argument. I find your argument far more compelling.

01:03:33.760 Yeah, I think everyone should be using a mineral sunscreen. So that's number one.

01:03:37.360 And let's talk again just about the why. So what is it that ultraviolet energy is doing to my skin

01:03:43.640 that is deleterious?

01:03:45.660 So I'm going to throw out more than ultraviolet. So we know there's UVA, and UVA is the longer

01:03:51.580 wavelength between the two ultraviolet rays that reach the Earth. That's A for aging. We have UVB,

01:03:58.180 and that's B for burns. That's the one that causes a lot of the redness in the sunburns

01:04:02.400 and leaves behind a lot of the atypia in the cells. So UVB probably causes more skin cancers

01:04:08.620 than UVA, but they're both implicated. But add to it, we have high energy visible light,

01:04:14.320 we have visible light, we have infrared light, all coming from the sun. So we have five different

01:04:20.720 rays, and they all play a role in how we age. So we worry about UVA, UVB with regards to skin cancer,

01:04:27.780 but high energy visible light and visible light also play a role in terms of hyperpigmentation,

01:04:34.460 infrared as well. And now there's some evidence maybe suggesting that because infrared light can

01:04:40.780 reach deeper into the skin, it may have a role on fat atrophy and bone remodeling. So I'd like to

01:04:46.880 see more studies along that. I don't know how you could possibly do that in an ethical way.

01:04:51.880 I mean, you could do animal studies. Assuming you had a comparable model for fat and bone,

01:04:57.540 that's the only way. You'd have to use the isolated spectrum. You couldn't do it in sunlight.

01:05:01.780 I assume you wouldn't be able to disentangle which energy wave was causing the effect.

01:05:06.120 But that's an interesting thought. Yeah, I think most of us think that,

01:05:09.360 most of us, I've always thought, well, the sunspots are unattractive, but my pigment's dark enough

01:05:14.780 that they don't really show up that much. And okay, so we know what sun is doing.

01:05:20.660 One more addition to talk about with the UV damage, because we could probably spend the

01:05:24.860 whole podcast on UV injuries. But in addition to everything that Susan said, a couple more things

01:05:31.240 that I think are important to hear are for the listeners is that UV also, not only do we know that

01:05:36.780 it damages DNA and can lead to tumors, cancers, melanoma, but it also injures collagen particles,

01:05:44.420 elastin particles, a lot of the ultrastructure of not only the cells have intracellular infrastructure,

01:05:52.340 but also extracellular infrastructure. So the matrix of the subcutaneous tissues, the dermis,

01:05:59.160 is built by this beautiful scaffolding. If you look at an 18-year-old skin under the microscope,

01:06:04.940 it's this thick, beautiful blanket layer of volume, because you've got this collagen elastin

01:06:11.560 structure that's holding this whole thing up and is filled with water molecules, have lots of space

01:06:16.880 to move around in and signals going back and forth. So all of that collagen elastin framework

01:06:22.220 also gets heavily injured by UV over time and it becomes cumulative. And that leads to thinning of

01:06:29.660 the skin, loss of the subcutaneous fat layer, loss of those intracellular connections so that

01:06:34.420 people start to get pitting and find lines and wrinkles. And so that's just from an aesthetic

01:06:38.700 standpoint, just another area just to know from UV damage.

01:06:42.740 I'm sure you've heard this before, but all of my black friends now are looking infinitely on a

01:06:49.020 relative basis. Their aging is slowing down. And so they always say, black don't crack. And so how

01:06:55.340 much of the difference that we see in black skin versus white skin is due to less damage from UV

01:07:03.260 versus other genetic differences that enhance what you're describing?

01:07:07.180 It's almost completely what you're saying is the protection value of the increased melanin

01:07:12.220 particles that people with darker skin have. There's a Fitzpatrick scale from one to six where

01:07:17.580 we talk about Fitzpatrick one is someone who's extremely fair, blonde, blue eyed, burns all the

01:07:23.480 time, never tans. And then it goes all the way to Fitzpatrick six, which is the darkest skin that

01:07:27.840 you'll see never tans, can't burn. And we're all somewhere in that spectrum.

01:07:31.980 So I'm a three, three plus probably. Yep. Maybe verging on a four.

01:07:36.960 Is there a basically a linear relationship between one and six in terms of how well you will age skin

01:07:42.520 wise? I think generally, yeah, that's about right. And the melanin factor is huge. Just to counter that

01:07:48.460 argument earlier about people who talk about trying to put sunscreens, the melanin evolutionarily,

01:07:54.560 if you actually look at what's happening when melanin is inside the cell, it's not just

01:07:59.420 randomly dispersed. It's actually the melanin forms a parasol over the nucleus.

01:08:05.160 To protect the DNA.

01:08:06.120 To protect the DNA. So evolution is showing us microscopically why it's so important to protect

01:08:12.280 ourselves from the UV because we get this parasol of melanin that sits on top of the nucleus to

01:08:17.400 protect it. And when we're Fitzpatrick two to six or two to five and you're exposed to sunlight,

01:08:23.020 we get immediate upregulation of melanin production by the tyrosin kinase pathway.

01:08:28.040 And all of that melanin doubles and triples.

01:08:31.080 So that's why we're tanning. The tan, it happens to be aesthetic, but the reason we tan is to create

01:08:37.300 more melanin to protect our DNA.

01:08:39.620 Yes. And it's only aesthetic in this day and age because it used to be that if you were tan,

01:08:44.600 you worked in the fields. So it was not a sign of prosperity and affluence. It is only aesthetic

01:08:50.620 in our current day and age. But yes, melanin is our own antioxidant. It's a very good antioxidant

01:08:56.520 and that's how it works.

01:08:58.080 Okay. To your point, we could spend the rest of the podcast on it. We won't. We've established the

01:09:02.260 fact that step one, the no regret move, protect your skin in the sun. What's the next level thing

01:09:10.060 that one can do for prevention?

01:09:12.560 So we may be on the same line. It might be a little bit different. I would say step two

01:09:17.160 would be a retinoid of some sort.

01:09:20.260 I was worried you were going to say that.

01:09:21.680 I know. Everyone says that.

01:09:23.460 It's just one more thing I have to apply.

01:09:25.420 Well, here's what I tell patients because you said you don't wash your face at night, right?

01:09:28.980 It's so gross.

01:09:29.840 Do you brush your teeth at night?

01:09:30.800 I do. I'm a religious flosser and teeth brusher.

01:09:34.000 Right next to your toothbrush, put your little tube of retinoid.

01:09:38.340 That's what I tell my patients. Retinoids, we have different categories. There's retinol,

01:09:42.960 which is the weakest one, and your body will go put it through two enzymatic changes to become

01:09:48.960 retinoic acid, which is what you get at the pharmacy. And that's great if you're in your

01:09:53.220 20s, late teens, early 20s, and you're just trying to be preventative with how your skin

01:09:58.800 is aging and at the same time maybe addressing some acne. Once you hit late 20s into your 30s

01:10:04.920 and early 40s, you need maybe something a little stronger, and that's where retinaldehyde

01:10:09.480 is a little bit better. And that's the next conversion. So retinol becomes retinaldehyde,

01:10:14.680 which then becomes retinoic acid. So retinaldehyde is that middle step,

01:10:18.600 and there's more actual enzyme in your body that can convert retinaldehyde to retinoic acid.

01:10:23.840 And that's less irritating for people to use. So in your case, if you get irritated very easily

01:10:29.280 and you're going to quit, it gives us an option to give patients something that's highly efficacious

01:10:33.960 that is going to irritate their skin less because it gets converted to the active form

01:10:38.660 after it's been absorbed into the skin. And then the gold standard is retinoic acid,

01:10:44.880 and that has multiple different strains. But that's someone who's in their mid-40s and up,

01:10:50.860 they're going to need it continuously to keep boosting collagen because our peak

01:10:55.080 collagen production, you want to venture a guess as to what age we peaked in our collagen production.

01:11:00.460 I would say late teens, early 20s. Yeah, 18. That was when our fibroblasts were making the most

01:11:06.480 of the matrix that Tanush was talking about. I guess that because that's when, in women,

01:11:10.580 bone density peaks at about 18 for men. It's about 20, 21. Yes, exactly. So 18, we start to make

01:11:16.880 less collagen, elastin, and glycosaminoglycan. So if we can add a retinoid in there, we're telling

01:11:22.640 the fibroblasts to boost more of those production of those ingredients, those peptides, and those

01:11:28.220 collagen matrix. If we are looking at the melanocytes, those retinoids also normalize the

01:11:34.560 function of melanocytes so that they're less aggregated, less overactive, and they also help

01:11:40.720 to normalize the turnover of the keratinocytes. So they're working on the major cellular structure

01:11:45.840 of the skin at the level of the DNA. Now, my recollection is there were two concentrations

01:11:50.680 of this stuff that you could get? Does that ring a bell? Of the prescription? Yes. There's three,

01:11:55.220 0.025, 0.05, 0.1, and then there's like 0.04, 0.08. Those first three are the major ones. And also

01:12:02.400 custom formulations. Yes. Yep. Yeah. And the few times I tried to use this, I couldn't do it every

01:12:09.000 day. It just got me too red. Did that mean I was on too high a formulation? I should have gone back to

01:12:14.400 the aldehyde. I was too young. I probably tried this 10 years ago and never did it again.

01:12:19.360 I take a different approach than even most of my colleagues. I tell people if they're trying

01:12:24.340 to achieve a goal, whether it's treating melasma, sun damage, or they're getting ready for a child's

01:12:29.580 wedding, or we have to do a procedure, I would tell them to tough it out. Because if you use that

01:12:34.440 retinoic acid every single day, your body acclimates to it very quickly. It may take six weeks,

01:12:40.420 seven weeks, eight weeks, but you get your skin used to it, and then you reap all the benefits.

01:12:45.120 But some patients are always going to quit. So from that standpoint...

01:12:49.440 I'm a quitter.

01:12:50.000 Yeah. So we would give you five days a week retinaldehyde, two days a week retinoic acid,

01:12:55.540 and tell you to start that way. And then maybe as your skin acclimates to it, you can change that

01:13:01.020 proportion.

01:13:02.120 Okay. And by the way, do you become more light sensitive when you take this? Does it make it

01:13:06.580 even more important that you're wearing sunscreen in the sun?

01:13:08.780 So those studies came out very early on, which is why people start to say, oh, I stopped my retinoid

01:13:13.840 in the summer, and that's the last thing you should do. Because initially, when you start a

01:13:18.620 retinoid, you will get exfoliation at the level of the dead layer of the skin, the stratum corneum.

01:13:23.960 But after you've been on the retinoid for a long time, that builds back up. You become less

01:13:28.880 light sensitive. You might always still be a little bit, but you're a lot less light sensitive than when

01:13:33.720 you first start a retinoid. But you should always have a sunscreen on and a hat. And retinoids have

01:13:39.100 been shown, even if you get sun exposure, they have the ability to repair some of that DNA damage

01:13:45.280 early on. So you really want to be on a retinoid all the time.

01:13:49.320 Okay. Anything you would add to that, Tanuj, on the retinoid before we go on?

01:13:52.700 No, I think that was great. I totally agree with everything Susan just said. I have a slightly

01:13:56.820 different protocol with retinoids and people who are sensitive. I might have them start out two or

01:14:01.500 three times a week and then gradually build up to nightly use over a couple of months. That's one

01:14:06.600 way to avoid the inflammatory aspect of retin-A. And then the other option would be to mix it with

01:14:12.660 some over-the-counter hydrocortisone 1% cream. I know people get really worked up about putting

01:14:17.680 steroids on their face, but over-the-counter hydrocortisone 1% is such a low concentration

01:14:22.380 that it's just enough to reduce some of that annoying irritation from the retin-A in that first few

01:14:28.420 weeks or month. But I was going to also add, when people are thinking about the core aspects of

01:14:34.660 what should they be using on their skin now that they're starting to notice some changes in their

01:14:39.700 20s or 30s, in addition to sunscreen and retinoids, I think that vitamin C is a really important molecule

01:14:47.060 to get onto the skin also.

01:14:49.120 Tried that too. Let me tell you why I stopped. It was mixed with like ferric acid.

01:14:54.480 Ferulic acid.

01:14:55.460 Yes, yes. And it stunk. I just hated the smell of it.

01:14:59.140 And the reason for that is because vitamin C is a notoriously complicated, easily reduced molecule.

01:15:07.320 And when manufacturers are formulating their vitamin C serums, it might be a year from when

01:15:14.640 it leaves the factory and gets onto your skin, if we're lucky. And in that year, all of the

01:15:20.800 relatively inexpensive vitamin C serums are going to degrade and not actually have any bioavailability

01:15:26.920 when that vitamin C is applied to the skin. And so the relatively more expensive formulations

01:15:33.060 are being produced by manufacturers that are doing all sorts of manufacturing flips and tricks

01:15:39.960 to try and stabilize that vitamin C. The product you're talking about, which I think I can probably

01:15:44.840 guess, is they use the ferulic acid to stabilize the vitamin C so that it maintains its bioavailability.

01:15:51.220 Other formulations of vitamin C will use an oil-based formula. It's not aqueous because then

01:15:56.740 the vitamin C is much less likely to be reduced in that kind of formulation. But those products

01:16:02.300 tend to be petroleum, oil-based, and also have all sorts of negatives associated with it.

01:16:08.320 And then there are some products that will micro-encapsulate or find other creative ways

01:16:12.460 of making sure that the vitamin C is actually bioavailable when it hits your skin. So that

01:16:18.180 product may have not worked for you, but there are other options to find a stable vitamin C.

01:16:23.260 And this is one of those products where, again, we have our own custom formulas, but I'll tell people

01:16:29.660 who are price-sensitive, go to Walgreens, buy a retinoid, buy a sunscreen. You don't need to spend

01:16:35.840 more than $10 or $15 on effective products. Vitamin C is something where you have to spend the money on.

01:16:41.320 And by the way, what retinoid can you buy at Walmart?

01:16:44.840 Retinol and some retinol.

01:16:46.760 I see. You can't get retinoic acid without a prescription.

01:16:49.620 Right. Got it. And is there any downside of using retinol or do you just need a lot more of it?

01:16:54.020 The problem is if you try to push that enzymatic chain reaction, you'll get dermatitis.

01:16:59.140 Got it. Okay. So in other words, if you can afford it, it's better to get the prescription. And

01:17:03.000 I'm guessing retinoic acid is not expensive.

01:17:05.420 Finally, it's come back down in price. I think now that they realize more and more people are

01:17:10.200 willing to spend out of the pocket to buy it, it's about $80 to $100 for a tube. That tube will

01:17:15.520 last about three months. If it's lasting longer, you're not putting enough.

01:17:19.500 And just show me as though I'm doing this. We're going to talk about how to wash the face and do

01:17:23.940 all that because I'm guessing you don't do this without washing your face, especially if you've had

01:17:27.280 sunscreen on all day. Are you putting this on like all over your face like this, even over my beard and

01:17:34.260 stuff?

01:17:34.720 So I tell people, first things first, you have to put the right amount on. Because every time we

01:17:39.560 give anyone any prescription, we tell them take this many milligrams once a day, twice a day. We

01:17:44.480 don't do a good job telling people how much sunscreen to put on, how much retinoid to put on. So I always

01:17:49.820 tell them, hold up your finger and it should be from the tip of your index finger to your DIP joint.

