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

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Hey everyone. Welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics@peterattiamd.com. In this podcast episode, I'm speaking with my friend, Dr. Brett Kotlis. Brett is a New York City based eye and facial plastic surgeon who specializes in cosmetic and reconstructive surgery of the face, but particularly specializing around things to do with everything with the eyes, including the skin around the eyes. He's trained both in general oculoplastic surgery and general cosmetic surgery. I met Brett about three years ago and I still remember our first meeting. We met for the first time when he just came by my office at some point and we sat around having coffee. And as he walked me through not just his training, which is actually quite unique, but also his particular approach, I realized we were kind of kindred spirits in our appreciation for nuance. As you'll learn in this episode, I know pretty much nothing about looking good and skin and eyes and all that stuff. And in many ways, to spend time with Brett is to spend time with someone who thinks a lot about how to make small and subtle changes over time that lead to long lasting effects. And I think the reason that resonated so much with me is my belief in longevity, of course, is that it's a compounding and therefore making small but consistent changes that lead to seemingly small improvements over the short run is actually what leads to amazing results over the long run with respect to the reduction of risk of disease, et cetera. Brett's approach to cosmesis is the same way, and I suspect that my bias is probably what has me thinking that that's really the right way to do it. And once I got to know Brett better and we started to collaborate and work together, and I sent a number of patients to Brett, I was always amazed by the responses because to me, the right way to, for example, do Botox is to be able to look at a patient after the procedure and say, I didn't know you had Botox. And so things that we talk about here are a bunch of things that you can do to make a huge impact on the health and vitality of your skin. And he does get into a number of these things specifically around Botox. He also gets into a growing list of sort of all the facial and cosmetic procedures that are out there. Lasers, peels, all of these sorts of things. And most importantly, I think he also helps you as the listener think about how to pick someone. Because again, many of you listening to this might find this stuff interesting. And sure, if you happen to be in New York and you want to meet Brett, that's great, but most likely you're not. And so the more important question is how do you sort of separate the good from the great or even the great from the not so great in this space? So again, like I said, I don't think a lot about this. Personally, I realize I should probably think about it more when I look at pictures of myself today versus pictures of myself when I was 30. I am sort of surprised at how much I feel like I look like I've aged. And I guess part of this was a bit of a wake up call for me that I might need to pay a little more attention to that. If for no other reason than just to have the optionality to look a little better when I'm 80, then I'm probably on the course to looking. Brett does a great job here explaining why our faces change over time, what he considers the three most important tools for skin care and rejuvenation. He gets into all the procedures, as I mentioned, the lasers, the peels, the needles, the devices. I really enjoyed his discussion of the right way to do Botox because I'd heard this before because of course Brett and I had discussed this a lot, but I. I'm glad we were able to sort of revisit that for people here. And he also talks a little bit about the current trends and future trends of cosmetic and plastic surgery. You can follow Brett on Instagram. He's doctorkotlus D R K O T L U S where he puts up lots of before and after photos, especially around the eyes, which I find particularly interesting. That's something about myself that I've always been curious about making better. And his website has the same URL. Lastly, you can see some stuff in the show notes here. I asked for Brett to give us kind of his recommendations on products that he suggests that his patients get that if anyone is interested in, they'll at least be able to sort of get that. And you can@peterattiamd.com podcast so without further delay here's my conversation with Dr. Brett Kotlis. Well, I'd like to welcome to the show today Dr. Brett Kotlis, who is an oculoplastic guru and also a close friend of mine. Brett, we met, what, about three years ago?

I would say maybe it's two.

Okay.

Yeah. It just seems like we've known each other a long time.

The first time we met, I remember being really impressed by kind of the nuance of your training.

Thank you.

I tend to think and talk a lot about longevity, but I don't tend to think and talk a lot about or know anything about looking younger. And you have learned an awful lot about that. So remind me, how. How did you train? What was your medical training?

When I was in medical school, I was drawn to this specialized field that was sort of a cross between ophthalmology and plastic surgery, and it's called oculoplastic surgery. I was watching this doctor do an orbital tumor resection, and so I decided this is what I want to do. And I learned that I needed to do a residency in ophthalmology before I can do a fellowship in oculoplastic surgery, which the field basically revolves around the eyes and the face and plastic procedures related to that. So I found out that I had to do an ophthalmology residency first. So I did that, and then I matched in this training program. The match process is sort of like the medical matchmakers, and you are assigned to a program based on a ranking system, which you've been through that as well. And I matched with this doctor in Tucson who happened to have transitioned his practice into cosmetic surgery. And so when I arrived, I thought I was going to be doing mostly orbital tumors and tear duct surgery and eyelid reconstruction, and that was part of what we did. But we were also doing a lot of facelifts and fat grafting and liposuction and lasers. And so my fellowship training qualified for two different organizations, the American Society of Ophthalmic Plastic and Reconstructive Surgery, and then also the American Academy of Cosmetic Surgery. So when I finished my fellowship, I ended up working in this practice in Michigan that was the largest medical spa in the Midwest. It was an exposure to even more lasers and more technology that was on the cutting edge of what doctors are doing for our appearance.

I remember one of the things that really surprised me when we spoke was just understanding that basically anybody with an MD can hang a shingle and do kind of whatever the heck they want with respect to facial plastic stuff. I mean, anybody can be injecting botox and fillers and all of these things. And of course, not everybody's doing this stuff. Well, and not everybody's doing this stuff with the eye towards how will this look down the road.

Right.

And I think your approach seemed very nuanced and sophisticated. So I hope to certainly touch on that today. But I kind of want to start with some just fundamentals. So I saw a picture of myself 20 years ago, meaning I recently saw a picture of myself from 20 years ago. And I was like, God, you were like a better looking dude back then. Why is it that at 25 I looked better than 45? And part of it I think is just my skin looked so much better. So even though by most people standards I'm not an old guy today, clearly my skin doesn't look like it used to. What has changed?

It's interesting because there does happen to be a double standard for men and women and we have the benefit of looking more distinguished as we age. So it's. I don't think all men feel that way, that we're looking worse as we age, but certainly our faces are changing. And there are some aging changes that are intrinsic and some that are extrinsic. Right. So your genetics, you're programmed to have certain changes over your lifespan, right? We lose bone as we age, which happens in our faces. We are losing facial fat as we age, and in some ways we're losing it in maybe the wrong places. And the sun that we're exposed to over many, many years causes something called solar elastosis. So we are losing collagen and elastin. The thickness of our skin is decreasing in many areas. And we're also gaining small blood vessels, the telangiectasias, and we are gaining brown spots. And the combination of these things on every layer of your skin, your fat, your muscle, your bone, the ligaments that connect the interplay between these layers are all losing support and they're getting thinner and they're degrading. So from the time that you're born until now, you started off with really chubby round cheeks. You look at your one year old son and it's all downhill from there.

Now there seems to be something about the face in particular. So I used to swim a lot and I used to swim outdoors, obviously. So I did spe sometimes 6 or 8 hours just swimming in the, out in the ocean. And I didn't even bother putting sunscreen on because, you know, I have dark skin, I have olive skin, I never get sunburned. So I'm pretty used to being the guy that's getting a ton of sun. And while I accept that that's probably caused some damage to my face, why does it not seem to have caused that same damage to say, my back, which was even more exposed to the sun when I'm swimming in a prone position?

Well, if you think about the tension at play based on your face and your back, I mean, they're, they're different. So your face has more movement, but there's also, because you need to move in certain ways, there's also more areas of laxity. Whereas your back, the skin is stretched and it's taut, even though you can certainly get brown spots and wrinkles on your back. Think about scars on the back tend to spread. They look wide and stretched and they don't heal well because it's under constant tension. But I think that tension makes the back skin look different than the facial skin. But you also have different oil glands in different parts of your body. So you have a higher density of sebaceous glands in your face. And the muscular expression, I think it affects the way that you age more than it does in other areas.

Now I read once that by about the age of 35, you'll lose about 10% of the fat in your face, which is kind of amazing to me, given that by the age of 35 I probably gained 10% of the fat in my body. What is it about the face that doesn't do what the rest of the body does, which is accumulate fat?

Yeah, well, I think there's probably local hormone effects that are making you accumulate in other areas. And in the face we have the fat cells come from different embryologic origins and for some reason that's what's happening there. And we're talking about very small amounts of fat. So you'll see those small differences. But think about your facial fat as insulation. And as you lose that insulation, you start to see the structures that are underlying the surface. And so you can see where the ligaments are tethered and you can see the places where they're not tethered, which would be an out pouching. And so all of those tight areas opposed. And just directly next to the areas that are not tightly attached, you see these contours. And so as you age and you deflate and you have gravity pulling down, I mean, the effect of gravity is real. Have you ever seen a, like a slow motion video of a runner and you see their face and the way that the face bounces up and down and there's so much force on those facial ligaments. And so you can imagine what happens as you're just walking and running up and down the stairs and over and you're smiling and you're doing all these things with your face. So there's wear and tear. Just like it happens on our joints, it happens on our facial ligaments. Have you ever lied down on your back and take a picture and then stand up and take a photo? That lying down image, that eliminates the effect of gravity on your face and that shows you what is gravity doing in combination with the deflation. So that's how you take a selfie is when you're lying down.

Here, take a lying down selfie. There's a tip number one, guys. The anti gravity selfie in longevity. I used to, used to, I still do. And I certainly don't, don't deserve credit for this. Smarter people than me have said this first, but the joke is the most important thing you can do to live longer is choose the right parents. So there are lots of things that you can do to live longer. But genes really play a role now in the longevity space. We have a pretty good sense of what those genes are. There are somewhere between about 8 and 12 genes that offer pretty remarkable protection in delaying the onset of chronic disease. And therefore centenarians, people who live to be 100 or longer, tend to be bestowed with a greater proportion of those genes. But you mentioned a second ago that genetic factors can also influence these sort of intrinsic changes that occur. Do we have a sense of what those genetic factors are? Clearly there are people who just have remarkable skin and they age with remarkable skin. And you know, you'll see a woman who's 40 who looks like she's 20 and her mom is 65 and she looks like she's 45.

Well, we know that there are some correlations between certain genetic types and certain traits and the way we age. I mean, if I see a lot of people for under eye bags and it's almost everybody says, hey, this is, this is genetic. Well, yes, I know it's genetic. I mean, your parents have it, you came in with your mom and she has it too. So the structure of your face obviously comes from your appearance. But when we talk about skin types and the skin color, darker skin types tend to have more connective tissue or denser connective tissue and tend to look better as they age. So maybe it's a generalization, but a lot of the Asians in my practice tend to look better, longer, darker skinned, Individuals the same thing. And so the darker pigment in skin does give you some UV protection. Doesn't mean that you don't have to wear sunscreen, but it offers photo protection. And I theorize that UV exposure from sunlight causes fat atrophy over many, many years.

