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

Episode Date: September 3, 2018

This episode explores the question of how we can maintain a naturally youthful look as we get older. Brett — a New York City oculofacial plastic surgeon who specializes in both non-surgical and surgical cosmetic and reconstructive procedures of the eyes and face — shares some remarkably practical advice on everything from the most extensive procedural options, down to the simple steps one can do themselves, starting today, that can make a tremendous impact. Brett also discusses how to pick a provider you trust while you’re sorting through the ever-growing list of facial treatments and cosmetic procedures. We discuss: History of medical training that led to Brett’s current interests [5:00]; What changes occur that make skin look older over time? [8:00]; How to avoid the “unnatural” look associated with cosmetic surgery [17:00]; Facial augmentation, fixing eye-bags, and picking the right provider [22:15]; Common botox mistakes, and how to do it right [37:30]; Protect and rejuvenate your skin with these 3 main tools [46:30]; Latest trends in cosmetic industry, botox, cryolipolysis, the various forms of facials, and PRP [1:05:00]; Importance of picking a provider you trust, rather than a device you want [1:31:30]; Future of the cosmetic field [1:33:00]; and More. Learn more at www.PeterAttiaMD.com Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Atia Drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peteratia-md.com.

This podcast episode, I'm speaking with my friend Dr. Brett Kotlis. Brett is a New York City-based eye and facial plastic surgeon who specializes in cosmetic and reconstructive surgery of the face, but particularly specializing around things to do with everything with the eyes, including the skin around the eyes. He's trained both in general ocular plastic surgery and general cosmetic surgery. I met Brett about three years ago and I still remember our first meeting.

We met for the first time when he just came by my office at some point and we sat around having coffee and as he walked me through not just his training but which is actually quite unique, but also his particular approach, I realized we were kind of kindred spirits in our appreciation for nuance. As you'll learn in this episode, I know pretty much nothing about looking good and skin and eyes and all that stuff.

And in many ways to spend time with Brett is to spend time with someone who thinks a lot about how to make small and subtle changes over time that lead to long lasting effects. And I think the reason that resonated so much with me is my belief in longevity, of course, is that it's a compounding issue. And therefore, making small but consistent changes that lead to seemingly small improvements over the short run is actually what leads to amazing results over the long run with respect to the reduction of risk of disease, et cetera. Bret's approach to Cosmosis is the same way. And I suspect that my bias is probably what has me thinking that that's really the right

way to do it. And once I got to know Brett better, and we started to collaborate and work together, and I've sent a number of patients to Brett, I was always amazed by the responses, because to me, the right way to, for example, do Botox is to be able to look at a patient after the procedure and say, I didn't know you had Botox.

And so, things that we talk about here are a bunch of things that you can do to make a huge impact on the health and vitality of your skin. And he does get into a number of these things specifically around Botox. He also gets into a growing list of sort of all the facial treatments and cosmetic procedures that are out there, lasers, peels, all of these sorts of things. And most importantly, I think he also helps you as the listener think about how to pick someone, because again,

many of you listening to this might find this stuff interesting and sure, if you happen to be in New York and you wanna meet Brett, that's great, but most likely you're not. And so the more important question is, how do you sort of separate the good from the great or even the great from the not so great in this space? So again, like I said, I don't think a lot about this personally.

I realize I should probably think about it more when I look at pictures of myself today versus pictures of myself. When I was 30, I am sort of surprised at how much I feel like I look like I've aged. And I guess part of this was a bit of a wake up call for me that I might need to pay a little more attention to that. If for no other reason than just to have the optionality to look a little better when I'm 80, then I'm probably on the course to looking. Brett does a great job here explaining why our faces change over time, what he considers

the three most important tools for skincare and rejuvenation. He gets into all the procedures, as I mentioned, the lasers, the peels, the needles, the devices. I really enjoyed his discussion of the right way to do Botox because I'd heard this before because, of course, Brett and I had discussed this a lot, but I'm glad we were able to sort of revisit that for people here. And he also talks a little bit about the current trends and future trends of cosmetic and plastic surgery.

You can follow Brett on Instagram. He's Dr. KotlisDRKOTLUS, where he puts up lots of before and after photos, especially around the eyes, which I find particularly interesting. That's something about my self that I've always been curious about making better. And his website has the same URL. Lastly, you can see some stuff in the show notes here. I asked for Brett to give us kind of his recommendations on products that he suggests that his patients get that if anyone is interested in, they'll at least be able to sort of get that. You can see that at peteratiamv.com forward slash podcast.

So without further delay, here's my conversation with Dr. Brett Kotlis. Well, I'd like to welcome to the show today, Dr. Brett Kotlis, who is an oculo plastic guru and also a close friend of mine. Brett, we met what about three years ago? I would say maybe it's two. Okay. Yeah, it just seems like we've known each other a long time. The first time we met, I remember being really impressed by kind of the nuance of your training. I tend to think and talk a lot about longevity, but I don't tend to think and talk a lot about,

or know anything about looking younger. And you have learned enough a lot about that. So remind me, how did you train? What was your medical training? When I was in medical school, I was drawn to this specialized field that was sort of a cross between ophthalmology and plastic surgery. And it's called ocular plastic surgery. I was watching this doctor do an orbital tumor resection. And so I decided this is what I want to do. And I learned that I needed to do a residency in ophthalmology before I can do a fellowship

in ocular plastic surgery, which the field basically revolves around the eyes and the face and plastic procedures related to that. So I found out that I had to do an ophthalmology residency first. So I did that. And then I matched in this training program, the match process is sort of like the medical matchmakers and you are assigned to a program based on a ranking system, which you've been through that as well.

And I matched with this doctor and Tucson who happened to have transitioned his practice into cosmetic surgery. And so when I arrived, I thought I was going to be doing mostly orbital tumors and tear duct surgery and eyelid reconstruction. And that was part of what we did. But we were also doing a lot of facelifts and fat grafting and liposuction and lasers.

And so my fellowship training qualified for two different organizations, the American Society of Oculopathalmic Plastic and Reconstructive Surgery, and then also the American Academy of Cosmetic Surgery. So when I finished my fellowship, I ended up working in this practice in Michigan. That was the largest medical spot in the Midwest. And it was an exposure to even more lasers and more technology that was on the cutting edge of what doctors are doing for our appearance. I remember one of the things that really surprised me when we spoke

was just understanding that basically anybody with an MD can hang a shingle and do kind of whatever the heck they want with respect to facial plastic stuff. I mean anybody can be injecting Botox and fillers and all of these things and Of course not everybody's doing this stuff well and not everybody's doing this stuff with the eye towards How will this look down the road right and I think? Your approach seemed very nuanced and sophisticated. So I hope to certainly touch on that today, but I kind of want to start with some just fundamentals. So I saw a picture of myself 20 years ago, meaning I recently saw a picture of myself from 20 years ago.

And I was like, God, you were like a better looking dude back then. Why is it that at 25, I looked better than 45? And part of it, I think, is just my skin looked so much better. So even though by most people standards, I'm not an old guy today, clearly my skin doesn't look like it used to. What has changed? It's interesting because there does happen to be a double standard for men and women,

and we have the benefit of looking more distinguished as we age. So I don't think all men feel that way that we're looking worse as we age, but we certainly where faces are changing. And there are some aging changes that are intrinsic and some that are extrinsic, right? So your genetics, your program to have certain changes over your lifespan, right? You're, we lose bone as we age, which happens in our faces. We are losing facial fat as we age and in some ways we're losing it in maybe the wrong places and the sun that we're exposed to over many, many years causes something called solar elastosis.

So we are losing collagen in elastin. The thickness of our skin is decreasing in many areas. And we're also gaining small blood vessels, the telangetages, and we are gaining brown spots and the combination of these things on every layer. Your skin, your fat, your muscle, your bone, the ligaments that connect the interplay between these layers are all losing support, and they're getting thinner, and they're degrading.

So from the time that you're born until now, you started off with really chubby round cheeks. You look at your one-year-old son and it's all downhill from there. Now, there seems to be something about the face in particular. So I used to swim a lot and I used to swim outdoors, obviously. So I'd spend sometimes six or eight hours just swimming in the ocean. And I didn't even bother putting sunscreen on because I have dark skin, I have olive skin, I never get sunburned. So I'm pretty used to being the guy that's getting a ton of sun, and while I accept that that's probably caused some damage to my face, why does it not seem to have caused that same damage to say my back, which was even more exposed to the sun when I'm swimming

in a prone position. Well, if you think about the tension at play based on your face and your back, I mean, they're different. So your face has more movement, but there's also because you need to move in certain ways, there's also more areas of laxity. Whereas your back, the skin is stretched and it's taught, even though you can certainly get brown spots and wrinkles on your back. I think about scars on the back tend to spread. They look wide and stretched and they don't heal well because it's under constant tension,

but I think that tension makes the back skin look different than the facial skin. But you also have different oil glands, different parts of your body. So you have a higher density of sebaceous glands in your face, and the muscular expression, I think it affects the way that you age more than it does in other areas. Now I read once that by about the age of 35, you'll lose about 10% of the fat in your face, which is kind of amazing to me given that by the age of 35, I probably gained 10% of the fat in your face, which is kind of amazing to me given that by the age of 35, I probably gained 10% of the fat in my body. What is it about the face that doesn't do what the rest of the body does, which is accumulate fat?

Yeah, well, I think there's probably local hormone effects that are making you accumulate in other areas. And in the face, we have fat cells come from different embryologic origins. And for some reason that's what's happening there. And we're talking about very small amounts of fat. So you'll see those small differences. But think about your facial fat as insulation. And as you lose that insulation, you start

to see the structures that are underlying the surface. And so you can see where the structures that are underlying the surface. And so you can see where the ligaments are tethered. And you can see the places where they're not tethered, which would be an outpouching. And so all of those tight areas opposed and just directly next to the areas that are not tightly attached, you see these contours. And so as you age and you deflate and you have gravity pulling down, I mean the effect of gravity is real. Have you ever seen a like a slow motion video of a runner and you see their face and the way that the face bounces up and down and there's

so much force on those facial ligaments and so you can imagine what happens as you're just walking and running up and down the stairs and over and you're smiling and you're doing all these things with your face. So there's wear and tear. Just like it happens on our joints, it happens on our facial ligaments. Have you ever lied down on your back and take a picture and then stand up and take a photo? That lying down image that eliminates the effect of gravity on your face. And that shows you what is gravity doing in combination with the deflation. So that's how you take a selfie is when you're lying down. You take a lying down selfie. There's tip number one guys. It's called the anti-gravity selfie. In longevity, I used to use to, I still do and I certainly don't, don't, don't deserve credit for this smarter people than me have said this first, but the joke is the most important thing you can do to live longer is choose the right parents.

So there are lots of things that you can do to live longer, but genes really play a role. Now in the longevity space, we have a pretty good sense of what those genes are. There are somewhere between about eight and 12 genes that offer pretty remarkable protection in delaying the onset of chronic disease. And therefore, centenarians, people who live to be a hundred or longer, tend to be bestowed with a greater proportion of those genes. But you mentioned a second ago that genetic factors can also influence these sort of intrinsic changes that occur. Do we have a sense of what those genetic factors are?

