@Suzan Obagi ：作为一名医生，我经常遇到病人抱怨看起来疲惫，却无法具体指出原因。我通过展示20岁和60多岁面部图表，解释面部脂肪隔间的萎缩和骨骼结构的变化。女性在40多岁开始出现衰老迹象，50岁后衰老加速，激素水平下降导致骨骼流失和脂肪萎缩。激素替代疗法可以帮助维持骨骼健康。生活方式压力也会加速衰老，而美容科学的质量参差不齐，行业内的经济动机也使情况更加复杂。面部脂肪隔间的作用是让肌肉滑动，而从腹部提取的脂肪移植到面部后，会表现出腹部脂肪的特性。 @Tanuj Nakra ：关于衰老过程有很多科学研究，骨骼结构随着年龄增长而衰退，骨骼是面部的基础。韧带将皮肤连接到骨骼，随着脂肪萎缩和骨骼后移，韧带拉扯皮肤，导致深层皱纹出现。面部脂肪与身体其他部位的脂肪不同，其代谢和对压力的反应也不同。慢性皮质醇升高可能对脸部的脂肪具有分解代谢作用。人类天生就对美丽有欣赏力，普遍欣赏面部的对称性、比例和性别二态性。社交媒体上的图片经过滤镜处理，是对美的夸张和不真实的表达。过度填充是一个严重的问题，不仅因为它看起来夸张和扭曲，而且还会扰乱正常的解剖结构，使以后的手术更加困难。

我最近与两位顶尖的医学美容专家，Suzan Obagi 医生和 Tanuj Nakra 医生进行了一次深入的对话，探讨了面部衰老的科学机制、皮肤健康的证据支持方法，以及现代医学美容领域中医生所面临的责任。这次对话让我对这个领域有了全新的认识，也希望能帮助读者更好地理解并应对自身的面部衰老问题。

面部衰老的生物学基础：骨骼、脂肪与韧带的共同作用

Obagi 医生指出，许多病人抱怨自己看起来疲惫，却无法具体说明原因。这正是面部衰老的微妙之处。她通过对比年轻和年长面部的解剖图，清晰地展现了随着年龄增长，面部脂肪隔间会发生显著萎缩，而支撑面部轮廓的骨骼结构也会发生变化。眼周、颧骨和下颌骨的骨骼密度下降，导致面部轮廓变得不清晰，皮肤松弛下垂。

这一衰老过程在女性身上尤为明显，通常在40多岁开始出现，并在50岁后加速。这与女性激素水平下降密切相关，雌激素的减少直接影响骨骼健康和脂肪代谢。Obagi 医生强调，激素替代疗法在维持骨骼健康和延缓面部衰老方面可能扮演着关键角色。

Nakra 医生补充道，面部衰老的科学研究已经取得了显著进展。CT扫描研究量化了随着年龄增长，下颌骨、上颌骨和额骨的骨密度和骨骼投影的减少。骨骼作为面部的基础结构，其变化直接影响面部整体形态。此外，连接皮肤和骨骼的韧带网络也至关重要。随着脂肪萎缩和骨骼后移，这些韧带会牵拉皮肤，形成深层皱纹。

面部脂肪的代谢特性与身体其他部位的脂肪有所不同，对压力的反应也更为敏感。慢性压力导致皮质醇水平升高，这可能加速面部脂肪的分解代谢，加剧衰老迹象。

美丽进化论与现代审美标准的扭曲

从进化的角度来看，人类天生就具有对美的感知能力。婴儿期就能区分美丽和不美丽的容貌，这表明对美的偏好是与生俱来的。这种对美的感知主要基于面部的对称性、比例和性别二态性特征，这些特征暗示着个体的健康状况和生育能力。

然而，现代社会，特别是社交媒体的兴起，对传统的审美标准造成了巨大的冲击。滤镜和修图软件营造出不真实的、夸张的美丽形象，扭曲了人们对美的认知，导致许多年轻人盲目追求不切实际的审美标准，甚至寻求过度的医学美容干预。

医学美容的伦理挑战与实践指南

两位医生都强调了医学美容领域中伦理责任的重要性。他们反对盲目跟风，提倡个性化治疗方案，并对青少年过早进行医学美容干预表示担忧。他们认为，医生有责任教育患者，避免追求不切实际的审美标准，并根据患者的具体情况，选择安全有效的治疗方案。

在实践方面，两位医生分享了他们对皮肤健康的科学方法。防晒是重中之重，他们强烈推荐使用矿物防晒霜，而非化学防晒霜，以避免潜在的激素干扰风险。维A酸类药物和维生素C是有效的抗衰老成分，但需要根据个人肤质和耐受性进行调整使用。他们还详细介绍了如何制定个性化的早晚护肤流程，以及如何有效管理痤疮，特别是囊性痤疮。

以我自身为例：一个真实的医学美容案例分析

对话的最后，我请两位医生对我自身的面部进行评估。他们从皮肤、容积、重力作用和骨骼结构四个方面进行了分析，指出我存在眼周皮肤松弛、面部脂肪萎缩、额头皱纹以及面部轻微不对称等问题。

针对我的情况，他们建议采取综合性的治疗方案，包括：使用矿物防晒霜和有效的护肤品（维A酸、维生素C等）、填充眼周和面部凹陷（自体脂肪移植或填充剂）、以及皮肤重塑（激光或化学换肤）。他们还强调了选择合适医生的重要性，并建议我优先关注眼周问题的改善。

结语：理性看待医学美容，追求健康与自信的平衡

这次对话让我深刻认识到，面部衰老是一个复杂的过程，涉及到骨骼、脂肪、韧带和皮肤等多个方面。现代医学美容技术为我们提供了多种选择，但我们必须理性看待，避免盲目跟风，选择正规的医疗机构和经验丰富的医生，并根据自身情况制定个性化的治疗方案。最终目标是追求健康、自信和自然和谐的美丽，而不是追求不切实际的完美。 医学美容应成为我们追求健康长寿旅程中的一部分，而非全部。

The Peter Attia Drive⋅1d ago

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11:34 病人通常说他们看起来很累，但不知道具体原因，我会用图表展示20岁和60多岁的人的面部变化。

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11:58 年轻的面部有11个脂肪隔间，它们饱满，有弹性，提供体积，并在皮肤和肌肉以及下面的骨骼之间提供缓冲。

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12:18 60多岁的人，这些脂肪垫会大量萎缩；20岁的人的眼部周围骨骼紧致，颧骨宽阔，下颌线条清晰，而60多岁的人的眼部周围骨骼更宽，颧骨和下颌骨较窄，高度也降低。

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12:42 随着年龄增长，骨骼支撑减少，皮肤看起来下垂，这种变化开始得很早，通常首先在眼睛周围显现。

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13:11 随着年龄增长，眼部周围的骨骼流失和脂肪萎缩增加，导致原本被脂肪垫覆盖的底层解剖结构开始显现。

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13:26 骨骼的流失很多时候是由于激素引起的，尤其是在女性身上。

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13:47 激素替代疗法对女性有益，因为维持雌激素水平可以维持骨骼健康。

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14:13 女性在40多岁就开始出现衰老迹象，到50岁时，与同龄男性相比，女性的面部骨骼结构、脂肪量、肌肉厚度和皮肤厚度都较差，因此衰老速度快约20年，尤其是在下面部。

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14:13 随着下颌回缩，颈部皮肤变得松弛，女性会开始抱怨颈部皮肤松弛。

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14:57 女性在50岁时抱怨颈部，医生应该在女性进入更年期之前与她们讨论激素替代疗法。

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15:23 关于衰老过程有很多科学研究。

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15:49 骨骼结构随着年龄增长而衰退，骨骼是面部的基础。

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16:16 韧带将皮肤连接到骨骼，随着脂肪萎缩和骨骼后移，韧带拉扯皮肤，导致深层皱纹出现。

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17:55 女性怀孕期间体重增加，即使在产后恢复到孕前体重，面部也会变瘦，多次怀孕会加剧这种情况。

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18:54 面部脂肪垫的代谢非常独特，随着年龄增长，它们大多会萎缩，经历体重波动会导致面部持续萎缩。

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19:21 就像身体的脂肪营养不良一样，面部的脂肪细胞会变得有缺陷，无法重新积累甘油三酯。

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19:49 脂肪垫的颜色不同，例如，内侧眶脂肪垫比外侧脂肪垫颜色浅，脂肪垫中β-胡萝卜素的含量存在差异，这可能只是导致脂肪群不同的众多因素之一。

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20:16 面部脂肪与腹部脂肪和下肢脂肪不同，脂肪移植后，脂肪来源会影响面部的长期效果。

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20:46 β-胡萝卜素是一种抗炎介质，其浓度高低会对脂肪的代谢反应和健康产生影响，尤其是在脂肪对压力的反应方面。

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21:14 管理皮质醇水平、保证睡眠和减少生活压力对身体有益，对脸部的脂肪和皮肤也有益，因为这些脂肪层和皮肤对身体长期积累的压力非常敏感。

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22:26 慢性皮质醇升高对身体的脂肪具有合成代谢作用，导致脂肪积累，对肌肉具有分解代谢作用，导致肌肉衰退，但对颈部以上的脂肪可能具有相反的效果，可能分解脂肪，从而加剧脂肪流失。

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22:55 生活方式压力因素有明显的影响。

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23:34 美容科学的质量一直很差。

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24:19 美容行业是一个非常赚钱的行业，很多提供科学信息的人或公司都希望从中获利，这使得情况变得模糊。

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25:07 面部脂肪隔间的作用是让肌肉在微笑、说话、吃饭和咀嚼时能够相互滑动。

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25:34 从腹部提取的脂肪具有最高浓度的干细胞，当移植到面部时，脂肪开始表现得更像腹部的脂肪。

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26:26 人类天生就对美丽有欣赏力。

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26:53 新生婴儿天生就喜欢看漂亮的脸。

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27:34 人们普遍欣赏面部的对称性、比例和性别二态性。

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28:29 面部对称意味着个体发育良好，营养充足，可能具有良好的基因。

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29:24 人们实际上在寻找平均值，将100张男性面孔和100张女性面孔平均成一张合成面孔，这张合成面孔被认为是普遍美丽的。

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29:44 强壮的下巴在男性中，丰满的嘴唇或大眼睛在女性中，通常表示较高的雌激素或较高的睾酮水平，这与生育能力有关。

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31:19 不同种族的美丽的人都有相似的面部测量数据。

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32:56 饮食的改变影响了面部结构，因为现代食物不需要太多的咀嚼，导致下颌线条不那么强壮，牙齿拥挤，面部形状发生变化。

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34:58 在寻找伴侣时，外貌可能不是最重要的，更重要的是对方是否是一个好配偶、好父母，以及是否与自己有共同的目标和价值观。

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36:07 从进化角度来看，我们不需要在20多岁之后还保持吸引力，因为我们原本不应该活这么久。

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36:19 从进化角度来看，大自然并没有帮助我们保持外貌，我们的外貌应该能维持到20或25岁左右。

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37:40 社交媒体和有影响力的人正在改变患者的看法和驱动力。

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38:09 那个家族正在把他们的外貌变现，并引领了很多潮流，让人们可以公开谈论改善外貌或修复困扰自己的问题。

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38:33 名人有钱去找医生来改变，但跟随他们的年轻人没有足够的钱来改变他们的身体，也不知道这样做的后果。

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39:00 医生有责任教育患者不要盲目跟风，要超越金钱方面，真正做一些让自己看起来和感觉更好的事情。

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40:01 社交媒体上的图片通常是经过滤镜处理的，是对美的夸张和不真实的表达。

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41:01 人们会潜意识地摆姿势，例如，当他们走过闪亮的建筑物时，会停下来看看自己，并稍微调整一下自己。

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41:46 社交媒体影响者正在推广夸张的性别特征，如更大的嘴唇或更大的眼睛，这导致了过度使用填充物来丰唇。

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42:33 一个伟大的外科医生的标志之一是乐于说不，乐于说，我不会这样做，因为我太优秀了，不需要你的生意。

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43:45 大多数医生是合乎道德的，但有些人会为了赚钱而迎合患者的需求，让患者自己做出决定。

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44:19 我们不应该让病人说他们想把自己变成一个完全不同的人，这在伦理上是错误的，这可能带来一系列心理问题，包括社交媒体畸形。

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45:05 不幸的是，医生、护士和广泛的美学治疗从业人员都有经济动机，包括肉毒杆菌毒素和填充剂注射。

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45:34 当你涉足美学增强领域时，你必须明白，你所寻求建议的人有相当大的经济动机来治疗你。

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46:42 整个美容行业实际上就是这样，因为你不仅在销售一种手术，你通常也在销售一种治疗方法。

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47:09 现在，在某些州，由于缺乏监管，一些不合格的人员，他们不是医疗服务提供者，也在进行注射和激光治疗，这可能会导致并发症。

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47:55 我们强烈认为，在我们的实践中，每一次治疗都有一位医生在监督，这样，如果出现并发症，我们就会负责处理。

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49:41 那些进入美容领域住院医师和研究员仍然有艺术心态。

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50:08 由于医学报销的减少和美容行业的利润丰厚，医生可能会因为经济原因而扭曲他们的道德观。

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50:35 由于医疗报销的减少，大学诊所的医生需要看更多的病人，但医生每天能看到的病人数是有限的，这导致了医生精疲力竭。

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50:59 由于我们的大部分病人都是自费的，所以我们有足够的时间与病人交谈，了解他们，以至于他们来寻求医疗建议和对其他医生建议的意见。

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52:30 青少年现在要求在额头上填充填充物和神经调节剂，并在嘴唇上填充填充物，这并不好。

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52:30 现在人们被告知，即使18岁，也可以开始预防性肉毒杆菌毒素治疗，但实际上并不需要。

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52:57 社交媒体上的图片经过高度过滤，人们会改变身体比例，并发布这些图片。

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53:25 在社交媒体上看到的图像是用一定的角度拍摄的，以增强某人的外貌，不应该试图让某人看起来像他们的照片，因为这会让他们在现实生活中看起来非常不同。

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54:19 过度填充是一个严重的问题，不仅因为它看起来夸张和扭曲，而且还会扰乱正常的解剖结构，使以后的手术更加困难。

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55:11 填充物会拉伸韧带，改变组织结构，实际上会使以后的常规手术更具挑战性。

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55:37 玻尿酸的代谢因人而异，有些人代谢快，有些人代谢慢，但我们对此没有很好的了解。

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56:04 现在有一种趋势是人们要求获得高拱形的眉毛效果，眉尾抬得很高，被称为“抢夺”外观。

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56:44 如果父母在场，并且是为了解决一些问题，比如病人鼻子上有驼峰，但不准备做鼻整形手术，那么我可以创造性地使用填充物来帮助减少驼峰的出现。

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58:16 年轻人面临着来自社会的美容压力，这导致他们在很小的时候就开始思考这些问题，并在20多岁时准备好投入其中。

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59:26 在澳大利亚进行的一项为期四年的研究表明，使用防晒霜的人衰老得更好，皱纹更少。

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59:50 应该使用矿物防晒霜，而不是化学防晒霜，因为我不相信阿伏苯宗和氧苯酮作为激素干扰物的安全性。

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01:00:27 化学防晒霜中的化学物质会随着时间的推移而失效。

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01:00:52 化学防晒霜中的化学物质吸收有害光线，但会导致活性氧的产生，从而损害细胞的DNA。

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01:02:14 护肤品的营销可能会误导消费者，公司为了销售而制造护肤品，他们希望人们对防晒霜感到满意。

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01:02:32 皮肤癌的发病率正在上升，这可能是因为防晒霜会迅速降解，导致人们认为自己受到了保护，但实际上并没有。

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01:03:55 来自太阳的UVA会导致衰老，UVB会导致烧伤，高能可见光和可见光会导致色素沉着过度，红外线可能会影响脂肪萎缩和骨骼重塑。

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01:05:47 紫外线不仅会损害DNA，导致肿瘤和癌症，还会损害胶原蛋白颗粒和弹性蛋白颗粒。

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01:06:06 紫外线会损伤胶原蛋白和弹性蛋白的框架，导致皮肤变薄，皮下脂肪层减少，细胞间连接减少，从而导致皮肤出现凹陷、细纹和皱纹。

00:09

Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. 语法解析

00:30

It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members. And in return, we offer exclusive member-only content and benefits above and beyond what is available for free. 语法解析

00:46

If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guests this week are Dr. Tanuj Nakra and Dr. Susan Obagi, two highly respected physicians in aesthetic medicine. To 语法解析

01:12

Tanuj is triple board certified in facial and ophthalmic plastic surgery, faculty at the Dell Medical School, and the director of the Cosmetic Surgery Fellowship at the TOCI and Face Institute in Austin. Susan is double board certified in dermatology and cosmetic surgery. She is an associate professor at the University of Pittsburgh and the director of the UPMC Cosmetic Surgery and Skin Health Center, where she leads advancements in cosmetic and laser surgery on a global health scale. 语法解析

01:40

In this episode, we talk about the biology of facial aging, how hormonal changes impact facial bone structure and skin integrity, and the critical role that hormone replacement therapy plays in preserving a youthful appearance. We talked about what makes a face attractive from an evolutionary perspective and a psychological perspective, and how modern media and social media filters are warping and distorting those standards. 语法解析

02:02

Talk about the troubling rise in cosmetic procedures among teenagers and how physicians can navigate ethical decisions around these things. And then we really get to the substance of this podcast, which is we talk through a practical and science-backed approach to skin health, including the essentials. 语法解析

02:18

sunscreen, retinoids, and vitamin C, and many more things. We talk about mineral sunscreens and why they are likely superior to chemical or organic sunscreens, how to use retinoids correctly based on skin type and sensitivity, what a personalized morning and evening skincare routine should look like, including cleanser type and application order, 语法解析

02:37

the medical management of acne, especially cystic acne, the psychology behind aesthetic consultations, and why trust, motivation, and emotional readiness are critical before undertaking procedures. And finally, and perhaps most importantly, at the end of this podcast, we turn the tables, I'm the patient. 语法解析

02:55

I'm sitting across from them and I'm asking them to be as brutal as they need to be and offer an assessment of what would be truly possible if someone in my shoes wanted to take all the steps of aesthetic medicine and apply them to their own appearance from the neck up. 语法解析

03:12

This was the most illuminating discussion. And while I realize that listening to it, it might sound like they're being overly harsh or critical. You have to understand this is exactly what I wanted. I wanted to understand these things. And honestly, I came away from this realizing there was more quote unquote wrong with my face than I ever imagined. Again, will I do anything about it? Truthfully, beyond the new skin regimen, I have adopted probably nothing. 语法解析

03:37

But nevertheless, I was intrigued by this. And I think that many of you who have been thinking about these things as well will come away either deciding maybe there are things you want to do from an aesthetic standpoint, or at a minimum, just taking care of your skin might be the right thing to do. And clearly, you'll come away from this with a great regimen for how to do that. So without further delay, please enjoy my conversation with Dr. Tanuj Nakra and Dr. Susan Obagi. 语法解析

04:04

Tanuj, Suzanne, great to have you here both. You're obviously in Austin. You traveled from Pittsburgh, right? Yes. Awesome. Well, this is a topic we get asked a lot about. And sometimes when we get asked about topics, I already know quite a bit. And this is absolutely an example of the opposite of that. This is a topic we get asked about a lot. And I would argue that my knowledge is even below that of the general public. 语法解析

04:33

I can't think of a time when I've done a discussion on the podcast on something where I know less than all things related to the health of one's skin and appearance. And so, yeah, thank you very much for both being here and thank you for helping me even think about how to structure a discussion on this topic. Maybe before we jump into it, just give us each a little bit of your backgrounds. I think it was… 语法解析

04:59

helpful to have not one but two experts here because you guys have sort of a different specialty. Obviously, within medicine, you have a different specialty. You overlap in things, but obviously do some things different. So tell us a little bit about your training, your background, and what you focus on. Yes. Thanks for having us, Peter. It's a pleasure to be here to talk about something I'm quite passionate about. And I know it's very confusing for a lot of listeners to understand aesthetics, and we'd love to demystify it a little bit. 语法解析

05:26

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

05:54

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

06:19

academics, teaching, residents. We have a fellowship program, two fellowship programs in our practice. It's a real pleasure to be involved in academics because it's the cutting edge of science and we'd like to perform clinical research. And in the academic community, which is how I know Susan, there's a lot of collaboration among specialties and we have an opportunity to dialogue and further the specialty that we care so much about. 语法解析

06:43

Awesome. Okay. And Susan, you are a dermatologist by training? Yes. And then I did a cosmetic surgery fellowship. And I am in academic medicine as well. I'm at the University of Pittsburgh. I've been there about 24 years. So I got to see the evolution of this entire field, starting with what we used to do at the time was surgeries and then maybe a few collagen injections. And now we have the plethora of all these tools at our disposal. 语法解析