01:17:54.240 Oh my God.

01:17:54.960 And that's a fingertip unit. And if you can do a fingertip unit of retinoid every night,

01:18:00.060 that's a great way to measure that you're getting enough on. And I can see your face.

01:18:04.640 You can see, I'm getting a troponin leak right now. Just thinking about applying that much stuff.

01:18:09.500 Yeah. And I have them put it on their face, including the under eye area, because that's

01:18:13.080 the thinnest skin. And that's the skin that's going to wrinkle and age first. So most people

01:18:18.380 are afraid to go around their eyes. I tell them, just don't get it in your eyes. Go around,

01:18:23.220 but make sure you're getting that under eye area. Once a week, maybe on the upper eyelid. And then

01:18:28.700 once or twice a week on the neck, because again, this is the thinnest skin. We've got to keep that

01:18:32.980 skin building collagen and elastin. Okay. The vitamin C and ferlic acid, would you put that on after?

01:18:42.540 First. So you always put the liquid before the thickest stuff. Thinnest to thickest.

01:18:48.800 Let's talk then about how you wash your face before you begin this procedure. So I've just

01:18:54.040 come in from whatever I've done. I'm brushing my teeth because that's the only time I'll do this.

01:18:58.620 I'm going to wash my face now. What should I do? I'm guessing that the hand sanitizer next to my

01:19:04.300 sink is not the thing to use. So there's been a huge shift in so many areas of skincare that is now

01:19:11.700 sinking more with what science is telling us. And so historically, there was a belief that you would

01:19:17.820 need to strip all the oil off your face and debris and dirt before you apply products.

01:19:23.600 We're talking about skincare routines from 10 or 20 years ago. We now know that that is harmful.

01:19:28.980 It creates inflammation. It disrupts the microbiome of the skin. It does all sorts of negative things.

01:19:35.180 A modern cleanser that we suggest is usually something that is glycerin-based. Usually there's

01:19:41.700 other versions, but it's a way of cleansing the skin without overly stripping the oils out of the

01:19:48.600 skin. Glycerin-based cleansers don't foam. That's certainly my bias. I'm sure you might have some

01:19:53.260 other thoughts, Susan, but that's the first step to get the debris and superficial oils off the face

01:20:00.240 and previously applied product. And then as Susan said, you go from thin to thick. And so usually on top

01:20:06.460 of that will be serums like vitamin C serum or retinols. And then finally, you'll put a moisturizer

01:20:12.860 on to kind of seal it all down. Okay. So hang on. Serum?

01:20:16.940 Any antioxidant serum. We mentioned vitamin C, but there are so many other great-

01:20:20.540 What are the others?

01:20:21.640 There are great antioxidant serums that contain sulamarin, floritin.

01:20:26.040 How does one pick?

01:20:26.960 That's where you have to look and see who's invested in doing the clinical research based

01:20:31.660 behind the products that they're promoting.

01:20:33.280 So you tell me, what are you guys using?

01:20:36.220 I would say that generically speaking, if you can find a vitamin C serum that has a higher

01:20:42.580 quality vehicle to make sure the bioavailability of the vitamin C gets to your skin, that product

01:20:48.860 is going to have additional associated antioxidants that are going to be very useful and helpful.

01:20:55.120 And again, to avoid naming brand names here, you can find that quite easily.

01:20:59.960 Can we go ahead and name brands? Because honestly, people just want to know.

01:21:04.080 So let's just give some brands that you guys trust, maybe across a range of price points.

01:21:10.180 I'll give you some names. I'll give you my brand name, but then also brands that I suggest

01:21:14.560 other people as well. My brand name is called Avia Skin Care, and it is designed to-

01:21:19.780 A-V-I-A?

01:21:20.520 A-V-I-A, yes.

01:21:21.600 A-V-I-A.

01:21:21.780 And we formulate these products to have medical rate efficacy, but we also incorporate some

01:21:27.600 Ayurvedic wisdom, which is anti-inflammatory. So it has turmeric and other Eastern botanicals

01:21:32.800 for anti-inflammatory care. And we have a vitamin C serum that is micro-encapsulated that also has

01:21:38.500 a retinol in it and also has various other antioxidants that are niacinamide that are all

01:21:45.600 useful to apply to the skin right after you've washed it. Now, there are other brands as well.

01:21:50.420 We can name a hundred of them, probably.

01:21:52.880 But if you couldn't use yours, what are two others?

01:21:55.840 SkinCeuticals is probably one of the most available.

01:21:57.200 That's the one I tried.

01:21:58.380 Yes.

01:21:58.760 When you said ferulic acid, yes.

01:22:01.440 That's a wonderful brand.

01:22:03.240 But there's no getting out of the stink of it.

01:22:05.080 There is, if you go again with a different brand.

01:22:07.100 A different vitamin C format. So they chose to use the ferulic approach to stabilize the

01:22:12.740 vitamin C. There's many other brands as well.

01:22:15.680 So what's another non-stinky one?

01:22:17.740 Obagi. Obagi Medical.

01:22:19.080 That's yours?

01:22:19.500 No, actually, that's not me. So that company is publicly owned, and I only formulate for

01:22:25.800 them a Susan Obagi MD line. But their vitamin C serum has been around quite a number of years.

01:22:31.860 So the original founder of Obagi is Zain Obagi, my father. But he has since left that company.

01:22:37.740 So this brand has been time-tested for 35 years now. Their vitamin C under a nitrogen vapor.

01:22:43.900 So it makes it so much more difficult and challenging to produce, but it's a very stable

01:22:48.020 form of L-ascorbic acid without the ferulic.

01:22:50.420 So what I'm hearing here is, this is not unlike what's the best diet for me. The best diet is

01:22:57.960 the one that allows you to maintain energy balance that requires the fewest amounts of neurons to

01:23:03.380 stay on. So I need to get three of these and figure out which one is the least annoying for me to put

01:23:10.620 on. And it's no offense to that company. It won't be SkinCeuticals, because every time I've tried it,

01:23:15.380 the smell of the ferulic acid or whatever has been annoying.

01:23:19.520 And Obagi, I didn't do a study for them, but they have a study that shows that their L-ascorbic acid

01:23:25.100 penetrates about four times deeper than the one from SkinCeuticals.

01:23:28.700 Okay, great. So I'm going to try both of yours.

01:23:30.600 And just to name some other brands, I mean, there's SkinBetter is another one that I think

01:23:35.360 produces good products. Maybe it's worth also mentioning, because we haven't done this yet,

01:23:39.640 why is vitamin C so important?

01:23:41.720 I assume it has to do with proline and collagen?

01:23:44.100 That's one aspect. So vitamin C is sort of like a wonder molecule when it comes to facial aesthetics,

01:23:48.900 because yes, it is a precursor for the collagen synthesis pathway in the proline synthesis pathway,

01:23:55.400 but it also is a powerful antioxidant. And so antioxidant application to the skin not only

01:24:02.080 has the power to remove injury, oxidative injury that has happened during the day,

01:24:08.440 but it also has the ability to reverse some existing damage that's in place.

01:24:14.320 Vitamin C also regulates the tyrosine kinase pathway, which is a scientific way of saying

01:24:20.500 that complexion, people talk about wanting to have good complexion. What does that mean?

01:24:24.780 And complexion is something that across societies, no matter what your Fitzpatrick scale is,

01:24:30.480 people like to have a good complexion. And that means having an even skin tone,

01:24:34.080 which is even distribution of melanin. It doesn't matter if you're black or white or brown,

01:24:39.380 people desire to have their skin look even without splotchy areas of pigmentation or nearby areas

01:24:45.540 of relative depigmentation. And so regulating the tyrosine kinase pathway so that there's

01:24:51.200 an even production of melanin throughout the skin is something that is valuable,

01:24:56.020 very valuable in an aesthetic sense. And that's something that vitamin C does as well.

01:25:00.060 Okay. We're going to go from the serum to the retinoic acid. Again, I'm being selfish and talking

01:25:05.380 about my demographics of people that are 40s, 50s and beyond. And then it sounds like the last thing

01:25:11.380 you said we want to do is a moisturizer. Yes. I would say the cheapest trick in skincare,

01:25:16.620 which actually is really true, is that deep moisturization locks down the skin barrier function

01:25:25.740 and allows the skin turgor of the skin dermis epithelium to thicken just by having that occlusive

01:25:34.340 barrier. So you can go to Walgreens and spend $6 on Aquaphor, which is basically petroleum jelly,

01:25:40.940 and put it on your face nightly, and your skin will look better in 30 days. Guaranteed. Because

01:25:47.760 your skin will thicken and a lot of the fine lines and crinkles will actually start to disappear

01:25:52.880 because your skin is being more hydrated. That's hydration. That's hydration. But what if I don't

01:25:56.700 want to grease up my pillow? I'm saying that as sort of like tongue in cheek. I'm not telling people

01:26:00.600 to do that. If you actually did a double-blinded study, you would see that there are real results in

01:26:05.160 30 days. But the reason why I mentioned that is that good, deep hydration can be performed with

01:26:11.520 an inexpensive product that you're using regularly, and it'll make a real difference because the

01:26:16.620 moisturization, especially overnight while you're sleeping, is a powerful tool for aesthetics.

01:26:21.980 Like I wouldn't give you, though, a moisturizer.

01:26:24.480 You can just tell I'm a greaseball to begin with?

01:26:26.460 No, you have young, thicker skin. Just like women age 20 years faster than guys in terms of the

01:26:33.240 bone remodeling and fat atrophy, the skin as well. My routine would be done after the retinoic acid?

01:26:38.880 From my standpoint, yes.

01:26:39.820 At this point. And then we might revisit that in a few years.

01:26:42.060 Yes. And I tend to give moisturizers as women become more mature, I don't want to use the word

01:26:47.980 older, because they do start to make less of their natural moisturizing factor. That even starts

01:26:54.000 to diminish even when we're 18. So most people, I think, into their mid-40s and 50s even, might not

01:27:02.000 always need a moisturizer with everything that they put on at night.

01:27:05.260 One caveat, though, sorry, is that your morning sunscreen and your serums have some moisturizing

01:27:11.040 quality to them also.

01:27:13.120 And I always have them put a super antioxidant serum or a vitamin C serum on at night before

01:27:17.280 they're retinoid. Because my feeling on this is that you spend the whole day outside or in your

01:27:23.140 car or being hit by LED lights and ultraviolet lights, those are also damaging the skin.

01:27:28.220 And so I think you should have an antioxidant on first thing in the morning, but it's going to

01:27:32.660 get depleted by the end of the day.

01:27:34.820 Wait, wait, wait. I'm sorry. I missed that. Are we putting the serum on in the morning?

01:27:38.660 Yes.

01:27:38.940 And at night?

01:27:39.820 I always have them repeated at night because it's depleted all day long.

01:27:43.480 Oh, God.

01:27:43.880 And we know that the cells undergo mitophagy and autophagy at night. We want to help the

01:27:49.420 repair factor. We want to put on an antioxidant at night again just to replenish the skin.

01:27:56.120 And the retinoic acid?

01:27:57.400 It also goes on top of that.

01:27:59.180 Morning and night?

01:27:59.960 No, no, no.

01:28:00.600 Just at night.

01:28:01.400 Okay.

01:28:01.760 And the retinoic acid has anti-inflammatory properties to it in addition to all the good

01:28:06.140 things it does in terms of building up collagen and elastin.

01:28:09.260 Okay. So just to go through this because I'm not the sharpest tool in the shed, my AM routine

01:28:15.220 is going to be-

01:28:16.620 Wash.

01:28:17.420 Okay. Let's assume I just came out of the shower.

01:28:19.160 All right.

01:28:19.780 By the way, in the shower, don't use your body soap on your face because it's going to strip

01:28:24.640 the oils out of your face. So again, you need a separate facial cleanser.

01:28:28.200 Oh, God. What do I need? The same glycerol-based thing?

01:28:31.680 Depends on your skin type too. I tend to be maybe a little bit more picky about-

01:28:37.680 I mean, if you saw the crap, I've got like a $2.99 bottle body wash from Target that I

01:28:44.560 scrub head to toe. I am the lowest, put it this way, when my wife met me in the hospital,

01:28:51.140 the first thing she noticed was how disgusting I was in that I used to take alcohol pads and

01:28:56.740 clean my face. Like that was my shower in the hospital.

01:29:00.200 That probably wasn't bad. It was a little harsh, but it probably wasn't bad. There were

01:29:04.120 worse things you could do.

01:29:04.980 All right. So we're going to do soap, we're going to do serum, and then we're going to

01:29:09.820 do sunscreen. That's the morning routine.

01:29:12.360 And some people might in their need, depending on if they have clogged pores, oilier skin,

01:29:17.820 they might need an alpha hydroxy acid or polyhydroxy acid before their sunscreen. But

01:29:22.660 you've nailed it right there. That's a very simple regimen you can follow.

01:29:25.840 Okay. And then the PM is soap, serum.

01:29:29.100 We'd prefer if you call it a cleanser, right?

01:29:30.880 Yes. Soap connotates a lot.

01:29:32.880 Because soap opens up the door to the Target 299 stuff.

01:29:34.800 Yeah, fair enough.

01:29:35.720 And now the difference is, I do have lots of patients like you, Peter, who are minimalists.

01:29:41.720 Again, it's trying to get them to use whatever they can to protect their skin and hopefully

01:29:47.280 start to improve the aging process.

01:29:49.260 I might, just to do the experiment for 90 days, try to commit to cleanser, serum, sunscreen

01:29:56.040 in the morning, cleanser, serum, retinoic acid in the evening. We agree that would be...

01:30:01.640 Yes.

01:30:02.120 Okay.

01:30:02.560 Yeah.

01:30:03.000 By the way, in the show notes, we'll get from you products that you guys like, including

01:30:07.540 your own. I just want to let people look through this and decide. And obviously, you

01:30:11.440 guys disclose your own products. Great. But let people see the full breadth of things.

01:30:15.360 And I'm sorry. And one of the things people ask about though, especially when they're

01:30:18.520 very into their nutrition and eating healthy, they say, well, why do I need to apply an

01:30:23.160 antioxidant if I'm eating a lot of antioxidants? And the skin being the largest organ in your

01:30:28.820 body, it's very unique. It's very good at keeping things out or from the inside coming

01:30:33.500 out as well. So outside things like water, pollution, it tries to protect that from getting

01:30:38.500 in and does a good job at keeping kind of homeostasis. So they have shown that the level

01:30:44.120 of vitamin C that you can achieve in the skin by topical application far exceeds what you

01:30:49.620 can do by ingesting it. The amount you would have to ingest to get the right amount in the

01:30:54.200 skin, you'd have GI issues. That would definitely make you quit.

