More Treatments Do Not Mean Better Results

So today's episode is with the brilliant and so good at educating Dr. Prem Tripathi. He is a physician, double board certified in facial plastic and reconstructive surgery, and the founder of Bay Hills Plastic Surgery in the San Francisco Bay Area. He's passionate about helping people feel confident through natural looking facial rejuvenation and personalized care that blends artistry with advanced surgical experience. You guys have heard me speak about him. He did my under-eye fat transfer and a laser, and I just love him. He's awesome. If you don't follow him on social media, you absolutely should because he's a wealth of knowledge. So I'll be sure to link his socials here. We are talking all things surgery, in-office procedures, skincare. Everything. So let's dig in.

So, Dr. Tripathi, thank you so much for taking the time being here with me today. So many of my listeners have already heard about me talk about you on previous podcast episodes, but I'm so excited to share your awesomeness with my listeners and the world. So thanks for being here.

Of course. Thank you so much for having me.

Yeah. So I want to cover all the topics of curiosity today, from surgeries to hip new trends to skincare, what people can do at home, literally all the things. I kind of wanted to start with a little bit of tell me what you're seeing in the industry that's headed in the right direction and tell me what you're seeing in the industry that's headed in the wrong direction.

Okay. Yeah. So thanks for having me. I think the trends in aesthetics are a little crazy, to be honest. Like, I'm, I'm sure you probably noticed the things that have headed in the— have sort of been in the wrong direction but are kind of heading in the right direction is regulation. So aesthetics is totally gray area, right? You can kind of market yourself as like a beauty practice and get around a lot of the regulations and it's legal. So in almost every state you can operate independently as a practice that is sort of gray area. But luckily things are changing and that is because of patient safety. There have been so many complications related to unlicensed practitioners, to facilities that didn't have the right equipment to help somebody with a complication. So that's all changing. And I think in the next few years that will change quite a bit. and that also goes down to some of the unregulated things that people are putting in other people's bodies, right? Not FDA regulated, which it has pluses and minuses, but also can come with some complications. So I'm glad to see that there's some increased regulation. I think the things that tend to be a little scary still is that you don't exactly know who's doing your treatment. So, you know, you can having a practitioner that took a weekend course that is still able to do your treatment and it's filler, right? Something that could blind you or a laser that could permanently burn you. And there's no law that prevents them from doing that. So that I think is still going to be an issue because as you know, like in healthcare, it's very hard to change licenses. It's very hard to regulate a license.

Absolutely. We see that too. I mean, it's so fascinating. I think with the evolution of social media as well. We just get all this information, expert advice from all these different areas. And it's really hard to differentiate even sometimes who's an actual doctor, like an MD, who is a chiropractor. And so I think that bleeds over the same constructs into aesthetics, which you're so right. I would say the vast majority of people who go to an aesthetics practice are seeing probably an esthetician, an injector, not a healthcare professional. Right. Et cetera.

Oh yeah, absolutely. And somebody that may not know how to manage a complication, which is the scariest part.

Oh yeah. I didn't even think about that.

Yeah.

Recognize it early enough to intervene, probably.

Yeah. And those are the ones that come to me because, right, something happened, they didn't know what was gonna happen and that person didn't recognize it. I always say like anybody can inject, right? You can push a syringe. It's not hard. It doesn't take that much skill. But it's the complication recognition that's the main issue.

Yeah. That's kind of why people think I'm a little crazy when I fly out to San Francisco to go to your office. And people are like, why are you doing this? I'm like, listen, like I'm in really good hands. It's worth taking a day for me. I'll fly there, I'll fly home. It's not a big deal.

I appreciate that.

Tell me in the same line of conversation, so when people are looking for a practice for aesthetic treatments or surgeons, tell me what would your advice be to them? Kind of guide them in the right direction to land in the hands of the right clinician, surgeon, et cetera?

Yeah, I think the bare minimum is just a specialty training in what you're going after, right? So, I mean, you'll see cosmetic surgeon, you'll see board-certified surgeon, but there's a lot of sort of resume padding and trying to trick the consumer into knowing, okay, they might be board-certified in sleep medicine, not in surgery. And I think people don't know that by law, any physician in the United States can practice anything that they feel comfortable with and it's fine. So they won't get hospital privileges to do surgery, but you know, your psychiatrist could do a bleph in the office and there is no law to prevent them from doing that. So I think the bare minimum is just board certification in the field that you're looking after. And then, you know, from there it actually gets a lot simpler talking to patients that have had the same procedure because the office should be able to give you that. Looking at the before and afters, meeting them virtually and in person if you can. All of those things are more of a vibe check, but the credentials part is, it, it can be tricky, but it's worth taking that extra step because even though there are laws to prevent, you know, false advertisement, people get around it all the time.