Wow. What do you base that hypothesis on?

We use heat and we use laser procedures in a very highly focused way. And we know that it destroys fat cells. So these externally applied devices that are available now and they effectively remove subcutaneous fat. And I believe that UV radiation does the same thing over a long period of time. And if you've seen people that have always protected themselves from the sun, they look like they have white porcelain skin, they have less wrinkles, and they have younger looking faces. I know we're moving away from the genetic question you're asking me, but I think you can often overcome many of the genetic things, just like with chronic diseases or with your lifestyle modifications. But I think that there is also an internal drive that we have to perpetuate our gene pool. We each have our own internal motivation to do that. That's just our evolutionary goals. And I think some of the more favorable genes become selected over time. And, and so I think there's a genetic motivation for people to want to look good because they want to present themselves in their best possible way to a possible mate.

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

Think about all the people that are walking by you on the street that have had work done and you haven't you don't notice it because it's done well. So I think you're seeing that every day, but you just don't know it.

Yeah, I only see, I only see the, the numerator. I don't see the denominator.

And what are the reasons for the unnatural appearance? Why do people get to that point? I think in some cases maybe it's unlimited access or unlimited resources. I think there are forces that push people in that direction. Your appearance is a very emotional subject and I think we tie ourselves to that. Maybe an age that we feel like that was our best age. Think about the actress that everyone knows for the role that they played when they were 20 years old. And in our minds we think of them as that person and it's almost hard for us to imagine them aging. And you see them and you're like, oh, look how old they look. And it's, it's, I think it's a natural tendency to think that because you're remembering that favorite movie that you saw them in. But think about the pressure they feel in that situation. Like my career is based on my image. And so if you try to hold on to that 20 year old version of yourself, at some point you're going to cross the line into an unnatural, distorted look. So there's probably a rough guideline. Your goal should, you know, if you want to look your best, maybe I'd like to be, look a little like seven years younger than where I am now or 10 years. But if you go beyond that, it's a little too much. That's one part of it, I think the images that we see around us. If you look at some of the, this is part of like what I call the Instagram effect, where you're scrolling through and you see these photos of celebrities that have blown up their lips and their cheeks are over the top or whatever it is. And some of it is Photoshop, but some of it is from medical augmentation. You start to think that that's the new normal, but it's overdone. And that exaggerated appearance, people around you in your circles might be doing some of these procedures. And so you all see each other like that and then you want to get a little bigger and just push it a little more. And then before you know it, you've gone too far and it can be a slippery slope. So I think people start to lose sight of where they started and what their goals were. Your goals maybe change and maybe you found a provider, there's a doctor or a Nurse injector that said, okay, you know, let's take this a little further, a little further. And then they say, you know, I think you're good here, let's stop it. But you want to go further so you'll find somebody and so you'll, you'll get to another provider and they'll do it. I personally feel this way. If someone comes into my office and they've had something done, I think I can fix them. But maybe you can't. Or maybe it's time to say, okay, let's put the brakes on. So I think there's different reasons why people get to that point. But the technical reason that someone looks unnatural is when you either try to enlarge something beyond its natural dimensions, there's only a certain point is how far the skin will stretch before you start to lose the contours. And we say, like, you can't have light without dark. So the goal of your face, the goal of a natural looking face is not to be totally smooth and to have no curves and no shadows and no lines. When you smile, you're supposed to, you see my brow elevate and you see some lines in my forehead. You know, I'm conveying expression, I'm conveying a message to you that I'm surprised or that I'm angry. And so if you lose those expressions, if you lose the shape of your lip, you have a cupid's bow where it looks like it dips down in the middle, or you have two pillows in the lower lip. And if you distort that by just blowing past all of that and filling it up. And so you have a sausage now for your lower lip, I mean, your eye will pick up on that very quickly. That that's not natural. You might not know how to describe what is natural, but you know what isn't. And so you distort the natural dimensions. And pulling will achieve the same type of distortion if you go too far. Facelifts when they're pulled back too tight because someone is being too aggressive on the surface of the skin, you see the windswept look, those type of things where, you know, you see it in older actresses or even actors. Maybe they feel like, okay, I can spend this much money to look like this version of myself. Well, there's no amount of money that will make you look naturally 30 years younger than where you are.

You know, if you compare, I think, people's bodies today to people's bodies 30 years ago, based on augmentation, there are some inevitable trends Now, I don't have any data to back this up, but I can only imagine that breast size is larger today. I think breast augmentation must be more common than it was 30 years ago. When it comes to facial augmentation, what are the trends? And I'm not talking about the. Just the extremes where people have, like, gone too far. But it would seem to me that people tend to have fuller lips these days. Is that. Would that be true?

I would say yes. And for good and bad reasons, I think we recognize now more and more that global volume loss is something that's happening to our faces as we age, and that includes the lips. So lips can be reinflated because they've lost volume in a natural looking way that you wouldn't know about. I think that there is a tendency now to focus on these areas. So look, when you come into my office and you say, hey, look at my face, what should I do? I'm probably not going to just say like, okay, you should do this, this, and this. I'm going to focus on what you're seeing. But I might point out certain things like, you know, you've lost a lot of volume in this part of your face. And I know you're focusing on your brows for some, let's say, but I see, I want to maintain a balance. So it's been popular to fill these nasolabial lines next to the lips, the lines that go from the corner of your nose to the outer corner of your mouth or to inflate the cheeks. But we have to look at the neighboring areas. Like, you're a car guy and you get a scratch on your car while you have to paint the panels next to it in order to make it look good. And so a good provider, a good physician will look at you and say, okay, your concern is your nasolabial lines. But I think we should also just at least consider your lips. Because let's look back at your photo from 10 years ago and look what your volume status was then, and let's look at it now. So I think in a good way, people are focusing on lips. But also I think the negative is that there's always going to be some people that are over the top. And I see it a lot when, you know, when you have a lip injection. You know, typically we're using hyaluronic acid fillers, which is something that's a constituent of our skin to begin with. So these are very safe in terms of that. They're not. They're biocompatible. There's no allergic reactions to them in general, and they're reversible. So we have an enzyme that can take them back if there's something that doesn't look right or there's an issue. But with these gel fillers, they tend to be hydrophilic, meaning that they absorb water. And for the first two or three days after you do it, your lips look like that person that you're trying to not look like. They get pretty big. So most people, for about two days, they're sort of like homebound or they're freaking out.

They're wondering if they overdid it.

Yes. But it's almost 100% of the time. The first time someone does lip filler and they come back and I said, okay, you were pretty swollen, I bet, for the first two days. And they say, yeah, but I sort of miss some of that swelling. And so the next time around we do a little bit more. And that's sort of like where you have to determine that's, that's. It's a personality thing. It's a personal decision in terms of, like, what is good. And, and it's a discussion between, you know, myself and my patient. And we don't always agree. Like, my patient may say, you know, I hear what you're saying. You're telling me this is natural. I want to go a little further. And, you know, I'm open to that.

Now that's something that doesn't like a facelift. Once you get a facelift, you're kind of stuck with it, right? I mean, a redo procedure there is going to be cumbersome.

It depends on, you know, what the reason is for doing. You can, there's a big, I think, role for revision facelift surgery. But you're right when you take something out. Right. Or you over reduce a nose or you overstretch someone, that can be very difficult to, to repair.

But obviously the hyaluronic acid doesn't last forever, right? Right. So if someone is doing, whether it's an extreme or incremental strategy of filling, how often do they have to do that?

It depends on the area. So, you know, lips tend to not last as long as other parts of the face. Like I, I do a lot of under eye filler under your eyes. You don't have a lot of movement there, even though you're blinking. Under eye filler lasts, you know, a year, two years. I've seen it last four or five years in some people. Whereas the lips, you're always talking and pursing Your lips and eating maybe six to eight months.

Now you have a very interesting technique of doing the under eye filler, which I've sent a number of patients to you because I've been so impressed by just how amazing it looks and how minimally invasive it is. What, what do you do different there?

So this has sort of become my niche in my practice and I probably do that one procedure more than anything else. And it's wasn't by design. I didn't plan for this to happen, but it was definitely an interest of mine. And you know, when you look at someone's face, the first thing that starts to age would be the eyes, because that's where we have so much movement. We're blinking all the time and we have the thinnest skin in our body. And combine that with the fat pads under your eyes, which can enlarge with time because they have a different embryologic origin. And we're losing fat in our cheeks. And the upper part of our cheek, which that groove where you get that shadow is called the tear trough, which I don't really like that term. It makes me think of like pigs eating at a trough. But that trough would be, if you were to cry, would sort of spill down that kind of slide in the inner corner of your eye.

This is what makes people look like they have almost a black eye sometimes from the shadow, right.

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

So what's a cannula for people who don't know?

It's like a needle, but the tip is dull. It's a blunt tipped needle. So what I do is I approach that area from the cheek, we make a little needle hole in the cheek, and then I introduce this cannula through that little needle hole so you have no needles under your eye. And I can use that cannula in a very accurate way. And at this point, I know exactly where my tip is all the time. Even though I don't always see the tip, I know where it is. And when I'm doing this, I'm imagining the surgical procedures that I do very frequently, which is blepharoplasty and so because I know the eye, which is what? So that's blepharoplasty just means a modification of the eyelids through surgery. And so cosmetic blepharoplasty is often either removing the fat pads, the bags, removing skin from the upper lids, or shifting the fat. Whatever I have to do to make your eyes look younger or the way that they used to look. So I do a lot of blepharoplasty, and because of that, I know what it looks like inside. And so I imagine that in my mind when I'm placing the filler and I'm placing this gel that takes up space and it's replacing the fat that you've lost, or it's also disguising the fat pad that might be bulging. And so by putting it in the right place and using the right filler, because there's certainly. There are hyaluronic gel fillers that are incorrect for that area because they just have the wrong properties, the wrong stiffness, the wrong amount of water attraction. But placing it in the right area.

And the right amount is Restylane, a hyaluronic acid paste filler.

That's one of the fillers that I use. And it's also amount of. It's having restraint. So I understand at which point that this will become puffy or look unnatural. And that's where we stop and sometimes we stage it. But this procedure will brighten up people's faces who look like they have bags and look like they're tired. And it's really gratifying to see people's reactions to this when they look in the mirror. Especially when you do one side and you look in the mirror and then you see the difference. It's pretty remarkable. And so it's one of the things I really enjoy doing. And I think that there's a lot of doctors that sort of stray away from it either because they're not comfortable with the idea of injecting under the eyes. There's risks with everything we do. To me, that's not a high risk procedure, but I think it's perceived as one.

