Well with Arielle Lorre - 173: The Surgery vs. 'Less Invasive' Procedures Debate with Dr. Amir Karam, MD

Episode Date: May 18, 2022

In this episode, I'm talking to Dr. Amir Karam, a highly sought-after facial plastic surgeon, about looking as good as you feel in terms of aging. He sheds light on the stigma of plastic surgery; how to preserve your youth with and without surgery; lifestyle tips to prevent aging. We also break down the surgery vs. procedure debate; how far procedures can actually get you; the 'sweet spot' to begin either; how to know if you're an ideal candidate and what to do if you're not. He also answers a bunch of specific listener questions on procedures!   Sponsors: Drinksound.com code BLONDE for 20% off Sakara.com/BLONDEFILES20 for 20% off your order Athleticgreens.com/blondefiles for a free 1 year supply of vitamin D and 5 free travel packs Helloned.com/blonde for 15% off   Produced by Dear Media.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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The following podcast is a dear media production. Hey, welcome to the blonde podcast. I'm your host Ariel Lori, and I'm here to talk all things wellness. From how to achieve optimal health and well-being to the best beauty tips and everything in between, no topic is off limits and I'm bringing it to you real and unfiltered. I know there is so much information out there, so I'm here to help you navigate it all. Thanks for listening. Let's get into it. Hi everybody. Welcome to the show. I have a great episode for you today all about beauty, aesthetics, skin care, aging, and of course, surgery, because I'm talking to Dr. Amir Karam. He's a double

board certified plastic surgeon based in San Diego. I've been following him for a long time. I really like his work. I really like his transparency and I really like his demeanor. And I loved talking to him. He just has a really honest and straightforward approach when it comes to all of this. And I think you guys are going to really enjoy it as well. So a little bit of background on him. As I said, he's double board certified. He has 15 years of experience. He's devoted his career to mastering facial plastic surgery and perfecting his unparalleled facial rejuvenation practice. He's one of the top surgeons in the country. He's established the Carmel Valley facial plastic surgery and aesthetic center in San Diego in 2008. His multi-award winning practice offers advanced techniques in facial rejuvenation,

delivering natural, safe, predictable results. Definitely go to his Instagram and check it out. And throughout his career, he's performed over 6,000 successful procedures for clients across the globe, including his patented vertical restore and vertical prevent techniques, which he talks about in this episode. Those address laxity in facial shape change associated with aging. And he uses, customized fat transfer as an innovative way to replace facial volume permanently. I think he actually came across my radar when I got fat transfer last year. And something that I appreciate about him and his social media is that he shows a lot of the healing process. So I kept referring to it when I was in recovery and healing because I was like, okay, this is normal for five days, seven days, ten days,

whatever and a lot of that also of course are the patients who allow him to post all of that. So Dr. Karam is double board certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Autolaryngology at Can't had a neck surgery. He has published over 20 peer-reviewed research articles, over 25 surgical textbook chapters on facial plastic surgery, and has co-authored his own surgical textbook Rejuvenation of the aging face. He's also the creator and founder of Karam MD skincare, a premium regimen that covers the entire spectrum of skin care for women and men of every age and skin type. So of course we talk about surgery, but we also talk a lot about prevention. And he knows that my audience ranges from,

you know, younger patients through all age ranges, really. But he wanted to focus on not only what to do when we start seeing changes, but how to best maintain, you know, our youth. And he has this concept of like looking as good as you feel on the outside as you do on the inside. So it's not just about chasing this look where you're just going to look young forever, but it's really matching how you feel inside with how you look on the outside. So with all of that said, I hope you guys enjoy the episode. Please don't forget to rate, review, and subscribe if you haven't. And enjoy. Okay, welcome, Dr. Karam. Happy to have you here. Thank you very much. It's my pleasure, Ariel. This is going to be a lot of fun. I'm excited. I was telling you before we recorded that I have been a

long time follower, and I really love your work. So I'm excited to talk about all of that. But to start out, can you just give the audience a little background on you and who you are and what you do. Absolutely. My pleasure. So I am a facial plastic surgeon that specializes in facial rejuvenation. And my entire practice is limited to procedures and techniques that essentially help people look as young as they feel. I mean, that's something that I think is such a foundational and important part of quality of life and feeling comfortable within your own skin. So I've limited every other aspect of the procedure and all we do is, you know, from a surgical perspective, we do these things and then and then cover the continuum on a skin aspect as well to basically bring those two worlds

together and help people achieve their goals in that way. I want to talk about that concept of looking as young as you feel because I feel like there's such a stigma still around cosmetic surgery and procedures. And it's fine if people don't want to do that and don't want to succumb to societal pressure, beauty standards, whatever you want to call it. But I think it is still so stigmatized and looked at as a negative thing. And, you know, I think that there's no reason why, especially with the advances in surgery and how natural it can look, people should have to not look as young as they feel. I agree with you. You know, what's interesting is because of that stigma, and by the way, it's gotten so much better over the last 15, 20 years that I've been in practice.

You know, the original surgical patient was typically in their 60s. They had, you know, jowling and neck laxity, you know, down to their chest, basically. And then only at that point did they feel that they were justified to go in and have a corrective procedure. And unfortunately, there's a lot of years between the onset of aging and the time when those those changes become severe. And all along that time, the individual for most cases, are feeling, you know, that they're drifting further and further away from their self-identity and their, and their youth and beauty. And what's really remarkable about it is that when you ask people,

and the listeners can test this, when you ask somebody to close their eyes and picture how young they feel, it's usually a lot younger than they actually are. And that, that, you know, for somebody who's in their 30s, it's probably pretty, pretty linked up. But then you get into somebody who's in their 40s, 50s, and 60s, they still feel like they're in their 30s, which is pretty amazing. That we don't catch up to our actual chronological age. And that's where the trouble is, because fundamentally, we're not even supposed to be living as long as we are. And because we're living this long, we're suddenly, we're forced to basically live with those aging changes that happened during paramedopause and postmenopause very, very reliably. But then there's a whole

continuum. I'd love to talk about the sort of the younger individuals who are, who I think the stigma is a little stronger in that particular group currently. But, you know, there's some interesting things going on there. But these changes, they just happen. And you're forced to either live with them or do something about it. And I think those individuals who do something about it live a life that is much more fulfilled because they don't feel like they're wearing a mask on their face anymore. As the changes that are causing their face to look different, you know, get corrected by the surgical procedures or whatever is recommended in those situations. And it's not just women either. It's men. I know men in their 60s, 70s who say the same thing.