01:30:58.880 Before we leave this, I guess one thing I just want to chat about is acne. Again, it's mostly

01:31:04.520 something that adolescents are experiencing, but adults get acne as well. Is that something you

01:31:09.140 guys spend much time on? I do. Give me the playbook you have on acne. I assume it involves

01:31:15.580 spironolactone. If it looks to be endocrine in nature, I'd be very curious to hear about

01:31:21.520 Accutane. I hear horror stories about it, but obviously it probably works very well. What do

01:31:26.260 people need to be aware of? What's your playbook for addressing acne? My number one thing I tell people

01:31:31.280 is for themselves or their children, try to treat the acne before it scars. Because I cannot tell you

01:31:37.740 how many times I see patients for consults for acne scars. They're in their 70s and they're still

01:31:42.800 crying about it as if it was yesterday. They've been traumatized all their life with these acne

01:31:47.620 scars. And what causes acne to scar? So it depends on how inflammatory your acne is. There are different

01:31:52.380 types of acne. There's comedonal acne, which are just your run-of-the-mill small pimples, whiteheads,

01:31:57.440 blackheads. Those don't typically scar unless someone picks at them. So number one rule for patients,

01:32:02.740 don't pick at your skin. Second thing, they can have a little bit more inflammatory acne. And those

01:32:08.960 tend to be the red ones that come up and they're maybe pustular on the skin. And if you don't pick

01:32:15.040 at them, those also might heal without scarring. And then there's cystic acne. And those are a

01:32:20.740 completely different type of acne where you're getting inflammation in that sebaceous, pylosebaceous

01:32:25.740 unit, which is the hair follicle and the oil gland feeding in there. And you get swelling deep in the

01:32:31.360 dermis. And then you might get enough inflammation and rupture of that cyst that you leave a divot

01:32:37.660 at that point. And that causes what we call a valley scar.

01:32:41.860 Even if not picked.

01:32:43.080 Even if not picked. So cystic acne is a true, in my standpoint, a medical emergency because you want

01:32:49.960 to treat it before...

01:32:50.440 Maybe not on the level of anaphylaxis, but...

01:32:52.240 Correct. Correct. But for parents...

01:32:54.580 It's a dermatologic medical emergency.

01:32:56.240 Yes. Because it can cause so much psychological trauma to the child. People with cystic acne,

01:33:02.540 even bad inflammatory acne, they're shy to go out in public. They want to hide their face. They

01:33:07.280 hide their face with their hair.

01:33:07.840 What percentage of adolescents will develop cystic acne?

01:33:11.120 I don't know that I can quote the exact percentages, but about 20%.

01:33:15.300 Oh, wow. So pretty high.

01:33:16.600 And it's very difficult to fix later.

01:33:18.440 Yes. And those patients, I'm not a big fan of antibiotic use. I don't want to alter their gut

01:33:23.960 microbiome. I do think that we're just touching on the surface of how important that is.

01:33:28.960 Those patients, I would quickly move to Accutane because nothing topical is going to work.

01:33:34.200 Or photodynamic therapy.

01:33:36.340 Okay. Say more about that.

01:33:37.780 So photodynamic therapy is where you take a molecule like aminoleviolonic acid, ALA,

01:33:42.940 and you paint it on the skin and you let it incubate for about an hour. And then you shine a red

01:33:47.880 light onto the skin to activate it. And that chemical gets into the sebaceous glands and

01:33:53.800 percolates down through the skin. And when you activate it, it causes a heat reaction and basically

01:34:00.240 induces damage in that whole area that's picking up that medication. So you're causing the oil glands

01:34:05.680 to shut down. You're taking away the nidus for the inflammatory acne. And for some patients who cannot

01:34:12.460 take Accutane or isotretinoin, that's a great alternative for them. It does feel uncomfortable

01:34:18.620 and not every doctor offers it, but it's a great adjunct or alternative if they can't take isotretinoin.

01:34:25.260 Would antibiotics work if not for the limitations and side effects of long-term systemic antibiotic use?

01:34:32.740 So antibiotics will work to a small degree. They might help shut down maybe a good proportion of

01:34:38.260 that cystic acne flare, but they won't get to the root cause, which is sebaceous unit overproduction

01:34:43.960 of oils, the bacteria that are in there feeding off of that, and the whole cascade. And there's

01:34:49.580 something genetic. Cystic acne tends to run in families. So there's some kind of genetic tendency

01:34:55.520 towards that milieu that causes cystic acne.

01:34:57.540 And how does Accutane work? What's the mechanism of Accutane?

01:34:59.700 So Accutane is a type of retinoid, and it's basically going to go in there and dry up

01:35:05.460 the oil production that's in these overactive sebaceous glands that are being driven by your

01:35:09.900 androgens. But you have to take it orally.

01:35:11.540 Correct. So they have used some topical variations of it for psoriasis and things like that, but the

01:35:18.960 best is to take it orally because then you bypass a lot of the surface dermatitis.

01:35:23.760 What is the main side effect or toxicity that people are trying to avoid with Accutane? Why does

01:35:27.940 it have a bad name? So it has a couple of bad connotations with it. First, it dries everyone out.

01:35:32.820 So for the five months you're on it, you are going to have dry lips, dry eyes. Some people

01:35:38.420 complain that their skin is too dry. Some people on high doses might get shedding of the hair.

01:35:43.600 And then you're not allowed to drink alcohol while you're on it. So that's a whole other issue with

01:35:48.420 kids and making sure they're compliant with that because it is metabolized by the liver.

01:35:53.220 Other than that, patients, if they're using it correctly, tolerate it very well.

01:35:57.700 And the teratogenic effect.

01:35:59.800 Oh, I'm sorry. Yeah.

01:36:00.940 Sorry, say again?

01:36:01.640 Teratogenicity.

01:36:03.100 Can't reproduce.

01:36:03.940 You're not getting pregnant on it because it will cause defects. So we have to go through this

01:36:07.900 whole FDA-required modules with the patients to make sure that they're using two forms of birth

01:36:12.740 control for the female patients. While they're on it, they're not donating blood while they're on it.

01:36:17.780 But it got a very bad reputation when I think it was a child or son of a senator committed suicide

01:36:24.360 while on that medication. And they said it was a depression induced by the medication.

01:36:28.660 When it turns out, when people look scientifically at the rate of depression.

01:36:31.980 Yeah, that sounds like junk science written all over it.

01:36:34.120 Exactly. If you look at depression scores in acne patients with cystic acne, it's significant.

01:36:39.640 And their depression actually improves when they take something like Accutane because they feel

01:36:44.180 monitor liver function tests while patients are on it the same way you do with lamictal or any of

01:36:48.720 the toe fungus type things. Is it that severe potentially?

01:36:51.880 It could be. It changes your lipid profile while you're on it. It can elevate your triglycerides and

01:36:56.780 elevate your cholesterol. And there are very few instances we would adjust the dose. We just tell

01:37:01.320 people to try to eat healthier while they're on it, especially triglyceride elevation. Liver enzymes,

01:37:06.680 it's a rare patient that gets a real significant bump, but you want to watch for that because you

01:37:11.340 want to stop the medication if that's the case. And it's also a proxy to make sure they're not

01:37:15.280 drinking. It's sort of a way of finding out if they're following the rules. Yes, we tell them we

01:37:19.820 can tell. Yeah. And I don't prescribe Accutane. This is usually something that is done by specific

01:37:24.620 physicians. This is a dermatologist should be doing it. Yes. And you mentioned five months.

01:37:28.340 Does that imply that you do this very lengthy five-month treatment and then you're done with this?

01:37:33.720 It eradicates the sebaceous glands to the level where the child, the teenager is done with this

01:37:41.400 treatment afterwards? For 85% of people that take it for five months, they're done. Then you've got

01:37:46.180 the small subset, then you need to take it again. And then I have my adult patients who might not have

01:37:52.120 a lot of acne, but they're very oily. I put them on it one month out of the year just to dry them up a

01:37:58.580 little bit. And it helps them feel better. It makes their pores look tighter, makes their skin

01:38:03.440 have a better texture to it. Because we always said, oh, if you have oily skin, you're going to

01:38:07.880 age better. That's so not true. Oil is inflammatory on the skin. So from that standpoint, I'd rather have

01:38:14.340 them use it to dry them up for about a month and then allow them to enjoy the beautiful skin for the

01:38:19.920 rest of the year. Sounds like a dumb question. How does one know if they have oily skin? Like I've

01:38:23.580 always thought I have oily skin. Do I? Well, your pores would be enlarged. Some people have to

01:38:27.820 blot their face midday. I don't have that. Okay. Let's move on now. By the way, that was super

01:38:33.440 interesting to me. By the way, I want to make sure we also get good products. We didn't talk

01:38:37.580 about it, but can you tell me, you mentioned for the cleanser, it just needs to be glycerol based.

01:38:43.400 Are these easy over the counter things to find? Should I be going to Target or Walgreens and literally

01:38:49.000 just going through the skin aisle and looking for cleansers that are glycerol based that won't

01:38:52.900 lather when I use them? Is that the litmus test? It's one way to do it. And we can also provide

01:38:57.700 give us a bunch of links to products. Include your own. I don't care. Just make it easy.

01:39:01.900 And if you're oilier, I'm going to give you one that's not quite so hydrating when you wash.

01:39:06.720 Okay. All right. Let us move now into the really confusing realm of I show up in your office,

01:39:17.100 can't tell you what's wrong, but I show you a picture of me 10 years ago and I say,

01:39:22.440 I want to look like that. And I should have brought a picture in of me so you could actually

01:39:27.780 see it, but you've already described it without having seen the picture. I don't have bags under

01:39:33.000 my eyes. My skin just looks better. Everything just looks better. Part of it is color. I will admit

01:39:41.820 10 years ago, there was no gray anywhere in my beard. We're not going to fix that problem. That's

01:39:46.600 fine. Oh, and the wrinkles in my forehead. I notice in pictures of me in the past, I had some wrinkles.

01:39:53.460 Now it looks like I have a wrinkle farm. Again, go over the changes. Assuming I had that photo,

01:39:59.100 how would you describe them pathologically? Or maybe that's too strong a word, but you know what I mean?

01:40:03.180 There are three basic changes that happen to every single person with aging. And we've touched on this

01:40:07.840 a little bit and we'll dive deeper now. So there are skin changes. There are volume changes.

01:40:13.540 There are gravitational changes. And maybe we should throw in the fourth, which is

01:40:19.020 bone structural foundational changes. And so those happen to everybody. When we see patients in our

01:40:25.320 clinics who are presenting the way you've just suggested, we will spend extra time analyzing

01:40:30.900 the individual nuances of skin volume, bony ligamentous anatomy, gravitational changes that are

01:40:38.300 specific to your face. And then also we'll just rely on general knowledge that we have about what types

01:40:45.020 of aging changes we see at this point. And it's a very complex process. I tried to analyze this a

01:40:51.720 little bit before walking into this podcast today. Like what am I actually thinking about when I'm

01:40:56.320 starting to communicate with the patient? As soon as I see the patient, while I'm making some niceties

01:41:02.020 and saying hello and get to know them, I'm already analyzing. I'm already looking at their skin.

01:41:06.980 I'm looking at the bone structure. I'm analyzing the facial proportion. I'm looking at areas where

01:41:11.760 there's volume loss. It's obvious. I'm looking at the dynamic movement of the forehead and the face.

01:41:16.800 I'm analyzing how much heaviness is on the eyes that might be driving frontalis muscle tone that's

01:41:22.620 causing forehead wrinkles. I'll be looking for facial asymmetries. So a lot of the physical exam

01:41:28.500 that we do in our offices happens in the first 15 seconds because we're just, this is what we do

01:41:34.840 and it just happens quickly in our mind. Big different. It's that blink moment. Yes. You look

01:41:39.360 at someone and you're like, I know what I'm going to do on them. Yes. Yes. The urologist doesn't have

01:41:43.900 this advantage. He can't, you know, examine the prostate and the scrotal tissue during that first

01:41:49.980 15 seconds. Very good point. Yes. So we do that when we walk into the room, that analysis already

01:41:55.680 happens. And then because I've already got that snapshot anatomic analysis already in my mind,

01:42:03.780 then the next step that I'm doing is, and I'd love to hear what your process is, Susan, but the next

01:42:09.460 step is I'm now going into their mind and trying to understand their psychology and what their motivation

01:42:15.640 is. And the problem that we have is that the patient doesn't know what words to say. Yeah,

01:42:21.060 they're like me. For them to communicate what's actually driving them. And so I have to pull that

01:42:27.200 out of them. This was a little bit of detective work, a little bit of background. My parents are

01:42:31.720 both psychiatrists. I actually went to medical school thinking I was going to go into psychiatry

01:42:35.740 and then I rapidly pivoted into surgery and ended up where I am. But that initial love and appreciation

01:42:44.100 for what's happening inside the neuronal processing and the subconscious is something that we actually

01:42:51.040 work with every single day in our offices. And so the next step that happens in a consultation is-

01:42:55.980 I would say hopefully. I mean, to me, that's a great thing. And not to be a downer, I don't know

01:43:00.260 that that's true of every person who is dealing with aesthetics. I would guess there are a lot of

01:43:04.880 people who are just kind of doing this in a coin operated way. Cookie cutter. Yeah. I think you're

01:43:08.860 right. Unfortunately, there can be a tendency to take a cookie cutter approach where you recognize

01:43:13.980 this. It's a knee-jerk reaction. There's wrinkles on the forehead. Inject Botox. You know, there's

01:43:19.360 jowls. Do a facelift. That's not the way that we should be practicing aesthetics. Every single

01:43:24.780 individual has a totally customized situation anatomically, physiologically, and psychologically.

01:43:32.180 And so our job is to try and figure that out when the patient doesn't have the ability to express.

01:43:39.880 So sometimes it's almost overlaps into pediatrics, which is something that I know you've got some

01:43:43.760 history with in surgery, but you're trying to do a physical exam and get history from someone who's

01:43:49.000 unable to communicate what they want you to figure out. And so I'll start asking questions.

01:43:54.820 Did you like the way you looked when you were 20? If they say yes, that means that they actually

01:43:59.920 like their natural facial proportions, and they're probably looking more for rejuvenation.

01:44:04.300 But if they say, you know, I always had a heavy eyelid and I never could put makeup on my eye,

01:44:09.080 then I know that they're maybe looking for something that's a more substantial result in

01:44:13.360 that particular area. That's just one example. And then I'll try to get to know them. What's their

01:44:18.620 occupation? What's their situation at home? Do they have kids? Tell me a little bit about your life.

01:44:23.660 I'm trying to understand their social history, see if there's any red flags that would

01:44:29.080 stop the process and say, okay, this is not the right time to be considering aesthetics. You got

01:44:33.380 to get your mental health in order before we proceed, which is something that I would very

01:44:38.620 openly tell a patient at the right time in the consultation. But if a woman came in and said,

01:44:44.320 my husband is leaving me, which is unfortunately probably not an uncommon thing. And let's make it

01:44:50.680 more extreme. A 50 year old woman comes in and says, my husband of 25 years is leaving me for a 20 year

01:44:57.300 old. Understandably, she's in duress and she's probably comparing herself to a 25 year old.

01:45:05.500 Would that be a non-starter in your mind? The scenario you described is actually very common.

01:45:11.280 I see this kind of situation all the time. And this is why I schedule 45 minutes or an hour for

01:45:16.220 initial consultations, because once we start talking about that, tears may start flowing.

01:45:21.040 The patient is now in a safe zone talking to a medical professional who's actually listening to

01:45:25.800 them. We were talking about time in a clinic before. Then we start to fall into the role of

01:45:29.800 a therapist and we're letting them express, because I want to see how deep is this trauma?