Yeah, no, absolutely. I see that commonly. So people are looking for a board-certified facial plastic surgeon, a board-certified plastic surgeon, just to be clear.

Exactly. Yes. And there are also board-certified oculoplastic surgeons. But in general, those are the three specialties that are, you know, they have a dedicated board, which means that we had to do residency training, fellowship training, and then take the associated exams. There are boards in other things that are sort of like you take a weekend course and you can get board certified. But those surgical subspecialties are distinct, specifically plastic surgery. They tend to be, you know, they're the longest one that's been around, so they are pretty rigorous. And the other part I think is also seeing if that person that does your surgery does a lot of the same thing, right? You could be a board-certified plastic surgeon and do one rhinoplasty a year. Probably not going to do as well as somebody who's doing 10 a month.

Yeah. Since we're talking about surgery, let's continue in this line of conversation. I would love for— I've heard you speak about this. This isn't a pop quiz, but I know that you've seen trends in the surgical sphere.

Yeah.

Last year, the last few years, and now you're seeing almost new trends to fix those.

Yeah.

That kind of aligns with my own personal story.

Sure.

I'd love for you to share a little bit about what you've seen over the past few years become pretty common, and then what you feel like things are evolving to, to either fix or just the next trend.

Yeah, I think everyone's sort of imminently aware of filler being like a bad thing nowadays, and it's not. But I think there was this huge push for filler. Everyone was getting filled, and if you had good work, you were almost lucky. And lots of people were just getting botched and overfilled. And so the trend in the last year and a half, 2 years is dissolving everything, restarting, or just going to something more natural like Sculptra or fat. So in my office, I think we probably do 10% injectables or fillers. The rest is a biosimulator or fat injections. And that is twofold, right? It, like you said, it does kind of correct some of the issues that people had with filler migration or just unhappy result. But it's also just a better, a better option to do fat grafting. You can use it almost anywhere. It helps skin quality last longer. So that is a huge trend. But The other thing that people, I think, are catching on to is that these aesthetic trends follow beauty trends. So, you know, we're not like— we're not in 2016, we're in 2026 where people are really going after that more natural aesthetic, both in, in plastic surgery. So people want a dramatic result, but they want it to look very, very undetectable. And that is, I think, resonating with people now. It just— the pendulum has swung so much in favor of dramatic but natural. So you see it in before and after, but you don't see it in person.

I love that.

Yeah.

And talk to me too about blephs. So my journey was I got a bleph, I got an upper and lower bleph. Love my upper bleph for the most part. My lower bleph had pros and cons and it left me like really, really hollow. I honestly didn't wanna like look in the mirror. It was so sad. I was like, I literally don't look at like myself when I look in the mirror. Yeah. And so originally the kind of aftermath of that is why I came to see you. Do you see that happen quite often? Talk to me about what can go wrong and how people can fix it, that kind of thing.

Yeah. So, you know, lower blepharoplasty specifically is, is a pretty challenging procedure because it is very patient dependent. You know, upper blepharoplasty for compared to lowers is a lot easier. I mean, there's, there is a variability, but it is a much more straightforward procedure. Lowers involve manipulation of fat pads. So we're trying to either move them around, we're trying to either take some of it out, you know, you could end up super hollow like you did. You could end up very puffy and still have a bag. So it's a really— it's sort of like a, a fine balance. In my practice, I do all my surgeries through the eyelid, so there's really no external scar, which is pretty common nowadays. But for most patients, I will move that bag down into the cheek rather than remove it. So because 10, 15 years ago, all surgery was reductive, taking fat pads out, we realized that patients were just getting hollowed out and it wasn't like you would trade one problem for another. You trade not having a bag for looking older, and that wasn't the goal. So I think the goal now is how do we just make that transition between the lower eyelid and the cheek look better? And for me, all of my patients, regardless of what I do, get a fat graft with that lower bleph. So I think it almost is like a, you know, added insurance policy in case too much fat is removed or not enough is taken out and it smooths things out. Well, look, I think all of us in the field have had a patient like you, right? We've all had a patient that we took too much fat out on or they hollowed out. So I, you know, I'm not an exception. I've definitely had patients like that, but it is a lot more challenging because lower blephs have so many more complications other than the hollowing. You can get your eyelid everted, you could have dry eyes for forever. So you really have to go to someone that just does this every single day or every week.