And it's interesting too because a lot of people that I ask who are in that older age range, they say that they feel better than they have, like in their whole lives. And I think it's, you know, obviously there are physical things that come with aging, but it's also the mindset. And we have this thing where we fear aging, but really people kind of say that it gets better as you go. But then they look at themselves in the mirror. And because they still feel like that 30 year old, it's jarring. Yes.

So it seems like a universal experience kind of. You know, it's universal. It's cross-cultural. It's, it's, I think, very human thing that you want to fundamentally look the way you feel. And I think the aging change is just, you know, they make a person look very different than that. And that's hard to live with. And I love the fact that I think overall the trend is is drifting in the right direction in that way. And from that perspective, I think we're seeing a lot more people actively sharing their stories

about these things. Also, you know, taking those steps to do these things without feeling as guilty about it because I think a lot of people generally still, although they do fight some of that vanity slash, you know, guilt is taking care of themselves aspect of things. But it's improving over time. And I think, like, as you said earlier, realizing that you can get things done that are natural looking and don't look like you've had any work done with more advanced approaches, it takes some of that stigma away too, because it is a little, you know, that is a choice of some people who had to make is, you know, the traditional stereotypical facelift, for example, you look like you had work done. And as a result of that, it wasn't always a good look, right? I mean, it made you look

kind of pulled, alien-ish, you know, look like a different person. So for a lot of people, it was a decision of whether they should look like that or look aged. But now with some of our newer approaches, we can, we can kind of, you know, have the best of both worlds. So I am traveling for the next few weeks and you better believe that you're better believe that I brought my stash of athletic greens with me. I love bringing athletic greens with me when I'm traveling. I take it daily at home just in my normal life, but I really love it for traveling because I never know what I'm going to be eating. And I just feel like being consistent with this, I cover all my bases. The travel packs are super convenient. So if you're wondering what exactly is this stuff,

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Hills. WithWit is dedicated to having real, raw, and occasionally ridiculous conversations with the people who have had a profound impact on me, because on WithWit, very little is off limits. Subscribe so you don't miss any of the amazing conversations to come. New episodes of WithWit are available every Tuesday on all platforms. Well, I definitely want to get into all of the surgical procedures. You're a surgeon.

But let's kind of rewind a little bit and talk about prevention because a lot of my audience is on the younger side. I mean, it really does span. But I think we're so much more cognizant of aging now too and things that affect it. You know, hopefully people aren't dousing themselves and whatever, copper, and laying in the sun with a reflector for eight hours a day, which I did when I was younger and the tanning bed. And, you know, probably not smoking as much. And people are just more aware of these things that lend themselves to aging.

So for somebody who is still relatively young and they're not at a point where they need any kind of intervention yet, what are some of the things that they should be doing to preserve their youth? Yeah, there's such a good question and such a important, what's about to come is, I think a very good nugget to carry with with yourself. So here's how it plays out. There are two fundamental things that make a person look older, right? One is the changes in the facial shape, right? So when you think about a young person, and I always, you know, spend a lot of time kind of examining just people and trying to understand, this is what I've come up

with. If you think about a young person, you have a youthful facial shape. And what basically that means is there's a certain level of volume in the face, right? There's a firm, of the jawline. There's a firmness and good contour of the neck. There's a nice position of the midface and eyelids don't have a ton of droopiness and excess skin. And that's, so those are things that affect shape, right? I think this is a really important, what's to come here. That you have no control in. That's just going to be genetics. That's going to be, you know, sort of natural time, you know, sequences that go by. Those things, there really isn't anything you can do to physically change that aspect, because that's happening in the deep fascia layer.

You know, loss of fat, for example, that causes the face to deflate. That's just happening. I mean, there's not much that one can do to prevent or preserve that. But then there's another piece of that. And I'll get back to why this is important to understand this aspect. The other part, you have full control over, which is the changes in facial skin, right, or the skin quality. So skin and shape are the two things that make a person look young, young looking skin and young looking facial shape. The skin, that's 100% up to the person. And what's beautiful about it is, is if somebody who's younger, say in their 20s and 30s decides that they want to take their skin into control their skin, what that means is you start off

with a good, healthy lifestyle, right? Good, clean living, as you alluded to, no smoking, very little sun exposure and, you know, using sunblocks and things like that. And then, comes down to active ingredients that you're going to put on your skin that are really, really important because this is the piece that I think is not very clearly understood, is what type of things do you want to put on your skin actively to resist the aging changes that are going to happen with it? And that comes down to things like retinol, vitamin C, you know, nicinamide, certain things, you know, good, good lotion that moisturizing and hydrating qualities to the skin. So those are the things that are going to keep the skin

from thinning over time. Because that's one of the things, if you think about, you ask yourself, well, why does somebody, say in the 30s and 40s and beyond need Botox in the first place, right? Why does that even become a thing? Why do we even talk about that? It's the same muscles that are moved when you're younger, but yet all of a sudden when you get older,

suddenly, you know, those lines start to show. It's because the skin is losing elasticity and it's getting thinner. So if you can do the things that are going to keep the skin thick over time, well, guess what? The skin is going to continue to look youthful, just like I did when it was in the 20s, 20s and you didn't need Botox and all these other things, right? So it's a very important perspective to have. And that's actually something that I've become more and more enamored with, you know, that

side of the aging process, the preventative side of it. And then why that's important for patients as they get older and then the other side of it starts to come in, because then once you know that those things you can't prevent, it's going to keep you from doing a lot of those things that you hear about from a high point of view, things like fillers, and, you know, this, this radio frequency device, that ultrasound device, this laser, that laser, all touted and positioned in a preventative framework, in reality, it not only doesn't prevent anything, but it also doesn't restore anything. So it puts people in a position where they're now empowered with knowledge and powered with understanding that, you know, when the time comes, when the shape starts to change,

