0:06 I'm here in Miami
0:09 and uh it's Thursday but I forgot my
0:11 lesson of the day Wednesday yesterday
0:15 Wednesday was our uh consult day and
0:17 we call it hump day hell day whatever
0:21 you want to call it I saw probably 45 46
0:25 people uh mostly new consult some old
0:27 consults coming back in to just talk
0:30 about things and again there was a theme
0:33 that popped up there's always a pattern
0:36 and I saw several patients yesterday
0:39 with really bad skin coming in for
0:42 facelands and they're lovely people so I
0:43 don't mean to insult their skin but they
0:44 had really bad skin and they're going
0:47 for a facelift and this is important
0:50 because face lifting is meant to make us
0:52 look more refreshed youthful and younger
0:55 and it's done by lifting sometimes we
0:57 add some volume to the face to brighten
1:00 the face as well but the number one most
1:02 important thing or the biggest most
1:05 important organ we have that we use in
1:07 face lifting is the tegument or the skin
1:10 and that's all this stuff
1:13 so uh what's the the purpose of lifting
1:15 if you're gonna still have bad skin
1:16 you're still going to throw Shadows
1:18 you're still not going to have that
1:19 bright appearance to you and
1:23 realistically really limited your result
1:25 so uh with these patients I try to
1:27 explain to them what's happening in
1:29 their skin and why it's important to
1:33 brighten it so with aging we see The
1:35 Superficial part of the skin can get sun
1:37 damaged and we're all familiar with that
1:38 because we see it on everyone's face
1:40 what we don't realize is that there are
1:41 several layers deep to that that
1:43 actually affect how that superficial
1:45 layer looks and that's different for the
1:47 eyes than it is for the cheeks than it
1:49 is for the lips the tissue layers are a
1:51 little different so to walk you through
1:55 it superficially we need to fix Vina's
1:59 face Vina Nevis and on your right so uh
2:01 Venus face is a good example so superficially
2:02 superficially
2:04 when you get sun damage you can get
2:08 separate keratosis you can get uh little
2:10 sun spots you can get a bunch of
2:12 different things the most common that we
2:14 see that's concerning is form or a
2:16 variety of melasma melasma is
2:18 superficial skin pigmentation and
2:21 melasma can happen from sun damage in
2:23 areas up over here especially around the
2:25 cheeks very common it can happen from
2:28 lasering which is like sun damage on
2:30 crack so if you laser someone who has
2:32 pigmentary issues it's just like putting
2:34 them in the Sun and accelerating it and
2:36 you get it from hormonal changes as well
2:38 when you go through hormonal changes
2:40 rapidly the pigment and the skin gets
2:42 more reactive for some reason so you do
2:45 see that it's up regulated so for
2:48 melasma or superficial pigmentation we
2:50 can treat patients with chemical peels
2:52 with lasers those are aggressive ways to
2:54 get it off if it's skin that's sensitive
2:56 and gonna react things like that might
2:57 just make it worse so we just give
3:00 people creams creams that can light new
3:02 creams they can calm the skin there's a
3:03 bunch of different things you can use
3:04 creams that can make the skin look
3:06 younger Retin-A is a common one that
3:10 people use for better skin turnovers the
3:13 skin turnover goes faster and you your
3:15 skin peels off faster it also allows
3:16 better depth of penetration of the
3:17 different creams that you put on that's
3:19 why people use it but you don't want to
3:23 use Retin-A on sensitive areas like here
3:24 or around the under eye so it becomes limiting
3:25 limiting
3:29 now that's it uh nothing's working and
3:32 you're Asian and you've got bad melasma
3:33 and you want to know what else to do
3:35 well there was a study done amongst
3:39 Asians uh using tranexamic acid txa this
3:43 is a an IV medication or oral medication
3:44 that we use for women who have heavy
3:46 menstruation heavy periods to help them
3:50 form blood clots and we've also found
3:53 that it helps with melasma so if
3:55 somebody takes melasma with recalcitrant
3:58 or resistant melasma where about one to
4:00 three months just depending on how long
4:01 you want to put them on it you can
4:02 lighten the large majority of these
4:04 people who don't lighten otherwise so
4:06 that's the melasma
4:09 there are the fine wrinkles and texture
4:10 and things like that and for those
4:12 things you have
4:16 Retin-A also you have CO2 lasers or
4:18 erbium yag lasers which are fractionated
4:20 lasers which help superficial texture by
4:22 ablating the surface that means it
4:24 explodes water and ablates the surface
4:26 they also can go a little bit deeper and
4:28 cause coagulative necrosis or other deep
4:32 damages in the dermis to tell your body
4:34 to remodel and make new collagen
4:36 other than just burning things off and
4:37 then you have radio frequency radio
4:39 frequency there are a lot of different
4:41 types and I'll talk about that totally