I think part of it too, is this gets back to your unique training. I mean, you trained first as an ophthalmologist, which, if I think about it, like I trained in general surgery, like, my scope of what I needed to know was so broad. But when you look at someone who's training in ophthalmology, like, you get to focus five years, years on, like, two inches of a person's body. So your knowledge of that Anatomy is. Is unparalleled.

Right? I was narrow to begin with, and then I became.

And then you become even more narrower. So it seems to me that the advantage that you have, and this is certainly why I've always felt very comfortable sending people to you, is I know that people who understand the anatomy because they've operated, they've actually been beneath the surface, can do exactly what you describe, which is there's sort of. They know what the art is. Put it this way, when I was in residency, there was never any confusion that I would go into plastic surgery or when I was in medical school. Like, I just don't have that artistic capacity.

But I would say, you know, at the same time, you know, I like to talk about my skills, but I don't. I think there's, like, a political part of this conversation where the question is, like, who do you go to? And who's the right kind of provider if you want to do something like this? I don't think it has to be a certain person or a certain kind of person. I think that there are good injectors and bad injectors. I think there's good doctors.

How can people distinguish? So if someone's listening to this podcast and they're saying, well, you know what? These bags under my eyes are driving me crazy. Let's say they don't live in New York. So that you're coming to see you wouldn't even be an option.

Well, people come from other places or countries to see me. But I think if you're looking for a provider for anything, obviously everyone says, oh, I did my research and they looked for it.

Put it this way, if your wife needed a procedure and you decided, you know what? I don't want to be the one to do it, because there's an emotional connection to this person. And how would you pick the person that would do this to your wife or your mom?

I think you have to find out first, what are the organizations that certify people for my field in, let's say, talking about blepharoplasty? I think there's a handful of specialists that would be competent. You could be a plastic surgeon, a facial plastic surgeon, an oculoplastic surgeon. I. I have unbiased towards oculoplastic surgeons, because that's a big part of what we do. I would look at that first. References like referrals from other people. Obviously. You know, look, if you wanted to find out the best surgeon in your. In the hospital, you probably ask the nurses or the Scrub techs and say tell me. Or the anesthesiologists because they have firsthand knowledge. So I think referrals go a very long way. And if you know somebody that had a great result or you know someone who's done something, but you have to meet with a few people because you might have the best surgeon or the best under eye injector or a lip filler person. And that person could also be a physician assistant, it could be a nurse. I mean I've seen some amazing physician assistant injectors that I would have inject myself, you know, without hesitation. But it's like, do you have a good rapport with that person? Do you think you're on the same page? Do you have the same goals and style? So it's almost like an interview when you go for a consultation, sometimes you have to pay for a consultation fee. But I think it's worth doing that at least for two or three or four doctors to meet with someone and say I get the wrong feeling here. Or this office seems frantic or the doctor just didn't even really look at me or listen to me. I mean those things I think are all really important. So I know doctors that are family practice doctors that are exquisite Botox injectors. And so I think it's wrong to fall into the political trap of you have to have this label next to your name or you, you have to be this kind of like training. I think that a lot of the training that I've done was post.

Post your formal training.

And some of the training is, are things that I developed on my own. But for blepharoplasty or eye procedures I recommend looking at the oculoplastic organization. But for things in general, I think you should look. You look at photos of people, all have their galleries online. They're going to show you their best work. So you look at those pictures and you say, oh, those look good or some. I look at some well known doctors and surgeons and I look at their photos and I think this does not look good to me at all. I don't think this is natural and they're promoting it as their best work. There are a lot of things that I see around the eyes where, you know, I preserve fat and sometimes I'm often adding fat which a lot of people don't like to do because they don't maybe have the same philosophy that I do. But I see hollowed out eyes and people are pushing that, putting that forward. Is that there? This is my best blepharoplasty Maybe for someone that is. Maybe that's the look they're going for.

You should want to ask how many procedures the person has done. Is there a certain number above which you sort of hit that threshold of okay? Now I've really.

You should ask all of these questions like how many procedures? I mean, look, I've done well over a thousand, two thousand of under eye fillers, blepharoplasties. Like it's thousands. So. But in early in my career, I did lots of procedures, and it was probably hundreds. So you should ask, and your doctor shouldn't be defensive about those questions. You can say, hey, can I talk to somebody who's had this with you? And we do that all the time. We connect patients with previous patients who are, who are open about it and say, hey, what was your experience? Or you say, well, tell me about the complications you've had. And if I get one of those, what are you going to do for me? How do I manage that? Do I have to pay to fix a complication? Those are questions you should be asking.

That's such an important thing in medicine in general. It's amazing how easy it is to gloss over consent forms, and you just sort of list a whole bunch of generic complications, but you don't actually talk about what probabilistically or expected complications could look like. And to your point, what are the next steps? So, for example, you know, with breast augmentation, I know a woman who had these really horrible contractures develop, and I was like, God, I'd never even heard of that. You know, I didn't even realize that was a complication. Obviously, I'm not in the loop in that space.

It's actually a common complication.

Yeah, it's about 3%, I've learned.

I think it could be even higher depending on the type of implant and the placement. So those are things that surgeons should be saying to every patient. That 3% is a relatively high rate.

Yeah, and you're right, it could be. I mean, it depends on the implant. So if you're using the different textured implants, it could be as high as 5%. I mean, 5% complication is really high. Right. 1 in 20 people who do this is going to have this. And a lot of times on redos, it still happens. Which is not to say one shouldn't have an augmentation. But, boy, I'd be very upset if someone I cared about had that procedure, wasn't told about that complication, and then developed it, especially if they required redo redo, of course.

And so that going into it, let's say this busy surgeon's doing 20 breast dogs a week, and so one patient every week is going to have potential reoperation. So going in, you should know, hey, I might have to do something else. And that's with, I think, any procedure, the risk is relatively low. With many of these things, sometimes we're talking about one. Certain complications might be one in a million. And so you don't have to put that as like this is likely for you to happen. But, yes, that's part of the discussion.

So let's go back to Botox for a second. I think about, like, six years ago, one of my good buddies from residency who's a plastic surgeon, I was just hanging out with him. We were just sort of playing patty cakes one day, and he was like, hey, dude, why don't I throw some Botox on your wrinkly forehead? And I was like, all right, fine. So I sat down in his little chair, and he whipped out some Botox and put, like, what felt like 3,000 injections into my forehead, and I put an ice pack on it, went home.

Classic mistake, though, I think, is what you're starting to describe treating your forehead directly.

Well, let me tell you. Oh, my God. I don't remember how long it took to wear off. I think it was about two to three months. The most miserable two to three months of my life. Because this was at a time when I was a very active cyclist. And I didn't realize it until, of course, I lost the ability to do so. But not being able to lift my brow meant I had absolutely no way to keep the sweat out of my eyes, even when I was wearing my kind of do rag under my helmet. So I couldn't believe how miserable I was not being able to lift my eyebrows.

Yeah. So it's uncomfortable. And then it's also a dead giveaway. So when you look around, let's say you're watching the Oscars on TV or something, and you want to know which people have had poorly done Botox. And it's a lot. It's when the. The frontalis muscle. Right. Which is the only.

So where is that for the people who are listening?

Forehead muscle. Right between the eyebrows and your hairline.

Okay.

Okay. So for some of us further back than others, but the frontalis muscle is the only muscle that raises your eyebrows. So you get those transverse, those horizontal lines across your forehead, and your instinct is like, oh, I should do Botox to get rid of these. Well, if you inject the frontalis to the degree where you smooth those lines, because those lines are formed by the muscle contraction, so your muscles don't contract anymore. And I said they're the only muscles that raise the brows. So now you can't raise your brows. In fact, they drop, but your forehead will be shiny smooth. So if you see somebody and they can't raise their brows at all, you just see smoothness. They were over Botoxed in their forehead. We say Botox as a generic term. It's actually. That's a trade name. And there's other.

That's the Amgen product. Right.

That one is Allergan.

Oh, it's Allergan. Okay.

Currently FDA approved is Botox, Xeomin, and Dysport. So those are all types of Botulinum toxin type A. There's slight differences in the molecules, but they all have the same effect. So the mistake that was made for you is going after the horizontal forehead lines and in fact, what.

Which seems like a common mistake, given on the frequency with which we see this.

Yeah, I think people know a little bit more about it now, but still, I think they use too many units up there. So the unit is the strength of how much is being injected. But what would have been better would be to inject the corrugator and procerus muscles, which are the ones that are just at the top of your nose, but the ones that furrow your brow, you treat that and then just a light sprinkling in the forehead. So you can still elevate your brows, but you weaken that. That muscle contraction. Then over time, if you do it a couple, it'll last you about four months. And then over time, as you repeat it, then those lines will soften because you're not making as much of that contraction.

So if somebody comes to you and says, brett, when should I start doing this stuff? Let's say someone takes the long view, right? Someone says, look, I'm, you know, whatever. I'm 40. I'm 30. I don't know what the age is, but I want to know that when I'm 70, I look more like I would otherwise. When I'm 50, they want to take that view, which is, I'm not trying to look like I did when I was 16, but I want to really take a long view of plenty of iterative interactions. Are you looking at a magnitude of wrinkling or are you saying, you know, we start with very, very small. For example, just looking at that area that furrows the brows, but not touching anything on the frontalis muscle above it. I mean, how do you think about this from that standpoint?

I think we have to think from the beginning that you don't have to do anything, right? Nobody has to do Botox. Nobody has to even spend this much time thinking about their appearance, right? People do it because it's important to them. And what's important to you might not be important to someone else. So with that aside, let's say your goal is to look your best as long as you can. You should probably first start focusing on the preventive things, which can include neurotoxins like Botox, but it should start with sun avoidance at a young age. You should do Botox or something like that before you start to get etched lines.

Is an etched line, one that means when your forehead is relaxed, the line still shows, Right?