then there's certain procedures, and quite honestly, it comes down to surgical procedures that are going to actually be able to address those things. And then everything else, you just avoid. I mean, it's that simple. It keeps you from wasting a lot of time, money and energy. I'm just thinking of the listener questions. And somebody did send a question asking, if there's anything that you can do to thicken skin, meaning once you've lost some of that elasticity, collagen, whatever, is there anything that you can do to, restore that or at that point are you just kind of looking at surgery? No, you know what? Actually, so this, it's a great question. I'm happy to answer it. So the thinning of the skin is not something that can happen over, a thickening of the skin is not something that can happen overnight. And that's a really important perspective. And it by the way, it has nothing to do with surgery either because even if you do surgery on somebody who has thinner skin, they're still going to have thinner

skin after surgery because you're moving the deep stuff around. You're not, you're not, you're not doing anything to improve the quality of the skin. So to improve the thickness of the skin, what you've got to do is you've got to increase the production of collagen. So how do you increase the production of collagen? So basically, you know, things like retinol, vitamin C, for example, those are products that when they're put on the skin every single day, they're working at the cellular level to increase the production of collagen. Then you get into things that you can do to your skin. Basically, anytime you injure your skin, right, anytime you perform microneed, or do a light chemical peel or do a light laser, for example.

Any injury to the skin sends signals back to those fibroblasts, those cells that create collagen, saying, hey, by the way, we got a little injury on our surface here. We need to heal. And healing is production of collagen and basically, you know, the scar formation. So that cycle can be completely used in our advantage to improve the quality of the skin over time. For somebody who's lost their thickness as a result, of aging. For example, my wife was in her mid-30s when she got really serious about her skin.

And when you look at her now at 50, her skin is actually much thicker, much more supple and a way better shape all around than it was when she was in her 30s. Because she grew up the same way. She was a cross-country runner, a tennis player in high school, all that kind of stuff, and was in the sun a lot. So as a result of that, her skin took a hit, but she was able to rebound, but it took a lot of dedicated, you know, lifestyle things. And one of them, a huge one of them was the lifestyle of doing the right things on your skin on a daily basis from a skincare point of view. And that was really, for me, that was my inspiration of why I got into the skincare arena in terms of trying to develop something that patients could use that would effectively do those type

of things over the long run. And that's where we came up with the trifecta. But you can do all of those components separately as well, but it's important to do them. And that's probably the biggest, biggest message there that somebody who's lost it can gain it, but it's going to be slow, but it can be done. And they can't, because if they do nothing, it's only going to get thinner. Right. It's sort of like, it's like muscle atrophy, basically. It's like your body gets in shape by working out regularly and eating well regularly. And if you don't do it, it's just going to continue to atrophy over time. So at any point in your life, when you want to get back in shape, it's worth it. And it'll slowly start to show the changes over time.

Okay, so now you've got to drop your wife's skincare routine. Is she using your product? Yeah, you know, it's an interesting thing. I mean, I can't take... She looks amazing, by the way. I've seen her on your Instagram. Yeah, thank you. No, I can't take credit for her skin looking the way it does. She does use my product. Now she does. But I mean, for 15 years, she's been doing all those components that are in my product, just doing them separately. But she's like one of the few people that was able to do like eight or ten steps on her skin and do them religiously. no matter what time you'd come home at night, you would do those steps and all that kind of stuff. But most of my patients who I try to mimic that type of a regimen, they just couldn't do it.

So that's why I consolidated it all into those three steps to make it usable for most people. Okay, so tell everyone about the three steps. Oh, so basically, I mean, every good skincare routine starts with cleansing, right? I mean, these are all fun things that I've learned because as a surgeon, you don't get trained to learn this. So this is stuff you have to learn on your own. And I recognize that the cleansing of the step is actually the most important first step to things. Because if you don't eliminate the debris, the dirt, the makeup, all that stuff, then nothing you put on your skin is going to penetrate the right way.

And there's so much to cleansing too, which is an interesting thing. Things that are foaming are abrasive and drying to the skin, for example, and all these nuances. So anyway, we came up with a cleanser that is mildly foaming, very, very good in terms of removing all the makeup and everything else, but also we added a bunch of anti-inflammatories to it, so it decreases the inflammation of the skin, which is important for pores and all that kind of stuff. So the cleansing step one, and that product is called rinse. Then there's the vitamin C step, which vitamin C, I mean, the more you learn about, the more you realize it has just so many positive effects on the skin. Like we mentioned, you know, improving collagen, decreasing pigmentation, you know,

it brightens the skin. There's a lot going on with vitamin C. And so the, the, the, particular vitamin C that we use is a combination of three different types of vitamin C that actually works better than like your typical vitamin C plus again more anti-inflammatories to the skin. So that's that's called quench. And then this is this was the inspiration, this final step, which originated because I wanted to something I could give to my surgical patients to make their life easy. This started like six years ago, five, six years ago. I just wanted to give them single product and tell them to go on their way and use it. And basically what happened is I put all of those things that we know are really, really important from an anti-aging point of view, all into a single

step. And that is called Illuminate. So there's like 15 different active ingredients in Illuminate. All the big names that you know, you hear about stem cells and peptides and, you know, vitamin C, still and more vitamin C, retinol, niacinamide, all those kind of key, key players, all living in one bottle. So then basically you do, you rinse, you do the vitamin C step, and then the all in one, and you're done. The whole thing takes like two, three minutes max. And then you've gotten your entire routine altogether. That is a really important thing because it leads to people doing it consistently. And you have beautiful skin. I can, I can, you know, you've obviously taken a lot of my stuff probably into practice yourself. Now I do. And it's, and it pays off. I mean, it's incredible. And people

start doing this stuff. When they do the right stuff, it's amazing. Even after a few weeks, they start seeing the changes in their skin, which is very encouraging to continue to doing it. I'm going to need to try that. I'll be happy to get you some. It's like right at my alley. I love less steps. Yeah. Less steps is,

I mean, for me, I never did any skincare because it was, I couldn't do all the steps that it took, you know, to do it normally. Now I do it religiously.