4:43 separately because it's confusing to
4:46 doctors and to patients all the
4:48 different types of radio frequency but
4:49 radio frequency can be used
4:51 superficially to stimulate the skin like
4:53 microneedling it can be used deep to
4:55 melt fat and it can use just in the
4:59 middle to go and thicken the dermis or
5:02 help the dermis get healthier
5:05 so what is below the skin we've got the
5:07 epidermis we've got the dermis under it
5:09 we've got more important layers as well
5:12 and the one right under it is called the
5:14 smash the smash is The Superficial
5:17 musculoponeurotic system this has its
5:20 own thick hydratory layer that's
5:22 interspersed with fat molecules
5:25 and a bunch of hyaluronic acid and fluid
5:27 amongst other tissue and then when you
5:29 go deep to it you have some mimetic
5:31 musculature so smiling muscles that it
5:33 wraps around so this mask kind of covers
5:35 all that but what I'm talking about is
5:36 the thick part of the smash that you
5:38 have on top of the orbicularis Ora's
5:39 muscle or the thick part that you have
5:41 going over the zygomatic is complex and
5:44 down into the Buckle you also have your
5:45 fat pads in the face and there are the
5:48 granular fat pads which we call the
5:50 superficial mail art pad or the law of
5:52 fat pads that you see around the zygoma
5:53 and then you have your buccal fat pad
5:55 which is totally different
5:57 and they contribute to appearance of
6:01 skin in different ways so this mass is
6:03 very very important if this Mass becomes
6:07 deflated or damaged in someone's face it
6:08 can start to make the whole face look
6:11 darker it is what is probably the most
6:13 responsible for the hydratory potential
6:15 or the cushiony appearance of your face
6:17 when you get rid of it the face starts
6:18 to throw Shadows everywhere not just
6:21 where it's folding so the smash is super
6:23 important I do see patients who come in
6:25 and they have an exaggerated appearance
6:27 to their face because their smash is
6:28 shrunken that could be because they have
6:31 Scleroderma and they've had multiple
6:33 bouts of fibrotic reactions in their
6:35 face where the smash just shrinks down
6:38 it could be from dissolver and filler
6:41 meaning they got overfilled and the skin
6:43 got damaged over time and the smash is
6:44 really where a lot of the filler stays
6:46 and when you dissolve it you have all
6:48 these microcystic little areas that have
6:49 expanded and it collapsed in an
6:52 exaggerated fashion after you dissolve
6:54 and that doesn't recuperate so well in
6:56 the mid face and I have I did see two
6:57 patients like that yesterday who didn't
7:00 understand why they look darker but when
7:02 I told them their timeline matched up
7:04 and that's exactly what happened I saw
7:06 two other patients who had had deflation
7:09 in the smash or the fat from repeat
7:11 radio frequencies and the type of radio
7:13 frequencies you have are the wand based
7:14 ones which generally you don't want to
7:15 put in the face you don't want to put
7:18 acutite in the face or face tight
7:20 melt the fat layers and melt the smash
7:22 you're going to shrink them people
7:23 imagine that you tighten these layers
7:25 concentrically and you get a lift out of
7:27 it realistically that's not happening
7:29 you're microwaving them and you're
7:30 shrinking them and reducing their
7:32 thickness so the support for the skin
7:34 over time ends up going down it's not
7:36 shrinking and tightening like you think
7:38 you do get some fibrosis and contracture
7:41 and density in that area because you
7:42 scarred it down that's where the
7:45 tightening comes from so it's important
7:47 to be cautious when we're doing these
7:50 deeper types of radio frequencies or
7:51 heat based treatments in the face or
7:53 repeats based treatments in the face
7:55 because even if you're not melting the fat
7:56 fat
7:58 you have to remember the smashes there
7:59 and even if you're not melting the smash
8:01 you're going to cause a fibrotic
8:03 reaction there and eventually it's going
8:05 to sclerosis it's going to scar down and
8:06 that's very very common and it's common
8:08 amongst people who do over aggressive
8:11 single treatments or are over aggressive
8:13 by doing multiple treatments so you have
8:14 to be cautious how many heat treatments
8:17 you're doing even CO2 laser when it's
8:19 overdone can do that so
8:22 the layers deep to the epidermis and
8:23 dermis which is what we consider the
8:26 integument are just as important to the
8:27 appearance of it
8:29 you have to keep them intact and it's
8:31 impossible to replace them we can't go
8:34 and replace a damaged smash we can't go
8:36 replace lost fat in the face we'd have
8:38 to take fat from somewhere else and try
8:40 to replace it so we have to be cautious
8:43 and make sure we keep this our entire
8:44 lives or you end up like these ladies in
8:46 my office who are getting darker or
8:48 getting older and accelerated with raids
