Facelift Trends vs Reality with Dr. Ben Talei

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:06):
Welcome to another episode of Plastic Surgery on Censored. I'm
your host, Doctor Roddy Rabon, and we have a fantastic
episode today. They're always fantastic, but this one's extra fantastic
because we have an extra fantastic Guess you guys are
going to be very lucky. We have a famous Beverly
Hills celebrity plastic surgeon, Facial Plastics Extraordinary. Ben is on fire.

(00:31):
Doctor Tally is with us today and he's honored us
with coming on the show. And as you know, I
don't generally bring too many doctors on the show. It's
not because I don't like playing in the sandbox. I
just don't want to bring anyone on the show that
I don't think is excellent because at the end of
the day, I think people who listen to the show
trust me and then if I have someone on And anyways,

(00:53):
long story short, Ben is here, Doctor Ben Tally, welcome
to the show.

Speaker 2 (00:57):
I appreciate it. I came fully censored sensors.

Speaker 1 (01:00):
Good, well, I will uncensor you I want. That's my
skills set. So we're going to talk about the probably
the hottest topic in plastic surgery today is facial aesthetics,
facial rejuvenation, which then really subdivides into specifics. So we're
going to kind of figure out the landscape. We're gonna
we're gonna define some terms, we're gonna try to demystify

(01:22):
some of this. Really, the crux of it, the epicenter
of this are facelifts, and they're just exploding. I just
saw your congratulations on your Denise Richards post. That's amazing.
She looks fantastic. So let's dive right in. I think
the thing that is so I personally, I think most

(01:43):
of what social media has done for plastic surgery, while
it has definite upsides, like oh my god, we're seeing
so many more patients, people are so more educated. If
I had to really really internalizing, like my gut feeling is,
I don't know that it's been good for plastic surgery.
It's been good for plastics virgins, but I think it's
created a lot of confusion, insecurities. Just I don't know

(02:07):
that it's been healthy. That being said, every once in
a while there is something that I think comes on
to the social media scene and it turns out that
it was beneficial, And I think for me personally, facelifting,
educating facelifting and the interest around face think has been beneficial.
And let me elaborate I think that now. So number

(02:29):
one things. When you I used to mention to a patient,
you know, they come in usually they'd be in there
mid to late forties, that's the standard. They'd have a
little bit of jowling, a little bit of marionetteing, and
a little bit of neck banding, right the traditional thing,
and maybe a little lateral brow descent. And they'd say, hey,
you know, I'm starting to look a little older, and
what are my options? And I would say, probably, even

(02:53):
though your practice is tilted very heavy towards facial aesthetics,
I would say that probably six years ago it would
be it would be a tall order to get a
forty three year old a forty six year old to
be like, to be honest with you, I think you
need a facelift. What how dare you? I mean, like
you're insulting me. Can't we do a filler or a
botox or a laser or a schmazer or some mini

(03:15):
Mickey Mouse something? And You're like, not really? And hence
why for I don't know, more than a decade, we
balloon the shit out of people. We not me and you,
but providers because the recipe called for hammer, right, and
we just keep fucking using a screwdriver because you know,
if you pull out the hammer, they freak out. So
luckily the collide between balloon facing and oh, that looks

(03:39):
terrible and the oh, I can get a facelift at
forty three, and it's not. You know, I did my
niece's noses at like sixteen, nobody even blinking an eyelash.
So now a forty some odd year old comes in
and you're like, listen, you need a face. So what
I was getting at is I think the trend in
that regard was very good because it allowed us to
operate on better candidates earlier to get better results. So

(04:01):
I don't know if you agree with that, but I
think that that's what I've seen that being said very confusing.

Speaker 2 (04:08):
Yeah, well, it's a mixed bag.

Speaker 3 (04:10):
When these things happen, the popularity or the trend kind
of arises and everyone gets excited about it, the patient base.
And if a patient base the population is excited about something,
surgeons get.

Speaker 2 (04:19):
Excited because they look at it.

Speaker 3 (04:22):
You know, not all surgeons, but there are tons of
surgeons out there who don't have lots of talent, they're
not focused on their work, and then they see the
trends in the market and they get very excited and
they say, well, if all these patients want it, it
must be good, and it means I want to do it,
So they start jumping into it. So, on one hand,
when I say it's a mixed bag, it's great because
it increases popularity. It increases acceptance of these things, social acceptance,

(04:46):
especially the downside becomes it becomes popular, and people start
doing it who shouldn't be doing it, both the patients
and then some practitioners who are just really getting you know,
their feet kind of warm with this stuff, and they
follow along the trends of what you see is this
huge trend comes and everyone's excited, and then three years
later it's just like tons of revisions.

Speaker 2 (05:06):
Sure, yeah, like liplifting.

Speaker 1 (05:08):
It happened with bbls everything, It's happened with you know,
this minimally invasive rhinoplasty, it happened with pizo like it's happened.
It happens with anything that's trend driven. But but so
let's let's first start through some definitions. Right. So back
in the day, if you saw a patient you say
you need a facelift, at least someone that was, you know,
maybe fifteen twenty years ago, the assumption was you needed

(05:29):
a facelift. And for those of you that are listening,
I'm basically lifting my whole face. And their assumption was
it was their entire.

Speaker 3 (05:35):
Face, right, And so they always say that, do you
mean a whole face?

Speaker 1 (05:38):
Yeah? And so today we don't, at least the majority
of us don't look at it that way. We I
refer to it as all a card it and we
go individually in the areas that the face, the total
face have started to age. It may you be your
lower eye, lad and maybe your brow. It may be
your face in next So why don't you tell me
in your analysis, let's just describe what when you look

(06:00):
at a patient you say you need. Let's just define
the terms and what they refer to. Because, for example,
a lot of patients say I don't want a facelift,
I want a necklift. I hate my neck, And I'm like, yeah,
I understand that, but it's a little bit of a
misnomer because the overwhelming power within a facelift, albeit you
do some mid face work is through the jaw lineing

(06:20):
in the neck, and so why don't you help us
define sort of if you will, like your analysis like
X equals to ex procedure and why and the terminology
if you will.

Speaker 3 (06:29):
Sure, Well, you have non aging face lifts or necklift,
and then you have the aging ones. Like the non
aging ones would be a younger patient who really has
like midline neck the center poor neck architecture. Sure, and
these patients don't have a major i'd say excess of skin, right,
I mean nobody does technically, but you're a major like
excessive skin or things like that. It's just the midline descendant.