And I think it's okay. You know, I have some etched lines and horizontal etched lines in my forehead, and I think it's acceptable for me and I'm okay with it. I mean, look, there's a range of what's acceptable. I used to look at Bill Clinton on TV all the time and I'd see his big eye bags. And when I was in my training, I'm thinking, oh, I would just die to be able to take out those nice juicy fat pads. But he doesn't care about them at all, right? And so it's meaningless to him. Or maybe he thought about it, but, you know, he obviously didn't pursue it. So it doesn't really matter if it doesn't matter to you. And I think, you know, what's interesting at the root of all of this is, you know, why do we do cosmetic procedures? And why do some people think it's so important? Why do people think it's nonsense? It's about your confidence, it's about how you feel about yourself, your self image. And I think that there are some people that will chase after confidence and may never be able to achieve it. And it's because of what happened to us in our childhood, our upbringing, the, I guess, the stability that we had when we were growing up. And it's being able to experience love in your family, experience acceptance, people that were proud of you. People can say that they love you, but if you didn't experience that, it's much harder to be self confident and to have a good self image. And so I think it all goes back to that. I think there's a healthy way to do it. And I think it's not something that we should frown upon. I think it's becoming more accepted in our society to have a focus on how we look and how we project ourselves. And I think the best way to do that is to have a healthy attitude about it in terms of, look, I'm doing this for me. I'm not trying to impress somebody. I'm not trying to fit in with somebody. And what's amazing is sometimes a little tiny thing that you wouldn't even know, you wouldn't notice it. But I see people walk out of the office with a different gait, or they're smiling when they weren't before, and we barely even did anything. But it's a little shift in the way that they were thinking about themselves. And so it's not so much exactly what you do, but how you help somebody to feel better. So in terms of doing, like a neurotoxin inject, like doing your first Botox injection, if you're looking at your parents and you see these lines and you think, I don't really want those lines. So you do it before they start to become fixed lines, those etched creases, you do it before you get that. So there's not really an age. I mean, I've injected people in their 20s, I've injected people in their 80s. I think it's never too late, but there's certainly times where it can be too early.

Now, have you ever found yourself in a situation where you felt it was unethical to participate in the care of a patient because you felt that they were just being too neurotic or they were asking for something that you felt was too much? I mean, did you find yourself in.

That situation all the time? All the time. I think that's the nature of what I do. Right. It goes along with it. And so the way that you look is tied in very closely to your emotions. And when you. Especially when it's your eyes. And I see people all the time that have had poorly done procedures and they're tearful when they're talking to me. And I see people, I think they're unrealistic. And I try to guide them. My goal is to be on their side all the time. So in order to sort of focus on overall wellness, not just appearance, but I think there's a connection between appearance and wellness. And if you seem to me like there's something else going on here, why are you chasing after this one line when anyone who would look at you objectively would say, oh, yes, you look younger, you look more relaxed, you look refreshed. Like, what are we really talking about here? Well, maybe there's something else to talk about.

So you're almost having to try to be a psychologist, psychiatrist at the same.

Time, in a way. I mean, maybe it's also. My wife is a therapist, and so some of that probably has brushed off on me in terms of how important it is having somebody to talk to that's outside of judgment. And so I think sometimes people need to. Maybe it's not just one thing, it's both. It's having someone to talk to. Maybe there's some other issues going on. And, you know, what is your goal in doing this?

Let's go back a little bit further. Let's say someone's listening to this, and maybe this is a lot of people, and they think, look, it's really good to know that there are people out there, like you, who can do the most nuanced, complicated grafting, injecting techniques above, below the eye, the forehead, et cetera. But what if they say, look, I don't want to do anything that I can't do as the patient myself, Meaning lotions, potions, behavioral changes. Let's start. You alluded to sun. Let's start there. I get asked all the time, and I'm kind of embarrassed because I just don't know the answer. And I have to say I have no clue. I get asked all the time, peter, what sunscreen should I be wearing? Like, I feel like it's easier for me to answer, like, how would you solve the Iran nuclear missile crisis? Or, you know, before, like, I don't have a clue what sunscreen to wear.

It's a complex marketplace, let's say, because the way that sunscreens are marketed, the way that the labeling is done, can be a little bit confusing. And there are technologies that are being employed now that are newer that we don't fully understand. So let's talk about.

So let me start with the first question, which is, there are some people out there who say sunscreen is horrible. You should never wear it. I'm assuming you don't think that that's the right approach.

It's absolutely untrue. I mean, I can't feel strongly enough about. Look, I see a lot of skin cancer, and I treat skin cancer. And it's like, it's obvious, and it's been well scientifically proven that there's a correlation between UV radiation and skin cancer. So I have to reconstruct people's eyelids, their faces, their noses, because they've had basal cells, which Basal cell carcinoma, which is related to sun exposure. My wife has had several Mohs procedures, which means a dermatologist with special surgical training has to remove pieces of skin. And then that has to be reconstructed. And, you know, I don't think anybody wants to go through that. Look, the recommendations. The American Academy of Dermatology is to protect children from sun. And there's recommendations about levels of sunscreen. So you can get your vitamin D even if you're using sunscreen.

So when we talk about uv, they talk about UVA and uvb. And you'll see these things on sunscreen. Can you explain what UVA and B are traditionally uv?

You can think about it as uva. The A might stand for aging and the UVB is for burning. UVB is what's responsible for your skin turning red. Okay. They're just different wavelengths, wavelengths of ultraviolet light. And when you're looking at spf, they're talking about uvb. The way that they determine SPF is they will take a subject. They'll do it probably. I think you need to have 10 subjects. This is just done on a person. It's not like a laboratory test that works well for this. They still use it on people. So they would put you under a light in a laboratory with uvb. And they would wait and see how long it takes for you to turn red and then an SPF. So that's UVB radiation. SPF 15 means what do we need to put on you that will make you turn red 15 times longer?

It'll take 15 times longer.

Longer to turn red. And 30.

And. And this is my sound silly question, but is there an objective metric for what redness is? Like, there's a color. You know how, like, you can define colors by the percent red, green.

You can measure the.

You can measure the color. Got it. It's a purely objective measurement. So it's interesting. SP15, which seems like very mild sunscreen, still gives you 15 more times. So if it takes you 10 minutes, this is going to take you to, you know, what 150 minutes is like two, two and a half hours. Basically.

If you look at the difference between SPF 30 and SPF 50, you're getting a difference of, I think it's like a 96 or 90, 96% protection against UV during that time versus 98% protection. So it's. It actually becomes less of a difference in protection from those rays as you go up higher. So over 30, you don't get that much more benefit. So. But you should be using at least a 30, but that's talking about UVB. If you want to protect yourself from UVA and UVB, which you should, you should be using a sunscreen that says broad spectrum.

Okay. And it's still the same SPF system.

Well, no, SPF does not apply to uva. It doesn't measure uva. In fact, there's no measurement of uva.

So if you buy a broad spectrum sunscreen, it will not have an SPF number on it, or if it has.

It has an spf, but it relates to only.

Okay, got it.

Because UVA doesn't cause redness, so you can't use that test.

Which of the two is more responsible for vitamin D synthesis?

That's a good question. I don't have the answer for you.

All right, we will, we will find out the answer to that question at some point. That should be known. My I, my intuition is it's uva, but I, I, I don't know.

But both are responsible for skin cancer.

Got it.

So UVA is, can, can lead to melanoma.

Now, I remember reading that, you know, I mean, I've read so many things like, you should always have zinc in your sunscreen. You should never have zinc in your sunscreen.

So there's other divisions of sunscreen types. And so there's something called organic and inorganic, which we also more commonly is termed chemical versus physical. So the inorganic sunscreens are physical, and those typically use zinc or titanium, which are metals, as a reflective agent. And it just reflects the rays of sun. So those are the ones that you think of like Baywatch, and you have, like the white under your eyes, but they don't look like that anymore because now they have micronized versions of those zincs and they have nanoparticle. So smaller particles mean that it looks clearer. You still get a little bit of that lightish. I think I gave you one of my sunscreens before. You get a little bit of a whitish hue, but it's not like a pasty white. Those are the ones I recommend because it reflects the light. Now, there are some newer chemical sunscreens that are thought to be safe, but there are some issues with the. So the way the chemical sunscreens work, which are considered the organic sunscreen sunscreens, they absorb the UV light and they convert them into heat, which disperses locally in your skin. So if you have melasma, those type of sunscreens could potentially worsen your melasma.

Tell us what melasma is.

Oh, sorry. So it's also a term like the mask of pregnancy. You see darkness or hyperpigmentation on the cheeks, the upper lip, the forehead. Any dyschromia or brown spots can be made worse by heat, which is why I recommend against some of the chemical sunscreens. I wouldn't say it's a blanket statement. Some of the chemical sunscreens also have hormonal disruptive effects, which is why they're not recommended for children. But I wouldn't recommend it for myself either.

So what are some. Maybe what we'll do in the show notes, we'll link to brands that you really, really like versus brands that people should really avoid. If you're sitting there at the CVS and you're trying to get some sunscreen before you go to the beach, are there any ingredients that are red flags that you should avoid?

So, I mean, I don't like octinoxate, which is a hormonal disruptor. I think it's debated and, you know, how much dose do you need in order to really disrupt hormones? But I don't really need that at all. If I. I just would look for physical sunscreen that has broad spectrum and at least an SPF 30. And that's pretty simple.

Some of them say they're waterproof versus not waterproof. Is that a gimmick or is that the real deal?

It's hard to mess with. Measure the waterproof effect, but they do that the same test, but they're spraying you down with water in the lab and then they're waiting to see how long you turn red. I think the key is that you have to apply enough. Most people don't put enough sunscreen on. I'm guilty of that as well. I mean, I was in Florida a month ago and I'm still sort of tan and I was wearing a wide brim hat and I'm applying sunscreen, but it obviously wasn't enough, so. And you apply every couple hours. I mean, every two hours, you should probably reapply.

Interesting.

I know people, we don't do it.

I don't do that either.

But if you care about how your face looks, then at least focus on that. And maybe your hands, too, and maybe your chest. We call the decolletage, like your chest. Those are the areas that are going to be exposed. And if you want to look your best, don't forget about your hands, because when you're 70, you'll have brown spots and you'll have wrinkly skin on your hands. If you don't protect yourself, your face, you don't want to get wrinkles, right? So put on sunscreen, wear a hat that has a wide brim. And then particularly for women, or if you wear a low cut shirt or you're wearing a V neck T shirt, then put it on your chest.

Are there certain moisturizing creams that people can apply that have sunscreen in them, but they're primarily like, they're not necessarily sunscreen per se. Like CeraVe is a product that I have used from time to time. It's not a very high SPF. It might be a 15, but I really like it because it's odorless. I think part of the thing I hate about sunscreen is I can't stand the smell of it and the greasiness of it. But the CeraVe, I really, I'm like, yeah, I can actually wear this.

Yeah, I think 15 is probably low. Look, if we're here in New York City and you know, you're walking from your home to your office and you're probably getting a blast of sun on your face, I put on a 30 in the morning. You can do a trial and error. You go to your cosmetic store, you go to, you know, your dermatologist's office and you ask to try a couple of them and you feel in your skin. I mean the, the technology is getting better and the scents are, I think have a wide range to appeal to a wide range of people. You'll find something that will suit you if you look for it.