Yeah. And talk to me about the process of fat grafting, because some— for some people that might be a little bit foreign.

Sure.

Also have somewhat of a unique approach to that in terms of what you put in and all of that. But I'd love for you to take people through the process.

Sure. So, you know, fat grafting is basically harvesting your own fat cells, which have the benefit of having stem cells and growth factors already in them that are not foreign to you. They're your— they're your own. And, and processing them and putting them in areas of your face that you would maybe have lost some volume in, or you've lost some collagen, or even just the areas have become dark because fat is yellow. It can make the areas look brighter. So a lot of my patients opt to do this in the office if they're not doing, you know, other procedures that require anesthesia. So we will locally inject, put some numbing medication on their legs or their belly or thighs and remove some fat. And then the way I process the fat is I chop up the fat particles in multiple different ways depending on where I put the fat. And I will also add other lab-sourced growth factors. And for me, the benefit of that is not just skin quality improvement, but I really believe that that helps the fat last longer because I've taken some of your— a chance with your own growth factors, which are variable based on your age. And then I've removed some of the variability by adding a, a large amount of growth factors that you know, are safe for you. So in doing that, I can add fat then back into your face, in your temples, under your eyes, in your cheeks, around your mouth, your forehead. Lots of places where either filler can be dangerous, filler can migrate, and fat just doesn't have that, you know, propensity. Even if it does move around a little bit, it's not going to be noticeable. Fat is not all going to take. So some of it will take and some of it won't. But I also think the body kind of figures it out. I've never done a fat graft, and I do probably 3 to 5 a week. I've never done one where I felt somebody looked overfilled. Definitely have some where patients need a touch-up like you. We know you did a touch-up. And that's why all my patients are offered a touch-up, because I don't want them to worry about that possibility. But it is just such a more natural, nicer result. You're— you either come in once, maybe twice if you need the touch-up. You don't have to worry about that migration aspect, but it is a semi-surgical procedure. So on the flip side, you know, it is a semi-surgical procedure. There obviously are risks. I would argue that the risks are lower than they are with filler, but filler is just done more widely and they can be done by a lot more people. So it's still much more common than fat grafting. But if it were up to me, I would opt for the fat option.

Yeah. And I love to— like, I appreciated so much that I could go in, not be put under anesthesia. That was really nice for me. It's strange, like anesthesia wrecks me for a little while. Yeah. The older I get, the harder it is. And so not having to deal with that was a big thing too, which I loved. And I felt like the recovery was wildly mild. Like, I've seen—

Good.

I share this with you. Like, I've seen fat transfers online that for like 3 months people look crazy and swollen. And I know everyone's different, but normally I am the swollen person. I am the water retention person.

Yeah.

And I'm the puffy girl in the room. And I had none of that. Like, I, Could have worn concealer the next day and no one would've known what happened. It was wild.

Yeah, I do think that's a really nice benefit of it. I have obviously had patients that are swollen for a little longer, but I think even then at a week out, their swelling that they notice is less obvious than other people. But yeah, it's such a nice thing. If you don't bruise from it, the downtime is so minimal. And I don't, I don't downplay that. It's comfortable, but it's not the most comfortable thing you're gonna do, right? But at the same time, I do think, you know, it is leaps and bounds more effective and better than filler. And it is nice to not have anesthesia for it.

Yeah, absolutely. Okay. I had one follow-up question to that and I can't remember it, so I might circle back. Oh yeah. Where do you use filler? Like you said, hey, I use filler in a couple specific locations.

Yeah.

Or every once in a while. Is it determined by location? Is it determined obviously per patient? Curious about that.

Yeah. So definitely both of those. I think obviously it's easier to do filler. So if somebody is short on time or doesn't want to go through the option, then of course filler. But I don't love fat in the lips, for example. I do think it does sort of the same thing as fat and fat and filler do the similar thing is that you're plumping up the lips. Fat doesn't migrate like filler does. But I do think if you're going for a more natural look, I just don't see a benefit of fat necessarily. And along the jawline, for me, most jawlines are built to be a bit more etched, be a bit more shaped. So I like to use a more firm filler that is more similar to bone. It still dissolves with time, but it creates more of that edge shape along the jawline. But honestly, I know lots of practitioners that do it— you do fat along the jawline and love it and they get great results. So I love the filler option for the jawline. I just think it looks so, so good. So it's not one that I love in that area, but maybe I will one day.