(06:52):
Then you have the kind of gliding descent or the
volumetric toosis, which there's two kinds of drooping that happened
in the face. So you have those two types, which
is more with aging. And with that you get into
more kind of the segments of the face that kind
of slide down, which is your face in your neck
like this kind of descending towards the midline. And then
you have the upper third, which is your scalp sort

(07:14):
of falling down. So I look at those kind of
gliding descents versus a midline descent on a younger person,
and I say, okay, I can do an internal necklift
on you, which means I'm just going to make access
decisions to recontour your muscle and possibly the visceral space
the deep neck space if I need to. And then
for the ones that were involved with aging, then I'm

(07:36):
going to say, okay, we need to go in and
do some kind of more substantial lift. And in that world,
for me, it's I'm just trying to optimize the movement
in this this kind of plan, which is different segmentally
depending on where you're looking at because of the way
the muscle system attaches, so it's a little bit different.
So that's the way I look at it. And for

(07:57):
the aging the way I see is you have two
types of descent.

Speaker 2 (08:02):
So you've got this.

Speaker 3 (08:03):
Which is your gliding movement where gravity takes effect, meaning
you lay down and it goes back, you sit up,
it comes down and it actually glides and the gliding
happens in the fourth layer of your face. And if
you take your hand and put it to the middle,
you have like one centimeter movement up, one center movement down,
and that's your glide basically, and it's not an open glide,
but it's a glide. The other type is volumetric loss.

(08:26):
And if you have your bone here and your skin
out here. When you're young, like a baby, you lay down,
no gravity effect, you sit up, no gravity effect, because
it's distended. As you get older, what will happen is
you lose the volume, whether it's bone, fat, muscle, fashion, water,
whatever it is between the skin. But the skin stays
the same, so it ends up like this, and when

(08:47):
you lay down it's like that. When you sit up,
it droops down like this, and so that's not a glide,
that's a volumetric tosis. So those are the two things
you're really trying to treat, because there's two types of tosis.
When you put them together, you get these three dimensional
changes where you see the pyramid the pyramids, because if
a pyramid is three dimensional, this is all two dimensional.
So I'm trying to correct all those things as much
as possible. And pretty much when you're aging, you're trying

(09:09):
to accommodate for the smaller size of the face. Right
you're a baby, the bones like this, the skin's like this.
Everything grows until you're like twenty something, and then the
outside stays the same and the inside starts to shrink
a little bit. Whatever it is, all that stuff, so
you're trying to accommodate for the new face size, and
that's why you put in filler sometimes when it's early
on and you can reverse it, versus once you get
too far gone, you can't go put all that volume

(09:31):
back in because it's not just fat you lost, so
you can't just put filler to replace it. You have
to lift, and when you lift, you're accommodating for a
smaller face size and fitting the skin to the smaller
face size, and you're revolumeizing.

Speaker 1 (09:43):
Yeah. No, excellent, So let me just kind of summarize that.
So basically, I would say you have two categories. You
have the patient who really is aging, and then you
have the patient who's not aging. They just have bad
an ant structure. Right. It's like the nose job I do.

(10:03):
It's just it's not that it's an old nose, it
just doesn't look right. So let's table that for a second,
because I think that's a really interesting subset, which is
that I'm thirty and I'm not aging or anything. I
just have a horrible neckline, and it usually applies to
the neck. But let's get to the more traditional ones,
which is I am aging. I'm going thirty, forty, fifty, sixty,

(10:24):
and as I'm aging irrespective of my ethnicity, my genetics. Everyone,
and this is an everyone will age and everyone will
age exactly the same way in different amounts at different times.
But when you take an eighty year old Asian woman,
Black woman, Middle Eastern woman, they're all going to have
the same changes, okay. And so what we're doing is

(10:44):
subdividing the area. So to me, when I look at
a patient, and I usually just grab a mirror and
I'm like, let's just go. Let's just literally go room
by room by room in your house. So here is
your brow, and your brow used to be here. I'll
hold it and now it's here. So you see what
a difference that in your eye? Oh wow, yeah, well
then your brow needs to be lifted. Oh look at

(11:05):
your upper eyelid. You see this redundant skin that's sitting
on your eyelashes. Yeah, I see that. Well, if we
remove that conservatively, oh that looks better, and so on
and so forth, whether that's a lower eyelid and then.
But I think the people people don't understand is when
we currently say facelift, at least the overwhelming majority of
us are referring to the mid and lower face. Yes,

(11:26):
So that's the first thing you guys need to understand. Historically,
when we would say facelift, it was just synonymous for
the whole face. So many older patients are like, I
just I don't know, I just had a facelift, and
then you look in their forehead and like that browlifts
and all this stuff, and it was just like they
throw it all together and just call it a facelift. Today,
because we are so advanced and we're tailoring it, we

(11:47):
don't just call it a facelift. But for most people
when they say I'm getting a facelif, where I need
a facelif, it's the mid face, like the right jawline
and neck. So that's very very important. The next thing
and that I think is that's really interesting. Let's talk
about first, let's go back and talk about the different types.

(12:08):
It's just very simple style. I think that there's a
lot of marketing. Right you are in an advanced level
within the area of facelifting. You you're in the courses
and whatever. But if you go on social media and
you look at the explosion of facelifting surgeons, meaning those

(12:29):
that provide facelifting, I don't know that there is an
equal level in rhinoplasty, in blepharoplasty, other things of more
confusing shit like in other words, there's minimally invasive dorsal
reduction sort of, and then there's traditional. Okay, fine, there's
two of those, right, But when it comes to facelift,
there's you know, SMAs ectomy this, and and there's the

(12:51):
internal dialogue you and me. There's probably four or five
of them, and then there's the outside dialogue, which is
how I'm marketing this, right, mini scarless minimum. So tell
me where you think. Let's what are the if you will,
as an incremental level this, let's describe to different types
of facelifts and sort of if you will, sort of

(13:12):
simultaneously their evolution, right, because facelifted we didn't invent it.
It was around for many years and a lot of
the things we're doing today while we've refined it and
we figured out, oh if I pull this lever a
little more, well, that's cool. But a lot of these
things were described well before any of us were even
in med school. So kind of tell me take me

(13:33):
through your description of the different types of facelifts.

Speaker 3 (13:36):
Sure well, so, first of that, there's a lot of confusion,
as you said, partially because of the marketing. How somebody's
gonna tell the world they do a unique type of
lift and this gives it a bunch of different names,
or they take advantage of what's popular in the market
at the time and they try to say that's what
I do more because it's exciting when you say the
word endoscopic, or you say the words deep playing, or

(13:57):
you say, you know, whatever it is you see, it
just catches people attention and they think that that ensures
a higher quality.

Speaker 2 (14:02):
Yeah.

Speaker 1 (14:02):
Of course, by the way, just to interrupt you, unlike
other things, you wouldn't even know if they did that, correct.
So that's the funny thing that I always mention to people,
like they'll come in and be like, you know, we're
doing consolets obviously more and they're like, hey, do you
do that? So for example very popular do you do
the deep plane and the answers I do that's sort
of how I've always done it, and the que and
then the thing that it makes me smile is like

(14:24):
if you went to sleep and woke up and you
had to face if you wouldn't have the foggiest if
it was deep plane or not correct. It's like going
to the mechanic and you're like, bro, we don't worry,
we rebuilt your transmission. Ye're like, you did show me
the parts, you know what I mean? Like, so go ahead,
you were saying, yeah.