07:08

And I train residents, medical students, and I have visiting physicians from all over the world that come in. And I love the multi-specialty collaboration that we have because we both belong to the American Academy of Cosmetic Surgery. And we hear a different approach from different specialists, maybe on the same procedures. In my practice, I focus on everything with regards to skin rejuvenation, peels, lasers. I also do a lot of fat grafting. 语法解析

07:37

We do body liposuction, mini facelifts, eye lifts. But everything when it comes to the face is about really enhancing the appearance of the skin first, because my feeling is that's the most important thing that everyone sees. So when a patient comes in like you, who has not had anything done or doesn't know about the field, I actually like that because I can take that opportunity to really educate them and pick the right things for them. Dr. Justin Marchegiani 语法解析

08:02

I appreciate you noticing I've had nothing done. We were talking before the podcast, but it's worth me stating this now again for everybody to hear. There is something about this podcast 语法解析

08:13

field of medicine that I have such a block in my brain to understanding. And Tanuj and I have met before. Tanuj helped me with a scar. So Brett Kotlis, a friend of mine who's actually been a former guest on the podcast, introduced us. I face planted one morning due to some hypotension and sustained a pretty nice scar here that I think for the most part is largely invisible today, probably in part because my face is leather to begin with. But I 语法解析

08:41

But I think in part because we did some 5FU microabrasion, we did a whole bunch of stuff, and I was actually pretty diligent about staying out of the sun for the period of time after it, et cetera. So I think we've also done a Botox treatment, which… 语法解析

08:56

It certainly reduced the wrinkles. Obviously, it's long gone, but I'd love to talk about that. My wife and her friends, it's almost like they've done fellowships themselves, the way they talk about this stuff. And maybe that is just true of women in their 40s, but the way they go on about these techniques, it must sound… 语法解析

09:17

like that when I talk about cars in front of them. It's so foreign. So as I was saying earlier, I have taken a strategy towards my appearance that is probably illogical, which is I'm just going to ignore it because I don't understand it. And I'm going to focus on things I understand. 语法解析

09:37

I would view it as an enormous win of this podcast if in a few hours I decided to do something that was sustainable and going to help me look a little better at 62 than I should look. I'm 52 today. I looked at a picture of myself 10 years ago before this podcast. 语法解析

09:58

What a difference 10 years has made. I look so much worse today than I did 10 years ago. I guess that's not uncommon. I would guess 42 to 52 is a big reduction in appearance, but it also made me realize, wow, the next 10 years, that reduction will probably be greater if I don't do something proactive. 语法解析

10:16

And to just make one final point about my abject laziness on this topic, I can't even bring myself, this is going to sound so disgusting. I can't even bring myself to wash my face before bed, which my wife is like, you are so disgusting. Just wash your face. But I'm like, eh, it's not like I'm that greasy. Who cares? She's always buying products for me. I just can't bring myself to do it. 语法解析

10:38

So you guys have your work cut out for me because if I can be educated on this, you can change the world. I was about to say that, Tanisha. We have our work cut out. Let's start a little bit with the biology of the aging face. And again, we're going to limit our discussion today to the neck up. Not that there isn't other things that are completely relevant around cosmetics, but that's just a big enough topic. I told you that when I looked at myself 10 years ago, I couldn't believe how much better I looked. 语法解析

11:08

But I'd have a hard time telling you why. I can't put my finger on it, but I bet you can without me showing you those pictures. Why did I look better at 42 than 52? That's exactly how my patients come in. A lot of times they'll come in and they'll say, I feel like I look tired. I don't know exactly what's going on, but I feel like I look tired. And I have these beautiful diagrams in my office and I show them the face of someone who's 20. 语法解析

11:34

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

11:58

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

12:18

And the opening around the eyes are nice and tight. The cheekbones are nice and wide. The jawline has a really good definition. And then you look at someone who's in their 60s, and all of a sudden, the opening around the eyes are wider. Really? Cheekbones are less wide, jawbones less wide, less height. And so now you've got that scaffolding that's diminished, and all the skin looks like it's just hanging. 语法解析

12:42

And that's what's happening, but it starts early. So what I see on most of my patients when they come in and say, I look tired and you said it. You look at your pictures 10 years ago and you look now and you don't know what's different. The first change is around the eyes. And I'm sure Tanishq can add to that. But basically what's happening is you're getting more bone loss around the eyes, more fat atrophy around the eyes. So you're starting to see the underlying anatomy, which was padded before. So first of all, this is completely news to me. 语法解析

13:11

Is this loss of bone comparable to what we would see in the reduction of bone density in a person's hips as they age? So a lot of it is hormonal. A lot of it is hormonal and you see it, especially in women. 语法解析

13:26

If they start to see the aging changes, they'll start to identify that in their early 40s. So this, in other words, is probably another reason why women would benefit from hormone replacement therapy, because maintaining estrogen levels would maintain bone health. Absolutely. And actually, that's something we need to stress more and more to them, because it starts in their probably early 40s. 语法解析

13:47

And then it just accentuates over time. But by the time they hit 50, all of a sudden, now if we're looking at them cross-sectionally, a group of 50-year-olds compared to guys who are 50, the men are holding up pretty good. Their facial bone structure is good. Their fat volume is good. Their muscle thickness and skin thickness is good. But from 50 to 60 or 70, women will age about 20 years faster than men, in the lower face especially. 语法解析

14:13

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

14:38

Because we both peak, both men and women peak in the early 20s. But at about 50, women fall off a cliff, whereas men just continue a linear decline. And so the gap really widens. Interesting to realize that the exact same thing is happening in the face. That's exactly it. And that's why women come in, the first thing they say when they're 50 is, I hate my neck. 语法解析

14:57

And I think we jump to try to surgically correct it or to augment it with fillers or neuromodulators to keep the muscle from pulling down. But I think we have to have a talk about hormone replacement. You have to catch those women before they're far along into menopause. Again, I'm blown away by that fact. And if I could hop in for a second, I love the direction of this conversation because I don't know if people realize how much science there is about the aging process. 语法解析

15:23

There were some seminal studies by Roerich and Pessa in the 90s and 2000s that delineated a lot of what Susan's talking about, where they looked at CT scans of the same individual over time. I think some of those studies had a 15 to 20 year span, and there was quantitative calculations of bone density and bone projection of the mandible, the maxilla, the frontal bone. 语法解析

15:49

And these bone structures all recede with aging. And the bone is the foundation for the face. And so when we're talking about youthful fullness of a face, a lot of that is the bone structure. And then as Susan said, of course, the fat compartments are a critical component of our facial aesthetics. And as we lose all that volume, the reason why people start to look more skeletal as we age, one of the most common areas that I see in my practice is people talking about their under eye bags and their 语法解析

16:16

lines that are showing up in their eyelids and their cheek area. It's because we have ligaments that attach the skin down to the bone. It's called the osteocutaneous ligamentous network of the face. And those ligaments are the same for every single individual, no matter what your ethnicity is. Of course, there's variations on the theme, but the orbital retaining ligament, the malar ligament, the temporal ligament, the mandibular ligament, the masseter ligament, the 语法解析

16:41

These ligaments are always present. And then as we lose that facial volume from fat atrophy and the bones move backwards, these ligaments are tugging on the skin and these deep lines start to show up. And that's, I would say, one of the fundamental changes we see with aging of the face. What I guess I don't understand is the following. Again, I'm just going to use myself as the example because I think I'm probably reflective of many people. 语法解析

17:07

10 years ago, I was less fat than I am today. Same body weight, by the way, almost to the pound. I'm the same as I was 10 years ago, but I would bet my body fat was two or 3% lower. In other words, I have accumulated fat in my body. 语法解析

17:27

Why am I losing fat in my face? What is it about facial subcutaneous fat depots that atrophies when for virtually every person the opposite is happening when they age? They're actually adding adipose tissue subcutaneously and unfortunately often viscerally. If I may answer that one, it's interesting because I talk a lot to my patients about that now. The vast majority of my patients are female. 语法解析

17:55

So they'll come in and they'll see me and I can look at their face. Let's say they're in their late 30s, early 40s, and I can guess how many kids they've had. 语法解析

18:03

Because what happens is you gain weight in pregnancy. It doesn't have to even be a lot. But then most people, if they're fit, they lose that post-pregnancy weight. I've had none, by the way, just in case you were wondering. That's good to know. And then they lose that post-pregnancy weight. And what happens is they go back to being the same weight that they were before they got pregnant, but their face is thinner. Second baby, more so. By the third baby… 语法解析

18:28

it takes a significant toll on the face, that weight gain, weight loss. So you can tell looking at a female face almost how many times they've gone through that weight gain, weight loss. And so what happens, the facial fat pads are very unique metabolically. Like I mentioned, most of the time they're just atrophying as we age. There are a couple of compartments that might in time get thicker, such as the nasolabial fat compartment, which is why some people have that deep fold 语法解析

18:54

But for the most part, they atrophy. And so if you go through this yo-yo change with your weight and you're progressively getting thinner and then getting some weight back, it doesn't go to the face. It goes to parts of the body we don't want. But the face continues to undergo that weight loss or the volume atrophy. But do we know biologically, because it's almost like a lipodystrophy where the fat cell becomes defective and can't reaccumulate triglyceride or whatever it is, whatever form it's going to store it in. 语法解析

19:21

Like so many things in medicine, there are things that we know and a lot that we don't know. Yeah. So we know that it's happening. We don't actually know the biochemical mechanism necessarily. We know some. I think we're just starting to understand the individual receptors and specific nature of different areas of fat. So for example, even in the eyelid region, when we're doing surgery on the face, we're doing surgery on the upper eyelid, we will see that the fat pads have different colors. So 语法解析

19:49

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

20:16

And we know this also practically speaking because when we're doing fat grafting procedures, the source of the fat can have a different long-term effect when it's ejected into the face depending on what the source was. So we know that fat is not the same throughout the body and it's not the same in the face. There is a general consensus that beta carotene is an anti-inflammatory mediator. Higher concentrations and lower concentrations of beta carotene can have some effect on the metabolic response. 语法解析

20:46

health of fat, especially how it responds to stress. And so in the world of longevity, there's a lot of discussions about managing cortisol levels. Sleep is helpful. Having lifestyles that reduce your overall stress level is good for your overall health in numerous ways. That's also true for the fat and the skin of the face because, again, a lot of this is not fully explained, but we're starting to get more and more details about 语法解析

21:14

as basic science progresses in this area, that these fat compartments and the skin, which we can talk more about, is exquisitely sensitive to stress that the body is experiencing cumulatively over time. So a lot of times people feel like they're really aging in their 40s, 语法解析

21:30

People have midlife crises. They're probably experiencing the maximum stress in their life at that stage typically, and I'm just generalizing here, but people will have a busy career. They've got kids. They've got financial worries. And so people are under a lot of stress in their 30s and 40s, and that contributes to some of the more rapid facial volume loss changes, some of the skin aging changes with elasticity, collagen, elastin changes that occur over time. 语法解析

21:58

And so that's where I think that this conversation really plugs in quite well into the line of education that you're providing your followers in terms of longevity benefits, because it overlaps here with cortisol stress and inflammation. And what's interesting is that chronic elevation of cortisol in the body is actually anabolic to fat. You accumulate fat. It's catabolic to muscle. Muscle decays. 语法解析

22:26

fat accumulates. It sounds like you're saying, okay, that's true from the neck down, but above the neck, chronic elevation of cortisol might have the opposite effect. It might actually be catabolic to fat and therefore it accentuates the fat loss. Am I hearing you correctly in that? Yes, I believe that's correct. Just yesterday in my clinic, I had a perfect example of this. I had patients back to back. One was 68 year old woman who has lived a very comfortable life. She comes from Afro-Columbian 语法解析

22:55

affluence, hasn't really had to work too hard in her life and has maintained things. Of course, she's used skincare products. And she's had a little bit of fillers and Botox, but no surgery. And she looked 10 years younger than her stated age because of the kind of life she's been living. And then the next patient I saw was from rural Texas, has been in the sun, has never been taking care of her skin, was working kind of a blue collar job, difficult life. 语法解析

23:23

couple marriages failed. She looked like she was 10 years older. And this is common. I'm sure you see this all the time as well, Susan. So lifestyle stress factors clearly have an effect. And 语法解析

23:34

And one of the reasons why, Peter, perhaps this is not an area that you've delved into in your vast experience in medicine is because the quality of science and aesthetics has historically been pretty poor. You're giving me way too much credit. I wish I could say that was I have delved into plenty of things where the science is poor. There is some other mental block I have. It might be that I'm not smart enough. 语法解析

23:57

to understand it all, but we'll continue and I appreciate your… And another reason why it becomes very murky to sort through the science, and I'm sure this exists in other areas of medicine too, but a lot of the individuals, corporations, forces that are delivering science to the masses and to physicians who are eating it up and regurgitating it to their patients, these 语法解析

24:19

These sources are questionable. They're profiting, as you, I'm sure, realize the aesthetic industry is a very, very lucrative industry worldwide, especially in the United States. There's a lot of forces where those that are delivering the science have a vested interest in receiving monetary benefit from what they're pushing out. And that makes things murky. But I think going back to the fat compartments, 语法解析

24:45

Think about it with our patients in general. The role of the fat compartments in the face are to allow muscle glide. So the muscles can move over each other when you smile, talk, eat, chew, all of that. And I don't understand why they should undergo such atrophy over time for such an important function. But then we look at the metabolic activity of the fat in other areas of the body, and it's very different. 语法解析

25:07

So when we do fat grafting, for example, and we take fat from the abdomen, which has the highest concentration of stem cells, pre-adipocytes there, and put them in the face, the fat starts to behave more like the fat from the abdomen when you put it in the face. So it retains its source. Yes. And then when they gain weight, you have to tell your patients specifically, don't try to gain more than a few pounds because it will hypertrophy like it would in the abdomen if they gained weight. 语法解析

25:34

Interesting. Is there an evolutionary explanation for any of this? I mean, I don't know if aesthetics, if you think about this through an evolutionary lens, but I mean, historically we didn't need to look good beyond our 20s if the purpose of looking good was to attract a mate. So none of us sitting around this table need to look good in Darwinian terms because we're not reproducing. Do you think that factors into any of these observations? 语法解析

25:59

A hundred percent. Yes. And so I think it's also good for the sake of the overall podcast for us to talk about the evolutionary aspects of beauty for just a moment, which could be a whole separate podcast. You could invite Nancy Etkoff from Harvard to come talk to you about the psychology of beauty. She wrote the definitive book on it and summarizes all of evolutionary beauty science. I have all of my fellows read her book. 语法解析

26:26

because I think it's just a beautiful compendium. The evolution of beauty is a fascinating topic because when you think back to the evolution of humans, why do we even care about beauty? The interesting fact is that we're actually genetically hardwired to appreciate beauty. And so there's this famous study from the University of Texas in the 1980s, Judith Langlaw is sort of a well-known name in psychology. 语法解析

26:53

She did what's called a preferential looking study of infants. I don't know if you've heard of this study, but it's fascinating. She took newborn infants who were literally weeks old, barely able to see six inches away from their face. 语法解析

27:06

She showed them pictures that are considered beautiful, faces that are beautiful, and faces that are less beautiful. And these newborn infants who've not yet been influenced by society preferentially were looking at the beautiful faces. And so that natural drive for us to appreciate beauty is present even at birth. Does that suggest that there is a definition of beauty that arcs time? Because 语法解析

27:34

I was actually going to ask a question, which would be a great detour for us to take after this point about how much is the definition of beauty changing? In other words, if you took Matthew McConaughey and transported him back 10,000 years ago, would he still be a hunk is sort of where I was going. 语法解析

27:51

I would say that the answer is generally yes. There's two layers here. The first layer is the genetic, biologic drive that we have to appreciate beauty in men and women. And then, of course, there is a societal impact that conditions us to appreciate certain versions of that beauty. But the fundamentals… 语法解析

28:12

have been studied in the 90s. And the fundamentals are that all humans across ethnicities all over the world have been studied and they appreciate certain features of beauty. So there's symmetry of the face, facial proportion, 语法解析

28:29

And then they also appreciate sexual dimorphisms. Those are kind of the three categories. And so symmetry, when a face is symmetric, it sort of connotes if you're out there in the reproductive world looking at the pool of your options, symmetry means that this individual most likely has had good development and nourishment and is most likely going to have good genetics for me to potentially connect with and pass on genetics together with. 语法解析

28:56

Facial proportion is similar. In fact, to go a little deeper into that, averageness is really what people are looking for. On the surface, that doesn't sound so attractive to be average, but if you take 100 faces of men, 100 faces of women, and average them all down to a single composite, you will average someone who has a little bit of a big nose or a small jaw or some aspect of their forehead shape, and all that gets averaged down into a composite 语法解析

29:24

that is considered universally beautiful across cultures. And again, that sort of unconsciously in the mating pool from an evolutionary standpoint is connoting healthy genetics to be able to pass on your genetics with. And then the third area, which is sexual dimorphism, we're talking here about strong jaws in meds, 语法解析

29:44

full lips or big eyes in women. These tend to connote either higher estrogen levels or higher testosterone levels, depending on whether you're looking at women or men. And again, that's fertility. That's subconscious communication of fertility. So those are the genetic absolutes that exist in all of us on the planet. And then on top of that, as you're bringing up 语法解析

30:08

Social media in this culture, this particular way of wearing your hair is considered beautiful. Those are conditioned upon us based on society, but it overlaps on top of that underlying genetic basis that we all have. And how much can those things override? Again, I'll just use examples that we can all appreciate. I was talking with my daughter about Cindy Crawford. 语法解析

30:29

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

30:55

If it becomes the case that blondes are really attractive, it doesn't matter. Cindy will override that. If it becomes the thing that women who weigh 30 pounds are attractive, it doesn't matter. Cindy will override that. Is that kind of what you're saying? If you look at even different races, a beautiful person in each of those, they actually all have similar measurements. So there are these masks that you can superimpose onto any image. 语法解析

31:19

and really dissect down every single angle, whether it's the cheek angle, the jawline angle, the shape of the nose, the eyes. If you look at that across different races, they all have that same kind of measurement that they hit. Talking about those symmetry, the upper third, the middle third, lower third, the face, the fifths going across the face, all of that, if you look at a beautiful person, no matter what race they are, they all kind of hit those measurements. 语法解析

31:45

Now, then there are nuances. Like you said, you change your hair, you change your makeup, you can transform yourself. But if you take someone without makeup and just look at them that way, they all kind of conform to those measurements. 语法解析

31:57

Doesn't this imply that over time, beauty should be one of the most preserved, concentrated traits of our evolution, given presumably the difficulty in acquiring a mate absent beauty? In other words, does it suggest that if you compared what we as a population look like today in 2025, 语法解析

32:18

to what we looked like 2,000 years ago, 10,000 years ago, 100,000 years ago, are we monotonically getting more attractive as a species? You would think so. 语法解析

32:28

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

32:56

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

33:18

And so it's interesting because there's a whole book on breath and they go through the anthropology of all of that and the changes in the skeletons that they've gone back and studied. And so that does fundamentally change. Now we have kids that have to have teeth extracted or we have to have palate expanders now because we realize when we extracted teeth before, we made the faces more narrow. And so now the thinking is let's preserve the teeth, expand the palate when the child is 10. 语法解析

33:45

allow those teeth to come in so there's less crowding, and then that face will be better and a stronger jawline. So it is something that we've changed. And then just to head into the area of sociology for just a moment, 10,000 years ago, if you were born in some place on Earth, Peter, the genetic pool that you'd be interacting with was tiny. There's some fact that I'm probably going to misstate, but somewhere around 1900, 语法解析

34:12

most people on this planet had not moved within 10 miles of where they were born. And now it's totally different. And with social media and the way that we can connect with people around the world, not only because we can fly all around the world, but we're also seeing people on screens. 语法解析

34:28

The apparent genetic pool of faces that we're looking at has exponentially blown up into this very strange world that we're living in in 2025 compared to where our evolutionary biology has taken us. And I wonder also at what point in our development did other, I don't want to say higher order, but other things became priorities in finding a mate. All of us, I think when we were looking for our mate, appearance was probably not the top of the list. 语法解析

34:58

It was one of the factors. You had to be attracted to the person, but I would guess for all of us, it was, will this person be a great spouse? Will this person be a great parent? Does this person share my goals and values and blah, blah, blah, blah, blah. It's hard to imagine our ancestors had the luxury of 语法解析