01:45:35.780 I'm trying to understand, is this something that is now a non-starter? Or what should we do here?

01:45:42.000 Because there are scenarios where someone is in that kind of scenario, situation, where we certainly

01:45:48.480 would not want to make any drastic moves or big changes or shifts. But is it appropriate to

01:45:55.540 recognize that this person is desiring something that is a reasonable goal, but the current emotional

01:46:01.520 state is not appropriate to do the procedure to get there? So maybe we say, look.

01:46:06.420 We do something reversible.

01:46:07.520 Yes, exactly.

01:46:08.200 Because of the fear. Sorry to interrupt, but I'm guessing that the fear here is if you say no to her,

01:46:13.200 she's going to find some guy down the block who will do anything. And it's better that you do

01:46:17.640 something small and develop a relationship with her that will ultimately serve her interests,

01:46:24.000 but you can't give her everything she wants at the moment. Is that a fair assessment?

01:46:28.000 Very well said. That is exactly right. We're trying to build that trust and build that relationship on

01:46:33.080 the front end so that this individual who's trying to get from A to B, we're going to take them there

01:46:40.360 safely. Whether it's over a couple of months or 10 years, we're going to try to get to that goal.

01:46:48.100 And there may be some obstacles along the way and choices that we have to make, but we'll navigate it

01:46:52.100 together. And it's all built on building that relationship on the front end. So the trust exists

01:46:56.980 where I can tell the patient, we are not going to do this maneuver right now. And then that patient

01:47:02.400 will listen to me because the trust has been built up enough that this individual knows that I have

01:47:07.240 their best interests in mind. And we're going to get to that goal eventually. And so yes,

01:47:11.660 this scenario that you're describing, the individual might be best served with, okay,

01:47:15.720 look, I think we can get there one day with procedures. But right now, I'm going to refer

01:47:20.260 you to a therapist. You have a lot going on in your life right now. Let's do some simple things that

01:47:25.660 we're not going to regret, like neuromodulators and fillers and some skin treatments or lasers,

01:47:31.140 things that are low risk. They're not going to create any scars or permanent changes. And then

01:47:36.320 we can eventually get to that next step. We're not going to do the facelift next week.

01:47:39.880 Correct. Yes. That's on hold. The first step is we do this snapshot anatomic dynamic analysis. It's

01:47:46.020 not just a single image as we're looking at the muscle movement. And then the second step is this

01:47:51.340 deep dive into their social situation, psychology, and then presuming that everything's moving along

01:47:58.480 smoothly. And now we're getting ready to talk about what should we do now. Then I'll spend time

01:48:03.280 educating the patient on their actual anatomy because they've never actually had that information

01:48:07.980 presented to them. So I will put the mirror in front of the patient and I will say, let's go through

01:48:13.200 what I'm seeing on your exam today together. And we'll start at the top and I'll go through every

01:48:19.300 little detail and I'll throw in little caveats like, I'm sorry, I'm not trying to make you feel bad

01:48:24.060 about your features, but you're here for me to tell you. So I'm going to tell you everything.

01:48:27.220 We're going to talk about your bones. We're going to talk about the wrinkles. We're going to talk

01:48:30.020 about the asymmetry you never noticed, which by the way, is almost always the case. People don't

01:48:34.140 notice their asymmetries. And so we point out these asymmetries to them. And then after that relatively

01:48:40.260 lengthy discussion about their individual anatomy, then we'll start to say, okay, now you initially

01:48:47.060 told me that these are some of the areas that bother you. Here's what we could do to fix your eye

01:48:53.440 region, your cheek, your mouth, your gel, whatever it is. And I'll present typically options that go

01:48:59.500 from minimally invasive to more substantial. And based on how the individual is responding to the

01:49:08.540 conversation, I can usually at this point, 20 years in my practice, dial in what is the appropriate

01:49:14.540 scope for this patient. They don't really know whether they want to facelift or not. Maybe I need to

01:49:19.860 explain them the complications, where the incisions are, so they really understand what that procedure

01:49:24.700 means. And then if that seems like it's too much for them, we will dial it back. And I'll have to

01:49:29.100 tell them, look, we're not going to be able to get the results of a facelift without a facelift,

01:49:32.240 but I don't think you're ready for a facelift. So maybe we should start with something smaller

01:49:36.380 and kind of taking baby steps. And then just to conclude, usually we'll end up finally telling the

01:49:42.320 patient what they showed up to hear, which is my opinion. I won't give them my opinion about what we

01:49:47.740 should do until we've gone through this whole process. And I've watched their body language as

01:49:52.400 we've talked about procedures. Sometimes I'll suggest something that's minimally invasive and

01:49:56.720 they seem uninterested because it's not enough for them. And I'll read that body language and kind of

01:50:00.700 dial in the treatment for what I suggest for them. And so that'll happen at the end of the

01:50:04.740 consultation, typically. So I know that was a long answer, but that does, I would say, describe my

01:50:11.340 typical consultation. How about you, Susan?

01:50:13.800 Pretty much everything that Tanish said. And I was so glad to hear that you talked to the patient

01:50:19.100 about their mental state at that time too, because we do a lot of almost like psychology and therapy

01:50:25.980 with our patients. If they open up to you, then that's an honor to you and you have to take that

01:50:31.900 and you have to help them through that issue. I have a psychology background as well. So I was biology

01:50:37.240 and psychology double major in school. I use it a lot. It's so important. I approach patients very

01:50:43.660 similarly, but I try to put things in terms that they can understand. So I tell them there are the

01:50:48.240 five R's of rejuvenation. And it doesn't mean they need all of it at that point in time, but at some

01:50:54.820 point in their life, they're going to need one of them. And they'll make it through all five. And that

01:50:59.240 is we need to relax overactive muscles. And I'm showing them on their face, the movements. I will say

01:51:05.260 we need to refill lost volume, whether it's through fat grafting, which is still one of my favorite

01:51:11.420 procedures to do or refilling with fillers. And I tell them we need to resurface the skin because to

01:51:17.360 me, how the skin looks is absolutely much more important than how tight they are. So patients

01:51:22.900 sometimes come in and they're like, I just want to lift here and they want to lift their lower face

01:51:26.740 and their skin is terribly wrinkled and they have hyperpigmentation and sunspots. And I'll tell them

01:51:32.600 if I lift you now, no one's going to notice that you look better. But if I make your skin look better,

01:51:37.580 people are going to notice you look better before I even do the surgery. So we have relax, refill,

01:51:42.660 resurface. We need to do re-draping. So there are going to be times that you can't fill enough. You

01:51:48.440 have to lift. So they either will lift with devices such as microneedling radiofrequency devices or

01:51:56.060 ultrasound devices to tighten the skin or a facelift of some sort. So those you need to do. And then what

01:52:02.680 people don't realize, my fifth R, is that you have to keep renewing because the aging process

01:52:08.280 continues. And the minute they leave your office, everything you just did on them looks great and

01:52:13.060 then it starts to diminish. And that's what we were just talking about. The renewal was the maintenance.

01:52:17.100 Absolutely. So you have to keep renewing because otherwise you're going to lose that benefit. And

01:52:21.600 what do I mean by renewing? You definitely maintain your neuromodulators and your fillers,

01:52:26.500 but they have to be strategically placed. You don't need a lot of fillers.

01:52:29.700 You need to keep the skin priming itself and turning over. So you can achieve a lot of that

01:52:35.440 at home. And I think people underestimate how much they can do at home with their skincare regimens

01:52:40.300 and then have to do less in the office. And that's my big emphasis. Do more at home and then let us do

01:52:46.220 in the office a little boost here and there afterwards. And so those five R's make it very

01:52:51.760 easy for these patients to comprehend. And they might not need all that yet, but at some point in their

01:52:56.740 life, they're going to have all those five R's. So what I want to do then is I want you to go

01:53:02.660 through the five R's looking at me and Tanuja, I want you to go through your four changes looking at

01:53:10.160 me. Just feel free to brutalize me. You're not going to humiliate me. So Susan, you look at me and

01:53:16.540 let's start with relax. What needs to be relaxed in my face? So here's the thing. You do move your

01:53:22.240 eyebrows a lot in your forehead. So you've got a lot of forehead wrinkles. I do notice the

01:53:26.820 glabellar 11s. These are those little sharp lines there. Yep. Yep. So knit your brows for me.

01:53:32.460 Yeah. Raise your eyebrows up. Now, part of the reason you're raising your eyebrows maybe now more

01:53:37.740 than you did 10 years ago is you have a little more hooding on your upper eyelids and your eyelids

01:53:42.760 are almost touching your eyelashes. And when that happens, you're sending a signal to the forehead

01:53:47.700 to lift so you can see better. Is that because I've lost elasticity in the eyelid and it's just

01:53:53.460 drooping more? Well, no more. So going back to what we were talking about, the bony structure,

01:53:58.500 we're losing bony support, fat atrophy, including the brow fat pad. And so now you've got a descent

01:54:04.380 a little bit of your brow, but a little more of the extra redundant skin there. I got it. So

01:54:09.660 I'm actually using this muscle more to try to keep these guys up. Exactly. Now, if you go to someone

01:54:16.020 who doesn't evaluate you like we do, they might look at your forehead like target practice and say,

01:54:21.960 I'm going to use a neuromodulator across that entire forehead and make it so you can't move.

01:54:27.180 And then you're going to walk around very hooded and very heavy. I would feel silly. I wouldn't

01:54:30.160 want to look that way. You would hate the feeling. It would feel very hooded and very heavy. And I've

01:54:34.060 done that on purpose to myself just to see what patients experience. And it's not a nice feeling.

01:54:38.720 Secondly, you are very fit. So you have not a lot of fat in your face. And like I said,

01:54:45.980 doesn't matter what you think your weight is on your body now, how much fat percentage you have

01:54:50.360 on your body, you've atrophied some of the facial fat pads. You've exposed the entire orbital rim.

01:54:55.120 I can see that. And you may also notice I have a scar here and it has created an asymmetry in the

01:55:01.740 drooping. So from my teenage years, when I was boxing, I actually had, I was split to my cheek

01:55:07.380 there. So that is a very deep scar. I suspect the connective tissue there is actually tethered

01:55:13.320 near the bone.

01:55:14.320 And we can free that up with subcision. So that is kind of similar to the microneedling

01:55:18.920 Tanuj did on your other scar, but this is going under the scar, the whole length of it and subsizing

01:55:24.160 or freeing up that tethering and that adhesion with or without adding fat or filler there.

01:55:29.220 Okay. Got it.

01:55:30.380 But I would. So if you look at what makes the eyes look youthful, it's definitely having a little

01:55:36.480 more platform show on the upper eyelid, but also it's reducing what we call the lengths

01:55:41.160 of the lid cheek junction. So the lengths are from your eyelash line down to where you can

01:55:45.760 actually see the cheek. That's elongating.

01:55:48.640 In me.

01:55:49.340 Yeah.

01:55:49.440 You've lost all that volume that was up here.

01:55:51.440 I think that if you were to ask me, Peter, what are you most self-conscious of aesthetically?

01:55:56.940 I think this is it. I think it is this thinness here, which I believe makes me look constantly

01:56:07.020 tired. Even when I feel like a million bucks, I think I'm more subconscious of this than I

01:56:12.600 am my wrinkled forehead.

01:56:14.120 Yeah. And that's where I would either use a little bit of your own fat if we could find

01:56:17.920 some.

01:56:18.360 Oh, I've got plenty.

01:56:19.000 And I would use that to rebuild this area and shorten that lid cheek junction so that

01:56:24.940 we create more of a youthful length rather than this kind of long hollow area.

01:56:29.360 And why, we're going to talk about this, of course, but when do you guys make the decision

01:56:33.200 of an autograft of fat versus Restylane you mentioned earlier?

01:56:39.120 I love fat if we can do it. Now with the advent of fillers, the volume of fat grafting we do

01:56:44.400 goes down. And I'll tell you why. On her, she came in and she had never had anything

01:56:49.300 before. And she was hollow everywhere.

01:56:52.860 How old?

01:56:53.560 69.

01:56:54.340 Okay.

01:56:54.980 So yes, we could use lots of fillers, but she'll spend a small fortune putting a lot of fillers

01:57:00.800 in her face over time. And I personally don't like to inject more than two or three syringes

01:57:05.140 of filler in one visit. So it's going to take a process to build up different areas on her

01:57:10.100 because I just don't want to have a reaction. And I also want to see where I'm placing

01:57:13.460 everything. But in her case, we went straight for the fat because she has a thin face, but

01:57:18.300 she has a normal body mass index. So her fat is going to do well.

01:57:22.380 How much filler would I require? What would your guess be?

01:57:25.740 I'd start with a syringe split between both under eyelids, and then I would do another syringe

01:57:30.980 probably in about three or four months if I need to.

01:57:33.380 What's the cost of each syringe? Not your cost, the patient's cost.

01:57:36.820 Yeah, about $800 to $1,000 depending on the filler.

01:57:40.140 Again, what is the cost of the procedure, the fat graft procedure? That's obviously much

01:57:44.860 more, but it's a lifetime, presumably.

01:57:46.480 It's about $5,000.

01:57:47.900 Okay, so five years worth of treatment, basically. So it's cheaper in the long run to do a fat

01:57:53.180 graft, presumably.

01:57:53.940 Yes, but also remember that we're just talking about your under eyes. But let's say you're

01:57:57.700 my typical patient. They need their temples filled, they need their cheeks filled, they

01:58:01.060 need their chin filled, jawline enhancement. So yesterday, I did about 35, 40 mLs of fat on my

01:58:09.100 patient. So that gets very expensive.

01:58:12.340 Are my temples too sunken?

01:58:14.540 Yours are still good. And your cheekbones are still good, your jawline is still good.

01:58:19.100 I would put a little neuromodulator or Botox in your platysma muscle because I am starting

01:58:23.760 to see some platysma banding there.

01:58:25.780 Wow.

01:58:25.820 Mine's worn off, so you don't want to look at mine. But that helps to relax that muscle

01:58:29.820 that does nothing but pull the lower face down. I would possibly add a little volume right

01:58:35.500 in your malar. In your case, I would love a biosimulatory filler, something like poly L-lactic

01:58:41.280 acid or Sculpture is the other name for it, to start building collagen and thicken your

01:58:46.180 dermis thickness in here because I'm starting to see some of your buccal fat pad atrophy

01:58:50.780 as well. And that just goes along with how fit you are. So using this to build your own

01:58:55.940 collagen is a great way. And if you were a female, very thin, we would have an issue because

01:59:01.600 those patients tend to burn through their fillers very quickly. So if we can get a biosimulatory

01:59:05.840 filler on board where they're building their own collagen, sometimes it works a little better.

01:59:10.800 Now, do you ever look at a patient like me and say, you're most fat depleted here and

01:59:15.960 here, but you're not yet fat depleted here and here. I only want to do one fat graft on

01:59:21.080 you. So let's cost aside, let's use fillers until I have to do this procedure once and for

01:59:28.060 all. And then I'll literally just take a bunch of fat off you and do it.

01:59:32.300 Absolutely.

01:59:32.880 Is that a better approach or are you afraid to do multiple fat grafts?

