The Peter Attia Drive - #355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance | Tanuj Nakra, M.D. & Suzan Obagi, M.D.

Episode Date: June 30, 2025

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Tanuj Nakra and Suzan Obagi, two leading experts in aesthetic medicine, join Peter to explore the science of facial aging and skin health as well as the responsibilities physicians face in the world of cosmetic procedures. In this episode, they examine the biological and hormonal drivers of facial aging, the evolutionary and psychological foundations of attractiveness, and the impact of modern media on beauty standards. They discuss the rise in cosmetic procedures among adolescents and the ethical responsibilities of physicians in these cases. The conversation then shifts to a practical, evidence-based guide to skin health—covering the use of mineral sunscreens, retinoids, vitamin C, and tailored skincare routines, as well as the management of acne and the psychology behind aesthetic consultations. The episode culminates in a candid, personal assessment of Peter’s own face, offering a revealing look at what aesthetic medicine can achieve and how to think critically about pursuing it. We discuss: Tanuj’s and Suzan’s training and expertise, and the evolving field of aesthetic medicine [4:00]; The biology of the aging face [10:45]; Why facial fat atrophies with age while body fat tends to accumulate [17:00]; How chronic stress accelerates facial aging [20:30]; The evolutionary biology of beauty, and how modern lifestyle, culture, and medicine interact with these ancient aesthetic instincts [25:30]; How social media and influencers have rapidly shifted aesthetic trends toward exaggerated features and unrealistic beauty standards [36:45]; The ethical challenges, financial incentives, and social pressures shaping modern aesthetic medicine [42:00]; The concerning trend of teenagers seeking cosmetic enhancements: the ethical and cultural impact of early beauty pressure [51:45]; Protecting the skin: UV damage and sunscreen recommendations [58:15]; Strategies for minimizing skin aging: retinoids, vitamin C, and evidence-based application methods [1:09:00]; Effective daily skincare routine: cleansing, antioxidants, retinoids, moisturization, and more [1:18:45]; The playbook for managing acne [1:31:00]; The 4 changes of aging and the complexities of aesthetic consultations including the anatomical, psychological, and ethical factors physicians must navigate [1:39:00]; The 5 R’s of rejuvenation [1:50:15]; A facial aging analysis and cosmetic strategy using Peter’s face as a real-time case study [1:53:00]; The decision-making process between fat grafting and dermal fillers for facial rejuvenation [1:56:30]; How self-image, eye aesthetics, and fleeting photos drive the desire for cosmetic enhancement [2:01:45]; Advice for wrinkles, causes of dark circles under the eyes, and the importance of facial symmetry [2:05:45]; Considerations that shape clinical decision making around fat grafting and other procedures to address the eye area [2:11:00]; The evolution of facial cosmetic surgery techniques, the serious risks involved, and how physician skill and procedure selection greatly impact outcomes [2:21:30]; How patients can make informed and safe choices when selecting a cosmetic surgeon [2:27:15]; A comparison of ablative versus non-ablative skin resurfacing treatments, laser vs. peels, and more [2:38:45]; How treatments are chosen and customized based on patient-specific factors [2:48:00]; The lifelong human desire to align physical appearance with self-identity [2:52:45]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free.

If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to PeterAtiyaMD.com forward slash subscribe. My guests this week are Dr. Tanuja Nakra and Dr. Susan Obaji, two highly respected physicians in aesthetic medicine. Tanuja is triple board certified in facial and ophthalmic plastic surgery, faculty at the Dell Medical School and the director of the cosmetic surgery fellowship at the TOCI

and FACE Institute in Austin. Susan is double board certified in dermatology and cosmetic surgery fellowship at the TOCI and FACE Institute in Austin. Susan is double board certified in dermatology and cosmetic surgery. She is an associate professor at the University of Pittsburgh and the director of the UPMC Cosmetic Surgery and Skin Health Center, where she leads advancements in cosmetic and laser surgery on a global health scale. In this episode, we talk about the biology of facial aging, how hormonal changes impact facial bone structure and skin integrity, and the critical role

that hormone replacement therapy plays in preserving a youthful appearance. We talk about what makes a face attractive from an evolutionary perspective and a psychological perspective, and how modern media and social media filters are warping and distorting those standards. Talk about the troubling rise in cosmetic procedures

among teenagers and how physicians can navigate ethical decisions around these things. And then we really get to the substance of this podcast, which is we talk through a practical and science-backed approach to skin health, including the essentials, sunscreen, retinoids, and vitamin C, and many more things. We talk about mineral sunscreens and why they are likely superior to chemical or organic sunscreens. How to use retinoids correctly based on skin type

and sensitivity. What a personalized morning and evening skincare routine should look like, including cleanser type and application order. The medical management of acne, especially cystic acne. The psychology behind aesthetic consultations, and why trust, motivation, and emotional readiness are critical before undertaking procedures. And finally, and perhaps most importantly, at the end of this podcast, we turn the tables. I'm the patient. I'm sitting across from them and I'm asking them to be as brutal as they need to be and offer an assessment of what would be truly possible if someone in my shoes wanted to take all the steps of aesthetic medicine and apply them to their own appearance from the neck up.

This was the most illuminating discussion. And while I realized that listening to it, it might sound like they're being overly harsh or critical, you have to understand this is exactly what I wanted. I wanted to understand these things. And honestly, I came away from this realizing there was more quote unquote wrong with my face than I ever imagined. Again, will I do anything about it? Truthfully, beyond the new skin regimen, I have adopted probably nothing, but nevertheless, I was intrigued by this. And I think that many of you who have been thinking about these things as well will

come away either deciding maybe there are things you want to do from an aesthetic standpoint or at a minimum just taking care of your skin might be the right thing to do and clearly you'll come away from this with a great regimen for how to do that. So without further delay, please enjoy my conversation with Dr. Tanuuj Nakra and Dr. Susan Abadji. Susan Obagi. Tanoosh, Suzanne, great to have you here both. You're obviously in Austin. You traveled from Pittsburgh, right? Yes. Awesome. Well, this is a topic we get asked a lot about. Sometimes when we get asked about topics, I already know quite a bit. This is absolutely an example of the opposite of that. This is a topic

we get asked about a lot and I would argue that my knowledge is even below that of the general public. I can't think of a time when I've done a discussion on the podcast on something where I know less than all things related to the health of one's skin and appearance. So, yeah, thank you very much for both being here and thank you for helping me even think about how to structure a discussion on this topic. Maybe before we jump into it, just give us each a little bit of your backgrounds. I think it was helpful to have not one but two experts here because you guys have sort of a different specialty. Obviously within medicine, you have a different specialty. You overlap in things, but obviously do some things different.

So tell us a little bit about your training, your background and what you focus on. Yes, thanks for having us, Peter. It's a pleasure to be here to talk about something I'm quite passionate about. And I know it's very confusing for a lot of listeners to understand aesthetics and we'd love to demystify it a

little bit. So my background, my core specialty is oculofacial plastic surgery. I trained in eye surgery and in facial surgery mostly at UCLA. Do you train in plastic surgery first? My original background is ophthalmology and then I did fellowships in ophthalmic plastic surgery and then another fellowship in facial cosmetic surgery in addition to that. My practice is limited to eye and face plastic surgery, basically.

That ranges from reconstruction of children, cancer reconstruction for elderly, and all the cosmetic surgeries that we can perform on the face. Including nose, neck. Including nose and neck, yes. I moved to Austin 16 years ago after training at UCLA, joined a large group here and we're also all in the faculty of the Dell Medical School.

So we are actively involved with academics, teaching, residence. We have a fellowship program, two fellowship programs in our practice. It's a real pleasure to be involved in academics because it's the cutting edge of science and we'd like to perform clinical research and in the academic community, which is how I know Susan, there's a lot of collaboration among specialties and we have an opportunity to dialogue

and further the specialty that we care so much about. Awesome, okay, and Susan, you are a dermatologist by training? Yes, and then I did a cosmetic surgery fellowship, and I am in academic medicine as well. I'm at the University of Pittsburgh. I've been there about 24 years. So I got to see the evolution of this entire field, starting with what we used to do at the time was surgeries

and then maybe a few collagen injections. And now we have the plethora of all these tools at our disposal. And I train residents, medical students, and I have visiting physicians from all over the world that come in. And I love the multi-specialty collaboration that we have because we both belong to the American Academy of Cosmetic Surgery. And we hear a different approach from different specialists, maybe on the same procedures.

In my practice, I focus on everything with regards to skin rejuvenation, peels, lasers. I also do a lot of fat grafting. We do body liposuction, mini face lifts, eye lifts. But everything when it comes to the face is about really enhancing the appearance of the skin first because my feeling is that's the most important thing that everyone sees. So when a patient comes in like you, who has not had anything done or doesn't know about the field, I actually like that because I can take that opportunity to really educate them and pick the right things for them. I appreciate you noticing I've had nothing done. We were talking before the podcast,

but it's worth me stating this now, again, for everybody to hear. There is something about this field of medicine that I have such a block in my brain to understanding. And Tanuja and I have met before. Tanuja helped me with a scar. So Brett Kotless, a friend of mine who's actually been a former guest on the podcast,

introduced us. I face planted one morning due to some hypotension and sustained a pretty nice scar here that I think for the most part is largely invisible today, probably in part because my face is leather to begin with, but I think in part because we did some 5-FU microabrasion, we did a whole bunch of stuff and I was actually pretty diligent about staying out of the sun for the period of time after it, et cetera.

I think we've also done a Botox treatment, which it's certainly reduced the wrinkles. Obviously, it's long gone, but I'd love to talk about that. My wife and her friends, it's almost like they've done fellowships themselves the way they talk about this stuff. And maybe that is just true of women in their 40s, but the way they go on about these techniques, it must sound like that when I talk about cars in front of them. It's so foreign. So as I was saying earlier, I have taken a strategy towards my appearance that is probably illogical, which is I'm just going to ignore it because I don't understand it and I'm going to focus on things I understand.

I would view it as an enormous win of this podcast if in a few hours I decided to do something that was sustainable and going to help me look a little better at 62 than I should look. I'm 52 today. I looked at a picture of myself 10 years ago before this podcast. What a difference 10 years has made. I look so much worse today than I did 10 years ago. I guess that's not uncommon. I would guess 42 to 52 is a big reduction in appearance.

But it also made me realize, wow, the next 10 years, that reduction will probably be greater if I don't do something proactive. And to just make one final point about my abject laziness on this topic, I can't even bring myself, this is going to sound so disgusting, I can't even bring myself to wash my face before bed. Which my wife is like, you are so disgusting, just wash your face. But I'm like, eh, it's not like I'm that greasy, who cares? She's always buying products for me,

I just can't bring myself to do it. So, you guys have your work cut out for me, because if I can be educated on this, you can change the world. I was about to say that, Tanish. We have our work cut out for me because if I can be educated on this, you can change the world. I was about to say that, Tanish. We have our work cut out. Let's start a little bit with the biology of the aging face.

Again, we're going to limit our discussion today to the neck up. Not that there isn't other things that are completely relevant around cosmetics, but that's just a big enough topic. I told you that when I looked at myself 10 years ago, I couldn't believe how much better I looked. But I'd have a hard time telling you why. I can't put my finger on it, but I bet you can without me showing you those pictures.

Why did I look better at 42 than 52? That's exactly how my patients come in. A lot of times they'll come in and they'll say, I feel like I look tired. I don't know exactly what's going on say, I feel like I look tired. I don't know exactly what's going on, but I feel like I look tired. And I have these beautiful diagrams in my office and I show them the face of someone who's 20,

the face of someone who's in their late 60s and I walk them through the changes. And the first thing I do is we show them the diagram with the skin peeled off. And you see about 11 different fat compartments in the youthful face, on each side of the face, that are plump, they're robust, they're giving volume, and they're giving a padding between the skin

and the muscle and the underlying bones. And then you look at someone who's in their late 60s and you peel the skin away, and you see a dramatic atrophy in all those fat pads. A few might increase in size, but the vast majority undergo atrophy. And then in addition to that, I show them what the bones are doing at that age too. So we look at the bony vault of a 20-year-old and the opening around the eyes are nice and

tight. The cheekbones are nice and wide. The jawline has a really good definition. And then you look at someone who's in their 60s and all of a sudden the opening around the eyes are wider. Really? Cheekbones are less wide, jawbones less wide, less height.

And so now you've got that scaffolding that's diminished and all the skin looks like it's just hanging. And that's what's happening. But it starts early. So what I see on most of my patients is when they come in and say, I look tired and you said it. You look at your pictures 10 years ago

and you look now and you don't know what's different. The first changes around the eyes. And I'm sure tenders can add to that. But basically what's happening is you're getting more bone loss around the eyes, more fat atrophy around the eyes. So you're starting to see the underlying anatomy, which was padded before. So first of all, this is completely news to me.

Is this loss of bone comparable to what we would see in the reduction of bone density in a person's hips as they age? So a lot of it is hormonal. A lot of it is hormonal. And you see it, especially in women. If they start to see the aging changes, they'll start to identify that in their early 40s.

So this, in other words, is probably another reason why women would benefit from hormone replacement therapy, because maintaining estrogen levels would maintain bone health. Absolutely. And actually, that's something we need to stress more and more to them, because it starts in their probably early 40s and then it just accentuates over

time, but by the time they hit 50 all of a sudden now if we're looking at them cross-sectionally a group of 50 year olds compared to guys who are 50, the men are holding up pretty good. Their facial bone structure is good, their fat volume is good, their muscle thickness and skin thickness is good. But from 50 to 60 or 70, women will age about 20 years faster than men in the lower face especially. They will get so much atrophy in the mandible.

That's why women start to say, I hate my neck. I hate the loose skin in my neck. Because if the mandible is retracting, the neck becomes looser. Yes. Again, this is remarkable because if you, bringing it back to the one thing I know about bone, it's when you look at men and women aging from a skeletal system, they're both going through a comparable decline starting in their 20s because we both peak, both men

and women peak in the early 20s. But at about 50, women fall off a cliff, whereas men just continue a linear decline. The gap really widens. Interesting to realize that the exact same thing is happening in the face. That's exactly it. That's why women come in, the first thing they say when they're 50 is, I hate my neck. I think we jump to try to surgically correct it or to augment it with fillers or neuromodulators

to keep the muscle from pulling down. But I think we have to have a talk about hormone replacement. You have to catch those women before they're far along into menopause. Again, I'm blown away by that fact. And if I could hop in for a second, I love the direction of this conversation because I don't know if people realize

how much science there is about the aging process. There were some seminal studies by Rorick and Pessa in the 90s and 2000s that delineated a lot of what Susan's talking about, where they looked at CT scans of the same individual over time. I think some of those studies had a 15 to 20 year span. And there was quantitative calculations of bone density and bone projection

of the mandible, the maxilla, the frontal bone. And these bone structures all recede with aging. And the bone is the foundation for the face. And so when we're talking about youthful fullness of a face, a lot of that is the bone structure. And then as Susan said, of course, the fat compartments are a critical component of our facial aesthetics. And as we lose all that volume, the reason why people start to look more skeletal as we age, one of the most common areas that I see in my practice is people talking about their under eye bags and their lines that are showing up in their eyelids and their cheek area. It's because we have ligaments that attach the skin down to the bone. It's called the osteocotaneous ligamentous network of the face.

And those ligaments are the same for every single individual, no matter what your ethnicity is. Of course, there's variations on theme, but the orbital retaining ligament, the malar ligament, the temporal ligament, the mandibular ligament, the masseter ligament, these ligaments are always present. And then as we lose that facial volume from fat atrophy and the bones move backwards, these ligaments are tugging on the skin and these deep lines

start to show up. And that's, I would say, one of the fundamental changes we see with aging of the face. 06. What I guess I don't understand is the following. Again, I'm just going to use myself as the example because I think I'm probably reflective of many people. Ten years ago, I was less fat than I am today. Same body weight, by the way.

Almost to the pound, I'm the same as I was 10 years ago. But I would bet my body fat was two or 3% lower. In other words, I have accumulated fat in my body. Why am I losing fat in my face? What is it about facial subcutaneous fat depots that atrophies when for virtually every person, the opposite is happening when they age. They're actually adding adipose tissue subcutaneously and unfortunately, often viscerally.

If I may answer that one, it's interesting because I talk a lot to my patients about that. Now, the vast majority of my patients are female. So they'll come in and they'll see me and I can look at their face. Let's say they're in their late 30s, early 40s, and I can guess how many kids they've had because what happens is you gain weight in pregnancy, it doesn't have to even be a lot, but then most people, if they're fit,

they lose that post-pregnancy weight. I've had none, by the way, just in case you were wondering. That's good to know. And then they lose that post-pregnancy weight, and what happens is they go back to being the same weight that they were before they got pregnant, but their face is thinner. Second baby, more so. By the third baby, it takes a significant toll on the face, that weight gain, weight loss. So you can tell, looking at a female

face, almost how many times they've gone through that weight gain, weight loss. And so what happens, the facial fat pads are very unique metabolically. Like I mentioned, most of the time they're just atrophying as we age. There are a couple of compartments that might in time get thicker, such as the nasolabial fat compartment, which is why some people have that deep fold. But for the most part, they atrophy.

And so if you go through this yo-yo change with your weight and you're progressively getting thinner and then getting some weight back, it doesn't go to the face. It goes to parts of the body we don't want, but the face continues to undergo that weight loss or the volume atrophy. But do we know biologically,

because it's almost like a lipodystrophy, where the fat cell becomes defective and can't reaccumulate triglyceride or whatever it is, whatever form it's gonna store it in. Like so many things in medicine, there are things that we know and a lot that we don't know. Yeah, so we know that it's happening. We don't actually know the biochemical mechanism

necessarily. We know some. I think we're just starting to understand the individual receptors and specific nature of different areas of fat. So for example, even in the eyelid region, when we're doing surgery on the face, we're doing surgery on the upper eyelid, we will see that the fat pads have different colors.