What brands do you like?

I don't necessarily want to promote a specific brand because I think that there are so many good products out there. If you look at the medical grade brands which are sold in doctor's offices, but you can find them also online. You can find them on some of the online vendors. ELTA is known to be a good brand. Maryland Solar Science. I like Replenix SkinCeuticals. You'll find a long list of potential products. I don't mean to leave any outer focus on those, but yeah, yeah, yeah.

Okay. So then the next thing I want to talk about as far as just sort of nuts and bolts maintenance stuff is something I've heard quite a bit about and also have tried from time to time, is retinoic acid. So first of all, what is it and why does one use it or how does it work?

Well, so we're talking about a form of vitamin A and it acts like a hormone. In fact that it works in the intracellular and the DNA level. So it's affecting Transcription of particular genes, it's promoting collagen synthesis, it's increasing the turnover of skin cells. It's one of the few things that's proven for anti aging but also for acne. So there are a wide range of forms of vitamin A, but it's one of the top three things I would recommend for everyone to be using if they are interested in having a skincare regimen that's effective.

Now, Retin A cannot be bought over the counter. Or can it?

You can get over the counter retinols.

Okay.

So the retinol is a less potent version of what you're referring to, which is tretinoin.

And do those over the counter versions, which are obviously less potent, do they have the same efficacy or do you have to apply them more frequently?

They're not as potent, but they have less side effects. So if you have not used one of these products before and you're looking primarily for anti aging or for anti wrinkles, you want your skin to look younger so it helps you have less wrinkles, it helps reduce pigment in your skin. Someone who's been using retinol from their 20s on, they always look better.

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

Yeah. So it's less drying when you're using the over the counter retinol type products. I would start with something like that if you haven't done it before. And often those have moisturizers or hyaluronic acid or other things, things in there that avoid some of that drying. If you do get dry from that, then you can just use it every second or third day. Or you can do sort of a pulse treatment where you put it on and then 10 minutes later you wash it off. So you've sort of gotten a short exposure if you can tolerate that. And it's primarily recommended for nighttime. And there's a myth that retinol is making you sun sensitive. I mean, it's possible because your skin has less pigment in it and your skin is less looks younger, but it's more that the retinol breaks down from sun exposure. Right. So it becomes ineffective.

I always assumed it was for what you said in the first place, which is you'll get more burned if you use it. And that's okay.

It's not necessarily true, but it is recommended. You know, we use it at nighttime. I use it every night now. If you can tolerate that, then you can talk to your doctor about getting a prescription for a higher strength.

And that's usually like, like 0.025% or 0.05% or 0.1.

So I'm up to 0.1 now, and I do it every night, and I have no side effects, but I use just the generic 0.1% tretinoin.

Yeah, that stuff ain't cheap.

Yeah, no, I know, but it's. And there's newer generations that also have less side effects. But the traditional tretinoin works nicely, but a little bit goes a really long way. I mean, you can use one of those 45 gram tubes, can last you several months.

And do you put it all over your face?

Yes. The other myth.

So for guys. So someone like me who's got kind of a beard, am I also supposed to apply it over the bearded area?

I think that's tough to do. The nice thing, as someone who shaves every day, that area, when you're shaving it, you're basically giving yourself like a microdermabrasion. So you're mechanically abrading the surface layer of your skin, which also promotes skin turnover. So you're probably a little bit protected there, But I would apply it to your whole face and include your eyelids. A lot of people say, don't put on your eyes. There's a myth, I think, that you have skin on your eyes right on your eyelids. So that skin, if anything, it's more effective because that skin is thinner, so you might not use it as often there. But I close my eyes. I apply it to my upper lids. I apply it all the way up to the eyelash line.

So if we're going to do. We got two things in our toolkit so far. We're going to put sunscreen on it in the morning. We're going to put retinoic acid on at night. Is there anything else that you recommend as part of a kind of overall maintenance plan?

So, like, vitamin C would be the third part of the trifecta. Right. Vitamin C is also vitamin C, which.

Most people think of as like a vitamin you take to avoid getting colds, though that seems to be kind of bogus.

So topical vitamin C, and this one might be a little bit more controversial. I mean, it's. It's not thought to be controversial because every skincare line promotes their vitamin C. And the question is, what type of vitamin C is effective? But think about vitamin C deficiency, right? What happens to your skin?

Yeah, well, you get scurvy, you get collagen deficiency.

Right. So we know that lack of vitamin C is a problem for the way you look in your skin. If you're healthy. Does vitamin C help your skin? Well, we know it's a very powerful antioxidant, so it's scavenging free radicals, so it's protecting you from UV damage in that way. It also is a cofactor for collagen synthesis. It turns out it does work better if you have it with vitamin E. But here's the thing. A lot of the products that are out there, they oxidize. Vitamin C oxidizes very easily. And the L ascorbic acid, which is meant to be, it's thought to be the form that penetrates the best and is the most effective. Once it's penetrated, it needs to be stabilized. And so there's different patents that are developed by these companies and they sort of have these patent wars, like whose patent is better for vitamin C? And they try to protect their technology so other companies can use it. You'll find a lot of stuff out there. And if your vitamin C can oxidize over time in the bottle, that's why.

They always tend to. These things come in very dark bottles. Right?

Right. And you keep it in your cabinet. Sun damaged skin tends to have lower vitamin C levels and I think vitamin C is effective in those cases.

Why can't they just add vitamin C to sunscreen, for example?

I don't know if it interacts.

Well, isn't there something about iron that they put in this as well?

I think the one that you're thinking of, that product, which is the CE ferulic, so the C and the E we know are synergistic. The ferulic acid is just another antioxidant. So it's just another form of antioxidant that's added into the mix. But the issue is, and what I've seen in the literature is that if you're serum levels of vitamin C are high, then your skin doesn't absorb topical vitamin C very well. So we don't know if applying vitamin C topically is preventing you from developing sun damage. We know that if you already have sun damage that it helps to reverse it.

And you put this on in the morning or in the evening?

I typically do in the morning, but you could do two times a day. But I use vitamin C in the morning and I do retinol at night.

And then the sunscreen goes on top.

Of the vitamin C. But I don't want too many steps. If I tell you you need to do 10 things, you're going to stop doing all of them. But if you can do these three things, which I Think that's pretty easy. You just have to think about your C and your sunscreen in the morning and your vitamin A.

Do you have to separate the time between the sunscreen and the vitamin C so they don't interact?

I like the serums, the C serums. So I usually wait a couple minutes and when it's dry, then I apply my sunscreen and look, this isn't a universal plan for everybody. We all have different skin needs and, but in general, this is a pretty good plan for most people.

Yeah, if one does this kind of stuff right. They say, look, I'm going to put the effort into what I do with respect to sunscreen with topical vitamin C, retinol. As you, you know, you alluded to earlier, I'm going to take greater care to care for my skin by wearing a hat, that kind of thing. What percentage of the benefit is someone getting in terms of an anti aging regimen? Is that like half the battle right there?

It will go a really long way. I've had patients where we didn't touch them with a needle. It's been no surgery, it's just been recommendations and a directed skincare regimen. And look, I'm not a dermatologist, but a lot of what I do is skin care using these powerful basics. I've seen amazing changes. And so when you combine that sometimes with some other concerns, some directed treatments that, and it's synergistic, it's even better. It sounds simple, right. But it's powerful.

I mean, I think that makes sense. I guess anybody can do those things. You do need prescriptions for at least the retinol, but I think everything else you. But only for the prescription, Only for the high grade. Yeah. So kind of going back to something we talked about earlier. What are some of the trends that we're seeing now? I mean, we alluded to at least one of them, which is lips getting a little fuller. Botox has certainly been around for quite a while now. Are we seeing people using Botox in ways today that they weren't doing it 10 years ago?

Well, yeah, I mean, there's many more indications for Botox. We have non cosmetic indications. Bladder spasms, vocal cord spasms, torticollis, migraines, axillary hyperhidrosis. Botox is being used for so many different things. And I think we've developed a more nuanced approach to how we treat people with Botox. I hope so. I still see people, I even know Botox injectors that have these Spock brows. If you've seen that where you get the overarched Nicole Kidman sort of had that appearance for a little while. Not to say that she doesn't look good or I don't know anything about how she was injected or treated or not. But that look is often not desired, especially if you didn't have that look before. So I still see a lot of those what I would consider amateur mistakes or maybe just not. The field has progressed and most of us have kind of gone along with it, but there's sort of a pressure, I think, for a lot of physicians to move into the cosmetic realm because the world of insurance doesn't reimburse as well as it used to. And so we're seeing a lot of new providers in the marketplace and some of them have more experience than others. But we do have better ways of using Botox, using it in smaller amounts, spread out over a larger area. Using different facial muscles, we can turn up the outer corners of the mouth so you don't look like you're frowning as much. We can reduce a gummy smile by injecting above the lip. I can treat the lower eyelids so that you can look like your eyes are slightly more open. Or we can reduce some of the squinching wrinkles that happen under the eyes. There's a lot of ways that we can use this that we didn't use them 15 years ago or 10 years ago.

We've talked about some of this stuff in the past. And one of the things that I think I've taken away from those discussions is that. But if you're going to have this kind of stuff done, you really want the person who's doing it to understand the anatomy because you can see the wrinkle on the surface. But you have to understand that the wrinkle is the product of changes in musculature and connective tissue and fat. And I'm sure when you look at a face, you actually are almost doing so with X ray vision. Right. Like you're not. You're seeing beyond the skin. You're seeing everything that's underneath it. And knowing that, well, look, if I actually want to reduce that wrinkle, I don't necessarily inject into the wrinkle. I'm injecting obviously where the muscle is. Yeah.

And it's not just looking or understanding. It's also asking the patient to move. I say, okay, I want you to frown for me. And I can touch them. I can see where the muscle's pulling. And there's a variation in the way that we're built. And so your muscle might come up at an angle and might be different on the two different sides. So it's important, important to look at those little differences and to see what's happening, not just. And people say, look, I like to avoid a cookie cutter approach. Everything's personalized. It's easy to say that everyone markets themselves as like, oh, we offer personalized care. Right. Every doctor says that that's what they do. But do they, you know, are they really like giving personalized. I know in your practice you're giving personalized care because you're diving deep, right? And you're, you're looking at things. You're not just, you don't just call the lab and say, hey, give me a CBC and a Chem 7, and then I'll tell a patient what he needs to do. You're diving deep. And so that's truly personalized care. And when you're looking at a patient and if I have a fellow following me, I sort of have to answer to what, you know, that someone who's training, I sort of have to answer to him too, in terms of what I'm doing. And if he sees me or she sees me doing the same procedure in the same place in every patient, they're going to ask me, like, why did you do that same thing? You know, I don't, because. And I feel that scrutiny for myself as well, that your treatment is going to be different from the other person's because you look different and your body's different and your muscles are in different places and you have different concerns. I mean, so that's, that's what personalized treatment is. It's not just saying it on your website.