Speaker 3 (14:39):
Well, And the other part of the confusion, which will
be a never ending is that the surgeons themselves they're
kind of at a very basic level of understanding of
the terminologies. And it's not their fault. It's taught incorrectly
over and over and over again all over the place.
So if a surgeon's confused about the terminology about what
it really is, the.

Speaker 2 (14:57):
Patients are going to be even more confused.

Speaker 1 (14:59):
Sure.

Speaker 3 (15:00):
Now, if you're looking at like the types of facelifting,
someone would say, or a surgeon would say, we have
like a deep plane, we have a high smaster of
different techniques. Someone who becomes very advanced doesn't just say
we have a deep plan.

Speaker 2 (15:12):
We say, tell me.

Speaker 3 (15:13):
The layer exactly, tell me where you're going, right below it,
right above it, a lot above it. And then tell
me are you doing on the side of the face
or the front of the face. It's two different things. Sure,
they're completely different.

Speaker 1 (15:23):
So that cluster, let's just for the real basic individual,
that cluster of variations is some type of maask based
deep plane surgery, whether the entry point is high or
mid face, whether it's thin or thick. The for the
listener and viewer, that collectively is called a deep plane.

(15:43):
And we'll get into some nuances as we go down.
There is of course still a lot of people who
do minimally invasive skin only type things, right, which in
some interest instances. In general, maybe it's not the ideal workhorse,
and it's I don't want to use the word lazy,
but it's definitely easier. But are instances where a very

(16:08):
skilled surgeon would use that very unique tool once in
a blue moon. Right, you have a super skinny face patient,
very they have not a lot of fat in their face,
et cetera, et cetera. But so we have skin only.
That's how this whole thing started. And then there's that
layer which we refer to as the smass or the
muscle layer or whatever you want to call. We won't
get too detailed, and then the options with that is

(16:29):
do you see surgeons still doing plycation right or applycation
typechnique techniques. The actually a lot of the minimally invasive
lunchtime type things that remember the Lifestyle Lift, of course, remember,
and that Lifestyle Lift was an infomercial that was crushing
it for years because they used really good lighting, and

(16:52):
that was about opening the skin, finding that muscle layer
and just putting a bunch of stitches in it and
pulling it up.

Speaker 3 (16:58):
Well, so the class action lawsuit was because they said
Lifestyle was a technique. They sold it as a technique,
but really what it was was a name of a
company and then the surgeons could do whatever they wanted,
whatever technique, as long as they got it done within
an hour to two hours.

Speaker 1 (17:12):
And I didn't even know that aspect of it. I
just knew that it was kind of Mickey Mouse.

Speaker 3 (17:17):
It was very Mickey Mouse, and the owner of the
company was like a decent surgeon. They would use his
before and afters mainly, and then they would grab one
and to hear from the other guys.

Speaker 2 (17:25):
But for this, I mean, the way I look at
it is.

Speaker 3 (17:30):
What we perceive to be like skin excess what we
perceived to be skin aging problems or dermal problems a
lot of the times is gliding issues and deflational issues.
Three dimensional contour changes. When you look at that, you
kind of separate out the face into two kind of chunks,
which revolves around exactly what you're saying, which is one

(17:51):
layer of the mass.

Speaker 2 (17:52):
So the smass.

Speaker 3 (17:52):
When everyone's talking about it, this is for everyone's gonna
be yeah, this is this is everything.

Speaker 1 (17:57):
Everything revolves around this layer, which we refer to as SMAs,
hence the words smass, and everything refers to where you
are relative to it.

Speaker 3 (18:08):
And the confusing part is surgeons even they're talking about
one part of this system, which is layer three of
the layer three of the face, which is the superficial smass.
But then there's deep smass even though it's a superficial system.
So this is confusing for everybody, and it leads to
a lot of confusion and videos and whatever else because
you look at from the side of the face or

(18:29):
the front or the junction zones, it's all different. Now
when you're addressing the face, people would address it either
from the skin level, saying it's a skin problem, and
then you could also address it from the mass level
above it or below it, depending on where you're going.
I tend to say, we need to maximize the movement
of that layer three mass level back to where it was,

(18:50):
keeping the skin and the fat intact, those three top layers. Yeah,
so I look at it as any patient I'm trying
to work on. I'm trying to maximize keeping those layers
together to keep them healthy and reposition them however you
want to do it. And this gets confusing for surgeons
because segmentally it's different how you can mobilize it depending
on where the deeper attachments are in the rest of

(19:10):
this mass system. So we're trying to reposition layer three
of this mass, but then you have these deeper attachments
here and here that keep it from.

Speaker 2 (19:18):
Moving and don't need to be moved. So lots of confusion.

Speaker 1 (19:21):
Yeah, I guess the basic principle of the idea was
when you lift, for the sake of discussion, the face,
and you're lifting the skin back into position and assume
the volume part. I'm both saggy and I'm hollow, so
hollowness doesn't get fixed by pulling, and as a result,

(19:41):
prior to us understanding that, oh wow, there's a significant
amount of hollowing that goes on. We would pull and
we would get decent results, but we would get a
lot of flattening and a lot of hollowing and weird shadowing,
and that sort of was the you know, the classic
wind swept part of the reason why people look like that.
The part of the reason why people look better today

(20:03):
is because we have a better understanding of volume. We
replace the volume where it needed to be replaced, or
we're operating on people who still have volume. Yeah, right,
a forty two year old is not deflated, whereas a
sixty five year old is more deflated. But when it
comes to the skin part, historically you would use the
skin to lift everything. You'd literally if I just pull

(20:24):
on the corner of my face on my skin, things
are lifted. But we all know skins not a really
good layer. It stretches, it does in the belly, it
does in the neck, it does in the breast, and
so one of the main principle it was to defer
or translate the stresses to something stronger and deeper, aka

(20:45):
this muscle layer. So you're lifting the face albeit because
that's really the main thing that moved on the muscles.
You anchor the muscles where they should be, and the
skin comes for a free ride. And therefore I think
that in general our scars are significantly better when executed correctly, again,
because there's less tension on the skin. So I think
that that that that basic principle of doing something with

(21:08):
this mask. Now, whether at a high level, it's high,
mid phase, uh, you know, you know, low medium, all
those nuances vary, and of course they're the kind of
the fun things for you guys to talk about. But
I think principally if someone is really want to understand it,
in most instances the we don't have a one size

(21:31):
fits all, but in most ins instances you want some
type of face lifting again mid face and neck, in
which the muscle layers are being lifted, elevated, manipulated so
that your skin and everything is connected together and looks
more natural and not separated.