So the medial orbital fat pad is lighter substantially compared to the much yellower and more orange lateral fat pad. And that color will be different than the buckle fat pad. And one of the differences, there's beta-carotene differences in the fat pads. And that's probably just one of maybe 100 that we'll eventually find out is contributing to the differences in the fat population. So we know that facial fat is different from abdominal fat, which is different from lower extremity fat.

And we know this also practically speaking, because when we're doing fat grafting procedures, the source of the fat can have a different long-term effect when it's ejected into the face depending on what the source was. So we know that fat is not the same throughout the body and it's not the same in the face. There is a general consensus that beta-carotene is an anti-inflammatory mediator. Higher concentrations and lower concentrations of beta-carotene can have some effect on the metabolic health of fat, especially how it responds to stress. And so in the world of longevity, there's a lot of discussions about managing cortisol levels. Sleep is helpful.

Having lifestyles that reduce your overall stress level is good for your overall health in numerous ways. That's also true for the fat and the skin of the face because again, a lot of this is not fully explained, but we're starting to get more and more details as basic science progresses in this area that these fat compartments and the skin, which we can talk more about, is exquisitely sensitive to stress that the body is experiencing cumulatively over time. So a lot of times people feel like they're really aging in their forties. People have midlife crises.

They're probably experiencing the maximum stress in their life at that stage typically. And I'm just generalizing here, but people will have a busy career. They've got kids, they've got financial worries. And so people are under a lot of stress in their 30s and 40s. And that contributes to some of the more rapid facial volume loss changes, some of the skin aging changes with elasticity, collagen, elastin changes that occur over time. And so that's where I think that this conversation really plugs in quite well into That's where I think that this conversation really plugs in quite well into the line of education that you're providing your followers in terms of longevity benefits because it

overlaps here with cortisol stress and inflammation. And what's interesting is that chronic elevation of cortisol in the body is actually anabolic to fat. You accumulate fat, it's catabolic to muscle. Muscle decays, fat accumulates. It sounds like you're saying, okay, that's true from the neck down, but above the neck, chronic elevation of cortisol might have the opposite effect. It might actually be catabolic to fat and therefore it accentuates the fat loss.

Am I hearing you correctly in that? Yes, I believe that's correct. Just yesterday in my clinic, I had a perfect example of this. I had patients back to back. One was 68 year old woman who has lived a very comfortable life. She comes from affluence, hasn't really had to work too hard in her life and has maintained things. Of course, she's just skincare products and she's had a little bit of fillers and Botox, but no surgery. And she looked 10 years younger than her stated age

because of the kind of life she's been living. And then the next patient I saw was from rural Texas, has been in the sun, has never been taken care of her skin, was working kind of a blue collar job, difficult life, couple of marriages failed. She looked like she was 10 years older. And this is common. I'm sure you see this all the time as well, Susan. kind of a blue collar job, difficult life, couple marriages failed. She looked like she was 10 years older.

And this is common. I'm sure you see this all the time as well, Susan. So lifestyle stress factors clearly have an effect. And one of the reasons why, Peter, perhaps this is not an area that you've delved into in your vast experience in medicine is because the quality of science and aesthetics has historically been pretty poor. You're giving me way too much credit. I wish I could say that was I have delved into plenty of things where the science is

poor. There is some other mental block I have. It might be that I'm not smart enough to understand it all, but we'll continue and I appreciate your and another reason why it becomes very murky to sort through the science, and I'm sure this exists in other areas of medicine too, but a lot of the individuals, corporations, forces that are delivering science to the masses and to physicians who are eating it up and regurgitating it to their patients, these sources are questionable. They're profiting, as you I'm sure realize, the aesthetic industry is a very, very lucrative industry worldwide, especially in the

United States. There's a lot of forces where those that are delivering the science have a vested interest in receiving monetary benefit from what they're pushing out, and that makes things murky. But I think going back to the fat compartments, think about it with our patients in general, the role of the fat compartments in the face are to allow muscle glide. So the muscles can move over each other

when you smile, talk, eat, chew, all of that. And I don't understand why they should undergo such atrophy over time for such an important function. But then we look at the metabolic activity of the fat in other areas of the body, and it's very different. So when we do fat grafting, for example, and we take fat from the abdomen,

which has the highest concentration of stem cells, pre-adipocytes there, and put them in the face, the fat starts to behave more like the fat from the abdomen when you put it in the face. So it retains its source. Yes, and then when they gain weight, you have to tell your patients specifically, don't try to gain more than a few pounds,

because it will hypertrophy like it would an abdomen if they gained weight. Interesting. Is there an evolutionary explanation for any of this? I mean, I don't know if aesthetics, if you think about this through an evolutionary lens, but I mean, historically, we didn't need to look good beyond our 20s if the purpose of looking good was to attract a mate. So,

none of us sitting around this table need to look good in Darwinian terms because we're not reproducing. Do you think that factors into any of these observations? 100%, yes. And so, I think it's also good for the sake of the overall podcast for us to talk about the evolutionary aspects of beauty for just a moment, which could be a whole separate podcast. You could invite Nancy Etkow from Harvard to come talk to you about the psychology of beauty. She wrote the definitive book on it and summarizes all of evolutionary beauty science. I have all of my fellows read her book because I think it's just a beautiful compendium. The evolution of beauty is a fascinating topic because when you think back to the evolution

of humans, why do we even care about beauty? The interesting fact is that we're actually genetically hardwired to appreciate beauty. And so there's this famous study from the University of Texas in the 1980s, Judith Langlaw is sort of a well-known name in psychology. She did what's called a preferential looking study of infants. I don't know if you've heard of this study, but it's fascinating.

She took newborn infants who were literally weeks old, barely able to see six inches away from their face. She showed them pictures that are considered beautiful, faces that are beautiful, and faces that are less beautiful. And these newborn infants who've not yet been influenced by society preferentially were looking at the beautiful faces. And so that natural drive for us to appreciate beauty is present even at birth. Does that suggest that there is a definition of beauty that arcs time? Because I was actually going to ask a question, which would be a great detour for us to take

after this point, about how much is the definition of beauty changing? In other words, if you took Matthew McConaughey and transported him back 10,000 years ago, would he still be a hunk? Is sort of where I was going. I would say that the answer is generally yes. There's two layers here. The first layer is the genetic, biologic drive

that we have to appreciate beauty in men and women. And then of course, there is a societal impact that conditions us to appreciate certain versions of that beauty. But the fundamentals have been studied in the 90s. And the fundamentals are that all humans across ethnicities all over the world have been studied and they appreciate certain features of beauty. So there's symmetry of the face, facial proportion, and then they also appreciate sexual dimorphisms. Those are kind of the three categories. And so symmetry, when a face is symmetric, it sort of connotes if you're out there in the reproductive world looking at the pool of your options, symmetry means that this individual

most likely has had good development and nourishment and is most likely going to have good genetics for me to potentially connect with and pass on genetics together with. Facial proportion is similar. In fact, to go a little deeper into that, averageness is really what people are looking for. On the surface, that doesn't sound so attractive to be average, but if you take a hundred faces of men, a hundred faces of women and average them all down to a single composite, you will average someone who has a little bit of a big nose or a small jaw or some aspect of their forehead shape. And all that gets averaged down into a composite that is considered

universally beautiful across cultures. And again, that sort of unconsciously in the mating pool from an evolutionary standpoint is connoting healthy genetics to be able to pass on your genetics with. And then the third area, which is sexual dimorphism, we're talking here about strong jaws and med, full lips or big eyes in women. These tend to connote either higher estrogen levels or higher testosterone levels depending on whether you're looking at women or men. And again, that's fertility, that's subconscious communication of fertility.

So those are the genetic absolutes that exist in all of us on the planet. And then on top of that, as you're bringing up social media in this culture, this particular way of wearing your hair is considered beautiful. Those are conditioned upon us based on society, but it overlaps on top of that underlying genetic basis that we all have. And how much can those things override? Again, I'll just use examples that we can all appreciate. I was talking with my daughter about Cindy Crawford.

And I was like, look at a picture of Cindy today. Look at a picture of Cindy in the mid-1990s. I mean, there is simply no way to describe beauty in any other way. It doesn't matter what your type is. Everybody would acknowledge Cindy is absurdly beautiful. And so you're saying she is hitting it out of the park on those three things,

independent of what the in vogue look of the moment is. If it becomes the case that blondes are really attractive, it doesn't matter, Cindy will override that. If it becomes the thing that women who weigh 30 pounds are attractive, it doesn't matter, Cindy will override that. Is that becomes the thing that women who weigh 30 pounds are attractive, it doesn't matter. Cindy will override that. Is that kind of what you're saying? If you look at even different races, a beautiful person in each of those, they actually all

have similar measurements. So there are these masks that you can superimpose onto any image and really dissect down every single angle, whether it's the cheek angle, the jawline angle, the shape of the nose, the eyes. If you look at that across different races, they all have that same kind of measurement that they hit. Talking about those symmetry, the upper third, the middle third, lower third, the face,

the fifths going across the face, all of that, if you look at a beautiful person, no matter what race they are, they all kind of hit those measurements. Now then there are nuances. Like you said, you change your hair, you change your makeup, you can transform yourself. But if you take someone without makeup and just look at them that way, they all kind of conform to those measurements.

Doesn't this imply that over time, beauty should be one of the most preserved, concentrated traits of our evolution, given presumably the difficulty in acquiring a mate absent beauty. In other words, does it suggest that if you compared what we as a population look like today in 2025 to what we looked like 2,000 years ago, 10,000 years ago, 100,000 years ago, are we monotonically getting more attractive as a species? You would think so.

Because the selection should be ramping it up. Exactly. So we should be marrying someone that looks better or mating with someone that looks better and having our progeny look better. But what's different is our diet. Go back 100 years, 200 years, 1,000 years, we had to chew a lot more to really digest our food. We were working our maceters, we were working our jawline. Our palates were not as high, our jawline was a lot wider,

our teeth were stronger. And then as we have changed our diet and everything is cooked and we don't have to make as much effort to chew it, you actually get more crowding in your teeth, your jawline is a little bit less strong, your palate changes, more people become mouth-breather as opposed to nose-breather. That changes the shape of your face. And that has been measured anthropologically.

And so it's interesting because there's a whole book on breath and they go through the anthropology of all of that and the changes in the skeletons that they've gone back and studied. And so that does fundamentally change. Now we have kids that have to have teeth extracted or we have to have palate expanders now because we realize when we extracted teeth before,

we made the faces more narrow. And so now the thinking is let's preserve the teeth, expand the palate when the child is 10, allow those teeth to come in so there's less crowding, and then that face will be better and stronger jawline. So it is something that we've changed. And then just to head into the area of sociology for just a moment, 10,000 years ago, if you were born in some place on Earth, Peter, the genetic pool that you'd be interacting with was tiny. There's some fact that I'm probably gonna

misstate, but somewhere around 1900, most people on this planet had not moved within 10 miles of where they were born. And now it's totally different. And with social media and the way that we can connect with people around the world, not only because we can fly all around the world, but we're also seeing people on screens. The apparent genetic pool of faces that we're looking at has exponentially blown up into this very strange world that we're living in in 2025 compared to where our evolutionary biology has taken us. And I wonder also at what point in our development

did other, I don't wanna say higher order, but other things became priorities in finding a mate. All of us, I think when we were looking for our mate, appearance was probably not the top of the list. It was one of the factors. You had to be attracted to the person, but I would guess for all of us, it was, will this person be a great spouse?

Will this person be a great parent? Does this person share my goals and values and blah, blah, blah, blah, blah. It's hard to imagine our ancestors had the luxury of maybe thinking about those things. So yeah, all of this is to say, it's way more complex today. It is, to hear you guys describe this, it's entirely fascinating to play the thought experiment of transport a hyper attractive person today back in time 10,000 years. And I would just be so curious as to how they would react to that individual. I think it's a fascinating thought experiment. And I think that if they meet those criteria that we're defining, they would be considered a hunk or a beauty. Yeah. One last thing, and then we can certainly move on to the next topic. But in terms of timing, it is important for us

to be evolutionarily attractive historically, not in the modern era, until you're about 20 or 25. Because we weren't supposed to live this long. One of the issues that comes up with longevity and trying to maximize our health span is that we were not really supposed to be living this long and healthy this long. And so evolutionarily, mother nature's not helping us

with our appearance. Our appearance was supposed to carry us through until about 20 or 25, at which point most people were procreating at 14. And then at 25, their kids were at the point where they were getting ready to procreate and then led out to pasture at that point, basically. So evolutionarily, what we do every day with our patients is we're really fighting biology. We're fighting genetics.

We're fighting unnatural existence that we have as a luxury of being born in this era. 06.00 How much do you see, even just speak about it through the length of your actual careers, how much do you see trends that dramatically change what people are asking for? In other words, Susan, 25 years ago, did men or women come into your practice significantly looking for something different in terms of an appearance and an outcome that they wanted you to shape? Yeah, I would say that's such a loaded question because 25 years ago, if we think back, there

was no social media. Television was very basic. Maybe there was some shows that had live people on there on different shows where they would talk about beauty or fashion, but you had to actually tune in and watch those shows to be able to see the trends. Magazines came out and that was the extent of it. Now you have social media and various channels on social media and then you have what we now know as influencers.

And they're changing what our patients are seeing and what's driving them. And the biggest one that I can talk about is basically that very well-known family in California that has monetized their appearance and set a lot of trends, for better or for worse. It's great to see that they're making it okay to talk about enhancing your appearance or fixing something that bothers you. But where I draw the line is when they start putting out their transformations,

and this trend now is something that everyone wants to emulate, and you're talking about young women changing, physically changing their body drastically to conform to what you said is a trend, which is exactly it. And trends, as the word says, are not permanent. So what happens when that trend ends? The celebrities have the money to go to the doctors and reverse all that.

Now it will take surgery, and they will have scars to show for it or hide from that. But the patients that follow them, these young women don't have all of that income to go back and then re-transform their body, and they don't know the implications of that. We have a duty as doctors definitely to try to educate our patients about not following trends so strongly

and look beyond the monetary aspect of it. And so from that standpoint, I try to really educate my patients to stay away from things that are trending and really do things that make them look and feel better but natural for themselves. Because I don't know in your practice, but I know people want to come in for the enhanced buttocks,

Brazilian butt lifts, and the small waist. And that's something, again, that's being undone by that family now. And you're gonna see a whole trend that's coming out that doesn't look like that. What are kind of the top above the neck trend? So what I see as I look around is I see lip size being something that's getting bigger, smaller, bigger, smaller. Where are we today by the way in lip size? So just to continue Susan's line of thought there, we're in this again, unusual era where the influencers that are affecting society are much more in our faces than they have been historically,

and they're affecting young people at much younger age, which is why we just let my 16 year old daughter have a social media account. And that influence of these influencers is quite powerful because what happens is on social media which is the primary exposure that people are receiving these days about beauty the images that are being posted are not real they're filtered they're unrealistic exaggerations of some of those three original factors that we're talking about the symmetry proportion people will photograph themselves in such a way where they look more proportionate. They will pull their jaw in a certain way

to make their proportions look better. Someone has to teach me how to do this because any time I see a video of myself, I'm like, that is the worst looking thing I've ever seen. Like I need to learn these tricks. You need a 20 year old. And a lot of this is subconscious posing. That's a term that I have used for this concept where people are subconsciously

posing. Like for example, a lot of people, when they walk past a shiny building, will stop and look at themselves and kind of like adjust themselves a little bit. Is that new? Like in other words, did our ancestors walk by a stream where the water was still and look at themselves? I mean, not that we can know that, but-

Possibly, I think so. But I think it's becoming so much more exaggerated now to the point where we can confidently state that social media influencers are selling exaggerated forms of beauty ideals, like the sexual dimorphism. So we talked earlier about larger lips or bigger eyes. One of the most popular procedures in Northeast Asia is surgeries to make the eyes wider. You actually cut into the canthus and perform TOSA surgery to make the eye look bigger. Then of course, this trend to have bigger lips,

fillers are being used left and right, unfortunately, to overdo lip volume and plump up lips. Because the social media influencers are posting it, it's becoming more exaggerated because these exaggerated gender traits are becoming normalized. And so the family that Susan's mentioning in California, they normalized overdone lips to the point where people come in asking for it and we have to say, no, I'm sorry, this is not a good direction for us to take you in.

I was talking to somebody yesterday where I said, one of the marks of a great surgeon is a person who is happy to say no, is happy to say, I'm not gonna do this because I'm so good that I don't need your business. I can be as selective as I want about what I do. That allows two things. That allows the right patient selection to get a good outcome. So, the discussion I had with a patient yesterday was about orthopedic surgery issue. And the doctor said, yeah, I think it's time to do the surgery. The patient was saying to me, well,

he does sort of have a vested interest in doing the surgery. After all, he's a surgeon. I said, yes, but I can speak about this surgeon in particular. I've watched him say no to a hundred patients because patient selection is the most important thing for him to drive amazing outcomes. He'll say no until it's time. In the cosmetic world, you add another layer to that decision and clearly you guys are both on the spectrum of, you're both the top of your field,

so you don't need an incremental patient. You're happy to say no. There's also, don't need an incremental patient, you're happy to say no. There's also, it sounds like an ethical reason for you to say no. Where I'm going with my rambling question is, where do you think the field is on the whole? Are you guys the outliers or are you guys the majority? Is there a handful of bad actors out there that will take any money from any 17-year-old who's being duped into thinking this is the way they need to look. I'm trying to get a sense of the scale of this problem.