One of the things I get asked about a lot by patients, and this is why I'm really glad I know people like you, because I obviously don't know the answer to any of these questions is my friend got such and such a laser treatment on his or her skin, and I want to do that and all these different types of lasers and these things. Can you give us, like kind of the 101 on laser treatment for skin?

I think lasers are effective in many ways, right? And the lasers are getting better. The technology is getting better. This fractional technology. There's different types of energy. It's confusing, though, to consumers because you don't know, are you selecting a doctor? Are you selecting a device? Anyone can buy a laser. If you have a certain amount of money and you have a certain amount of patience and how much of the work is being done by the laser by itself. You just turn it on and it just happens. Or is it the provider selecting the right patients and changing the settings? So there's a lot of variables. There are some devices that doesn't matter who does it for the most part. Like the cryolipolysis. Coolsculpting. It's a device that suctions your fat and it freezes it at a certain temperature. And it uses an algorithm to figure out what temperature it needs to stay at for how long to adequately cause apoptosis of those fat cells. And so basically someone just has to say, okay, this is the area we're going to do it and they stick the machine on you. There's a little bit of understanding and training that goes into it, but once you turn it on, it's done right. You sit there and it happens and then you.

And is this coolsculpt procedure effective?

It's effective, yeah. And there are other ones too. There's other types of the sculpture. There's other devices that also effectively non surgically can reduce fat, but they don't require a lot of. It's not an operator dependent for the most part. Right. So you turn them on and they're good. And so you can probably go to most places and they'll do a good job for that.

There's a procedure where they use heat and then there's a procedure where they use use cold. What is more effective?

They're both effective. There's a lot of devices, but the two main leaders in the market are both effective and they're probably equally effective. They work in different amounts of time, but usually you get about 20, 20% of subcutaneous fat reduction with that course of treatment.

So if a person wants to take a little bit of fat off, presumably you do this on your belly or you can do it like in your.

Flanks, anywhere you can pinch fat, you can do it. Right. So it's subcutaneous fat. It's not visceral fat that's under the muscle, but it's the subcutaneous fat and it works well as long as you can apply the applicator. There are some limitations, but they both the main devices have FDA approval for nex as well. So those devices doesn't really matter so much about who's doing it. You want to go to a reputable place, you want to make sure it's the real device. There are like, there are Chinese knockoffs that are not FDA approved. So you want to get the real one. You know, you can go to. There's like coolsculpting is an FDA approved cryolipolysis device. But I've seen fat freeze or something and it's. And then you look into it and you say this wasn't even approved by the FDA for marketing.

So got it. So at least make sure you're going with an FDA approved procedure or device.

There are lasers that work on skin. There are lasers, yeah.

What are the skin laser like people talk about like getting their face lasered for skin. I've had a chemical peel once a little while ago I was really. I mean this has got to be. It's got to be about five or six years ago. I was amazed at two things. First of all, how quick and easy it was to. For this dermatologist to apply this stuff to my face. That's the first thing. The second thing that amazed me was how red I was for like five days and how I had to like lather myself up in aquaphor. And then third, I was just amazed at how many sunspots vanished.

Yeah, well, I mean that procedure can be very effective. Effective. There's lots of different types of peels. There's phenol peels which can have more risk but more benefit. In fact, for a phenol peel you have to be connected to an ekg. So you don't. So you're monitoring for arrhythmias. There are TCA peels which can be also equally strong. There's a lot of experience that goes into selecting the type of peel, how they're, how it's being applied, how many layers, what you're seeing. That that is a very operator dependent procedure.

So is there a chemical peel that you would say is if you were going to have one tomorrow that you would preference?

I wouldn't say that. I think it's. That's more of a depends on your skin type. There are certain things that are not safe for darker skin types. So that's a very specific treatment plan for each.

So what questions could people ask the provider to know that. That. Because really what you're saying is you have to rely on the provider judgment very heavily.

Very heavily. And you can get a burn and you can get a scar.

So how do you screen out for who the right person is?

Well, it's asking, you know, how many of these have you done? Can you show me examples and is this safe for my skin type and what are the risks? So chemical peels are essentially using an acid or a chemical to burn away the outer layer of your Skin, that's why you look so red. And they go at different depths depending on how many layers of chemical are being applied and what type of chemical and the strand strength. So I can use a 10% TCA peel on you, and you'll look slightly red and you'll, you know, look a little better. I can use a 35% and you'll, your skin will peel off like a snake. So there's a wide range and, and might not be safe for all skin types.

So let's look at me right now. I'm kind of a olive skin dude. I've probably got. I don't know where I would rank on the sun damage scale, but I.

I would say for you, either you're looking at a. Let's say you want to just do a skin rejuvenation. You want to look smoother, less wrinkles, improve texture and brown spots. So we would either talk about a chemical peel, like maybe a TCA peel of 20% and I might recommend three treatments, or we would talk about a laser. So the laser does the same thing that the chemicals do, except it's using energy to burn the surface. Most lasers today are fractional, meaning that they're not taking away everything like a peel would. Right. The liquid from the chemical peel is going to take off all of your skin, at least the outer layer, in a continuous fashion, whereas the fractional laser is creating dots and leaving some normal skin in between. So the most common lasers for resurfacing would be erbium and CO2, carbon dioxide. And again, within those, there's different levels and different energy settings. And certain patients are not candidates for those, and some are. So that relies heavily also on the experience of the provider. Now there are some very safe lasers that are very low grade, like a laser like clear and brilliant, Very low risk at causing a problem for most people. And doesn't always have to be a doctor performing the procedure. Depending on your state laws, can be an esthetician or a nurse.

And are these painful procedures? Do people need some sedation for them?

Usually no. I mean, it depends on your pain tolerance. The heavier duty lasers, the more powerful, are going to require some type of anesthetic, whether it's an injection, topical anesthesia, sometimes sedation. Often we do them in combination with surgery. So my patient's asleep while I'm lasering them. We're doing one thing and then we're lasering another. That is something where you need a consultation and someone to evaluate your skin type and say, okay, this is my recommendation. For you, based on my experience and my knowledge, my training. But there are also, I think, what you would also lump into that, that category would be the energy devices that are now becoming more rampant. And these are designed for facial rejuvenation in terms of tightening, not the skin surface. So the first generation, when things like thermage that use radio frequency or today CL therapy, which is a focused ultrasound, you're seeing more plasma devices. The idea is heat is stimulating collagen synthesis and contraction and tightening. And for the most part, I'm underwhelmed with these technologies. In a way it's almost like, you know, I kind of referred to like the emperor wears no clothes. Right. Where the doctor has invested a lot of money in this device and so they have some stake in it working whether it does or not. And the patient is investing a substantial amount of money potentially for them. And so you don't want to feel like you're a sucker and you've spent a lot of money on something that doesn't work. But you have to look at the before and after photos and if you have a hard time telling which is which, then you're not going to see a lot.

Is anybody doing anything with PRP in terms of facial rejuvenation? Prp, platelet rich plasma has obviously been achieved, you know, some success, although I think it is still somewhat questionable. But at least anecdotally, there are people who are certainly reporting success in the periphery, for example, treating orthopedic injuries with it.

And it started out, I think, in the dental realm for dry sockets. I mean, I think they sort of pioneered PRP in a lot of ways.

Oh, I didn't know that.

And I think, you know, here in New York, I feel like you can get PRP on every corner now it's become so widespread in medical spas and cosmetic practices because it's so accessible for providers to purchase.

And it's always autologous.

Yes, of course.

So what that means for people is it's your own, they take yours out, they spin it, they return it, versus aloe, which would mean you could use it from a donor. So what do people do in skin with this?

I think you probably feel the same way as me. Whenever there's something is like touted as, like a, as a cure all, you have to be a little bit skeptical. Right. Can PRP help your joint pain? And can it make your skin look smoother? And can it replace your hair? And is it going to heal all.

Your wounds, enhance your erections?

I know. So I think it's a nice thought to think that we have that the magic that we were looking for all these years was inside of us. Right? It's like. It's like the end of a Disney movie. But is it true? I mean, I'm skeptical. I've had PRP injected in my head, my scalp, for prevention of hair loss, and I'm underwhelmed. But I mean, think about. All right, so let's talk about, for hair loss, the mechanisms that are causing hair loss in men. The androgenic alopecia are still happening, right? Whether I do an injection or not. So how often are you going to have to do it? If, let's say it does work, right, you're creating. What does PRP do? I mean, there's. You're talking about the platelets in your blood, which are. What is their purpose? They're there to help with injuries, right? They clot, they send out signals saying, we have an injury here, so send more growth factors. Let's heal this injury. There's angiogenesis, neocollagenesis.

So let's explain those terms. So angiogenesis means recruiting more blood vessels, building neocolagen, more collagen.

We're trying to create a scaffolding and a framework to heal wound. So when you have a cut on your arm and your platelets go to that area and they create a clot.

They send out chemical signals to also do those other things.

So we do heal ourselves, right? And if you're an animal in the woods and you get a gash in your leg, then you'll get a clot there and it'll contract. And hopefully if you don't get infected, then you'll just have a scar. So for hair growth, if you inject it in your scalp, then I think there's probably a role for. The idea is that you're creating an environment that will help to stimulate the existing stem cells that lie within your hair follicles, maybe creating more blood flow to allow for more hair or prolong the cycle of hair growth. The hairs grow longer, so you have more of them and they become potentially thicker. But we still have the hormones of 5ht is still in that area, and it's still fighting in the opposite direction. So if you do have a benefit, and let's say you do three treatments a month apart and you look a little bit thicker, then how often do you have to repeat it? Like every four months or every three months or.

Wow, that's a lot of work.

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

And do you stratify by, you know, patients that are taking five alpha reductase inhibitors. So a drug like Propecia or Avodart that block the conversion of testosterone to dht, the hormone that's responsible for hair loss. And then you can also apply these topical things like Minoxidil.

Yeah, I mean, you can go all in and that probably is better. Or if you're having hair grafting, right, like transplants, then it's often done at the same time you do prp. So I think I haven't seen any negative to it other than sometimes I think it's ineffective. And I think it's one of those things also, like these skin tightening lasers, the facelift lasers, that I think it's oversold. And the same thing with facial rejuvenation. You know, it's very popular to do this thing called vampire facial.

What's that?

