0:03 live hello everybody my name is Benjamin
0:07 tale and I hear I'm here working for uh
0:13 Esther Rodriguez and this is Marcos from
0:15 Mexico and today's lesson of the day is
0:17 you should drink tequila
0:22 and have Chick-fil-A so
0:24 lesson of the day today if anybody's
0:27 wondering was Wednesday it's hump day
0:30 and we tell everybody hump day means
0:33 that's the day I get home so it was it
0:35 was a rough one today my poor patients
0:37 have to wait a long time today
0:38 um they always look at me like why why
0:41 why and I just feel so terrible
0:43 um lesson of the day today oh hello in
0:45 Pakistan uh lesson of the day today is about
0:46 about
0:49 longevity of surgery because this was
0:51 something where I got a lot of questions
0:53 about it today question I have for
0:54 everybody though and you can answer as
0:58 we go along is what do I do with this
1:00 painting so I have this it's been
1:03 sitting in the office for a while it was
1:07 a gift Esther so we don't trash give sit
1:10 on sale but uh
1:12 I wonder what people will think if I
1:14 have this hanging so where shall I put this
1:15 this
1:17 um other thing if you guys haven't seen
1:19 yet we have a wall of visitors here
1:21 that's starting and everyone who's
1:23 visited is going to be up on this wall
1:26 so we have to like fill the rest of the
1:29 wall we have tons and tons of photos
1:31 um and that's that's uh oh somebody says
1:34 trash can bathroom okay there we go okay
1:36 all right in the bathroom lots of
1:38 bathrooms bathroom options okay well so
1:40 just so people know what my bathroom
1:42 looks like
1:47 little fancy guys this is a mosaic
1:48 um that's that's what the bathroom looks like
1:49 like so
1:51 so
1:54 we'll see if we can go over there so
1:56 um perfect so
1:59 now the question I got today a lot this
2:01 is Alex fancy
2:03 um was
2:06 how long was my surgery supposed to last
2:08 and this was from patients who had had
2:12 surgery by other uh surgeons and this
2:15 led into a lot of questions about why
2:17 they look so good initially and why
2:20 things went way quickly and all these
2:23 things so first off when you do aging
2:26 face surgery aging face surgery is like
2:29 brow lifts and eyelids and things where
2:31 you look older that's called the aging
2:34 face surgery most of them are likely
2:36 going to last about 10 years if it's
2:39 done properly so if you do like a really
2:41 really good surgery that should all last
2:43 about 10 years and then you age out of
2:44 it because you keep aging and it's not
2:46 that you've stayed perfect for 10 years
2:48 it's you get improved from here to here
2:51 and then it lasts about like this to
2:53 nine years 10 years eight years whatever
2:55 one year so uh it lasts about 10 years
2:57 before you do these surgeries again
3:01 most people look fantastic the first six
3:04 months after a facelift or upper eyelids
3:06 because they have extra volume in the
3:09 face and this blows out the shadows and
3:11 it's because all tissue layers are
3:14 hydrated so most people wonder why they
3:16 looked so good the first six months and
3:18 then things tend to kind of deflate and
3:21 go a little bit worse after and it's
3:23 because the face is healing the
3:25 lymphatics are impaired you can't drain
3:27 properly so your face just has more
3:28 fluid in it your immune system is more
3:30 active and you don't drain them as well
3:33 so the tissue layers get more cushioned
3:35 and you have less Shadows on the face
3:37 and people love that they love the way
3:38 it looks they love the way their lips
3:40 look their face looks their eyes everything
3:42 everything
3:44 now some of the heat treatments are like
3:46 that too like ulthera and those kind of
3:48 things they tighten you up and sip in
3:50 you for like six months then they go
3:51 away because your immune system is
3:53 active during that time healing the
3:56 injured areas and then it tends to calm
3:58 down and then you lose that effect
4:00 so I tell patients if you want to
4:03 maintain that effect there's no great
4:05 way to do it other than doing PRP micro
4:06 needling you could do micro needling
4:10 with PRP every uh three four months and
4:12 it'll stimulate the skin and hydrate it
4:15 the reason you can't fix it or get
4:18 anyone to a hundred percent and this was
4:21 the other question was Doctor can't we
4:23 do anything more about this doctor can't
4:26 we do anything more about this and
4:29 um it was a patient who had a pretty
4:30 impressive result when you look at it
4:33 before and after pretty massive but she