I would say the vast majority of physicians are ethical. I do think there are some out there though where it is something that's monetized. So they will mask, treat patients. Their goal is to have surgery after surgery coming in and basically letting the patients make their own informed decision about it to an extent. But I always look at it akin to managing hypertension or diabetes. We never let the patients determine how much insulin to use or how much

antihypertensive medication to take. And I don't think we should let the patients say that they wanna transform themselves to some completely different person. I just ethically think that's wrong. I think that brings to mind a whole bunch of other psychological issues that might be playing there, including what we call social media dysmorphism, where people come in with pictures

of themselves with a filter and say, can you make me look like this picture? By the way, is that a recognized diagnosis in the DSM-5 now? Oh, in the DSM-5, I don't know if it's made it that far, but it is something that is mentioned at different meetings now. So I don't know that it's made it into the DSM-5. If not, it probably will be in the sixth. If I could chime in, I think that Susan's obviously a very ethical, outstanding surgeon

and physician. I do have to say I'm an optimist. I have to say that I think the situation's worse than what you're saying. I think that there are, unfortunately, financial incentives for physicians, nurses, and the broad spectrum of people that perform aesthetic treatments, including Botox and filler injections. It's very poorly regulated. There are tons of people out there ranging from hairdressers up to surgeons who will be happy to take your money and find a place to put the syringe or filler because they know it's going to be money revenue into their practice.

And so I don't want to be overly negative, but I think this is sort of a cautionary warning to people who are listening to this podcast that when you're delving in the area of aesthetic enhancement, you have to understand that there's an overlay where the person that you're seeking out advice from has a substantial financial incentive to treat you. I think it's a real issue. Yeah. I'll tell you, one of the things I always caution patients towards in my world is you

need to be really careful when you're seeing a quote unquote longevity doc who is selling tests and selling treatments for the results of that test. When you go to see somebody and they're selling a biologic clock whose treatment is this supplement and they're monetizing those two things, I just don't see how you can trust that individual. I don't see how even a person with good intentions can't get conflicted there. And I guess I never thought of it until you said that. But the entire aesthetic industry is effectively that

because you're not just selling a procedure, you're often selling a treatment. You're getting paid on both ends. And what's happened is like Tinez was saying, the providers have changed. So before it used to be only dermatologists that would do the injectables. And then it became dermatologists and plastic surgeons.

And then it became the RNs and the physician assistants. And those are still all medical providers, including dentists who are very well trained, can do that. But then you get in certain states, lack of regulation. So you're seeing unqualified people who are not medical providers doing injectables and laser treatments that they may not be trained for and all of a sudden you start to open up a whole Pandora's box

of complications there. And this is a shame because patients might not know enough to ask about qualifications. They might see that it's a nice storefront, the person's wearing a lab coat, they look professional. So from that standpoint, they might go in trusting that this person has their best interests. There might not be a physician overseeing everything. We feel very strongly in our practices that there is a physician overseeing every treatment, whether we're doing it, our nurses or our PAs are doing it. We're overseeing all of that to make sure that if there's a complication, that complication is ours.

No matter what, we're going to take care of that patient. So it is a shame. And I do warn a lot of young residents coming into the field to enter the fields if they truly love the field and are passionate about dermatology, ophthalmology, oculoplasty, all of that, because if they're going into it thinking they're gonna be the next glamorous doctor

on social media, then they're not gonna have a lot of treatments that they can offer because at that point, all these other providers are doing those treatments. They're gonna have to find a niche for themselves to make a name for themselves doing something differently. So it's really fascinating right now, the times that we're living in.

And do you see a change in residents today? So, when I was in medical school, which is almost 30 years ago now, the people, and maybe it's such a small sample that it's an irrelevant statement, but when I think back to everybody I knew that ultimately chose plastic surgery, they all had a very artistic bent to them. I'm not going to say that they didn't pick it because it was also a lucrative field and things like that. Maybe if plastic surgeons made 50,000 a year, they wouldn't have done it. But I never got the sense that that was their primary motivation. When I think back to my friends in medical school that went into plastics, they were artists. They really took an interest in the art of this. Do you still see incoming residents largely of that philosophy where they're interested

in the aesthetic component of it, the underlying physiology of it? In other words, are they cut from the cloth you guys are cut from or do you see a trend towards, no, this is literally a cash machine and as reimbursements are going lower and lower and lower across the entire field of medicine, it is clearly more attractive to be in specialties where reimbursements either remain very high and or it's mostly cash. I'll take a more optimistic tone here. I think that those who are coming into residency and fellowships in the world of aesthetics, I think really still have that same artistic mindset. People who are painters or musicians, they have that

artistic mind. And it's something we actually look for in our fellowship when we're considering candidates because we know that they have that right brain mentality of being able to handle medical problems. But the reality is that, as you said, medical reimbursements are going down, the lucrative nature of aesthetics is high and getting higher as time goes by. And so someone can go through all the training and then when they see the dollars come in the door they're just gonna want more of that. It can distort their ethics and they may not even realize they're doing it. I'm not saying that there are physicians out there who are knowingly duping patients into having treatments, but I think it just

becomes this unconscious drive because of the finances. We were talking about that earlier. And I do think it's a challenge because here we go again, Medicare just got cut again in terms of reimbursements. And that's sad because we're talking about in our university practices, there's a huge push for doctors to see more patients

because reimbursement is dropping. And so the only way that the medical centers can compensate is to increase the volume. There's only so many patients though in a day that we can see and offer really good care. So Tanuja and I have a very unique practice because most of our patients are self-pay. So we have the luxury of time. We can talk to our patients, get to know them to the point that a lot of our patients come to us seeking medical advice and opinions on other advice that they've gotten from other

physicians and we can help them decipher the facts. Whereas their other physicians may be fabulous, but they have to see 30, 40 people in a day. And that's a shame. That's the detriment now that the physician's market is in because we're burning out a lot of really good physicians who want to give good care, but find themselves having to see more and more patients so they can only spend 10 minutes a patient. And that's really unfair.

And that's not why all of us go into medicine. And for both of us, we entered our fields before all of these devices and treatments existed. So I think we did come into it with a passion for what we love, but we both have an artistic bent to our personalities as well. So we kind of gravitated towards this. I want to put a bow on the social media thing for a moment. What is the most concerning trend,

or what is the most concerning request you are getting from people that you believe is unique to the social media phenomenon. What I'm seeing a lot more are teenagers now coming in asking for fillers and neuromodulators in their forehead, fillers in their lips, and that's sad. Would a neuromodulator do anything when you're at that age anyway? No, but they're now being told that even 18, for example, it's okay to start preventative botox. You don't need that until you're a lot further along in age.

So that's just an abject lie that they're being told. Yes. Unfortunately, they're also being made to feel very poorly about their shape of their lips. They're being inundated with images. And like Tanisha was saying, these are highly filtered images. We know a lot of people who will take in their waist,

take in their thighs, all of that, change the proportions and then post that image. What I try to tell patients is that what you see in terms of images that are on social media, A, are filtered, B, are taken with certain angles of the camera to enhance someone's appearance, and we will never, at least in my practice, take

someone's photo that they took on their phone and then try to enhance them to look like their photo because what's happening is that you're going to make them look very different in life, in real life. You're only going to photograph beautifully if you're the most symmetric person. And that's why even the most beautiful model in a photograph, if you look at them in person, they're very pretty, but you wouldn't them in person, they're very pretty. But you wouldn't think that they're supermodels sometimes. But when they photograph, they photograph beautifully

because of their symmetry. But for us, with our forward-facing cameras that we point at ourselves to take our selfies, they're going to distort our face. If you tilt one way, you elongate the face. Tilt it a different way, you shorten the face. And patients get hung up on that. That's really sad because in real life,

they look fabulous. Now, is this a 95-5 female-male problem that is arising from social media? Or are there, I guess from the purpose of this discussion, I would guess it's mostly female. My guess is the male issue is probably much more on anabolic steroid abuse and things that young men are being influenced by.

Is that safe to assume? Yeah. What is it that you see, Tanuze, that young men are being influenced by? Is that safe to assume? Yeah. What is it that you see, Tanu, that is most disconcerting? Is there a particular product or a particular procedure that is showing up that would have been unheard of before social media? I would say two areas. One is because fillers are non-surgical, relatively accessible price points and low risk and are ubiquitous. You can find a clinic within one mile

if you live in a major city. I think overfilling is a serious problem, whether it's the lips or the cheeks, over-volumization has become an epidemic. And it's a serious problem, not only because it looks exaggerated and distorted and strange, but even when as a facial surgeon, I go in to perform surgeries,

I will find that filler has disrupted normal anatomy. And so decades later, the companies will tell you that filler only lasts one year in the face and then you have to refill it. That's definitely not true. I have patients coming in who don't mention that they've had fillers in the past, but then in surgery, I will see filler in their cheek or in their face because they had it eight or 10 years ago and it's still there. And it's stretching the ligaments, it's changing the structure of the tissues, it actually

makes routine surgical procedures later more challenging. And by the way, are there biologic features of the individual that would make that more or less true? Are there some people in whom fillers go away after a year or are you saying that for the most part they last longer? So that's also another whole complex topic is the metabolism of hyaluronic acid and some people are higher metabolizers, some are slower metabolizers. And we actually don't have a good sense of that.

We have some general concepts just based on experience, but there's very little science on that. We can't really predict. So one doesn't know. One really doesn't know. Okay, and I'm sorry, you were gonna get to a second point. Yeah, no. The second point is from a surgical standpoint,

there is a trend right now where people are asking for this high arched brow effect, where it's hyper exaggerated. The tail of the brow comes up very high. It's called a snatched look. About once every week or two, I've got someone who seriously wants to have their face distorted with a surgical procedure with me. And I have to say, I'm sorry, we're not going to do that.

Is it safe to say that anyone who walks into a physician's office to do this needs to be able to be over 18 to provide consent? But is it safe to say, or is it the case that people younger than 18 can do this in less reputable places without parent consent? It should be 18. It's like any other medical procedure. You have to be 18 years of age to consent.

There are rare instances where I will treat someone who's 16 or 17 if the parent is there. And if it's for something, for example, a patient has a hump on their nose that they don't like, but they're not ready to commit to a rhinoplasty. So I can use fillers in a creative way to help reduce the appearance of that. But that's very far and few in between, but-

The parent is there. Yes, absolutely. I did have a very interesting incidence where I had an 18 year old though come in. She had just had a rhinoplasty and was coming to see me for fillers and for neuromodulators. I asked her, I said, you're 18,

is someone here with you from one of your parents? And no, nobody was there with her. And the interesting thing is though, she is 18 thinking that she's an adult, but she's only a junior in high school. So I was very conflicted. I kept referring back to something along the lines of, you need to talk to your parents, you need to tell them what we discussed here. That really bothered me for a long time that here is this 18-year-old who's still in high school that wants

to do things and I don't see a parent there with her. But I think it's not a huge problem probably across the board that people under 18 are getting treatments, but they're getting fed all of this societal pressure. I like to use the term beauty pressure, like peer pressure, it's beauty pressure that's now more extreme because of social media. They're getting all this beauty pressure at a's now more extreme because of social media. They're getting all this beauty pressure at a very young age, 12, 13 onwards.

And so by the time they get into their 20s, they've been thinking about this for years and years and years and they're ready to dive into it. Now there's probably not a lot of people in my audience that are particularly young, but maybe we can start the discussion through the lens of preventive care. We can talk about preventive care and then move into maybe where I am now, where I missed the boat on pure

prevention and I now need to start being active. For the person who's listening to this, who's still in their prime from an aesthetic perspective, I guess they're in their 20s, maybe even in their 30s, depending on their genes. The only thing I know is wearing sunscreen is a net positive. So I understand enough to say that UV damages skin. Is it damaging elastin? Is it damaging collagen? Or is it purely just these sunspots that it creates? What is it that sun is doing that is damaging?

Quite a bit. I'm glad you mentioned sunscreen because if anyone's gonna come in and say, what's the absolute minimum thing I should use on my skin every day, it would be sunscreen. And in fact, there was a four-year study out of Australia that followed people for four years, and either they wore sunscreen or they didn't, and the ones that did aged better. Was it randomized? It was randomized. Okay, good.

They aged better, fewer lines, fewer wrinkles, and that's in a country that has a lot of sun. So that shows you the power of using sunscreen. Now I'll take it a step further. I tell my patients they have to use mineral sunscreens as opposed to chemical sunscreens because I'm not convinced of the safety of avobenzone, oxybenzone as hormone disruptors.

I do think there are some scientific studies that suggest maybe they play a role in infertility. You can measure them in the bloodstream, especially if you're putting them over the entire body. The skin is a great portal for chemicals to enter into the bloodstream if it's the right size chemical. So there have been already studies done that show a huge spike in the amount of these in your bloodstream after application. After saying this for 15 years, I think the FDA just a couple weeks ago finally told the companies they must do animal safety studies. It's about time. It's very late. Yeah, so late in the game.

It's very late. Sorry to interrupt. I'm so on board with you about the problems with chemical sunscreens because the other problem it creates is that patients think they're covered and then the chemicals that are actually protecting against the UV damage become inactivated over time. Because you still have the film on you. You have the film on you and you don't know at what time of day you no longer have any solar protection. It's within an hour.

You put a sunscreen SPF 70 on, go outside. If it's strong sun, it's going to be deactiv's within an hour. You put a sunscreen SPF 70 on, go outside. If it's strong sun, it's gonna be deactivated within an hour. People will burn on SPF 70, SPF 100. There should be nothing above a SPF 50 mineral. What is the use case for the chemical sunscreen? Are they less expensive? What was the rationale for them?

They blend in. They blend in very easily. People love it because there's no white film when they put it on. A mineral sunscreen takes a little bit more work to blend it in, or it's going to cost more because you're going to have to get a micronized formula of zinc oxide or titanium dioxide.

So my Eltamd 30 to 50, I think I have one of each. I'm pretty sure that's a mineral sunscreen. You have to work to put it in. Yes, and some of them, Eltam makes some mineral and some chemical ones. one of each. I'm pretty sure that's a mineral sunscreen. You have to work to put it in. Yes, and some of them, Elta makes some mineral and some chemical ones. So just double check. And they make it confusing on purpose, by the way.

So you have to go out of your way to actually find formulas that are primarily mineral, because the companies want to sell you both products. And they know that customer satisfaction is higher with chemical. And this doesn't have to anything do this conversation specifically, but Susan has created skincare, and so have I created skincare.

So we've really dived into this world of skincare. And the marketing of skincare can really mislead consumers. Companies that are creating skincare are motivated by sales. They want people to be happy with their SPF. When it's a chemical sunscreen, they're going to be happier with it because it doesn't have that white pasty effect, but it's just not as effective. And the other thing that happens, if you look at the amount of skin cancer in the US, it's increasing, including melanoma. So why do we have generations now of people from the late 90s on up who say they use sunscreen

all the time and our skin cancer rates are going up? I think it's twofold. I think it's because A, like you said, Tanush, the sunscreens degrade very quickly when they put on a chemical sunscreen. And I'm going to take it one step further. When those chemical sunscreens absorb those harmful rays, whether it's UVB or UVA, the chemicals absorb them and they neutralize those rays, but they cause reactive oxygen species and those reactive oxygen species damage the DNA of the cells, which then

accentuates the damage that you're getting from whatever other UVA gets through the sunscreen. So you're really causing more damage and probably causing these cells to become more atypical over time. By the way, you know that there's a group of people who argue, and I don't agree with this at all, that argue that sun and UV rays have no causal role in melanoma. And the argument they put forth is sunscreen use

has been increasing, and yet we see a significant increase in the incidence of melanoma. So they're pointing at the same observation. They're offering a different argument. I find your argument far more compelling. Yeah. I think everyone should be using a mineral sunscreen. So that's number one.

And let's talk again just about the why. So what is it that ultraviolet energy is doing to my skin that is deleterious? So I'm going to throw out more than ultraviolet energy is doing to my skin that is deleterious? So I'm going to throw out more than ultraviolet. So we know there's UVA, and UVA is the longer wavelength between the two ultraviolet rays that reach the earth. That's A for aging. We have UVB, and that's B for burns. That's the one that causes a lot of the redness in the sunburns and leaves behind a lot of

the atypia in the cells. So UVB probably causes more skin cancers than UVA but they're both implicated. But add to it we have high energy visible light, we have visible light, we have infrared light all coming from the Sun. So we have five different rays and they all play a role in how we age. So we worry about UVA, UVB with regards to skin cancer, but high-energy visible light and visible light also play a role in terms of hyperpigmentation, infrared as well. Now there's some evidence maybe suggesting that because infrared light can reach deeper into the skin,

it may have a role on fat atrophy and bone remodeling. So I'd like to see more studies along that. I don't know how you could possibly do that in an ethical way. I mean, you could do animal studies, assuming you had a comparable model for fat and bone. That's the only way you'd have to use the isolated spectrum. You couldn't do it in sunlight. I assume you wouldn't be able to disentangle which energy

wave was causing the effect. But that's an interesting thought. Yeah, I think most of us think that, most of us, I've always thought, well, the sunspots are unattractive, but my pigment's dark enough that they don't really show up that much. Okay, so we know what sun is doing.

One more addition to talk about with the UV damage, because we could probably spend the whole podcast on UV injuries. But in addition to everything that Susan said, a couple more things that I think are important to hear for listeners is that UV also not only do you know that it damages DNA and can lead to tumors, cancers, melanoma, but it also injures collagen particles, elastin particles. A lot of the ultra structure of not only the cells have intracellular infrastructure, but

also extracellular infrastructure. So the matrix of the subcutaneous tissues, the dermis is built by this beautiful scaffolding. If you look at an 18-year-old's skin under the microscope, it's this thick, beautiful blanket layer of volume because you've got this collagen elastin structure that's holding this whole thing up and it's filled with water molecules, have lots of space to move around in and signals going back and forth.