So that's taking the prp, which is your, you know, from your own blood. That's where the term came from. This was like a. I think it's probably like a Kardashian. How much.

How much blood do they need to do a PRP treatment?

Typically, if I'm so. And I offer this treatment, I don't oversell it, but I offer it in my practice. I'll draw, let's say 10 vials, 8cc vials, so a total of, let's say, 80ml and we spin it down. I do a double spin method and then we extract the platelets from. We separate it from the platelet poor plasma and the red blood cells and then we. I activate those platelets. That's also controversial. There's a lot of different methods of creating PRP and there's a lot of variety. And so that's one of the problems with the studies that are out there, that there's inconsistent methods and not everybody is also quantifying how much PRP are they collecting? Some doctors have counters in their offices and they can say, okay, this is the concentration I'm delivering. But there are different methods and so you don't know what you're getting. Some people are injecting platelet poor plasma and platelet rich plasma together and calling it prp, but it's not necessarily so.

If you're going to get PRP done, you should confirm that the person doing this has a way of counting the platelets.

Not necessarily. I think you just have to have a proven method of concentrating the platelets. They have to know exactly what they're doing.

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

So when, when I especially.

Because the platelet and the red blood cell are the same color.

Right.

So you can easily be confused by color contamination.

No, but you can see what the difference is when you spin this down.

Yeah, the density should separate.

The red blood cells are all. That bottom section is all red and I don't want any of that. But when I first started doing it, I, I did send the samples into the lab and we got an emergency call in the middle of the night. Your patient has super high platelets and. Oh, it's okay. We were just checking it, but I did quantify it initially. I don't quantify it every time time because I'm still using the same method. But then the question is, do you activate the platelets or do you just put them there and hope that they're going to activate?

And what do you activate them with?

You can usually use some form of calcium, like calcium gluconate or calcium chloride. And so you just, and you dilute.

The platelets obviously when you inject before you inject them, or do you inject them in that concentrated.

So I go from that 80cc of initial blood draw and I end up with about 8cc's total of PRP and.

That'S fully concentrated platelet.

There's a little bit of platelet poor plasma in there, but I've gotten rid of most of that platelet, poor plasma. So it's platelet suspended in plasma, but it's highly concentrated and many fold more than what you'd have in your serum. So the vampire facial, what we're doing is taking microneedling pen, which is a pen that has 12 needles at the tip that are surgical, small needles. And these are not reusable. They're per patient. So it's a sterile setting. This pen has a motor, and it's going up and down, driving the needles in and out of your skin. That sounds really pleasant at a selected depth. It actually doesn't hurt like you would think it does. You come in and I'll do it on you sometime. I might pass on that, but I can do it at a depth of a millimeter. I can do 1.5 millimeters, 2 millimeters. The deeper we go, the more you bleed. It doesn't hurt like you think. We numb you first with a topical anesthetic, but. But as you bleed from those channels, the face looks sort of bloody. And I think that's where the term vampire facial came. But then we're using the PRP on the surface, but also applying it as we're doing the needling to drive the PRP into those channels.

So this is a hollow bore or solid bore needle?

Solid bore needle.

A solid bore needle creates the trauma. And then how do you get the PRP into it?

So this is variable among doctors and providers, but you apply. You can apply it to the surface and then needle over it. The idea is that you're driving it into the channel. You can apply it to the channel and assume that it's going to absorb because you have now, like, more porosity. And you can also inject it directly under the skin like a filler. I'm not a major proponent of this procedure.

I mean, besides infection, what are the other big risks of this?

It's actually a pretty low risk procedure. I think the biggest risk is financial loss.

How much does this procedure cost?

I would say on average, it's about, you know, let's say 800 to $1,200. A treatment for the PRP. With the microneedling, you can spend a.

Lot of money trying to look good, huh?

Yeah. And, you know, it's recommended to do it every couple months or do it every six months. I mean, so I wouldn't say. I'm not saying I'm against this procedure, but I don't think it's well proven because, look, it's marketed for wrinkles, for acne, scarring, for hyperpigmentation, for anti aging most of the time. So again, look at the before and afters because everyone's going to put their best workout. So if you look at the before and afters that I've seen, like type in Instagram PRP facial or microneedling facial or PRP injections and look at the acne scarring pictures and it's very hard to find good results that are not the result of differences in lighting. Right. You have a, you have a shadowy picture before and then you have a front facing light in the after. And I would say the majority of the time any benefit that you're seeing is from that. There's some evidence, there's some evidence that it does help. And on a histologic level, yes, we're building collagen, but it has to be significant enough to be observable to the people around you. Otherwise, are we just like making ourselves feel better or are we just jumping onto the bandwagon or is it a money grab for a doctor's office? I mean, I'm not criticizing anyone for doing this, but I don't think it's been fully vetted. And so I think because it's a relatively safe procedure, I think it's. Overall, I don't think it's detrimental, but the results speak for themselves.

You know, is it safe to say then that these are three broad categories of facial rejuvenation? You've got the chemical peels where you're like physically applying a chemical to the skin and burning it. You've got the laser peels where you're fractionating and selectively burning. And then you've got this whole PRP vampire trick and microneedling.

There's radio frequency needles. I mean, there's a huge realm of devices and there's a lot of money in this industry. So there's definitely a drive that's motivated financially for companies to come out with the next thing and they have to sell the next thing to the doctor's office.

What is the typical FDA approval process? I mean, a drug typically takes takes more than 10 years to get approved.

It's not that lengthy. And it depends if there's a predicate device. So if there's something that's a similar energy, it's much easier and you can usually get it based on the previous device. A new device can take longer. You know, it depends, but it could be, it depends what it is. If there's an IRB study that's been already done, it could be six Months, it could be a year, it could be two years. But you also have to have an understanding that because something's FDA approved doesn't mean that it's effective, it just means that it's safe.

Yeah.

So there's lots of devices that I think are bogus and I see them all the time. And you, you have to look at what's really going on here. Is it that this industry needs to make more devices? And I hate to say that, like, I'm not trying to criticize my friends and my colleagues that are in the industry, but I think we do have to step back sometimes and look at this and say, who are we serving? You know, are we serving ourselves? Are we serving our patients? If I do a treatment on you and it's not that effective, are you going to come back to me? I mean, you might, but if I do it again and again and patients are walking, you know, that's not the foundation of my practice and hopefully it's not like that for everyone, but everyone has different motivations. And I would say I wouldn't do something on you that I wouldn't do on a family member. And hopefully that's how most people are. And it probably is. I think most physicians, most providers have good motivations, but it's not universal. And so I think, yeah, have to be careful. If you look for a device or a treatment, it's probably better to look for a provider that you trust than to look for the device. I mean, devices, you can find the same devices in most cosmetic offices. But how are they being used and who are they being offered to and are they being selective? I mean, there's a treatment that I do now that's called thread lifting. Right. It's a dissolving thread that has barbs in it. And we sort of lift the skin non surgically. And more than half the people that come in asking for it, I turn them away because I think they're not candidates. And I think it's effective in a very select group of people. And everyone else, I have to say, I'm sorry, but I don't want you to walk around saying that it did it and it didn't work.

So it's interesting, when I was in residency, I remember one of the attendings saying something that I never forgot, which was he said, you know, your reputation as a surgeon is going to be much more about the patients you choose not to operate on, the patients you choose to operate on.

Yeah, I think that's true.

I didn't really understand it. At the time, but it certainly has made sense later on down the line, which is effectively what you're saying. You know, if you. You only need a couple of times where you've done something on someone who shouldn't have had it done, and it can out outweigh the benefits of the, you know, the hundreds of people who responded.

Well, yeah, and those are the ones.

You stay awake thinking about, right? We stay awake thinking about the mistakes.

Yeah, it's true. And hopefully you learn from them. I mean, the other phrase that you hear a lot is like, to the hammer, the world's a nail. Right. And so how that applies to this field is when you go into someone's office, are they willing to refer you to somebody for something that they don't do or that they don't think that they're the best person to do? If someone comes to me and they want tattoo removal, I might have a laser that can do tattoo removal, but it's not the best one. If I'm not going to do it on my wife, then, and I'd rather, you know, I'm going to send her to my dermatologist friend that has the picosecond laser, then I'm not going to push you into that box. So I think you have to be wary, too, if you're looking for a solution, you have a problem and you want a solution and you go to somebody, are they giving you the solution they have? Are they giving you the solution that you need?

So that could be another good filtering question for patients, which is when you meet with a doctor, say, hey, doctor, so and so, what are the types of procedures you typically don't do? And you refer out, and depending on their honesty with that, you may get, you know, better insight into, you know, who they are.

Yeah. Or if there's a procedure, let's say there's a problem that you have and you say, what is your solution? And say, are there other solutions that are out there that you can discuss?

So then my area of interest, which is longevity, I spend a little bit of time, not a tremendous amount of time, but maybe 10% of my energy goes into thinking about the future. What are the step function changes? What are the things that are out there that are not a part of what I do today because they're not ready for prime time, or they're still very theoretical, but they're the things I want to keep enough tabs on because I hope that within the next decade or maybe beyond, they become relevant. What fits that description in your field? What are the things that maybe aren't ready for use yet but show promise?

It sort of makes me shudder to think about the future because I imagine myself 20 years from now, hopefully I'm still practicing, and I'm going to look back and think like, wow, we were in Plato's cave at that time. We were seeing the shadows on the wall and not seeing the true objects. Right? And I think we are, in a sense, right? I mean, what is. How limited is our understanding and the things that we. We don't know, that we don't know them yet. And so I think there are things, things that we're doing today that I don't fully understand, like things like fat grafting. I use it and I think there's some predictability to it, but we don't fully understand why it works and how it works. And I think some of that relates to the stem cells, the stem cell effect. And you hear a lot about stem cells being used for all types of medicine. And it's the same with cosmetic procedures. And I do some procedures.

I think of stem cells like, I think of Chevy Chase describing ball bearings. And Fletch, you know that scene when he's like, you know, that's all ball bearing. The guy's like, ball bearings. He's got all ball bearings nowadays. And it's like, that's like stem cells and ball bearings. It's just the same thing.

To me, it's the cure all. It's the PRP of the future, which.

Remains to be seen how viable it is. Right.

It's the PRP of today. I think, look, there's something there. We know there's something there. We just can't exactly understand. We can't put our finger quite on it. And there's some good science there now, but I think there's definitely going to be something. And I have colleagues, I have friends that are doing a lot of stem cell treatments, whether it's intravenous direct injections. I'm in a sense using nanofat as a stem cell. You know, the. But our fat is a rich source of stem cells.

Yeah. This is counterintuitive, isn't it? People have always considered fat to be a totally inert tissue, but it's actually an endocrine tissue.