I love it.

Yeah.

Okay, so let's move to like in-office procedures and chat about that. Tell me about some of your favorite in-office procedures that you offer and indications why people would use them.

Yeah, I think the most impactful procedure in my opinion for that you can do in the office or just in general is an upper blepharoplasty, right? It's removing some skin, some fat, modifying the muscle a little bit, and just making your eyes look brighter in the office. It can be done in, say, 30 minutes or so, sometimes a little bit longer. The downtime's maybe a week to a week and a half. The stitches come out. You could put makeup on. Most, I would say 99% of people say they wish they had done it earlier rather than waited for it. It's, you know, you don't need anesthesia. It's just very straightforward for the most part. Obviously, every patient's unique and you have to tailor it properly. But it is a very high satisfaction procedure. I would say the vast majority of my patients that do this procedure, especially ones that travel, will pair it with something like fat and a laser because now you're just, you're modifying a few different other things. You're optimizing your result and things can again all be done in the office. So fat and upper blephs I think are some of the best. But you know, I do chin implants, I do skin pinches for the under eyes. I will do, you know, small things like that in the office. And again, it's pretty comfortable. Even ptosis repair can be done in the office without anesthesia.

I love that. Yeah. Talk with me a little bit because I've heard you touch on this and I haven't gotten to speak with you about it myself. Talk to me about how you feel about ZERF.

Yeah. So it's—

I should say too, in case.

Yeah, ZERF is— it's sort of like taking over the market right now. So it is a radiofrequency skin tightening device. So radiofrequency is just a type of energy that's delivered into the skin. And it can be delivered at multiple different depths. So that's kind of the benefit of XRF is you can target the skin and you can target the lower area. So the SMAS, which is the network of muscle and tissue underneath the skin in the face, it can be done on the face and neck. They advertise it— I don't know if you've had it, but they advertise it as sort of like minimal downtime, no pain. And it does look like something that from what I've seen, it doesn't look like patients are just, you know, uncomfortable. It doesn't look like they have downtime at all. Honestly, they look better coming out of the office. But I think to me, that's probably the only main benefit at this time because I still don't think that heating up the SMAS layer, the layer that you truly manipulate during a facelift, should be heated. We don't tighten, we don't heat that layer up. When you heat something up, you almost deflate that area. So I'm not a firm believer in doing that. Maybe once or twice in your life, probably is not going to be a huge issue. But over time, continuing to do that treatment in my opinion, just sort of contracting the very layer that you're trying to preserve during a facelift and serve in your life. So I like that it is not painful because other options like Morpheus Ultra, those are painful. And, you know, I've done them myself and I told myself I'd never do it again because it was so painful. So I think that's the huge issue now is that people like it. I don't think it is a replacement for a lift and I don't think people should be advertising that way.

So.

You got to know what you're going to get when you try something minimally invasive and you can't expect a surgical result with something minimally invasive.

But you could theoretically maybe increase a small percentage and then you do need to be careful about repeat usage if you think you'll have a facelift later, right?

Yeah. So I do think like especially after a lift, great option, right? You just sort of help maintain some of the result, especially with the skin once or twice in your life. I can't imagine it's going to be that detrimental. But I will say, you know, through the years we have seen this happen before. We've seen devices that promise really great results that have some, if they're used for the right indication, and we've seen the issues during surgery when we open up the face for patients that have had these repeated treatments, right? I think now 85% of my patients have had some nonsurgical treatment, and I can tell that either they're scarred or it's harder to get through a tissue layer. Or I had one recently where she had had so many that the blood supply was compromised to that area. So now you're saying, well, I mean, you're frying blood vessels, so how are you gonna heal the best way possible if now your blood vessels are thinned out? Right? So I do think we're gonna see the same issue with XRF or the same issue with the next thing that comes out. But now that you have social media and things spread rapidly, you go from having 100 patients that maybe do it a day to 1,000. And it, it's going to be the same thing soon, but I don't think that it should necessarily alarm the consumer. It just needs to be another thing that you think about what your eventual goal is. I tell all my patients like, don't focus on the device. Like I can guide you through that, right? You don't tell your cardiologist how many milligrams of your, you know, medication to give. That's up to the provider. But tell me what your ultimate goal is. Like, do you want an etched out jawline? Do you want this to last 10 years? If that's the case, then we got to do what it takes. Like, the dream costs what it costs.