Speaker 3 (21:47):
Yeah, and a better way to think about it, so
that there's two ways of thinking that get you to
that point. One was starting at the skin level and
then saying how can I get the skin to move
with less tension and kind of saying okay, I'm gonna
keep go into deeper layers and then relieve the tension
on the skin. And that is a lifting approach that
doesn't really go look at aging. It just says, I'm

(22:09):
gonna lift. And that's the first approach that ninety percent
of the world was taking. And still they're still looking
at it that way, saying how can I get this
to move, take off the tension, and do all that.
The other approach is to simply say how did the
face come down?

Speaker 2 (22:24):
That's it.

Speaker 3 (22:25):
So you say how did it come down? Because I
want to just reverse what happened. I don't look at
a person and say I want to lift them. I
look at a person and say how did it get here?
And when you do that, then you realize that it
is that third layer that's moving over the fourth layer
and kind of gliding down, and then that deflation which
is happening, and the deflation is happening, and mainly where

(22:45):
you have just skin, muscle, whatever, and layers two and four,
and then in areas where you have deeper pads and
layer five, which is like your buckle and your temporal
So when you look at it that approach, then you
say it, well, layers one two and three, which is
the skin, the subdermal fat, fashion, and the superficial layer
of this mass. All came down together in every person.
It always does. They're one composite unit. We call that composite, right,

(23:07):
So it all came down together. I want to figure
out how to move them back up together as much
as possible. And what I want to do is take
the approach where I really don't care about things that
didn't move right. These areas we have deep anchoring. These
areas that you see have deep anchoring. I don't care
about what didn't move. I care about what moved this
moved down onto this. I want to move it back.
This moved down onto this, I want to move it back.

(23:29):
So my goal becomes, let me keep these layers together
as much as possible, release where they are mobile up
to where they're fell onto, and lift them off of it.

Speaker 1 (23:39):
Yeah, that's think an alternative conceptualization of our end goal. So,
like everything there is constant progress. Progress is the wrong word.
There's constant push to be different. Some of that is

(23:59):
considered innovation, and some of that is considered marketing, and
some of it is considered ego driven. As a result
of that, usually eventually something or some things will come
out that are ten percent of the stuff that comes
out of it is useful and ninety percent of it
was a waste of time, probably shouldn't have been done,

(24:20):
people probably paid the price, etc. So one huge movement
in the area of facelifting is the shift from scar
to nonscar endoscopic aka ponytail, etc. And you have colleagues
who do it, who show results that work and are good.
And now that drives the market again because at the

(24:41):
end of the day, it's not me and you talking
about it at a meeting. It's now direct to consumer,
right because now the conversation, at least, for example and
breast implant is, oh, I want a motiva implant done
in a minimally invasive balloon preservey. It's like when on
Earth did a pay should come to me and tell
me I want to micro diskect exactly that it's just

(25:03):
never happened. It's unique to plastic surgery. So what are
your thoughts on this progress? Do you think it's the
new next best thing, do you think it's going to
die out? What are your thoughts on it? In general?

Speaker 3 (25:18):
Well, the endoscopic stuff does work for a large like
a good subset of people for a good subset of things.
It doesn't work for everything. It treats the gliding movement.
If you're looking at where most people are treating, like
the scalp, what do you call a browlift, which is
really a scalp, you know, resetting or restoration. It works

(25:38):
for that, and that's the easiest place to conceptualize it
because this moves, and we get into that with an
endoscope or endoscopically and move it back. Now, what they've
been trying to do with trachyko mark money these guys
do a little differently is to actually go perform some
sort of deeper procedure that they would call a deep
plane in the mid phase because the jawline and neck
they access from the back anyways, so that's kind of

(26:00):
classic standard surgery, so it's really can they bring this
stuff back up endoscopically. The older school ones were sub periosteal,
meaning they went right on the bone, but the bone
doesn't move and the periossium doesn't move.

Speaker 1 (26:13):
Not a very good plan.

Speaker 3 (26:13):
You can't really lift something they didn't move, so they
would all fail after about like a year and a half,
when the swelling went away, so they're saying, can I
go into what actually moved? So they're trying to do that,
and they're getting some decent results for the mid face
with adding some volume. They can't get massive movements with
it because again, you have to accommodate for the smaller
face size if it's an aging person. So because of

(26:35):
that reason, if it's someone who's face skeletally and tissue
wise got smaller and the skin didn't, you have to
accommodate by moving it somewhere right, and the scalp has
the benefit of moving back to a bigger cranium in
the back, so it redistributes. The face has this anchoring
point around the ear, and there's.

Speaker 1 (26:52):
So much you can pull it before, only so much
to move it.

Speaker 3 (26:54):
And you can't accommodate for a smaller face size, so
that becomes kind of your limitation on it. The other
limitation is is the technique reproducible. So you have exceptional
surgeons doing this like Marso genius, you know, and tat
to you like if you see them dissect, it's really
crazy to watch. It's like it's really cool stuff. I
don't think other people can reproduce. So not only is

(27:16):
it something where it's a very select patient base and
you have to be the right surgeon to pick the
right patient, which is already hard, then you have to
be able to reproduce what these guys are doing, yeah,
which is incredibly difficult. So I think the world of
it's very interesting.

Speaker 2 (27:29):
I do like it.

Speaker 3 (27:30):
I do like that they're learning about it and kind
of progressing, and I trust them both, and I watch
them and I just see it, but I don't jump
into it myself because I'm waiting for them to figure
out all the kinks over ten years or so and
then yeah, maybe I'll try it that up.

Speaker 1 (27:42):
Yeah, it seems to me. I do agree. I think
it's an incredibly novel approach to a similar to a
problem that we've been addressing that I think, to be
honest with you, I think our current understanding and execution
of facelifts is outstanding now. I think we've reached a
very very good place, and to create a new approach
to the same problem, the onus falls on them. If

(28:04):
what we're doing is trying to what we're trying to
do realistically is save you know, five centimeters of a scar,
which when done correctly. You and I both could show
one hundred examples is invisible. I mean, I can't say
that about certain scars. Those scars are really good, but

(28:24):
face the scars, when done correctly in the right patient
should be invisible. Right. So to do all this contorting
to save that would be the same argument I make
because you know, I do a ton of noses, and
I do all them open, because I do a lot
of things that I think are sophisticated, and as a result,
I need better visibility. To save three millimeters is insane

(28:47):
to me, right, So I feel that maybe this's and
I do think maybe blood supply.

Speaker 2 (28:51):
Do they get a little increase of like improved blood supply?

Speaker 1 (28:53):
Yeah, no, it doesn't. There are some benefits to it,
but as you said, there are everything's in exchange. I
do think at the end it'll be just something that
a handful of people will probably.