So all of that collagen elastin framework also gets heavily injured by UV over time and it becomes cumulative. And that leads to thinning of the skin, loss of the subcutaneous fat layer, loss of those intracellular connections so that people start to get pitting and fine lines and wrinkles. And so that's just from an aesthetic standpoint, just another area just to know from UV damage. I'm sure you've heard this before, but all of my black friends now are looking infinitely on a relative basis, their aging is slowing down.

And so they always say, black don't crack. And so how much of the difference that we see in black skin versus white skin is due to less damage from UV versus other genetic differences that enhance what you're describing. It's almost completely what you're saying is the protection value of the increased melanin particles that people with darker skin have. There's a Fitzpatrick scale from one to six where we talk about, Fitzpatrick one is someone who's extremely fair, blonde, blue-eyed, burns all the time, never tans,

and then it goes all the way to Fisphatric 6, which is the darkest skin that you'll see, can't burn, never tans, can't burn, and we're all somewhere in that spectrum. So I'm a three? Three plus, probably. Okay. Yep, maybe verging on a four. Is there basically a linear relationship

between one and six in terms of how well you will age skin-wise? I think generally, yeah, that's about right. And the melanin factor is huge. Just to counter that argument earlier about people who talk about trying to put sunscreens, the melanin evolutionarily, if you actually look at what's happening when melanin is inside the cell,

it's not just randomly dispersed. It's actually the melanin forms a parasol over the nucleus. To protect the DNA. To protect the DNA. So evolution is showing us microscopically why it's so important to protect ourselves from the UV because we get this parasol of melanin that sits on top of the nucleus to protect it. And when we're Fitzpatrick 2 to 6 or 2 to 5, and you're exposed to sunlight, we get immediate upregulation of melanin production by the tyrosine kinase pathway and all of that melanin doubles and triples.

So that's why we're tanning. The tan, it happens to be aesthetic, but the reason we tan is to create more melanin to protect our DNA. Yes, and it's only aesthetic in this day and age because it used to be that if you were tan, you worked in the fields. So it was not a sign this day and age, because it used to be that if you were tan, you worked in the fields. So it was not a sign of prosperity and affluence.

It is only aesthetic in our current day and age. But yes, melanin is our own antioxidant. It's a very good antioxidant, and that's how it works. Okay, to your point, we could spend the rest of the podcast on it, we won't. We've established the fact that step one, the no regret move, protect your skin in the sun. What's the next level thing that one can do for prevention?

So we may be on the same line, it might be a little bit different. I would say step two would be a retinoid of some sort. I was worried you were gonna say that. I know, everyone says that. It's just one more thing I have to apply. Well, here's what I tell patients, because you said you don't wash your face at night, right?

It's so gross. Do you brush your teeth at night? I do, I'm a religious flosser and teeth brush. Right next to your toothbrush, put your little tube of retinoid. That's what I tell my patients. Retinoids, we have different categories. There's retinol, which is the weakest one,

and your body will go put it through two enzymatic changes to become retinoic acid, which is what you get at the pharmacy. And that's great if you're in your 20s, late teens, early 20s, and you're just trying to be preventative with how your skin is aging, and at the same time, maybe addressing some acne.

Once you hit late 20s into your 30s and early 40s, you need maybe something a little stronger and that's where retinaldehyde is a little bit better. And that's the next conversion. So retinol becomes retinaldehyde, which then becomes retinoic acid. So retinaldehyde is that middle step and there's more actual enzyme in your body that can convert retinaldehyde to retinoic acid. And that's less irritating for people to use. So in your case, if you get irritated very easily and you're going to quit, it gives us an option to give patients something that's highly efficacious, that is going to irritate their skin less because it gets converted to

the active form after it's been absorbed into the skin. Then the gold standard is retinoic acid, and that has multiple different strains, but that's someone who's in their mid-40s and up, they're gonna need it continuously to keep boosting collagen, because our peak collagen production, you wanna venture a guess as to what age

we peaked in our collagen production. I would say late teens, early 20s? Yeah, 18. That was when our fibroblasts were making the most of the matrix that Tanush was talking about. I guess that because that's when, in women, bone density peaks at about eighteen. For men, it's about twenty-twenty-one.

Yes, exactly. So eighteen, we start to make less collagen, elastin, and glycosaminoglycan. So if we can add a retinoid in there, we're telling the fibroblasts to boost more of those production of those ingredients, those peptides and those collagen matrix. If we are looking at the melanocytes, those retinoids also normalize the function of melanocytes

so that they're less aggregated, less overactive, and they also help to normalize the turnover of the keratinocytes. So they're working on the major cellular structure of the skin at the level of the DNA. Now my recollection is there were two concentrations of this stuff that you could get. Is that ringing a bell? Of the prescription? Yes. There's three, 0.025, 0.05, 0.1. And then there's like 0.04, 0.08.

Those first three are the major ones. And also custom formulations. Yes. Yeah. And the few timesulations. Yes. Yeah. And the few times I tried to use this, I couldn't do it every day. It just got me too red. Did that mean I was on too high a formulation?

I should have gone back to the aldehyde. I was too young. I probably tried this 10 years ago and never did it again. I take a different approach than even most of my colleagues. I tell people if they're trying to achieve a goal, whether it's treating melasma, sun damage, or they're getting ready for a child's wedding, or we have to do a procedure,

I would tell them to tough it out. Because if you use that retinolic acid every single day, your body acclimates to it very quickly. It may take six weeks, seven weeks, eight weeks, but you get your skin used to it, and then you reap all the benefits. But some patients are always going to quit. So from that standpoint, then-

I'm a quitter. Yeah, so we would give you five days a week retinaldehyde, two days a week retinoic acid, and tell you to start that way, and then maybe as your skin acclimates to it, you can change that proportion. Okay, and by the way, do you become more light sensitive

when you take this? Does it make it even more important that you're wearing sunscreen in the sun? So those studies came out very early on, which is why people start to say, oh, I stopped my retinoid in the summer, and that's the last thing you should do. Because initially when you start a retinoid,

you will get exfoliation at the level of the dead layer of the skin, the stratum corneum. But after you've been on the retinoid for a long time, that builds back up. You become less light sensitive. You might always still be a little bit, but you're a lot less light sensitive than when you first started retinoid. But you should always have a sunscreen on and a hat. And retinoids have been shown, even if you get sun exposure, they have the ability to repair some of that DNA damage

early on. So you really want to be on a retinoid all the time. Okay. Anything you would add to that, Tanuja, on the retinoid before we go on? No, I think that was great. I totally agree with everything Susan just said. I have a slightly different protocol with retinoids and people who are sensitive. I might have them start out two or three times a week and then gradually build up to nightly

use over a couple of months. That's one way to avoid the inflammatory aspect of Retin-A. And then the other option would be to mix it with some over-the-counter hydrocortisone 1% cream. I know people get really worked up about putting steroids on their face, but over-the-counter hydrocortisone 1% is such a low concentration that it's just enough to reduce some of that annoying irritation from the retinae in that first few weeks or month.

But I was gonna also add, when people are thinking about the core aspects of what should they be using on their skin now that they're starting to notice some changes in their 20s or 30s, in addition to sunscreen and retinoids, I think that vitamin C is a really important molecule to get onto the skin also. Tried that too.

Let me tell you why I stopped. It was mixed with like ferric acid. Ferric acid. Yes, yes. And it stunk. I just hated the smell of it. And the reason for that is because vitamin C is a notoriously complicated, easily reduced molecule and

when manufacturers are formulating their vitamin C serums, it might be a year from when it leaves the factory and gets onto your skin, if we're lucky, and in that year all of the relatively inexpensive vitamin C serums are going to degrade and not actually have any bioavailability when inexpensive vitamin C serums are going to degrade and not actually have any bioavailability when that vitamin C is applied to the skin. And so the relatively more expensive formulations are being produced by manufacturers that are doing all sorts of manufacturing flips and tricks to try and stabilize that vitamin C. The product you're talking about, which I think I can probably guess is they use the frulic acid to stabilize the vitamin C so that it maintains

by availability. Other formulations of vitamin C will use an oil-based formula. It's not aqueous because then the vitamin C is much less likely to be reduced in that kind of formulation. But those products tend to be petroleum, oil-based, and also have all sorts of negatives associated with it. And then there are some products that will micro-encapsulate or find other creative ways of making sure that the vitamin C is actually bioavailable when it hits your skin. So that product may have not worked for you, but there are other options to find a stable vitamin C. And this is one of those products where, again,

we have our own custom formulas. But I'll tell people who are price sensitive, go to Walgreens, buy a retinoid, buy a sunscreen. You don't need to spend more than $10 or $15 on effective products. Vitamin C is something where you have to spend the money. And by the way, what retinoid can you buy at Walmart? Retinol and some retinol that I have.

I see, you can't get retinoic acid without a prescription. No, that's prescription. Right, got it. And is there any downside of using retinol or do you just need a lot more of it? The problem is if you try to push that enzymatic chain reaction, you'll get dermatitis. Got it, okay, so in other words,

if you can afford it, it's better to get the prescription and I'm guessing retinoic acid is not expensive. Finally, it's come back down in price. I think now that they realize more and more people are willing to spend out of pocket to buy it, it's about 80 to $100 for a tube. That tube will last about three months. If it's lasting longer, you're not putting enough.

And just show me as though I'm doing this, we're gonna talk about how to wash the face and do all that, because I'm guessing you don't do this without washing your face, especially if you've had sunscreen on all day. Are you putting this on like all over your face like this, even over my beard and stuff? So I tell people, first things first,

you have to put the right amount on. Because every time we give anyone any prescription, we tell them, take this many milligrams once a day, twice a day. We don't do a good job telling people how much sunscreen to put on, how much retinoid to put on. So I always tell them, hold up your finger, and it should be from the tip of your index finger

to your DIP joint. Oh my God. And that's a fingertip unit. And if you can do a fingertip unit of retinoid every night, that's a great way to measure that you're getting enough on. And I can see your face. You can see, I'm getting a troponin leak right now. I'm just thinking about applying that much stuff.

Yeah, and I have them put it on their face, including the under eye area, because that's the thinnest skin, and that's the skin that's going to wrinkle and age first. So most people are afraid to go around their eyes. I would tell them, just don't get it in your eyes. Go around, but make sure you're getting that under eye area. Once a week maybe on the upper eyelid,

and then once or twice a week on the neck, because again, this is the thinnest skin. We've got to keep that skin building collagen and elastin. Okay. The vitamin C and ferulic acid, would you put that on after? First. So you always put the liquid before the thickest stuff. Thinnest to thickest.

Let's talk then about how you wash your face before you begin this procedure. So I've just come in from whatever I've done. I'm brushing my teeth, because that's the only time I'll do this. I'm gonna wash my face now. What should I do? I'm guessing that the hand sanitizer next to my sink

is not the thing to use. So there has been a huge shift in so many areas of skincare that is now sinking more with what science is telling us. And so historically, there was a belief that you would need to strip all the oil off your face and debris and dirt before you apply products. We're talking about skin care routines from 10 or 20 years ago. We now know that that is harmful. It creates inflammation.

It disrupts the microbiome of the skin. It does all sorts of negative things. A modern cleanser that we suggest is usually something that is glycerin based. Usually there's also other versions, but it's a way of cleansing the skin without overly stripping the oils out of the skin. Glycerin-based cleansers don't foam. That's certainly my bias. I'm sure you might have some other thoughts, Susan, but that's the first step to get the debris and superficial oils off the face and previously a pride product. And then as Susan said, you go from thin to thick.

And so usually on top of that will be serums like vitamin C serum or retinols. And then finally, you'll put a moisturizer on to kind of seal it all down. Okay, so hang on serum. Any antioxidant serum. We mentioned vitamin C, but there are so many other great. What are the others?

There are great antioxidant serums that contain sulamerin, Floritin. How does one pick? That's where you have to look and see who's invested in doing the clinical research based behind the products that they're promoting. So you tell me, what are you guys using? I would say that, generically speaking,

if you can find a vitamin C serum that has a higher quality vehicle to make sure the bioavailability of the vitamin C gets to your skin. That product is going to have additional associated antioxidants that are going to be very useful and helpful. And again, to avoid naming brand names here, you can find that quite easily. Can we go ahead and name brands? Because honestly, people just want to know. So let's just give some brands that you guys trust maybe across a range of price points. I'll give you some names. I'll give you my brand name, but then also brands that I suggest other people as well. My brand name is

called Avia Skincare and it is designed to- Avia. Avia, yes. And we formulate these products to have medical rate efficacy. We also incorporate some Ayurvedic wisdom, which is anti-inflammatory. So it has turmeric and other eastern botanicals for anti-inflammatory care. And we have a vitamin C serum that is microencapsulated that also has a retinol in it

and also has various other antioxidants that are niacinamide that are all useful to apply to the skin right after you've washed it. Now there are other brands as well. We can name a hundred of them probably. But if you couldn't use yours, what are two others? SkinCeuticals is probably one of the most available.

That's the one I tried. Yes, the vitamin C formula. When you said ferulic acid, yes. That's a wonderful brand. But there's no getting out of the stink of it. There is if you go again with a different brand. A different vitamin C formula. So they chose to use the ferulic approach

to stabilize the vitamin C. There's many other brands as well. So what's another non-stinky one? Obagi, Obagi Medical. That's yours? No, actually that's not me. So that company's publicly owned and I only formulate for them a Susan Obagi MD line.

But their vitamin C serum has been around quite a number of years. So the original founder of Obagi is Zain Obagi, my father. But he has since left that company. So this brand has been time tested for 35 years now. They're a vitamin C under a nitrogen vapor. So it makes it so much more difficult and challenging to produce, but it's a very stable form of

L-ascorbic acid without deferulic. So what I'm hearing here is this is not unlike what's the best diet for me. The best diet is the one that allows you to maintain energy balance that requires the fewest amounts of neurons to stay on. So I need to get three of these and figure out which one is the least annoying for me to put on. And it's no offense to that company. It won't be skin-suticols, because every time I've tried it,

the smell of the furielloic acid or whatever has been annoying. In Obagi, I didn't do the study for them, but they have a study that shows that their L-ascorbic acid penetrates about four times deeper than the one from SkinCeuticals. Okay, great. So I'm going to try both of yours.

And just to name some other brands, I mean, there's SkinBetter is another one that I think produces good products. Maybe it's worth also mentioning, because we haven't done this yet, why is vitamin C so important? I assume it has to do with proline and collagen? That's one aspect. So vitamin C is sort of like a wonder molecule when it comes to facial aesthetics, because yes,

it is a precursor for the collagen synthesis pathway in the proline synthesis pathway. But it also is a powerful antioxidant. And so antioxidant application to the skin not only has the power to remove injury, oxidative injury that has happened during the day, but it also has the ability to reverse some existing damage that's in place. Vitamin C also regulates the tyrosine kinase pathway, which is a scientific way of saying that complexion, people talk about

wanting to have good complexion. What does that mean? Complexion is something that across societies, no matter what your Fitzpatrick scale is, people like to have a good complexion. And that means having an even skin tone, which is even distribution of melanin. It doesn't matter if you're black or white or brown. People desire to have their skin look even without splotchy areas of pigmentation or nearby areas of relative depigmentation. And so regulating the tyrosine kinase pathway so that there's an even production of melanin

throughout the skin is something that is valuable, very valuable in an aesthetic sense. And that's something that vitamin C does as well. Okay. We're gonna go from the serum to the retinoic acid. Again, I'm being selfish and talking about my demographic. So people that are forties fifties and beyond, and then it sounds like the last thing you said we want to do is a moisturizer.

Yes. I would say the cheapest trick in skincare, which actually is really true is that deep moisturization locks down the skin barrier function and allows the skin turgor of the skin dermis epithelium to thicken just by having that occlusive barrier. So you can go to Walgreens and spend six dollars on aqua for which is basically petroleum jelly and put it on your face nightly and your skin will look better in 30 days, guaranteed. Because your skin will thicken, and a lot of the fine lines and crinkles

will actually start to disappear because your skin is being more hydrated. That's hydration. That's hydration. But what if I don't wanna grease up my pillow? I'm saying that as sort of like tongue and cheek. I'm not telling people to do that. If you actually did a double-blinded study,

you would see that there are real results in 30 days. But the reason why I mentioned that is that good, deep hydration can be performed with an inexpensive product that you're using regularly, and it'll make a real difference because the moisturization, especially overnight while you're sleeping, is a powerful tool for aesthetics. Like I wouldn't give you, though, a moisturizer.

You can just tell I'm a grease ball to begin with. No, you have young, thicker skin. Just like women age 20 years faster than guys in terms of the bone remodeling and fat atrophy, the skin as well. My routine would be done after the retinoic acid. From my standpoint, yes. At this point, and then we might revisit that

in a few years. Yes, and I tend to give moisturizers as women become more mature. I don't want to use the word older. Because they do start to make less of their natural moisturizing factor. That even starts to diminish, even when we're 18. So most people, I think, into their mid-40s and 50s even,

might not always need a moisturizer with everything that they put on at night. One caveat though, sorry, is that your morning sunscreen and your serums have some moisturizing quality to them also. Yes, exactly. And I always have them put a super antioxidant serum or a vitamin C serum on at night before their retinoid. Because my feeling on this is that you spend the whole day outside or in your car or being

hit by LED lights and ultraviolet lights, those are also damaging the skin. And so I think you should have an antioxidant on first thing in the morning, but it's going to get depleted by the end of the day. Wait, wait, wait, I'm sorry, I missed that. Are we putting the serum on in the morning? Yes. And at night?

I always have them repeated at night because it's depleted all day long. Oh God. And we know that the cells undergo mitophagy and autophagy at night. We want to help the repair factor. We want to put on an antioxidant at night again, just to replenish the skin. And the retinoic acid. It also goes on top of that morning and night. No, no, no, just at night.