01:59:36.400 Oh, no. I have patients that come for fat grafting as they need it. So I've done some

01:59:40.080 patients three, four times, but I have turned down a lot of patients who come in actually

01:59:44.860 asking for fat grafting for lips or for under eyes. And I tell them since they don't need it

01:59:50.500 elsewhere, that's too much of a procedure to go through for like one anatomic area. And in the

01:59:55.240 lips, it doesn't hold as long, but under the eyes, it works beautifully, but I would do

01:59:59.600 it when they need it elsewhere.

02:00:01.760 I will probably never need lip fat grafting. When I was little, people made fun of the size

02:00:06.620 of my lips. I'm pretty sure I'm safe on that. Before we go on to resurfacing, Tanuj, what

02:00:12.540 would you change or add or how would you approach my face?

02:00:16.340 Well, I think Susan's analysis was spot on. I agree. I think that what I hear you saying

02:00:21.420 is the biggest issue that bothers you is your under eye area. So because you're someone who's

02:00:27.040 never had a procedure before.

02:00:29.020 Actually, Brett Kotlis did stick Restylane in there, gosh, how many years ago? Probably

02:00:34.360 2018, 2017.

02:00:36.740 Okay.

02:00:37.060 I'll tell you what I remember of the procedure. I was amazed at how much I bruised. He told me I

02:00:42.960 would. So it's not like this was an unexpected complication, but I looked like I had two black

02:00:46.240 eyes for a couple of days. Otherwise it looked really good. And then it went away after a period

02:00:51.680 of time, but it definitely was not a year that it lasted. I also suspect I metabolized it very

02:00:56.640 quickly.

02:00:57.460 We have longer lasting fillers though that we can use under.

02:00:59.900 He also mentioned that this scar was problematic. He said, it's very difficult to fill this eye.

02:01:06.940 And you might ask, well, why didn't you just keep doing it? Just the same reason I don't do

02:01:10.900 anything. Just sheer laziness. I was just like the thought of actually doing that again,

02:01:16.680 having a couple of black eyes for a couple of days, blah, blah, blah, blah, blah. I just sort

02:01:20.680 of gave up. So anyway, I have that one experience.

02:01:23.480 So your under eye area, and by the way,

02:01:26.380 Being lit this way is an abomination.

02:01:29.600 But just by the way, bruising from fillers is a lot less these days because we don't use

02:01:33.800 needles as much anymore. We actually use cannulas, which are blunt tipped catheters, and they don't

02:01:38.620 typically bruise hardly much at all. So that's one big change that's happened in the last five,

02:01:43.260 eight years is switching to cannulas. And people have different philosophies on that. Some people

02:01:47.240 use needles for specific locations, but I just wanted to mention that, that bruising in your

02:01:51.720 under eye would probably be less if you had fillers again. But again, kind of going back to the way

02:01:55.880 that I do a cosmetic exam, because I just heard you say the thing that bothers me the most is this

02:02:00.920 area. And we could list off another 10 things that are, quote unquote, aesthetically problematic.

02:02:05.740 Like, I didn't even notice this. So now you've given me something to be self-conscious about.

02:02:10.920 I should have prefaced this saying, I'm just going to point out some things.

02:02:13.820 I wanted you to. I'm totally teasing. I'm totally teasing.

02:02:17.080 So I would laser focus on the area that the patient is now presenting to me as their major

02:02:23.120 reason for even calling up my office and making an appointment is probably because they wanted to

02:02:29.060 address this area. And yes, they're curiously interested in all the other things that I had to say,

02:02:33.420 but because this patient, in this case, you never had surgery on their face, is probably not looking

02:02:40.740 for massive shifts in their face. I would probably laser focus on this one area, not just because it's

02:02:46.480 what you pointed out, but also in the realm of rejuvenation procedures that we perform

02:02:53.200 surgically or non-surgically. The eye region is probably the sweet spot. Just again, going back to

02:03:00.760 psychology evolution, we focus on people's eyes in conversation. When we talk about beauty, we're

02:03:06.800 looking at the eyes. When people's eyes are now starting to become further and further away from

02:03:14.080 the way they remembered when they were younger, it creates this discomfort. It's the self-discrepancy

02:03:19.140 theory from psychology where you've got the self-image of yourself, and then you look at yourself,

02:03:24.140 you're like, wait a second, that's not me. And then it creates this discomfort of like,

02:03:28.020 is that what I really look like? And then it creates the psychological effect of maybe a little

02:03:32.500 less confidence or dissatisfaction with your appearance. That's the big motivator for why

02:03:38.500 people actually end up coming to see someone like us, is because that self-discrepancy theory is

02:03:43.340 kicking in and the delta between their self-view and their actual appearance is getting greater and

02:03:49.020 greater. It's one of the reasons I, it sounds ridiculous that I'm saying this on video and that

02:03:53.680 I have a podcast. I freaking hate being on video. I don't mind the sound of my voice seeing me on a

02:04:00.980 video. And as you know, in this type of a situation, you're always overhead led. It is an unbearable

02:04:06.140 appearance because when you have these bags under your eyes, overhead lighting just makes it look 10

02:04:11.380 times worse. So if I pass myself in the mirror, I'm like, eh, I notice it. If someone ever sends me a

02:04:18.300 clip of me on video, I'm like, how in the hell are we allowing this to be in the public domain?

02:04:25.560 I mean, seriously. And part of it may be what we were mentioning earlier, that subconscious posing,

02:04:29.720 because when you're looking in the mirror, you know, you're looking in the mirror and your

02:04:32.760 subconscious makes you lift your cheek a little bit. Maybe I angle my head different or something.

02:04:36.240 You angle your head or you smile a little bit and it pulls the cheek up and minimizes that hollow

02:04:40.660 between your under eye and your cheek. And everybody does this. And that's why people tend to be

02:04:45.000 shocked by photographs that are taken of them when they weren't prepared for it. They're not

02:04:49.460 prepared to pose for the picture. And their flat, undynamic face in a photograph that's taken like

02:04:56.240 that is shocking to them. It's often a big motivator for them to come to see us.

02:05:00.240 I also made the mistake of once reading some comments on social media where people were just

02:05:04.600 ripping me apart for how horrible I look. You can say what you want, like, I don't care,

02:05:09.140 but you do care. If you read a bunch of people saying you look horrible, you're like,

02:05:12.660 well, that sucks. I don't like that.

02:05:14.980 But you know, when people show you that picture of themselves that someone took,

02:05:18.180 because they bring it to the console. They bring a picture and like, oh my God,

02:05:21.220 I saw myself last week. Look at how I look. And you're like, give me your phone. I take their

02:05:25.440 phone. I take a picture of them in the exam room and show them, look how good you look.

02:05:30.860 This was one nanosecond in one way you were moving your mouth or tilting your head or a shadow.

02:05:37.800 You don't look like that. So delete that picture. We will not address

02:05:41.860 how you look in a nanosecond compared to how you look the rest of the day.

02:05:45.840 Totally agree. Yeah.

02:05:47.260 And then what about the wrinkle situation?

02:05:49.180 Yeah. So what I would do is I would go through all of the areas, the four areas that we're

02:05:53.540 talking about, and then I would laser focus on the eyes. So to go through the four areas,

02:05:57.520 we're talking about skin. We've done a lot of discussion already on skincare.

02:06:01.700 I think that you should start a skincare regimen. I think you'll appreciate it as time goes by.

02:06:05.720 I'm going to commit to three months for sure.

02:06:08.280 You have uneven pigmentation in your face. You have some fine lines that are more concentrated

02:06:13.200 in the eye region because the eyelid skin is the thinnest on the entire body. It's the one area of

02:06:17.860 the body. You're a surgeon by training. You know that when you cut into the body, there's always a

02:06:22.060 fat layer, not in the eyelids. So the eyelid does not have a subcutaneous fat layer. It's the only

02:06:26.520 place on the body.

02:06:27.600 So what's underneath the skin?

02:06:29.040 The orbicularis muscle.

02:06:30.520 Wow.

02:06:30.780 And so there are four causes of dark circles under the eyes. There's visibility of the orbicularis

02:06:36.040 muscle. There's shadowing, which is why you probably don't like your appearance in this

02:06:40.360 kind of situation because the shadowing is visible down here. There's hemocytorin deposition,

02:06:45.700 and then there's hyperpigmentation. So those are the four reasons why people get dark circles

02:06:49.400 under the eyes, and you actually have all four of them. So we would definitely want you to get onto

02:06:54.180 a good quality skincare regimen because it's one of the four areas that needs to be addressed,

02:06:58.840 not only to reverse some changes, but for prevention purposes.

02:07:03.040 And when it comes to volume loss, I think Susan's already picked you a part there.

02:07:07.020 You've got volume loss in the midface. I think your temporal volume loss is enough where if you

02:07:12.540 are going to have some kind of volume treatment, putting a little bit in would be nice. Your left

02:07:17.600 temple sinks in a little more than the right.

02:07:20.080 Oh, okay. Yeah. I'm mostly looking at this side of his face.

02:07:23.020 Yeah. Yeah. The right temple is less hollow.

02:07:24.580 Is that common?

02:07:25.740 Yes.

02:07:25.940 It's extremely common. So when I put that mirror up in front of patients and start pointing out

02:07:30.340 their asymmetries, I'm not kidding, 95 to 99% of the time, people are unaware of their own

02:07:36.060 asymmetries until I point them out to them. And the reason why it's important to point it out to them,

02:07:40.840 because if I'm going to be employed to manipulate their face, they need to know where the starting

02:07:45.440 point was.

02:07:46.360 Do we want to fix asymmetries all the time? Like, does it matter?

02:07:49.660 Sometimes. We don't want to make it worse, certainly. That's probably a big, big factor.

02:07:54.740 And then if there's a way to make it better when we're doing maneuvers, we'll dial that in. Because

02:07:59.000 again, going back to the three biological reasons of why people perceive beauty, it'll make that

02:08:04.400 person look more handsome or beautiful.

02:08:06.540 Okay.

02:08:06.900 And some people do have significant asymmetries.

02:08:09.600 They do.

02:08:09.720 I have ladies, for some reason, where one jawline is aging beautifully and very well defined,

02:08:14.180 and the other one's like a centimeter shorter in length.

02:08:17.380 And Peter has some of the asymmetries too. I mean, his right side of the face, even though

02:08:21.160 you had that injury on your right cheek, your right side of your face is the smaller side

02:08:25.720 of your face. So imagine in utero, we're laying-

02:08:28.620 I had literally no idea.

02:08:30.800 Yes. And the other funny thing is another reason why people feel uncomfortable when they

02:08:35.020 see photographs of themselves is because you're used to looking at your mirror image of yourself.

02:08:39.620 Think about this. Nobody on the planet has actually ever seen themselves.

02:08:44.660 You've only seen yourself in the mirror or you've seen a photograph of yourself. You

02:08:48.780 actually don't really know what you look like in the flesh. And so because there's that discrepancy

02:08:53.360 between the mirror and a photograph, because the mirror is a flipped image of yourself and

02:08:59.080 the photograph is not, that's why people don't like photographs of themselves, especially when

02:09:04.260 they're more asymmetric. So if we measure the distance between the outside corner of your eye

02:09:08.680 to your mouth, it's about 10% longer on your left side because the bone structure is wider.

02:09:15.360 So again, imagine you're laying in utero, you're in the womb, and you're probably spending more

02:09:21.700 time on one side of your face than the other. There's so many factors we can imagine as to why

02:09:25.580 do we get facial asymmetry? It's because of maybe the growth rates were different. Maybe there's a

02:09:30.480 slightly different cytokine difference between the left and the right at six weeks. And maybe you're

02:09:35.580 laying on one side of your face for two months. These are all the reasons why we end up with a

02:09:40.240 little asymmetry. And these things are present at birth and they become more exaggerated as we age,

02:09:46.780 because when you have that devolumization of the fat pockets and the ligaments show up,

02:09:52.740 the underlying bone structure starts to become more visible. And then finally, if we saw some pictures

02:09:58.080 of you when you're 20 and we put them side by side with you right now, even though you have a great

02:10:03.520 jawbone, it's probably lost about 10 to 15% of the volume that you had when you were 20.

02:10:09.280 And so comprehensive treatment would be to volumize either with some fillers or some fat

02:10:15.340 grafting to the areas of volume we talked about, the skincare regimen we talked about.

02:10:20.060 I would probably put some volume along the jaw and your cheekbone because you've lost that

02:10:24.740 projection with aging. We just know that someone of your age is going to have a certain degree of

02:10:29.660 deprojection. How do you put volume along the job? How do you keep it in the area you want it to be

02:10:35.300 without it looking odd and protruding? So the art of fillers and fat grafting is really, truly an art.

02:10:43.800 There's depth of placement, replacing it in the pre-periosteal layer to emulate as if it were

02:10:49.340 a larger bone structure. If you're trying to hide jowling, then you might put it into the muscle

02:10:56.060 layer because you're trying to plump up the valley next to the hill so that it becomes smoother

02:11:00.740 looking. Choosing the right filler? Choosing the right filler. Is fat always a superior filler?

02:11:06.880 Not necessarily. I do like fat because it's your own living tissue. And of course,

02:11:11.940 it has those stem cells in it that can become multiple different types of tissue. So if you

02:11:16.620 place it at the periosteal level, it can build bone. If you put it in fat, it becomes fat. And if you put

02:11:22.480 it along muscle, it can turn into muscle. And if you put it under the skin, it enhances how the skin

02:11:27.660 ages. So something anecdotally, there are many of us that do a lot of fat grafting and we were on a

02:11:33.100 panel one day talking about it. Before we knew about the stem cells being in the fat, we're talking

02:11:37.700 15, 20 years ago. And we're talking about the fat grafting patients and how they all uniformly look

02:11:44.620 like they just age better and their skin ages better. And now you start to realize all of that.

02:11:50.360 Where do you harvest from? Numerous areas of pre-adipocytes, I should say. The tissue that

02:11:56.080 has the most pre-adipocytes is the abdomen. So subcutaneous abdomen. But I really like the

02:12:02.340 flanks because it turns out you don't just want the fat and the fat stem cells. You need all the

02:12:08.180 connective tissue stem cells as well. And when you go to the flanks, the reason the flanks feel so firm,

02:12:13.640 even though they may have fat in them, is they have a lot of septae and sternal tissue there.

02:12:18.760 And when you aspirate the fat, you're also aspirating along with it some of that stromal

02:12:22.780 tissue. So you're getting the matrix and the scaffolding cells that will help that fat also

02:12:28.260 repopulate. And just give me a sense of volume. So if you decided to go full bore on somebody and

02:12:33.800 do temporal and eye and outside of the lip and jaw, how much fat are you putting in and how much fat

02:12:39.920 and tissue do you need to harvest to acquire the necessary volume?

02:12:43.140 So we may differ in our techniques. I'll let Tanoosh speak to his. I will typically harvest

02:12:48.720 about 120 cc's of fat. So we're talking about an area about the size of a small cantaloupe.

02:12:55.360 Just to put that in perspective, if a person undergoes liposuction, how much is being harvested?

02:12:59.860 Usually we're filling canisters.

02:13:01.640 So liters.