Speaker 3 (29:02):
Market because most likely because it's a high skill level
and you have to be very astute about who you
can get away with it on.

Speaker 2 (29:09):
And that's a big issue.

Speaker 3 (29:11):
When people try to go in and do it, they're
going to be doing revisions for like five years because
they get inadequate results.

Speaker 2 (29:16):
If they pick the wrong person.

Speaker 1 (29:17):
Yeah, I think that'll be true. Well, Shen takes us
to revisions, and then that takes us to you know,
the basic premise of the whole show. The show I've
done for now since twenty nineteen whatever, three hundred some
odd episodes. Every episode really revolves around what can go
fucking wrong? Because at the end of the day, well,
all this is interesting. Really, as a patient out there,

(29:39):
you're like, oh, that's cool, Wow, this isip cocking really
interesting stuff. And their main concern is I want to
get this done. I'm in Ohio or I'm in England.
I just don't want to have a complication or some
catastrophic outcomes. So I always spend a decent chunk of
time talking about what are the risks in incremental sort
of catastrophic order, and what is it that we need

(29:59):
to do to avoid those risks, because I think ultimately
that's really the goal, right is I'm listening, I'm interested,
I want to do it. How do I determine what
could go wrong? And how do I avoid that? So
why don't you take us through that a little bit?

Speaker 3 (30:13):
Well from I always tell surgeons, you know, what's a pessimist,
you know that's saying It's like, what's a pessimist is.

Speaker 2 (30:20):
An experienced optimist.

Speaker 3 (30:21):
So you have to sure be excited about what we're doing,
but be scared about everything at all times. And in facelifting,
you're scared about the common risks and the uncommon ones.
The blood collections, the saliva collections, the serious fluid collections,
nerve weakness, and blood supply. These are like the things
that we're looking at trying to control. For the patient

(30:43):
out there saying how do I minimize my risk? Is
really they have to find somebody in any field that
just does a lot of that. And it doesn't have
to be just faces. They can do face and breast
and this and that, but they have to be experienced
in it. Fear inside of aur is the best thing.

Speaker 1 (31:01):
You can have.

Speaker 3 (31:01):
And when people talk about like board specialization, all this stuff,
they think it's going to make the surgeon really talented
and good.

Speaker 2 (31:08):
I tell them, no, it makes them safe, which is
what you need. First.

Speaker 3 (31:11):
You need somebody who has fear in them. They've seen complications,
they've dealt with it. They even residency. You know, that's
like what you're gaining is fear and not being some
you know, like the dermatologist guy in Beverly Hills who
goes and does twenty gallons of LiPo and then kills
the patient from fluid shifts because they didn't do a
residency and see complications. They think that it's just about

(31:31):
doing the technique. So I tell the patient base overall
when I'm just teaching and kind of giving those online lecture,
they say, when you're looking for a surgeon, look for
one who does a good amount of this stuff, or
at least has done a good amount of this stuff,
because the first thing you want is, of course you
want a good outcome, but you want to also kno
get a bad outcome.

Speaker 1 (31:48):
Sure, yeah, I always tell patients you're the beneficiary of
my neurosis, exactly right, So that's you know, I'm Jewish,
I'm Persian, I'm very pessimistic. Is barely half full, exactly,
And you know there's always this know this. The other
analogy I use is that you know, you know, you
may have raised a lion from when it was a cub, right,

(32:08):
so you know this this lion is for all intentsive
purposes your pet, and you play with it and you
hug it and you whatever, but at any moment, it
can eat you because it's still a lion. And the
way I see all my procedures is they're all great
until they're not, and it just takes one oh shit, right,
as they say to erase a thousand out of boys. Right,
these are all These are all fucking things that I've

(32:28):
heard over the years. So one hundred percent I agree
with that. So let's take let's go one by one
to talk about these complications, albeit they should be rare.
So one of them obviously is himatoma. Right. Hematoma is
for those of you listening, is you do your surgery.
Everything's great, you go home, hopefully you go home, but
it could occur in the recovery. But the surgery is done,

(32:49):
and then all of a sudden, you're accumulating blood underneath
or in the space that we operated, whether it's the
right side or left side or worse, they're communicating and
you suddenly have this huge blood collection that you need
to go back and address. So what are the things
you do, namely two or three things you do to
try to mitigate against that.

Speaker 3 (33:12):
My main thing is the way I do the surgery now,
meaning it's like limited skin dissection. The more skin dissection
you do, the more of the little tiny vessels that
you have that can't be cauterized or even found. So
the limited amounts of dissection I've done means that for
years now I haven't gotten any midfaced hematomas because there's
only really like two vessels that perferrate through there, so

(33:32):
you can find them every time. In the neck, same thing,
minimal dissection of skin. I have this small kind of
dead space now, so what I do is in that
dead space. I was netting it for a while, which
is a suture techniqu where you mat down the skin,
and now I've switched to using rtise, which is just
like a fibrine jum exactly exactly you can spray in there.

(33:55):
And I've minimized my hematomas like that pretty substantially. And
there's hmas that are a nuisance, which are the little
baby like droplets here and there, you know, one along
the jaw line. And then there's you know, the life
threatening ones where if you have a really big cavity
in the neck and you start getting a big bleeder
on someone who's hypertensive, anxious, or large, then they can

(34:17):
really die from it. And it's super rare that would happen, obviously,
but that's the scary part. So minimizing the skin dissection
has helped.

Speaker 2 (34:25):
Me a lot. And then they are are teas.

Speaker 1 (34:27):
Yeah. I think also for me, what I've realized is
so many patients are on so many things that make
them more prone to bleeding. And you know, we have
so many healthy patients, which is great. You know, they're
coming in with like four hundred and sixty two supplements.
My ioretic doctor told me to take X and we
have a very stringent policy here which is zero supplements.

(34:50):
But what about vitamin C? Zero supplements? The way I
see it is it can't it may or may not
help you, but it's sure as hell can make it bad.
So you know, unfortunately, a perfect example is fish oil,
which is an amazing item or flax seat, and some
people take it at very high doses and in some
people it stays for weeks. And so that's number one.

Speaker 3 (35:10):
And number yeah, it's a California problem.

Speaker 1 (35:12):
Yeah. And then the second thing was I think that
I am much more cautious, even more in men than
I am women because of the beard and the degree
of I mean, the blood vessels are like ten times
that you're feeding an entire organ of facial hair. So
those are the things. But I do agree with you.
Neck disection and you know, meticulous hemostasis is a huge thing.