Yeah, no, I agree. And it's the long game. And I think we're in an era of quick wins.

Yeah.

That potentially compromise the long game.

Totally.

Is Softwave the same? Because that's the other thing I hear a lot about.

Good question. You know, Softwave, it is a little different. So Softwave, the benefit is that it's not getting into that deeper layer. You are heating up the dermis, so it will get to the dermis. Which can and can't have its own issues. But the nice thing is that you're not targeting this mass layer. So I personally have done software. I didn't notice much of a difference, but I think there are patients that really swear by it. You may, with continued use, also have the same issue with blood supply, in my opinion, because again, you're heating things up. But I don't see the same issue with that as I would with something like Ulthera or Zerv. And again, I don't— I don't have any affiliation with these brands, but I also don't want to tell people not to do it because, of course, you have your choice of what you could do. I just think that the consumer needs to be aware of the goods and bads. Right. And every patient, all of your patients get the risk-benefit discussion, right? The anesthetics, it— the waters get a little muddy because people think that we're doing it specifically for, for profit. And so we're trying to push a device on you. But any good provider is going to, you know, have your best interests at heart. And so it is— it does require that conversation.

Good information. Talk to me too, like when we're thinking about what we can do now as women in like our 40s, maybe 50s, knowing like I know eventually I will have a facelift. I will.

Sure.

I'll do it. I'm that girl, right? So I do think about what can I do now that will preserve the potential of that supportive, you know, surgical intervention later. Yeah. And I hear also about Sculptra compromising the ability to later have a facelift. So I'd love for you to weigh in on that and then compare to something like Xerf or Softwave, how they interact at a level of facelift compromise.

Sure. So I think some of the easiest things you can do at home, which is I think probably the vast majority of what your, your listeners are doing, is sunscreen. And I know it sounds like, you know, a broken record, but sunscreen truly is the easiest thing you can do. Because you're preserving that collagen degradation. And when you preserve that collagen degradation, your results are going to be so much better. The— your— the need for a facelift down the line will likely be staved off by having consistent sunscreen use. So maintaining a good skincare routine where you're producing collagen with things like vitamin C and retinoids and just being super diligent with sunscreen, easiest thing you can do at home, probably the most cost effective. There are some other nice preventative treatments. I think Botox is just helping you prevent lines from getting deeper. And so again, your facelift results are going to look better. You're not— you know, you're not making it more difficult to have that procedure in the future. And then any surface-level treatments, lasers, surface-level microneedling, these will all help prevent, preserve, and help take you into the next few decades of your life. The thing about Sculptra— so Sculptra is an injection. It's almost like just a bunch of cut-up suture that we inject into the face. And it helps stimulate collagen. So it's great. Collagen production is great. I think we're a little sort of biased in that that's all people talk about is collagen production. It's one piece of the puzzle. But we're, you know, you're just sort of shifting that balance and degrading collagen for a little bit more production. But you will at some point likely shift the balance into scar tissue. And Sculptra is an injection, so it's blind, meaning that it can be injected in any tissue plane. Without necessarily that person knowing where it's injected. And, you know, I hate to use the word make it impossible. I don't think it's ever been impossible to do a facelift in a patient that's had any of these treatments, but it does make it harder for your surgeon. And if it's harder for your surgeon from the standpoint of more scar tissue, that puts you at more risk of a complication or at more risk for not having the optimal result. So deep plane facelifts, which is what I do, if you're— scarred in the area between the SMAS layer and the facial nerve, the nerve that controls your face, then that is going to be harder to peel away from the areas where we want to preserve. So I don't want to get anywhere near your facial nerves. I want to preserve them, keep them down, keep them out of the way. And that is a nice plane to go through. When you have stuff that is like melting layers together, it can be more challenging, just like having had another facelift. If you have another facelift, it's more scar tissue. So I do think that is something that consumers need to keep in mind is when you repeat things like collagen biostimulators or heat-based treatments, you may not make it impossible. I don't think I've had a patient where it was impossible, and I don't think most surgeons will say it's impossible. But when you get to a point where it is now hard to peel away layers that should be peeled away easily, it will— it will compromise your result in the long term.

Mm-hmm.

So that is something that people just need to kind of keep in mind. Did I answer everything?

You did. Compare Sculptra to like Xerth. Tell me when you feel like could be harder for facelift future. Yeah.