8:50 and they don't know exactly what's
8:52 happening so what do I offer them when I
8:54 see this deflation I recognize the
8:55 deflation in the face when it's caused
8:57 from Smash or fat deflation it's a
8:59 different type of darkness and collapse
9:03 I tell them they could do nanofat PRP if
9:05 you take nanofat and PRP and inject it
9:07 back into the dermis subdermis and a
9:10 smash you'll actually get a surprising
9:12 amount of Rejuvenation in those areas
9:15 and patients skin just turns brighter a
9:17 lot of that is from the return of
9:19 hydratory potential of the face where
9:21 the face like a sponge starts to inflate again
9:22 again
9:25 that's decently easy to treat the hard
9:28 one is when there's damage with age or
9:31 sun or lasers to the dermis and you get
9:32 that dry appearance to it that's really
9:34 hard to rejuvenate I still use nanofab
9:36 PRP for that but what I do recommend
9:38 that's very easy is to do micro needling
9:43 micro needling uh is touted for collagen
9:45 production it doesn't really produce
9:47 much collagen what micro needling by
9:48 itself or micro needling with PRP is
9:51 good for is stimulating the skin and I
9:53 like to tell patients to go do it maybe
9:56 three four times a year and what happens
9:58 is they needle the skin the skin gets
10:00 pissed off or stimulated your immune
10:01 system wakes up comes and tries to heal
10:05 the area and in doing so uh hydrates it
10:07 more aggressively so now chronically dry
10:09 skin becomes more hydrated
10:13 people use oils hyaluronic acids and
10:15 Retin-A and these things can have a
10:17 positive or negative effect just based
10:18 on your skin type you never know micro
10:21 needling unlikely has any negative skin
10:24 type negative skin reaction the
10:27 micro needling RF or radio frequency is
10:30 totally different so not the same kind
10:35 so the message in the end of all this is
10:37 if you're in the position where you're
10:39 trying to go get a facelift because you
10:41 want your face to look brighter nicer
10:43 and younger you first need to focus
10:45 yourself on improvements in the skin
10:47 quality and you need to be religious
10:49 about that that's why I always send my
10:52 patients to Jen Hollander first go see I
10:54 said go see her start getting uh going
10:56 on a skin regimen make your skin
10:58 brighter and I'm not when I'm talking
11:00 about skin I'm never just looking at the
11:02 outer skin I'm looking at what's under
11:04 the skin too because I recognize it I've
11:06 seen it so many times so I look for
11:08 deflation and I look for darkness and I
11:09 look for different things that you see
11:12 over time that happen again with age
11:14 with filling and dissolving or that
11:16 happen with heat based therapies or
11:18 repeat bouts of scarring again like
11:20 Scleroderma and those kind of autoimmune
11:23 issues where you get rapid dehydration
11:25 and skin quality changes so you have to
11:27 treat all of these when you are looking
11:30 at the aging face so it's not just one
11:32 level of skin integument you have your
11:34 smash you have have your fat below that
11:36 there's the mimetic muscles below that
11:38 there's fat pads again and you need all
11:40 of them the medic muscles The Smiling
11:42 muscles in the face do not function
11:44 properly when they are bogged down with
11:46 a lot of fluid like filler or silicone
11:47 and they don't function well when
11:48 they're denuded when they're stripped
11:51 down if somebody overheat treats or over
11:54 dissolves the muscles start to work a
11:56 little weird they they contract too much
11:58 or they relax too much it doesn't
11:59 function well and when you get rid of
12:01 the buccal fat pad that's an entirely
12:02 different one that I just touched upon
12:04 the buccal fat pad is a support
12:06 structure for this part of the face so
12:07 when you get rid of the buccal fat pad
12:09 in some people you start to see collapse
12:11 here and it's a whole other type of
12:12 Darkness that you see in people where
12:15 they start to get indentations here in
12:18 front of the pre-gel fold is what I call
12:20 it or the marionettes as it comes down
12:22 so all these things are important you
12:25 can't replace them so this is more you
12:27 know it's a message for like young
12:28 people especially don't think that you
12:30 could just keep doing heat treatments
12:32 over time and it's going to be healthy
12:34 and have no problem problem these things
12:36 can slowly damage you they slowly just
12:37 think about it they just slowly
12:39 microwave your face and you keep eating
12:40 it too much or if you get too much
12:42 filler you've expanded it now you've
12:44 damaged your tissue and somebody's gonna
12:46 go try to dissolve you and the dissolver
12:49 is gonna now deflate you so much because
12:51 you are over expanded already so take it
12:53 easy on all this stuff and don't think
12:55 we can fix it because we can't fix everything
12:57 everything
13:00 happy Thursday for the Wednesday message