That's true. Right. And then why are we going to bone marrow for stem cells when it's closer to the surface, it's right there and it's abundant in a lot of people. When I do procedures with fat grafting, and I'm thinking, hey, I'm injecting fat and these fat cells are making them look younger. But it might be that the fat cells are not. None of them might be none of.

The fat cells at all. It might be the adipokines or the.

Cytokines, maybe it's a combination. Or when I do what I call nanofat, which is the stromal vascular fraction or the soup that's in between the fat cells and now I inject that with the fat. Am I supporting my fat grafts with these factors? Maybe. I mean I'm seeing results and we sort of look at the literature which is limited and we look at large scale studies which are also limited. We're looking for answers in doing these things and we try to stay safe. But there's definitely a lot to learn when it comes to that particular area. Right. We know that. We look at other types of growth factors. I've seen some promise with fibroblast growth factor, which is also an injectable. I consider that a biologic therapy.

In FGF world, which is the abbreviation for fibrobuscular factor, we. There are so many numbers to them. Are you talking FGF21 or.

Well, this is something that's not even. It's not a proven in the US we don't have it here. There's been studies in Asia actually, I don't even know which version. I probably have it in my notes here because I haven't been able to do it.

But basically are they harvesting autologous FGF from an individual?

These are laboratory derived.

Got it. So they're basically making FGF as a growth factor and just injecting it.

Correct.

And is this done in Europe?

Europe, it's done in Asia.

And what's the indication?

Volumization, facial volumization. And it seems to have long lasting results.

So is the FDA evaluating this stuff now?

I'm not clear about that. I don't know, I haven't, I haven't heard of any studies. I don't know if anyone who's part of an irb, but it seems to hold some promise. I think customization, like what you do in your practice and you're going to get down to the specific gene level eventually and hopefully we'll be able to have a full map of everything and each person will know exactly what drug is going to work well for them and will be like that. I think with cosmetic procedures. How is your skin going to respond to this laser and what energy setting is appropriate for you versus this other person based on what your Genetic screening told us. I think that's definitely in the future. I think customization in terms of 3D printing, bioprinting. So let's say there's something you don't like. You want to change your ear. We'll probably be able to print ears. We'll be able to print organs. I mean, there's no question that bioprinting is in the future. And we'll be able to replace blood vessels, organs, skin.

That just seems so far out. I mean, as an interesting aside, I remember once being in your office and you showed me a bunch of surgical instruments that you designed yourself and had 3D printed and they were just perfect, right? It was like you knew exactly what you wanted. And you were like, well, this doesn't exist. I'll just make it right.

I mean, in the past, you would have to go to a manufacturer and you'd have to convince this industry person of what you want to make, right? Make a fab that they're going to say, well, how many people are going to buy this? And how useful. Well, I don't know. It's for me, it's useful for me. But then they're not going to make an injection mold for me based on, let's say, the 300 eyelid surgeon specialists in the country. That's a limited market. So with a 3D printer, I just draw what I want and I have it translated into a digital file and then I print it in a. There's a place in Long Island City, Queens, and they make it in stainless steel. And then it comes to my office and I'm using them every day and I've sent them out to my friends and that kind of thing. But we're in the future, we'll be able to make what we want. Imagine a box that is connected to your computer and whatever you can imagine will be in that box. And it doesn't have to be just like in silly. Like it doesn't have to be a hello Kitty made in plastic. It can be made out of multiple materials. And so you can have imagine your phone. I mean, I'm not trying to promote 3D printing and it's not. My practice isn't 3D printing, but let's say just you pay on Amazon and then you press the button and then it prints the phone in your box and then you have the new iPhone. I mean, I think that's conceivable in the future. I mean, it's easily conceivable. And so the same thing with organs. I think there's a big.

See, I didn't realize we could go beyond. I mean, I've certainly seen amazing things in 3D printing where you're dealing with something that's homogeneous, but a phone is like a completely heterogeneous thing.

Well, you can print circuits, you can print in different materials. Right. Now you can print in different thicknesses in rubbers. So you can have a soft rubber inside of a hard rubber. So you can print a. Let's say you can print a silicone breast implant. Right. And you can make it exactly your shape. So I would scan your body. Well, I don't know if you want a breast implant.

Yeah, I'll probably pass.

But maybe you want a pec implant, though, and I would scan your body.

Are you saying my peculiar, certain inferior, you just.

You can use a little bit of bulk? Okay, I know you did the Joe Rogan podcast, so maybe you're thinking it to be a little beefier.

Yeah, I take a lot of heat for looking too scrawny on that.

But I could scan your body.

Right.

With a 3D camera. I would probably get some CT scans of you as well. To look at your bone structure, we would design an implant that was. And you'd have, you know, maybe your left pack needs to be a little bit higher and your right one needs to be a little more projection. And it would fit your body exactly. And it would be, let's say, soft on the inside and a little firmer on the outside. So it feels like muscle. But when you press on it, it's kind of squishy like muscle. But why stop there? Why not just make it out of muscle cells? We'll create a scaffolding, and that scaffolding will populate with cells that we cultured from your muscle in a lab. And then we populated it onto the scaffolding and we grow it over a week or two. And then we just use a. A small incision and we implanted in you.

Yeah. It's interesting. When I was in medical school, my very first summer, the first lab I worked in was the lab of an ENT surgeon. And he was interested in growing septal chondrocytes. So taking these chondrocytes, these cartilage producing progenitor cells, and growing ears. And at the time, a very, very popular paper. By God, I'm trying to remember the name. It was Langer and Vacanti, two very famous guys in this space from MIT and Harvard.

And they grew the ear.

They grew the ear in the mouse. Yeah. And we had that picture up in Our lab and you know, we were trying to replicate. And of course, the challenge at the time was coming up with biodegradable scaffolds. Yeah, has that. And of course, I haven't paid attention to this problem in 20 years, but.

Well, there are scaffolds now. There's people that are printing blood vessels. Look. But I think it's a big regulatory obstacle. I think for me, when. But what I was always interested in was printing in materials that are already approved, like silicone. And I think the living cell printing will be there. But think about the regulation of if you're in the operating room and you want your tissue printing device, you have to approve it for every indication. So you have to approve it for making this thing, for this procedure. And you have to. It's like an endless permutation. So the FDA now is looking at. At 3D printing and they do have new guidelines in regard to that. And they're recognizing that this is the future and that medical 3D printing is growing, but it's definitely going to happen. There's been use of 3D printed implants in University of Michigan for infants with tracheomalacia. It's actually considered to be 4D printing because these implants change over time. So the implants can grow with the patient and eventually can reabsorb. But someone with a baby with a narrow trachea, they were building 3D printed cages and suturing the trachea to the cage to hold it open externally. And then as the patient grows, the cage enlarges and then eventually it can absorb.

So the application here goes far beyond cosmetic surgery.

And it will be unbelievable. And I mean, it is believable to me, but I can talk about it for another two hours. It's just. It's mind blowing and it's exciting and it's frustrating because I want the next step and we're. It takes money, it takes time, and it takes people that are interested. But if somebody's listening and wants to talk to me about developing 3D printed materials for surgical procedures, I mean, I have something specific in mind. I've been trying to do that for a while. I've. I have non disclosures with a lot of large companies, but it's hard to get someone to, to invest money in something that doesn't give you a return in the next two years. Right. That's one of the, I think, the struggles.

Well, speaking of people contacting you, I follow you on Instagram because I just love looking at your before after photos and how can people follow you? What's the best way to follow you?

So on Instagram, it's Rkotlus C R K O T L U S. You can look me up on my website. I have some videos and procedures.

And what's your URL?

It's drcotlus.com d r k o t l u s. But yeah, I share a lot of my stuff on Instagram. I think that's kind of fun because people can give me feedback and I've seen my audience grow. And I'm following you on Instagram too, with your race cars and your nonsense. It's fun. I think Instagram has connected me with a lot of people that I probably wouldn't have met otherwise. I mean, the Internet and social media has. Has made the world a smaller place in a way. Look, there's a lot of garbage to wade through, but it's not all bad.

I don't think there's anything I do clinically that is really relevant to Instagram.

Well, it's not visual, but it is. Right. I mean, I think people are interested in seeing what you're doing in your day. I'm interested in your routines. I'm interested in like, oh, what is he eating? What is that indwelling device that you have that's measuring your blood glucose? Or what's going on in your lab? You posted that picture on your white whiteboard of your, like, it looked like your Einstein theories of longevity. I mean, it's actually very poignant breakdown of your longevity approach. And I've seen you working on the whiteboard. So I'm imagining you writing that and sort of like constructing your book that everyone's waiting for. But I think people are looking for insight into your life and into your philosophy. And it doesn't have to be. I mean, for me, it's a little bit easier, maybe because I can show a before and after, but that's not. I think the before and after is not the important thing. The important thing is, like, the story behind the before and after. Like, this is a teacher, and she came to me because she was recently divorced and she's thinking about finding a new partner maybe, or maybe just feeling better about herself because she's surrounded by younger teachers. Like, those kind of stories to me are the powerful things. And what's important, like, what I love about what I do is that people bring me into their lives in the. In many ways, not just for an injection, but to tell me about why they want to do it.

Yeah. You have a video on your website that you produced. Right?

Right. Yeah. So that was just, I think, trying to convey my philosophy in a way that I thought was more powerful about the stories of people who are seeking my help or my advice. And so I'm always thinking about the next one. I think I could do it better, but that was a fun project.

Well, Brett, I can't thank you enough for this. I've learned a lot from you over the last couple of years and I.

Feel the same way.

But I appreciate you taking the time to sit down today. I hope that people get something out of this. And again, it could be as extreme as they know that they want to do some of these procedures and now they feel armed to scrutinize the providers out there and make sure they're getting the best care possible. And alternatively it may be I don't want to do any of that stuff, but boy, if I can just do these three things, put my sunscreen on, use some retinoic acid, and maybe a little tiny topical vitamin C, that's going to make a ten year delta.

Well, thank you for inviting me to do this and for leading the way for many of us in terms of searching for the answers and also sharing those answers.

It's great to see you and we'll continue this discussion, I'm sure. All right, see you. You can find all of this information and more@peterattiamd.com podcast there you'll find the show notes, readings and links related to this episode. You can also find my blog and the Nerd safari@peterattiamd.com what's a nerd Safari, you ask? Just click on the link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my subjectively non lame once a week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, etc. On social media. You can find me on Twitter, Instagram and Facebook, all with the id PeterAttiyamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice and note no doctor patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice diagnoses or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have, and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and and or Advise, please visit peterattiamd.com forward slash about.