(35:33):
Then we have the area of necrosis, which sort of
dovetails into the same thing you just said, which is, Oh,
I did my surgery and I'm a few days out
and a section of the skin that was a section
of the skin that was dissected is now black and dead. Yeah,
black and dead like Gangreene dead toe whatever should a
begann be very rare. But obviously number one is obviously

(35:55):
the less dissection you do, the less undermining, the less
a schemia, anything else that you do to kind of
minimize your schemic risk.

Speaker 3 (36:04):
Yeah, well, ischemia is the one that scares me the most.
I'm not worried about nerves, like nerves from her I
know the planes, and I don't really have any permanent
nerve fear.

Speaker 2 (36:14):
Temporary can always happen. Skin.

Speaker 3 (36:16):
I tell patients in the consult I always tell them
about the risk of a SCHEMI and I describe it
a bunch of different ways so they understand it. And
I tell them it's not something I can control. Just
so you know, I do whatever I can, and I
will do whatever I can. However, it's kind of luck
of the draw. And I tell them one in five
hundred to one in one thousand can have this schemic
problem because it's an ischemic surgery. Like, what do you

(36:36):
mean I got? Every facelift is ischemic. You're elevating skin,
You're cutting off blood supply. That's how it is. And
I try to minimize that. So how have I minimized
that in my surgeries? Is limiting skin dissection is one
limiting the length of dissection.

Speaker 2 (36:52):
So I've found ways or kind of my limit.

Speaker 3 (36:55):
And when you're trying to get better in surgery, you
keep releasing more and more and more, and then at
some point you realize it didn't help me.

Speaker 2 (37:01):
It just hurt me.

Speaker 3 (37:01):
Let me back off to that sweet spot where I
get what I need.

Speaker 1 (37:05):
Yeah, And that's exactly actually ironically the same in abdominoplasty.
Just as a point of reference, I know most guys
that do abdominoplasties have this sort of dogmatic thing. I
released all the way up to the ribcage. I'm like
seven centimeters ten centimeters away from the rib cage because
that extra five six centimeters of release adds zero point
one in extra gain and it's ninety nine percent of

(37:26):
time causes the aeschemia. So I do understand, but you
kind of have to figure that on your own a
little bit.

Speaker 3 (37:31):
Yeah, unless someone figured out and then teaches you.

Speaker 1 (37:33):
Well, I'm that true, but I'm saying you sort of
you have to. You have to get a feel for
where that. Okay, Now I got to pull back a
notch and I you know the same thing with breast surgery.
All the surgeries that we do, they're all relatively a
schemia driven and you got to it's kind of a
risk benefit ratio. Okay, what else.

Speaker 3 (37:51):
Uh? Then I'm careful about the netting and packing and
all that.

Speaker 1 (37:56):
Because I see a lot of netting and it is
inherently While I ad stand the concept because we do
progressive quilting or progressive tension sutures conceptually to obliterate dead space, yes,
but inherently as causes a schemia. I mean you're trapping and.

Speaker 3 (38:11):
So quilting futures subdermal progressive ones cause more eschemia than
percutaneous ones just because they're pulling on the dermis itself
and the dermal plexus superficially. When you throw them, it's
not as bad. And so the Arswald and Oswald in
Brazil had been studying this on the Arswald net which
is that whole netting procedure, and he saw that in

(38:32):
his patients he had like not zero, but like very
very low schemic issues after doing hundreds of these, and
it does work well, and it's a game changer, life
saver for when you do have bleeding, it's fantastic. Or
even postop you get a croma or something like that,
you use a net and it takes care of it.
My problem was I formed deeper contours than most people
around the jawline and going neck specifically, and because I

(38:56):
have such deep contours, I have to limit my net
use and I can't listen to someone else's because if you.

Speaker 1 (39:02):
Grab something you deeper least the reason because when you netted,
it actually pulls it superficial.

Speaker 3 (39:08):
So well, anytime you're looking at any sort of concavity
that you have, you have to have arterial kind of
in flow out flow, and venus in Flappa has to
come out. And then if you're across a flat surface
and you net it, it's not a problem. If you're
in this deep portion of a of a dip and
you put a net down there, you're going to restrict
the blood flow coming back your contours, Yeah, if you

(39:32):
have deep contours exactly. So I had I had to
learn that myself the hard way and see it the
next morning when I saw Andreas doing it all day long,
and it's fine, but I'm creating crazy deep contours, not unnatural,
but like very deep, and it was a problem for me.
So I backed off on netting. And that's why I
switched to artis for when I can, and I use
the net uh for saving my ass, and I also

(39:54):
use it for I use tax futures because a big
problem in facelooking surgery that's undiagnosed is skin sharing, and
you'll have skin movement in the first couple of days
of healing.

Speaker 2 (40:05):
Surgeons don't recognize it. You're more prone to cerromas.

Speaker 3 (40:07):
But also they don't recognize and it heels like that
and nobody talks about it. Nobody knows about it, but
it happens. Of course, it happens. Skin has you know,
it moves, it doesn't get here right away. So I
throw attacks. I throw attack here, attack, they're attacked there,
and I try to keep the skin from moving, which
also lowers my hematoma serram rate.

Speaker 1 (40:23):
And the last one, and there's many of these. I
think I just really collectively say the three sort of
big It's kind of like Safari the Big five, right,
this is the big three of facelifting, of course, being
hematoma is ischemia, and then the last is nerve damage.
And so obviously when you're above the muscle, you're good
to go. You don't get any nerve damage because you're

(40:44):
nowhere near the nerves, but you don't get any of
the advantages of being underneath. When you go underneath, you're
now with the plumbing, right, You're all the electrical wires
are there and they're important. Right, So tell me a
little bit. Obviously, you know, the more of something you do,
the more comfortable you come with the anatomy, the less
concern it becomes. But there's still a technique involvators blaze
through it and you know where everything is. So the

(41:07):
concern being that as you deep, as you dive deep
under this muscle, layer that we've talked so much about.
You're going to potentially bag a nerve or something of
that nature. So tell me what you were doing with
that and how we're mitigating against that.

Speaker 3 (41:22):
So, yeah, so these are motor nerves. We have sensory
nerves that they all get damage when you elevate skin
for any surgery, and they have to grow back in
and they never grow back how they work. Those are
sensory nerves. Motor nerves are what we're talking about. And
it's the animation, smiling exactly, all of that. And the
motor nerve exits out the front of the It comes
out of this canal over here and exits out the

(41:42):
front of the parotid gland, and from the product land
it follows in that plane. And so you have to
know where you can mobilize without damaging that nerve, and
then where you say, okay, I have to actually go
above the muscle layer. So this is where you decide
or I've decided and I want to do not just
side of the phase surgery, which is like a high
smass tech. I want to do front of the face surgery.
So I want to go around and if I want

(42:04):
to mobilize that here. I know, with these nerves the
way they're traveling, if I go under, I'm going to
hit them. Yeah, So I go directly on top of
the muscle, which instead of elevating layers one, two, and three,
I elevate layers one and two and then accommodate over
three and I tighten up three independently down over here,
which is so technically here you're supersmass in the zygomaticus,
in the buckle fascia, not buckle capsule, but buckle fashion

(42:26):
layer three.