35:13

Maybe thinking about those things. So yeah, all of this is to say it's way more complex today It is to hear you guys describe this. It's entirely fascinating to play the thought experiment of Transport a hyper attractive person today back in time 10,000 years and I would just be so curious as to how they would react to that individual I think it's a fascinating thought experiment and I think that if they meet those criteria that we're defining They would be considered a hunk or a beauty 语法解析

35:41

Yeah. One last thing, and then we can certainly move on to the next topic. But in terms of timing, it is important for us to be evolutionarily attractive historically, not in the modern era, until you're about 20 or 25, because we weren't supposed to live this long. One of the issues that comes up with longevity and trying to maximize our health span is 语法解析

36:07

is that we were not really supposed to be living this long and healthy this long. And so evolutionarily, Mother Nature is not helping us with our appearance. Our appearance was supposed to 语法解析

36:19

carry us through until about 20 or 25, at which point most people were procreating at 14. And then at 25, their kids were at the point where they were getting ready to procreate and then led out to pasture at that point, basically. So evolutionarily, what we do every day with our patients is we're really fighting biology. We're fighting genetics. We're fighting unnatural existence that we have as a luxury of being born in this era. 语法解析

36:47

How much do you see, even just speak about it through the length of your actual careers, how much do you see trends that dramatically change what people are asking for? In other words, Susan, 25 years ago, did men or women come into your practice significantly looking for something different in terms of an appearance and an outcome that they wanted you to shape? 语法解析

37:14

Yeah, I would say that's such a loaded question because 25 years ago, if we think back, there was no social media. Television was very basic. Maybe there was some shows that had live people on there on different shows where they would talk about beauty or fashion. But you had to actually tune in and watch those shows to be able to see the trends. Magazines came out and that was the extent of it. 语法解析

37:40

Now you have social media and various channels on social media, and then you have what we now know as influencers. And they're changing what our patients are seeing and what's driving them. And the biggest one that I can talk about is basically that very well-known family in California that has monetized their appearance and set a lot of trends for better or for worse. It's great to see that they're making it okay to talk about enhancing your appearance or fixing something that bothers you. 语法解析

38:09

But where I draw the line is when they start putting out their transformations. And this trend now is something that everyone wants to emulate. And you're talking about young women changing, physically changing their body drastically to conform to what you said is a trend, which is exactly it. And trends, as the word says, are not permanent. So what happens when that trend ends? 语法解析

38:33

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

39:00

and look beyond the monetary aspect of it. And so from that standpoint, I try to really educate my patients to stay away from things that are trending and really do things that make them look and feel better but natural for themselves. Because I don't know in your practice, but I know people want to come in for the enhanced buttocks, Brazilian butt lifts, and the small waist. And that's something, again, that's being undone by that family now. And you're going to see a whole trend that's coming out that doesn't look like that. Dr. Justin Marchegiani 语法解析

39:27

What are kind of the top above the neck trends? So what I see as I look around is I see lip size being something that's getting bigger, smaller, bigger, smaller. Where are we today, by the way, in lip size? 语法解析

39:41

So just to continue Susan's line of thought there, we're in this, again, unusual era where the influencers that are affecting society are much more in our faces than they have been historically. And they're affecting young people at a much younger age, which is why we just let my 16-year-old daughter have a social media account. 语法解析

40:01

And that influence of these influencers is quite powerful because what happens is on social media, which is the primary exposure that people are receiving these days about beauty, the images that are being posted are not real. They're filtered. They're unrealistic exaggerations of some of those three original factors that we're talking about, the symmetry, proportion, 语法解析

40:24

People will photograph themselves in such a way where they look more proportionate. They will pull their jaw in a certain way to make their proportions look better. 语法解析

40:32

better. Someone has to teach me how to do this because anytime I see a video of myself, I'm like, that is the worst looking thing I've ever seen. Like I need to learn these tricks. You need a 20 year old. And a lot of this is subconscious posing. That's a term that I have used for this concept where people are subconsciously posing. Like for example, a lot of people when they walk past a shiny building will stop and look at themselves and kind of like adjust themselves a little bit. Is that new? Like in other words, did 语法解析

41:01

Did our ancestors walk by a stream where the water was still and look at themselves? I mean, not that we can know that, but… 语法解析

41:18

are selling exaggerated forms of beauty ideals like the sexual dimorphism. So we talked earlier about larger lips or bigger eyes. One of the most popular procedures in Northeast Asia is surgeries to make the eyes wider. You actually cut into the canthus and perform ptosis surgery to make the eye look bigger. And then, of course, this trend to have bigger lips. Fillers are being used left and right, unfortunately, to overdo lip volume and plump up lips. 语法解析

41:46

because the social media influencers are posting it, it's becoming more exaggerated because these exaggerated gender traits are becoming normalized. And so the family that Susan's mentioning in California, they normalized overdone lips to the point where people come in asking for it and we have to say, no, I'm sorry, this is not a good direction for us to take you in. I was talking to somebody yesterday where I said, 语法解析

42:11

One of the marks of a great surgeon is a person who is happy to say no, is happy to say, I'm not going to do this because I'm so good that I don't need your business. I can be as selective as I want about what I do. That allows two things. That allows the right patient selection to get a good outcome. So the discussion I had with a patient yesterday was about an orthopedic surgery issue. 语法解析

42:33

And the doctor said, yeah, I think it's time to do the surgery. The patient was saying to me, well, he does sort of have a vested interest in doing the surgery. After all, he's a surgeon. I said, yes, but I can speak about this surgeon in particular. I've watched him say no to 100 patients because patient selection is the most important thing for him to drive amazing outcomes. He'll say no until it's time. 语法解析

42:53

In the cosmetic world, you add another layer to that decision. And clearly you guys are both on the spectrum of, you're both the top of your field, so you don't need an incremental patient. You're happy to say no. There's also, it sounds like an ethical reason for you to say no. Where I'm going with my rambling question is, where do you think the field is on the whole? Are you guys the outliers or are you guys the majority? 语法解析

43:17

Is there a handful of bad actors out there that will take any money from any 17-year-old who's being duped into thinking this is the way they need to look? I'm trying to get a sense of the scale of this problem. I would say the vast majority of physicians are ethical. I do think there are some out there, though, where it is something that's monetized. So they will mask, treat patients. Their goal is to have surgery after surgery coming in. 语法解析

43:45

and basically letting the patients make their own informed decision about it to an extent. 语法解析

43:51

But I always look at it akin to managing hypertension or diabetes. We never let the patients determine how much insulin to use or how much antihypertensive medication to take. And I don't think we should let the patients say that they want to transform themselves to some completely different person. I just ethically think that's wrong. I think that brings to mind a whole bunch of other psychological issues that might be playing there, including what we call social media dysmorphism, or 语法解析

44:19

Where people come in with pictures of themselves with a filter and say, can you make me look like this picture? By the way, is that a recognized diagnosis in the DSM-5 now? Oh, in the DSM-5, I don't know if it's made it that far, but it is something that is mentioned at different meetings now. 语法解析

44:36

So I don't know that it's made it into the DSM-5. If not, it'd probably be in the six. If I could chime in, I think that Susan's obviously a very ethical, outstanding surgeon and physician. I do have to say, I'm an optimist. I have to say that I think the situation's worse than what you're saying. I think that there are, unfortunately, financial incentives for physicians, nurses, and the broad spectrum of people that perform 语法解析

45:05

aesthetic treatments, including Botox and filler injections. It's very poorly regulated. There are tons of people out there ranging from hairdressers up to surgeons who will be happy to take your money and find a place to put the syringe or filler because they know it's going to be money revenue into their practice. And so I don't want to be overly negative, but I think this is sort of a cautionary warning to people who are listening to this podcast that 语法解析

45:34

When you're delving in the area of aesthetic enhancement, you have to understand that there's an overlay where the person that you're seeking out advice from has a substantial financial incentive to treat you. I think it's a real issue. 语法解析

45:48

Yeah. I'll tell you, one of the things I always caution patients toward in my world is you need to be really careful when you're seeing a quote unquote longevity doc who is selling tests and selling treatments for the results of that test. When you go to see somebody and they're selling a biologic clock whose treatment is this supplement and they're monetizing those two things, 语法解析

46:16

I just don't see how you can trust that individual. I don't see how even a person with good intentions can't get conflicted there. And I guess I never thought of it until you said that, but the entire aesthetic industry is effectively that because you're not just selling a procedure, you're often selling a treatment. You're getting paid on both ends. And what's happened is like Taneuza was saying, the providers have changed. 语法解析

46:42

So before, it used to be only dermatologists that would do the injectables. And then it became dermatologists and plastic surgeons. And then it became the RNs and the physician assistants. And those are still all medical providers, including dentists who are very well-trained can do that. But then you get, in certain states, lack of regulation. So you're seeing unqualified people who are not medical providers doing injectables and laser treatments that they 语法解析

47:09

they may not be trained for. And all of a sudden, you start to open up a whole Pandora's box of complications there. And this is a shame because patients might not know enough to ask about qualifications. They might see that it's a nice storefront, the person's wearing a lab coat, they look professional. 语法解析

47:26

So from that standpoint, they might go in trusting that this person has their best interests. There might not be a physician overseeing everything. We feel very strongly in our practices that there is a physician overseeing every treatment, whether we're doing it, our nurses or our PAs are doing it. We're overseeing all of that to make sure that if there's a complication, that complication is ours. No matter what, we're going to take care of that patient. So it is a shame. And I do warn a lot of young residents coming into the field. 语法解析

47:55

To enter the fields if they truly love the field and are passionate about dermatology, ophthalmology, oculoplastics, all of that. Because if they're going into it thinking they're going to be the next glamorous doctor on social media, then they're not going to have a lot of treatments that they can offer. Because at that point, all these other providers are doing those treatments. 语法解析

48:15

They're going to have to find a niche for themselves to make a name for themselves doing something differently. So it's really fascinating right now, the times that we're living in. And do you see a change in residents today? So when I was in medical school, which is almost 30 years ago now, the people, and maybe it's such a small sample that it's an irrelevant statement, but when I think back to everybody I knew that ultimately chose plastic surgery, they 语法解析

48:39

They all had a very artistic bent to them. I'm not going to say that they didn't pick it because it was also a lucrative field and things like that. Maybe if plastic surgeons made $50,000 a year, they wouldn't have done it. 语法解析

48:50

But I never got the sense that that was their primary motivation. When I think back to my friends in medical school that went into plastics, they were artists. They really took an interest in the art of this. Do you still see incoming residents largely of that philosophy where they're interested in the aesthetic component of it, the underlying physiology of it? In other words, are they cut from the cloth you guys are cut from, or do you see a trend towards… 语法解析

49:17

No, this is literally a cash machine. And as reimbursements are going lower and lower and lower across the entire field of medicine, it is clearly more attractive to be in specialties where reimbursements either remain very high and or it's mostly cash. I'll take a more optimistic tone here. I think that those who are coming into residency and fellowships in the world of aesthetics, I think really still have that same 语法解析

49:41

artistic mindset. People who are painters or musicians, they have that artistic mind. And it's something we actually look for in our fellowship when we're considering candidates because we know that they have that right brain mentality of being able to handle medical problems. But the reality is that, as you said, medical reimbursements are going down. The lucrative nature of aesthetics is high and getting higher as time goes by. And so the 语法解析

50:08

someone can go through all the training, and then when they see the dollars come in the door, they're just going to want more of that. It can distort their ethics, and they may not even realize they're doing it. I'm not saying that there are physicians out there who are knowingly duping patients into having treatments, but I think it just becomes this unconscious drive because of the finances. We were talking about that earlier, and I do think it's a challenge because, here we go again, Medicare just got cut again in terms of reimbursements. And that's sad because 语法解析

50:35

We're talking about in our university practices, there's a huge push for doctors to see more patients because reimbursement is dropping. And so the only way that the medical centers can compensate is to increase the volume. There's only so many patients, though, in a day that we can see and offer really good care. So Tanush and I have a very unique practice because most of our patients are self-pay. 语法解析

50:59

So we have the luxury of time. We can talk to our patients, get to know them to the point that a lot of our patients come to us seeking medical advice and opinions on other advice that they've gotten from other physicians. And we can help them decipher the facts. 语法解析

51:15

Whereas their other physicians may be fabulous, but they have to see 30, 40 people in a day. And that's a shame. That's the detriment now that the physician's market is in because we're burning out a lot of really good physicians who want to give good care, but find themselves having to see more and more patients so they can only spend 10 minutes a patient. And that's really unfair. And that's not why all of us go into medicine. And 语法解析

51:38

And for both of us, we entered our fields before all of these devices and treatments existed. So I think we did come into it with a passion for what we love, but we both have an artistic bent to our personalities as well. So we kind of gravitated towards this. I want to put a bow on the social media thing for a moment. What is the most concerning trend or what is the most concerning request you are getting from people that you believe is unique to the social media phenomenon? 语法解析

52:06

What I'm seeing a lot more are teenagers now coming in asking for fillers and neuromodulators in their forehead, fillers in their lips. And that's sad. Would a neuromodulator do anything when you're at that age anyway? No, but they're now being told that even 18, for example, it's okay to start preventative Botox. You don't need that until you're a lot further along in age. So that's just an abject lie that they're… 语法解析

52:30

that they're being told. Yes. Unfortunately, they're also being made to feel very poorly about their shape of their lips. They're being inundated with images. And like Tanush was saying, these are highly filtered images. We know a lot of people who will take in their waist, take in their thighs, all of that, change the proportions, and then post that image. What I try to tell patients is that what you see in terms of images that are on social media, A, are filtered, 语法解析

52:57

B, are taken with certain angles of the camera to enhance someone's appearance. And we will never, at least in my practice, take someone's photo that they took on their phone and then try to enhance them to look like their photo because what's happening is that you're going to make them look very different in life, in real life. You're only going to photograph beautifully if you're the most symmetric person. And that's why even the most beautiful model in a photograph, if you look at them in person, they're very pretty. 语法解析

53:25

But you wouldn't think that they're supermodels sometimes. But when they photograph, they photograph beautifully because of their symmetry. But for us, with our forward-facing cameras that we point at ourselves to take our selfies, they're going to distort our face. If you tilt one way, you elongate the face, tilt a different way, you shorten the face. And patients get hung up on that. That's really sad because in real life, they look fabulous. 语法解析

53:48

Now, is this a 95-5 female-male problem that is arising from social media? I guess from the purpose of this discussion, I would guess it's mostly female. My guess is the male issue is probably much more on anabolic steroid abuse and things that young men are being influenced by. Is that safe to assume? Yeah. What is it that you see, Tanuj, that is most disconcerting? Is there a particular product or a particular procedure that is showing up that would have been unheard of before social media? 语法解析

54:15

I would say two areas. One is because 语法解析

54:19

Fillers are non-surgical, relatively accessible price points, and low risk, and are ubiquitous. You can find a clinic within one mile if you live in a major city. I think overfilling is a serious problem. Whether it's the lips or the cheeks, over-volumization has become an epidemic. It's a serious problem, not only because it looks exaggerated and distorted and strange, but 语法解析

54:44

But even when, as a facial surgeon, I go in to perform surgeries, I will find that filler has disrupted normal anatomy. And so decades later, the companies will tell you that filler only lasts one year in the face and then you have to refill it. That's definitely not true. I have patients coming in who don't mention that they've had fillers in the past, but then in surgery, I will see filler in their cheek or in their face because they had it eight or 10 years ago and it's still there. 语法解析

55:11

and it's stretching the ligaments, it's changing the structure of the tissues, it actually makes routine surgical procedures later more challenging. And by the way, are there biologic features of the individual that would make that more or less true? Are there some people in whom fillers go away after a year, or are you saying that for the most part they last longer? That's also another whole complex topic is the metabolism of hyaluronic acid, and some people are higher metabolizers, some are slower metabolizers. 语法解析

55:37

And we actually don't have a good sense of that. We have some general concepts just based on experience, but there's very little science on that. We can't really predict. So one doesn't know. One really doesn't know. Okay. And I'm sorry, you were going to get to a second point. Yeah, no. The second point is from a surgical standpoint, there is a trend right now where people are asking for this high arched brow effect where it's hyper exaggerated. The tail of the brow comes up very high. It's called a snatched look. 语法解析

56:04

About once every week or two, I've got someone who seriously wants to have their face distorted with a surgical procedure with me. And I have to say, I'm sorry, we're not going to do that. Is it safe to say that anyone who walks into a physician's office to do this 语法解析

56:19

needs to be able to be over 18 to provide consent. But is it safe to say, or is it the case that people younger than 18 can do this in less reputable places without parent consent? It should be 18. It's like any other medical procedure. You have to be 18 years of age to consent. There are rare instances where I will treat someone who's 16 or 17 if the parent is there. And 语法解析

56:44

And if it's for something, for example, a patient has a hump on their nose that they don't like, but they're not ready to commit to a rhinoplasty. So I can use fillers in a creative way to help reduce the appearance of that. But that's very far and few in between. But the parent is there. Yes. Yeah, absolutely. I did have a very interesting incidence where I had an 18-year-old, though, come in. She had just had a rhinoplasty and was coming to see me for 语法解析

57:11

fillers and for neuromodulators, I asked her, I said, you're 18. Is someone here with you from one of your parents? And no, nobody was there with her. And the interesting thing is, though, she is 18 thinking that she's an adult, but she's only a junior in high school. So I was very conflicted. I kept referring back to something along the lines of, you need to talk to your parents. You need to tell them what we discussed here. That really bothered me. 语法解析

57:40

for a long time that here is this 18-year-old who's still in high school that wants to do things and I don't see a parent there with her. 语法解析

57:48

But I think it's not a huge problem, probably, across the board that people under 18 are getting treatments, but they're getting fed all of this societal pressure. I like to use the term beauty pressure, like peer pressure. It's beauty pressure that's now more extreme because of social media. They're getting all this beauty pressure at a very young age, 12, 13 onwards. And so by the time they get into their 20s, they've been thinking about this for years and years and years, and they're ready to dive into it. 语法解析

58:16

Now, there's probably not a lot of people in my audience that are particularly young, but maybe we can start the discussion through the lens of preventive care. So we can talk about preventive care and then move into maybe where I am now, where I missed the boat on pure prevention and I now need to start being active. So 语法解析

58:36

For the person who's listening to this, who's still in their prime from an aesthetic perspective. So I guess they're in their twenties, maybe even in their thirties, depending on their genes. The only thing I know is wearing sunscreen is a net positive. So I understand enough to say that UV damages skin. Is it damaging elastin? Is it damaging collagen or is it purely just these sunspots that it creates? What is it that sun is doing that is damaging? 语法解析

59:03

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

59:26

And that's in a country that has a lot of sun. So that shows you the power of using sunscreen. Now, I'll take it a step further. I tell my patients they have to use mineral sunscreens as opposed to chemical sunscreens because I'm not convinced of the safety of avobenzone, oxybenzone as hormone disruptors. I do think there are some scientific studies that suggest maybe they play a role in infertility. You 语法解析

59:50

You can measure them in the bloodstream, especially if you're putting them over the entire body. The skin is a great portal for chemicals to enter into the bloodstream if it's the right size chemical. So there have been already studies done that show a huge spike in the amount of these in your bloodstream after application. After saying this for 15 years, I think the FDA just a couple weeks ago finally told the companies they must do animal safety studies. 语法解析

01:00:14

It's about time. It's very late. Yeah, so late in the game. It's very late. Sorry to interrupt. I'm so on board with you about the problems with chemical sunscreens because the other problem it creates is that patients think they're covered and 语法解析

01:00:27

And then the chemicals that are actually protecting against the UV damage become inactivated over time. Because you still have the film on you. You have the film on you, and you don't know at what time of day you no longer have any solar protection. It's within an hour. You put a sunscreen SPF 70 on, go outside. If it's strong sun, it's going to be deactivated within an hour. People will burn on SPF 70, SPF 100. 语法解析

01:00:52

There should be nothing above an SPF 50 mineral. What is the use case for the chemical sunscreen? Are they less expensive? What was the rationale for them? They blend in. They blend in very easily. People love it because there's no white film when they put it on. A mineral sunscreen takes a little bit more work to blend it in, or it's going to cost more because you're going to have to get a micronized formula of zinc oxide or titanium dioxide. So my Elta MD 30 to 50, I think I have one of each, 语法解析

01:01:21

I'm pretty sure that's a mineral sunscreen. You have to work to put it in. Yes. And some of them, Elta makes some mineral and some chemical ones. So just double check. And they make it confusing on purpose, by the way. So you have to go out of your way to actually find formulas that are primarily mineral because the companies want to sell you both products. And they know that customer satisfaction is higher with chemical. And this doesn't have anything to do with this conversation specifically, but 语法解析