02:13:02.460 Liters. Two, three, four liters of fat.

02:13:04.380 Okay. So this is not going to make a material difference in your

02:13:06.880 subcutaneous fat depot in your body.

02:13:08.940 Correct. And if we artistically do it, we can take it from both sides so that you don't have

02:13:13.080 any divots or asymmetries. But people always have an asymmetry even on their body. So I tell them,

02:13:18.320 you know, the benefit of this is I'm taking also the fat and evening you out with your other hip.

02:13:23.120 And they're like, oh, I never even knew I was asymmetric. So I typically harvest about 120 cc's

02:13:29.160 and then we centrifuge it.

02:13:30.660 Yep.

02:13:31.300 And it condenses it down. So it takes off all the anesthetic fluid you put in. We have albumin in

02:13:36.360 there to restore some of the oncotic pressure as well. And we are taking people's own PRP,

02:13:41.900 spinning their blood down to get the PRP, the platelet-rich plasma, adding that in along with

02:13:46.620 something that we call nanofat. So it turns out if you take fat and you graft it into tissue,

02:13:52.500 a certain percentage will take. But if you take fat and then you add in extra stem cells,

02:13:58.580 more of that tissue will take. So what we do is we harvest extra fat and extract the nanofat from

02:14:05.460 that, meaning all the pre-adipocytes, by running it through some meshes and adding that back in

02:14:10.680 to supplement the fat.

02:14:11.820 But it's the patient's own.

02:14:12.700 It's autologous.

02:14:13.780 Everything. The PRP, all of that.

02:14:16.440 Okay. How does your protocol differ from that?

02:14:19.160 Very similar, remarkably. And full disclosure, when I was coming through training in 2005 to

02:14:25.840 2007, finishing up my fellowships, I spent a lot of time listening to Dr. Obagi's talks at

02:14:31.000 conferences. So my fat transfer technique has basically mirrored hers for quite some time.

02:14:35.960 I probably do a little less harvesting, a little less injecting, because most of my fat grafting is

02:14:40.280 being done in conjunction with a facelift or an upper and lower eyelid surgery called blepharoplasty.

02:14:46.220 So when I'm surgically manipulating the tissues, I'm lifting and moving tissues. I'm not in need of

02:14:53.340 as much volume to make the change that we're looking for, but very similar overall.

02:14:57.600 Okay. That gets to the eyelid problem. You alluded to a procedure that lifts the eyelids

02:15:04.740 and doing so presumably makes you require less these frontalis muscles. So are my eyelids a

02:15:12.460 problem?

02:15:13.460 So the short answer is at this point, you would probably qualify for your insurance company to

02:15:18.080 cover your upper eyelid surgery because that's how droopy they are.

02:15:21.180 Holy crap.

02:15:21.980 Yeah. They're sitting on your eyelashes.

02:15:23.940 Yes.

02:15:24.260 This is hilarious. I had no idea how bad I was.

02:15:28.780 Well, we're not saying you're bad.

02:15:29.860 No, no, no. But if you're telling me insurance would cover a cosmetic procedure in me.

02:15:36.420 If we did a visual field test on you where you relaxed your forehead muscles and you were required

02:15:42.000 to look straight ahead and kind of hit a button every time you saw a light flash in your peripheral

02:15:46.820 field and we did the same test with your eyelids taped up, you'd probably have a 30% difference in

02:15:52.340 your peripheral field.

02:15:52.720 So this could be affecting my driving.

02:15:54.860 Probably. You're probably finding yourself having to look a little harder at your blind

02:15:58.920 spot because of that. Now, it becomes a very complicated issue. One of the most common things

02:16:03.680 that we'll see in our practice here in Austin is that patients will come in and say, I think I need

02:16:09.960 to have my eyelids done. And then we say, yes, but. And the thing is, people don't realize that

02:16:16.280 the face is not isolated into individual pieces of anatomy. Your eyelid is connected to your eyebrow,

02:16:22.880 which is connected to your forehead. So if we're going to do an upper eyelid surgery,

02:16:27.620 because you're constantly lifting your forehead muscle to be able to see better, your brain's

02:16:33.160 compensating for this pathology. If we do an upper blepharoplasty, whether it's insurance or

02:16:38.840 cosmetic or whatever, all of a sudden that visual field will improve and your frontalis muscle

02:16:44.140 automatically relax and your brow will come down and it'll create a new problem that you didn't

02:16:50.120 know you had. And so these are some of the conversations we have to have with patients that

02:16:54.800 maybe we leave you alone unless you're also ready to have your forehead lifted or at least have what

02:17:02.560 we call a medical brow lift with Botox. So muscles pull the eyebrows up, muscles pull the eyebrow down.

02:17:09.600 If you preferentially inject Botox into the depressor muscles, which are here and here,

02:17:15.320 naturally the tone of the front else will lift the forehead a little bit, even without wrinkles

02:17:20.380 showing. So I'll tell patients, look, if we do an upper lid surgery, that'll be fine. But we either

02:17:26.780 have to commit to regular use of Botox to keep your eyebrows in check, or we have to do a brow lift at

02:17:33.880 the same time. Where's the incision for the brow lift? Do you do it through the same incision?

02:17:38.620 So I would say that when it comes to designing surgeries, what I train my fellows in residence

02:17:44.400 is that there is no single surgery. Every single surgery is totally custom designed for the individual

02:17:51.420 patient's anatomy. There's general patterns we use, but we should always infinitely manipulate

02:17:57.080 the procedure to achieve the goal of what we're trying to do artistically. In your case, it's

02:18:02.140 complex because someone who doesn't have hair, we usually would hide incisions behind the hairline.

02:18:07.580 It is possible for you to have an endoscopic forehead reset procedure, and we would make the

02:18:13.420 incisions further back and smaller, and it'll be a more technically challenging procedure,

02:18:19.020 but there's a way to lift the forehead with incisions that would not be socially visible,

02:18:24.220 and then those incisions can be closed in such a way that as time goes by, especially with

02:18:29.220 post-surgical treatments like microneedling with 5-fluor uracil and topical treatments,

02:18:33.980 that you can get those scars to become what I call socially invisible.

02:18:37.800 Which, I mean, it just, to me, seems like I could never commit to that much work.

02:18:42.660 You know what I mean? So does that mean I'm just stuck with droopy eyes?

02:18:45.800 Yes. Then in the conversation with the patient, what we would come to, probably in your case, is,

02:18:51.860 okay, we can do a blepharoplasty, which is an upper lip surgery, but we're going to undertreat you.

02:18:57.500 We're going to do less than what you think you need. It's not going to make a huge shift,

02:19:02.980 but on the other hand, we also don't want to change the entire relationship neurologically that

02:19:08.200 your frontals muscle has with your eyelid. So by taking a patient through all the potential

02:19:13.880 pathways, they sometimes recognize they can't get what they thought they were coming for,

02:19:18.280 and we're going to undertreat them, so we avoid a potential problem.

02:19:21.980 And similar things happen with the under-eye area. So your under-eye area is pretty complex,

02:19:26.420 too, because you do have bulging fat visible in the under-eye area, which, by the way,

02:19:31.540 is exactly the same contour that you had when you were 20. It's just become unveiled because you've

02:19:37.440 lost volume and the cheek has descended, and now we're looking at the orbital retaining ligament

02:19:41.400 and the malar ligament. So this line right here corresponds to when you're looking at a skeleton

02:19:46.560 and there's a big circles where the eyes are supposed to be. This is that bottom half of the

02:19:51.000 circle where the ligament is sticking down. So if you put your finger on the skin right below an eye

02:19:56.280 bag, you'll be touching the edge of your orbital rim bone right there. And so from my standpoint,

02:20:02.200 if we're going to do something that is definitive to treat that, it's going to also have to treat the

02:20:07.260 volume issue in your cheek. It's also going to have to address some of the skin textural issues

02:20:12.500 in the region. And then sometimes some people have an issue where there's a triangle that catches

02:20:18.520 between the orbital rim, which is that hollow we were talking about in the under-eye area,

02:20:23.160 and another line that exists in the cheek a little bit lower, and it creates a triangle where fluid

02:20:28.560 can collect. So I don't know if you've noticed that, but you've got that little triangle right here

02:20:32.060 on both sides. That area is called a malar mound. It's kind of like a sponge under the skin. It

02:20:37.700 collects fluid. It's worse in the mornings because we're laying flat and we have a little more edema in

02:20:42.740 our face. If you've had salty food the night before, it'll puff up a little more. People will

02:20:48.580 use preparation H. This is a time-tested home remedy to try to shrink down that swelling that's present

02:20:55.340 there. This would have to be part of what's addressed if we were going to address your under-eyes.

02:20:59.220 And if we were going to do something to address your under-eyes, it would be something that would

02:21:03.660 reduce the bulk of the bag, fill volume in the cheek, smooth the skin out, and address that malar

02:21:11.200 mound. And so this is a common maneuver of what we would do in our practice, which is we would,

02:21:16.440 under anesthesia, make a hidden incision behind the eyelid and take those eyelid fat pads that are

02:21:22.340 making that bag and create a pocket down in front of the cheekbone where the volume loss is occurring

02:21:28.940 and where the ligaments are showing their hollowing and then move that fat down. That's called a

02:21:34.420 transposition lower blepharoplasty. So one of the big changes that's happened in aesthetic surgery from

02:21:41.140 1995 to now is back in the old days of cosmetic surgery, there was a lot of cutting fat out,

02:21:49.300 cutting skin out to make eyelids look tighter, cutting skin in front of the ears to tighten the face,

02:21:55.020 doing surgeries that mostly remove tissue. And now we're becoming much more sophisticated where

02:22:01.340 we're actually manipulating the ligamentous attachments to the bone. And so because we're

02:22:07.040 recognizing the ligaments- You don't have to remove the skin necessarily.

02:22:09.660 We don't have to remove as much, yes.

02:22:11.220 If you do, you can tighten it with lasers and peels.

02:22:13.620 Yes, exactly.

02:22:14.400 So just to conclude what the suggestion would be for someone with your kind of anatomy,

02:22:18.760 we would transpose the fat, which would two birds, one stone, reduce bulk here, add volume here,

02:22:25.420 three birds actually, because it would basically eliminate the visibility of the ligament because

02:22:29.440 there's fat under it now, which is pushing it forward. And then we would do something to improve

02:22:35.120 the skin, as Susan said, either a laser surfacing or a chemical peel. And then there's a new technique

02:22:40.380 that we're using where we're injecting tetracycline into areas of swelling of the face. So this is

02:22:46.380 pretty cutting edge. It's been around for several years now, and we've got pretty good experience

02:22:50.160 with this technique. But tetracycline is an old drug that was repurposed by the pulmonologists

02:22:55.240 to address pulmonary issues where they want the pleura to stick to the lining better. And because it has

02:23:02.240 that property of basically creating fibrous attachments, it can be used to shrink that sponge down by

02:23:08.680 injecting delicately into the maelar mound to kind of flatten it. And so that would be the

02:23:13.100 constellation of procedures. And what can go wrong here? Because I think for many people that would

02:23:19.700 be contemplating something like this, it's one thing if you are having a procedure where, well,

02:23:26.640 first of all, this is a cosmetic procedure. So out of the gate, A, it's not essential. B, if you don't

02:23:32.940 look better when it's done, it's the worst possible outcome. And then C, it's the most visible part of

02:23:38.660 your body. I've heard stories of women who have breast augmentations where they have complications

02:23:43.240 and at least the breasts aren't always visible, meaning the actual skin itself. So even if you

02:23:50.740 have to re-operate and it creates another scar, it's only visible to her partner. But here,

02:23:57.100 it's just the highest stakes game. So how do you navigate complications, risks, and mitigation

02:24:03.480 strategies?

02:24:04.000 And that's what we were talking about before. You have to make sure that whoever's doing your

02:24:08.840 treatments, A, is well-trained, qualified to do the injections, and can manage the complications

02:24:15.080 because everyone's going to have complications. We've had complications. And speaking for me,

02:24:20.180 I'm sure you've seen this.

02:24:21.160 Of course, yes.

02:24:21.900 You can't treat patients and then not do enough cases to not have a complication. But there are some

02:24:27.380 really notable complications that are vision-threatening or tissue-threatening. So when you're

02:24:34.040 treating around the eyes, for example, or even into the temples, there are reported instances of

02:24:38.940 stroke and death and vision loss, including treating around the nose. Because all of these

02:24:45.860 vessels interconnect with the internal carotid system. So anywhere you inject a filler and you get

02:24:52.140 into a vessel on the outside of the skin-

02:24:53.920 You can create an embolism.

02:24:54.860 You can create an embolism. And it's going to go follow the path of least resistance. Once you

02:24:59.080 bolus it into the tissue, it's going to backflow, but then it's going to be pushed forward again. It's

02:25:04.060 going to go to the ophthalmic artery. It may go into your central nervous system, into your brain,

02:25:09.780 I should say, and the vasculature there and create a stroke. Now, some of the more serious strokes

02:25:14.820 were caused by people injecting fat with needles. But all of these other complications really come

02:25:20.180 from injecting fillers in this kind of central face area. So there is a technique. There's

02:25:25.200 knowledge of the anatomy. There's knowledge of how to do very little pressure, aspirate where you

02:25:31.100 need to aspirate, depending on the filler you're using, and watching the tissue, looking for signs

02:25:36.240 of any kind of embolus that's forming.

02:25:38.880 What about the obviously less consequential, but still troubling side effects where, hey, the person

02:25:44.800 doesn't have a good cosmetic outcome. So they didn't have a stroke. They're alive. Their vision is fine,

02:25:49.000 but they don't look better. Something went wrong. What would go wrong? What are the things that go

02:25:53.480 wrong here?

02:25:54.180 I would say the most common types of complications that we'll see either, any surgeon will have

02:25:59.120 complications. I've had complications. In our practices and in my practice, I will see a lot

02:26:03.240 of patients referred in with complications where we have to try to identify how to improve a bad outcome.

02:26:08.880 So the most common reasons why bad outcomes occur in the world of cosmetic surgery, and you're right,

02:26:13.820 the stakes are high, is because either the wrong procedure was done, which is much more common than

02:26:21.020 one might expect, or there was a technical issue where the surgery wasn't done correctly. Those are

02:26:27.000 the most common causes. Now, I will certainly have patients where I will do my very best, and one side

02:26:33.000 will be a little asymmetric, and six months after surgery, you might have to go to the procedure room

02:26:37.500 to do a minor touch-up to kind of enhance things. That's one level of a problem, but when it comes

02:26:43.500 to the more substantial disfiguring situations where people had been quote-unquote botched, is the

02:26:49.320 word people like to use for that, it's usually the wrong procedure was done, or it wasn't done well.

02:26:56.160 I think that that is a very scary topic for listeners to be thinking about if they're even

02:27:01.000 considering going down the pathway of rejuvenation or some sort of plastic surgery procedure on their face.

02:27:07.500 And it can be very confusing because you're getting so much information from marketing and social

02:27:13.960 media, and physicians who perform cosmetic procedures are advertising and showing their

02:27:20.060 best before and afters, and so how does someone figure out how to navigate this? And I would say

02:27:25.040 probably the best advice that we could give someone who's thinking about going down this pathway is

02:27:29.540 you got to take the narrative into your own hands. You have to understand your own anatomy.