Speaker 2 (42:27):
And then in the platisma.

Speaker 3 (42:28):
Because it's a big gliding plane over the MASSI you're
able to go sub platismal subsmass over here, and then
subsmass over here on the parodid in the neck. But
the product in the neck has nerves coming out immediately,
so you have to use a tunneling technique, a different technique.
Sure get the parodi away from the platisma. Now you
can mobilize potisma. And what I've done now is with

(42:50):
the subsmass, I mobilize as much as possible automatically with
the area that I'm supersmass. I have to figure out, Yeah,
I lifted layers one and two. But what about my
layer three? How do I get that ten stuff to
improve smile function, to get rid of laxity and all that.
Most of that is achieved from temper prietal setbacks. So
you do this, This connects straight to those muscles, So

(43:10):
I combine those.

Speaker 1 (43:11):
What do you do when the patient says, I don't
want to do that? So we have patients obviously who
come in and they can't afford or don't want to do.
And this is actually takes me into the concept which
is unique to facial rejuvenation. Someone comes to me and says,
I don't want to do my breast, I just want
to do my abdomen. Fine, of course, if you do
them together it looks more harmonious, but they're far enough
apart where they're not related. The critical part of facial

(43:32):
rejuvenation which makes it challenging is that when you do
your say, midphace, and you don't do your under eyelids,
and you still have a hollow in a trough and fatterniation,
and or even more important, you do your face and
don't do your lateral brow, which is a continuum, you
sort of will inevitably create an arbitrary transition between my

(43:53):
new house and my old house. You walk through a
room and you're like, oh, okay, yeah, I see this
nineteen seventies home. And so it's always something that's a
little challenged because you know you're limited.

Speaker 3 (44:06):
Yeah, so I have good ways of approaching it.

Speaker 2 (44:08):
Now.

Speaker 3 (44:08):
If it's a financial thing for the brow, I just
do it.

Speaker 2 (44:11):
I don't care.

Speaker 3 (44:12):
I'm like, I have to do it on you or
else you're going to end up with a disjunction here
where you see these pores come down and I go sideways.

Speaker 2 (44:18):
I'm like, you can't do that. So let me just
make an incision there. I'll set it back.

Speaker 3 (44:21):
I'll make sure not to change you, but I do
need to pepper relax. And I have to do it
because I explain, it's a domino effect, and there's certain
things that aren't a domino effect where I can do
here there, and I can leave your eyes ugly if
you want no problem, that's up to you. But I
can't lift your face without causing a problem here. So
let me move it back and I explain if it's financial,
I'll just do it if they can get away with it,

(44:45):
which is another subset of patients, I say, I could
just extend your incision higher up and then tighten that
layer independently. I'd rather not, but I can. Nobody says
yes to that. And if they say no, no, no,
I say, okay, I'm not doing your surgery. You're going
to make me create something awkward. I can't do that.
So you have to either let me do it properly
or just go to somebody else who's going to jack

(45:06):
you up.

Speaker 1 (45:06):
And you know I'm not going to do it. We'll
see you in revision land. Yeah, yeah, I agree, hundred percent.
I think that you know, this idea or notion that
we give with a patient what they want is absurd.
That's like me giving my son what he wants he's four.
That's not going to happen. You know. When it doesn't matter,
I let him choose, But when it matters, I choose
for him. And so whenever I have patience, and I've

(45:28):
always had patients for twenty one years where they'll say,
you know, I don't really want to do X, Y
and Z, And if I know it's going to ultimately
lead to a bad outcome and they're not comprehending that
bad outcome, then I just refuse to do it because oh, well,
they don't care what difference does make I'm doing it.
It's like it's like assisted suicide. Like I'm not going
to do that. So I think that that really is

(45:48):
a very very important part of when you get to
a place where you want your work to always be excellent.

Speaker 3 (45:53):
Yeah, and as part of can you make the person happy?
And if they're not down with what you're talking about,
then the answer no, you can't make them happy.

Speaker 1 (46:01):
Yeah. Yeah, I definitely think there has to be some
harmony between your vision and theirs. I mean, it doesn't
have to be like you're some mad scientists and you
have to do what I say or get the hell out.
At the same time, you can't just arbitrarily make shit
up like I want to pool on the third floor
of my kitchen. It's like not happenningbody. The last thing
I want to switch to is the last part, which
is all the adjunctive things that are being done, which

(46:24):
one of them is an area that you really have
dived deep into, which is the lip. But you know,
I refer to as the four core areas of the
face as the brow, the upper eyelid, the lower eyelid
and the face and neck. Right, that's just sort of
what I consider the big four of Safari.

Speaker 2 (46:43):
Roosevelt wanted five of these.

Speaker 1 (46:44):
Yeah, yeah, yeah, But but there are other areas that
need to or can be, or sometimes really make a
big difference. And let's kind of just march down some
of your sort of adjunctive things. I always just start
with the one you love most, which is the idea
of a lip which, in my opinion, is amazing. When
it's right, it's holy shit, and when it's not, it's

(47:07):
holy shit. Yes, And I think I don't think way overdone.
I mean, like when a twenty four year old girl
who's otherwise perfect, otherwise perfect, who wants that Instagram look
and looks like she has a cleft lip, gets a
lip lift so she looks good in photos and looks
bizarre and bananas in person, it's out we fucked her up.

(47:28):
But that goes without saying with every procedure. But let's so,
I know you like to reset the lip. Let's talk
about that for a second.

Speaker 3 (47:35):
Yeah, Well, the problem I'll talk you about the lip
lift is in general for everybody. But it's just basically
making an decision under the base of the nose for
a subnasal liplift. There's direct lip lifts, there's corner lip lifts.
We're talking about subnasal and what you're doing is shortening
the height of the film trump And I've found ways
to do it where you can actually design it to
change the shape of the lip, which changes the character
and the contour the show. I have ways of controlling it.

(47:59):
The prom with liplifting is the same as the problem
with browlifting. The foundational understanding of it is wrong. So
the foundational the landmark papers for browlifting talk about browshape,
brow conto a brow position.

Speaker 2 (48:10):
It's all wrong.

Speaker 3 (48:12):
The liplifting papers and corner lifting papers are equally wrong,
where they talk about there's a certain height. And they
got these misunderstandings here and here from studying pretty people.
And they went and studied supermodels and said, very simplistically,
these people are pretty, and to make someone exactly, to
make people pretty, I need to use these numbers and

(48:32):
that's how you make someone pretty, which is a crazy idea,
but that is the foundational understanding of browlifting and the
foundational understanding of liplifting. So what goes wrong, everybody ends up,
you know, when you're doing on someone too young or
it's too long, or there's an imbalance. They look they
can't close their mouth, they have too much tooth show.
If you can't close your mouth, your neck starts aging
more rapidly. They look sad, They look like this, They

(48:53):
look disproportionate.