4:34 still has some shadowing in the face and
4:36 is wondering can anything else be done
4:39 and I I I said
4:40 um I'm not God I'm just a really good
4:42 surgeon like maybe you should talk to
4:44 God about that one but the answer wasn't
4:46 enough so I explained the Aging in the
4:49 face is multifactorial there are other
4:51 issues that go on in the face that you
4:53 can't fix with just a surgery so let's
4:54 say I'm doing a facelift
4:57 this area over here in the jowls and
4:58 pre-jowls if you look at my photos they
5:00 get huge changes but there's always some
5:02 residuals so I tell people when they say
5:04 is it going to be like this I say no no
5:06 it'll be like 80 you'll get like an 80
5:09 Improvement you're always going to have
5:12 about 20 remaining from all these other
5:15 factors and it is because there are so
5:17 many changes in the face in different
5:19 layers not only do we not know exactly
5:21 what to do with each layer but it's
5:23 impossible to rejuvenate those layers so
5:24 when we age
5:27 you don't just get fat loss it is very
5:29 simplistic to think your face is just
5:31 fat you don't just get collagen loss
5:33 it's very simplistic to think that your
5:34 soft tissues are just made of collagen
5:36 or your skin is you get lost in all
5:38 tissue layers so your dermis can
5:41 actually thin a little bit these
5:43 hypodermis which is fat you can lose a
5:45 little bit the smash layer which is
5:47 largely your hydratory layer or the
5:49 layer of cushion that retains fluid in
5:52 your face and is responsible for some of
5:54 the color of your skin and looking
5:56 radiant when people wonder like why do
5:58 some people look radiant some don't it's
6:00 because they have more hyaluronic acid
6:02 probably in their dermis and in their
6:04 smash or they carry more water in both
6:06 and they reflect light better so they
6:08 look more radiant regardless of
6:11 pigmentation so all these tissue layers
6:14 with elastin collagen hyaluronic acid
6:17 Desmond vementin you name it every tiny
6:20 thing in your skin can become depleted
6:22 over time or change its character and
6:24 you carry less water you carry you have
6:28 have less fat so all these things tend
6:30 to atrophy now it's impossible to go
6:32 back in and replace every single one
6:34 that's why we do a shotgun effect
6:36 treatment sometimes where we'll go use a
6:39 radio frequency to damage everything in
6:42 the dermis and say please I hope you can
6:44 recover and regenerate some Alas and
6:47 hyaluronic and collagen or are we going
6:49 to do fat grafting and we try to do it
6:51 in multiple layers to plump it up or we
6:54 do hyaluronic in this Mass with these
6:57 profilio or other types of fillers but
7:00 nothing can replace every layer that was
7:02 deflated and so I tell my patients I say
7:05 don't expect Perfection I can do a great
7:08 great job I can do better than anybody
7:10 uh can or as good as anybody else can
7:13 but you'll still have some deficits and
7:16 I can't fix everything because there are
7:18 too many things and too many layers to
7:21 fix it's not possible so that's really
7:23 what I try to explain in my patients to
7:25 expect ultimately makes no difference
7:27 they still want everything to be perfect
7:28 and still want everything to be better
7:30 you can't blame them we're all uh
7:31 perfectionist if we're going into this
7:34 world of plastic surgery but not every
7:36 kind of bit of perfection can be
7:39 attained and it's important to know that
7:40 because sometimes you chase things and
7:42 go too far
7:45 um and end up making things worse so the
7:47 other thing I try to tell patients today
7:50 is that there's not always a solution so
7:52 I did have some patients who wait six
7:55 months to see me sadly and when they got
7:57 here I told them no there's nothing to
8:00 do you shouldn't do anything and to them
8:02 that's uh you know fortunately they
8:05 understood it's it's a good advice and
8:07 save them from doing something bad some
8:08 people would come in and think I wasted
8:12 their time ultimately it's difficult to
8:14 assess people sometimes just from photos
8:17 so you do have to see them in person so
8:20 questions regarding duration of lifting
8:22 for each thing came about so how long
8:24 does a brow lift last a brow lift for
8:26 most people if you do an endoscopic
8:28 style brow lift should last about 10
8:31 years if you maintain it with botox if
8:32 you don't maintain with botox it can
8:34 come down around five years or sooner or