Clearly there are people who just have remarkable skin and they age with the remarkable skin. And you know, you'll see a woman who's 40, who looks like she's 20, and her mom is 65, and she looks like she's 45. Well, we know that there are some correlations between certain genetic types and certain traits and the way we age.

I mean, I see a lot of people for our under eye backs. And it's almost everybody says, this is genetic. Well, yes, I know it's genetic. I mean, your parents have it. You came in with your mom and you she has it too. So the structure of your face obviously comes from your parents. But when we talk about skin types, in the skin color,

darker skin types tend to have more connective tissue or denser connective tissue and tend to look better as the age. So, I mean, it's a generalization, but a lot of the Asians in my practice tend to look better longer. Darker skin individuals the same thing. And so the darker pigment in skin does give you some UV protection. It doesn't mean that you don't have to wear sunscreen, but it offers photo protection. And I theorize that UV exposure from sunlight causes fat atrophy over many, many years. Wow. What do you base that hypothesis on? We use heat and we use laser procedures in a very highly focused way, and we know that

it destroys fat cells. So these externally applied devices that are available now, and they effectively remove subcutaneous fat. And I believe that UV radiation does the same thing over a long period of time. And if you've seen people that have always protected themselves from the sun, they look like they have white porcelain skin, they have less wrinkles, and they have younger looking faces. I know we're moving away from the genetic question you're asking me, but I think you can often overcome many of the genetic things just like with chronic diseases or with your lifestyle modifications.

But I think that there is also an internal drive that we have to perpetuate our gene pool that we each have our own internal motivation to do that. That's just our evolutionary goals. And I think some of the more favorable genes become selected over time. And so I think there's a genetic motivation for people to want to look good because they want to present themselves in their best possible way to a possible mate. Kind of like a peacock. We don't have feathers. One of the things that I'm sure anybody listening to this,

and certainly I've always found a little bit, I don't know who worry some is God if I had a dollar for every time I saw someone walking down the street and who'd looked like they'd had a million Procedures done and you just feel bad for them. You feel like God something went wrong there. I'm You don't look natural or normal and I think for many people it becomes off putting and they think well gosh I don't want to do anything. So it begs the question are there strategies that one should take to consider gracefully aging in as much as one cares. I mean look I think in the end some people are going to say I don't care about any of this stuff but presumably if someone is still listening to us talking now a few minutes into, they probably care. How do you think about this? And maybe how does

that differ from what other docs think or what would be a traditional point of view? Think about all the people that are walking by you on the street that have had worked on and you haven't. You don't notice it because it's done well. So I think you're seeing that every day, but you just don't know it. Yeah, I only see the numerator. I don't see the denominator. And what are the reasons for the unnatural appearance? Why do people get to that point? I think in some cases, maybe it's unlimited access or unlimited resources. I think there are forces that push people in that direction. Your appearance is a very emotional subject and I think we tie ourselves to that maybe an age that we feel like that was our best

age. Think about the actress that everyone knows for the role that they played when they were 20 years old and in our minds we think of them as that person and it's almost hard for us to imagine the matching and you see them and you're like, oh, look how old they look. And I think it's a natural tendency to think that because you're remembering that favorite movie that you saw them in. But think about the pressure they feel in that situation. Like my career is based on my image.

And so if you try to hold on to that 20-year-old version of yourself, at some point you're going to cross the line into a natural distorted look. So there's probably a rough guideline. Your goal should, you know, if you want to look your best, maybe I'd like to be look a little, like, seven years younger than where I am now, or 10 years. But if you go beyond that, it's a little too much. That's one part of it. I think the images that we see around us, if you look at some of this is part of like what I call the Instagram effect where you're scrolling through and you see these photos of celebrities that have blown up their lips and their cheeks are over the top or whatever it is.

And some of it is Photoshop, but some of it is from medical augmentation. You start to think that that's the new normal, but it's overdone. And that exaggerated appearance, it's people around you and your circles might be doing some of these procedures. And so you all see each other like that and then you want to get a little bigger and just push it a little more. And then before you know it, you've gone too far. And it can be a slippery slope. So I think people start to lose sight of where they started and what their goals were. Your goals maybe change. And maybe you've found a provider. There's a doctor or a nurse injector that said, okay, you know, let's take this a little further a little further And then they say, you know, I think you're good here. Let's stop it

But you want to go further so you'll find somebody and so you'll you'll get to another provider and they'll do it I personally feel this way. Someone comes into my office and they've had something done I think I can fix them But maybe you can't or maybe it's time to say okay. Let's put the on. So I think there's different reasons why people get to that point. But the technical reason that someone looks unnatural is when you either try to enlarge something beyond its natural dimensions, there's only a certain point is how far the skin will stretch

before you start to lose the contours. And we say, like, you can't have light without dark. So the goal of your face, the goal of a natural looking face is not to be totally smooth and to have no curves and no shadows and no lines. You're when you smile, you're supposed to see my brow elevate and you see some lines in my forehead. You know, I'm conveying expression. I'm conveying a message to you that I'm surprised or that I'm angry.

And so if you lose those expressions, if you lose the shape of your lip, you have a cupid's bow where it looks like it dips down in the middle or you have two pillows in the butt lower lip. And if you distort that by just blowing past all of that and filling it up, and so you have a sausage now for your lower lip, I mean, your eye will pick up on that very quickly that that's not natural. You might not know how to describe what is natural, but you know it isn't. And so you distort the natural dimensions, and pulling will achieve the same type of distortion if you go too far. Face lifts when they're pulled back too tight, because someone is being too aggressive on the surface of the skin, you see the wind-swept look. Those type of things where,

on the surface of the skin, you see the wind swept look, those type of things where you see it in older actresses or even actors, maybe they feel like, okay, I can spend this much money to look like this person of myself. Well, there's no amount of money that will make you look naturally 30 years younger than where you are. You know, if you compare, I think, people's bodies today

to people's bodies 30 years ago, based on augmentation, there are some inevitable trends. Now, I don't have any data to back this up, but I can only imagine that breast size is larger today. I think breast augmentation must be more common than it was 30 years ago. When it comes to facial augmentation, what are the trends? And I'm not talking about the just the extremes where people have like gone too far, but it would seem to me that people tend to have fuller lips these days. Is that, would that be true? I would say yes. And for good and bad reasons, I think we recognize now more and more that global volume loss is something that's happening to our faces as we age. And that includes the lips. So is something that's happening to our faces as we age. And that includes the lips.

So lips can be reinflated because they've lost volume in a natural looking way that you wouldn't know about. I think that there is a tendency now to focus on these areas. So look, when you come to my office and you say, hey, look at my face, what should I do? I'm probably not going to just say, like, okay, you should do this, this, and this. I'm going to focus on what you're seeing. But I might point out certain things like, you know, you've lost

a lot of volume in this part of your face, and I know you're focusing on your brows for some of me, let's say, but I see, you know, I want to maintain a balance. So it's been, you know, popular to fill these nasolabial lines next to the lips, you know, the lines that go from the corner of your nose to that outer corner of your mouth, or to inflate the cheeks, but we have to look at the neighboring areas like your car guy, and you get a scratch on your car, well, you have to paint the panels next to it in order to make it look good. And so a good provider, a good physician will look at you and say, okay,

your concern is your nasolabial lines, but I think we should also just at least consider your lips because let's look back at your photo from 10 years ago and look what your volume status was then, and let's look at it now. So I think in a good way people are focusing on lips, but also I think the negative is that there's always going to be some people that are over the top. And I see it a lot when you have a lip injection, typically we're using hyaluronic acid fillers, which is something that's a constituent of our skin to begin with. So these are very safe in terms of that they're not, they're biocompatible, there's no allergic

reactions to them in general. And they're reversible. So we have an enzyme that can take them back if there's something that doesn't look right or there's an issue. But with these gel fillers, they tend to be hydrophilic, meaning that they absorb water. And for the first two or three days after you do it,

your lips look like that person that you're trying to not look like. They get pretty big. So most people, for about two days, they're sort of like homebound or... They're freaking out. They're wondering if they overdid it. Yes, but it's almost 100% of the time. The first time someone does lip filler and they come back and I said, okay, you were pretty

swollen, I bet, for the first two days and they say, yeah, but I sort of miss some of that swelling. And so the next time around, we do a little bit more. And that's sort of like where you have to determine. And that's, that's a personality thing. It's a personal decision in terms of like what is good and it's a discussion between, you know, myself and my patient. And we don't always agree.

Like, my patient, I say, you say, I hear what you're saying. You're telling me this is natural. I wanna go a little further. And I'm open to that. Now that's something that doesn't like a facelift. Once you get a facelift, you're kinda stuck with it, right? I mean, a redo procedure there is gonna be cumbersome.

It depends on what the reason is for redoing. There's a big role for a vision facelift surgery, but you're right, when you take something out, are you overreducing those or you overstretch someone, that can be very difficult to repair. But obviously the hyaluronic acid doesn't last forever, right? So if someone is doing whether it's an extreme or incremental strategy of filling, how often do they have to do that? It depends on the area. So, you know, lips tend to not last as long as other parts of the face.

Like, I do a lot of undrife filler. Under your eyes, you don't have a lot of movement there. Even though you're blinking, undrife filler lasts, you know, a year or two years. I've seen it last four or five years in some people. Whereas the lips, you're always talking and person your lips and eating maybe six to eight months. Now, you have a very interesting technique of doing the under-eye filler, which I've sent a number of patients to you because I've been so impressed by just how amazing it looks and how minimally invasive it is.

What do you do different there? So, this has sort of become my niche in my practice. And I probably do that one procedure more than anything else. And it wasn't by design. I didn't plan for this to happen. But it was definitely an interest of mine. And when you look at someone's face, the first thing that starts to age is, or it would be the eyes, because that's where we have so much

movement. We're blinking all the time and we have the thinnest skin in our body. Combine that with the fat pads under your eyes, which can enlarge with time because they have a different embryologic origin. And we're losing fat in our cheeks and the upper part of our cheek, which that groove where you get that shadow is called the tear trough. Which I don't really like. That term makes me think of pigs eating at a trough,

but that trough would be if you were to cry, it would sort of spill down that kind of slide in the inner corner of your eye. This is what makes people look like they have almost a black eye, some dyes from the shadow. Right, and people think, everyone says I'm tired, but I'm not.

And so when you combine the puffy under eyes with the tear trough area, you look tired and you might not be, or maybe you are, but you just don't want people who know it. So what I do with fillers, I use a hyeronic gel filler and I inject it there, but with a cannula. So a cannula. So what's a cannula for people who don't know?