And the retinoic acid has anti-inflammatory properties to it in addition to all the good things it does in terms of building up collagen and elastin. Okay, so just to go through this because I'm not the sharpest tool in the shed, my AM routine is gonna be. Wash. Okay, let's assume I just came out of the shower. All right.

By the way, in the shower, don't use your body soap on your face because it's gonna strip the oils out of your face. So again, you need a separate facial cleanser. Oh God, what do I need? The same glycerol-based thing? Depends on your skin type too. I tend to be maybe a little bit more picky about-

I mean, if you saw the crap, I've got like a 299 bottle body wash from Target that I scrub head to toe. I am the lowest, put it this way, when my wife met me in the hospital, the first thing she noticed was how disgusting I was in that I used to take alcohol pads and clean my face. Like that was my shower in the hospital. That probably wasn't bad.

It was a little harsh, but it probably wasn't bad. There were worse things you could do. All right, so we're gonna do soap, we're gonna do serum, That probably wasn't bad. It was a little harsh, but it probably wasn't bad. There were worse things you could do. All right, so we're gonna do soap, we're gonna do serum, and then we're gonna do sunscreen. That's the morning routine. And some people might in their need, depending on if they have clogged pores, oily skin,

they might need an alpha hydroxy acid or poly hydroxy acid before their sunscreen, but you've nailed it right there. That's a very simple regimen you can follow. Okay and then the PM is soap, serum. We prefer if you call it a cleanser right? Yeah, soap connotates a lot harsh. And now the difference is I do have lots of patients like you Peter who are minimalists. Again it's trying to get them to use whatever they can to protect their skin and hopefully start to improve

the aging process. I might, just to do the experiment for 90 days, try to commit to cleanser serum sunscreen in the morning, cleanser serum retinoic acid in the evening. We agree that would be- Yes. Okay. Yeah. By the way, in the show notes,

we'll get from you products that you guys like, including your own. I just want to let people look through this and decide. And obviously you guys disclose your own products. Great. But let people see the full breadth of things. And I'm sorry. You know, one of the things people ask about though, especially when they're very into their nutrition and eating healthy, they say, well, why do I need to apply an antioxidant if I'm eating a lot of antioxidants?

And the skin being the largest organ in your body, it's very unique. It's very good at keeping things out or from the inside coming out as well. So outside things like water, pollution, it tries to protect that from getting in and does a good job at keeping kind of homeostasis. So they have shown that the level of vitamin C that you can achieve in the skin by topical application far exceeds what you can do by ingesting it. The amount you would have to ingest to get the right amount in the skin,

you'd have GI issues. That would definitely make you quit. Before we leave this, I guess one thing I just wanna chat about is acne. Again, it's mostly something that adolescents are experiencing, but adults get acne as well. Is that something you guys spend much time on? I do.

Give me the playbook you have on acne. I assume it involves spironolactone, if it looks to be endocrine in nature. I'd be very curious to hear about Accutane. I hear horror stories about it, but obviously it probably works very well. What do people need to be aware of? What's your playbook for addressing acne?

My number one thing I tell people is, for themselves or their children, try to treat the acne before it scars. Because I cannot tell you how many times I see patients for consults for acne scars. They're in their 70s and they're still crying about it as if it was yesterday. They've been traumatized all their life with these acne scars. And what causes acne to scar?

So it depends on how inflammatory your acne is. There are different types of acne. There's comodonal acne, which are just your run of the mill, small pimples, whiteheads, blackheads. Those don't typically scar unless someone picks at them. So number one rule for patients, don't pick at your skin. Second thing, they can have a little bit more inflammatory acne, and those tend to be the red ones that come up and they're maybe pustular on the skin. And if you don't pick at them, those also might heal without scarring.

And then there's cystic acne. And those are a completely different type of acne where you're getting inflammation that's sebaceous, pylosebaceous unit, which is the herafolical and the oil gland feeding in there. And you get swelling deep in the dermis. And then you might get enough inflammation and rupture of that cyst that you leave a divot at that point. And that causes what we call a valley scar. Even if not picked. Even if not picked. So cystic acne is a true, in my standpoint,

a medical emergency because you want to treat it before- Maybe not on the level of anaphylaxis, but- Correct, correct. But for parents- It's a dermatologic medical emergency. Yes, because it can cause so much psychological trauma to the child. People with cystic acne, even bad inflammatory acne,

they're shy to go out in public. They wanna hide their face. They hide their face with their hair. What percentage of adolescents will develop cystic acne? I don't know that I can quote the exact percentages, but about 20%. Oh wow, so pretty high. And it's very difficult to fix later.

Yes, and those patients, I'm not a big fan of antibiotic use. I don't wanna alter their gut microbiome. I do think that we're just touching on the surface of how important that is. Those patients I would quickly move to Accutane because nothing topical is going to work. Or photodynamic therapy.

Okay, say more about that. So photodynamic therapy is where you take a molecule like amino levulonic acid, ALA, and you paint it on the skin and you let it incubate for about an hour, and then you shine a red light onto the skin to activate it. And that chemical gets into the sebaceous glands and percolates down through the skin.

And when you activate it, it causes a heat reaction and basically induces damage in that whole area that's picking up that medication. So you're causing the oil glands to shut down. You're taking away the nidus for the inflammatory acne. And for some patients who cannot take Accutane or Isotretinoin, that's a great alternative for them. It does feel uncomfortable and not every doctor offers it,

but it's a great adjunct or alternative if they can't take Isotretinoin. Would antibiotics work if not for the limitations and side effects of long-term systemic antibiotic use? So antibiotics will work to a small degree. They might help shut down maybe a good proportion of that cystic acne flare, but they won't get to the root cause, which is sebaceous unit overproduction of oils, the bacteria that are in there overproduction of oils, the bacteria

that are in there feeding off of that and the whole cascade. And there's something genetic, cystic acne tends to run in families. So there's some kind of genetic tendency towards that milieu that causes cystic acne. And how does Accutane work? What's the mechanism of Accutane? So Accutane is a type of retinoid and it's basically going to go in there and dry up the oil production that's in these overactive sebaceous glands that are being driven by your androgens.

But you have to take it orally. Correct. So they have used some topical variations of it for psoriasis and things like that, but the best is to take it orally, because then you bypass a lot of the surface dermatitis. What is the main side effect or toxicity that people are trying to avoid with Accutane?

Why does it have a bad name? So it has a couple of bad connotations with it. First, it dries everyone out. So for the five months you're on it, you are going to have dry lips, dry eyes. Some people complain that their skin is too dry. Some people on high doses might get shedding of the hair. And then you're not allowed to drink alcohol

while you're on it. So that's a whole other issue with kids and making sure they're compliant with that because it is metabolized by the liver. Other than that, patients, if they're using it correctly, tolerate it very well. And the teratogenic effect. Oh, I'm sorry, yeah.

Sorry, say again? Teratogenicity. Can't reproduce. You're not getting pregnant on it because it will cause defects. So we have to go through this whole FDA required modules with the patients to make sure that they're using two forms of birth control for the female patients while they're on it. They're not donating blood while they're on it, but it got a very bad reputation when I think it was a child or son of a senator committed suicide while on that medication.

And they said it was a depression induced by the medication. When it turns out when people look scientifically at the rate of depression. Yeah, that sounds like junk science written all over it. Exactly. If you look at depression scores in acne patients with cystic acne, it's significant. And their depression actually improves

when they take something like Accutane because they feel better. And do you have to monitor liver function tests while patients are on it the same way you do with Lemictal or any of the toe fungus type things? Is it that severe potentially? It could be. It changes your lipid profile while you're on it.

It can elevate your triglycerides and elevate your cholesterol. And there are very few instances we would adjust the dose. We just tell people to try to eat healthier while they're on it, especially triglyceride elevation. Liver enzymes, it's a rare patient that gets a real significant bump, but you wanna watch for that

because you wanna stop the medication if that's the case. And it's also a proxy to make sure they're not drinking. It's sort of a way of finding out if they're following the rules. Yes, we tell them, we can tell. Yeah, and I don't prescribe Accutane. This is usually something that is done by specific physicians. This is a dermatologist

should be doing it. And you mentioned five months. Does that imply that you do this very lengthy five month treatment and then you're done with this? It eradicates the sebaceous glands to the level where the child, the teenager is done with this treatment afterwards? For 85% of people that take it for five months,

they're done. Then you've got the small subset that need to take it again. And then I have my adult patients who might not have a lot of acne, but they're very oily. I put them on it one month out of the year, just to dry them up a little bit. And it helps them feel better. It makes their pores look tighter,

makes their skin have a better texture to it. Because we always said, oh, if you have oily skin, you're going to age better. That's so not true. Oil is inflammatory on the skin. So from that standpoint, I'd rather have them use it to dry them up for about a month and then allow them to enjoy the beautiful skin for the rest of the year. Sounds like a dumb question. How does one know if they have oily skin?

Like I've always thought I have oily skin, do I? Well, your pores would be enlarged. Some people have to blot their face midday. I don't know about that. Okay, let's move on now. By the way, that was super interesting to me. By the way, I wanna make sure we also get good products. We didn't talk about it, but can you tell me,

you mentioned for the cleanser, it just needs to be glycerol-based. Are these easy over-the-counter things to find? Should I be going to Target or Walgreens and literally just going through the skin aisle and looking for cleansers that are glycerol-based that won't lather when I use them? Is that the litmus test?

It's one way to do it, and we can also provide- Give us a bunch of links to products. You can include your own, I don't care. Yeah. Just make it easy. And if you're oilier, I'm gonna give you one that's not quite so hydrating when you wash. Okay.

All right, let us move now into the really confusing realm of I show up in your office, can't tell you what's wrong, but I show you a picture of me 10 years ago, and I say, I wanna look like that. And I should have brought a picture in of me so you could and I say, I want to look like that. And I should have brought a picture in of me so you could actually see it, but you've already described it without having seen the picture. I don't have bags under my eyes.

My skin just looks better. Everything just looks better. Part of it is color. I will admit 10 years ago, there was no gray anywhere in my beard. We're not going to fix that problem. That's fine. Oh, and the wrinkles in my forehead. I notice in pictures of me in the past, I had some wrinkles. Now it looks like I have a wrinkle farm.

Again, go over the changes, assuming I had that photo. How would you describe them pathologically? Maybe that's too strong a word, but you know what I mean? There are three basic changes that happen to every single person with aging and we've touched on this a little bit and we'll dive deeper now. So there's skin changes, there are volume changes, there are gravitational changes, and maybe we should throw in the fourth, which is bone structural foundational changes.

And so those happen to everybody. When we see patients in our clinics who are presenting the way you've just suggested, we will spend extra time analyzing the individual nuances of skin volume, bony ligamentous anatomy, gravitational changes that are specific to your face. And then also we'll just rely on general knowledge that we have about what types of aging changes we see at this point. And it's a very complex process. I tried to analyze this a little bit before walking into this podcast today. Like what am I actually thinking about when I'm starting to communicate with the patient?

As soon as I see the patient, while I'm making some niceties and saying hello and get to know them, I'm already analyzing, I'm already looking at their skin. I'm looking at the bone structure, I'm analyzing the facial proportion. I'm looking at areas where there's volume loss, it's obvious. I'm looking at the dynamic movement of the forehead and the face. I'm analyzing how much heaviness is on the eyes that might be driving frontalis muscle tone that's causing forehead wrinkles. I'll be looking for facial asymmetries.

So a lot of the physical exam that we do in our offices happens in the first 15 seconds because we're just, this is what we do and it just happens quickly in our mind. Big difference. It's that blink moment. Yes, it is. You look at someone and you're like, I know what I'm gonna do on them.

Yes, yes. The urologist doesn't have this advantage. Right. He can't examine the prostate and the scrotal tissue during that first 15 seconds. Very good point, yes. So we do that when we walk into the room, that analysis already happens.

And then because I've already got that snapshot anatomic analysis already in my mind, then the next step that I'm doing is, and I'd love to hear what your process is, Susan, but the next step is I'm now going into their mind and trying to understand their psychology and what their motivation is. And the problem that we have is that

the patient doesn't know what words to say. Yeah, they're like me. For them to communicate what's actually driving them. And so I have to pull that out of them. This was a little bit of detective work, a little bit of background. My parents are both psychiatrists. I actually went to medical school thinking I was going to go into psychiatry. And then I rapidly pivoted into surgery and ended up where I am. But that initial love and appreciation for what's happening inside the neuronal processing and the subconscious is something that we actually work with

every single day in our offices. And so the next step that happens in a consultation is... I would say hopefully. I mean to me that's a great thing and not to be a downer. I don't know that that's true of every person who is dealing with aesthetics. I would guess there are a lot of people who are just kind of doing this in a coin operated way. Yeah. I think you're right. Unfortunately, there can be a tendency to take a cookie cutter approach where you recognize

this, this is a knee-jerk reaction. There's wrinkles on the forehead, inject Botox. You know, there's gels, do a facelift. That's not the way that we should be practicing aesthetics. Every single individual has a totally customized situation, anatomically, physiologically, and psychologically. And so our job is to try and figure that out when the patient doesn't have the ability to express. So sometimes it's almost overlapped into pediatrics, which is something that I know you've got some history with in surgery, but you're trying to do a physical exam and get history from

someone who's unable to communicate what they want you to figure out. And so I'll start asking questions. Did you like the way you looked when you were 20? If they say yes, that means that they actually like their natural facial proportions and they're probably looking more for rejuvenation. But if they say, you know, I always had a heavy eyelid and I never could put makeup on my, then I know that they're maybe looking for something

that's a more substantial result in that particular area. That's just one example. And then I'll try to get to know them. What's their occupation? What's their situation at home? Do they have kids? Tell me a little bit about your life. I'm trying to understand their social history, see if there's any red flags that would stop the

process and say, okay, this is not the right time to be considering aesthetics. You got to get your mental health in order before we proceed, which is something that I would very openly tell a patient at the right time in the consultation. But if a woman came in and said, my husband is leaving me, which is unfortunately probably not an uncommon thing, and let's make it more extreme. A 50-year-old woman comes in and says, my husband of 25 years is leaving me for a 20-year-old.

Understandably, she's in duress, and she's probably comparing herself to a 25-year-old. Would that be a non-starter in your mind? The scenario you described is actually very common. I see this kind of situation all the time and this is why I schedule 45 minutes or an hour for initial consultations because once we start talking about that, tears may start flowing. The patient is now in a safe zone talking to a medical professional who's actually listening to them. We were talking about time in a clinic before.

Then we start to fall into the role of a therapist and we're letting them express because I want to see how deep is this trauma. I'm trying to understand is this something that is now a non-starter or what should we do here? Because there are scenarios where someone is in that kind of scenario, situation, where we certainly would not want to make any drastic moves or big changes or shifts, but is it appropriate to recognize that this person is desiring something

that is a reasonable goal, but the current emotional state is not appropriate to do the procedure to get there? So maybe we say look we do something reversible Yes, exactly because of the fear sorry to interrupt but I'm guessing that the fear here is if you say no to her she's gonna find some guy down the block who will do anything and it's better that you do something small and Develop a relationship with her that will ultimately serve her interests

But you can't give her everything she wants at the moment. Is that a fair assessment? Very well said. That is exactly right. We're trying to build that trust and build that relationship on the front end so that this individual who's trying to get from A to B, we're going to take them there safely. Whether it's over a couple of months or 10 years, we're going to try to get to that goal. And there may be some obstacles along the way and choices that we have to make, but we'll navigate it together. And it's all built on building that relationship on the front end. So the trust exists where I can tell the patient, we are not going to

do this maneuver right now. And then that patient will listen to me because the trust has been built up enough that this individual knows that I have their best interest in mind and we're going to get to that goal eventually. And so yes, this scenario that you're describing, the individual might be best served with, okay, look, I think we can get there one day with the procedures, but right now,

I'm going to refer you to a therapist. You have a lot going on in your life right now. Let's do some simple things that we're not going to regret, like neuromodulators and fillers and some skin treatments or lasers, things that are low risk. They're not going to create any scars or permanent changes and then we can eventually get to that next step. We're not going to do the facelift next week. Correct. Yes, that's on hold. The first step is we do this snapshot anatomic dynamic analysis.

It's not just a single image as we're looking at the muscle movement. And then the second step is this deep dive into their social situations, psychology, and then presuming that everything's moving along smoothly and now we're getting ready to talk about what should we do now. Then I'll spend time educating the patient on their actual anatomy because they've never actually had that information presented to them. So I will put the mirror in front of the patient and I will say, let's go through what I'm seeing on your exam today together. And we'll start at the top and I'll go through every little detail and I'll throw in little caveats like, I'm sorry, I'm not trying to make you feel bad about your features, but you're here for me to tell you

So I'm gonna tell you everything we're gonna talk about your bones. We're gonna talk about the wrinkles We're gonna talk about the asymmetry you never noticed which by the way is almost always the case people don't notice that are asymmetries And so we point out these asymmetries to them and then after that relatively lengthy discussion about their individual anatomy Then we'll start to say okay now you initially told me that these are some of the areas that bother you. Here's what we could do to fix your eye region, your cheek, your mouth, your gel, whatever it is. And I'll present typically options that go from minimally invasive to more substantial. And based on how the individual is responding to the conversation, I can usually at this point, 20 years in my practice, dial in what is the appropriate scope for this patient.

They don't really know whether they want to facelift or not. Maybe I need to explain them the complications where the incisions are, so they really understand what that procedure means. And then if that seems like it's too much for them, we will dial it back and I'll have to tell them, look, we're not gonna be able to get the results of a facelift without a facelift, but I don't think you're ready for a facelift, so maybe we should start with something smaller and kind of taking baby steps. And then just to conclude, usually we'll end up finally telling the patient what they showed up to hear, which is my opinion.