8:36 if you don't do a great brow lift
8:38 obviously you can come down sooner
8:41 patient asks me why do I still have
8:43 wrinkles here and I explained you can do
8:45 the old school style brow lift where you
8:46 cut out skin and do a forehead type
8:49 reduction or a coronal lift and pull
8:51 everything back and you will have
8:54 reduced wrinkles but you might look a
8:56 little unnatural and age differently
8:59 over time because it's impossible to
9:03 design a brow lift appropriately for
9:05 somebody where you go and cut out a
9:07 certain amount of skin because this part
9:09 of the brow came up that part of the
9:11 brow went down this part of the brow
9:13 came down this part medialized that part
9:16 lateralized so it's impossible to go try
9:18 to draw something that compensates for
9:20 all those bits of drooping that have
9:22 happened over time whereas if you go in
9:24 and do a deep plane or endoscopic brow
9:25 lift you're just going through incisions
9:28 you release everything and you just go
9:30 back to where it naturally came from so
9:32 you actually do get a better lift that
9:34 way or more appropriate lift so I tell
9:39 my patients I would rather do a
9:41 endoscopic less invasive a little bit
9:44 more natural uh brow lift and then
9:45 depend on Botox rather than do those
9:47 cuts so let's say you do either one of
9:49 those it'll last about 10 years if it's
9:51 done properly for upper eyelids same
9:53 thing it lasts about 10 years and upper
9:56 eyelids you could do skin reduction fat
9:58 grafting fat repositioning chemical peel
10:00 lasers you could do all that stuff as
10:02 far as upper eyelid surgery goes
10:04 lacrimal gland pexy all this is upper
10:07 eyelid surgery also about 10 years lower
10:08 eyelid surgery really depends because
10:11 you can do fat repositioning now I
10:13 advise people do not do fat reduction
10:14 unless there's a specific indication
10:17 like you have one fat bag left after two
10:19 surgeries okay go reduce it otherwise
10:23 fat removal surgery in my opinion has no
10:26 place in the year 2022 we do fat
10:28 repositioning unless you're doing
10:31 grafting at the same time fine but we're
10:32 doing fat repositioning and when you do
10:34 fat repositioning that should be
10:38 permanent if it works so one part of the
10:39 lower eyelid surgery can be permanent
10:41 however you do still Hollow over time so
10:43 you'll likely need to touch up again
10:45 sometime within 10 years could be a
10:47 laser it could be a skin excision could
10:50 be a cantho pexy if you droop could be a
10:51 million things
10:54 as far as lip lips go lip lifts I don't
10:57 know how long they last I think for most
10:59 people we could assume that they will
11:01 not grow out of the lip lift in about 30
11:04 years 20 years I don't know I've only
11:07 been doing them about eight years so my
11:09 guess is about 20 30 years although it's
11:11 not impossible that somebody would need
11:14 a bigger lift facelift there's a
11:16 difference between
11:20 small smash glycation extended smash
11:25 lifts Max lifts Heist Mass lifts deep
11:27 plane lifts and extended deep plane lift
11:30 so all these have a different amount of
11:32 lifting and on different skin types and
11:35 different face types work to different
11:37 extents so the bigger lift you get in
11:38 general the bigger Improvement you get
11:40 in general the longer it's going to last
11:42 the less scarring you have you can
11:43 assume it's going to last longer so the
11:45 way these things work which I said in
11:49 other sessions before is smash glycation
11:52 is done by elevating the skin grabbing
11:54 this Mass layer and tying it up with
11:56 stitches tightening it up
11:59 that you're not really lifting anything
12:02 to lift something you have to release it
12:05 from its insertion point take it up and
12:06 put it back down without any tension so
12:09 it heals in that new position if you go
12:12 and try to tighten things by pulling you
12:14 don't get much of a lift because the
12:16 skin the soft tissues just grow around
12:18 the the Stitch over time it's a human
12:21 body it's not a wooden nails so it tends
12:22 to go back down but you can get some
12:24 good manipulation of the platysma
12:26 because you are everybody who does a
12:28 smash application goes in here and does
12:29 a little bit of a deep plane whether
12:31 they know it or not and they grab that
12:32 muscle bring it together and then
12:34 laterally there's a bunch they can do so
12:36 either way with these Mass glycation
12:38 lifts if you look at older series