And it's an AMPM, so it's a very simple thing to do. That was going to be my next question. So aside from skincare, obviously SPF is a huge one. Is there any other lifestyle tip that you have before we get into surgery and procedures and all of that. Is there any other lifestyle thing that people might not think of off the top of their head

that really helps with maintaining or preventing each? Yeah. So I think, think about your skin and your fashion and all the stuff is, you know, just an extension, obviously, of all the other parts of your body, right? So if you think about when I say living like a clean lifestyle, what you're talking about is is a good healthy diet with lots of lots of nutrients and a lot you know a varied type of a diet that's so important because every part of your of your skin and your fashion needs those things to function well right then there's hydration hydration can't be you know overestimated

it mean it's it's one of those situations where you know your skin once it gets dehydrated that's where it starts to show fine lines and wrinkles and we lose that kind of suppleness and a lot of that comes from the kind of, you know, hydration that you actually take in your body. It's not just what you put on your skin. So, so, you know, starting in a continuum on the far left, if you think about, you know, your diet, your hydration, then SPF, then your daily skincare, you know, routine that you do, then further to the right, then you've got things, and this is important to put this in perspective, then you've got things like, you know, lasers, microneedling, exfoliation, all that kind of stuff that will improve certain aspects of your skin, but those are more like boot camps,

right? Those are kind of things that jumpstart you to another level, but by themselves, if nothing follows that point, then it's every, you deteriorate back to where you were. And so, for so many people, they think the opposite, they start on the right hand side of the continuum. They, they, you know, ask them, what are you doing for your skin? They say, oh, once or twice a year, I go get a laser, you know? And then they don't do anything in between. And they don't do any of the things that we just mentioned. And their skin is basically not either continue to deteriorate or not, not improving. So that little understanding of where things lie on that continuum and how you should kind of play it out is so critical to success and actually making an impact. But like I said,

I mean, those other components, the shape size, shape changes, there's really not a whole lot you can do other than I would say probably living a life that is less stressful, you know, because that's the other thing you see when people have these high stress situations or have a, you know, unfortunate life event, they can age very quickly through that, through that event. And that seems to be a correlation as well. Just look at presidents and politicians. There you go. Yeah.

Yeah. 100%. You look at a four-year term, they look very different. Yeah. It's like, who is this person? Exactly right. So I am either going to Italy by the time this releases or I'm there already. I'm not exactly sure.

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You can go to www.w.org.org.com and use the code blonde at checkout for 20% off your first purchase. Again, that's drinksound.com. The code is blonde, B-L-O-O-N-D-E, for 20% off your first purchase. Well, I was telling you before we started recording that I really appreciate that you share on your page the healing process and that your patients are willing to share because you don't see that on a lot of, doctors pages. And I was telling you that throughout various procedures that I've gotten, I've referred to your page because it's really the only place that I can go, aside from like maybe real self, where I can actually see like different stages of healing. And you have a few procedures that really stand out to me and probably that you do the most. And that's fat, fat transfer, vertical prevent, and vertical restore. So maybe we can go through each of those, starting with fat and talk about just a little bit about the procedure, what it can do, what it can't do, who.

it's appropriate for, all of that. Absolutely. So that's a great, great question because this is, I think there's a lot of misinformation and misunderstanding around fat. So think about aging in three columns, right? So there's a skin, there's the volume, and then they're sagging, right? So fat transfer sits in the column of treating volume loss. Now, so does fillers and sort of sculptor, you know, those components live in there.

But what a lot of people, the mistake that a lot of people make is they don't realize that volume loss is just one part of the aging process. And as a result, they think that by treating volume, they're actually treating, you know, the sagging and all these other things. So there's a lot of misuse of volume. And with a misuse of volume, we see people overfilling a face to try to create a lift or try to, you know, improve the shape issues that we discuss. and before you know, they start looking more and more different and in some cases extremely bad, right? I mean, they look huffy and wide and heavy in the jawline and all this kind of stuff. And all the while there's continuing to sag and they're starting to, you know, that none of that is being affected. And I think after 15 years of playing around with volume treatments, we were starting to finally realize this.

So where does fat transfer fit in? Fat transfer is one of those procedures that, you know, it's been around for a long time. but for for whatever reason, there are very few surgeons who do it and do it well. And as a result of that, you know, there's been a lot of bad wrap around it. I'm sure you've heard of, you know, it doesn't work. It disappears. It gets lumpy bumpy, you know, all these different things. And I think all of that is probably true when it's not done well.

So now we're going to talk about when it's done well, what can happen. So in my practice, I got into it in 2004, you know, before I actually started, I was a resident at that time, you know, fellow in training. And, and I realized that it was such a critical part of rejuvenating the face that I, you know, I got deeply into it. And once I learned how to do it, I did it on every single patient that I treated for either a facelift or eyelid surgery or any of that kind of stuff. So at this point, I've done like 7,000 plus fat transfers. So here's the, it's track record in my hands. I never see lumpy, bumpy, I never see it disappear. It doesn't go away. It's always even between the sides. And the thing is, what it does is I use it simply to replace lost volume.

As simple as that, it's like you lose a little bit and you put it back. And with it, when you do it that way, you never run the risk of looking different or unusual, but you're using it appropriately in that way. But one of the huge advantages of fat over filler is because it's a graft, fat belongs to your body. And when you put it into into the face from whenever you take it from the legs or the stomach or wherever, it becomes a resident of that area. It, it just becomes part of it. Your body accepts it, just like it would if it was a hair graft or a skin graft or cartilage and rhinoplasty, all these things. So it becomes a part of it. And because it becomes a part of it, you're done. Once you get a fat transfer, you don't have to play around with fillers and all

that kind of stuff. And back to my wife when she was 36 or whatever, I did a fat transfer on her 14, 15 years ago, that was the last time we did real volume on her. Yeah, we used a little filler for a little lip augmentation or a fine line here and there. But she didn't, I mean, I literally could probably count on one hand, the number of syringes of fillers she's had in the last 15 years, you know. And that's the beauty of it, the permanence of it, you know, the ability to use it in all the different areas that you lose volume is really huge. But the other cool thing about it is a pack with stem cells. You know, a lot of people don't realize that you're getting all the stem cells, which stem cells help rejuvenate the local tissues. So skin gets better. Aging slows down a little bit.

So there's a lot of magic behind fat transfer if it's done well. That's where it's, it sits in our practice as a tool that goes along with a lot of our other surgeries. But here's the thing. They're only patient. This is the key point because a lot of people get excited about it after we have a talk like this. But the only people who are candidates for a fat transfer alone are people who have absolutely no sagging in their skin, no laxity.