I won't give them my opinion about what we should do until we've gone through this whole process and I've watched their body language as we've talked about procedures. Sometimes I'll suggest something that's minimally invasive and they seem uninterested because it's not enough for them. And I'll read that body language and kind of dial in the treatment for what I suggest for them. And so that'll happen at the end of the consultation, typically. So I know that was a long answer, but that does, I would say, describe my typical consultation. How about you, Susan?

Pretty much everything that Tanush said. And I was so glad to hear that you talked to the patient about their mental state at that time, too, because we do a lot of almost like psychology and therapy with our patients. If they open up to you, then that's an honor to you and you have to take that and you have to help them through that issue. I have a psychology background as well.

So I was biology and psychology double major in school. I use it a lot. It's so important. I approach patients very similarly, but I try to put things in terms that they can understand. So I tell them there are the five Rs of rejuvenation. And it doesn't mean they need all of it at that point in time, but at some point in their life, they're going to need one of them.

And they'll make it through all five. And that is we need to relax overactive muscles, and I'm showing them on their face the movements. I will say we need to refill lost volume whether it's through fat grafting which is still one of my favorite procedures to do or refilling with fillers and I tell them we need to resurface the skin because to me how the skin looks is absolutely much more important than how tight they are. So patients sometimes come in they're like I just want to lift here, and they want to lift their lower face,

and their skin is terribly wrinkled, and they have hyperpigmentation and sunspots. And I'll tell them, if I lift you now, no one's going to notice that you look better. But if I make your skin look better, people are going to notice you look better before I even do the surgery. So we have relax, refill, resurface.

We need to do redraping. So there are going to be times that you can't fill enough. You have to lift. So they either will lift with devices such as microneedling radio frequency devices or ultrasound devices to tighten the skin or a facelift of some sort. So those you need to do. And then what people don't realize, my fifth are, is that you have to keep renewing because the aging process continues.

And the minute they leave your office, everything you just did on them looks great and then it starts to diminish. And that's what we were just talking about. The renewal was the maintenance. Absolutely. So you have to keep renewing because otherwise you're going to lose that benefit.

And what do I mean by renewing? You definitely maintain your neuromodulators and your fillers, but they have to be strategically placed. You don't need a lot of fillers. You need to keep the skin priming itself and turning over. So you can achieve a lot of that at home. And I think people underestimate how much they can do at home with their skincare regimens

and then have to do less in the office. And that's my big emphasis. Do more at home and then let us do in the office a little boost here and there afterwards. And so those five Rs make it very easy for these patients to comprehend. And they might not need all that yet, but at some point in their life,

they're gonna have all those five Rs. So what I wanna do then is I want you to go through the five Rs looking at me. And Tanuja, I want you to go through the five Rs looking at me and Tanuja, I want you to go through your four changes looking at me. Just feel free to brutalize me. You're not going to humiliate me. So Susan, you look at me and let's start with relax. What needs to be relaxed in my face?

So here's the thing. You do move your eyebrows a lot in your forehead. So you've got a lot of forehead wrinkles. I do notice the Glabella 11s. These are those little sharp lines there, yep. Yep, so knit your brows for me, yeah. Raise your eyebrows up. Now, part of the reason you're raising your eyebrows

maybe now more than you did 10 years ago, is you have a little more hooding on your upper eyelids, and your eyelids are almost touching your eyelashes. And when that happens, you're sending a signal to the forehead to lift so you can see better. Is that because I've lost elasticity in the eyelid and it's just drooping more? Well, no, more so going back to what we were talking about,

the bony structure. Ah, that's right, the bone. We're losing bony support, fat atrophy, including the brow fat pad. And so now you've got a descent, a little bit of your brow, but a little more of the extra redundant skin there. I got it.

So I'm actually using this muscle more to try to keep these guys up. Exactly. Now, if you go to someone who doesn't evaluate you like we do, they might look at your forehead like target practice and say, I'm gonna use a neuromodulator across that entire forehead and make it so you can't move.

And then you're gonna walk around very hooded and very heavy. I would feel silly. I wouldn't wanna look that way. You would hate the feeling. It would feel very hooded and very heavy. And I've done that on purpose to myself just to see what patients experience. And it's not a nice feeling.

Secondly, you are very fit. So you have not a lot of fat in your face. And like I said, doesn't matter what you think your weight is on your body now, or how much fat percentage you have on your body, you've atrophied some of the facial fat pads. You've exposed the entire orbital rim, I can see that. And you may also notice I have a scar here,

and it has created an asymmetry in the drooping. So from my teenage years when I was boxing, I actually had, I was split to my cheek there. So that is a very deep scar. I suspect the connective tissue there is actually tethered near the bone. And we can free that up with subcision. So that is kind of similar to the micro-nudeling Tanuja did on your other scar,

but this is going under the scar, the whole length of it, and subsizing or freeing up that tethering and that adhesion with or without adding fat or filler there. A filler or something. Okay, got it. But I would, so if you look at what makes the eyes look youthful, it's definitely having a little more platform show on the upper eyelid, but also it's reducing what we call the length of the lid cheek junction.

So the length from your eyelash line down to where you can actually see the cheek. That's elongating. In me, yeah. You've lost all that volume that was out here. I think that if you were to ask me, Peter, what are you most self-conscious of aesthetically? I think this is it. I think it is this thinness here,

which I believe makes me look constantly tired, even when I feel like a million bucks. I think I'm more subconscious of this than I am my wrinkled forehead. Yeah. And that's where I would either use a little bit of your own fat if we could find some. Oh, I've got plenty. And I would use that to rebuild this area and shorten that lid-cheek junction so that we create more of a youthful length

rather than this kind of long hollow area. We're gonna talk about this of course, but when do you guys make the decision of an auto-graft of fat versus Restylane you mentioned earlier? I love fat if we can do it. Now with the advent of fillers, the volume of fat grafting we do goes down.

And I'll tell you why. On her, she came in, she had never had anything before. And she was hollow everywhere. How old? Sixty-nine. Okay. So yes, we could use lots of fillers, but she'll spend a small fortune putting a lot of fillers in her face over time. And I personally don't like to inject more than two or three syringes of filler in one

visit. So it's going to take a process to build up different areas on her because I just don't want to have a reaction and I also want to see where I'm placing everything. But in her case, we went straight for the fat because she has a thin face, but she has a normal body mass index. So her fat is going to do well. How much filler would I require? What would your guess be?

I'd start with a syringe split between both under eyelids and then I would do another syringe probably in about three or four months if I need to. What's the cost of each syringe? Not your cost, the patient's cost. Yeah, about 800 to $1,000, depending on the filler. Again, what is the cost of the procedure, the fat graft procedure?

That's obviously much more, but it's a lifetime, presumably. It's about 5,000. Okay. So five years worth of treatment, basically. So it's cheaper in the long run to do a fat graft, presumably. Yes. But also remember that we're just talking about your under eyes. But let's say you're my typical patient.

They need their temples filled, they need their cheeks filled, they need their chin filled, jawline enhancement. So yesterday I did about 35, 40 mLs of fat on my patient. So that gets very expensive. Are my temples too sunken? Yours are still good. And your cheekbones are still good, your jawline is still good. I would put a little neuromodulator, a Botox,

in your platysmal muscle, because I am starting to see some platysmal banding there. Mine's worn off so you don't want to look at mine. But that helps to relax that muscle that does nothing but pull the lower face down. I would possibly add a little volume right in your malar. In your case, I would love a biostimulatory filler, something like polylactic acid or Sculptor is the other name for it, to start building collagen and thicken your dermis thickness in here because I'm starting to see some of your buccal fat pad atrophy as well.

And that just goes along with how fit you are. So using this to build your own collagen is a great way. And if you were female, very thin, we would have an issue because those patients tend to burn through their fillers very quickly. So if we can get a biostimulatory filler on board where they're building their own collagen, sometimes that works a little better. Now, do you ever look at a patient like me and say, you're most fat depleted here and here, but you're not yet fat depleted here and here?

I only want to do one fat graft on you. So let's cost aside, let's use fillers until I have to do this procedure once and for all, and then I'll literally just take a bunch of fat off you and do it. Absolutely. Is that a better approach or are you afraid to do multiple fat grafts?

Oh no, I have patients that come for fat grafting as they need it. So I've done some patients three, four times, but I have turned down a lot of patients who come in actually asking for fat grafting for lips or for under eyes. And I tell them, since they don't need it elsewhere, that's too much of a procedure to go through for like one anatomic area.

And in the lips, it doesn't hold as long, but under the eyes, it works beautifully. But I would do it when they need it elsewhere. I will probably never need lip fat grafting. When I was little, people made fun of the size of my lips. I'm pretty never need lip fat grafting. When I was little, people made fun of the size of my lips. I'm pretty sure I'm safe on that. Before we go on to resurfacing, Tanuze, what would you change or add or how would you approach my face?

Well, I think Susan's analysis was spot on. I agree. I think that what I hear you saying is the biggest issue that bothers you is your under eye area. So because you're someone who's never had a procedure before. Actually Brett Kotless did stick Restylane in there, gosh, how many years ago? Probably 2018, 2017. I'll tell you what I remember of the procedure.

I was amazed at how much I bruised. He told me I would, so it's not like this was an unexpected complication, but I looked like I had two black eyes for a couple of days. Otherwise it looked really good, and then it went away after a period of time, but it definitely was not a year that it lasted. I also suspect I metabolized it very quickly.

I also- We have longer lasting fillers, so that we can use on your face. Okay, he also mentioned that this scar was problematic. He said, it's very difficult to fill this eye. And you might ask, well, why didn't you just keep doing it? Just the same reason I don't do anything, just sheer laziness.

I was just like the thought of actually doing that again, having a couple black eyes for a couple days, blah, blah, blah, blah, blah, I just sort of gave up. So anyway, I have that one experience. So your under eye area, and by the way- Being lit this way is an abomination. Yeah. But just by the way, bruising from fillers

is a lot less these days because we don't use needles as much anymore. We actually use cannulas, which are blunt tipped catheters, and they don't typically bruise hardly much at all. So that's one big change that's happened in the last five, eight years is switching to cannulas. And people have different philosophies on that. Some people use needles for specific locations,

but just wanted to mention that that bruising your undry would probably be less if you had fillers again. But again, kind of going back to the way that I do a cosmetic exam, because I just heard you say the thing that bothers me the most is this area. And we could list off another 10 things that are quote unquote, aesthetically problematic. Like I didn't even notice this. So now you've given me something to be self-conscious about. I should have prefaced it saying I'm just going to point out some things.

I wanted you to. I'm totally teasing. I'm totally teasing. So I would laser focus on the area that the patient is now presenting to me as their major reason for even calling up my office and making an appointment is probably because they wanted to address this area. And yes, they're curiously interested in all the other things that I had to say, but because this patient, in this case you, never had surgery on

their face, is probably not looking for massive shifts in their face, I would probably laser focus on this one area, not just because it's what you pointed out, but also in the realm of rejuvenation procedures that we perform surgically or non-surgically, the eye region is probably the sweet spot. Just again, going back to psychology, evolution, we focus on people's eyes in conversation.

When we talk about beauty, we're looking at the eyes. When people's eyes are now starting to become further and further away from the way they remembered when they were younger, it creates this discomfort. It's the self-discrepancy theory from psychology where you've got the self-image of yourself and then you look at yourself, you're like, wait a second, that's not me. And then it creates this discomfort of like, is that what I really look like? And then it creates the psychological effect

of maybe a little less confidence or dissatisfaction with your appearance. That's the big motivator for why people actually end up coming to see someone like us is because that self-discrepancy theory is kicking in and the delta between their self-view and their actual appearance is getting greater and greater. It's one of the reasons I, it sounds ridiculous that I'm saying this on video and that I have

a podcast. I freaking hate being on video. I don't mind the sound of my voice. Seeing me on a video and as you know, in this type of a situation, you're always overhead lit. It is an unbearable appearance because when you have these bags under your eyes, overhead lighting just makes it look 10 times worse. If I pass myself in the mirror, I'm like, I notice it.

If someone ever sends me a clip of me on video, I'm like, how in the hell are we allowing this to be in the public domain? I mean, seriously. And part of it may be what we were mentioning earlier, that subconscious posing, because when you're looking in the mirror, you know you're looking in the mirror and your subconscious makes you lift your cheek a little bit. Maybe I angle my head different or something. You angle your head or you smile a little bit and it pulls the cheek up and minimizes

that hollow between your under eye and your cheek. And everybody does this. And that's why people tend to be shocked by photographs that are taken of them when they weren't prepared for it. They're not prepared to pose for the picture. And their flat, undynamic face in a photograph that's taken like that is shocking to them. It's often a big motivator for them to come to see us.

I also made the mistake of once reading some comments on social media where people were just ripping me apart for how horrible I look You can say what you want like I don't care But you do care if you read a bunch of people saying you look horrible. You're like that sucks I don't like that Yeah You know when people show you that picture of themselves that someone took because they bring it to the content They bring a picture and like oh my god. I saw myself last week. Look at how I look and you're like, give me your phone

I take their phone. I take a picture of them in the exam room and show them, look how good you look. This was one nanosecond in one way you were moving your mouth or tilting your head or shadow. You don't look like that. So delete that picture. We will not address how you look in an ounce second compared to how you look the rest of the day. Totally agree, yeah. And then what about the wrinkle situation? Yeah.

So what I would do is I would go through all of the areas, the four areas that we're talking about, and then I would laser focus on the eyes. So to go to the four areas, we're talking about skin. We've done a lot of discussion already on skincare. I think that you should start a skincare regimen. I think you'll appreciate it as time goes by. I'm going to commit to three months for sure. You have uneven pigmentation in your face. You have some fine lines that are more concentrated in the eye region

because the eyelid skin is the thinnest on the entire body. It's the one area of the body. You're a surgeon by training. You know that when you cut into the body, there's always a fat layer, not in the eyelids. So the eyelid does not have a subcutaneous fat layer. It's the only place in the body. So what's underneath the skin? The orbicularis muscle. Wow. And so there are four causes of dark circles

under the eyes. There's visibility of the orbicularis muscle. There's shadowing, which is why you probably don't like your appearance in this kind of situation because the shadowing is visible down here. There's hemocytidine depositionosition and then there's hyperpigmentation. So those are the four reasons why people get dark circles under the eyes and you actually have all four of them.

So we would definitely want you to get onto a good quality skincare regimen because it's one of the four areas that needs to be addressed, not only to reverse some changes, but for prevention purposes. And when it comes to volume loss, I think Susan's already picked you apart there. You've got volume loss in the mid-face. I think your temporal volume loss is enough where if you were going to have some kind of volume treatment, putting a little bit in would be nice.

Your left temple sinks in a little more than the right. Oh, okay, yeah. I'm mostly looking at this side of his face. Yeah, yeah, the right temple's less hollow. Is that common? Extremely common. So when I'm mostly looking at this side of his face. Yeah, yeah, the right temple is less hollow. Is that common? Yes. Extremely common. So when I put that mirror up in front of patients that start pointing out their asymmetries,

I'm not kidding, 95 to 99% of the time, people are unaware of their own asymmetries until I point them out to them. And the reason why it's important to point it out to them, because if I'm going to be employed to manipulate their face, they need to know where the starting point was. Do we want to fix asymmetries all the time? Like, does it matter? Sometimes. Sometimes.

We don't want to make it worse. Certainly. That's probably a big, big factor. And then if there's a way to make it better when we're doing maneuvers, we'll dial that in because again, going back to the three biological reasons of why people perceive beauty, it'll make that person look more handsome or beautiful. OK. And some people do have significant asymmetries.

I have ladies for some reason where one jawline is aging beautifully and very well defined, and the other one's like a centimeter shorter in length. And Peter has some of these asymmetries too. I mean, his right side of the face, even though you had that injury on your right cheek, your right side of your face is the smaller side of your face. So imagine in utero-

I had literally no idea. Yes. And the other funny thing is another reason why people feel uncomfortable when they see photographs of themselves is because you're used to looking at your mirror image of yourself. Think about this. Nobody on the planet has actually ever seen themselves. You've only seen yourself in the mirror or you've seen a photograph of yourself. You actually don't really know what you look like in the flesh. And so because there's that discrepancy between the mirror and a photograph,

because the mirror is a flipped image of yourself and the photograph is not, that's why people don't like photographs of themselves, especially when they're more asymmetric. So if we measure the distance between the outside corner of your eye to your mouth, it's about 10% longer on your left side because the bone structure is wider. So again, imagine you're laying in utero, you're in the womb, and you're probably spending more time on one side of your face than the other. There's so many factors we can imagine as to why do we get facial asymmetry. It's because of maybe the growth rates were different. Maybe there's a slightly different cytokine difference between the left and

the right at six weeks. And maybe you're laying on one side of your face for two months. These are all the reasons why we end up with a little asymmetry. And these things are present at birth and they become more exaggerated as we age because when you have that devolumization of the fat pockets and the ligaments show up, the underlying bone structure starts to become more visible. And then finally, if we saw some pictures of you

when you're 20 and we put them side by side with you right now, even though you have a great jawbone, it's probably lost about 10 to 15% of the volume that you had when you were 20. And so comprehensive treatment would be to volumize either with some fillers or some fat grafting to the areas of volume we talked about, the skincare regimen we talked about. I would probably put some volume along the jaw and your cheekbone because you've lost that projection with aging. We just know that some of your age is going to have a certain degree of deprojection.