It's like a needle, but the tip is dull. It's a blunt tip's needle. So what I do is I approach that area from the cheek. We make a little needle hole in the cheek. And then I introduce this cannula through that little needle hole. So you have no needles under your eye. And I can use that cannula in a very accurate way. And at this point, I know exactly where my tip is all the time,

even though I don't always see the tip, I know where it is. And when I'm doing this, I'm imagining the surgical procedures that I do very frequently, which is blepharoplasty. And so because I know the eye- Which is what? So that's a blepharoplasty just means that modification of the eyelids through surgery. And so cosmetic blepharoplasty is often either removing the fat pads, the bags, removing skin from the upper lids or shifting the fat, whatever I have to do to make your eyes look younger

or the way that they used to look. So I do a lot of blepharoplasty and because of that I know what it looks like inside. And so I imagine that in my mind when I'm placing the filler and I'm placing this gel that takes up space and it's replacing the fat that you've lost. Or it's also disguising the fat pad that might be bulging. And so by putting it in the right place and using the right filler,

because there are certainly there are hyaluronic gel fillers that are incorrect for that area because they just have the wrong properties, the wrong stiffness, the wrong amount of water attraction, but placing it in the right area and the right amount. Is restaulun, how you're only a facet-paste filler? That's one of the fillers that I use, and it's also, it's having more strength. So I understand at which point that this will become puffy or look unnatural, and that's

where we stop. And sometimes we stage it, but this procedure will brighten up people's faces who look like they have bags and look like they're tired. And it's really gratifying to see what people's reactions to this when they look in the mirror, especially when you do one side, and you look in the mirror and then you see the difference. It's pretty remarkable. And so it's one of the things I really enjoy doing. And I think that there's a lot of doctors that sort of stray away from it either because

they're not comfortable with the idea of injecting under the eyes. There's risks with everything we do. To me, that's not a high-risk procedure, but I think it's perceived as one. I think part of it, too, is this gets back to your unique training. I mean, you trained first as an ophthalmologist, which, you know, if I think about it, like I trained in general surgery, like my, my scope of what I needed to know was so broad, but when you look at someone who's training in ophthalmology, like you get to focus five years on, like, two inches of a person's body, so your knowledge of that anatomy is, is, is unparalleled.

Right. It was narrow to begin with, and then I became even more narrow. And then you become even more narrow. So it seems to me that the advantage that you have, and this is certainly why I've always felt very comfortable sending people to you, is I know that people who understand the anatomy because they've operated, they've actually been beneath the surface, can do exactly what you describe, which is they're sort of, they know what the art is. Put it this way, when I was in residency, there was never any confusion that I would go into plastic surgery when I was in medical school. was never any confusion that I would go into plastic surgery

when I was in medical school. Like I just don't have that artistic capacity. But I would say, you know, at the same time, you know, I like to talk about my skills, but I don't, I think there's like a political part of this conversation where the question is like, who do you go to and who's the right kind of provider? If you want to do something like this,

I don't think it has to be a certain person or a certain kind of person. I think that there are good injectors and bad injectors. I think there's good doctors. How can people distinguish? So if someone's listening to this podcast and they're saying, well, you know what, these bags under my eyes are driving me crazy.

Let's say they don't live in New York. So that you're coming to see you wouldn't even be an option. Well, people come from other places, other countries to see me, but I think when you're looking for a provider for anything, obviously everyone says, oh, I did my research. So I put it this way, if your wife needed a procedure and you decided, you know what? I don't want to be the one to do it because there's an emotional connection to this person. And how would you pick the person that would do this to your wife or your mom?

I think you have to find out first, what are the organizations that certify people? From my field, and let's say talking about blepharoplasty, I think there's a handful of specialists that would be competent. You could be a plastic surgeon, a facial plastic surgeon, an ocular plastic surgeon. I have Ibiased towards ocular plastic surgeons because that's a big part of what we do. I would look at that first. References like referrals from other people, obviously, you know, look, if you wanted to find out the best surgeon in your, in the hospital, you probably asked the nurses or the scrub

techs and say, tell me, or the anesthesiologists, because they have first hand knowledge. So I think referrals go a very long way. And if you know somebody that had a great result, or you know someone who's done something, but you have to meet with a few people because you might have the best surgeon or the best under eye injector or lip filler person. And that person could also be a physician assistant,

it could be a nurse. I mean, I've seen some amazing physician assistant injectors that I would have inject myself without hesitation. But it's like, do you have a good rapport with that person? Do you think you're on the same page? Do you have the same goals and style? So it's almost like an interview when you go for a consultation. Sometimes you have to pay for a consultation fee.

But I think it's worth doing that, at least for two or three or four doctors To me with someone and say I get the wrong feeling here or this office seems frantic or the doctor Just didn't even really look at me or listen to me. I mean those things I think are all really important So I know doctors that are family practice doctors that are exquisite Botoxinjectors. And so I think it's wrong to fall into the political trap of you have to have this label next to your name or you have to be this kind of like training. I think that a lot of the training that I've done was post your formal training. And some of the training is things that I developed on my own.

But for Bluffer Plastier, I procedures, I recommend looking at the ocular plastic organization. But for things in general, I think you should look at photos of people who all have their galleries online, they're going to show you their best work. So you look at those pictures and you say, oh, those look good. I look at some well-known doctors and surgeons and I look at their photos. And I think this does not look good to me at all. I don't think this is natural, and they're promoting it as their best work.

There are a lot of things that I see around the eyes where I preserve fat, and sometimes I'm off an adding fat, which a lot of people don't like to do, because they don't maybe have the same philosophy that I do, but I see hollowed-out eyes, and people are pushing that, putting that forward, is that this is my best blepharoplasty Maybe for someone that is maybe that's the look they're going for. You should want to ask how many procedures the person has done is there a certain

Number above which you sort of hit that threshold of okay now. I've really you should ask all of these questions like how many procedures? I mean look I've done well over a thousand two thousand of And look, I've done well over 1,000, 2,000 under eye fillers, bluffer plastic, it's 1,000. But in early my career, I did lots of procedures and was probably hundreds. So you should ask, and your doctor shouldn't be defensive about those questions. You can say, hey, can I talk to somebody who's had this with you? And we do that all the time. We connect patients with previous patients who are open about it and say, Hey, what was your experience? Or is it, can you say, well, tell me about the complications you've had? And if I get one of those, what are you going to do for me?

How do you, how do I manage that? Do I have to pay to fix the complication? Those are questions you should be asking. That's such an important thing in medicine in general. It's amazing how easy it is to gloss over consent forms. And you just sort of list a whole bunch of generic complications, but you don't actually talk about what probabilistically or expected complications could look like and to your point. What are the next steps? So for example, you know with breast augmentation, I know a woman who had these really horrible contractures develop and I was like, God, I'd never even heard of that.

You know, I didn't even realize that was a complication. Obviously, I'm not in the loop in that space. It's actually a common complication. Yeah, it's about 3% I've learned. I think it could be even higher depending on the type of implant and the placement. So those are things that surgeons should be saying to every patient that the 3% is a, you know a relatively high rate. Yeah, and you're right. It depends on the implants. So if you're using the different textured implants,

it could be as high as 5%. I mean, 5% complication is really high. One in 20 people who do this is going to have this. And a lot of times on Redoos, it still happens, which is not to say one shouldn't have an augmentation, but boy, I'd be very upset if someone I cared about had that procedure wasn't told about that complication and then developed it, especially if they required re-do-re-do. Of course, and so that going into it, let's say this busy surgeon is doing 20 breast dogs a week, and so one patient every week is going to have potential re-operation, so going in you should know, hey, I might have to do something else.

And that's with, I think, any procedure, the risk is relatively low with many of these things. And sometimes we're talking about one. Certain complications might be one in a million. And so you don't have to put that as like, this is likely for your to have. But yes, that's part of the discussion. So let's go back to Botox for a second. I think about like six years ago,

one of my good buddies from residency who's a plastic surgeon, I was just hanging out with him, we were just sort of playing patty cakes one day. And he was like, hey dude, what on my throw some Botox on your wrinkly forehead? And I was like, all right, fine. So I like sat down in his little chair

and he whipped out some Botox and put like what felt like three thousand injections into my forehead. And you know, put an ice pack on it, went home. Classic mistake, though, I think, is what you're starting to describe. He's treating your forehead directly. Well, let me tell you. Oh, my God. I don't remember how long it took to wear off.

I think it was about two to three months. The most miserable two to three months of my life, because this was at a time when I was a very active cyclist. And I didn't realize it until, of course, I lost the ability to do so, but not being able to lift my brow meant I had absolutely no way to keep the sweat out of my eyes, even when I was wearing my kind of du-reg under my helmet. So I couldn't believe how miserable I was not being able to lift my eyebrows. Yeah, so it's uncomfortable. And then it's also a dead giveaway.

So when you look around, let's say you're watching the Oscars on TV or something and you want to know which people have had poorly done Botox and it's a lot. It's when the frontalis muscle, right, which is the only... So where is that for the people who are listening? That's the forehead muscle, right between the eyebrows and your hairline, okay? Okay, so for some of us further back than others, but the frontalis muscle is the only muscle that raises your eyebrows. So you get those transverse those horizontal lines across your forehead and your instinct is like, oh, I should do bow talks to get rid of these. Well, if you inject the frontalis to the degree where you smooth those lines because, you know, those lines are formed by the muscle contraction. So your

muscles don't contract anymore. And I said, they're the only muscles that raise the brows. So now you can't raise your brows. In fact, they drop. But your forehead will be shiny smooth. So if you see somebody and they can't raise their brows, it all you just see smoothness, they were over Botoxed in their forehead. And we say Botox as a generic, it's actually, that's a trade name. And there is the amgen product, right? That one is, um, Allergan. Botox, Allergan, okay. Currently FDA approved his Botox, Zemin, and Disport. So those are all types of botulinum toxin type A. There's slight differences in the molecules, but they all have the same effect. So the mistake that was made for you was going after the horizontal forehead lines.

And in fact, what? Which seems like a common mistake given on the frequency with which we see this. Yeah, I think people know a little bit more about it now, but still I think they use too many units up there. So the unit is the strength of how much is being injected, but what would have been better would be to inject the corrugator and praceris muscles, which are the ones that are just at the top of your nose, but the ones that follow your brow, you treat that, and then just a light sprinkling in the forehead so you can still elevate your brows, but you weaken that muscle contraction.