Because if you try to do it on somebody who's saying they're late 40s or any age when there's laxity, it ends up becoming very underwhelming, you know, terms of the outcome. And if you overuse it to try to, you're back to that square one of trying to, you're trying to overfill the face. So the right candidate is somebody who's younger, who has just volume loss, but doesn't have sagging. And then the other candidates are the ones who have sagging who use it in addition to other surgeries. So in your hands, does somebody retain close to 100% of what you graft? So what can people expect to retain? So what people, so I think about it like this. It's not about the percentage.

of take, because who really knows what the percentage is, right? I don't think there's, I mean, filler is a hundred percent take until it starts to go away. You always overfill a little bit because every surgeon has kind of their own percentage of attrition. But here's the key point there. Because it's a living tissue, if it doesn't get a blood supply, it disappears within a day or two, right? So based on a surgeon's own experience, Like, for example, I know when I see a deficiency, how much fat to add to it to get a proper result 100% of the time. Based on that, it's just this numbers thing.

But those numbers, you know, in my hands don't necessarily equate to somebody else because there's like three or four steps before you get to the point of injection that have to be done in a standardized way so that you can get that predictable outcome there. So the answer to the question is that 100% of our cases lead to a, what I would say, an appropriate volume response. And what I mean by that is if 100% is like what you look like when you're 15, you know, we're shooting for like 80%. We're not shooting for 100 because, I mean, 100% is, is too close for comfort for overfill.

Yeah. Right? Because if you overdo it a little bit and all of a sudden you're 105% filled, you're in trouble because you can't get rid of it. It's permanent. So it's better to be. Yeah, you can't. You're stuck with it. So I think of a glass is 100% full. I shoot for like 75, 80% of the way there,

which is typically enough to create that refreshed, rejuvenated look. Volume is what makes us look tired. Sagging is what makes us look old. So all we want to do is kind of freshen the face and make them look healthy. And that doesn't take 100% filled to accomplish that. Right. Okay, so when people do have a little bit of sagging, can you explain the difference between like a vertical prevent and then the vertical restore?

Yeah. So here's the conceptual idea. People are on again thinking of aging as a continuum. I think historically, as I mentioned, we thought of people just being really old, you know, like in their 60s, et cetera, 70s and then having a procedure done, right? We thought of aging at that stage. But we know based on what we see that people age at all different ages, right? I mean, there are people who actually start aging in their 30s, showing signs of aging in their 30s, and then some in the 40s, et cetera. But what happens is the problems associated with aging or the changes are what we have to actually treat, not the age, right? So when we see laxity, when it's early in the spectrum, the 30-something-year-old may have historically, I shouldn't even say historically, even today, but outside of our practice, out of our universe, that person would probably go for like non-surgical treatments,

you know, certain types of radio frequency devices, lasers, you know, all those type of things to try to fix the laxity. But again, back to my, the point that I made is those things don't correct it. So that 30-something year old was left with, you know, just trying different things, threads and all these different things, trying it to correct it to no avail. So the vertical prevent procedure was designed basically using all the foundational techniques that are important for long-lasting, kind of like basically kill the aging process type of a thing. So deep plane, you know, releasing all the deeper ligaments, all that kind of stuff.

But the only exception is for those younger patients who are starting to see their midface dropping and a little bit of laxity along their jaw lines, et cetera, they weren't, they're not seeing their neck involved. So we don't treat the neck. So the difference between vertical restore and vertical prevent is the continuum hasn't gotten them to the point where their neck is started to show laxity. And as a result of their neck not showing laxity, we don't need to do like a full-blown neck procedure on them the way we would on somebody who does show signs of neck aging.

So that's where prevent and restore changes. Otherwise, fundamentally, I didn't want it to be a lighter version of the other procedure because at the end of the day, why would you want to go through a procedure and then need to do something again, you know, three years later again, right? I mean, that would be a drag. If you're in your 30s or 40s, early 40s and you're starting to see things changing, you want to be kind of one and done for a long time. So these particular procedures, because of the way they're done, they buy the person two things. One is probably about 10 or 15 years before they consider doing anything else. So that's a long time in, you know, sort of facelift terms, probably two to three times as long as your typical lift.

but also they change the way the face ages literally forever. So once somebody gets into that deep plane and does all those things, the face is never going to age as quickly as it would naturally. So you end up aging very slowly and gracefully for the rest of your life, which is really cool. I think that that's one of the questions that I get the most from people who listen to the podcast who are kind of like in maybe the mid to late 30s, early to mid-40s where they're like, well, things are starting to change, but I don't know if

I'm ready yet. So should I do it now before things get to that point? Or do I need to wait a little bit until they do get to the point where it's like worse? You know, like, where is that sweet spot, really? You know, here's the thing. There's no right answer in terms of you have to be this age or this far along. Remember, it's back to the original point of all of this, right? It's about self-image, self-confidence, you know, comfort in your own skin, looking as young as you feel, et cetera, right? And that trigger point is different for everyone. You know, that really is a different point. What I tell people is when they say, hey, am I a candidate? I said, there's two things that you have to answer. One is, I mean, two things that has to be answered. One is, do you

feel ready, right? I mean, is this bothering you enough for you to go through the procedure and the expense and the downtime and all that kind of stuff. And if it's bothering you enough, then the sooner you get it done, the better. Because it's like, you know, why would you want to live with something that's bothering you arbitrarily? Get to a point. The second thing is you have to have enough there surgically to justify a procedure. That's my decision, right? I have to look at the face and touch the face or whatever it is and say, okay, yeah, there's enough laxity here to actually do some good. Sometimes we get people who are so, so early in the process, we just simply tell them, hey, you're just, you're not a candidate because there's just nothing here to make an impact on.