01:01:49

Susan has created skincare and so have I created skincare. So we've really dived into this world of skincare and the marketing of skincare can really mislead consumers. Companies that are creating skincare are motivated by sales. They want people to be happy with their SPF. When it's a chemical sunscreen, they're going to be happier with it because it doesn't have that white pasty effect, but it's just not as effective. 语法解析

01:02:14

And the other thing that happens, if you look at the amount of skin cancer in the U.S., it's increasing, including melanoma. So why do we have generations now of people from the late 90s on up who say they use sunscreen all the time and our skin cancer rates are going up? 语法解析

01:02:32

I think it's twofold. I think it's because, A, like you said, Tannoush, the sunscreens degrade very quickly when they put on a chemical sunscreen. And I'm going to take it one step further. When those chemical sunscreens absorb those harmful rays, whether it's UVB or UVA, the chemicals absorb them and they neutralize those rays, but they cause reactive oxygen species 语法解析

01:02:53

And those reactive oxygen species damage the DNA of the cells, which then accentuates the damage that you're getting from whatever other UVA gets through the sunscreen. So you're really causing more damage and probably causing… 语法解析

01:03:06

These cells have become more atypical over time. By the way, you know that there's a group of people who argue, and I don't agree with this at all, that argue that sun and UV rays have no causal role in melanoma. And the argument they put forth is sunscreen use has been increasing and yet we see a significant increase. 语法解析

01:03:26

in the incidence of melanoma. So they're pointing at the same observation. They're offering a different argument. I find your argument far more compelling. Yeah, I think everyone should be using a mineral sunscreen. So that's number one. And let's talk again just about the why. So what is it that ultraviolet energy is doing to my skin that is deleterious? So I'm going to throw out more than ultraviolet. So we know there's UVA, and UVA is the longer wavelength between the two ultraviolet rays that reach the Earth. 语法解析

01:03:55

That's A for aging. We have UVB, and that's B for burns. That's the one that causes a lot of the redness and the sunburns and leaves behind a lot of the atypia in the cells. So UVB probably causes more skin cancers than UVA, but they're both implicated. But add to it, we have high-energy visible light, we have visible light, we have infrared light, all coming from the sun. So we have five different rays, and they all play a role in how we age. 语法解析

01:04:23

So we worry about UVA, UVB with regards to skin cancer, but high energy visible light and visible light also play a role in terms of hyperpigmentation. Infrared as well. And now there's some evidence maybe suggesting that because infrared light can reach deeper into the skin, it may have a role on fat atrophy and bone remodeling. So 语法解析

01:04:46

So I'd like to see more studies on that. I don't know how you could possibly do that in an ethical way. I mean, you could do animal studies, assuming you had a comparable model for fat and bone. That's the only way. You'd have to use the isolated spectrum. You couldn't do it in sunlight. I assume you wouldn't be able to disentangle which energy wave was causing the effect. But that's an interesting thought. Yeah, I think most of us think that… 语法解析

01:05:09

Most of us. I've always thought, well, the sunspots are unattractive, but my pigment's dark enough that they don't really show up that much. And okay, so we know what sun is doing. One more addition to talk about with the UV damage, because we could probably spend the whole podcast on UV injuries. 语法解析

01:05:27

But in addition to everything that Susan said, a couple more things that I think are important to hear are for listeners is that UV also not only do you know that it damages DNA and can lead to tumors, cancers, melanoma, but it also injures collagen particles, elastin particles, a lot of the ultra structure. 语法解析

01:05:47

of not only the cells have intracellular infrastructure, but also extracellular infrastructure. So the matrix of the subcutaneous tissues, the dermis is built by this beautiful scaffolding. If you look at an 18 year old skin under the microscope, it's this thick, 语法解析

01:06:06

beautiful blanket layer of volume because you've got this collagen-elastin structure that's holding this whole thing up and is filled with water molecules, have lots of space to move around in and signals going back and forth. So all of that collagen-elastin framework also gets heavily injured by UV over time and it becomes cumulative. 语法解析

01:06:27

And that leads to thinning of the skin, loss of the subcutaneous fat layer, loss of those intracellular connections so that people start to get pitting and find reliance and wrinkles. And so that's just from an aesthetic standpoint, just another area just to know from UV damage. I'm sure you've heard this before, but all of my black friends now are… 语法解析

01:06:46

are looking infinitely on a relative basis, their aging is slowing down. And so they always say, black don't crack. And so how much of the difference that we see in black skin versus white skin is due to less damage from UV versus other genetic differences that enhance what you're describing? It's almost completely what you're saying is the protection value of the increased melanin particles that people with darker skin have. 语法解析

01:07:15

There's a Fitzpatrick scale from one to six where we talk about Fitzpatrick one is someone who's extremely fair, blonde, blue-eyed, burns all the time, never tans, and then it goes all the way to Fitzpatrick six, which is 语法解析

01:07:26

The darkest skin that you'll see never tans, can't burn. And we're all somewhere in that spectrum. So I'm a three? Three plus, probably. Yep. Maybe verging on a four. Is there basically a linear relationship between one and six in terms of how well you will age skin-wise? I think generally, yeah, that's about right. And the melanin factor is huge. Just to counter that argument earlier about people who talk about trying to put sunscreens 语法解析

01:07:52

The melanin evolutionarily, if you actually look at what's happening when melanin is inside the cell, it's not just randomly dispersed. It's actually the melanin forms a parasol over the nucleus. To protect the DNA. To protect the DNA. So evolution is showing us microscopically why it's so important to protect ourselves from the UV because we get this parasol of melanin that sits on top of the nucleus to protect it. And when we're Fitzpatrick 2 to 6 or 2 to 5, 语法解析

01:08:21

and you're exposed to sunlight, we get immediate upregulation of melanin production by the tyrosine kinase pathway. And all of that melanin doubles and triples. So that's why we're tanning. The tan, it happens to be aesthetic, but the reason we tan is to create more melanin to protect our DNA. Yes, and it's only aesthetic in this day and age because it used to be that if you were tan, you worked in the fields. So it was not a sign of prosperity and affluence. 语法解析

01:08:49

It is only aesthetic in our current day and age. But yes, melanin is our own antioxidant. It's a very good antioxidant and that's how it works. Okay. To your point, we could spend the rest of the podcast on it. We won't. We've established the fact that step one, the no regret move, protect your skin in the sun. What's the next level thing that one can do for prevention? So we may be on the same line. We might be a little bit different. I would say step two is 语法解析

01:09:17

Would be a retinoid of some sort. I was worried you were going to say that. I know. Everyone says that. It's just one more thing I have to apply. Well, here's what I tell patients. Because you said you don't wash your face at night, right? It's so gross. Do you brush your teeth at night? I do. I'm a religious flosser and teeth brusher. Right next to your toothbrush, put your little tube of retinoid. That's what I tell my patients. 语法解析

01:09:39

Retinoids, we have different categories. There's retinol, which is the weakest one, and your body will go put it through two enzymatic changes to become retinoic acid, which is what you get at the pharmacy. And that's great if you're in your 20s, late teens, early 20s, and you're just trying to be preventative with how your skin is aging and at the same time maybe addressing some acne. Once you hit late 20s into your 30s and early 40s, you need maybe 语法解析

01:10:06

maybe something a little stronger, and that's where retinaldehyde is a little bit better. And that's the next conversion. So retinol becomes retinaldehyde, which then becomes retinoic acid. So retinaldehyde is that middle step. And there's more actual enzyme in your body that can convert retinaldehyde to retinoic acid. And that's less irritating for people to use. So in your case, if you get irritated very easily and you're going to quit, it gives us an option to give patients something that's highly efficacious. 语法解析

01:10:34

that is going to irritate their skin less because it gets converted to the active form after it's been absorbed into the skin. And then the gold standard is retinoic acid, and that has multiple different strains. But that's someone who's in their mid-40s and up. They're going to need it continuously to keep boosting collagen because our peak 语法解析

01:10:54

collagen production, you want to venture a guess as to what age we peaked in our collagen production. I would say late teens, early 20s. Yeah, 18. That was when our fibroblasts were making the most of the matrix that Tanisha was talking about. I guess that because that's when in women, bone density peaks at about 18. For men, it's about 20, 21. Yes, exactly. So 18, we start to make less collagen, elastin, and glycosaminoglycan. So 语法解析

01:11:19

If we can add a retinoid in there, we're telling the fibroblasts to boost more of those production of those ingredients, those peptides and those collagen matrix. If we are looking at the melanocytes, those retinoids also normalize the function of melanocytes so that they're less aggregated, less overactive, and they also help to normalize the turnover of the keratinocytes. 语法解析

01:11:43

So they're working on the major cellular structure of the skin at the level of the DNA. Now, my recollection is there were two concentrations of this stuff that you could get. Does that ring a bell? Of the prescription? Yes. There's three, 0.025, 0.05, 0.1. And then there's like 0.04, 0.08. Those first three are the major ones. And also custom formulations. Yes. Yeah. Yeah. 语法解析

01:12:04

And the few times I tried to use this, I couldn't do it every day. It just got me too red. Did that mean I was on too high a formulation? I should have gone back to the aldehyde. I was too young. I probably tried this 10 years ago and never did it again. I take a different approach than even most of my colleagues. I tell people if they're trying to achieve a goal, whether it's treating melasma, sun damage, 语法解析

01:12:27

or they're getting ready for a child's wedding, or we have to do a procedure, I would tell them to tough it out. Because if you use that retinoic acid every single day, your body acclimates to it very quickly. It may take six weeks, seven weeks, eight weeks, but you get your skin used to it, and then you reap all the benefits. But some patients are always going to quit. So from that standpoint, then… I'm a quitter. Yeah. So we would give you five days a week retinaldehyde, two days a week retinoic acid. 语法解析

01:12:55

and tell you to start that way. And then maybe as your skin acclimates to it, you can change that proportion. Okay. And by the way, do you become more light sensitive when you take this? Does it make it even more important that you're wearing sunscreen in the sun? So those studies came out very early on, which is why people start to say, oh, I stopped my retinoid in the summer. And that's the last thing you should do. Because initially when you start a retinoid, you will get exfoliation at the level of the dead layer of the skin, the stratum corneum. 语法解析

01:13:23

But after you've been on the retinoid for a long time, that builds back up. You become less light sensitive. You might always still be a little bit, but you're a lot less light sensitive than when you first start a retinoid. But you should always have a sunscreen on and a hat. And retinoids have been shown, even if you get sun exposure, they have the ability to repair some of that DNA damage early on. So you really want to be on a retinoid all the time. 语法解析

01:13:49

Okay. Anything you would add to that, Tanej, on the retinoid before we go on? No, I think that was great. I totally agree with everything Susan just said. I have a slightly different protocol with retinoids and people who are sensitive. I might have them start out two or three times a week and then gradually build up to… 语法解析

01:14:04

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

01:14:29

I was going to also add, when people are thinking about the core aspects of what should they be using on their skin now that they're starting to notice some changes in their 20s or 30s, in addition to sunscreen and retinoids, I think that vitamin C is a really important molecule to get onto the skin also. Tried that too. Let me tell you why I stopped. It was mixed with like ferric acid. Ferric acid. Yes, yes. And it stunk. 语法解析

01:14:57

I just hated the smell of it. And the reason for that is because vitamin C is a notoriously complicated, easily reduced molecule. And when manufacturers are formulating their vitamin C serums, it might be a year from when it leaves the factory and gets onto your skin, if we're lucky. And in that year, 语法解析

01:15:19

All of the relatively inexpensive vitamin C serums are going to degrade and not actually have any bioavailability when that vitamin C is applied to the skin. And so the relatively more expensive formulations are being produced by manufacturers that are doing all sorts of 语法解析

01:15:37

manufacturing flips and tricks to try and stabilize that vitamin C. The product you're talking about, which I think I can probably guess, is they use the ferulic acid to stabilize the vitamin C so that it maintains its bioavailability. Other formulations of vitamin C will use an oil-based formula. It's not aqueous because then the vitamin C is much less likely to be reduced in that kind of formulation. But those products tend to be 语法解析

01:16:03

petroleum, oil-based, and also have all sorts of negatives associated with it. And then there are some products that will microencapsulate or find other creative ways 语法解析

01:16:12

of making sure that the vitamin C is actually bioavailable when it hits your skin. So that product may have not worked for you, but there are other options to find a stable vitamin C. And this is one of those products where, again, we have our own custom formulas, but I'll tell people who are price sensitive, go to Walgreens, buy a retinoid, buy a sunscreen. You don't need to spend more than $10 or $15 on effective products. Vitamin C is something where you have to spend the money. 语法解析

01:16:41

And by the way, what retinoid can you buy at Walmart? Retinol and some retinol. I see. You can't get retinoic acid without a prescription. Right. Got it. And is there any downside of using retinol or do you just need a lot more of it? The problem is if you try to push that enzymatic chain reaction, you'll get dermatitis. Got it. Okay. So in other words, if you can afford it, it's better to get the prescription. And I'm guessing retinoic acid is not expensive. Finally, it's come back down in price. 语法解析

01:17:07

I think now that they realize more and more people are willing to spend out of pocket to buy it, it's about $80 to $100 for a tube. That tube will last about three months. 语法解析

01:17:16

If it's lasting longer, you're not putting enough. And just show me as though I'm doing this. We're going to talk about how to wash the face and do all that because I'm guessing you don't do this without washing your face, especially if you've had sunscreen on all day. Are you putting this on like all over your face like this, even over my beard and stuff? So I tell people, first things first, you have to put the right amount on because 语法解析

01:17:38

Because every time we give anyone any prescription, we tell them, take this many milligrams once a day, twice a day. We don't do a good job telling people how much sunscreen to put on, how much retinoid to put on. So I always tell them, hold up your finger, and it should be from the tip of your index finger to your DIP joint. Oh, my God. And that's a fingertip unit. And if you can do a fingertip unit of retinoid every night, that's a great way to measure that you're getting enough on. Yeah. 语法解析

01:18:03

And I can see your face. You can see I'm getting a troponin leak right now just thinking about applying that much stuff. Yeah, and I have them put it on their face, including the under eye area, because that's the thinnest skin. And that's the skin that's going to wrinkle and age first. So most people are afraid to go around their eyes. I tell them, just don't get it in your eyes. Go around, but make sure you're getting that under eye area. Once a week, maybe on the upper eyelid. 语法解析

01:18:27

And then once or twice a week on the neck, because again, this is the thinnest skin. We've got to keep that skin building collagen and elastin. Okay. The vitamin C and ferlic acid, would you put that on after? First. So you always put the liquid before the thickest stuff. Thinnest to thickest. Let's talk then about how you wash your face before you begin this procedure. So 语法解析

01:18:53

I've just come in from whatever I've done. I'm brushing my teeth because that's the only time I'll do this. I'm going to wash my face now. What should I do? I'm guessing that the hand sanitizer next to my sink is not the thing to use. So there's been a huge shift in so many areas of skincare that is now sinking more with what science is telling us. And so 语法解析

01:19:15

Historically, there was a belief that you would need to strip all the oil off your face and debris and dirt before you apply products. We're talking about skincare routines from 10 or 20 years ago. We now know that that is harmful. It creates inflammation. It disrupts the microbiome of the skin. It does all sorts of negative things. A modern cleanser that we suggest is usually something that is glycerin-based. Usually, there's also other versions, but it's a way of 语法解析

01:19:43

cleansing the skin without overly stripping the oils out of the skin. Glycerin-based cleansers don't foam. That's certainly my bias. I'm sure you might have some other thoughts, Susan. But that's the first step to get the debris and superficial oils off the face and previously a pride product. And then as Susan said, you go from thin to thick. And so usually on top of that will be serums like vitamin C serum, 语法解析

01:20:08

or retinols. And then finally, you'll put a moisturizer on to kind of seal it all down. Okay. So hang on. Serum. Any antioxidant serum. We mentioned vitamin C, but there are so many other great- What are the others? There are great antioxidant serums that contain salamarin, fluoritin. How does one pick? That's where you have to look and see who's invested in doing the clinical research based behind the products that they're promoting. So you tell me, what are you guys using? 语法解析

01:20:36

I would say that generically speaking, if you can find a vitamin C serum that has a higher quality vehicle to make sure the bioavailability of the vitamin C gets to your skin, that product is going to have additional associated antioxidants that are going to be very useful and helpful. And again, to avoid naming brand names here, you can find that quite easily at 语法解析

01:21:00

Can we go ahead and name brands? Because honestly, people just want to know. So let's just give some brands that you guys trust, maybe across a range of price points. I'll give you some names. 语法解析

01:21:11

I'll give you my brand name, but then also brands that I suggest to other people as well. My brand name is called Avia Skin Care, and it is designed to… A-V-I-A? A-V-Y-A, yes. And we formulate these products to have medical-grade efficacy. We also incorporate some Ayurvedic wisdom, which is anti-inflammatory. So it has turmeric and other eastern botanicals for anti-inflammatory care. And we have a vitamin C serum that is micro-encapsulated. 语法解析

01:21:37

that also has a retinol in it and also has various other antioxidants that are niacinamide that are all useful to apply to the skin right after you've washed it. Now, there are other brands as well. We can name a hundred of them probably. But if you couldn't use yours, what are two others? SkinCeuticals is probably one of the most available. That's the one I tried. Yes, when you said ferulic acid, yes. That's a wonderful brand. 语法解析

01:22:03

But there's no getting out of the stink of it. There is if you go again with a different brand. A different vitamin C formula. So they chose to use the Ferulic approach to stabilize the vitamin C. There's many other brands as well. So what's another non-stinky one? Obagi. Obagi Medical. That's yours? No, actually, that's not me. So that company's publicly owned, and I only formulate for them a Susan Obagi MD line. But their vitamin C serum has been around quite a number of years. 语法解析

01:22:31

So the original founder of Obagi is Zain Obagi, my father. But he has since left that company. So this brand has been time-tested for 35 years now. They're a vitamin C under a nitrogen vapor. So it makes it so much more difficult and challenging to produce, but it's a very stable form of L-ascorbic acid without deferulic. So what I'm hearing here is… 语法解析

01:22:53

This is not unlike what's the best diet for me. The best diet is the one that allows you to maintain energy balance that requires the fewest amounts of neurons to stay on. So I need to get three of these and figure out which one is the least annoying for me to put on. And it's no offense to that company. It won't be skinceuticals because every time I've tried it, the smell of the furuloic acid or whatever has been annoying. No. 语法解析

01:23:19

And Obagi, I didn't do a study for them, but they have a study that shows that their L-ascorbic acid penetrates about four times deeper than the one from SkinCeuticals. Okay, great. So I'm going to try both of yours. And just to name some other brands, I mean, there's SkinBetter is another one that I think produces good products. 语法解析

01:23:36

Maybe it's worth also mentioning, because we haven't done this yet, why is vitamin C so important? I assume it has to do with proline and collagen? That's one aspect. So vitamin C is sort of like a wonder molecule when it comes to facial aesthetics, because yes, it is a precursor for the collagen synthesis pathway in the proline synthesis pathway. 语法解析

01:23:55

But it also is a powerful antioxidant. And so antioxidant application to the skin not only has the power to remove oxidative injury that has happened during the day, but it also has the ability to reverse some existing damage that's in place. 语法解析

01:24:14

Vitamin C also regulates the tyrosine kinase pathway, which is a scientific way of saying that complexion, people talk about wanting to have good complexion. What does that mean? 语法解析

01:24:24

Complexion is something that across societies, no matter what your Fitzpatrick scale is, people like to have a good complexion. And that means having an even skin tone, which is even distribution of melanin. It doesn't matter if you're black or white or brown, people desire to have their skin look even without splotchy areas of pigmentation or nearby areas of relative depigmentation and 语法解析

01:24:47

And so regulating the tyrosine kinase pathway so that there's an even production of melanin throughout the skin is something that is valuable, very valuable in an aesthetic sense. And that's something that vitamin C does as well. Okay. We're going to go from the serum to the retinoic acid. Again, I'm being selfish and talking about my demographic. So people that are 40s, 50s and beyond. And then it sounds like the last thing you said we want to do is a moisturizer. 语法解析

01:25:13

Yes. I would say the cheapest trick in skincare, which actually is really true, is that deep moisturization locks down the skin barrier function and allows the skin turgor of the skin dermis epithelium to thicken just by having that 语法解析

01:25:33

occlusive barrier. So you can go to Walgreens and spend $6 on Aquaphor, which is basically petroleum jelly, and put it on your face nightly, and your skin will look better in 30 days, guaranteed, because your skin will thicken and a lot of the fine lines and crinkles will actually start to disappear because your skin is being more hydrated. That's 语法解析