Then over time, if you do it a couple, it'll last you about four months, and then over time, as you repeat it, then those lines will soften because you're not making as much of that contraction. So, if somebody comes to you and says, Brett, when should I start doing this stuff? Let's say someone takes the long view, right? Someone says, look, I'm, you know, whatever, I'm 40, I'm 30, I don't know what the age is, but I want to know that when I'm 70, I look more like I would otherwise when I'm 50. They want to take that view, which is I'm not trying to look like I did when I was 16,

but I want to really take a long view of plenty of iterative interactions. Are you looking at a magnitude of wrinkling or are you saying, you know, we start with very, very small, for example, just looking at that area that furrows the brows, but not touching anything on the frontalis muscle above it. I mean, how do you think about this from that standpoint? I think we have to think from the beginning that you don't have to do anything, right? Nobody has to do Botox. Nobody has to even spend this much time thinking about their appearance, right? People do it because it's important to them and what's important to you might not be important to someone else. So with

that aside, let's say your goal is to look your best as long as you can. You should probably first start focusing on the preventive things, which can include neurotoxins like Botox, but it should start with sun avoidance at a young age. You should do Botox or something like that before you start to get etched lines. Is an etched line one that means when your forehead is relaxed, the line still shows? Right. And I think it's okay. You know, I have some etched lines

and horizontal hedge lines in my forehead and I think it's acceptable for me. And I'm okay with it. I mean, look, there's a range of what's acceptable. I used to look at Bill Clinton on TV all the time and I'd see his big eye bags. And when I was in my training, I'm thinking, I would just die to be able to take out those nice juicy fat pads,

but he doesn't care about them at all. Right? And so it's meaningless to him. Or maybe he thought about it, but, you know, he obviously didn't pursue it. So it doesn't really matter if it doesn's meaningless to him. Or maybe he thought about it, but you know, he obviously didn't pursue it. So it doesn't really matter if it doesn't matter to you. And I think, you know, it's interesting at the root of all of this is, you know, why do we do cosmetic procedures? And why does some people think it's so important? Why do people think it's nonsense? It's about your confidence. It's about how you feel

about yourself, your self-image. And I think that there are some people that will chase after confidence and may never be able to achieve it. And it's because of what happened to us in our childhood, our upbringing, the, I guess, the stability that we had when we were growing up. And it's being able to experience love in your family, experience acceptance, people that were proud of you. People can say that they love you, but in the future, you didn't experience that. It's much harder to be self-confident and to have a good self-image. And so I think it all goes back to that. I think there's a healthy way to do it.

And I think it's not something that we should frown upon. I think it's becoming more accepted in our society to have a focus on how we look and how we project ourselves. And I think the best way to do that is to have a healthy attitude about it in terms of look I'm doing this for me. I'm not trying to impress somebody. I'm not trying to fit in with somebody. And what's amazing is sometimes a little tiny thing that you wouldn't even know, you wouldn't notice it,

but I see people walk out of the office with a different gate, or they're smiling when they weren't before, and we barely even did anything, but it's a little shift in the way that they were thinking about themselves, and so it's not so much exactly what you do, but how you help somebody to feel better.

So in terms of doing like a neurotoxin injection like doing your first Botox injection, if you're looking at your parents and you see these lines, you think I don't really want those lines. So you do it before they start to become fixed lines, those etched creases. You do it before you get that. So there's not really an age. I mean, I've injected people in their 20s, I've injected people in their 80s. I think it's never too late. But there's certainly times where it can be too early. Now, have you ever found yourself in a situation where you felt it was unethical to participate

in the care of a patient because you felt that they were just being too neurotic or they were asking for something that you felt was too much? I mean, did you find yourself in that situation? All the time. All the time. I think that's the nature of what I do, right? It goes along with it. And so the way that you look is tied in very closely to your emotions.

And when you, especially when it's your eyes, and I see people all the time that have had poorly done procedures and they're tearful when they're talking to me, um, and I see people, I think they're unrealistic. And I try to guide them. My goal is to be on their side all the time. So in order to sort of focus on overall wellness, not just appearance, but there is, I think there's a connection between appearance and wellness.

And if you seem to me like, there's something else going on here. Why are you chasing after this one line when anyone who would look at you objectively would say, oh yes, you look younger, you look more relaxed, you look refreshed, like what are we really talking about here? Well, maybe there's something else to talk about. So you're almost having to try to be a psychologist psychiatrist at the same time.

In a way, I mean, maybe it's also my wife is a therapist. And so some of that probably has brushed off on me in terms of how important it is, having somebody to talk to that's outside of judgment. And so I think sometimes people need to, maybe it's not just one thing, it's both. It's having someone to talk to, maybe there's some other issues going on.

And what is your goal in doing this? Let's go back a little bit further. Let's say someone's listening to this, and maybe this is a lot of people, and they think, look, it's really good to know that there are people out there like you who can do the most nuanced, complicated, grafting, injecting techniques above, below the eye, the forehead, et cetera.

But what if they say, look, I don't want to do anything that I can't do is the patient myself, meaning, lotions, potions, behavioral changes. Let's start, you alluded to Sun. Let's start there. I get asked all the time, and I'm kind of embarrassed because I just don't know the answer, and I have to say, I have no clue. I get asked all the time and I'm kind of embarrassed because I just don't know the answer and I have to say I have no clue. I get asked all the time, Peter, what sunscreen should

I be wearing? It's like I feel like it's easier for me to answer like how would you solve the Iran nuclear missile crisis or you know before like I don't have a clue what sunscreen to wear. It's a complex marketplace. Let's say because the way that sunscreens are marketed, the way that the labeling is done can be a little bit confusing. And there are technologies that are being employed now that are newer that we don't fully understand. So let's start with the first question, which is there are some people out there who say sunscreen is horrible, you should never wear it. I'm assuming you don't think that that's the right approach. It's absolutely untrue. I mean, I can't feel strongly enough about, look, I see a lot of skin

cancer and I treat skin cancer and it's obvious and it's been well scientifically proven that there's a correlation between UV radiation and skin cancer. All right, so I have to reconstruct people's eyelids, their faces, their noses, because they've had basal cells, which basal cell carcinoma, which is related to sun exposure. My wife has had several most procedures, which means a dermatologist with special surgical training

has to remove pieces of skin, and then it has to be reconstructed. And I don't think anybody wants to go through that. Look, the recommendations the American Academy of Termatology is to protect children from sun and there's recommendations about levels of sunscreen. So you can get your vitamin D, even with your using sunscreen. So when we talk about UV, they talk about UVA and UVB, and you'll see these things on

sunscreen. Can you explain what UVA and BR? Traditionally, you can think about it as UVA, the A might stand for aging, and the UVB is for burning. UVB is what's responsible for your skin turning red. Okay, they're just different wavelengths. They're different wavelengths of ultraviolet light. And when you're looking at SPF, they're just different. It's different wavelengths. We'll have links to the Travita light. And when you're looking at SPF, they're talking about UVB. The way that they determine SPF

is they will take a subject. They'll do it probably. I think you need to have 10 subjects. This is just done on a person. It's not like a laboratory task that works well for this. They still use it on people. So they would put you under a light in a laboratory with UVB and they would wait and see how long it takes for you to turn red. And then an SPF, and so that's UVB radiation. SPF 15 means what do we need to put on you that will make you turn red 15 times longer? It takes 15 times longer to turn red. and 30. And this is my silly question, but is there an objective metric for what redness is? Like there's a color, you know, how like you can define colors by the percent red green. You can measure the, you can measure

the color. God, it's a purely objective measurement. So it's interesting. SP 15, which seems like very mild sunscreen, still gives you 15 more time. So if it takes you 10 minutes, this is going to take you to, you know, what, 150 minutes is like two, two and a half hours, basically. If you look at the difference between SPF 30 and SPF 50, you're getting a difference of, I think it's like a 96 or 96% protection against UV during that time versus a 98% protection. So it actually becomes less of a difference in protection from those rays as you go up higher.

So over 30, you don't get that much more benefit. But you should be using at least a 30. But that's talking about UVB. If you want to protect yourself from UVA and UVB, which you should, you should be using a sunscreen that says broad spectrum. Okay. And it's still the same SPF system. Well, no, SPF does not apply to UVA. It doesn't measure UVA. In fact, there's no measurement of UVA.

So if you buy a broad spectrum sunscreen, it will not have an SPF number on it. Or if it does. It has an SPF, but it relates to only, okay, got it. So UVA doesn't cause redness. So you can use that test, which of the two is more responsible for vitamin D synthesis? That's a good question. I don't have the answer for you. All right. We will, we will find out the answer to that question at some point.

That should be known. Mike, I, my intuition is its UVA, but I, I, I don't know. All right, we will we will find out the answer to that question at some point that should be known Mike My intuition is its UVA, but I I don't know but Both are responsible for skin cancer Got it. So UVA is can can lead to melanoma now I remember reading that yeah, I mean I've read so many things like you should always have zinc in your sunscreen You should never have zinc in your sunscreen So there's other divisions of sunscreen types, and so there's something called organic

and inorganic, which we also more commonly is termed chemical versus physical. So the inorganic sunscreens are physical, and those typically use zinc or titanium, which are metals, as a reflective agent, and it just reflects the rays of sun. So those are the ones that you think of like Baywatch, and you have like the white under your eyes, but they don't look like that anymore because now they have micronized versions of those zincs, and they have nanoparticle. All right, so smaller particles mean that it looks clearer.

You still get a little bit of that lightish. I didn't give you one of my sunscreens before. I get a little bit of a whiteish hue, but it's not like a pasty white. Those are the ones I recommend because it reflects the light. Now, there are some newer chemical sunscreens that are thought to be safe, but there are some issues with the,

so the way the chemical sunscreens work, which are considered the organic sunscreens, they absorb the UV light, and they convert them into heat, which disperses locally in your skin. So if you have melasma, those type of sunscreens could potentially worsen your melasma. Tell us what melasma is.

Oh, sorry. So it's also a term like the mask of pregnancy. You see darkness or hyperpigmentation on the cheeks, the upper lip, the forehead. Any discromy or brown spots can be made worse by heat, which is why I recommend against some of the chemical sunscreens. I wouldn't say it's a blanket statement. Some of the chemical sunscreens also have hormonal disruptive effects, which is why they're not recommended for children, but I wouldn't recommend it for myself either. So what are some, maybe what we'll do in the show notes will link to like brands that

you really, really like versus brands that people should really avoid. If you're sitting there at the CVS and you're trying to get some sunscreen before you go to the beach, are there any ingredients that are red flags that you should avoid? So, I mean, I don't like octanoxate, which is a hormonal disruptor. I think it's debated, you know, how much dose do you need in order to really disrupt hormones? But I don't really need that at all. If I just would look for physical sunscreen that has broad spectrum and at least an SPF 30, and that's pretty simple.

Some of them say their waterproof versus not waterproof is that a gimmick or is that the real deal? It's hard to measure the waterproof effect, but they do that at the same test, but they're spraying it down with water in the lab, and then they're waiting to see how long you turn red. I think the key is that you have to apply enough. Most people don't put enough sunscreen on. I'm guilty of that as well.

I mean, I was in Florida a month ago, and I'm still sort of 10, and I was wearing a wide brim hat, and I'm applying sunscreen, but it obviously wasn't enough. So, and you apply every couple hours. I mean every two hours you should probably reapply. Interesting. I know people, I don't do it. I don't do it either. But if you care about how your face looks, then at least focus on that and maybe your hands too and maybe your chat, what we call the declitage, like your chest. Those are the areas that are going to be exposed. And if you want to look your best,

don't forget about your hands because when you're 70, you'll have brown spots, and you'll have wrinkly skin on your hands. If you don't protect yourself, your face, you don't want to get wrinkles, right? So put on sunscreen wear a hat that has a wide brim. And then particularly for women, or if you wear a low cut shirt,

or you wearing a V-neck T-shirt, then put it on your chest. Are there certain moisturizing creams that people can apply that have sunscreen in them, but they're primarily, like they're not necessarily sunscreen per se, like, serivie is a product that I have used from time to time. It's not a very high SPF, it might be a 15, but I really like it because it's odorless. I think part of the thing I hate about sunscreen is I can't stand the smell of it and the greasiness of it, but the serivvy, I'm like, yeah, I can actually wear this. Yeah, I think 15 is probably low.