But if somebody has enough to make an impact, and I usually just tell them to kind of grab, you know, while we're on these virtual consults, you grab your cheek, the top of your cheeks and your jawline, you kind of lift upward. And if it improves the shape of the face and you like the way that looks, people do that anyway. I mean, that's usually another sign that they need it is kind of they do that on their own a lot. Then if it does that, then okay, then you're a surgical candidate. And then if it bothers you, then you do it. I'm not. a big believer in anything of just waiting, you know, oh, come back in five years, you know, just because. I mean, that's a lot to ask of somebody just to be bothered by something that can be

treated very reliably, very naturally, et cetera, early. And like I said before, is when you do do it earlier, you just simply turn, not only turn back the clock, but the clock going forward is ticking at a much slower rate. Also, that person, if you said, come back in five years, they're going to go and they're going to do ulthera and threads and filler and this, every single thing that you possibly do in that time and probably make things worse. I'm the same as you. I'm like, give me the surgery. I feel 22.

Give me the surgery. Yeah. No, exactly right. And that's the hard. That's exactly the thing is because if you don't offer the solution for the person, that person is going to just continue to seek out solutions. And whether that means, you know, finding another surgeon who will do it for them, or doing these other other procedures.

If you say, so I don't, I don't honestly, I don't have a super high threshold, you know, for when to do it on the continuum. I think, I mean,

everyone has a right to, to, again, look as young as you feel, to look as good as they feel, and to feel comfortable and confident. I think that's really what all we're doing is enhancing and improving that and doing it in a reliable and a very natural way at the end of the day, right?

I mean, it's, what can be more natural than fat transfer and surgery? It's like, it's not, we're not putting any foreign bodies in. We're not, you know, doing anything artificial. It's just simply, you know, renovating with what you have. Well, and that's the thing that I find so interesting. I understand being nervous or apprehensive about getting surgery,

but so many people, again, DM me, ask me questions, and they say, like, I don't want surgery, but what can I do? That's X, Y, and they'll do anything aside from surgery. And I'm like, I understand, again, like I said, not wanting to do it, maybe having financial restraints or whatever. But I'm with you. I'm like, that's the most natural thing you can do aside from like, you know, the process maybe is a little uncomfortable for a week or two or whatever.

But then you're done. And then you're not like spending so much money on maintenance and just chasing whatever it is that you're trying to fix. No, you're totally right. And the thing is the financial argument is really. interesting because when people tell us, you know, the DM us and same kind of thing. It's like, oh, I can't afford to do this. Well, what you can't afford is to waste more money on things that don't work, right? In that situation, that's like the exact person that shouldn't be doing

all the things that are, because I mean, trust me, that stuff starts adding up incredibly, in a very sneaky way, it starts adding up. I mean, each thread, you know, drop three to five thousand each, you know, three or four syringes of filler, you're talking two to three thousand, you know, depending on the filler. Like, it just starts adding over a period of years. I mean, you've, you've paid for a lift and a fat transfer and this and that, like, you know, over and over again. It's incredible. But, you know, like in our practice, a big thing that I advocate for it for the people. And sometimes, you know, I'm at, if you follow my Instagram, I mean, I'll be very straight about what works, what doesn't work, and all that kind of stuff.

And I know I've upset a lot of my colleagues and a lot of my, you know, the people who actually refer surgery to me and all that kind of stuff because it's like, this is the stuff that they do. But I feel at the end of the day, you know, we're in a medical field, right? At the end of the day, we're physicians, we're surgeons, you know, this is something. And there's this, you know, this Hippocratic oath that we all took, which is, you know, first do no harm and also advise, you know, in a very ethical way. of what, you know, if you have a diagnosis, what is the treatment that's the best treatment available?

Right. Telling somebody to do, say, all therapy when they're in their 50s and have full-blown laxity, for example, nothing could be more, you know, sort of, I guess, you know, clearly it's not going to treat the problem. There's no chance. Or telling a person to go do Kybella for a big, heavy, lax neck. You know that's not going to treat the problem. So telling your person to do that, to me, it's always been like this, you know,

thrown to my side of our profession and why it can't be a little bit more, you know, sort of honest and transparent about these type of things. Because I think if you can't correct the problem, you shouldn't be doing it. And that's why, like in our practice, first of all, we don't have any of those devices. I mean, we literally don't have those devices. I mean, we don't have threads. We don't have, you know, all these things. And I can't even tell you the fortune I would make if I had those things in my,

because as somebody who, you know, use, you know, an authority on facial rejuvenation. If I tell somebody, you know, to go do those things, they would do it. But I think in the long run, I would probably not be an authority because I would lose my credibility and trust. And as a result, I would end up being like all these other places where, you know, you're just kind of not the, you don't have the same trust that has been gained with the patient. And I think our profession, it really needs a lot of makeover in that way.

You know, I think it starts with, I think empowering the listeners. the viewers, you know, the people who follow along in our social media to give them the tools so then when they go and sit down with somebody and they give them a recommendation, now they know. It's like, okay, this isn't going to fix the problem. So let's not do it. What's wasting time and money on that? I love that. Well, we have a few minutes.

So I want to definitely get to some listener questions. Yeah. So, okay, let's talk a little bit about like an upper blephoroplasty and a brow lift. I think that these are things that people kind of think are interchangeable. And a lot of people ask me like, if I can just do one, what should I do? And I'm like, first of all, this is not, I'm not, don't ask me. But can you explain each one and what it treats? Absolutely.

So that's a really good question, actually. So the upper lid, there's three things that are actually happening at the same time. Number one, there's excess skin of the eyelid, right? So that's excess skin. The second thing is there's laxity of the corner of the brow that comes down. And the temporal temporal starts to sag. And that's part of the whole fascia starting to come down as well. So if you look down further, the midfaces is sagging as well.

But when the corner starts to sag, you start to see kind of hooding in the corners of the eyes. The other thing that's happening is you're losing volume in the temples and above the eyelid. So there's three sort of changes happening simultaneously. the upper blephroplasty just removes the excess skin. The, you know, and I don't, I'm not a fan at all of just traditional brow lifts where you lift the entire brow, because that's the way you make people look kind of surprised and different. I lift up the corner of the brow. I do that either by itself as a technique we call lateral brow lift or it's included in the vertical restore and vertical prevent.