How do you put volume along the job? How do you keep it in the area you want it to be without it looking odd and protruding? So the art of fillers and fat grafting is really truly an art. There's depth of placement, replacing it in the pre-periosteal layer to emulate as if it were a larger bone structure. If you're trying to hide jowling, then you might put it into the muscle layer

because you're trying to plump up the valley next to the hill so that it becomes smoother looking. Choosing the right filler. Choosing the right filler. Is fat always a superior filler? Not necessarily. I do like fat because it's your own living tissue. And of course, it has those stem cells in it

that can become multiple different types of tissue. So if you place it at the periosteal level, it can build bone. If you put it in fat, it becomes fat. And if you put it along muscle, it can turn into muscle. And if you put it under the skin, it enhances how the skin ages. So something anecdotally, there are many of us

that do a lot of fat grafting. We were on a panel one day talking about it. Before we knew about the stem cells being in the fat, we're talking 15, 20 years ago. We were talking about the fat grafting patients and how they all uniformly look like they just age better and their skin ages better and now you start to realize all of that. Where do you harvest from? Numerous areas of pre-adipocytes I should say. The tissue that has the most pre-adipocytes is the

abdomen. So subcutaneous abdomen. But I really like the flanks because it turns out you don't just want the fat and the fat stem cells. You need all the connective tissue stem cells as well. And when you go to the flanks, the reason the flanks feel so firm, even though they may have fat in them, is they have a lot of septate and stromal tissue there. And when you aspirate the fat, you're also aspirating along with it some of that stromal tissue. So you're getting the matrix and the scaffolding cells that will help that fat also repopulate. And just give me a sense of volume. So if you decided to go full bore on somebody and do temporal and eye and outside of the

lip and jaw, how much fat are you putting in and how much fat and tissue do you need to harvest to acquire the necessary volume? So we may differ in our techniques. I'll let Tanush speak to his. I will typically harvest about 120 cc's of fat. So we're talking about an area about the size of a small cantaloupe. Just to put that in perspective,

if a person undergoes liposuction, how much is being harvested? Usually we're filling canisters. So liters. Liters, two, three, four liters of fat. Okay, so this is not gonna make a material difference in your subcutaneous fat depot in your body. Correct, and if we artistically do it,

we can take it from both sides so that you don't have any divots or asymmetries. But people always have an asymmetry even on their body. So I tell them, you know, the benefit of this is I'm taking also the fat and evening you out with your other hip, and they're like, oh, I never even knew I was asymmetric. So I typically harvest about 120 cc's and then we centrifuge it.

And it condenses it down. So it takes off all the anesthetic fluid you put in. We have albumin in there to restore some of the oncotic pressure as well. And we are taking people's own PRP, spinning their blood down to get the PRP, the platelet-rich plasma, adding that in along with something that we call nanofat. So it turns out if you take fat and you graft it into tissue, a certain percentage will take.

But if you take fat and then you add in extra stem cells, more of that tissue will take. So what we do is we harvest extra fat and extract the nanofat from that, meaning all the pre-adipocytes by running it through some meshes and adding that back in to supplement the fat. But it's the patient's own, it's autologous. Everything, the PRP, all of that. Okay, how does your protocol differ from that?

Very similar, remarkably. And full disclosure, when I was coming through training in 2005 to 2007, finishing up my fellowships, I spent a lot of time listening to Dr. Ubaji's talks at conferences. So my fat transfer technique has basically mirrored hers for quite some time. I probably do a little less harvesting, a little less injecting because most of my fat grafting is being done in conjunction with a facelift or an upper and lower eyelid surgery called blepharoplasty. So when I'm surgically manipulating the tissues, I'm lifting and moving tissues.

I'm not in need of as much volume to make the change that we're looking for, but very similar overall. Okay. That gets to the eyelid problem. You alluded to a procedure that lifts the eyelids and doing so presumably makes you require less these frontalis muscles. So are my eyelids a problem? So the short answer is at this point you would probably qualify for your insurance company to cover your upper eyelid surgery because that's how droopy they are. Holy crap. They're sitting on your eyelashes.

Yes. This is hilarious. I had sitting on your eyelashes. Yes. This is hilarious. I had no idea how bad I was. Well, we're not saying you're bad. No, no, no. But if you're telling me insurance would cover a cosmetic procedure in me. If we did a visual field test on you where you relax your forehead muscles and you were

required to look straight ahead and kind of hit a button every time you saw a light flash in your peripheral field. And we did the same test with your eyelids taped up. You'd probably have a 30% difference in your peripheral field. So this could be affecting my driving. Probably you're probably finding yourself having to look a little harder at your blind spot because of that. Now it becomes a very complicated issue.

One of the most common things that we'll see in our practice here in Austin is that patients come in and say, I think I need to have my eyelids done. And then we say, yes, but... And the thing is people don't realize that the face is not isolated into individual pieces of anatomy. Your eyelid is connected to your eyebrow, which is connected to your forehead. So if we're going to do an upper eyelid surgery, because you're constantly lifting your forehead muscle to be able to see better, your brain's compensating for this pathology. If we do an upper blood forplasty, whether it's insurance or cosmetic or whatever, all of a sudden that visual field will improve and your frontalis muscle automatically relax

and your brow will come down and it'll create a new problem that you didn't know you had. And so these are some of the conversations we have to have with patients that maybe we leave you alone unless you're also ready to have your forehead lifted or at least have what we call a medical brow lift with Botox.

So muscles pull the eyebrows up, muscles pull the eyebrow down. If you preferentially inject Botox into the depressor muscles, which are here and here, naturally the tone of the front else will lift the forehead a little bit. Even without wrinkles showing. So I'll tell patients, look, if we do an upper lid surgery, that'll be fine. But we either have to commit to regular use of Botox to keep your eyebrows in check, or we have to do a brow lift at the same time. Where's the incision for the brow lift? Do you do it through the same incision? So I would say that when it comes to designing surgeries,

what I train my fellows and residents is that there is no single surgery. Every single surgery is totally custom designed for the individual patient's anatomy. There's general patterns we use, but we should always infinitely manipulate the procedure to achieve the goal of what we're trying to do artistically. In your case, it's complex because someone who doesn't have hair, we usually would hide incisions behind the hairline. It is possible for you to have an endoscopic forehead reset procedure and we would make the incisions further back and smaller and it'll be a more technically challenging procedure.

But there's a way to lift the forehead with incisions that would not be socially visible and then those incisions can be closed in such a way that as time goes by, especially with post-surgical treatments like microneedling with five-flour uracil and topical treatments, that you can get those scars to become what I call socially invisible. Which I mean, it just to me seems like I could never commit to that much work. You know what I mean? So does that mean I'm just stuck with droopy eyes? Then in the conversation with the patient,

what we would come to, probably in your case is, okay, we can do a blepharoplasty, which is an upper lip surgery, but we're gonna under-treat you. We're gonna do less than what you think you need. It's not gonna make a huge shift. But on the other hand, we also don't wanna change the entire relationship neurologically

that your frontalis muscle has with your eyelid. So by taking a patient through all the potential pathways, they sometimes recognize they can't get what they thought they were coming for, and we're going to under treat them. So we avoid a potential problem. And similar things happen with the under eye area. So your under eye area is pretty complex too, because you do have bulging fat visible in the under eye area, which by the way is exactly the same contour that you had when you're 20. It's just become unveiled because you've lost volume and the cheek has descended. And now we're looking at the orbital retaining ligament and the malar ligament. So this line right

here corresponds to when you're looking at a skeleton and there's a big circles where the eyes are supposed to be. This is that bottom half of the circle where the ligament is sticking down. So if you put your finger on the skin right below an eye bag, you'll be touching the edge of your orbital rim bone right there. And so from my standpoint, if we're going to do something that is definitive to treat that, it's going to also have to treat the volume issue in your cheek. It's also going to have to address some of the skin textural issues in the region. And then sometimes some people have an issue where there's a triangle that catches between the orbital rim, which is that hollow we were talking about

in the under eye area, and another line that exists in the cheek a little bit lower and it creates a triangle where fluid can collect. So I don't know if you've noticed that but you've got that little triangle right here on both sides. That area is called a malar mound. It's kind of like a sponge under the skin. It collects fluid. It's worse in the mornings because we're laying flat and we have a little more edema in our face.

If you've had salty food the night before, it'll puff up a little more. People will use preparation H. This is a time tested home remedy to try to shrink down that swelling that's present there. This would have to be part of what's addressed if we were going to address your under eyes. And if we were going to do something to address your under eyes, it would be something that would reduce the bulk of the bag, fill volume in the cheek, smooth the skin out, and address that malar amount. And so this is a common maneuver of what we would do in our practice,

which is we would, under anesthesia, make a hidden incision behind the eyelid and take those eyelid fat pads that are making that bag and create a pocket down in front of the cheekbone where the volume loss is occurring and where the ligaments are showing they're hollowing and then move that fat down. That's called a transposition lower blepharoplasty.

So one of the big changes that's happened in aesthetic surgery from 1995 to now is back in the old days of cosmetic surgery. There was a lot of cutting fat out, cutting skin out to make eyelids look tighter, cutting skin in front of the ears to tighten the face, doing surgeries that mostly remove tissue. And now we're becoming much more sophisticated where we're actually manipulating the ligamentous attachments to the bone. And so because we're recognizing the ligaments.

You don't have to remove the skin necessarily. We don't have to remove as much, yes. If you do, you can tighten it with lasers and peels. Yes, exactly. Rather than cutting it out. Just to conclude what the suggestion would be for someone with your kind of anatomy, we would transpose the fat, which would,

two birds, one stone, reduce bulk here, add volume here, three birds actually, because it would basically eliminate the visibility of the ligament because there's fat under it now, which is pushing it forward. And then we would do something to improve the skin, as Susan said, either laser resurfacing or chemical peel. And then there's a new technique that we're using where we're injecting tetracycline

into areas of swelling of the face. So this is pretty cutting edge. It's been around for several years now and we've got pretty good experience with this technique. But tetracycline is an old drug that was repurposed by the pulmonologist to address pulmonary issues where they want the pleura to stick to the lining better. And because it has that property of basically creating fibrous attachments, it can be used to shrink that sponge down by injecting delicately into the male arm mound to kind of flatten it. And so that would be the constellation of procedures. And what can go wrong here? Because I think for many people that would be contemplating

something like this, it's one thing if you are having a procedure where, well, first of all, this is a cosmetic procedure. So out of the gate, A, it's not essential. B, if you don't look better when it's done, it's the worst possible outcome. And then C, it's the most visible part of your body. I've heard stories of women who have breast augmentations where they have complications,

and at least the breasts aren't always visible, meaning the actual skin itself. So even if you have to re-operate and it creates another scar, it's only visible to her partner. But here, it's just the highest stakes game. So how do you navigate complications, risks, and mitigation strategies? And that's what we were talking about before. You have to make sure that whoever's doing your treatments, A, is well-trained, qualified to do the injections,

and can manage the complications, because everyone's going to have complications. We've had complications. And speaking for me, I'm sure you've seen this. Of course, yes. You can't treat patients and then not do enough cases to not have a complication. But there are some really notable complications that are vision threatening or tissue threatening. So when you're treating around the eyes, for example, or even into the temples, there are

reported instances of stroke and death and vision loss, including treating around the nose. Because all of these vessels interconnect with the internal carotid system. So anywhere you inject a filler and you get into a vessel, on the outside of the skin- You could create an embolism. You can create an embolism and it's going to go follow the path of least resistance.

Once you bolus it into the tissue, it's gonna backflow, but then it's gonna be pushed forward again. It's gonna go to the ophthalmic artery. It may go into your central nervous system, into your brain, I should say, and the vasculature there and create a stroke. Now, some of the more serious strokes were caused by people injecting fat with needles, but all of these other complications really come from injecting fillers in this kind of central face area.

So there is a technique, there's knowledge of the anatomy, there's knowledge of how to do very little pressure, aspirate where you need to aspirate depending on the filler you're using, and watching the tissue, looking for signs of any kind of embolus that's forming. What about the obviously less consequential but still troubling side effects where,

hey, the person doesn't have a good cosmetic outcome. So they didn't have a stroke, they're alive, their vision is fine, but they don't look better. Something went wrong. What would go wrong? What are the things that go wrong here? I would say the most common types of complications that we'll see either,

any surgeon will have complications, I've had complications. In our practices and in my practice, I will see a lot of patients referred in with complications where we have to try to identify how to improve a bad outcome. So the most common reasons why bad outcomes occur in the world of cosmetic surgery, and you're right the stakes are high, is because either the wrong procedure was done, which is much more common than one might expect, or

there was a technical issue where the surgery wasn't done correctly. Those are the most common causes. Now, I will certainly have patients where I will do my very best and one side will be a little asymmetric and six months after surgery, we might have to go to the procedure room to do a minor touch-up to kind of enhance things.

That's one level of a problem. But when it comes to the more substantial disfiguring situations where people had been quote unquote botched is the word people like to use for that. It's usually the wrong procedure was done or it wasn't done well. I think that that is a very scary topic for listeners to be thinking about if they're even considering going down the pathway of rejuvenation or some sort of plastic surgery procedure on their face. And it can be very confusing because you're getting so much

information from marketing and social media and physicians who perform cosmetic procedures are advertising and showing their best before and afters. And so how does someone figure out how to navigate this? And I would say probably the best advice that we could give someone who's thinking about going down this pathway is you got to take the narrative into your own hands. You have to understand your own anatomy. You have to do a deep dive in understanding some of the techniques, not some, all the techniques that are available to address the issues that are your particular concern. And that might require multiple consultations.

It might require choosing good resources online, which are usually society websites. So the American Academy of Dermatology, the American Academy of Cosmetic Surgery, ASPS, which is a plastic surgery society, these society websites will have accurate information on procedures, and you should avoid getting secondhand information from people you know or from social media. But you got to do your homework. You have to learn the anatomy. You have to understand your own situation and your choices that are available to you. And then it's kind of like analogous to dating and marriage. How do you know when it's the right person? You just know.

So let's go deeper into that. If I said, Hey, I'm going to introduce you to my friend. She's going to go and sit down with a surgeon. You're not going to do the procedure on her, even though you'd be fully qualified to do it. You're not going to do the procedure, but I want you to be her advocate while she sits in the consultation room.

And you can tell her what questions to ask, and you can help her interpret the results. But your job is to help her find the best doctor. What are the questions you're asking, and what are the red flags you're looking for, and what are the green flags that are making you say, I like and trust this person? I think it starts with your rapport with the patient too.

You can quickly get a sense with the doctor you're working with if you and he or she can see eye to eye in terms of what you're seeing, what they're seeing, how knowledgeable they are describing the procedures that they're suggesting for you. Does it make sense? Do you really, for example, if they're telling you you need a brow lift, and you've seen several other people and no one mentioned a brow lift, maybe you need to think about why did this person mention a brow lift and the other one didn't? Or if everyone says you need a brow lift and one person says you don't, you have to figure out and go back

and look in the mirror and try to understand what they're trying to point out to you as to what makes sense from that standpoint. Is it a comprehensive approach or are they just attacking basically the issue that you have that you're bothered by? I think people should take a comprehensive approach and just at least get that information, even if they don't act on all of that. The person evaluating you should give you an overall look at everything, just like Tenuj did, just like I did, addressing all the different areas that maybe you didn't even know to ask about. On top of that, understanding their strong suit. I don't do rhinoplasties. If I start telling a patient I'm going to do a rhinoplasty on them, they should run. They should ask me, how

often are you doing this? What are your complication rates? What is the retreatment rate? How happy are your patients with this procedure? So to everything I do, I can show them my before and afters. I can tell them and I show them multiple, for example a facelift. I'll show them different faces because everyone has a different shape face. You can't get the same result depending on their anatomy. So I'll show them different things. I'll say now this one looks more like your neck and your jawline. This is kind of the result you can hope to get. And I tell them the complications in my hands.

I tell them the overall complications, but I tell them in my hands, this is what I see. And it's one of the challenges, by the way, that's exactly what I tell people in general when they're interacting with surgeons is, it's one thing to know the complication rate when you're getting a colonoscopy. It's another thing to know their complication rate when you're getting a colonoscopy. It's another thing to know their complication rate and their patient population because

it's not always the case. For example, if you're having cardiac surgery, a low complication rate isn't always a great thing. It might mean low complexity. It gets more complicated. Anything you would add to that, Tanuja, as far as questions that they should be asking or red flags or green flags? I agree completely there with what Susan said and maybe some additional things to add, which

some of these things matter more than others. But I think having had the right training and board certification is one level that should be met. Whoever is doing your procedure should have board certification in the specific area. Yes. So sorry, just interrupt. For eyes, what percentage of people doing eye procedures, like a lift, a blood phoplasty, would be oculoplastics trained? Is that a rare thing? Is that uncommon or common? It's the most common procedure that an oculoplastic surgeon would do probably. But how many non-oculoplasticians would do that procedure?

A lot. In 2025, there's so much more overlap that's happening than what used to exist because each field that has an aesthetic aspect to it, we're talking about dermatology, plastic surgery, ENT, ophthalmology, or maxillofacial surgery. These are the most common specialties that have an aesthetic overlap. The aesthetic focus in these training programs has dramatically ramped up in the last 20 years, where part and parcel of these training programs include aesthetic surgery. But in addition to those birth certifications, I think that experience matters. What's the minimum number of procedures you want to see

done by the practitioner in a year to say, yep, you've got enough reps? It really depends on the procedure. Okay, for a rhinoplasty, something like that. For a rhinoplasty, you're gonna wanna have someone who's at least doing 25 a year. Okay, for a facelift? For a facelift, you want someone

who's doing at least 25 a year. I think it also is gonna matter how many other procedures they do too. Someone who's doing at least 25 a year? I think it also is going to matter how many other procedures they do, too. Someone who's doing face and body might be doing a lot of body liposuction. So they're doing facelifts, but they're doing also body lipo, maybe they're doing eyes, all of that. Do you want generalists or do you want specialists? If you're going to get something done to your face,

my intuition, which could be entirely incorrect, is, I don't want them doing breasts and butts and lipo. I want them to be maniacally focused on the thing that I want them to do to me. So I would say in my practice, I do five things, for example. But I do those five things a lot. But I don't do only one. And you don't do only one, even though your ocular plastics and your facial plastics as well, though. Yes. I generally agree with what you're saying is that I don't do any body surgery.