02:27:35.360 You have to do a deep dive in understanding some of the techniques, not some, all the techniques that

02:27:41.640 are available to address the issues that are your particular concern. And that might require

02:27:47.000 multiple consultations. It might require choosing good resources online, which are usually society

02:27:54.520 websites. So the American Academy of Dermatology, the American Academy of Cosmetic Surgery, ASPS,

02:28:00.960 which is the Plastic Surgery Society, these society websites will have accurate information on

02:28:06.220 procedures. And you should avoid getting secondhand information from people you know, or from social

02:28:11.680 media. But you got to do your homework, you have to learn the anatomy, you have to understand your own

02:28:17.640 situation and your choices that are available to you. And then it's kind of like analogous to dating and

02:28:24.400 marriage. How do you know when it's the right person? You just know.

02:28:29.880 So let's go deeper into that. If I said, hey, I'm going to introduce you to my friend,

02:28:33.660 she's going to go and sit down with a surgeon. You're not going to do the procedure on her,

02:28:38.860 even though you'd be fully qualified to do it. You're not going to do the procedure,

02:28:42.100 but I want you to be her advocate while she sits in the consultation room. And you can tell her what

02:28:48.460 questions to ask, and you can help her interpret the results. But your job is to help her find the

02:28:54.380 best doctor. What are the questions you're asking? And what are the red flags you're looking for? And

02:29:00.480 what are the green flags that are making you say, I like and trust this person?

02:29:05.280 I think it starts with your rapport with the patient too. You can quickly get a sense with the

02:29:10.900 doctor you're working with if you and he or she can see eye to eye in terms of what you're seeing,

02:29:17.620 what they're seeing, how knowledgeable they are describing the procedures that they're suggesting

02:29:23.360 for you. Does it make sense? Do you really, for example, if they're telling you you need a brow

02:29:27.560 lift and you've seen several other people and no one mentioned a brow lift, maybe you need to think

02:29:32.220 about why did this person mention a brow lift and the other ones didn't? Or if everyone says you need

02:29:37.600 a brow lift and one person says you don't, you have to figure out and go back and look in the mirror

02:29:42.860 and try to understand what they're trying to point out to you as to what makes sense from that

02:29:47.440 standpoint. Is it a comprehensive approach or are they just attacking basically the issue that you

02:29:53.500 have that you're bothered by? I think people should take a comprehensive approach and just at least get

02:29:58.700 that information, even if they don't act on all of that. The person evaluating you should give you an

02:30:03.660 overall look at everything, just like Tanuj did, just like I did, addressing all the different areas

02:30:09.100 that maybe you didn't even know to ask about. On top of that, understanding their strong suit.

02:30:14.020 I don't do rhinoplasty. If I start telling a patient I'm going to do a rhinoplasty on them,

02:30:18.020 they should run. They should ask me, how often are you doing this? What are your complication rates?

02:30:23.500 What is the retreatment rate? How happy are your patients with this procedure? So to everything I do,

02:30:29.020 I can show them my before and afters. I can tell them and I show them multiple, for example,

02:30:33.520 a facelift. I'll show them different faces because everyone has a different shaped face. You can't get the

02:30:38.720 same result depending on their anatomy. So I'll show them different things. I'll say,

02:30:42.000 now this one looks more like your neck and your jawline. This is kind of the result you can

02:30:46.380 hope to get. And I tell them the complications in my hands. I tell them the overall complications,

02:30:51.320 but I tell them in my hands, this is what I see. And it's one of the challenges, by the way,

02:30:55.740 that's exactly what I tell people in general when they're interacting with surgeons is it's one thing

02:31:01.020 to know the complication rate when you're getting a colonoscopy. It's another thing to know their

02:31:06.100 complication rate and their patient population, because it's not always the case. For example,

02:31:10.620 if you're having cardiac surgery, a low complication rate isn't always a great thing.

02:31:15.220 It might mean low complexity. It gets more complicated. Anything you would add to that,

02:31:19.480 Tanuj, as far as questions that they should be asking or red flags or green flags?

02:31:23.620 I agree completely there with what Susan said. And maybe some additional things to add, which

02:31:28.960 some of these things matter more than others. But I think having had the right training and board

02:31:34.400 certification is one level that should be met. Whoever is doing your procedure should have more

02:31:41.920 certification in the specific area. Yes.

02:31:46.040 So sorry, just interrupt. For eyes, what percentage of people doing eye procedures like a lift,

02:31:51.800 a blethoplastically would be oculoplastics trained? Is that a rare thing? Is that uncommon or

02:31:57.300 common?

02:31:57.540 It's the most common procedure that an oculoplastic surgeon would do.

02:32:00.600 But how many non-oculoplasticians would do that procedure?

02:32:03.900 A lot. In 2025, there's so much more overlap that's happening than what used to exist, because

02:32:10.540 each field that has an aesthetic aspect to it, we're talking about dermatology, plastic surgery,

02:32:18.200 ENT, ophthalmology, or maxillofacial surgery. These are the most common specialties that have an

02:32:24.700 aesthetic overlap. The aesthetic focus in these training programs has dramatically ramped

02:32:30.580 up in the last 20 years, where part and parcel of these training programs include aesthetic

02:32:35.980 surgery. But in addition to all those birth certifications, I think that experience matters.

02:32:42.420 What's the minimum number of procedures you want to see done by the practitioner in a year to say,

02:32:48.380 yep, you've got enough reps?

02:32:50.020 It really depends on the procedure.

02:32:51.860 Okay. For a rhinoplasty, something like that.

02:32:54.460 For a rhinoplasty, you're going to want to have someone who's at least doing 25 a year.

02:32:58.200 Okay. For a facelift?

02:32:59.540 For a facelift, you want someone who's doing at least 25 a year?

02:33:02.460 I think it also is going to matter how many other procedures they do, too. Someone who's doing face

02:33:07.440 and body might be doing a lot of body liposuction. So they're doing facelifts, but they're doing also

02:33:12.780 body lipo. Maybe they're doing eyes, all of that.

02:33:16.380 Do you want generalists or do you want specialists? If you're going to get something done to your face,

02:33:20.720 my intuition, which could be entirely incorrect, is I don't want them doing breasts and butts and lipo.

02:33:26.300 Like, I want them to be maniacally focused on the thing that I want them to do to me.

02:33:31.660 So I would say in my practice, I do five things, for example. I do those five things a lot. But I

02:33:37.260 don't do only one. And you don't do only one, even though your oculoplastics and your facial

02:33:42.360 plastics as well, though.

02:33:43.640 Yes. I generally agree with what you're saying, is that I don't do any body surgery. So I'll refer

02:33:48.620 that all out to people who specialize in that. And most people who do body cosmetic surgery will

02:33:53.400 focus on body cosmetic surgery, because facial cosmetic surgery is a different animal altogether.

02:33:59.280 So I think that that kind of specialization matters. Look, I was a young surgeon once,

02:34:05.280 and certainly going to a surgeon who's right out of training can be fine for a limited,

02:34:12.000 isolated procedure. But I'm sorry to the young physicians in the audience, but a few years of

02:34:17.160 training is usually helpful in building your repertoire and experience to be able to handle

02:34:22.460 complications. And sophisticated listeners would probably naturally end up choosing more

02:34:27.500 experienced surgeons for that reason. And I think another important thing is that this is a creative

02:34:33.820 specialty we're talking about. And so you want to choose someone who is evolving and moving with

02:34:41.700 the times and preferably is helping to advance that edge of medicine. That means that they're

02:34:47.360 constantly thinking and questioning and improving their results and not resting on laurels and not

02:34:53.440 stagnating in one particular way of performing a procedure. I think that's a very, very important

02:34:58.900 aspect of trying to identify someone.

02:35:01.340 So in that sense, do academics, because you would normally not associate cosmetic surgery with an

02:35:08.120 academic affiliation. You would normally say, well, I get it. If I have an oncologic issue,

02:35:12.540 there's an advantage to being in an academic setting because of the research and because of

02:35:17.440 the affiliation with the other branches of oncology, et cetera. You can come up with some,

02:35:21.440 but you don't always think that way about people doing cosmetic surgery. But what you're saying

02:35:25.720 would probably fit more neatly into the box of someone with an academic affiliation.

02:35:31.540 I agree. And the interesting thing about aesthetic surgery is that it's a little bit of the black

02:35:37.620 sheep in the world of medicine. So academic cosmetic surgery, academic plastic surgery is different

02:35:44.480 from the traditional sense of what academic might mean. So in the world of facial aesthetics,

02:35:50.140 you can have a single surgeon in private practice, no university affiliation, who's 100% academic

02:35:57.540 because they are publishing, they're going to meetings, they're lecturing, they are helping to move

02:36:03.980 the dial in the artistic world of what we're doing in facelifts or eyelid surgeries or brow lifting.

02:36:10.760 It might be someone who's at a university full-time, but it doesn't have to be. And that's very unique

02:36:15.620 to aesthetic surgery.

02:36:17.460 I also think that the universities don't support their aesthetic doctors. So a lot of times universities

02:36:23.000 cannot figure out a model that works for them to profit share or to find a compensation model for

02:36:30.360 an aesthetic doctor that's appealing to them to make them not go into private practice.

02:36:34.280 So they end up shortchanging themselves and then the doctors leave and they go into private practice.

02:36:39.440 Whereas I think if you can get the universities to wrap their head around how to build out a really

02:36:44.660 strong academic practice like we did with our university at the University of Pittsburgh Medical

02:36:49.640 Center, we were rare. We were one of the first in the nation to purposely build an academically-based

02:36:55.460 cosmetic surgery practice with the intention of training plastic surgery residents if they want

02:37:00.060 to rotate oculoplastics, facial plastics, dermatology residents, and people from around the world.

02:37:05.380 I mean, it makes a lot of sense because of the amazing overlap between surgery in general,

02:37:11.780 especially oncologic surgery and reconstruction. Like if you think about it, every time a woman

02:37:16.940 undergoes a mastectomy, she should be immediately plugged into a plastic surgeon

02:37:22.660 to, if nothing else, make sure that that reconstruction is as cosmetically pleasing as

02:37:28.380 possible. And then you think about all the head and neck cancers and things like that. There's a

02:37:31.500 clear incentive, maybe incentive is the wrong word, just if nothing else, a business case to be made

02:37:36.980 for better patient care with the integration of that type of service.

02:37:41.460 The universities can't see that though. The problem is they think it's a one size fits all and

02:37:45.520 they don't understand the differences. Like for example, your cosmetic practice has to have

02:37:50.500 a more aesthetic look. It's going to cost them more to build it out. They're going to need the

02:37:54.420 devices. They need investments. And it's really hard to get some of these universities to see that.

02:38:00.420 You have to work with them and become your own business manager, for example, and propose to them

02:38:05.240 a business plan, return on investment, all of that.

02:38:08.280 But practically speaking for the listeners, if you're trying to find someone to help you on a path

02:38:14.540 in this category of aesthetic surgery, finding someone who is speaking at conferences, teaching,

02:38:21.020 involved in the cutting edge of medicine, I think that's definitely a qualification.

02:38:24.740 I think another thing that you mentioned earlier is maybe asking them how often they are receiving

02:38:30.480 complications and managing them. That's probably a sign of skill and seniority in the field. If you're

02:38:37.680 kind of the person who's, again, it's not about calling out who those complications belong to,

02:38:41.940 but it's, hey, you know, okay. So we've talked for a lot longer than I thought we would, but I'm sorry

02:38:47.920 if we can get you to hold on for a minute longer. We can't get out of this podcast without me

02:38:52.160 understanding the difference between lasers, micro abrasions, micro needling, chemical peels.

02:38:58.620 I can't understand any of these things, but you mentioned resurfacing. You mentioned my skin sucks.

02:39:05.920 So clearly before I go on the path of my rejuvenating anti-aging protocol, I might as well do something

02:39:15.120 to fix the situation we have going on here. We could do a crash course. I know this podcast is

02:39:21.080 running long, but it's just a massive subject to cover. Let's start with lasers.

02:39:24.860 Could we take one step back maybe and talk about the difference between ablative and non-ablative,

02:39:29.900 and maybe you talk about peels. So maybe the way to go is there are various technologies

02:39:36.100 that will, in a controlled manner, injure the skin to harness the body's natural healing cascade,

02:39:45.080 which then will produce the aesthetic benefits we're looking for, which is more collagen production,

02:39:51.260 smoother skin, less pigment issues. And that's the goal. And so the bottom line is there's a

02:39:58.040 relationship with how aggressive the treatment is and how much of an aesthetic improvement you're

02:40:01.780 going to get. But the more aggressive it is, the more downtime there is. So that's always the

02:40:05.860 balancing act. And that's why there's such a confusing array of options that exist, because

02:40:11.320 there's a huge spectrum going from the least invasive, which has least result, to the most

02:40:17.620 aggressive with the best result. And so I guess to generalize, there are treatments that are not

02:40:25.280 truly ablative, meaning they're going to penetrate through the skin. And then there are treatments

02:40:30.900 that are. I think hopefully I set that up for you, Susan, to maybe go from there.

02:40:34.880 So that's the definition. Ablative means it penetrates the skin?

02:40:37.780 Yes. Ablative, yes. And non-ablative doesn't penetrate the skin.

02:40:40.680 So what are the non-ablative, which are presumably the less severe, which means shorter recovery time,

02:40:46.700 less overall response?

02:40:48.340 So non-ablative things, you can start with even your topical skincare regimen,

02:40:52.220 because that is going to remodel the skin and set the stage for you to even prime it so you make

02:40:57.700 more collagen. And then you can do things such as light chemical peels, which are only going to

02:41:04.560 affect the epidermis of the skin. You can do things like non-ablative fractional lasers.

02:41:10.720 And those are going to, again, send tiny fractionated beams of light onto the very surface of the skin

02:41:16.920 and just damage the upper layers of the epidermis. And that's going to stimulate a cascade of cytokines

02:41:23.280 to build on the collagen and texture, but it's going to be minor. And they might help with some

02:41:29.020 minor pigmentation issues. Those are non-ablative devices for resurfacing.

02:41:34.480 What was the last one?

02:41:35.540 Non-ablative fractional lasers. We also have non-ablative vascular lasers. Those are lasers that

02:41:41.320 are going to penetrate with a beam of light to hit the dilated blood vessels in people who have

02:41:46.660 rosacea.

02:41:47.940 What's the brand name on one of a non-ablative fractional?

02:41:51.360 FRAXIL or clear and brilliant. Within those, there are different ones. The FRAXIL has multiple

02:41:56.420 different ones. Clear and brilliant is just superficial. And then you have non-ablative

02:42:01.380 things like vascular laser that will help treat broken blood vessels, scars, texture change.

02:42:07.680 And that one, even though it's shattering some of the dilated blood vessels deep in the skin,

02:42:12.460 it's not leaving an open wound on the surface. So when we say non-ablative, there might be things

02:42:17.100 happening deep down, but the surface of the skin is intact. So there's no raw wound.

02:42:22.100 We might want to pause on that category for one second, just because that is probably one of the

02:42:26.840 most high-yield areas for someone to try out as an initial intervention with a physician or provider.