You know, Sculptra is really nice because it produces collagen. It creates almost like a scaffold under your skin. Your body fills it in with collagen and then the scaffold kind of goes away. That's the idea. The potential downside is that it does create some inflammation and that is how that collagen is produced. It signals your cells to make collagen. You get some of your own and you can do that, you know, forever. The other downside, and when you compare it to ZERF, is that ZERF is very, a little bit more tunable. So you can tell to a certain degree which layer that energy is being delivered into. Sculptra, you can, based on feel, kind of tell where you're delivering the Sculptra, but that doesn't mean it's not going to get into other areas. And if you push a little harder, that needle is going to go through an area where you don't want want to be in terms of putting that Sculptra. So I do think both have the issue in long term making it harder and they have their risks and benefits. But I also think that for the average consumer, even for the average injector, it is very hard to— for them to say, well, I'm going to be in the right layer so you don't have to worry about it because these are theoretically blind procedures, right? They're very dependent on the user, the person delivering the treatment. Yeah. It is a push device. And if you push too hard or not hard enough, there are risks.

And then you go back to the person who's administering it, right?

Yeah.

So many people can administer both of those things.

Totally.

Yeah.

That's the other thing is there are indications for all this, right? There is an indication for Botox, for Sculptra, for Zerf. But that is when you see patients unhappy is when that is spilled over into people that aren't good candidates, just like Kybella, right? Kybella was designed for people with a very small bit of fat underneath their chin. Now you're seeing people that have turkey necks getting Kybella, and so they're going to be unhappy. They're going to have complications. And I see those 2 to 3 times a week. So because it's so easy to do, anyone can shoot a needle. Right. So when you increase that indication to people where it's not indicated, you're gonna see a lot of complications. You're gonna see a lot of people that are not happy and then they've sort of made it difficult for their future journey.

Yeah. So true. Okay. We're gonna shift a little bit.

Mm-hmm.

If someone has a week of downtime, 7 to 10 days, they're mid-forties, mid-fifties, somewhere around there and they want to show up to an event, look really, really refreshed, put together even. What would you say?

I would say the easiest thing is some toxin and a laser, only because your makeup is going to sit better having done a laser, right? The skin is going to be fresh. You're not going to have as noticeable pores. The top layer is taken off. You're just going to look brighter, tighter, just more awake. If you have just a few more days and you know you're going to wear makeup, I think a bleph is great if you meet the criteria. Everybody's looking right at your eyes and that's where most of your makeup is focused. That's where everybody's going to first thing they're going to see. And when that hooding is taken off the lash line, it is a subjective thing that people see when they look at you that they can't put their finger on, but they know that you look more awake. It just looks like you got a full night of sleep, which is what I think most people want. My wife had a bleph done a few years ago and I was like, really? Like, okay. Like, I don't— sounds good. I mean, it's your body. and I can't— I mean, it's so shocking how much the difference is. And this is coming from someone that does it every day. I thought, okay, yeah, sure. But it was dramatic. And again, maybe a week of downtime could put makeup on pretty easily after and not, not noticeable. Then when you move into other things, I mean, fat grafting too is on that. But when you move into other things, you'll need a little more downtime.

Tell me about like 3 months. If someone had the ability to like do a regimen for 3 months, Now prepare for an event. What would you say?

So I tell people that most surgical procedures, 2 to 3 weeks till you're there, 2 or so weeks till you're presentable and 3 months till you look your absolute best. So if you have a wedding coming up, I wouldn't do it before that 3-month mark. But if you really are, you know, I have a lot of patients whose kids are getting married and they want to look best. So a full face rejuvenation sounds outrageous. But you don't need a ton of downtime to do the facelift and the eyes and the skin. You need probably 3 weeks, 2 to 3 weeks of social downtime. And I usually let patients work out within that first 10 days, but it's social downtime. So if everyone in your circle knows you're getting it done, there's almost no downtime at all. But at the 2 to 3 month mark, you're really going to shine. I mean, the swelling mostly has come down, skin is going to look tighter and brighter. And what I tell people is focus on what bugs you, focus on what bothers you. But at the same time, everything on the face ages together. So when it's all treated together, you're going to look your best. If you're focused on non-surgical, which I think is also great, you know, maybe you're on your— just a journey to get your skin looking its best, then a nice skin treatment plan where you do 3 lasers back to back, your skin is prepped really well with skincare, and then you're doing some maintenance after also can be huge. I mean, you can in that time significantly improve brown spots, redness, texture, pores. because at the 3-month mark you're getting quite a bit of collagen production too. So you're setting yourself up for the best possible results at that 3-month mark. And there's no question.