01:25:54

That's hydration. That's hydration. But what if I don't want to grease up my pillow? I'm saying that as sort of like tongue-in-cheek. I'm not telling people to do that. If you actually did a double-blinded study, you would see that there are real results in 30 days. But the reason why I mentioned that is that good, deep hydration can be performed with an inexpensive product that you're using regularly, and it'll make a real difference because the moisturization, especially overnight while you're sleeping, is a powerful tool for aesthetics. 语法解析

01:26:22

Like I wouldn't give you though a moisturizer. You can just tell I'm a greaseball to begin with? No, you have young, thicker skin. Just like women age 20 years faster than guys in terms of the bone remodeling and fat atrophy, the skin as well. My routine would be done after the retinoic acid. From my standpoint, yes. At this point. And then we might revisit that in a few years. Yes. And I tend to give moisturizers as women become more mature. I don't want to use the word older. 语法解析

01:26:48

because they do start to make less of their natural moisturizing factor. That even starts to diminish even when we're 18. So most people, I think, into their mid-40s and 50s even, might not always need a moisturizer with everything that they put on at night. One caveat, though, sorry, is that your morning sunscreen and your serums have some moisturizing quality to them also. And I always have them put a super antioxidant serum or a vitamin C serum on at night before their retinoid. 语法解析

01:27:18

Because my feeling on this is that you spend the whole day outside or in your car or being hit by LED lights and ultraviolet lights. Those are also damaging the skin. And so I think you should have an antioxidant on first thing in the morning, but it's going to get depleted by the end of the day. Wait, wait, wait. I'm sorry. I missed that. Are we putting the serum on in the morning? 语法解析

01:27:38

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

01:28:00

No, no, just at night. Okay. And the retinoic acid has anti-inflammatory properties to it in addition to all the good things it does in terms of building up collagen and elastin. Okay. 语法解析

01:28:09

Okay. So just to go through this, because I'm not the sharpest tool in the shed, my AM routine is going to be… Wash. Okay. Let's assume I just came out of the shower. All right. By the way, in the shower, don't use your body soap on your face because it's going to strip the oils out of your face. So again, you need a separate facial cleanser. Oh God. What do I need? The same glycerol-based thing? Depends on your skin type too. I tend to be… 语法解析

01:28:34

maybe a little bit more picky about… I mean, if you saw the crap, I've got like a $2.99 bottle body wash from Target that I scrub head to toe. I am the lowest… 语法解析

01:28:48

put it this way. When my wife met me in the hospital, the first thing she noticed was how disgusting I was in that I used to take alcohol pads and clean my face. Like that was my shower in the hospital. That probably wasn't bad. It was a little harsh, but it probably wasn't bad. There were worse things you could do. All right. So we're going to do soap. We're going to do serum. Yes. And then we're going to do sunscreen. Yes. That's the morning routine. And some people might in their need, depending on if they have 语法解析

01:29:15

clogged pores, oilier skin, they might need an alpha-hydroxy acid or polyhydroxy acid before their sunscreen. But you've nailed it right there. That's a very simple regimen you can follow. Okay. And then the PM is soap, serum. We prefer if you call it a cleanser, right? Because soap opens up the door to the Target 299 stuff. Yeah, fair enough. And now the difference is I do have lots of patients like you, Peter, who are minimalists. 语法解析

01:29:41

Again, it's trying to get them to use whatever they can to protect their skin and hopefully start to improve the aging process. 语法解析

01:29:49

I might, just to do the experiment for 90 days, try to commit to cleanser, serum, sunscreen in the morning, cleanser, serum, retinoic acid in the evening. We agree that would be? Yes. Okay. Yeah. By the way, in the show notes, we'll get from you products that you guys like, including your own. I just want to let people look through this and decide. And obviously you guys disclose your own products. Great. But let people see the full breadth of things. 语法解析

01:30:15

And I'm sorry, one of the things people ask about though, especially when they're very into their nutrition and eating healthy, they say, well, why do I need to apply an antioxidant if I'm eating a lot of antioxidants? And the skin being the largest organ in your body, it's very unique. It's very good at keeping things out or from the inside coming out as well. 语法解析

01:30:34

So outside things like water, pollution, it tries to protect that from getting in and does a good job at keeping kind of homeostasis. So they have shown that the level of vitamin C that you can achieve in the skin by topical application far exceeds what you can do by ingesting it. The amount you would have to ingest to get the right amount in the skin, you'd have GI issues. That would definitely make you quit. 语法解析

01:30:58

Before we leave this, I guess one thing I just want to chat about is acne. Again, it's mostly something that adolescents are experiencing, but adults get acne as well. Is that something you guys spend much time on? I do. Give me the playbook you have on acne. I assume it involves spironolactone. If it looks to be endocrine in nature, I'd be very curious to hear about Accutane. I hear horror stories about it, but obviously it probably works very well. What do people need to be aware of? 语法解析

01:31:27

What's your playbook for addressing acne? My number one thing I tell people is for themselves or their children, try to treat the acne before it scars. Because I cannot tell you how many times I see patients for consults for acne scars 语法解析

01:31:40

They're in their 70s and they're still crying about it as if it was yesterday. They've been traumatized all their life with these acne scars. And what causes acne to scar? So it depends on how inflammatory your acne is. There are different types of acne. There's comodonal acne, which are just your run-of-the-mill small pimples, whiteheads, blackheads. Those don't typically scar unless someone picks at them. So number one rule for patients, don't pick at your skin. 语法解析

01:32:04

Second thing, they can have a little bit more inflammatory acne. And those tend to be the red ones that come up and they're maybe pustular on the skin. And if you don't pick at them, those also might heal without scarring. And then there's cystic acne. And those are a completely different type of acne where you're getting inflammation that's sebaceous, pilosabaceous unit. 语法解析

01:32:26

which is the hair follicle and the oil gland feeding in there, and you get swelling deep in the dermis, and then you might get enough inflammation and rupture of that cyst that you leave a divot at that point, and that causes what we call a valley scar. Even if not picked. Even if not picked. So cystic acne is a true, in my standpoint, a medical emergency because you want to treat it before— Maybe not on the level of anaphylaxis, but— Correct. Correct. 语法解析

01:32:52

Correct. But for parents. It's a dermatologic medical emergency. Yes, because it can cause so much psychological trauma to the child. People with cystic acne, even bad inflammatory acne, they're shy to go out in public. They want to hide their face. They hide their face with their hair. What percentage of adolescents will develop cystic acne? I don't know that I can quote the exact percentages, but about 20%. Oh, wow. So pretty high. And it's very difficult to fix later. Yes. 语法解析

01:33:18

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

01:33:36

Okay. Say more about that. So photodynamic therapy is where you take a molecule like aminolevulonic acid, ALA, and you paint it on the skin and you let it incubate for about an hour. And then you shine a red light onto the skin to activate it. And that chemical gets into the sebaceous glands and percolates down through the skin. And when you activate it, it causes a heat reaction and basically induces damage in that whole area that's picking up that medication. So you're 语法解析

01:34:04

causing the oil glands to shut down. You're taking away the nidus for the inflammatory acne. And for some patients who cannot take acutane or isotretinoin, that's a great alternative for them. It does feel uncomfortable and not every doctor offers it, but it's a great adjunct or alternative if they can't take isotretinoin. Would antibiotics work if not for the limitations and side effects of 语法解析

01:34:30

long-term systemic antibiotic use? So antibiotics will work to a small degree. They might help shut down maybe a good proportion of that cystic acne flare, but they won't get to the root cause, which is sebaceous unit overproduction of oils, the bacteria that are in there feeding off of that, and the whole cascade. And there's something genetic. Cystic acne tends to run in families. 语法解析

01:34:52

So there's some kind of genetic tendency towards that milieu that causes cystic acne. And how does Accutane work? What's the mechanism? So Accutane is a type of retinoid, and it's basically going to go in there and dry up the oil production that's in these overactive sebaceous glands that are being driven by your androgens. But you have to take it orally. Correct. So they have used some topical variations of it. 语法解析

01:35:16

for psoriasis and things like that, but the best is to take it orally because then you bypass a lot of the surface dermatitis. What is the main side effect or toxicity that people are trying to avoid with Accutane? Why does it have a bad name? So it has a couple of bad connotations with it. First, it dries everyone out. So for the five months you're on it, you are going to have dry lips, dry eyes. Some people complain that their skin is too dry. Some people on high doses might get shedding of the hair. 语法解析

01:35:43

And then you're not allowed to drink alcohol while you're on it. So that's a whole other issue with kids and making sure they're compliant with that because it is metabolized by the liver. Other than that, patients, if they're using it correctly, tolerate it very well. And the teratogenic effect. Oh, I'm sorry. Yeah. Sorry, say again. Teratogenicity. Can't reproduce. You're not getting pregnant on it because it will cause defects. So we have to go through this whole FDA required modules with the patients. 语法解析

01:36:10

to make sure that they're using two forms of birth control for the female patients. While they're on it, they're not donating blood while they're on it. But it got a very bad reputation when I think it was a child or son of a senator committed suicide while on that medication. And they said it was the depression induced by the medication 语法解析

01:36:28

When it turns out, when people look scientifically at the rate of depression. Yeah, that sounds like junk science written all over it. Exactly. If you look at depression scores in acne patients with cystic acne, it's significant. And their depression actually improves when they take something like Accutane because they feel better. And do you have to monitor liver function tests while patients are on it the same way you do with Lamictal or any of the toe fungus type things? Is it that severe potentially? It could be. It changes your lipid profile while you're on it. 语法解析

01:36:54

It can elevate your triglycerides and elevate your cholesterol. And there are very few instances we would adjust the dose. We just tell people to try to eat healthier while they're on it, especially triglyceride elevation. 语法解析

01:37:05

Liver enzymes, it's a rare patient that gets a real significant bump, but you want to watch for that because you want to stop the medication if that's the case. And it's also a proxy to make sure they're not drinking. It's sort of a way of finding out if they're following the rules. Yes, we tell them, we can tell. Yeah, and I don't prescribe Accutane. This is usually something that specific physicians are. Yes. And you mentioned five months. 语法解析

01:37:28

Does that imply that you do this very lengthy five-month treatment and then you're done with this? It eradicates the sebaceous glands to the level where the child, the teenager, is done with this treatment afterwards? For 85% of people that take it for five months, they're done. Then you've got the small subset that need to take it again. And then I have my adult patients who don't. 语法解析

01:37:50

might not have a lot of acne, but they're very oily. I put them on at one month out of the year just to dry them up a little bit. And it helps them feel better. It makes their pores look tighter, makes their skin have a better texture to it. 语法解析

01:38:05

Because we always said, oh, if you have oily skin, you're going to age better. That's so not true. Oil is inflammatory on the skin. So from that standpoint, I'd rather have them use it to dry them up for about a month and then allow them to enjoy the beautiful skin for the rest of the year. Sounds like a dumb question. How does one know if they have oily skin? Like I've always thought I have oily skin, do I? Well, your pores would be enlarged. Some people have to block their face midday. I don't have that. Okay. Okay. 语法解析

01:38:30

Let's move on now. By the way, that was super interesting to me. By the way, I want to make sure we also get good products. We didn't talk about it, but can you tell me, you mentioned for the cleanser, it just needs to be glycerol based. Are these easy over the counter things to find? Should I be going to Target or Walgreens and literally just going through the skin aisle and looking for cleansers that are glycerol based that won't lather when I use them? Is that the litmus test? 语法解析

01:38:55

It's one way to do it. And we can also provide- Give us a bunch of links to products. You can include your own. I don't care. Yeah. Just make it easy. And if you're oilier, I'm going to give you one that's not quite so hydrating when you wash. Okay. All right. Let us move now into the really confusing realm of I show up in your office. 语法解析

01:39:16

Can't tell you what's wrong, but I show you a picture of me 10 years ago and I say, I want to look like that. 语法解析

01:39:25

And I should have brought a picture in of me so you could actually see it. But you've already described it without having seen the picture. I don't have bags under my eyes. My skin just looks better. Everything just looks better. Part of it is color. I will admit, 10 years ago, there was no gray anywhere in my beard. We're not going to fix that problem. That's fine. Oh, and the wrinkles in my forehead. I notice in pictures of me in the past, I've 语法解析

01:39:51

I had some wrinkles. Now it looks like I have a wrinkle farm. Again, go over the changes. Assuming I had that photo, how would you describe them pathologically? Or maybe that's too strong a word, but you know what I mean? There are three basic changes that happen to every single person with aging. And we've touched on this a little bit and we'll dive deeper now. So there are skin changes. There are volume changes. There are gravitational changes. And maybe we should throw in the fourth, which is 语法解析

01:40:19

bone structural foundational changes. And so those happen to everybody. When we see patients in our clinics who are presenting the way you've just suggested, we will spend extra time analyzing the individual nuances of skin volume, bony ligamentous anatomy, gravitational changes that are specific to your face. And then also we'll just rely on general knowledge that we have about what types of aging changes we see at this point. 语法解析

01:40:47

And it's a very complex process. I tried to analyze this a little bit before walking into this podcast today. Like what am I actually thinking about when I'm starting to communicate with the patient? As soon as I see the patient, while I'm making some niceties and saying hello and get to know them, I'm already analyzing, I'm already looking at their skin. I'm looking at the bone structure. I'm analyzing the facial proportion. I'm looking at areas where there's volume loss, it's obvious. 语法解析

01:41:13

I'm looking at the dynamic movement of the forehead and the face. I'm analyzing how much heaviness is on the eyes that might be driving frontalis muscle tone that's causing forehead wrinkles. I'll be looking for facial asymmetries. So a lot of the physical exam that we do in our offices happens in the first 15 seconds because we're just, this is what we do. 语法解析

01:41:34

And it just happens quickly in our mind. Big difference. It's that blink moment. Yes, it is. You look at someone and you're like, I know what I'm going to do on them. Yes, yes. The urologist doesn't have this advantage. Right. He can't examine the prostate and the scrotal tissue during that first 15 seconds. Very good point, yes. So we do that when we walk into the room. That analysis already happens. And then because I've already got that snapshot anatomic analysis already in my mind, 语法解析

01:42:03

Then the next step that I'm doing is, and I'd love to hear what your process is, Susan, but the next step is I'm now going into their mind and trying to understand their psychology and what their motivation is. And the problem that we have is that the patient doesn't know what words to say. Yeah, they're like me. For them to communicate what's actually driving them. 语法解析

01:42:25

And so I have to pull that out of them. This was a little bit of detective work, a little bit of background. My parents are both psychiatrists. I actually went to medical school thinking I was going to go into psychiatry. And then I rapidly pivoted into surgery and ended up where I am. But that initial love and appreciation for what's happening inside the neuronal processing and the subconscious, 语法解析

01:42:49

It's something that we actually work with every single day in our offices. And so the next step that happens in a consultation is- I would say hopefully. I mean, to me, that's a great thing. And not to be a downer, I don't know that that's true of every person who is dealing with aesthetics. I would guess there are a lot of people who are just kind of doing this in a coin-operated way. Cookie cutter. Yeah. I think you're right. Unfortunately, there can be a tendency to take a cookie cutter approach where you recognize this. It's a knee-jerk reaction. There's wrinkles on the forehead. Inject Botox. 语法解析

01:43:18

you know, there's gels, do a facelift. That's not the way that we should be practicing aesthetics. Every single individual has a totally customized situation anatomically, physiologically, and psychologically. And so our job is to try and figure that out when the patient doesn't have the ability to express 语法解析

01:43:39

So sometimes it's almost overlaps into pediatrics, which is something that I know you've got some history with in surgery, but you're trying to do a physical exam and get history from someone who's unable to communicate what they want you to figure out. And so I'll start asking questions. Did you like the way you looked when you were 20? If they say yes, that means that they actually like their natural facial proportions and they're probably looking more for rejuvenation. 语法解析

01:44:04

But if they say, “You know, I always had a heavy eyelid and I never could put makeup on my eye,” then I know that they're maybe looking for something that's a more substantial result in that particular area. That's just one example. And then I'll try to get to know them. What's their occupation? What's their situation at home? Do they have kids? Tell me a little bit about your life. I'm trying to understand their social history, see if there's any red flags 语法解析

01:44:28

that would stop the process and say, okay, this is not the right time to be considering aesthetics. You got to get your mental health in order before we proceed, which is something that I would very openly tell a patient at the right time in the consultation. But if a woman came in and said, my husband is leaving me, which is unfortunately probably not an uncommon thing. And 语法解析

01:44:49

And let's make it more extreme. A 50-year-old woman comes in and says, my husband of 25 years is leaving me for a 20-year-old. Understandably, she's in duress and she's probably… 语法解析

01:45:03

comparing herself to a 25-year-old, would that be a non-starter in your mind? The scenario you described is actually very common. I see this kind of situation all the time. And this is why I schedule 45 minutes or an hour for initial consultations, because once we start talking about that, 语法解析

01:45:19

Tears may start flowing. The patient is now in a safe zone. Talking to a medical professional who's actually listening to them. We were talking about time in a clinic before. Then we start to fall into the role of a therapist and we're letting them express because I want to see how deep is this trauma. I'm trying to understand, is this something that is now a non-starter or what should we do here? Because there are scenarios where someone is in that kind of scenario, situation, and 语法解析

01:45:46

where we certainly would not want to make any drastic moves or big changes or shifts, but is it appropriate to recognize that this person is desiring something that is a reasonable goal, but the current emotional state is not appropriate to do the procedure to get there? So maybe we say, look. We do something reversible. Yes, exactly. Because the fear, sorry to interrupt, but I'm guessing that the fear here is 语法解析

01:46:11

If you say no to her, she's going to find some guy down the block who will do anything. And it's better that you do something small. 语法解析

01:46:19

and develop a relationship with her that will ultimately serve her interests, but you can't give her everything she wants at the moment. Is that a fair assessment? Very well said. That is exactly right. We're trying to build that trust and build that relationship on the front end so that this individual who's trying to get from A to B, we're going to take them there safely. 语法解析

01:46:41

Whether it's over a couple of months or 10 years, we're going to try to get to that goal. And there may be some obstacles along the way and choices that we have to make, but we'll navigate it together. And it's all built on building that relationship on the front end so the trust exists where I can tell the patient, we are not going to do this maneuver right now. 语法解析

01:47:01

And then that patient will listen to me because the trust has been built up enough that this individual knows that I have their best interests in mind and we're going to get to that goal eventually. And so, yes, this scenario that you're describing, the individual might be best served with, okay, look, I think we can get there one day with procedures, but right now I'm going to refer you to a therapist. You have a lot going on in your life right now. Let's do some simple things that we're not going to regret. 语法解析

01:47:26

like neuromodulators and fillers and some skin treatments or lasers, things that are low risk. They're not going to create any scars or permanent changes. And then we can eventually get to that next step. We're not going to do the facelift next week. Correct. Yes, that's on hold. The first step is we do this snapshot anatomic dynamic analysis. It's not just a single image. We're looking at the muscle movement. 语法解析

01:47:49

And then the second step is this deep dive into their social situation, psychology. And then, presuming that everything's moving along smoothly and now we're getting ready to talk about what should we do now, then I'll spend time educating the patient on their actual anatomy because they've never actually had that information presented to them. So I will put the mirror in front of the patient and I will say, let's go through what I'm seeing on your exam today together. 语法解析

01:48:16

and we'll start at the top and I'll go through every little detail and I'll throw in little caveats like, I'm sorry, I'm not trying to make you feel bad about your features, but you're here for me to tell you. So I'm going to tell you everything. We're going to talk about your bones. We're going to talk about the wrinkles. We're going to talk about the asymmetry you never noticed, which by the way is almost always the case. People don't notice their asymmetries. And so we point out these asymmetries to them. And then after that relatively lengthy discussion about their individual anatomy, then we'll start to say, okay, 语法解析

01:48:45

okay, now you initially told me that these are some of the areas that bother you. Here's what we could do to fix this. 语法解析

01:48:52

your eye region, your cheek, your mouth, your gel, whatever it is. And I'll present typically options that go from minimally invasive to more substantial. And based on how the individual is responding to the conversation, I can usually at this point, 20 years in my practice, dial in what is the appropriate scope for this patient, 语法解析

01:49:16

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

01:49:43

showed up to here, which is my opinion. I won't give them my opinion about what we should do until we've gone through this whole process. And I've watched their body language as we've talked about procedures. Sometimes I'll suggest something that's minimally invasive and they seem uninterested because it's not enough for them. And I'll read that body language and kind of dial in the treatment for what I suggest for them. And so that'll happen at the end of the consultation. 语法解析

01:50:05

Typically. So I know that was a long answer, but that does, I would say, describe my typical consultation. How about you, Susan? Pretty much everything that Tanishq said. And I was so glad to hear that you talked to the patient about their mental state at that time too, because we do a lot of almost like psychology and therapy with our patients. If they open up to you 语法解析