It just automatically goes up. But what that does is it lifts the, you know, that hooding out of, and that kind of heaviness out of the corner. and why it's important to get that diagnosis right and that assessment right is because if you just take out extra skin all the way out to the edge of the brow, you're actually going to pull the brow further down, right? If you try to take out, and it still won't get rid of the hooding. It'll actually just pull it further down and you'll still have the hooting. It's just you have less space between your eyelid and your brow. So it's really important to get the brow to position where it needs to be to open up that outer segment and then take out an assess and take out the extra skin. So for me,

that's always a very careful assessment between, you know, lateral brow and eyelid. And I think a very important part is refilling that upper eyelid sulcus because when the eyelid gets hollow, it starts to look really gaunt and skeletonized and not very healthy looking. So adding a little bit of volume to that region is a very beautiful way of restoring that youthful look, which is at the end of the day, what you're trying to do is you're trying to go backwards in time. So you have to get the diagnosis right. And you're restoring that volume with fat. I do it with fat.

Yeah. Some people use fillers and things like that, but I do with that. When you said that the lateral brow is kind of included in the vertical prevent or restore, is that because of where the incision starts? No, it's because my, after all these years, I've realized that the face ages from top to bottom. So what ends up happening is if you think about it, what's happening anatomically, there's fascia that connects up to the top of your temporal region, and then the same fascia attaches down to the clavicle.

that along the way, the neck muscle, if we start from the base, the neck muscle, the platyismal muscle attaches to the fascia in the face was just called the SMAS. Then that's attached up to the temporal fascia up here. All of these basically elongates with aging. It just, it's an elongation process. I have this little video that I made on, and I think I posted on Instagram once where I showed this like pizza dough, I'm holding it upside down, or just holding it and watching it kind of elongate.

That's basically what's happening to the fascia. It's elongating. that happens, all of that area starts to elongate together. And the vertical restore and vertical prevent is about bringing all of it back up together so that there's no disconnect between these these different zones of the face. Got it. Interesting. I guess we can just kind of go down. So a lot of people also ask about lower eyelids. So I feel like when people notice aging, at least people that I talk to, they notice around their eyes first and then maybe the jowls and then the neck. And so it is kind of this top down thing.

I would assume maybe it's because when you look at yourself, you're looking at your eyes. So we can kind of move down. So lower eyelids, if people are noticing crepeiness, hollowness, maybe when is it a good time for a lower bluff and one is it just a good time for restoring volume with fat or something? These are great questions. The audience is going to be so,

they have a very powerful. knowledge base here. So here's what's happening. The lower eyelid, like the upper eyelid, is aging in a combination way. So you're going to hear this kind of recurring thing, right? So what's the combination that's happening to the lower eyelid? There's three things that age the lower eyelid as well. There's excess skin of the lower eyelid. There's puffiness that happens in some people, but not in others, right? The bags we look at. And then there's loss of volume. So loss of volume is what makes the eyes look hollow. It makes the eyes look gaunt. It makes the eyes look tired. Then there's the, so then you've got loss there, and then you've got this excess above it. So where does that,

where the lines divide, because this is an important point, it gets confusing, because when we talk about fat transfer and removing fat, people are like, well, why are you doing removing in one case and taking it out, you know, like, why is that, it doesn't make sense. So the orbital rim, which is the bone along the eyelid. Underneath the muscle and on top of the bone, there's a layer of fat there. And that layer of fat begins to diminish with age. And when that fat diminishes, all of a sudden, the eyelid runs into the cheek through a distance that you call the eyelid cheek junction. And that distance gets longer. And when it gets longer, that's where you see people, they look hollow and gaunt and tired, et cetera. They also look darker because the tear trough,

which is the corner of the eyelid where it connects to the nose. that area especially gets deep. So that's volume loss happening there. And then above the bone, and this is why the bone is an important point of demarcation, above the bone is where you start to get the excess stuff happening. That's where the skin and the fat become excessive. And when that happens, when you look at that eye, you have to examine exactly what's going on and you have to diagnose it properly because if all you do is take out the fat from the eyelid, right, the puffiness from the eyelid. Well, you still have a very long eyelid cheek junction. The eye's still going to look gaunt and tired looking, but there won't be puffiness, but there still could be excess skin there, too.

So it's like, so, you know, it's so important to examine the eye correctly and then associate the right treatment. So when I do this, I'm looking at all three of those things. And my general treatment plan would be fat transfer to fill the volume loss. And then for the excess, I get, I have two options there. One is called a skin pinch, which is just the removal of skin only. And then the other one is a lower blephroplasty, which is the removal of fat and a skin pinch. It combines the two. So basically, you know, we want to make sure we address all three of them.

When you do that, it's this beautifully rejuvenated eye that looks so rested in tight. But it really starts with, I mean, you can't have it without volume augmentation. But I personally will not, I truly will not do a lower bleferoplasty. without fat transfer. You know, I mean, even if the patient says, no, I don't want a fat transfer. I'm sorry, I'm not doing your blephroplasty because you just can't get a refreshed-looking eye

without volume there. And you'll never really see somebody with aging eyes that doesn't have volume loss in addition to it. So that's what's happening to the lower lids. For the younger people who don't necessarily need or want surgery, do you, are you okay with putting filler under the eyes? any point? You are good. It's like a perfect question.

Because I've done everything. Yeah, yeah, that's a perfect question. So here's what it comes down to. So there are definitely candidates for tear trough fillers in younger people who only have volume loss confined to the tear trough and it's literally minimal, right? So, and I think I did a video on this, posted on Instagram where I showed three different types of volume loss patterns along the lower lid. if it's just confined to the tear trough and there's no excess skin and no puffiness,

this is an important point to make because it has nothing to do with age. There are 20-year-olds who have fat pads under their eyes, right? And what ends up happening in those cases to an injector who is perhaps not as experienced or quite understand this concept, what they will do is they'll put a lot of filler underneath the eye to try to match the height of the bag, right? The eyelid bag. And when you do that, you're just overwhelming the local tissues with too much. filler. And too much filler in that area ends up causing tindle effect. It causes this kind of weird

puffiness in that region. So the ideal candidate for lower eyelid fillers is somebody who just has very minimal volume loss confined to the tear trough. And with that truly 0.2.0.3 cc's maximum. So that's a quarter to a third of a syringe of like a product like wrestling is enough to correct the problem. If you're if you're using a half to a cc or a full cc of volume, using filler, you're using too much for what is going on with your eyes. And that's where you're going to run into trouble. You have a similar philosophy about that when it comes to like doing filler in the midface, like in the cheeks or is it just like if you need more than a little bit, then you're then you need, then you're a candidate for something more permanent?