I love it. Tell me what laser you're thinking about in that situation.

So it depends on the skin type, obviously. But if you're light-skinned like you and you can use any laser, I like combination treatments. I will use broadband light to help with pigment redness. I will use some more aggressive laser like HALO or TRL, which is the laser I used on you. That's a fully ablative laser, meaning it You know, you're mowing the lawn, you're not coring the lawn. And even though the downtime is a little annoying in terms of redness and peeling, the result is that much better. And I think people are under this assumption that CO2 is sort of like the best thing out there. And CO2 is great, but CO2 does cause quite a bit more collateral damage and more downtime. And TRL is arguably more effective, at least in some of the most— in some of the preliminary research, it can be significantly more effective for fine lines, wrinkles, and texture. So. If you have that downtime, that TRL is great. But if you want to more focus on the result, which is what I, again, I tell patients, I have 10 lasers, I can pull out whatever's needed to give you what you need. And I'm just focused on getting you the best results so that I can't tell you how many times where we've decided on a treatment plan and I get in there, I'm like, I'm just going to take this other laser out. It doesn't matter to me what I have to use. I just, as long as you can take the downtime, I want you to get the best result. Let's just go for it. And then I think it's different than other practices where you get to maybe choose your device or you are given one device or charged by device, which I think again is how aesthetics is changing. We want people to get the best results. I don't want to be told what tool to use because that's my expertise, but I also want to know what you were wanting to get out of it. And so if we're aligned that way, it doesn't matter what I use.

I MACHT] totally agree. I mean, I think part of the thing that sucks in the beauty industry right now is people are literally telling the clinician, the physician, whoever it is, this is what I want, and it might not be the best thing for them. And then kind of culturally, people are like, okay, you can have that, you know?

Yeah.

I got to tell you too, I had CO2 laser under my eye a few years ago.

Oh, huh?

Yeah.

And then I had TRL with you. There was no comparison. Like, I mean, I will get a full face TRL at some point in the fairly near future.

Sure.

I will be holed up in a hotel room for a week because my husband may divorce me if I come home like that. But I will absolutely be doing it. And it was a little— it was intense. It kind of was.

Yeah. And I think— and you correct me if I'm wrong, but I feel like the intensity after that first— I mean, it's hard to see the vision. But after that first week, I think you're like, okay, I can kind of tell now what—

Oh God, yeah.

And see, yeah.

I mean, after the first few days, like you can see, and then the skin underneath is so rewarding that it's so worth it. But no, it's— I think I was flying home immediately after that and I was like, ooh, yeah, this was tough.

It was uncomfortable.

Yeah.

I look terrifying right now, but totally. It was absolutely life-changing for my under eyes. Awesome. Tell me about skincare. So if you were on a desert island—

Yep.

You could have 5 skincare products that you could take with you, what would it be?

Of course, sunscreen. Obviously everyone knows about that. I don't ever stop my tretinoin in the summer. I know people are worried about sun exposure and, and yeah, that's a myth. I mean, you can use your tretinoin all year long as long as you're protecting yourself with sunscreen. It is the most studied product in the world. It's been studied for decades. And the most effective retinoid from a prescription standpoint. So I think beauty and medication, sometimes there's a blurred line there. Tretinoin is a medication FDA approved to treat fine lines, wrinkles, sun damage, and acne. So anything you buy off the counter is— it'll say on there, will improve the appearance of— they can't even use the terminology of will fix sun damage, but you can with the medication. So of course, tretinoin. vitamin C, cuz it's only gonna make your skin healthier, protect yourself from pollution and sun damage. I like an exfoliant, so glycolic acid, that is like my go-to, probably once a week I'm using a little glycolic acid. And I like trying new things. So some kind of growth factor or peptide-based product. I think that is the new wave now. There's a lot more data being done on it, more promising research showing growth factors and peptides produce collagen. Cuz for a long time we used the same kind of 3, 4 things. And that's what I prescribe, or that's what I recommend for every patient in my office to some degree based on their skin type and their sensitivity. They're getting those 5 things because I want the best evidence-based treatments for my patients. And skincare can feel very— you're doing your— getting your hair done, getting your nails done, and using skincare. And it sort of is like that is an experience thing. But if you're actually trying to change the way your skin looks, feels, and ages, it's scientific and it should be based right, in science, which is what we all want for our patients.