02:42:34.820 Because the downtime is easy, we're talking about non-ablative, for example, intense pulse

02:42:39.880 light or broadband light, which is IPL or BBL for short. Those are in the category that Susan just

02:42:46.300 mentioned of non-ablative light treatments. And it's a huge, huge category. There are so many devices in

02:42:54.320 this category that it would be kind of silly to even list them, but they're very effective in that they

02:42:59.520 don't have a lot of downtime and produce improvements that are real for patients.

02:43:04.580 Sorry to interrupt. I thought we should just pause there for one sec.

02:43:07.600 Absolutely. And I think a lot of them work.

02:43:09.900 Moxie is another non-ablative.

02:43:11.840 I'd have to look and see what the technology on Moxie is. If I'm not mistaken, I think that one

02:43:17.040 might be radiofrequency microneedling.

02:43:19.820 I think that's right. Yeah.

02:43:20.880 Yes.

02:43:21.320 That kind of bridges the gap a little bit.

02:43:22.980 It depends. It is semi-ablative because you're literally piercing the skin with a bunch of needles

02:43:27.920 and delivering radiofrequency energy through those needles. And those will stimulate collagen. So

02:43:34.060 anything that generates heat in the skin to a certain level, to a certain temperature, I should

02:43:39.120 say, will then cause the formation of something called heat shock protein. And that causes a whole

02:43:44.860 cascade of other activity within the dermis of the cells, the dermis of the skin,

02:43:49.160 to make you produce collagen, elastin, shrink the overactive sebaceous glands, and reduce some of

02:43:57.160 the dilated blood vessels. So there is a lot of benefit beyond just treating the vasculature that

02:44:02.400 you see. So I tell patients, like, for example, if we treat their rosacea and they get improvement

02:44:06.860 after two or three sessions, they should come every year and repeat it, even if their rosacea is quiet,

02:44:11.880 because it really does help with anti-aging. And so from that standpoint, those are your non-ablative.

02:44:17.060 And if we go to ablative, we've got deeper chemical peels. We've got the modified TCA peels.

02:44:23.120 We've got modified phenol peels.

02:44:25.700 So we don't need to worry about brand names at this point. We're really talking to the

02:44:29.300 practitioner and saying, do we want to move into an ablative peel? I'm going to get a better result,

02:44:34.500 but I'm going to have a greater downtime. Presumably, I need to do it less frequently.

02:44:38.540 Yes. And that's exactly it. What you said is key. I think the big mistake is to come in and say,

02:44:43.660 oh, all my friends are having moxie. I want moxie. Let's talk about what it is. We might

02:44:48.280 have something that does similar results, or maybe even something that does better results.

02:44:52.820 Or maybe it's not the right choice for you, even though your friend thinks you should get it.

02:44:56.600 And so the field is so confusing to consumers, and honestly, even practitioners, because it's a

02:45:03.060 gold rush. There's so much money to be made in this area. Every company is getting private equity

02:45:09.760 money and getting an FDA approval for some kind of device because they want a piece of the action.

02:45:13.800 And they're purposefully confusing everybody because it's like snake oil. Everybody wants to

02:45:19.040 sell their product. And some of the products work well, some don't.

02:45:23.100 Any products you think people should just absolutely avoid, just based on lack of efficacy?

02:45:28.240 No, but I do caution my younger patients, the ones who are under the age of 40,

02:45:32.820 even up to 45 in some cases, to really avoid doing things such as ultrasound tissue tightening,

02:45:40.460 radiofrequency tissue tightening at that young of an age, because there is some fat atrophy that

02:45:45.500 happens. And I would caution against prematurely aging their face.

02:45:50.060 Yeah, I agree. I mean, those are the categories that are probably have the most hoopla with the

02:45:54.900 least effect is ultrasound-based energy. And look, I mean, there once was a time where that was the only

02:46:00.140 non-surgical option for tightening the neck, but it didn't do a great job. And most people have left

02:46:04.740 it by the wayside.

02:46:05.780 I like it though, in addition to a bio-stimulatory filler. So you inject a little sculpture under the

02:46:11.400 skin and then you come over it with a ultrasound.

02:46:14.440 Synergistic properties could exist for those devices.

02:46:16.940 And that's what I was going to say. If you know your physics with all these devices,

02:46:20.900 you can achieve so much with your lasers beyond what the company tries to sell you.

02:46:24.980 How do you then decide, I understand the fork in the road between ablative and non-ablative,

02:46:29.500 but let's say once you commit to an ablative therapy, how are you deciding between a chemical

02:46:35.600 peel, a laser, a microneedle? And I vaguely remember my wife telling me something or overhearing

02:46:42.800 her and her friends saying that if you had melasma, you couldn't do this one, but you could do this one.

02:46:49.840 What are some of the do's and don'ts as you navigate that?

02:46:52.480 There are a lot of nuances to this conversation, but to generalize a little bit,

02:46:56.660 chemical peels are generally safe for all skin tones, generally. Laser resurfacing,

02:47:03.540 ablative laser resurfacing can be riskier for higher Fitzpatrick skin types that have more

02:47:10.940 pigmentation because the melanin cells are sitting deeper in the skin. And the deeper the laser goes,

02:47:17.020 the more it can create permanent injury to pigment cells and create permanent pigment problems.

02:47:22.860 Whereas the chemical peels, you can control that depth a little differently. And so that's one,

02:47:27.600 I would say, generalization that's probably worth mentioning.

02:47:30.600 So I should not do a laser peel?

02:47:32.860 You can have a laser, but you're the kind of person who needs a lot of preparation and caution

02:47:37.380 heading into it. You would need to probably get onto a regimen to control your pigment cells with

02:47:42.260 hydroquinone.

02:47:42.660 So why would I bother? Why take the risk?

02:47:45.060 Because the results could be better.

02:47:46.720 I see.

02:47:47.320 I guess just to complete the conversation about the different categories,

02:47:51.180 the most effective non-surgical skin interventions are in the category of ablative lasers

02:47:58.420 and phenol peels because they go the deepest.

02:48:01.500 And TCA. I'm going to have to throw that in there.

02:48:03.380 TCA, sure.

02:48:04.000 TCA peels.

02:48:04.960 Deep TCA peels are something that should be done by someone who really knows what they're doing.

02:48:08.460 So going to your point, how do I choose? Sometimes on the same patient, I'll do all three.

02:48:13.540 So on most of their face, I may do a medium depth TCA peel, especially because I can get the ears,

02:48:19.940 I can get into the brows, I can feather onto the neck, into the hairline.

02:48:23.460 So I don't leave any area unresurfaced. And the medium depth peels are going to go

02:48:28.100 just to the level of what's called the papillary dermis, which is the sweet spot

02:48:31.960 for tissue tightening. And peels of that sort.

02:48:35.000 And this is TCA or phenol?

02:48:36.440 TCA. And these peels penetrate and they percolate into pores. So I love peels for large pores.

02:48:43.040 You'll see the solution sit in the pores and they'll just go a little bit deeper just in

02:48:47.260 those pores. And as the tissue heals, they'll contract. Then I may take a patient who has very deep

02:48:52.940 perioral lines and use my fractionated ablative CO2 laser on those. And then someone with redundant

02:49:00.600 skin on the lower eyelids, I may take my phenol peel and apply it there. So in one sitting,

02:49:06.300 the patient might have all three, but I'm going to pick and choose where I do it.

02:49:09.820 In some patients, I may, depending if they don't want an eye lift or I did an eye lift on them

02:49:14.400 a number of years ago and they're just starting to get redundant skin, I may just ablate that tissue

02:49:19.640 with either my laser or the phenol peel and get a mini eye lift again that might buy them two or

02:49:24.960 three more years. What is the downtime from an ablative intervention?

02:49:29.580 Every treatment is customized to the patients who can vary, but in general, a patient who's going to

02:49:35.000 have an ablative CO2 laser, which I would say is the relative gold standard for an ablative laser,

02:49:41.340 is going to have seven to 10 days of requiring an occlusive dressing with some kind of ointment.

02:49:48.220 That's a real downtime there. And then from weeks one to three, their skin will be transitioning

02:49:55.020 and epithelializing. They'll start to return to normal activities, but they'll still scare

02:49:59.540 children at a grocery store for three weeks.

02:50:01.860 Because they'll be red.

02:50:03.000 A lot of redness and swelling still. And then beyond three weeks, they can use concealer,

02:50:09.440 which we actually encourage them to do because it's a built-in UV protection also. And they can

02:50:13.620 kind of get back to life. But without makeup on, some people can have redness for months.

02:50:19.100 Expect this person to do this procedure how often?

02:50:22.000 This might be once every five or 10 years to have a full ablative CO2 laser.

02:50:26.500 Is it uncomfortable?

02:50:27.700 If they're awake, it can be. These can be done under some sedation. It's also quite common these

02:50:33.140 days to have these done with a nitrous delivery device. So there are now FDA approved devices that mix

02:50:38.240 oxygen and nitrous so that it can be done in the office without an anesthesiologist because

02:50:43.200 they're getting 50% oxygen, but yet they're getting the benefit of the nitrous as well.

02:50:48.080 Like laughing gas.

02:50:49.000 Yes.

02:50:49.240 Pronox.

02:50:49.920 Exactly. Yes.

02:50:51.080 I mean, that sounds absolutely unappealing.

02:50:53.660 I also painted the picture of the most aggressive skin laser that we do. And of course,

02:50:59.260 it can be dialed down like if a patient has a certain timeframe in mind.

02:51:03.140 All right. So what would I do? I mean, a week offline would be tough. Doable, but tough.

02:51:07.460 Certainly three weeks, four weeks offline, not an option.

02:51:10.720 So one thing that is useful information is that some of the lasers that are still ablative,

02:51:17.200 but are dialed down in their intensity. So now we're talking about fractionated

02:51:20.740 lasers at lower intensity. They can have a downtime that's a week or less, more or less.

02:51:26.820 And then it's not going to produce the same results, but the effects stack over time. So if

02:51:32.100 you committed to doing a light erbium laser, and the reason why I'm talking about erbium laser instead

02:51:38.940 of a CO2 laser is because the erbium lasers tend to burn with a little less heat, thermal injury. And

02:51:45.180 so the recovery is a little bit faster. If you committed to doing this once a quarter,

02:51:49.960 as time goes by, you would get a similar effect to the full blade of CO2 laser that you can do in

02:51:55.180 one sitting. And I would also say that you can manipulate other things. So like we'll take a

02:51:59.720 clear and brilliant laser and apply a light chemical peel solution on top of that the same

02:52:04.920 day. So two non-ablative therapies. Correct. And then you get like three or four days of peeling,

02:52:09.440 and then you're done. And someone like you, because you're a male, you have thicker skin,

02:52:13.760 you need us to push it a little more than just what the clear and brilliant will do or the light

02:52:18.160 peel by itself. But synergistically, they can have a nice effect. And over time, there'll be cumulative

02:52:23.320 improvement in your skin, especially if you follow your home regimen. But what I would tell people

02:52:28.900 like you, Peter, is that really think about it hard and embrace this investment in yourself because

02:52:35.540 you do everything else right. You eat, you exercise, you watch the sun. It's much, much better to do this

02:52:44.640 now at your age than to wait five or 10 more years and say, I wish I had done it. Because at that point,

02:52:50.880 what you need might be a lot more drastic. And to maybe bring this full circle, Susan,

02:52:55.840 I know we're concluding the podcast here now. Beauty and aesthetics is an integral part of being

02:53:01.440 human. And that's why we're even having this conversation because people really want to know

02:53:06.580 how to navigate this world of aesthetics and choosing to make changes that are appropriate

02:53:13.220 for your situation that has the potential of increasing quality of life. Humans, as we age and

02:53:19.320 live longer and longer and longer, you may have someone who's 60 or 70 years old who's following

02:53:25.000 Peter Atiyah's regimen. And they're out there playing golf, living their marginal decade in the

02:53:31.160 way they want to. But they also care about their appearance. I mean, you've seen this, right, Susan,

02:53:35.780 that I have patients who are 94 years old, who are coming in for skin cancer reconstruction after

02:53:41.420 Mohs surgery. And you're not thinking at all about putting your aesthetic hat on. I'm now a

02:53:45.880 reconstructive surgeon. This 94-year-old woman is terribly concerned about what it's going to look

02:53:51.500 like afterwards. That desire to limit the delta of the self-discrepancy theory for ourselves

02:53:58.500 continues until we're no longer on this planet. Well, guys, thank you very much. This was

02:54:04.840 fantastic. And honestly, accomplished goal number one, which is I feel like I have a greater

02:54:09.940 understanding of the solution space. Again, I think I'm going to probably have you guys send

02:54:18.740 me a few links on some of the serums and cleansers. And I guess I need to get a prescription for some

02:54:24.460 Retin-A or steal my wife's. I'll double check my sunscreen. I know that my sunscreen that I use

02:54:32.080 when I'm going outside for prolonged periods of time, my Ulta MD is a good one. I don't think I have a good

02:54:38.820 daily throw it on just because I'm indoors even, and I'm going outside for five minutes here and

02:54:43.900 there. I need to double check on that. So I think that's a win. I guess if I do nothing but commit

02:54:49.180 to a daily skin routine, that's great. I will admit this whole ablative, non-ablative skin thing

02:54:55.340 has me a little shaken up and now reeling in the idea that I just don't know if I have the intestinal

02:55:02.060 fortitude to go through with an ablative therapy. But maybe I start with some baby steps, like two

02:55:07.780 non-ablative therapies. And then I think we're going to have to think about, do I want to fix my

02:55:12.580 face? How far down the rabbit hole do I want to go with the under eyes, over eyes, and all that

02:55:18.500 stuff? But the point here is I have a better understanding. And I hope that more importantly,

02:55:22.300 the people listening are able to see bits of themselves in me. I think I'm not that uncommon

02:55:27.280 in my problems. So hopefully they've been able to pick up on these things as well. So thank you very

02:55:32.140 much, guys. This was a different podcast, nonetheless. It was super interesting for me.

02:55:36.460 Thank you. Thank you for having us. It was fun. And we didn't mean to pick you apart.

02:55:40.860 I asked you to, so no, it was fully appreciated.

02:55:42.980 Thanks, Peter. We appreciate the opportunity to be here and have this conversation.

02:55:46.720 Thank you for listening to this week's episode of The Drive. Head over to

02:55:50.800 peteratiamd.com forward slash show notes if you want to dig deeper into this episode. You can also

02:55:58.480 find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us

02:56:04.480 review on Apple podcasts or whatever podcast player you use. This podcast is for general

02:56:10.520 informational purposes only and does not constitute the practice of medicine, nursing,

02:56:14.400 or other professional healthcare services, including the giving of medical advice. No

02:56:19.360 doctor-patient relationship is formed. The use of this information and the materials linked to this

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02:56:30.980 professional medical advice, diagnosis, or treatment. Users should not disregard or delay

02:56:36.120 in obtaining medical advice from any medical condition they have, and they should seek the

02:56:40.540 assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts

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02:56:51.520 please visit peteratiamd.com forward slash about where I keep an up-to-date and active list

02:56:58.220 of all disclosures.

The Peter Attia Drive - June 30, 2025

#355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance ｜ Tanuj Nakra, M.D. & Suzan Obagi, M.D.

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