12:41 The more limited smashifications usually
12:43 have a big effect for about three years
12:46 and then they mellow out the nicer smash
12:48 placations are more skilled surgeons
12:50 doing them can go five to ten years
12:53 really just depending on the surgeon the
12:56 quoted uh amount of time in literature
12:57 is about eight to ten years if you look
12:59 at the studies from mataraso and
13:00 everybody who were doing research
13:02 studies on when people come back for
13:04 surgery it doesn't mean that everything
13:06 lasted 10 years it just means that's how
13:08 long they go before they come back for a
13:10 surgery a deep plane is kind of the same
13:12 you look at about eight to ten years 10
13:14 years or so
13:17 the difference is the Deep plan if you
13:19 do a little deep plane you get a smaller
13:20 change if you do an extended deep plane
13:23 that means you released everything so
13:25 modified extended deep plans means you
13:27 release everything here you release the
13:28 neck you release everything and bring it
13:30 up the more you release the bigger
13:32 movement you get the longer it lasts
13:34 still you're not getting much over 10
13:35 years so
13:37 is there a difference if you're revising
13:40 both of them at 10 years yes there is if
13:42 you do a big extended deep plane you
13:44 will look better from beginning to end
13:46 of that 10 years than you would have if
13:48 you did a lesser lift again this varies
13:50 from surgeon to surgeon so someone's
13:52 saying they did a deep plane versus a
13:54 smash really makes no difference you
13:56 have to look at the surgeon what kind of
13:57 change they're getting you can have
13:58 surgeons who do some applications who
14:00 get incredible results and you have
14:02 surgeons who do deep plane who get
14:04 really results so
14:08 um it really is all surgeon based so I
14:09 think that is largely what we went over
14:13 today with all the patients and the
14:15 other question was I lost fat over time
14:18 can I restore it I tell people no what
14:20 we do is we take fat from somewhere else
14:22 and we try to mimic the fat that was
14:24 lost it does not restore the fat that
14:26 you had and in fact it has a different
14:27 brain when you bring abdominal fat and
14:29 put it in the face it's going to grow
14:32 like abdominal fat and they ask does it
14:36 survive and I say yes it can survive uh
14:38 but no matter what you get a benefit so
14:39 people always ask how much of the fats
14:40 going to survive the answer to that is
14:43 zero to a hundred percent you do not
14:46 know no one can tell you 30 or 60 or 75
14:48 you have no idea
14:51 fat loss however much it lasts all we
14:52 know is that if you inject it faster
14:54 when you take it out of the body it'll
14:56 most likely survive better if you add
14:58 PRP to it it'll most likely survive
15:00 better but no matter what when you
15:02 inject fat it does have some kind of
15:05 benefit to the skin it has some kind of
15:07 weird stem cell potential and makes
15:08 people look a little bit better but does
15:11 have a mind of its own which means if
15:13 you get fat in your abdomen your face
15:15 can get fat if you have hormonal changes
15:17 from menopause and your fat cells change
15:19 they can change in your face and they
15:20 can grow so you never want to inject
15:22 enough that you can't control
15:25 and fat injected can also add volume
15:27 once it's injected so if you inject fat
15:29 and you inject one milliliter and it
15:31 survives just like Sculptra sitting
15:33 there fat can induce an inflammatory
15:35 response around it and you can actually
15:37 grow volume from granulation around fat
15:40 that can happen too especially in the lip
15:41 lip
15:44 collagen can collagen be restored no
15:47 don't be stupid you cannot restore
15:50 collagen that's been lost over time you
15:51 can however
15:53 make more collagen there's a difference
15:56 here and it's important to know the
15:57 difference because people think that injecting
15:59 injecting
16:02 sculpture radiesse all this stuff
16:05 regenerates collagen that was lost over
16:07 time this is not true you're adding
16:10 collagen in by forming Scar Tissue but
16:12 you're not replacing the collagen that
16:14 was lost it's almost impossible to
16:15 replace the collagen that was lost by
16:17 doing those things however if you do
16:19 radio frequency treatments micro
16:22 needling with PRP you do all these
16:24 different things you can generate new
16:27 formation of collagen you can generate