Yeah. And if you're listening and you're not on tretinoin, you should probably go have a conversation with your doctor because it is the easiest tangible thing that definitely gave me better skin in my, like, mid-30s than I ever had my whole life. So worth it. Tell me, maybe the sunscreen that you wear, the, the growth factors, peptides, some of your favorites of those.

Yeah. Sunscreens, I go back and forth. So I have like a warmer skin tone. I can't really use like sunscreens that are very white. So mineral or chemical, I don't really care. I'll use whatever just feels the best. I like EltaMD. I think it's just tried and true, great for sensitive skin. I love SkinCeuticals 'cause I think it's just like elegant, nice sunscreen. But I have probably 50 Korean sunscreens that I got from Korea last year.

Mm-hmm.

And those are just, hands down, no matter what you use from Korea, it is so easy to use, so easy to put on, never greasy, feels great. And that's just because their technology is better and they can get through the FDA— their own FDA faster. So any sunscreen that you can wear that you like, it should be the one you wear. For my kids, honestly, I just put on whatever I can get. Like, if I can get a Target sunscreen that they'll put on, that's what they're wearing. If you're going to be consistent, use that one. So I like exosome-based products because I do think that they are the wave of the future. Exosomes are, you know, they're little vesicles that your cells use to communicate with each other. So in those little vesicles are things like growth factors that improve skin quality, regeneration, collagen production. So I like a brand called AU79 Care. They are made in Korea, sold in the United States. SkinCeuticals has something called an RGN-6. That's a newer product. It's also great for like post-procedure. But I also have something coming out next year that is growth factor Yeah. So I've been using, I've been formulating that for the last 2 years and I use that morning and evening, but I just can't tell you what it is yet.

Darn. I can't wait. Like early next year, late next year.

When? Early, early, early. Yeah, it is all, it's finished. I'm just getting through it. So I'm doing third-party clinical testing, which a lot of brands don't do, but like that's my shtick. So I want to make sure that it does what I say it's going to do. And that takes 3 months. So, and I'm not doing it during the summer because everyone's out in the sun.

I love it.

And you'll be the first.

Last question. Oh yeah, please let me know. Please keep me posted. 3 products that everyone should have in their anti-aging regimen, or maybe not everybody, not medical advice, but the vast majority of people could benefit from.

If you can't use tretinoin, 'cause for some people they just can't, some sort of cosmetic retinal or retinol. These are the precursors or the chemical that will be converted into tretinoin just in a slower way. And maybe with some other products in there that help your skin just not get as irritated. So hands down, the thing that is going to benefit your skin the most other than sunscreen is a retinoid. I think people don't understand how effective it is. It will turn your skin over faster, which slows down with age. It will help with pigment, with your complexion, with texture, with pores, with acne. So you really are getting a, a product that does everything. And if you get tretinoin, it is cheaper than almost any over-the-counter product. So that's the other benefit. It might be a little hard to get 'cause you need your doctor or some, an online company, but no question, that is what you should be using. Vitamin C. So vitamin C is other, uh, the other very well-studied, uh, product. It protects your skin from the sun, especially when you pair it with sunscreen. It will help brighten your skin. It's not gonna get rid of brown spots, but it'll help your skin look brighter. I can always tell when I, I have a patient that is used SkinCeuticals Vitamin C for the past 20 years. They just have a look. And I think we're all used to kind of seeing that. So again, if you can't use that one, it's the most active form. There are other types of vitamin C that you can use. But again, one of the best well-studied things and probably the least sexy is either sunscreen or moisturizer, right? We know sunscreen, but a moisturizer— your skin loves water. So give your skin hydration. It's immediately going to look better and it's going to stay looking better if you're giving it emollients and, and things that help manage and nourish your barrier. We, I think for a long time, we're getting really excited about exfoliating our skin to death. Like if you're a kid from the '90s and early 2000s, we just like burned the hell out of our skin. So, you know, cause we were scared that we were just going to get acne from moisturizers and now products are so much more elegant. So a basic moisturizer, which your sunscreens are in a moisturizer base. So if you can't, you don't want to put two things on, great.

But.

a moisturizer is just the easiest thing to do.

Yeah, I love it. Well, this has been so valuable for me. I'm sure it's going to be valuable for everyone else as well. Thank you so much for taking the time— Of course. —and sharing your knowledge. And it was a pleasure.

Likewise. Thank you for having me. Appreciate it.