01:50:28

then that's an honor to you and you have to take that and you have to help them through that issue. I have a psychology background as well. So I was biology and psychology double major in school. I use it a lot. It's so important. I approach patients very similarly, but I try to put things in terms that they can understand. So I tell them there are the five R's. 语法解析

01:50:49

of rejuvenation. And it doesn't mean they need all of it at that point in time, but at some point in their life, they're going to need one of them. And they'll make it through all five. And that is we need to relax overactive muscles, and I'm showing them on their face the movements. I will say we need to refill lost volume, whether it's through fat grafting, which is still one of my favorite procedures to do, or refilling with fillers. 语法解析

01:51:14

And I tell them we need to resurface the skin because to me, how the skin looks is absolutely much more important than how tight they are. So patients sometimes come in, they're like, I just want to lift here and they want to lift their lower face. And their skin is terribly wrinkled and they have hyperpigmentation and sunspots. And I'll tell them if I lift you now, no one's going to notice that you look better. But if I make your skin look better, people are going to notice you look better before I even do the surgery. So we have relax, refill, resurface. 语法解析

01:51:43

We need to do re-draping. So there are going to be times that you can't fill enough. You have to lift. 语法解析

01:51:49

So they either will lift with devices such as microneedling radiofrequency devices or ultrasound devices to tighten the skin or a facelift of some sort. So those you need to do. And then what people don't realize, my fifth R, is that you have to keep renewing because the aging process continues. And the minute they leave your office, everything you just did on them looks great and then it starts to diminish. And that's what we were just talking about. The renewal was the maintenance. Yes. 语法解析

01:52:16

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

01:52:40

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

01:52:59

So what I want to do then is I want you to go through the five R's looking at me. And Tanuja, I want you to go through your four changes looking at me. Just feel free to brutalize me. You're not going to humiliate me. So Susan, you look at me and let's start with relax. What needs to be relaxed in my face? So here's the thing. You do move your eyebrows a lot in your forehead. So you've got a lot of forehead wrinkles. I do notice the glabella 11s. 语法解析

01:53:27

These are those little sharp lines there. Yep. Yep. So knit your brows for me. Yeah. Raise your eyebrows up. Now, part of the reason you're raising your eyebrows maybe now more than you did 10 years ago is you have a little more hooding on your upper eyelids and your eyelids are almost touching your eyelashes. 语法解析

01:53:44

And when that happens, you're sending a signal to the forehead to lift so you can see better. Is that because I've lost elasticity in the eyelid and it's just drooping more? Well, no, more so going back to what we were talking about, the bony structure. Ah, that's right, the bone. We're losing bony support. 语法解析

01:53:59

fat atrophy, including the brow fat pad. And so now you've got to descent a little bit of your brow, but a little more of the extra redundant skin there. I got it. So I'm actually using this muscle more to try to keep these guys up. Exactly. Now, if you go to someone who doesn't evaluate you like we do, they might look at your forehead like target practice. 语法解析

01:54:21

and say, I'm going to use a neuromodulator across that entire forehead and make it so you can't move. And then you're going to walk around very hooded and very heavy. I would feel silly. I wouldn't want to look that way. You would hate the feeling. It would feel very hooded and very heavy. And I've done that on purpose to myself just to see what patients experience. And it's not a nice feeling. Secondly, you are very fit. So you have… 语法解析

01:54:43

Not a lot of fat in your face. And like I said, it doesn't matter what you think your weight is on your body now or how much fat percentage you have on your body, you've atrophied some of the facial fat pads. You've exposed the entire orbital rim. I can see that. And you may also notice I have a scar here and it has created an asymmetry in the drooping. So from… 语法解析

01:55:03

My teenage years when I was boxing, I actually had, I was split to my cheek there. So that is a very deep scar. I suspect the connective tissue there is actually tethered near the bone. And we can free that up with subcision. So that is kind of similar to the microneedling Tannoush did on your other scar, but this is going under the scar. 语法解析

01:55:22

the whole length of it and subsizing or freeing up that tethering and that adhesion with or without adding fat or filler there. Okay, got it. But I would. So if you look at what makes the eyes look youthful, it's definitely having a little more platform show on the upper eyelid, but also it's reducing what we call the length of the lid-cheek junction. So the length from your eyelash line 语法解析

01:55:44

down to where you can actually see the cheek, that's elongating. In me, yeah. You've lost all that volume that was out here. I think that if you were to ask me, Peter, what are you most self-conscious of aesthetically? I think this is it. I think it is this thinness here, which I believe makes me look constantly tired, even when I feel like a million bucks. 语法解析

01:56:09

I think I'm more subconscious of this than I am my wrinkled forehead. Yeah. And that's where I would either use a little bit of your own fat if we could find some. Oh, I've got plenty. And I would use that to rebuild this area and shorten that lid cheek junction so that we create more of a youthful length rather than this kind of long hollowed area. We're going to talk about this, of course, but when do you guys make the decision of an autograft of fat versus Restylane you mentioned earlier? 语法解析

01:56:39

I love fat if we can do it. Now, with the advent of fillers, the volume of fat grafting we do goes down. And I'll tell you why. On her, she came in, she had never had anything before. And she was hollow everywhere. How old? 69. Okay. 语法解析

01:56:54

So yes, we could use lots of fillers, but she'll spend a small fortune putting a lot of fillers in her face over time. And I personally don't like to inject more than two or three syringes of filler in one visit. So it's going to take a process to build up different areas on her because I just don't want to have a reaction. And I also want to see where I'm placing everything. But in her case, we went straight for the fat because she has a thin face, but she has a normal body mass index. 语法解析

01:57:20

So her fat is going to do well. How much filler would I require? What would your guess be? I'd start with a syringe split between both under eyelids, and then I would do another syringe probably in about three or four months if I need to. What's the cost of each syringe? Not your cost, the patient's cost. Yeah, about $800 to $1,000, depending on the filler. Again, what is the cost of the procedure, the fat graft procedure? That's obviously much more, but it's a lifetime, presumably. It's about $5,000. 语法解析

01:57:47

Okay, so five years worth of treatment, basically. So it's cheaper in the long run to do a fat graft, presumably. Yes, but also remember that we're just talking about your under eyes. But let's say you're my typical patient. They need their temples filled, they need their cheeks filled, they need their chin filled, jawline enhancement. So yesterday I did about 35, 40 mLs of fat on my patient. So that gets very expensive. Are my temples too sunken? Yours are still good. Okay. 语法解析

01:58:15

And your cheekbones are still good. Your jawline is still good. I would put a little neuromodulator or Botox in your platysma muscle because I am starting to see some platysma banding there. Mine's worn off, so you don't want to look at mine. But that helps to relax that muscle that does nothing but pull the lower face down. I would possibly add a little volume right in your malar. In your case, I would love a biostimulatory filler. Something like polylactic acid or Sculptra is the other name for it. 语法解析

01:58:43

to start building collagen and thicken your dermis thickness in here because I'm starting to see some of your buccal fat pad atrophy as well. And that just goes along with how fit you are. So using this to build your own collagen is a great way. And if you were female, very thin, we would have an issue because those patients tend to burn through their fillers very quickly. So if we can get a biosimilatory filler on board where they're building their own collagen, sometimes that works a little better. 语法解析

01:59:10

Now, do you ever look at a patient like me and say, you're most fat depleted here and here, but you're not yet fat depleted here and here. I only want to do one fat graft on you. So let's cost aside. 语法解析

01:59:23

let's use fillers until I have to do this procedure once and for all, and then I'll literally just take a bunch of fat off you and do it? Absolutely. Is that a better approach or are you afraid to do multiple fat grafts? Oh, no. I have patients that come for fat grafting as they need it. So I've done some patients three, four times. But I have turned down a lot of patients who come in actually asking for fat grafting for lips or for under eyes. 语法解析

01:59:48

And I tell them, since they don't need it elsewhere, that's too much of a procedure to go through for like one anatomic area. And in the lips, it doesn't hold as long. But under the eyes, it works beautifully. But I would do it when they need it elsewhere. I will probably never need lip fat grafting. When I was little, people made fun of the size of my lips. I'm pretty sure I'm safe on that. Before we go on to resurfacing, Tanuj, what would you change or add or how would you approach my face? 语法解析

02:00:16

Well, I think Susan's analysis was spot on. I agree. I think that what I hear you saying is the biggest issue that bothers you is your under eye area. 语法解析

02:00:25

So because you're someone who's never had a procedure before. Actually, Brett Kotlis did stick Restylane in there. Gosh, how many years ago? Probably 2018, 2017. Okay. I'll tell you what I remember of the procedure. I was amazed at how much I bruised. He told me I would. So it's not like this was an unexpected complication, but I looked like I had two black eyes for a couple of days. Otherwise it looked really good. And then it went away after a period of time, but it definitely was not a year that it lasted. 语法解析

02:00:54

I also suspect I metabolized it very quickly. We have longer lasting fillers though that we can use under here. He also mentioned that this scar was problematic. He said, it's very difficult to fill this eye. And you might ask, well, why didn't you just keep doing it? Just the same reason I don't do anything. Just sheer laziness. I was just like the thought of actually doing that again, having a couple of black eyes for a couple of days, blah, blah, blah, blah, blah. I just sort of gave up. So anyway, I have that one experience. 语法解析

02:01:22

So your under eye area, and by the way… Being lit this way is an abomination. But just by the way, bruising from fillers is a lot less these days because we don't use needles as much anymore. We actually use cannulas, which are blunt tipped catheters, and they don't typically bruise hardly much at all. So that's one big change that's happened in the last five, eight years is switching to cannulas. And people have different philosophies on that. Some people use needles for 语法解析

02:01:48

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

02:02:16

So I would laser focus on the area that the patient is now presenting to me as their major reason for even calling up my office and making an appointment is probably because they wanted to address this area. And yes, they're curiously interested in all the other things that I had to say. But because this patient, in this case, you never had surgery on their face, is probably not looking for massive shifts in their face. 语法解析

02:02:42

I would probably laser focus on this one area, not just because it's what you pointed out, but also in the realm of rejuvenation procedures that we perform surgically or non-surgically, the eye region is probably the sweet spot. Just again, going back to psychology evolution, we focus on people's eyes in conversation. When we talk about beauty, we're looking at the eyes. When people's eyes are now starting to become… 语法解析

02:03:11

further and further away from the way they remembered when they were younger, it creates this discomfort. It's the self-discrepancy theory from psychology where you've got the self-image of yourself and then you look at yourself, you're like, wait a second, that's not me. And then it creates this discomfort of like, is that what I really look like? And then it creates the psychological effect of maybe a little less confidence or dissatisfaction with your appearance. 语法解析

02:03:36

That's the big motivator for why people actually end up coming to see someone like us is because that self-discrepancy theory is kicking in and the delta between their self-view and their actual appearance is getting greater and greater. It's one of the reasons I, it sounds ridiculous that I'm saying this on video and that I have a podcast. I freaking hate being on video. 语法解析

02:03:57

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

02:04:20

How in the hell are we allowing this to be in the public domain? I mean, seriously. And part of it may be what we were mentioning earlier, that subconscious posing. Because when you're looking in the mirror, you know you're looking in the mirror and your subconscious makes you lift your cheek a little bit. Maybe I angle my head different or something. You angle your head or you smile a little bit and it pulls the cheek up and minimizes that hollow between your under eye and your cheek. And everybody does this. And that's why people tend to be shocked by photographs that are taken of them when they weren't prepared for it. 语法解析

02:04:48

They're not prepared to pose for the picture. And their flat, undynamic face in a photograph that's taken like that is shocking to them. It's often a big motivator for them to come to see us. I also made the mistake of once reading some comments on social media where people were just ripping me apart for how horrible I look. You can say what you want, like, I don't care, but you do care. If you read a bunch of people saying you look horrible, you're like, 语法解析

02:05:12

That sucks. I don't like that. But you know, when people show you that picture of themselves that someone took, because they bring it to the consult. They do. They bring a picture and like, oh my God, I saw myself last week. Look at how I look. And you're like, give me your phone. I take their phone. I take a picture of them in the exam room and show them, look how good you look. This was one nanosecond in one way you were moving your mouth or tilting your head or shadow. Right. 语法解析

02:05:37

You don't look like that. So delete that picture. We will not address how you look in a nanosecond compared to how you look the rest of the day. Totally agree. Yeah. 语法解析

02:05:47

And then what about the wrinkle situation? Yeah. So what I would do is I would go through all of the areas, the four areas that we're talking about, and then I would laser focus on the eyes. So to go through the four areas, we're talking about skin. We've done a lot of discussion already on skincare. I think that you should start a skincare regimen. I think you'll appreciate it as time goes by. I'm going to commit to three months for sure. 语法解析

02:06:08

You have uneven pigmentation in your face. You have some fine lines that are more concentrated in the eye region because the eyelid skin is the thinnest on the entire body. It's the one area of the body, you're a surgeon by training, you know that when you cut into the body, there's always a fat layer, not in the eyelids. So the eyelid does not have a subcutaneous fat layer. It's the only place in the body. So what's underneath the skin? The orbicularis muscle. Wow. 语法解析

02:06:31

And so there are four causes of dark circles under the eyes. There's visibility of the orbicularis muscle. There's shadowing, which is why you probably don't like your appearance in this kind of situation because 语法解析

02:06:41

The shadowing is visible down here. There's hemocitarin deposition, and then there's hyperpigmentation. So those are the four reasons why people get dark circles under the eyes, and you actually have all four of them. So we would definitely want you to get onto a good quality skincare regimen because it's one of the four areas that needs to be addressed, not only to reverse some changes, but for prevention purposes. 语法解析

02:07:02

And when it comes to volume loss, I think Susan's already picked you apart there. You've got volume loss in the midface. I think your temporal volume loss is enough where if you are going to have some kind of volume treatment, putting a little bit in would be nice. Your left temple sinks in a little more than the right. Oh, okay. I'm mostly looking at this side of his face. Yeah, yeah. The right temple is less hollow. Is that common? Yes. Extremely common. So when I put that mirror up in front of patients and start pointing out their asymmetries, 语法解析

02:07:31

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

02:07:50

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

02:08:06

Okay. And some people do have significant asymmetries. They do? I have ladies for some reason where one jawline is aging beautifully and very well defined. Yes. And the other one is like a centimeter shorter. Yes. In length. And Peter has some of these asymmetries too. I mean, his right side of the face, even though you had that injury on your right cheek, it 语法解析

02:08:23

your right side of your face is the smaller side of your face. So imagine in utero– I had literally no idea. Yes. And the other funny thing is another reason why people feel uncomfortable when they see photographs of themselves is because you're used to looking at your mirror image of yourself. Think about this. Nobody on the planet has actually ever seen themselves. You've only seen yourself in the mirror or you've seen a photograph of yourself. You actually don't really know what you look like in the flesh. 语法解析

02:08:51

And so because there's that discrepancy between the mirror and a photograph, because the mirror is a flipped image of yourself and the photograph is not, that's why people don't like photographs of themselves, especially when they're more asymmetric. So if we measured the distance between the outside corner of your eye to your mouth, 语法解析

02:09:09

It's about 10% longer on your left side because the bone structure is wider. So again, imagine you're laying in utero, you're in the womb, and you're probably spending more time on one side of your face than the other. There's so many factors we can imagine as to why do we get facial asymmetry. It's because of maybe the growth rates were different. Maybe there's a slightly different cytokine difference between the left and the right at six weeks. And maybe you're laying on one side of your face for two months 语法解析

02:09:38

These are all the reasons why we end up with a little asymmetry. And these things are present at birth and they become more exaggerated as we age because when you have that devolumization of the fat pockets and the ligaments show up, the underlying bone structure starts to become more visible. And then 语法解析

02:09:56

Finally, if we saw some pictures of you when you're 20 and we put them side by side with you right now, even though you have a great jawbone, it's probably lost about 10 to 15% of the volume that you had when you were 20. And so comprehensive treatment would be to volumize either with some fillers or some fat grafting to the areas of volume we talked about. 语法解析

02:10:17

the skin care regimen we talked about, I would probably put some volume along the jaw and your cheekbone because you've lost that projection with aging. We just know that someone of your age is going to have a certain degree of deep projection. 语法解析

02:10:30

How do you put volume along the jaw? How do you keep it in the area you want it to be without it looking odd and protruding? So the art of fillers and fat grafting is really truly an art. There's depth of placement, replacing it in the preperiosteal layer to emulate as if it were a larger bone structure. If you're trying to hide jowling, then you might put it into the muscle layer because you're trying to plump up the valley next to the hill. 语法解析

02:10:59

so that it becomes smoother looking. Choosing the right filler. Choosing the right filler. Is fat always a superior filler? Not necessarily. I do like fat because it's your own living tissue. And of course, it has those stem cells in it that can become multiple different types of tissue. So if you place it at the periosteal level, it can build bone. If you put it in fat, it becomes fat. And if you put it along muscle, it can turn into muscle. And if you put it under the skin, it enhances how the skin ages. So 语法解析

02:11:28

Something anecdotally, there are many of us that do a lot of fat grafting and we were on a panel one day talking about it. Before we knew about the stem cells being in the fat, we're talking 15, 20 years ago. We're talking about the fat grafting patients and how they all uniformly look like they just age better and their skin ages better. And now we start to realize all of that. 语法解析

02:11:50

Where do you harvest from? Numerous areas of pre-adipocytes, I should say. The tissue that has the most pre-adipocytes is the abdomen. So subcutaneous abdomen. But I really like the flanks because it turns out you don't just want the fat and the fat stem cells. You need all the connective tissue stem cells as well. And when you go to the flanks, the reason the flanks feel so firm, even though they may have fat in them, is they have a lot of septate and sternal tissue there. 语法解析

02:12:19

And when you aspirate the fat, you're also aspirating along with it some of that stromal tissue. So you're getting the matrix and the scaffolding cells that will help that fat also repopulate. And just give me a sense of volume. So if you decided to go full bore on somebody and do temporal and eye and outside of the lip and jaw, how much fat are you putting in and how much fat and tissue do you need to harvest to acquire the necessary volume? So we may differ in our techniques. I'll let Tanisha speak to his. 语法解析

02:12:46

I will typically harvest about 120 cc's of fat. 语法解析

02:12:51

So we're talking about an area about the size of a small cantaloupe. Just to put that in perspective, if a person undergoes liposuction, how much is being harvested? Usually we're filling canisters. So liters? Liters. Two, three, four liters of fat. Okay, so this is not going to make a material difference in your subcutaneous fat depot in your body. Correct. And if we artistically do it, we can take it from both sides so that you don't have any divots or asymmetries. But people always have an asymmetry even on their body. 语法解析

02:13:17

So I tell them, you know, the benefit of this is I'm taking also the fat and evening you out with your other hip. And they're like, oh, I never even knew I was asymmetric. 语法解析

02:13:25

So I typically harvest about 120 cc's and then we centrifuge it. And it condenses it down. So it takes off all the anesthetic fluid you put in. We have albumin in there to restore some of the oncotic pressure as well. And we are taking people's own PRP, spinning their blood down to get the PRP, the platelet-rich plasma, adding that in along with something that we call nanofat. So it turns out if you take fat and you graft it into tissue, a certain percentage will take. 语法解析

02:13:54

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

02:14:16

Okay. How does your protocol differ from that? Very similar, remarkably. And full disclosure, when I was coming through training in 2005 to 2007, finishing up my fellowships, I spent a lot of time listening to Dr. Obagi's talks at conferences. So my fat transfer technique has… 语法解析

02:14:33

basically mirrored hers for quite some time. I probably do a little less harvesting, a little less injecting because most of my fat grafting is being done in conjunction with a facelift or an upper and lower eyelid surgery called blepharoplasty. So when I'm surgically manipulating the tissues, I'm lifting and moving tissues. I'm not in need of as much volume to make the change that we're looking for, but very similar overall. 语法解析

02:14:58

Okay, that gets to the eyelid problem. You alluded to a procedure that lifts the eyelids and doing so presumably makes you require less these frontalis muscles. So are my eyelids a problem? 语法解析

02:15:13

So the short answer is at this point, you would probably qualify for your insurance company to cover your upper eyelid surgery because that's how droopy they are. Holy crap. They're sitting on your eyelashes. Yes. This is hilarious. I had no idea how bad I was. Well, we're not saying you're bad. No, no, no. But if you're telling me insurance would cover a cosmetic procedure in me. If we did a visual field test on you where you relax your forehead muscles. 语法解析

02:15:41

and you were required to look straight ahead and kind of hit a button every time you saw a light flash in your peripheral field. 语法解析