So I'll refer that all to people who specialize in that. And most people who do body cosmetic surgery will focus on body cosmetic surgery because facial cosmetic surgery is a different animal altogether. So I think that that kind of specialization matters. Look, I was a young surgeon once, and certainly going to a surgeon who's right out of training

can be fine for a limited, isolated procedure, but I'm sorry to the young physicians in the audience, but a few years of training is usually helpful in building your repertoire and experience to be able to handle complications, and sophisticated listeners would probably naturally end up choosing more experienced surgeons for that reason. And I think another important thing is that this is a creative specialty we're talking about.

And so you want to choose someone who is evolving and moving with the times and preferably is helping to advance that edge of medicine. That means that they're constantly thinking and questioning and improving their results and not resting on laurels and not stagnating in one particular way of performing a procedure. I think that's a very, very important aspect of trying to identify someone. So in that sense, do academics, because you would normally not associate cosmetic surgery with an academic affiliation. You would normally say, well, I get it if I have an oncologic issue.

There's an advantage to being in an academic setting because of the research and because of the affiliation with the other branches of oncology, et cetera. You can come up with some, but you don't always think that way about people doing cosmetic surgery. But what you're saying would probably fit more neatly into the box of someone with an academic affiliation. I agree. And the interesting thing about aesthetic surgery is that it's a little bit of the black sheep in the world of medicine.

So academic cosmetic surgery, academic plastic surgery is different from the traditional sense of what academic might mean. So in the world of facial aesthetics, you can have a single surgeon in private practice, no university affiliation, who is 100% academic because they are publishing, they're going to meetings, they're lecturing. meetings, they're lecturing, they are helping to move the dial in the artistic world of what we're doing in facelifts or eyelid surgeries or brow lifting. It might be someone who's at a university full-time, but it doesn't have to be. And that's very unique to aesthetic surgery. I also think that the universities don't support their aesthetic doctors. So a lot of times universities cannot figure out a model that works for them to profit share or to find a compensation model for an aesthetic doctor that's appealing to them

to make them not go into private practice. So they end up shortchanging themselves and then the doctors leave and they go into private practice. Whereas I think if you can get the universities to wrap their head around how to build out a really strong academic practice like we did with our university at the University of Pittsburgh Medical Center. We were rare. We were one of the first in the nation to purposely build an academically based cosmetic

surgery practice with the intention of training plastic surgery residents if they want to rotate oculoplastic, facial plastics, dermatology residents, and people from around the world. I mean, it makes a lot of sense because of the amazing overlap between surgery in general, especially oncologic surgery and reconstruction. Like if you think about it, every time a woman undergoes a mastectomy, she should be immediately plugged into a plastic surgeon to, if nothing else, make sure that that reconstruction is as cosmetically pleasing as possible. And then you think about all the head and neck cancers and things like that. There's a clear incentive, maybe incentive is

the wrong word, just if nothing else, a business case to be made for better patient care with the integration of that type of service. The universities can't see that though. The problem is they think it's a one size fits all and they don't understand the differences. Like for example, your cosmetic practice has to have a more aesthetic look. It's gonna cost them more to build it out. They're gonna need the devices.

They need investments. And it's really hard to get some of these universities to see that. You have to work with them and become your own business manager, for example, and propose to them a business plan, return on investment, all of that. But practically speaking for the listeners, if you're trying to find someone to help you on a path in this category of aesthetic surgery, finding someone who is speaking at conferences,

teaching, involved in the cutting edge of medicine, I think that's definitely a qualification. I think another thing that you mentioned earlier is maybe asking them how often they are receiving complications and managing them. That's probably a sign of skill and seniority in the field. If you're kind of the person who's, again, it's not about calling out who those complications belong to, but it's, hey, you know, okay, so we've talked for a lot longer than I thought we would, but I'm sorry if we can get you to hold on for a minute longer.

We can't get out of this podcast without me understanding the difference between lasers, micro abrasions, micro needling, chemical peels. I can't understand any of these things, but you mentioned resurfacing, you mentioned my skin sucks. So clearly, before I go on the path of my rejuvenating anti-aging protocol, I might as well do something to fix the situation we have going on here.

We could do a crash course. I know this podcast is running long, but it's just a massive subject to cover. Let's start with lasers. Could we take one step back, maybe, and talk about the difference between ablative and non-ablative, and maybe talk about peels? So maybe the way to go is there are various technologies that will, in a controlled manner,

injure the skin to harness the body's natural healing cascade, which then will produce the aesthetic benefits we're looking for, which is more collagen production, smoother skin, less pigment issues. And that's the goal. And so the bottom line is there's a relationship with how aggressive the treatment is and how much of an aesthetic improvement you're going to get. But the more aggressive it is, the more downtime there is.

So that's always the balancing act. And that's why there's such a confusing array of options that exist, because there's a huge spectrum going from the least invasive, which has the least result, to the most aggressive with the best result. And so, I guess to generalize, there are treatments that are not truly ablative, meaning they're gonna penetrate through the skin, and then there are treatments that are. I think I'll hopefully set that up for you, Susan,

to maybe go from there. So that's the definition. Ablative means it penetrates the skin? Yes, ablative, yes, and non-ablative doesn't penetrate the skin. So what are the non-ablative, which are presumably the less severe, which means shorter recovery

time, less overall response? So non-ablative things, you can start with even your topical skin care regimen, because that is going to remodel the skin and set the stage for you to even prime it so you make more collagen. And then you can do things such as light chemical peels, which are only going to affect the epidermis of the skin. You can do things like non-ablative fractional lasers, and those are going to, again, send tiny fractionated beams of light onto the very surface of the skin and just damage the

upper layers of the epidermis. And that's going to stimulate a cascade of cytokines to build on the collagen and texture, but it's gonna be minor. And they might help with some minor pigmentation issues. Those are non-ablative devices for resurfacing. What was the last one? Non-ablative fractional lasers. We also have non-ablative vascular lasers.

Those are lasers that are going to penetrate with a beam of light to hit the dilated blood vessels in people who have rosacea. What's the brand name of a non-ablative fractional? Faxil or clear and brilliant. Within those, there are different ones. The Faxil has multiple different ones. Clear and brilliant is just superficial.

And then you have non-ablative things like vascular laser that will help treat broken blood vessels, scars, texture change. And that one, even though it's shattering some of the dilated blood vessels deep in the skin, it's not leaving an open wound on the surface. So when we say non-ablative, there might be things happening deep down, but the surface of the skin is intact. So there's no raw wound. We might want to pause on that category for one second,

just because that is probably one of the most high yield areas for someone to try out as an initial intervention with a physician or provider. Because the downtime is easy, we're talking about non-ablative, for example, intense pulse light or broadband light, which is IPL or BBL for short. Those are in the category that Susan just mentioned of non-ablative light treatments.

And it's a huge, huge category. There are so many devices in this category that it would be kind of silly to even list them. But they're very effective in that they don't have a lot of downtime and produce improvements that are real for patients. Sardin Trump, I thought we should just pause there for one sec. Absolutely, and I think a lot of downtime and produce improvements that are real for patients. Start and interrupt. I thought we should just pause there for one sec.

Absolutely, and I think a lot of them worked. Moxie is another non-ablative. I'd have to look and see what the technology on Moxie is. If I'm not mistaken, I think that one might be radio frequency micro-needling. I think that's right, yeah. Yes. That kind of bridges the gap a little bit.

It depends, it is semi-ablative because you're literally piercing the skin with a bunch of needles and delivering radio frequency energy through those needles. And those will stimulate collagen. So anything that generates heat in the skin to a certain level, to a certain temperature, I should say, will then cause the formation

of something called heat shock protein. And that causes a whole cascade of other activity within the dermis of the cells, the dermis of the skin, to make you produce collagen, elastin, shrink the overactive sebaceous glands, and reduce some of the dilated blood vessels. So there is a lot of benefit beyond just treating the vasculature that you see. So I tell patients, like for example, if we treat their rosacea and they get improvement after two or three sessions, they should come every year and repeat it,

even if their rosacea is quiet, because it really does help with anti-aging. And so from that standpoint, those are your non-ablative. And then if we go to ablative, we've got deeper chemical peels. We've got the modified TCA peels. We've got modified phenol peels. So we don't need to worry about brand names at this point.

We're really talking to the practitioner and saying, do we want to move into an ablative peel? I'm going to get a better result, but I'm going to have a greater downtime. Presumably, I need to do it less frequently. Yes, and that's exactly it. What you said is key. I think the big mistake is to come in and say,

oh, all my friends are having Moxie. I want Moxie. Let's talk about what it is. We might have something that does similar results or maybe even something that does better results and delivers better results. Or maybe it's not the right choice for you, even though your friend thinks you should get it. Exactly. And so the field is so confusing to consumers and honestly, even practitioners, because it's a gold rush. There's so much money to be made in this area.

Every company is getting private equity money and getting an FDA approval for some kind of device because they want a piece of the action. And they're purposefully confusing everybody because it's like snake oil. Everybody wants to sell their product and some of the products work well, some don't. Any products you think people should just absolutely avoid?

Just based on lack of efficacy? No, but I do caution my younger patients, the ones who are under the age of 40, even up to 45 in some cases, to really avoid doing things such as ultrasound tissue tightening, radio frequency tissue tightening at that young of an age, because there is some fat atrophy that happens and I would caution against prematurely aging their face. Yeah I agree I mean those are the categories that are probably have

the most hoopla with the least effect is ultrasound based energy and look I mean there once was a time where that was the only non-surgical option for tightening the neck but it didn't do a great job and most people have left it by the wayside. I like it though, in addition to a biostimulatory filler. So you inject a little Sculptra under the skin and then you come over it with a ultrasound. Synergistic properties can exist for those devices. And that's what I was gonna say.

If you know your physics with all these devices, you can achieve so much with your lasers beyond what the company tries to sell you. How do you then decide, I understand the fork in the road between ablative and non-ablative, but let's say once you commit to an ablative therapy, how are you deciding between a chemical peel, a laser, a micro needle, and I vaguely remember my wife

telling me something or overhearing her and her friends saying that if you had melasma, you couldn't do this one, but you could do this one. What are some of the do's and don'ts as you navigate that? There are a lot of nuances to this conversation, but to generalize a little bit, chemical peels are generally safe for all skin tones, generally. Laser resurfacing, a blade of laser resurfacing can be riskier for higher fit spectric skin types that have more pigmentation because the melanin cells are sitting deeper in the skin and the deeper the laser goes the more it can create permanent injury to pigment cells and create permanent pigment problems. Whereas the chemical peels, you can control that depth a little differently.

And so that's one, I would say, generalization that's probably worth mentioning. So I should not do a laser peel. You can have a laser, but you're the kind of person who needs a lot of preparation and caution heading into it. You would need to probably get onto a regimen to control your pigment cells with hydroquinone. Why would I bother?

Why take the risk? Because the results could be better. I see. I guess just to complete the conversation about the different categories, the most effective non-surgical skin interventions are in the category of ablative lasers and phenol peels because they go the deepest.

And TCA. I'm gonna have to throw that in there. TCA, sure. TCA peels. Deep TCA peels are something that have to throw that in there. TCA, sure. TCA peels. Deep TCA peels are something that should be done by someone who really knows what they're doing. So going to your point, how do I choose? Sometimes on the same patient, I'll do all three.

So on most of their face, I may do a medium-depth TCA peel, especially because I can get the ears, I can get into the brows, I can feather onto the neck, into the hairline. So I don't leave any area on resurface. And the medium depth peels are gonna go just to the level of what's called the papillary dermis, which is the sweet spot for tissue tightening. And peels of that sort. And this is TCA or phenol?

TCA. And these peels penetrate and they percolate into pores. So I love peels for large pores. You'll see the solution sit in the pores and they'll just go a little bit deeper just in those pores and as the tissue heals, they'll contract. Then I may take a patient who has very deep perioral lines and use my fractionated ablative CO2 laser on those. And then someone with redundant skin on the lower eyelids,

I may take my phenol peel and apply it there. So in one sitting, the patient might have all three, but I'm gonna pick and choose where I do it. In some patients, I may, depending if they don't want an eye lift or I did an eye lift on them a number of years ago and they're just starting to get redundant skin, I may just ablate that tissue with either my laser or the phenol peel

and get a mini eye lift again that might buy them two or three more years. What is the downtime from an ablative intervention? Every treatment is customized to the patients who can vary, but in general, a patient who's gonna have an ablative CO2 laser, which I would say is the relative gold standard for an ablative laser,

is going to have seven to 10 days of requiring an occlusive dressing with some kind of ointment. That's a real downtime there. And then from weeks one to three, their skin will be transitioning and epithelializing. They'll start to return to normal activities, but they'll still scare children at a grocery store.

For three weeks. So they'll be red. A lot of redness and swelling still. And then beyond three weeks, they can use concealer, which we actually encourage them to do because it's a built-in UV protection also. And they can kind of get back to life, but without makeup on, some people can have redness for months.

Expect this person to do this procedure how often? This might be once every five or 10 years to have a full ablative CO2 laser. Is it uncomfortable? If they're awake, it can be. These can be done under some sedation. It's also quite common these days to have these done with a nitrous delivery device. So there are now FDA approved devices that mix oxygen and nitrous so that it can be done

in the office without an anesthesiologist because they're getting 50% oxygen, but yet they're getting the benefit of the nitrous as well. I don't think- Like laughing gas. Yes. Tronox. Exactly, yes. I mean, that sounds absolutely unappealing. I also painted the picture of the most aggressive skin laser that we do.

And of course it can be dialed down, like if a patient has a certain timeframe in mind. All right, so what would I do? I mean, a week offline would be tough, doable, but tough. Certainly three weeks, four weeks offline, not an option. So one thing that is useful information is that some of the lasers that are still ablative but are dialed down in their intensity. So now we're talking about fractionated lasers at lower intensity.

They can have a downtime that's's a week or less more or less And then it's not going to produce the same results, but the effects stack over time So if you committed to doing a light Erbium laser and the reason why I'm talking about erbium laser instead of a co2 laser is because the erbium lasers tend to Burn with a little less heat thermal injury And so the recovery is a little bit faster if you tend to burn with a little less heat thermal injury and so the recovery is a little bit faster. If you committed to doing this once a quarter,

as time goes by, you would get a similar effect to the full ablative CO2 laser that you could do in one sitting. And I would also say that you can manipulate other things. So like we'll take a clear and brilliant laser and apply a light chemical peel solution on top of that the same day. So two non-ablative therapies.

Correct. And then you get like three or four days of peeling and then you're done. And someone like you, because you're a male, you have thicker skin, you need us to push it a little more than just what the clear and brilliant will do or the light peel by itself. But synergistically, they can have a nice effect. And over time, there'll be cumulative improvement in your skin, especially if you follow your home regimen. But what I would tell people like you, Peter, is that really think about it hard and embrace this investment in yourself because you do everything else right.

You eat, you exercise, you watch the sun. It's much, much better to do this now at your age than to wait five or ten more years and say, I wish I had done it. Because at that point, what you need might be a lot more drastic. And to maybe bring this full circle, Susan, I know we're concluding the podcast here now. Beauty and aesthetics is an integral part of being human. And that's why we're even having this conversation,

because people really want to know how to navigate this world of aesthetics. is an integral part of being human. And that's why we're even having this conversation, because people really want to know how to navigate this world of aesthetics. And choosing to make changes that are appropriate for your situation has the potential of increasing quality of life. Humans, as we age and we live longer and longer and longer, you may have someone who's 60 or 70 years old who's

following Peter Atiyah's regimen, and they're out there playing golf, and longer and longer, you may have someone who's 60 or 70 years old, who's following Peter Atiyah's regimen, and they're out there playing golf, living their marginal decade in the way they want to, but they also care about their appearance. I mean, you've seen this, right, Susan, that I have patients who are 94 years old, who are coming in for skin cancer reconstruction after Mohs surgery, and you're not thinking at all about putting your aesthetic hat on, I'm now a reconstructive surgeon. This 94 year old woman is terribly concerned about what it's gonna look like afterwards.

That desire to limit the delta of the self-discrepancy theory for ourselves continues until we're no longer on this planet. Well guys, thank you very much. This was fantastic and honestly accomplished goal number one, which is I feel like I have a greater understanding of the solution space. Again, I think I'm gonna probably have you guys send me

a few links on some of the serums and cleansers. And I guess I need to get a prescription for some Retin-A or steal my wife's. I'll double check my sunscreen. I know that my sunscreen that I use when I'm going outside for prolonged periods of time, my Ulta MD is a good one.

I don't think I have a good daily throw it on just because I'm indoors even, and I'm going outside for five minutes here and there. I need to double check on that. So I think that's a win. I guess if I do nothing but commit to a daily skin routine, that's great. I will admit this whole ablative, non-ablative skin thing has me a little shaken up and now reeling in the idea that I just don't know if I have the intestinal fortitude to go through with an ablative therapy, but maybe I start with some baby steps, like two non-ablative therapies.

And then I think we're going to have to think about, do I want to fix my face? How far down the rabbit hole do I want to go with the under eyes, over eyes and all that stuff? But the point here is I have a better understanding and I hope that more importantly, the people listening are able to see bits of themselves in me. I think I'm not that uncommon in my problems. So hopefully they've been able to pick up on these things as well. So thank you very much guys.

This was a different podcast nonetheless. It was super interesting for me. Thank you. Thank you for having us. It was fun and we didn't mean to pick you apart. I asked you to so no, no, I fully appreciate it. Thanks Peter. We appreciate the opportunity to be here and have this conversation.

Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us review on Apple podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional health care services, including the giving of medical advice. No doctor-patient relationship

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