Look, we're here in New York City and you're walking from your home to your office and you're probably getting a blast of sun on your face. I put on a 30 in the morning. You can do a trial and error, you go to your cosmetic store, you go to your dermatologist office, and you ask to try a couple of them and you feel in your skin. I mean, the technology is getting better, and the sense are, I think,

it have a wide range, the two appeal to a wide range of people. You'll find something that will suit you if you look for it. What brands do you like? I don't necessarily want to promote a specific brand because I think that there are so many good products out there. If you look at the medical grade brands, which are sold in doctors offices, but you can find them also online, you can find them on some of the online vendors. Elta is known to be a good brand, MD solar science, I like replenics, skin-suiticles. You'll find the long list of potential products. I don't mean to leave

any out or focus on those, but yeah. Okay, so then the next thing I want to talk about as far as just sort of nuts and bolts maintenance stuff is something I've heard quite a bit about and also have tried from time to time is retinolic acid. So first of all, what is it and why does one use it or how does it work? Well, so we're talking about a form of vitamin A and it acts like a hormone in the fact that it works in the intracellular and the DNA level. So it's affecting transcription of particular genes. It's promoting collagen synthesis. It's increasing the turnover of skin cells.

It's one of the few things that's proven for anti-aging, but also for acne. So there are a wide range of forms of vitamin A, but it's one of the top three things I would recommend for everyone to be using if they are interested in having a skincare regimen that's effective. Now, retinate cannot be bought over the counter or can it? You can get over the kind of retinolce. Okay. So the retinol is a less potent version of what you're referring to, which is retinol. And do those over the counter versions, which are obviously less potent, do they have the

same efficacy or do you have to apply them more frequently? They're not as potent, but they have less side effects. So if you have not used one of these products before and you're looking primarily for anti-aging or franty wrinkles, you want your skin to look younger. So it helps that you have less wrinkles, it helps reduce pigment in your skin. Someone who's been using retinol from their 20s on, they always look better. How often should one use it?

This stuff can dry your skin out, right? Yeah, so it's less drying when you're using the over-the-counter retinol type products. I would start with something like that if you haven't done it before, and often those have moisturizers or hyaluronic acid or other things in there that avoid some of that drying. If you do get dry from that, then you can just use it every second or third day, or you can do sort of a pulse treatment where you put it on, and then 10 minutes later you wash

it off. So you've sort of of a pulse treatment where you put it on, and then 10 minutes later you wash it off. So you've sort of gotten a short exposure. If you can tolerate that, and that's primarily recommended for nighttime, and there's a myth that retinol is making you sun sensitive. I mean, it's possible because your skin has less pigment in it, and your skin looks younger, but it's more that the retinal breaks down from sun exposure.

Right, so it becomes ineffective. I always assumed it was for what you said in the first place, which is you'll get more burned if you use it, and that's okay. It's not necessarily true, but it is recommended, you know, we use it at nighttime. I use it every night. Now, if you can tolerate that, then you can talk to your doctor about getting a prescription for a higher strength And that's usually like point 0.025% or 0.05% or point one So I'm up to point one now and I do it every night and I have no side effects But I use just the generic 0.1% tretenoan. Yeah, that's tough ain't cheap. Yeah, no, I know but it's and there's newer generations that also have less side effects But the traditional tre the traditional treadmill works nicely.

But a little bit goes a really long way. I mean, you can use one of those 45 gram tubes, can last you several months. And you put it all over your face? Yes. The other myth. So for guys, someone like me who's got kind of a beard, am I also supposed to apply it over the bearded area? I think that's tough to do.

The nice thing is someone who shaves every day, that area, when you're shaving it, you're basically giving yourself like a microdermabrasion, so you're mechanically abrating the outer surface layer of your skin, which also promotes skin turnover. So you're probably a little bit protected there, but I would apply it to your whole face and include your eyelids. A lot of people say, don't put on your eyes, there's a myth, I think, that you have skin on your eyes, right, on your eyelids. So that skin, if anything, it's more effective because that skin is thinner.

So you might not use it as often there, but I close my eyes, I apply it to my upper lids, I apply it all the way up to the eyelash line. So if we're going to do, we got two things in our toolkit so far. We're going to put sunscreen on in the morning. We're going to put retinologacid on at night. Is there anything else that you recommend as part of a kind of overall maintenance plan? So like vitamin C would be the third part of the trifecta. My vitamin C is awesome.

Vitamin C, which most people think of, is like a vitamin you take to avoid getting cold, so that seems to be kind of bogus. So, topical vitamin C and this one might be a little bit more controversial. I mean, it's not thought to be controversial because every skin care line promotes their vitamin C and the question is what type of vitamin C is effective. But think about vitamin C deficiency, right? What happens to your skin? Yeah, well, you get scurvy, you get collagen deficiency. Right. So we know that lack of vitamin C is a problem for the way you look in your skin. If you're healthy, does vitamin C help your skin?

Well, we know it's a very powerful antioxidant, so it's scavenging free radicals, so it's protecting you from UV damage in that way. It also is a co-factor for collagen synthesis. It turns out it does work better if you have it with vitamin E. But here's the thing. A lot of the products that are out there, they oxidize. Vitamin C oxidizes very easily. And the L-ascorbic acid, which is meant to be, it's thought to be the form that penetrates

the best and is the most effective once it's penetrated. It needs to be stabilized. And so there's different patents that are developed by these companies, and they sort of have these patent wars, like who's patent is better for vitamin C, and they try to protect their technology so other companies can use it.

You'll find a lot of stuff out there, and if your vitamin C can oxidize over time in the bottle. That's why they always tend to, these things come in very dark bottles, right? Right. And you keep it in your cabinet. Sun-damage skin tends to have lower vitamin C levels. And I think vitamin C is effective in those cases. Why can't they just add vitamin C to sunscreen, for example?

I don't know if it interacts well. Isn't there something about iron that they put in this as well? I think the one that you're thinking of that product, which is the CE phuloc. So the C in the E we know are synergistic. The phuloc acid is just another antioxidant. So it's just another form of antioxidant that's added into the mix. But the issue is, and what I've seen in the literature, is that if your serum levels of vitamin C are high,

then your skin doesn't absorb topical item and C very well. So we don't know if applying vitamin C topically is preventing you from developing sun damage. We know that if you already have sun damage that it helps to reverse it. And you put this on in the morning or in the evening? I typically do it in the morning, but you could do two times a day,

but I use the vitamin C in the morning and I do retinol at night. And then the sunscreen goes on top of the vitamin C? Yes. But I don't want too many steps. If I tell you you need to do 10 things, you're gonna stop doing all of them. So, but if you can do these three things,

which I think that's pretty easy, like, you just have to think about your C and your sunscreen the morning and your vitamin A and the evening. Do you have to separate the time between the sunscreen and the vitamin C so they don't interact with you? I like the serums, the C serums.

So I usually wait a couple of minutes and when it's dry, so they don't interact. I like the serums, the C serums, so I usually wait a couple minutes and when it's dry, then I apply my sunscreen. And you look, this isn't a universal plan for everybody. We all have different skin needs, but in general, this is a pretty good plan for most people. Yeah. If one does this kind of stuff, right, they say, look, I'm gonna put the effort into what I do

with respect to sunscreen, with topical vitamin C, retinal, as you alluded to earlier, I'm going to take greater care to care for my skin by wearing a hat, that kind of thing. What percentage of the benefit is someone getting in terms of an anti-aging regimen? Is that like half the battle right there? It will go a really long way. I've had patients where we didn't touch them with a needle. It's been no surgery.

It's just been recommendations and a directed skin care regimen. And look, I'm not a dermatologist, but a lot of what I do is skin care. Using these powerful basics, I've seen amazing changes. And so when you combine that sometimes with some other concerns, some directed treatments, and it's synergistic, it's even better. It sounds simple, right? But it's powerful. I mean, I think that makes sense. I guess anybody can do those things.

You do need prescriptions for at least the retinol, but I think everything else you'd... But only for the prescription for the high grade, yeah. So kind of going back to something we talked about earlier. What are some of the trends that we're seeing now? I mean, we alluded to at least one of them, which is lips, getting a little fuller. Botox has certainly been around for quite a while now. Are we seeing people using Botox in ways today that they weren't doing it 10 years ago? Well, yeah. I mean, there's many more indications for Botox. We, you know, we have non-cosmetic indications, bladder spasms, vocal cords spasms,

toward a colis, migraines, axillary hyperhydrosis, Botoxis being used for so many different things. And I think we've developed a more nuanced approach to how we treat people with Botox. I hope so. I still see people, I even know Botox injectors that have these like spock brows. You know, if you've seen that where to get the over-arched, Nicole Kidman sort of had that appearance for a little while, not to say that she doesn't look good or, you know, I don't know anything about how she was injected or treated or not, but that look is often not desired, especially if you didn't have that look before. So I still see a lot of those what I would consider like amateur mistakes or maybe just not

the field has progressed and most of us have kind of gone along with it, but I still see a lot of those, what I would consider like amateur mistakes or maybe just not, the field has progressed and most of us have kind of gone along with it. But there's sort of a pressure, I think, for a lot of physicians to move into the cosmetic realm because the world of insurance doesn't reimburse as well as it used to. And so we're seeing a lot of new providers in the marketplace and some of them have more experience than others. But we do have better ways of using Botox using it in smaller amounts, spread out over larger area, using different facial muscles. We can turn up the outer corners of the mouth, so you don't look like you're frowning

as much. We can reduce a gummy smile by injecting above the lip. I can treat the lower eyelids so that you can look like your eyes are slightly more open, or we can reduce some of the squinting wrinkles that happen under the eyes. There's a lot of ways that we can use this, that we didn't use them 15 years ago or 10 years ago. We've talked about some of the stuff in the past, and one of the things that I think I've taken away from those discussions is that if you're going to have this kind of stuff done, you really want the person who's doing it to understand the anatomy.

That's true. You can see the wrinkle on the surface, but you have to understand that the wrinkle is the product of changes in musculature and connective tissue and fat. And I'm sure when you look at a face, you actually are almost doing so with x-ray vision, right? Like you're not, you're seeing beyond the skin, you're seeing everything that's underneath it and knowing that, well, look, if I actually want to reduce that wrinkle, I don't necessarily inject into the wrinkle, I'm injecting, obviously, where the muscle pull is. And it's not just looking or understanding, it's also asking the patient to move. I say, okay, I want you to frown for me, and I can touch them, I can see where the muscle is pulling. And there's a variation in the way that we're built.