02:15:47

and we did the same test with your eyelids taped up, you'd probably have a 30% difference in your peripheral field. So this could be affecting my driving. Probably. You're probably finding yourself having to look a little harder at your blind spot because of that. Now, it becomes a very complicated issue. One of the most common things that we'll see in our practice here in Austin is that patients will come in and say, I think I need to have my eyelids done. And then we say, yes, but… And the thing is, people don't realize that… 语法解析

02:16:16

The face is not isolated into individual pieces of anatomy. Your eyelid is connected to your eyebrow, which is connected to your forehead. So if we're going to do an upper eyelid surgery, because you're constantly lifting your forehead muscle to be able to see better, your brain's compensating for this pathology. If we do an upper blepharoplasty, whether it's insurance or cosmetic or whatever, all of a sudden that visual field will improve and your frontalis muscle automatically relaxes 语法解析

02:16:45

and your brow will come down and it'll create a new problem that you didn't know you had. And so these are some of the conversations we have to have with patients that maybe we leave you alone 语法解析

02:16:57

unless you're also ready to have your forehead lifted, or at least have what we call a medical brow lift with Botox. So muscles pull the eyebrows up, muscles pull the eyebrow down. If you preferentially inject Botox into the depressor muscles, which are here and here, naturally the tone of the frontals will lift the forehead a little bit, even without wrinkles showing. So I'll tell patients, look, if we do an upper lid surgery, 语法解析

02:17:24

That'll be fine, but we either have to commit to regular use of Botox to keep your eyebrows in check, or we have to do a brow lift at the same time. Where's the incision for the brow lift? Do you do it through the same incision? So I would say that when it comes to designing surgeries, what I train my fellows and residents is that 语法解析

02:17:45

There is no single surgery. Every single surgery is totally custom designed for the individual patient's anatomy. There's general patterns we use, but we should always infinitely manipulate the procedure to achieve the goal of what we're trying to do artistically. 语法解析

02:18:00

In your case, it's complex because someone who doesn't have hair, we usually would hide incisions behind the hairline. It is possible for you to have an endoscopic forehead reset procedure and we would make the incisions further back and smaller. 语法解析

02:18:15

And it'll be a more technically challenging procedure, but there's a way to lift the forehead with incisions that would not be socially visible. And then those incisions can be closed in such a way that as time goes by, especially with post-surgical treatments like microneedling with five-floor uracil and topical treatments, that you can get those scars to become what I call socially invisible. Which, I mean, it just, to me, seems like I could never commit to that much work. You know what I mean? Yeah. 语法解析

02:18:43

So does that mean I'm just stuck with droopy eyes? Then in the conversation with the patient, what we would come to, probably in your case, is, okay, we can do a blepharoplasty, which is an upper lid surgery, but we're going to undertreat you. We're going to do less than what you think you need. It's not going to make a huge shift. But on the other hand, we also don't want to change the entire relationship neurologically that your frontalis muscle has with your eyelid. 语法解析

02:19:10

So by taking a patient through all the potential pathways, they sometimes recognize they can't get what they thought they were coming for and we're going to undertreat them so we avoid a potential problem. 语法解析

02:19:21

And similar things happen with the under eye area. So your under eye area is pretty complex too because you do have bulging fat visible in the under eye area, which by the way is exactly the same contour that you had when you're 20. It's just become unveiled because you've lost volume and the cheek has descended and now we're looking at the orbital retaining ligament and the malar ligament. 语法解析

02:19:43

So this line right here corresponds to when you're looking at a skeleton and there's a big circles where the eyes are supposed to be. This is that bottom half of the circle where the ligament is sticking down. So if you put your finger on the skin right below an eye bag, you'll be touching the edge of your orbital rim bone right there. And so from my standpoint, if we're going to do something that is definitive to treat that, it's going to also have to treat the volume issue in your cheek. 语法解析

02:20:09

It's also going to have to address some of the skin textural issues in the region. And then sometimes some people have an issue where there's a triangle that catches between the orbital rim, which is that hollow we were talking about in the under eye area, and another line that exists in the cheek a little bit lower, and it creates a triangle where fluid can collect. So I don't know if you've noticed that, but you've got that little triangle right here on both sides. 语法解析

02:20:32

That area is called a malar mound. It's kind of like a sponge under the skin. It collects fluid. It's worse in the mornings because we're laying flat and we have a little more edema in our face. If you've had salty food the night before, it'll puff up a little more. People will use preparation H. This is a time-tested home remedy to try to shrink down that swelling that's present there. This would have to be part of what's addressed if we were going to address your under eyes. 语法解析

02:20:59

And if we were going to do something to dress your under eyes, it would be something that would reduce the bulk of the bag, fill volume in the cheek, smooth the skin out, and address that malar mound. And so this is a common maneuver of what we would do in our practice, which is we would, under anesthesia, make a hidden incision behind the eyelid and take those eyelid fat pads that are making that bag 语法解析

02:21:23

and create a pocket down in front of the cheekbone where the volume loss is occurring and where the ligaments are showing they're hollowing, and then move that fat down. That's called a transposition lower blepharoplasty. So one of the big changes that's happened in… 语法解析

02:21:39

Aesthetic surgery from 1995 to now is back in the old days of cosmetic surgery. There was a lot of cutting fat out, cutting skin out to make eyelids look tighter, cutting skin in front of the ears to tighten the face. 语法解析

02:21:55

doing surgeries that mostly remove tissue. And now we're becoming much more sophisticated where we're actually manipulating the ligamentous attachments to the bone. And so because we're recognizing the ligaments- You don't have to remove the skin necessarily. We don't have to remove as much, yes. If you do, you can tighten it with lasers and peels. Yes, exactly. Rather than cutting it out. Just to conclude what the suggestion would be for someone with your kind of anatomy, we would transpose the fat, which would 语法解析

02:22:20

Two birds, one stone. Reduce bulk here, add volume here. Three birds actually, because it would basically eliminate the visibility of the ligament because there's fat under it now, which is pushing it forward. 语法解析

02:22:32

And then we would do something to improve the skin, as Susan said, either a laser resurfacing or a chemical peel. And then there's a new technique that we're using where we're injecting tetracycline into areas of swelling of the face. So this is pretty cutting edge. It's been around for several years now, and we've got pretty good experience with this technique. But tetracycline is an old drug that was repurposed by the pulmonologists to address pulmonary issues where they want the pleura to stick to the lining better. 语法解析

02:23:01

And because it has that property of basically creating fibrous attachments, it can be used to shrink that sponge down by injecting delicately into the malar mound to kind of flatten it. And so that would be the constellation of procedures. And what can go wrong here? Because… 语法解析

02:23:18

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

02:23:44

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

02:24:13

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

02:24:39

and death, and vision loss, including treating around the nose. Because all of these vessels interconnect with the internal carotid system. So anywhere you inject a filler and you get into a vessel on the outside of the skin, you can create an embolism. And it's going to go follow the path of least resistance. Once you bolus it into the tissue, it's going to 语法解析

02:25:01

backflow, but then it's going to be pushed forward again. It's going to go to the ophthalmic artery. It may go into your central nervous system, into your brain, I should say, and the vasculature there and create a stroke. Now, some of the more serious strokes were caused by people injecting fat with needles, but all of these other complications really come from injecting fillers in this kind of central face area. So there is a technique, there's knowledge of the anatomy, there's knowledge of how to do very little pressure and 语法解析

02:25:29

aspirate where you need to aspirate depending on the filler you're using and watching the tissue, looking for signs of any kind of embolus that's forming. What about the obviously less consequential but still troubling side effects where, hey, the person doesn't have a good cosmetic outcome. So they didn't have a stroke, they're alive, their vision is fine, but 语法解析

02:25:49

They don't look better. Something went wrong. What would go wrong? What are the things that go wrong here? I would say the most common types of complications that we'll see either any surgeon will have complications. I've had complications in our practices and in my practice. I will see a lot of patients referred in with complications where we have to try to identify how to improve a bad outcome. So the most common reasons why bad outcomes occur in the world of cosmetic surgery, and you're right, the stakes are high. 语法解析

02:26:15

is because either the wrong procedure was done, which is much more common than one might expect, or there was a technical issue where the surgery wasn't done correctly. Those are the most common causes. Now, I will certainly have patients where I will do my very best, and one side will be a little asymmetric, and six months after surgery, you might have to go to the procedure room to do a minor touch-up to kind of enhance things. 语法解析

02:26:40

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

02:27:07

And it can be very confusing because you're getting so much information from marketing and social media and physicians who perform cosmetic procedures are advertising and showing their best before and afters. And so how does someone figure out how to navigate this? And I would say probably the best advice that we could give someone who's thinking about going down this pathway is, 语法解析

02:27:29

You got to take the narrative into your own hands. You have to understand your own anatomy. You have to do a deep dive in understanding some of the techniques, not some, all the techniques that are available to address the issues that are your particular concern. And that might require multiple consultations. It might require choosing good resources online, which are usually society websites. So the American Academy of Dermatology, the American Academies, 语法解析

02:27:58

Academy of Cosmetic Surgery, ASPS, which is the Plastic Surgery Society. These society websites will have accurate information on procedures, and you should avoid getting secondhand information from people you know or from social media. But you got to do your homework. You have to learn the anatomy. You have to understand your own situation and your choices that are available to you. And then it's kind of like analogous to dating and marriage. How do you know when it's the right 语法解析

02:28:27

person. You just know. So let's go deeper into that. If I said, hey, I'm going to introduce you to my friend. She's going to go and sit down with a surgeon. You're not going to do the procedure on her, even though you'd be fully qualified to do it. You're not going to do the procedure, but I want you to be her advocate while she sits in the consultation room and you can tell her what questions to ask and you can help her interpret the results and 语法解析

02:28:52

But your job is to help her find the best doctor. What are the questions you're asking and what are the red flags you're looking for and what are the green flags that are making you say, I like and trust this person? I think it starts with your rapport with the patient too. You can quickly get a sense with the doctor you're working with if you and he or she can see eye to eye in terms of what you're seeing, what they're seeing. 语法解析

02:29:19

How knowledgeable they are describing the procedures that they're suggesting for you doesn't make sense. Do you really, for example, if they're telling you you need a brow lift and you've seen several other people and no one mentioned a brow lift, maybe you need to think about why did this person mention a brow lift and the other ones didn't? 语法解析

02:29:35

Or if everyone says you need a brow lift and one person says you don't, you have to figure out and go back and look in the mirror and try to understand what they're trying to point out to you as to what makes sense from that standpoint. Is it a comprehensive approach or are they just attacking basically the issue that you have that you're bothered by? I think people should take a comprehensive approach. 语法解析

02:29:57

and just at least get that information, even if they don't act on all of that. The person evaluating you should give you an overall look at everything, just like Tanej did, just like I did, addressing all the different areas that maybe you didn't even know to ask about. On top of that, understanding their strong suit. I don't do rhinoplasty. If I start telling a patient I'm going to do a rhinoplasty on them, they should run. They should ask me, how often are you doing this? What are your complication rates? What is the retreatment rate? 语法解析

02:30:25

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

02:30:53

It's one of the challenges, by the way, that's exactly what I tell people in general when they're interacting with surgeons is it's one thing to know the complication rate when you're getting a colonoscopy. It's another thing to know their complication rate and their patient population because it's not always the case. For example, if you're having cardiac surgery, a low complication rate isn't always a great thing. It might mean low complexity. It gets more complicated when 语法解析

02:31:18

Anything you would add to that, Tanuj, as far as questions that they should be asking or red flags or green flags? I agree completely there with what Susan said. And maybe some additional things to add, which some of these things matter more than others, but 语法解析

02:31:31

I think having had the right training and board certification is one level that should be met. Whoever is doing your procedure should have board certification in the specific area. Yes. So, sorry, just to interrupt. For eyes, what percentage of people doing eye procedures, like a lift, a bloodthroat plastic surgery, 语法解析

02:31:52

would be oculoplastics trained. Is that a rare thing? Is that uncommon or common? It's the most common procedure that an oculoplastic surgeon would do probably. How many non-oculoplasticians would do that procedure? A lot. In 2025, there's so much more overlap that's happening than what used to exist because each field that has an aesthetic aspect to it, we're talking about 语法解析

02:32:16

Dermatology, plastic surgery, ENT, ophthalmology, or maxillofacial surgery, these are the most common specialties that have an aesthetic overlap. 语法解析

02:32:26

The aesthetic focus in these training programs has dramatically ramped up in the last 20 years where part and parcel of these training programs include aesthetic surgery. But in addition to all those birth certifications, I think that experience matters. What's the minimum number of procedures you want to see done by the practitioner in a year to say, yep, you've got enough reps? It really depends on the procedure. Okay. For a rhinoplasty, something like that. 语法解析

02:32:54

For a rhinoplasty, you're going to want to have someone who's at least doing 25 a year. Okay. For a facelift? For a facelift, you want someone who's doing at least 25 a year. I think it also is going to matter how many other procedures they do, too. Someone who's doing face and body might be doing a lot of body liposuction. So they're doing facelifts, but they're doing also body lipo. Maybe they're doing eyes, all of that. Do you want generalists or do you want specialists? If you're going to get something done to your face, my intuition, which could be entirely incorrect, is 语法解析

02:33:23

I don't want them doing breasts and butts and lipo. Like I want them to be maniacally focused on the thing that I want them to do to me. So I would say in my practice, I do five things for 语法解析

02:33:34

for example, but I do those five things a lot. But I don't do only one. So, and you don't do only one, even though your oculoplastics and your facial plastics as well, though. Yes. I generally agree with what you're saying is that I don't do any body surgery. So I'll refer that all out to people who specialize in that. And most people who do body cosmetic surgery will focus on body cosmetic surgery because facial cosmetic surgery is a different animal altogether. So I think that that kind of specialization matters. 语法解析

02:34:03

Look, I was a young surgeon once, and certainly going to a surgeon who's right out of training can be fine for a limited, isolated procedure, but 语法解析

02:34:13

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

02:34:35

And so you want to choose someone who is evolving and moving with the times and preferably is helping to advance that edge of medicine. That means that they're constantly thinking and questioning and improving their results and not resting on laurels and not stagnating in one particular way of performing a procedure. I think that's a very, very important aspect of trying to identify 语法解析

02:35:00

So in that sense, do academics, because you would normally not associate cosmetic surgery with an academic affiliation. You would normally say, well, I get it if I have an oncologic issue. 语法解析

02:35:13

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

02:35:39

academic cosmetic surgery, academic plastic surgery is different from the traditional sense of what academic might mean. So in the world of 语法解析

02:35:49

facial aesthetics. You can have a single surgeon in private practice, no university affiliation, who's 100% academic because they are publishing, they're going to meetings, they're lecturing, they are helping to move the dial in the artistic world of what we're doing in facelifts or 语法解析

02:36:08

eyelid surgeries or brow lifting. It might be someone who's at a university full-time, but it doesn't have to be. And that's very unique to aesthetic surgery. I also think that the universities don't support their aesthetic doctors. So a lot of times, universities cannot figure out a model that works for them to profit share or to find a compensation model for an aesthetic doctor that's appealing to them to make them not go into private practice. 语法解析

02:36:34

So they end up shortchanging themselves and then the doctors leave and they go into private practice. Whereas I think if you can get the universities to wrap their head around how to build out a really strong academic practice like we did with our university at the University of Pittsburgh Medical Center, we were rare. We were one of the first in the nation to purposely build an academically based cosmetic surgery practice with the intention of training 语法解析

02:36:58

plastic surgery residents, if they want to rotate oculoplastics, facial plastics, dermatology residents, and people from around the world. I mean, it makes a lot of sense because of the amazing overlap between surgery in general, especially oncologic surgery and reconstruction. Like if you think about it, every time a woman undergoes a mastectomy, she should be immediately plugged into a plastic surgeon and 语法解析

02:37:22

to, if nothing else, make sure that that reconstruction is as cosmetically pleasing as possible. And then you think about all the head and neck cancers and things like that. There's a clear incentive, maybe incentive is the wrong word, just if nothing else, a business case to be made for better patient care with the integration of that type of service. The universities can't see that though. The problem is they think it's a one size fits all and they don't understand the differences. Like for example, 语法解析

02:37:48

Your cosmetic practice has to have a more aesthetic look. It's going to cost them more to build it out. They're going to need the devices. They need investments. And it's really hard to get some of these universities to see that. You have to work with them and become your own business manager, for example, and propose to them a business plan, return on investment, all of that. But practically speaking for the listeners, if you're trying to find someone to help you on a path in this category of aesthetic surgery, 语法解析

02:38:16

Finding someone who is speaking at conferences, teaching, involved in the cutting edge of medicine, I think that's definitely a qualification. I think another thing that you mentioned earlier is maybe asking them how often they are receiving complications and managing them. That's probably a sign. 语法解析

02:38:34

skill and seniority in the field. If you're kind of the person who's, again, it's not about calling out who those complications belong to, but it's, hey, you know, okay, so we've talked for a lot longer than I thought we would, but I'm sorry if we can get you to hold on for a minute longer. We can't get out of this podcast without me understanding the difference between lasers, micro abrasions, microneedling, chemical peels. I 语法解析

02:38:58

I can't understand any of these things, but you mentioned resurfacing. You mentioned my skin sucks. So clearly before I go on the path of my rejuvenating anti-aging protocol, I might as well do something to fix that. 语法解析

02:39:16

the situation we have going on here. We could do a crash course. I know this podcast is running long, but it's just a massive subject to cover. Let's start with lasers. Could we take one step back maybe and talk about the difference between ablative and non-ablative and maybe talk about peels? So maybe the way to go is there are various technologies that will, in a controlled manner, injure the skin to harness the body's natural healing cascade of 语法解析

02:39:45

which then will produce the aesthetic benefits we're looking for, which is more collagen production, smoother skin, less pigment issues. And that's the goal. And so the bottom line is there's a relationship with how aggressive the treatment is and how much of an aesthetic improvement you're going to get. But the more aggressive it is, the more downtime there is. So that's always the balancing act. And that's why there's such a confusing array of options that exist because 语法解析

02:40:11

There's a huge spectrum going from the least invasive, which has the least result, to the most aggressive with the best result. And so I guess to generalize, there are treatments that are not truly ablative, meaning they're going to penetrate through the skin. 语法解析

02:40:29

And then there are treatments that are. I think hopefully I set that up for you, Susan, to maybe go from there. So that's the definition. Ablative means it penetrates the skin? Yes, ablative, yes. And non-ablative doesn't penetrate the skin. So what are the non-ablative, which are presumably the less severe, which means shorter recovery time, less overall response? So non-ablative things, you can start with even your topical skincare regimen because that is going to remodel the skin and set the stage for you to even prime it so you make more collagen. 语法解析

02:40:59

And then you can do things such as light chemical peels, which are only going to affect the epidermis of the skin. You can do things like non-ablative fractional lasers. And those are going to, again, send tiny fractionated beams of light onto the very surface of the skin and just damage the upper layers of the epidermis. And that's going to stimulate a cascade of cytokines to build on the collagen and texture, but it's going to be minor. 语法解析

02:41:27

And they might help with some minor pigmentation issues. Those are non-ablative devices for resurfacing. What was the last one? Non-ablative fractional lasers. We also have non-ablative vascular lasers. Those are lasers that are going to penetrate with a beam of light to hit the dilated blood vessels in people who have rosacea. What's the brand name of a non-ablative fractional? Fraxel or Clear and Brilliant. 语法解析

02:41:53

Within those, there are different ones. So Fraxel has multiple different ones. Clear and Brilliant is just superficial. And then you have non-ablative things like vascular laser that will help treat broken blood vessels, scars, texture change. And that one, even though it's shattering some of the dilated blood vessels deep in the skin, it's not leaving an open wound on the surface. So when we say non-ablative, there might be things happening deep down, but the surface of the skin is intact. So there's no raw wound. 语法解析

02:42:21

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

02:42:49

And it's a huge, huge category. There are so many devices in this category that it would be kind of silly to even list them. But they're very effective in that they don't have a lot of downtime and produce improvements that are real for patients. Sorry to interrupt. I thought we should just pause there for one sec. Absolutely. And I think a lot of them work. Moxie is another non-ablative. I'd have to look and see what the technology on Moxie is. 语法解析

02:43:15

If I'm not mistaken, I think that one might be radiofrequency microneedling. I think that's right, yeah. Yes. That kind of bridges the gap a little bit. It depends. It is semi-ablative because you're literally piercing the skin with a bunch of needles and delivering radiofrequency energy through those needles. And those will stimulate collagen. So anything that generates heat in the skin to a certain level, to a certain temperature, I should say, will then cause the formation of something called heat shock protein. And that collagen… 语法解析

02:43:43

causes a whole cascade of other activity within the dermis of the cells, the dermis of the skin, to make you produce collagen, elastin, shrink the overactive sebaceous glands, and reduce some of the dilated blood vessels. So there is a lot of benefit beyond just treating the vasculature that you see. So I tell patients, like, for example, if we treat their rosacea and 语法解析