100%. Because one of the biggest reasons why people put midface fillers in is because of that groove that forms, you know, in the middle of the cheek and the midface. But, But that groove is not just volume loss. It's the midface actually descending. It's dropping and getting heavier and encroaching on the nasal labial fold. So a simple test is if you put your finger on the outer part of your cheekbone, you know, your outside cheekbone and kind of pull up, if by lifting it, it smooths that area out, then the answer is not to fill that region because if you fill it,

you're just going to get this heaviness to that middle portion of your face. All the while your midface keeps dropping further. down and now you're giving more volume on top of your nasal labial folds and then it looks terrible. So no situation. Like for example, when I do the vertical restore vertical prevent and a fat transfer, eight or nine out of ten times, I don't put any fat transfer or any volume in the midface. That's all corrected because I'm doing a deep plane approach. I release all of the ligaments of the midface and I'm actually able to lift the midface up.

And when I lift it, then I don't need to use volume because the cheek already has its own volume that just, you know, smooth that area out. So that's a very, very common area for people to get overfilled because they're trying to correct that depression there. And that depression is not, it's not a volume problem. It's a sagging problem in most cases. Yeah, I've been there. Okay. We only have a little bit of time left so we can kind of end on like the jowls, the neck area. is there anything that people can do that's less invasive that is effective if they are not

candidates for surgery yet? Yeah. So the total honest answer to that is no. I mean, there really is, I mean, you name a category and I can I can tell you that that's not going to effectively address that. Yeah, that's a great question actually because I had a somebody, one of the reporters was just asking for a discussion on that. And I think, I rained on their parade a little bit because I told them the Botox. So here's where Botox and the neckbands actually work for, you know, that's a common area of people. If somebody has a dynamic neckband, meaning the kind that, you know, when you talk and eat and the muscle is just firing away, you get those, you know, flex it looks like a lizard, right? That type of an effect.

When that muscle flexes, if it's doing that in a hyperactive way, you're going to look like you have neckbands and you can be 20s and 30s or whatever it is. That person can benefit from Botox to quiet that muscle down a little bit. But if you have true laxity, you know, the muscle is actually loose. So meaning that muscle, those neck bands are there, even when you're not talking, flexing, et cetera, and they're just kind of hanging there a little bit, that's not going to get better with Botox. So doing Botox in that area is, I mean, all it takes is trying it one time and then you'll realize if it works or doesn't work. If it works, then great. If it doesn't work, then you just simply don't do it. The bigger investment is for people who are doing,

you know, trying threads and things like that, because threads, although may temporarily improve it, it's not going to give a long-term result. I mean, long-term, I'm talking greater than six months, result with it. And then so, you know, it's a big thing to go through for, I mean, you think it's not a big thing, but I mean, anytime you're piercing the tissues with with something and putting something in there, you're running the risk of infection, irregularities, you know, all these kind of things that we know happen with, with threads. In fact, I presented a published study on thread lifts. It was like, you know, 30% complication rate, you know, with thread lifts.

And that's, that's a massive number for something that literally disappears after about six months. I mean, that's a big thing. So I'm not a big fan of anything for laxity, short of surgery. And it sounds like, oh, again, you're a surgeon. Of course you're going to say that. Well, yeah, but as a surgeon, I could also do those things. I could have nurses and nurse practitioners and PAs do those things all day long in my office. I just don't do it because it's not fair to the patient to be misguided.

That's all it is, you know? I did threads a few years ago. My listeners know how I feel about them. And being somebody who's done threads and who's done different surgeries, I found the threads to be the most traumatic thing that I've gone through aesthetically, like, period. I mean, surgery, you're out and like, yeah, you wake up and you're like, yeah, you wake up and you're a little out of it and it can be uncomfortable for four or five days, whatever. Threads, that whole experience was horrible.

And it's so expensive. And it didn't laugh. I mean, I was swollen for a little bit and then it was just nothing. I mean, it makes zero sense because you're not removing anything, you know, you're not removing excess skin. You're not doing anything. And then these newer threads, these PTO threads, this next generation threads, they all disappear. I mean, they're meant to disappear because the original original, threads were permanent, you know, back when I was in residency, they had just come out and talk about

a nightmare. I mean, these were, I'm sure some of the listeners of experiences, this was, you know, literally 15 plus years ago. And there were barbed permanent sutures that you stick into the face and then you hike up the skin on top of these barbs. And it was so painful and all, everything got bunched up. And it was, I did a couple of them in a fellowship. And it was just, like, okay, this is not a good idea. That was the last time I did that. But it didn't take, and then they disappeared. Everyone realized how bad they were.

They disappeared. And then years later, almost 10 years later, they came out as these, these absorbable PDO threads. And now it's making another sort of marketing run. But before, you know, all these things have like a life cycle. It takes a little while. Everyone gets behind him, gets excited. And then the truth comes out, you know, in mass.

And then they're like, okay, well, I'm not doing that again. And I think we're in the tail end of thread lift. popularity right now. Yeah, I agree. I think now people are realizing that maybe that's not what Bella and Kendall did because they've gotten it done, the people have gone into the med spas and done it and it didn't do anything. So yeah, exactly. Reading the word. Exactly. Amazing. Well, thank you so much for coming on. I had so much fun talking to you. Where can everybody find you? Where can they get your skin care, all of that? Yeah, absolutely. So my Instagram and YouTube are both really great, you know, resources for education and content and things like that.

They're both Dr. D.R. Amir Karam, both those. And our skincare website is caram-m-d-skin.com. And then for the skincare Instagram is just caram-m-b-skin. So that's where you can find me. And then my surgical website is just Dr. Karam.com. Amazing. Thank you so much. It's really, really fun. A lot of great questions.

really enjoyed it. Thank you so much. Thank you. I hope you enjoyed that episode. If you liked it, and if you like the show in general, please take a second to rate, review, and subscribe. It goes a long way, and it's actually the best way to support the show. Also, if you want to see more about each episode, you can head over to The Blonde Files podcast on Instagram. I'm always posting about each episode there or over on my personal page at Ariel Lori.