And so your muscle might come up at an angle and it might be different on the two different sides. So it's important to look at those little differences and to see what's happening, not just, and people say, look, I like to avoid a cookie cutter approach, everything's personalized. It's easy to say that. Everyone markets themselves is like, we offer personalized Right? Every doctor says that that's what they do. But do they, you know, are they really like giving personalized, I know in your practice,

you're giving personalized care because you're diving deep, right? And you're, you're looking at things, you're not just ordering, you don't just call the lab and say, hey, give me a CBC and a chem seven. And, and then I'll tell a patient what he needs to do. You're diving deep. And so that's truly personalized care. And when you're looking at a patient, and if I have a fellow following me, I sort of have to answer to what, you know, that someone is training. I sort of have to answer to him too, in terms of what I'm doing. And if he sees me, or she sees me doing the same procedure in the same place and every patient, they're going to ask me, like, why did you do that same thing? You know,

I don't, because, and I feel that scrutiny for myself as well, that your treatment is going to be different from the other person's, because you look different in your body's different, and your muscles are in different places, and you have different concerns. I mean, so that's what personalized treatment is. It's not just saying it on your website. One of the things I get asked about a lot by patients, and this is why I'm really glad I know people like you because I obviously don't know the answer to any of these questions, is my friend got such and such a laser treatment on his or her skin, and I want to do that

and all these different types of lasers and these things. Can you give us the kind of the 101 on laser treatment for skin? I think lasers are effective in many ways. And the lasers are getting better, the technology is getting better, the fractional technology. There's different types of energy. It's confusing though to consumers because you don't know, are you selecting a doctor, are you selecting a doctor? Are you selecting a device? Anyone can buy a laser if you have a certain amount of money and you have a certain amount of patience

And how much of the work is being done by the laser by itself? You just turn it on and just happens or is it the provider selecting the right patients and changing the settings? So there's a lot of variables There are some devices that doesn't matter who does it for the most part, like the cryo-li-polisist, cool sculpting. It's a device that sucks your fat and it freezes it at a certain temperature and it uses an algorithm to figure out what temperature needs to stay at for how long to adequately cause a poptosis of those fat cells. And so basically, someone just has to say, okay,

this is the area we're going to do it. And they stick the machine on you. There's a little bit of understanding and training that goes into it. But once you turn it on, it's done. You sit there and it happens and then you... Is this cool sculpt procedure effective? It's effective, yeah.

And there are other ones too. There's other types of the sculpture. There's other devices that also effectively non-surgically can reduce fat, but they don't require a lot of it's not an operator dependent from the for the most part Right, so you turn them on and they're good and so you can probably go to most places and they'll do a good job for that There's a procedure where they use heat and then there's a procedure where they use cold. What is more effective? They're both effective. There's a lot of devices, but the two main leaders in the market are both effective and they're probably equally effective.

They work in different amounts of time, but usually you get about 20% of subcutaneous fat reduction with that course of treatment. So if a person wants to take a little bit of fat off, presumably you do this on your belly or you can do it like... In your flanks, anywhere you can pinch fat, you can do it, right? So it's subcutaneous fat. It's not visceral fat.

That's under the muscle, but it's the subcutaneous fat. And it works well as long as you can apply the applicator, there are some limitations, but they both the main devices have FDA approval for necks as well. So those devices doesn't really matter so much about who's doing it. You want to go to a reputable place. You want to make sure it's the real device. There are Chinese knockoffs that are not FDA approved. So you want to get the real one.

You can go to, there's like cool sculpting as an FDA-approved cryolypolicis device, but I've seen fat freeze or something. And then you look into it and you say, this wasn't even approved by the FDA for marketing. So. Got it. So at least make sure you even approved by the FDA for marketing. So. Got it.

So at least make sure you're going with an FDA approved procedure or device. There are lasers that work on skin. There are lasers. Yeah. What are the skin laser? Like people talk about like getting their face lasered for skin.

I've had a chemical peel once a little while ago. I was really, I mean, this has got to be, it's got to be about five or six years ago. I was amazed at two things. First of all, how quick and easy it was for this dermatologist to apply this stuff to my face. That's the first thing. The second thing that amazed me was how red I was for like five days and how I had to like lather myself up in aqua four. And then third, I was just amazed at how many sunspots have vanished. Yeah. Well, I mean, that procedure can be very effective. There's lots of different types of peels.

There's phenol peels, which can have more risk, and but more benefit. In fact, for a phenol peel, you have to be connected to an EKG. So you're monitoring for Rhythmias. There are TCA peels, which can be also equally strong. There is a lot of experience that goes into selecting the type of peel, how it's being applied, how many layers, what you're seeing. That is a very upper-year dependent procedure. So is there a chemical peel that you would say is, if you were

going to have one tomorrow that you would preference? I wouldn't say that. I think that's more of a depends on your skin type. There are certain things that are not safe for darker skin types. So that's a very specific treatment plan for each of the questions. So what are the questions? Could people ask the provider to know that that, because really what you're saying is you have to rely on the provider's judgment to know that very heavily and you can get a burn and you can get a scar.

So how do you screen out for who the right person is? Well, it's asking, you know, how many of you have you done? Can you show me examples? And is this safe for my skin type and one of the risks? So, chemical peels are essentially using an acid or a chemical to burn away the outer layer of your skin. That's why you look so red. And they go at different depths,

depending on how many layers of chemical are being applied, and what type of chemical in the strength. So I can use a 10% TCA peel on you, and you'll look slightly red, and you'll look a little better. I can use a 35% and your skin will peel off like a snake. So there's a wide range and it might not be safe for all skin types. So let's look at me right now. I'm kind of a olive skin dude. I've probably got, I don't know where I would rank on the sun damage scale, but I... I would say for you, either you're looking at it, let's say you want to just do a skin rejuvenation, you want to look smoother, less wrinkles, improve texture and brown spots. So we would either talk

about a chemical peel, like maybe a TCA peel of 20% and I might recommend three treatments, or we would talk about a laser. So the laser does the same thing that the chemicals do, except it's using energy to burn the surface. Most lasers today are fractional, meaning that they're not taking away everything like a peel would, right? The liquid from the chemical appeal is gonna take off all of your skin, at least the outer layer in a continuous fashion, whereas the fractional laser is creating dots and leaving some normal skin in between.

So the most common lasers for resurfacing would be Irbium and CO2, carbon dioxide. And again, within those, there's different levels and different energy settings, and certain patients are not candidates for those in summer. So that relies heavily also on the experience of the provider. Now, there's some very safe lasers that are very low grade, like a laser-like clear and brilliant, very low risk at causing a problem for most people, and doesn't always have

to be a doctor performing the procedure, depending on your state laws can be an aesthetician or a nurse. Are these painful procedures to people need some sedation for them? Usually no, it depends on your pain tolerance. The heavier duty lasers, the more powerful are going to require some type of anesthetic, whether it's an injection, topical anesthesia, sometimes sedation. And often we do them in combination with surgery, so my patients asleep. type of anesthetic, whether it's an injection, topical anesthesia, sometimes sedation. And often we do them in combination with surgery, so my patients asleep while I'm lasering

them, we're doing one thing and then we're lasering another. That is something where you need a consultation and someone to evaluate your skin type and say, okay, this is my recommendation for you based on my experience and my knowledge, my training. But there are also, I think, what you would also lump into that category would be the energy devices that are now becoming more rampant, and these are designed for facial adjuvenation in terms of tightening, not the skin surface. So the first generation, one of the things like thermos that use radiofrequency, or today

you see all therapy, which is a focused ultrasound. You're seeing more plasma devices. The idea is heat is stimulating collagen synthesis and contraction and tightening. And for the most part, I'm underwhelmed with these technologies. In a way, it's almost like, you know, I kind of referred to like the emperor, where it's no like, you know, I kind of referred to like the emperor wears no clothes, right? where the doctor has invested a lot of money in this device and so they have some stake in it working whether it does or not and the patient is investing in substantial amount of money, potentially for them

and so you don't want to feel like you're a sucker and you've spent a lot of money on something that doesn't work but you have to look at the before and after photos. And if you have a hard time telling which is which, then you're not going to see a lot. Is anybody doing anything with PRP in terms of facial rejuvenation? PRP, Plaklaverge Paisma, has obviously achieved some success, although I think it is still somewhat questionable,

but at least anecdotally, there are people who are certainly reporting success in the periphery, for example, treating orthopedic injuries with it. And it started out, I think, in the dental realm for dry sockets, I mean, I think they sort of pioneered BRP in a lot of ways. Well, I didn't know that.

And I think, you know, here in New York, I feel like you can get BRP on every corner now. It's become so widespread in medical spas and cosmetic practices because it's so accessible for providers to perform. And it's always a talligas. Yes. Yeah, of course. So what that means for people is it's your own. They take yours out, they spin it, they return it versus aloe, which would mean you could use it from a donor. So what do they, what do people do in skin with this? I think you probably feel the same way as me.

Whenever there's something is like touted as like a cure all, you have to be a little bit skeptical. All right, can PRP help your joint pain and can it make your skin look smoother and can it replace your hair and is it going to heal all your wounds? And answer erections. I know, so I think it's a nice thought to think that we have that the magic that we

were looking for all these years was inside of us, right? It's like, uh, it's like the end of a Disney movie. But is it true? I mean, I'm skeptical. I've had PRP injected on my head, my scalp for, um, prevention of hair loss. And I'm underwhelmed. But I mean, think about, all right, so let's talk about for hair loss. The mechanisms that are causing hair loss in men, the antrogenic alopecia are still happening, right? Whether I do an injection or not. So how often are you gonna have to do it?

If, let's say it does work, right? You're creating, what does PRP do? I mean, you're talking about the platelets in your blood, which are, what is their purpose? They're there to help with injuries, right? They clot. They send out signals saying we have an injury here. So, sending more growth factors. Let's heal this injury. There's some angiogenesis, neocologenesis. So let's explain this term. So angiogenesis means recruiting more blood vessels, yeah. Building neocologin, more collagen.

We're trying to create a scaffolding and a framework to heal a wound. So when you have a cut on your arm and your plate, let's go to that area and they create a clot. They send out chemical signals to also do those other things. So we do heal ourselves, right? And if you're an animal in the woods and you get a gas in your leg, then you'll get a clot there and it'll contract and hopefully if you don't get infected, then you'll just have a scar. So for hair growth, if you inject it in your scalp, then I think there's probably a role for the ideas that you're creating in an environment that will

help to stimulate the existing stem cells that lie within your hair follicles, maybe creating more blood flow to allow for more hair or prolong the cycle of hair growth. Right, so the hairs grow longer, so you have more of them, and they become potentially thicker. But we still have the hormones of 5HT

is still in that area, and it's still fighting in the opposite direction. So if you do have a benefit, and let's say you do three treatments a month apart and you look a little bit thicker, then how often do you have to repeat it like every four months or every three months or? Wow, that's so a lot of work. And for me it was uncomfortable. I mean, look, you can do a ring block.

You can numb the area by injecting all the way around your head. I drew my own blood, but then I had my dermatologist friend inject it for me, but by the time I did that, the anesthetic that we injected had already worn off, and it was uncomfortable. I tolerated it, and I don't think it was, I didn't get a great result. I think it's known to work better for females, but the literature is not, it doesn't support it very strongly. I think maybe it will eventually, we just don't have good studies on it. And do you stratify by, you know, patients that are taking five alpha-bredactase inhibitors

so a drug like propitia or avidart that block the conversion of testosterone to DHT, the hormone that's responsible for hair loss, and then you can also apply these topical things like menoxidilion. I mean, you can go all in and that probably is better. Or if you're having hair grafting, like transplants, then it's often done at the same time in DPRP.