16:29 other good um
16:29 um
16:33 types of connective tissue within the
16:34 dermis and underneath however it's never
16:37 exactly what was there before so it's
16:39 really important to know that in aging
16:42 face surgery we are doing everything we
16:45 can to mimic what was lost but we cannot
16:47 restore to how things exactly were
16:51 last question was about symmetry again
16:53 um doctor I went to my other doctor and
16:55 they said that during the surgery you
16:56 could have made the Brows more symmetric
16:59 and I said well it's not possible
17:03 because we are asymmetric and she said
17:04 well I understand but surgery you can
17:06 make it more symmetric can you I said
17:09 yes to some extent you can so the reason
17:11 we have asymmetries in the face is not
17:13 only because we grow differently on each
17:16 side of the face depending on how we age
17:18 or droop but it's also because we have
17:19 different neuromuscular dominance
17:22 patterns which means that the brain can
17:24 tell this part of the face to move
17:25 differently than that part of the face
17:26 because they're wired differently and
17:29 together and this part can actually move
17:30 differently than that part and that part
17:32 so you can be dominant on this side of
17:34 the face but this side of the brow
17:38 dominance on one side of the face or one
17:40 side of the body is what leads to one
17:41 side being stronger than the other just
17:42 like if you're right-handed or
17:45 left-handed so when somebody is dominant
17:47 on one side and their brow is higher on
17:49 one side you can do all the lifting you
17:50 want in the world that side will always
17:53 want to go higher the only thing you can
17:55 do to change that is Botox because
17:58 you're affecting the neuromuscular
18:01 Cascade let's say and the other thing is
18:03 if asymmetry is bad enough then yes
18:06 physically you can actually do an
18:08 asymmetric lift directly to bring one
18:09 side higher than the other but it has to
18:11 be different enough so you can't just
18:13 have like a little shape change and a
18:14 minor shape change and say I'm going to
18:15 make them symmetric it's not going to
18:18 work but if it's bad enough then yes you
18:21 can get improvements in symmetry so
18:25 symmetry also is really Irrelevant for
18:28 most of what we do in Beauty it treats
18:31 neurosis meaning it treats uh patients
18:33 anxiety and patients nitpicking about
18:35 things does not change how people
18:37 perceive them nor their beauty and about
18:39 90 percent of cases and what people look
18:41 for however there are 10 percent of
18:43 cases that it is important to treat
18:45 asymmetry because the asymmetries are
18:47 affecting how someone looks because it's
18:49 either affecting their function or it's
18:51 straining their face or it's to the
18:53 point where you go to babak azizade
18:56 who's the master of treating real facial
18:59 asymmetries from facial paralysis so
19:00 those are cases where you really want to
19:02 treat it other cases where you want to
19:04 treat asymmetry is where the nose is one
19:05 side higher than the other midline
19:08 structures tend to be more perceptible
19:11 you can see them a little bit better and
19:13 notice them and it bothers people's eyes
19:14 a little bit more when midline
19:16 structures are asymmetric so those are
19:18 some exceptions but overall when people
19:22 come to me looking for symmetry I advise
19:24 them I'm not that kind of doctor I like
19:25 to make things look really really pretty
19:27 and I do everything I can to make it
19:29 look pretty I don't do things for no
19:32 point it's not fun I don't enjoy it and
19:34 it's not going to improve Beauty
19:36 so 90 of people who asked for the
19:39 Symmetry I don't really uh do much for
19:40 it I don't think it'll help them but 10
19:43 of people I certainly do because they
19:44 see some things I don't sometimes
19:46 they'll see like a cheek is higher on
19:47 this side flatter on that side and I say
19:48 you know what you're right we should
19:51 actually improve that symmetry you look
19:53 better on both sides so these were the
19:56 questions for today which are uh general
19:59 questions that you receive a lot in uh
20:01 this world of facial Plastics and
20:04 Plastics alike I will post this in case
20:06 anybody needs and
20:08 um in case I'm a little incoherent it's
20:10 because I've been going straight from
20:13 six in the morning without a break so uh
20:15 seven o'clock and we gotta go hope
20:18 everyone has a lovely night I'm headed