02:44:05

and they get improvement after two or three sessions, they should come every year and repeat it, even if their rosacea is quiet, because it really does help with anti-aging. And so from that standpoint, those are your non-ablative. And if we go to ablative, we've got deeper chemical peels. We've got the modified TCA peels. We've got modified phenol peels. So we don't need to worry about brand names at this point. We're really talking to the practitioner and saying, 语法解析

02:44:30

Do we want to move into an ablative peel? I'm going to get a better result, but I'm going to have a greater downtime. Presumably I need to do it less frequently. Yes. And that's exactly what you said is key. I think the big mistake is to come in and say, oh, all my friends are having moxie. I want moxie. Let's talk about what it is. We might have something that does similar results or maybe even something that does better results. Or maybe it's not the right choice for you, even though your friend thinks you should get it. And so 语法解析

02:44:57

The field is so confusing to consumers and honestly, even practitioners because it's a gold rush. There's so much money to be made in this area. Every company is getting private equity money and getting an FDA approval for some kind of device because they want a piece of the action. And they're purposefully confusing everybody because it's like snake oil. Everybody wants to sell their product and some of the products work well, some don't. Any products you think people should just absolutely avoid? 语法解析

02:45:25

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

02:45:52

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

02:46:19

with all these devices, you can achieve so much with your lasers beyond what the company tries to sell you. How do you then decide? I understand the fork in the road between ablative and non-ablative, but let's say once you commit to an ablative therapy, how are you deciding between a chemical peel, a laser, a microneedle? And I vaguely remember my wife telling me something or overhearing her and her friends saying that 语法解析

02:46:44

If you had melasma, you couldn't do this one, but you could do this one. What are some of the do's and don'ts as you navigate that? There are a lot of nuances to this conversation, but to generalize a little bit, chemical peels are generally safe for all skin tones, generally. Laser resurfacing, ablative laser resurfacing can be riskier for higher Fitzpatrick skin types that have more pigmentation. 语法解析

02:47:11

because the melanin cells are sitting deeper in the skin. And the deeper the laser goes, the more it can create permanent injury to pigment cells and create permanent pigment problems. 语法解析

02:47:22

Whereas the chemical peels, you can control that depth a little differently. And so that's one, I would say, generalization that's probably worth mentioning. So I should not do a laser peel. You can have a laser, but you're the kind of person who needs a lot of preparation and caution heading into it. You would need to probably get onto a regimen to control your pigment cells with hydroquinone. But why would I bother? Why take the risk? Because the results could be better. I see. I guess just to complete the conversation about the different categories, 语法解析

02:47:51

The most effective non-surgical skin interventions are in the category of ablative lasers and phenol peels because they go the deepest. And TCA. I'm going to have to throw that in there. TCA, sure. TCA peels. Deep TCA peels are something that should be done by someone who really knows what they're doing. So going to your point, how do I choose? Sometimes on the same patient, I'll do all three. 语法解析

02:48:13

So on most of their face, I may do a medium-depth TCA peel, especially because I can get the ears, I can get into the brows, I can feather onto the neck, into the hairline, so I don't leave any area unresurfaced. And the medium-depth peels are going to go just to the level of what's called the papillary dermis, which is the sweet spot for tissue tightening. 语法解析

02:48:33

And this is TCA or phenol? 语法解析

02:48:59

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

02:49:26

What is the downtime from an ablative intervention? Every treatment is customized to the patients who can vary, but in general, a patient who's going to have an ablative CO2 laser, which I would say is the relative gold standard for an ablative laser, is going to have seven to 10 days of requiring an occlusive dressing with some kind of ointment. That's some real downtime there. And then from weeks one to three, 语法解析

02:49:52

Their skin will be transitioning and epithelializing. They'll start to return to normal activities, but they'll still scare children at a grocery store. For three weeks. Because they'll be red. A lot of redness and swelling still. And then beyond three weeks, they can use concealer, which we actually encourage them to do because it's a built-in UV protection also. And they can kind of get back to life. But without makeup on, some people can have redness for months. 语法解析

02:50:18

Expect this person to do this procedure how often? This might be once every five or 10 years to have a full ablative CO2 laser. Is it uncomfortable? If they're awake, it can be. These can be done under some sedation. 语法解析

02:50:31

It's also quite common these days to have these done with a nitrous delivery device. So there are now FDA-approved devices that mix oxygen and nitrous so that it can be done in the office without an anesthesiologist because they're getting 50% oxygen, but yet they're getting the benefit of the nitrous as well. Like laughing gas. Yes. Pronox. Exactly. Yes. I mean, that sounds absolutely unappealing. 语法解析

02:50:53

I also painted the picture of the most aggressive skin laser that we do. And of course it can be dialed down. Like if a patient has a certain timeframe in mind, 语法解析

02:51:02

All right, so what would I do? I mean, a week offline would be tough. Doable, but tough. Certainly three weeks, four weeks offline, not an option. So one thing that is useful information is that some of the lasers that are still ablative, but are dialed down in their intensity, so now we're talking about fractionated lasers at lower intensity, they can have a downtime that's a week or less, more or less. 语法解析

02:51:26

And then it's not going to produce the same results, but the effects stack over time. So if you committed to doing a light erbium laser, and the reason why I'm talking about erbium laser instead of a CO2 laser is because the erbium lasers tend to 语法解析

02:51:42

burn with a little less heat, thermal injury, and so the recovery is a little bit faster. If you're committed to doing this once a quarter, as time goes by, you would get a similar effect to the full ablative CO2 laser that you can do in one sitting. And I would also say that you can manipulate other things. So like we'll take a clear and brilliant laser and apply a light chemical peel solution on top of that the same day. So two non-ablative therapies. Correct. And then you get like three or four days of peeling and then you're done. 语法解析

02:52:10

And someone like you, because you're a male, you have thicker skin, you need us to push it a little more than just what the Clear and Brilliant will do or the light peel by itself. But synergistically, they can have a nice effect. And over time, there'll be cumulative improvement in your skin, especially if you follow your home regimen. But what I would tell people like you, Peter, is that really think about it hard and embrace this investment in yourself because you do everything else right. You eat, you exercise. 语法解析

02:52:39

you watch the sun, it's much, much better to do this now at your age than to wait five or 10 more years and say, I wish I had done it. Because at that point, what you need might be a lot more drastic. And to maybe bring this full circle, Susan, I know we're concluding the podcast here now. Beauty and aesthetics is an integral part of being human. And that's why we're even having this conversation because people really want to know how 语法解析

02:53:06

how to navigate this world of aesthetics and choosing to make changes that are appropriate for your situation that has the potential of increasing quality of life. Humans, as we age and we live longer and longer and longer, you may have someone who's 60 or 70 years old who's following Peter Attia's regimen 语法解析

02:53:26

And they're out there playing golf, living their marginal decade, you know, in the way they want to. But they also care about their appearance. I mean, you've seen this, right, Susan, that I have patients who are 94 years old who are coming in for skin cancer reconstruction after Mohs surgery. And you're not thinking at all about putting your aesthetic hat on. I'm now a reconstructive surgeon. 语法解析

02:53:47

This 94-year-old woman is terribly concerned about what it's going to look like afterwards. That desire to limit the delta of the self-discrepancy theory for ourselves continues until we're no longer on this planet. 语法解析

02:54:02

Well, guys, thank you very much. This was fantastic and honestly accomplished goal number one, which is I feel like I have a greater understanding of the solution space. Again, I think I'm going to probably have you guys send me a few links on some of the serums and cleansers. And I guess I need to get a prescription for some Retin-A or steal my wife's. I'll double check my sunscreen. I know that my… 语法解析

02:54:30

sunscreen that I use when I'm going outside for prolonged periods of time. My Ulta MD is a good one. I don't think I have a good daily throw it on just because I'm indoors even, and I'm going outside for five minutes here and there. I need to double check on that. So I think that's a win. I guess if I do nothing but commit to a daily skin routine, that's great. 语法解析

02:54:51

I will admit this whole ablative, non-ablative skin thing has me a little shaken up and now reeling in the idea that 语法解析

02:55:00

I just don't know if I have the intestinal fortitude to go through with an ablative therapy, but maybe I start with some baby steps, like two non-ablative therapies. And then I think we're going to have to think about, do I want to fix my face? How far down the rabbit hole do I want to go with the under eyes, over eyes and all that stuff? But the point here is I have a better understanding and I hope that more importantly, the people listening are able to see bits of themselves in me. I think I'm not that uncommon in my problems. 语法解析

02:55:28

So hopefully they've been able to pick up on these things as well. So thank you very much, guys. This was a different podcast. Nonetheless, it was super interesting for me. Thank you. Thank you for having us. It was fun. And we didn't mean to pick you apart. I asked you to, so no, no, it was fully appreciated. Thanks, Peter. We appreciate the opportunity to be here and have this conversation. Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes if you want to dig deeper into this episode. 语法解析

02:55:57

You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. 语法解析

02:56:21

The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. 语法解析

02:56:44

Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures. 语法解析

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Edit:2025.07.03

“美和审美是人类不可或缺的一部分……选择根据自身情况做出改变，有可能提高生活质量。 ”——Tanuj Nakra

3a217d2329c5b54eb4ddd23cfc87672e7763e86bc564b2038a92811cfa43fd7d经过彼得·阿蒂亚

2025年6月30日

阅读时间96 分钟

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Tanuj Nakra 和 Suzan Obagi 两位美容医学领域的权威专家将与 Peter 一起探讨面部衰老和皮肤健康的科学原理，以及医生在美容领域所面临的责任。在本期节目中，他们探讨了面部衰老的生物学和激素驱动因素、吸引力的进化和心理基础，以及现代媒体对审美标准的影响。他们还探讨了青少年美容手术的兴起以及医生在这些案例中的伦理责任。随后，话题转向了实用的、循证的皮肤健康指南，涵盖了矿物防晒霜、维甲酸、维生素C的使用方法、个性化护肤流程，以及痤疮的管理以及美容咨询背后的心理学原理。本期节目以 Peter 本人坦诚的个人面部评估​​结束，揭示了美容医学的潜力以及如何批判性地思考其实践。

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#355 – 护肤策略、面部衰老科学以及美容干预指导 | Tanuj Nakra 医学博士和 Suzan Obagi 医学博士

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

1×15秒30秒

0:00 2:57:05

• Tanuj 和 Suzan 的培训和专业知识，以及不断发展的美容医学领域 [4:00]；
• 面部衰老的生物学[10:45]；
• 为什么面部脂肪会随着年龄增长而萎缩，而身体脂肪却容易堆积[17:00]；
• 慢性压力如何加速面部衰老[20:30]；
• 美丽的进化生物学，以及现代生活方式、文化和医学如何与这些古老的审美本能相互作用[25:30];
• 社交媒体和影响者如何迅速将审美趋势转向夸张的特征和不切实际的美容标准[36:45]；
• 影响现代美容医学的伦理挑战、经济激励和社会压力 [42:00]；
• 青少年寻求整容的令人担忧的趋势：早期美容压力的伦理和文化影响[51:45]；
• 保护皮肤：紫外线伤害和防晒建议[58:15]；
• 延缓皮肤老化的策略：类维生素 A、维生素 C 和循证应用方法 [1:09:00];
• 有效的日常护肤程序：清洁、抗氧化剂、类维生素 A、保湿等 [1:18:45];
• 管理痤疮的剧本[1:31:00]；
• 衰老的 4 个变化以及美容咨询的复杂性，包括医生必须应对的解剖、心理和伦理因素 [1:39:00];
• 复兴的 5R 原则 [1:50:15]；
• 以彼得的面部为实时案例研究的面部衰老分析和美容策略[1:53:00]；
• 脂肪移植和真皮填充剂在面部年轻化中的决策过程[1:56:30]；
• 自我形象、眼部美学和转瞬即逝的照片如何推动人们对整容的渴望 [2:01:45]；
• 有关皱纹的建议、黑眼圈的原因以及面部对称的重要性 [2:05:45]；
• 影响脂肪移植和其他眼部手术临床决策的考虑因素 [2:11:00]；
• 面部整容手术技术的演变、所涉及的严重风险以及医生的技能和手术选择如何极大地影响结果 [2:21:30]；
• 患者在选择整形外科医生时如何做出明智、安全的选择[2:27:15]；
• 剥脱性与非剥脱性皮肤重修治疗、激光与去皮等的比较 [2:38:45];
• 如何根据患者具体因素选择和定制治疗方法[2:48:00]；
• 人类一生都渴望将外貌与自我认同相结合 [2:52:45]；
• 更多的。

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• 这是 Peter 经常被问到的一个话题，而他对此的了解甚至比公众还要少
• 在这个话题上拥有两位专家是非常有帮助的，因为他们各自有不同的专长

请简单介绍一下您的培训内容、背景以及关注点 

塔努吉·纳克拉博士 

• Tanuj 的核心专业是眼面部整形手术
• 他主要在加州大学洛杉矶分校接受眼科手术和面部手术培训
  • 他原本的背景是眼科
  • 随后，他又获得了眼科整形外科和面部整形外科的奖学金
• 他的业务仅限于眼部和面部整形手术
  • 范围包括儿童重建、老年人癌症重建以及我们可以进行的所有面部整形手术
  • 包括鼻子和脖子
• Tanuj 16 年前在加州大学洛杉矶分校接受培训后搬到了奥斯汀，并加入了这里的一个大型团体 [ TOC 眼部和面部]，他也是戴尔医学院的教员 
• 他积极参与学术、教学和住院事务
  • 该诊所有两个奖学金项目 

> “能够参与学术研究真的非常荣幸，因为它代表着科学的前沿。我们喜欢进行临床研究，在学术界（我就是这样认识苏珊的），不同专业之间有很多合作，我们有机会进行对话，并进一步发展我们非常关心的专业。” —— Tanuj Nakra

苏珊·奥巴吉博士 

• Suzan 是一名受过培训的皮肤科医生，她曾获得过整形外科的奖学金
• 她在匹兹堡大学学习医学
• 她在那里已经工作了大约 24 年，见证了整个领域的发展
  • 他们曾经做过手术和一些胶原蛋白注射
  • 现在他们拥有大量可用的工具
• 她培训来自世界各地的住院医生、医学生和访问医生
• 她喜欢多专业合作
• 两位嘉宾都属于美国整形外科学会，他们与不同的专家有不同的方法，有时甚至对同一手术
• Suzan 的实践专注于皮肤再生、去皮、激光等一切
  • 她做了很多脂肪移植手术
  • 她做身体吸脂、面部拉皮、眼部拉皮手术 

> “当涉及到面部护理时，首先要真正改善皮肤的外观，因为我觉得这是每个人都能看到的最重要的东西。”—— Suzan Obagi

• 当一个病人来找我时，他还没有做过任何事，或者对这个领域一无所知，苏珊其实很喜欢这样，因为她可以借此机会真正地教育他们，并为他们选择合适的东西

彼得开玩笑说：“我很感激你注意到我什么都没做。 ”

在播客开始之前，他们正在讨论彼得在外表方面采取的策略  

• 彼得对于医学领域的某些事情理解起来非常困难
• 他之前见过 Tanuj：Tanuj 帮助他治疗了伤疤
  • Peter 的朋友Brett Kotlus （第 13 集嘉宾）介绍了他们
  • 一天早上，彼得因低血压摔倒在地，留下了一道漂亮的疤痕，今天基本上看不出来（可能是因为他的脸本来就是皮革的）
  • 部分原因是他做了一些5-FU 微磨损以及一系列治疗，而 Peter 实际上在之后的一段时间里非常注意避免晒太阳
  • 他还接受了肉毒杆菌治疗，这确实减少了皱纹（显然皱纹早已消失）
• 彼得对他的外表采取了一种可能不合逻辑的策略：他忽略了它，因为他不理解它
  • 他专注于自己理解的事情

彼得补充道：“如果几个小时后，我决定做一些可持续的事情，并能帮助我在62岁时看起来比我应该看起来更好一些，我会认为这是这个播客的巨大胜利。（我今天52岁了）。 ”

• 彼得在播客节目播出前看了一张自己十年前的照片，十年过去了，他发生了多么大的变化
  • 他今天看上去糟多了 
  • 这可能并不罕见，我猜想 42 到 52 的外观会有很大下降
• 这让他意识到，如果他不采取主动行动，未来 10 年的减排幅度将会更大
• 彼得承认，“我甚至不敢在睡觉前洗脸。 ”
  • 他的妻子觉得恶心
• Tanuj 和 Suzan 的任务已经完成，因为如果 Peter 能够接受这方面的教育，他们就能改变世界

• 我们将讨论限制在颈部以上

为什么彼得 42 岁时看起来比 52 岁时好看？ 

• 苏珊的病人就是这样进来的；他们说：“我感觉我看起来很累。我不知道到底发生了什么…… ”
• 她用 20 岁和 60 多岁人的面部图表来解释这些变化
• 如果你看一下剥掉皮肤后的面部图表，你会看到年轻的面部有大约 11 个不同的脂肪隔室（如下图所示）
  • 脸部两侧的皮肤丰满、结实，它们提供了体积，并在皮肤、肌肉和下面的骨骼之间提供了填充。

图1. 面部浅表脂肪室。图片来源：MAIPS

• 然后你观察一个 60 多岁的人，剥开皮肤，你会看到脂肪垫急剧萎缩
  • 一些可能会增大，但绝大多数会萎缩

{节目笔记预览结束}

看看这篇帖子 ，了解演出笔记的详细内容。立即注册会员，即可访问。

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Tanuj Nakra毕业于圣路易斯华盛顿大学，获得生物学、心理学和美术学士学位。他毕业于芝加哥拉什医学院，获得医学学位。他曾在加州大学洛杉矶分校朱尔斯·斯坦眼科研究所完成住院医师培训和专科培训，分别主修眼科和眼眶及眼科整形外科。Nakra 医生拥有眼科、眼科整形外科和面部美容外科的三重认证。 

Nakra 博士在TOC 眼部和面部诊所执业。他因其在美容和重建外科方面的专业知识而广受认可，十多年来一直被《德克萨斯月刊》、《奥斯汀月刊》、《卡斯尔康诺利》和《医学名人录》评为顶级医生。Nakra 博士是德克萨斯大学奥斯汀分校戴尔医学院的全职教师，也是 TOC 眼部和面部诊所美国美容外科学会 (AACS) 研究员项目的负责人。他撰写了 75 多篇同行评审的科学论文和书籍章节。他的研究重点是开发新的手术技术，例如用于治疗面部静脉的电灼术、用于治疗甲状腺眼病的定制眼眶覆盖植入物和用于治疗纤维发育不良的改良韦伯-弗格森切口，以及先进的修复手术和技术，例如脂肪移植程序。Nakra 博士是医疗级阿育吠陀护肤品牌[AVYA Skincare的联合创始人。 TOC 眼部和面部诊所]

Instagram：Tanuj Nakra MD FACS 

LinkedIn：Tanuj Nakra

苏珊·奥巴吉（Suzan Obagi）在加州大学圣地亚哥分校获得生物学和心理学学士学位。她在匹兹堡大学获得医学学位。她在加州大学欧文分校完成了实习。她在匹兹堡大学分别完成了皮肤科和美容外科的住院医师培训和专科培训。奥巴吉医生拥有皮肤科和美容外科的双重认证。

Obagi 博士是匹兹堡大学皮肤科副教授，同时兼任整形外科系副教授，以及临床与转化科学副教授。她是匹兹堡大学医学中心(UPMC)最先进的美容外科和皮肤健康中心的主任，并在那里为患者诊治。此外，她还担任匹兹堡大学美容外科奖学金项目主任，并指导皮肤科住院医师培训项目的外科核心课程。 

Obagi 博士是国际知名的美容皮肤科和外科专家。她为世界各地的医生提供最新的美容和激光外科培训。她撰写了大量关于皮肤健康修复、自体脂肪填充（脂肪移植）、肉毒杆菌和软组织填充剂、化学剥皮、磨皮和激光的文章和书籍章节。她专注于美容外科领域的最新技术进展，包括激光和射频技术的应用。她的研究兴趣包括提高脂肪细胞（脂肪）移植后存活率以进一步提升自体脂肪填充手术效果的方法、皮肤重修的安全性以及雷诺氏现象的激光治疗。Obagi 博士利用她在皮肤再生和循证研究方面的专业知识，开发了护肤系列SUZANOBAGIMD™和Veea Face。[ UPMC ]

Instagram：@suzanobagimd

LinkedIn：Suzan Obagi，医学博士

https://peterattiamd.com/tanujnakraandsuzanobagi/

Edit:2025.07.03

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