So I think I haven't seen any negative to it other than sometimes I think it's ineffective. And I think it's one of those things also like these skin tightening lasers, the facelift lasers that I think it's oversold. And the same thing with facial adjuvenation. You know, it's very popular to do this thing called vampire facial. What's that?

So that's taking the PRP, which is your, you know, from your own blood. That's where that term came from. This was like a, I think it's probably like a car dash. How much blood do they need to do a PRP treatment? Typically if I'm, so, and I offer this treatment, I don't over sell it, but I offer it in my practice. I'll draw, let's say, 10 vials, HCC vials. So a total of, let's say, 80 milliliters, and we spin it down.

I do a double spin method. And then we extract the platelets from, we separate it from the platelet, poor plasma, and the red blood cells. And then we, I activate those platelets from we separated from the platelet poor plasma and the red blood cells. And then we activate those platelets. That's also controversial. There's a lot of different methods of creating PRP and there's a lot of variety. And so that's one of the problems with the studies that are out there that there's inconsistent methods and not everybody is also quantifying how much PRP are they collecting. Some doctors have counters in their offices and they can say, okay, this is the concentration I'm delivering. But there are different methods and so you don't know what you're getting. Some people are injecting platelet poor plasma

and platelet rich plasma together and calling it PRP, but it's not necessarily... So if you're going to get PRP done, you should confirm that the person doing this has a way of counting the platelets. No, not necessarily. I think you just have to have has a way of counting the platelets. Not necessarily. I think you just have to have a proven method of concentrating the platelets. They have to know exactly what they're doing. I used to have a lot of experience with a pharesis when I was back in the lab, and this was super complicated.

I mean, at the time we were identifying, we were trying to extrapolate or rather identify lymphocytes. So you would put a huge 14 gauge needle in one arm draw a bunch of blood out, run through the A for ESA's machine, and basically return everything except the lymphocyte. That's serious business. Like you've got to know exactly what you're doing. It seems that PRP would be similar, wouldn't it? So when I...

Especially because the platelet and the red blood cell are the same color. Right. So you can easily be confused by color contamination. No, but you can see what the difference is. When you spin this down, the density should separate. The red blood cells are all that the bottom sections are all red. And I don't want any of that. But when I first started doing it, I did send the samples into the lab.

And we got an emergency call in the middle of the night. Your patient has super high platelets. And I was like, oh, it's okay, we were just checking it. But I did quantify it initially. I don't quantify it every time because I'm still using the same method. But then the questions, do you activate the platelets or do you just put them there and hope that they're going to activate them? And what do you activate them with? You can usually use some form of calcium, like calcium, gluconator, calcium chloride.

And so you just... And you dilute the platelets obviously when you inject them. Or do you inject them in that Concentrate? So I go from that ADCC of initial blood draw and I end up with about eight CCs total of PRP and that's fully Concentrated platelet. There's a little bit of platelet poor plasma in there, but I've gotten rid of most of that platelet poor plasma. So it's platelets suspended in plasma, but it's highly concentrated and many fold more than what you'd have in your serum. So the vampire facial, what we're doing is taking micro-needling pen, which is a pen that has 12 needles of the tip that are surgical, small needles, and these are not reusable,

they're perpatient. So it's a sterile setting. This pen has a motor and it's going up and down, driving the needles in and out of your skin. That sounds really pleasant. And a selected depth that actually doesn't hurt like you would think it does. You come in and I'll do it on you some time. No, I'm way past it. But I can do it at a depth of a millimeter.

I can do 1.5 millimeters, 2 millimeters. The deeper we go, the more you bleed. It doesn't hurt like you think. We numb you first with a topical anesthetic. But as you bleed from those channels, the face looks sort of bloody. And I think that's where the term vampire facial came. But then we're using the PRP on the surface, but also applying it as we're doing the needling to drive the PRP into those channels. So this is a hollow bore or solid bore needle.

Solid bore needle creates the trauma. And then how do you get the PRP into it? So this is variable among doctors and providers, but you apply, you can apply it to the surface and then needle over it, the ideas that you're driving it into the channel, you can apply it to the channel and assume that it's going to absorb because you have now like more porosity and you can also inject it directly under the skin like a filler. I'm not a major proponent of this procedure. I mean besides infection, what are the other big risks of this? It's actually a pretty low risk procedure. I think the biggest risk is financial loss. How much does this procedure cost? I would say on average it's about, you know, let's say, 800 to $1,200 a treatment for the PRP with the micro-needling.

You can spend a lot of money trying to look good, huh? Yeah, and you know, it's recommended to do it every couple months or do it every six months. I mean, so I wouldn't say, I'm not saying I'm against this procedure, but I don't think it's well proven because look, it's marketed for wrinkles, for acne scarring, for hyperpigmentation, for anti-aging, most of the time. So, again, look at the before and afters, because everyone's going to put their best work out.

So, if you look at the before and afters that I've seen, like, type in Instagram, PRP Facial or Micro-Netal-Link Facial or PRP injections, and look at the acne scarring pictures. And it's very hard to find good results that are not the result of differences in lighting. Right, you have a shadowy picture before, and then you have a front facing light in the after. And I would say the majority of the time, any benefit that you're seeing is from that.

There's some evidence, there's some evidence that it does help. And on a histologic level, yes, we're building collagen, but it has to be significant enough to be observable to the people around you. Otherwise, are we just like making ourselves feel better, or are we just jumping on to the bandwagon, or is it a money grab for a doctor's office? I mean, I'm not criticizing anyone for doing this, but I don't think it's been fully vetted. And so I think because it's a relatively safe procedure, I think it's overall, I don't think it's detrimental, but the results speak for themselves, you know. Is it safe to say then that these are three broad categories of facial rejuvenation?

You've got the chemical peels where you're like physically applying a chemical to the skin and burning it. You've got the laser peels where you're fractionating and selectively burning. And then you've got this whole PRP vampire trick. And microneedling, there's radio frequency needles. I mean, there's a huge realm of devices. And there's a lot of money in this industry. So there's definitely a drive that's motivated financially for companies to come out with

the next thing. And they have to sell the next thing to the net to the doctor's office. What is the typical FDA approval process? I mean, a drug typically takes more than 10 years to get approved. It's not that lengthy, and it depends if there's a predicate device. So if there's something that's a similar energy, it's much easier, and you can usually get it based on the previous device. A new device can take longer, you know, it depends, but it could be, it depends what it is. If there's an IRB

study that's been already done, it could be six months, it could be a year, it could be two years, but you also have to have an understanding that such because something's FDA approved doesn't mean that it's effective, it just means that it's safe. So there's lots of devices that I think are bogus, and I see them all the time. And you have to look at what's really going on here, is that this industry needs to make more devices. And I hate to say that I'm not trying to criticize my friends and my colleagues that are in the industry.

But I think we do have to step back sometimes and look at this and say, who are we serving? Are we serving ourselves? Are we serving ourselves? Are we serving our patients? If I do a treatment on you and it's not that effective, are you going to come back to me? I mean, you might, but if I do it again and again and patients are walking, you know, that's not the foundation of my practice. And hopefully it's not like that for everyone, but everyone has different motivations. And I would say I wouldn't do something I knew that I wouldn't

do on a family member. And hopefully that's how most people are. And it probably is. I think most physicians, most providers have good motivations, but it's not universal. And so I think you have to be careful. If you look for a device or a treatment, it's probably better to look for a provider that you trust than to look for the device. I mean, devices that you can find the same devices in most cosmetic offices, but how are they being used and who are they being offered to and are they being selective. I mean, there's a treatment that I do now that's called thread lifting, right? It's a dissolving thread that has

barbs in it and we sort of lift the skin non-surgically and more than half the people that come in asking for it, I turn them away because I think they're not candidates. And I think it's effective in a very select group of people. And everyone else I have to say I'm sorry, but I don't want you to walk around saying that it didn't work. So it's interesting. And I was in residency.

I remember one of the attending saying something that I never forgot, which was, he said, you know, your reputation as a surgeon is going to be much more about the patients you choose not to operate on than the patients you choose to operate on. Yeah. I didn't really understand that at the time, but it certainly has made sense later on down the line, which is effectively what you're saying. You know, if you, you only need a couple of times where you've done something on someone who shouldn't have had it done, and it can out outweigh the benefits of the, you know, the

hundreds of people who responded well. Yeah. And those are the ones you stay awake thinking about. Right. Right. We stay awake thinking about the mistakes. Yeah. It's true.

And hopefully you learn from them. I mean, the other phrase that you hear a lot is like to the hammer the world's a nail, right? And so how that applies to this field is when you go into someone's office. Are they are they willing to refer you to somebody for something that they don't do or that they don't think that they're the best person to do? If someone comes to me and they want tattoo removal, you know, I might have a laser that can do tattoo removal, but it, I might have a laser that can do tattoo removal, but it's not the best one.

If I'm not gonna do it on my wife, then I'd rather, you know, I'm gonna send her to my dermatologist friend that has the picosecond laser, then I'm not gonna push you into that box. So you, I think you have to be wary too if you're looking for a solution. You have a problem and you want a solution and you go to somebody, are they giving you the solution they have? Are they giving you the solution that you need?

So that could be another good filtering question for patients, which is when you meet with a doctor, say, hey, doctor, so and so, what are the types of procedures you typically don't do when you refer out? Right. And depending on their honesty with that, you may get better insight into who they are. Yeah, or if there's a procedure, let's say there's a problem that you have and you say, what is your solution and say, are there other solutions that are out there that you can discuss? So, in my area of interest, which is longevity, I spend a little bit of time, not a tremendous amount of time, but maybe 10% of my energy goes into thinking about the future.

What are the step function changes? What are the things that are out there that are not a part of what I do today? Because they're not ready for prime time or they're still very theoretical. But they're the things I want to keep enough tabs on because I hope that within the next decade or maybe beyond they become relevant. What fits that description in your field? What are the things that maybe aren't ready for you yet, but show promise?

It sort of makes me shudder to think about the future because I imagine myself 20 years from now, hopefully I'm still practicing. And I'm gonna look back and think like, well, we were in Plato's cave at that time, like we were seeing the shadows on the wall and not seeing the true objects, right? And I think we are in a sense, right? I mean, what is our, how limited is our understanding and the things that we, we don't know that we don't know them yet.

And so I think there are things, the things that we're doing today that I don't fully understand, like things like fat grafting, I use it and I think there's some predictability to it. But we don't fully understand why it works and how it works. And I think some of that relates to the stem cells, the stem cell effect, and you hear a lot about stem cells being used for all types of medicine. And it's the same with cosmetic procedures, and I do some procedures like that. I think of stem cells like I think of Chevy Chase describing ball bearings and Fletch you know that scene when he's like

You know, that's all ball bearing and the guy's like ball bearing. He's like that's all ball bearings nowadays And it's like that's like stem cells and ball bearings. It's just the same thing to me. It's the cure It's the PRP of the future Which remains to be seen how viable it is right right? It's the peer-up you have today. I think, look, there's something there. We know there's something there. We just can't exactly understand. We can put our finger quite on it. And there's some good science there now. But I think there's definitely going to be something. I have colleagues, I have friends that are doing a lot of stem cell treatments, whether it's intravenous, direct injections. I'm in a sense using nano fat as a stem cell,

you know, our fat is a rich source of stem cells. Yeah, this is counterintuitive, isn't it? People have always considered fat to be a totally inert tissue, but it's actually an endocrine tissue. That's true, right? And then why are we going to bone marrow for stem cells when it's closer to the surface, it's right there. And it's abundant in a lot of people.

When I do procedures with fat grafting, and I'm thinking, hey, I'm injecting fat and these fat cells are making them look younger, but it might be that the fat cells are not, none of them are too naive. Might be none of the fat cells at all. Might be the adipocines or the cytokines of the... Maybe it's a combination, or when I do, when I call nanofat, which is the stromal vascular fraction, or the soup that's in between the fat cells, and now I inject that with the fat, am I supporting my fat grafts with these factors?

Maybe. I'm seeing results and we sort of look at the literature, which is limited and we look at large-scale studies, which are also limited. We're looking for answers and doing these things and we try to stay safe, but there's definitely a lot to learn when it comes to that particular area. We know that. We look at other types of growth factors. I've seen some promise with fibroblast growth factor, which is also an injectable. I consider that a biologic there. In FGF world, which is the abbreviation for fibroresco factor, there are so many numbers to them.

Are you talking FGF 21 or? Well, this is something that's not even, it's not approved in the US. We don't have it here. There's been studies in Asia. Actually, I don't even know which version. I probably have it in my notes here because I haven't been able to do it.

But basically, are they harvesting a tolligas FGF from an individual? No, these are laboratory derived. Got it. So they're basically making FGF as a growth factor and just injecting it. Correct. And is this done in Europe? It's done in Asia. And what's the indication?

Volumization, facial volumization. And it seems to have long lasting results. So is the FDA evaluating this stuff now? I'm not clear about that. I don't know. I haven't heard of any studies. I don't know if anyone who's part of an IRB, but it seems to hold some promise. I think customization, like what you do in your practice,

and you're going to get down to the specific gene level eventually. And hopefully we'll be able to have a full map of everything And you're going to get down to the specific gene level eventually, right? And hopefully we'll be able to have a full map of everything. And each person will know exactly what drug is going to work well for them. And we'll be like that, I think, with, you know, cosmetic procedures, right? How is your skin going to respond to this laser? And what energy setting is appropriate for you versus this other person based on what your genetic screening told us? I think that's definitely in the future. I think customization in terms of 3D printing,

bio printing. So let's say there's something you don't like, you want to change your ear, we'll probably be able to print ears. We'll be able to print organs. I mean, there's no question that bio printing is in the future and will be able to replace blood vessels organ skin. That just seems so far out. I mean, as an interesting aside, I remember once being in your office and you showed me a bunch of surgical instruments that you designed yourself and had 3D printed and they were just Perfect, right? It was like you knew exactly what you wanted and you were like, well, this doesn't exist. I'll just make it. Right. I mean, in the past you would have to go to a manufacturer and you'd have to convince this industry person of what you want to make.

Make a fab. And then they're going to say, well, how many people are going to buy this and how useful? Well, I don't know. It's for me. It's useful for me. But then they're not going to make an injection mold for me based on, you know, let's say the 300-i-led surgeon specialists in the country. That's a limited market.

So with a 3D printer, I just draw what I want and I have it translated into a digital file and then I print it in a, there's a place in Long Island City, Queens, and they make it in stainless steel and then it comes to my office and I'm using them every day. And I've sent them out to my friends and that kind of thing, but we're in the future we'll be able to make what we want. Imagine a box that is connected to your computer and whatever you can imagine will be in that box. And it doesn't have to be just like in silly,

like it doesn't have to be a Hello Kitty made in plastic. It can be made out of multiple materials and so you can have, imagine your phone. I mean, I'm not trying to promote 3D printing and it's not my practice isn't 3 printing, but let's say just you pay on Amazon and then you press the button and then it prints the phone in your box and then you have the new iPhone. I mean, I think that's conceivable in the future. I mean, it's easily conceivable. And so the same thing with organs, I think there's a big.

So I didn't realize we could go beyond, I mean, I've certainly seen amazing things in 3D printing, where you're dealing with something that's homogeneous. But a phone is like a completely heterogeneous thing. Well, you can print circuits, you can print in different materials right now. You can print in different thicknesses and rubbers, so you can have a soft rubber inside of a hard rubber, so you can print a silicone breast implant, right? And you can make it exactly your shape. So I would scan your body. Well, I don't know if you want a breast implant.

Yeah, I'll probably pass, but maybe you want a peck implant, though. And I would scan your body. Are you saying my peck's certain inferior? You can use a little bit of bulk. I know you did the Joe Rogan podcast. So maybe you're thinking you need to be a little beefier. Yeah, I take a lot of heat for looking too scrawny on that. But I could scan your body with a 3D camera. I would probably get some CT scans of you as well to look at your bone structure, who design an implant that was, and you'd have, you know, maybe your left

pack needs to be a little bit higher and you're right, one needs to be a little bit higher and your right one needs to be a little more projection and it would fit your body exactly and it would be, let's say, soft on the inside and we'll firm on the outside so it feels like muscle but when you press on it, it's kind of squishy like muscle. But why stop there? Why not just make it out of muscle cells? We'll create a scaffolding and that scaffolding will populate with cells that we cultured from your muscle in the lab, and then we populated it onto the scaffolding and we grow it over a week or two, and then we just use a small incision and we implant it in you. Yeah, it's interesting. When I was in medical school, my very first summer, the first lab I worked in was the lab of an E&T surgeon,

and he was interested in growing septal condrocytes So taking these condro sites, these cartilage-producing progenitor cells and growing ears. And at the time, a very, very popular paper by... God, I'm trying to remember the name. It was Langer and Vacanti, two very famous guys in this space from MIT and Harvard. And they grew the ear in the mouth. Yeah, and we had that picture up in our lab. And we were trying to replicate. And of course, the year in the mouse. Yeah. And we had that picture up in our lab and, you know, we were trying to replicate.

And of course, the challenge at the time was coming up with biodegradable scaffolds. Yeah. And it has that, and of course, I haven't paid attention to this problem in 20 years, but- Well, there are scaffolds. Now, there's people that are printing blood vessel. Look, but I think it's a big regulatory obstacle. I think for me, what I was always interested in was printing in materials that are already approved, right, like silicone.

And I think the living cell printing will be there. But think about the regulation of if you're in the operating room and you want your tissue printing device, you have to approve it for every indication. So you have to approve it for making this thing for this procedure. And you have to, it's, it's like an endless permutation. So the FDA now is looking at 3D printing and they do have new guidelines and regard to that. And they're recognizing that this is the future and that medical 3D printing is growing. But it's definitely going to happen. There's been use of 3D printed implants in University of Michigan for infants with tracheum lacia It's actually considered to be 4D printing because these implants change over time

So the implants can grow with the patient and eventually can reabsorb but some with a baby with a narrow trachea They were building 3D printed cages and suturing the trachea to the cage to hold it open externally. And then as the patient grows, the cage enlarges and then eventually it can absorb. So the application here goes far beyond cosmetic surgery. It will be unbelievable. And I mean, it is believable to me, but I can talk about it for another two hours. It's just, it's mind blowing and it's exciting and it's frustrating because I want the next step

and it takes money, it takes time and it takes people that are interested. But if somebody is listening and wants to talk to me about developing 3D printed materials for surgical procedures, I mean I have something specific in mind. I've been trying to do that for a while. I have non-disclosures with a lot of large companies, but it's hard to get someone to invest money and something that doesn't give you a return in the next two years, right?

That's one of the, I think, the struggles. Well, speaking of people contacting you, I follow you on Instagram, because I just love looking at you before after photos, and how can people follow you? What's the best way to follow you on Instagram because I just love looking at your before after photos and how can people follow you? What's the best way to follow you? So on Instagram it's at Dr. KotlisCRKOTLUS. You can look me up on my website.

I have some videos and procedures and what's your URL. It's Dr.Kotlis.com, DRKOTLUS. But yeah, I share a lot of my stuff on Instagram. I think that's kind of fun because people can give me feedback. And I've seen my audience grow. And I'm following you on Instagram too with your race cars and your, my nonsense. Yeah. It's fun.

I think Instagram has connected me with a lot of people that I probably wouldn't have met otherwise. I mean, the internet and social media has made the world a smaller place in a way. Look, there's a lot of garbage to wade through, but it's not all bad. I don't think there's anything I do clinically that is really relevant to Instagram. Well, it's not visual, but it is, right? I mean, I think people are interested in seeing what you're doing in your day. I'm interested in your routines. I'm interested in like,

what is he eating? What is he? What is that indwelling device that you have that's measuring your blood glucose or what's going on your lap? You posted that picture on your whiteboard of your, like it looked like your Einstein theories, longevity, I mean, it's actually very poignant breakdown of your longevity approach. And I've seen you working on the whiteboard, so I'm imagining you writing that and sort of like

constructing your book that everyone's waiting for. But I think people are looking for insight into your life and into your philosophy. And it doesn't have to be. I mean, for me, it's a little bit easier maybe because I can show a before and after. But that's not, I think the before and after is not the important thing. The important thing is like the story behind the before and after. Like this is a teacher. And she came to me because she was recently divorced and she's thinking about finding a new partner maybe or maybe just feeling better about herself because she's surrounded by younger teachers. Like those kind of stories to me are the powerful things and what's important, like what I love about

what I do is that people bring me into their lives in many ways, not just for an injection, but to tell me about why they want to do it. Yeah. You have a video on your website that you produced, right? Right. Yeah. So that was just, I think, trying to convey my philosophy in a way that I thought was, you know, more powerful about the stories of people who are seeking my help or my advice.

And so I'm always thinking about the next one, I think I could do it better. But that was a fun project. Well, Brett, I can't thank you enough for this. I've learned a lot from you over the last couple of years. And I feel the same way. But I appreciate you taking the time to sit down today. I hope that people get something out of this. And again, it could be as extreme as they know that they want to do some of these procedures

and now they feel armed to scrutinize the providers out there and make sure they're getting the best care possible and alternatively it may be. I don't want to do any of that stuff but boy if I can just do these three things, you know put my sunscreen on, use some red nook acid and maybe a little topical vitamin C, that's going to make a 10-year delta. Well, thank you for inviting me to do this and for leading the way for many of us in terms of searching for the answers and also sharing those answers. It's great to see you and I will continue this discussion, I'm sure. Alright, see you. You can find all of this information and more at peteratiamd.com forward slash podcast. There you'll find the show notes, readings, and links related to this episode.

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