Speaker 2 (48:54):
They look rabbit.

Speaker 1 (48:55):
Rabbit or Geisha is the one that I always referred to.
Sure you know you do this tiny little middle central
subnasal lift. They have a very wide mouth, super narrow
nasal base, and then they look crazy.

Speaker 3 (49:06):
Yeah, so you have to look at the mouth overall
and say, how can I improve it on this person?
Not how do I put a supermodel's face on this
mister potato head doesn't work, and say how can I
take this person? And the issue we have as surgeons
is we're used to looking at photos from front view.
We're not looking at a three dimensional structure, which is
a horseshoe of the teeth, horseshoe of this and you
have this part suspended by the nose, this part hanging

(49:28):
from the face, and the buckle cheek and the buckle
teeth are kind of pushing out against it, right, So
you have to just look at the lip overall and
say how can I match it or improve it on
this individual's face?

Speaker 2 (49:39):
Not are there numbers?

Speaker 1 (49:40):
Yeah, which is really the essence of all esthetic surgery, right.
I mean again, I do a ton of noses, and
you know I don't even allow anyone to bring photos.
It's like, what that doesn't do me any Like, I
don't care that you like this nose. This nose has
nothing to do with you, nothing, zero, not the name,
same projection. You don't have, different maxilla, you have it.
So you are, ultimately, as a good surgeon, trying to

(50:01):
find the sort of ideal or the midpoint of not
enough and way too much of that individual's transformation. So
I think lips are for sure the same way. What
are your thoughts on the directliplift because that's becoming popular now.

Speaker 3 (50:17):
This is like trending by the worst surgeons in the world,
and there's no nice way to say. I don't need
to be nice about it. They are fucking horrible and
all of them are like, who do directly? That's a
cancer surgery? When you're going across the vermilion, that is
a cancer surgery. So if somebody has cancer and you
need to cut there yes, you cut there. Otherwise you
don't go gash across the most beautiful contour on the

(50:39):
entire face, the vermilion, which gives you sensuality definition, sexuality like,
you don't do that. So it's a horrendous procedure. There
is no situation where you're doing it esthetically that's going
to not cause it to look slightly weird, kind of weird,
medium weird, where you could have obtained a good result
another way. So the surgeons who are doing it are

(50:59):
severely dysmorphic. I know who's doing it. They're all dysmorphic.
I've seen their work. They have dysmorphic brains, dysmorphic results.
They don't get good results. Now, there is a direct
lift that happens out here, which is called the corner lift.
Why does that work but this one doesn't work is
because here we have a vermilion roll sure that.

Speaker 1 (51:16):
Cannot be recreated, and anatomy there is completely different.

Speaker 3 (51:19):
It's completely different here on the side of the face,
on the side of the mountain, so you can actually
make a direct lift there. I'm totally fine with that.
But these direct vermilion lifts, they make people look ridiculous.
It looks round. It looks strange. You can't control the shape.
They're all kind of rounded, cartoonish. They go for study
looking lips, so they try to get as much volume
as possible, which is why the surgeon wants to do it,
because the surgeon is dysmorphic with bad taste and like

(51:41):
slutty looking faces. So they go and do that, and
it cannot be reversed. So here's another rule, is we
shall try to do as many surgeries as possible that
can be fixed if something goes wrong. That's like a
good general rule, like try to at least I know
there's some things we can't reverse course, but try to
do things that if it goes wrong, you can fix it.
Incisions here cannot be fixed, that's impossible.

Speaker 1 (52:03):
It's interesting because you know, as a surgeon, there are
definitely things that come up within the areas that you
do that you just vehemently are just like, oh my god,
what a what a disaster. And you know, for example,
an abdominoplastyse the notion or this push towards reverse abdominoplasty,
which is it's like, you know what your excess is

(52:25):
above your abdellary button. Let's just pull upwards, tack this
under your breast, create a web in the middle of
your breast. It never works correctly, and as a result,
I'm so against it. But there are lots of people
doing it, and while they may get the occasional mediocre result,
that's not an indication to make that the new procedure. Y, yeah, exactly,
So I think that that's that's good to hear. Is

(52:47):
there anything else that you think that's adjunctive that's kind
of like, well, like, I think these are the few
things that I I given that the patient has the
indication for that I think are necessary in addition to
the big four.

Speaker 3 (53:00):
Well, the fat grafting and fat restoration is a huge
part of it. And when you say that at meetings
or whatever, people kind of generally accept it. But they
don't have a science for it. They don't have a
precise way of applying it or looking at it. They
just say, Okay, volume is volume, I need to add volume.
They don't say exactly where, exactly, how much, exactly what

(53:22):
cells size, and they've talked about cell size, but they
don't fully understand why they're doing it. So fat grafting
is super important because when you look at the aging
of the skin, especially around the mouth. Let's say we're
talking about the mouth and especially in white girls, so
you're talking about lips and white girls when they're forty
fifty years old. The first sign of wrinkles and poor
formation and aging is coming from loss of fat in

(53:45):
the layer two and layer four, and it's loss of
support for the skin that was distended outwards before.

Speaker 2 (53:50):
So before you get any.

Speaker 3 (53:51):
Dermal issues from sun damage and all that that we
talk about all the time, you're actually getting volume loss
and that's the first sign of a wrinkle a port
it's from that. So when you get really really good
at looking at the fat grafting and what you can
do with it, you're able to achieve better skin quality.
And it's not true skin quality. It's the perceived scandal.

Speaker 1 (54:11):
But there is also something to be said for the
actual plury current cells that they mean. If there's some
amazing data out of there was a paper out of
Italy where they would use it in radiation breast and
they were doing it to make the breast look prettier.
It was volumester volume restoration, but the skin quality in
a radiated burnt breasts was so much better. So there

(54:31):
is definitely in addition to the volumization of it, which
is just expanding. You know, I would say, my child
is you know, fattened round and my mom is hollow,
and you know what I mean, There is something that
actually changes in the actual cellular structure of it.

Speaker 3 (54:44):
So which actually helps for the conversation out with patients
when they say how much of it survives, because there
is no number on any patient that you know that's
going to survive.

Speaker 2 (54:52):
It's like a range.

Speaker 1 (54:53):
Sure it's five to seventy five.

Speaker 3 (54:55):
Yeah, yeah, somewhere somewhere. It's in a big range. But
I tell them what you need to understand is part
of it stays, and part of it is gonna volumize
and look great. So your success is one hundred percent.
You're gonna look great. And then part of it is
going to have this weird stem cell potential we don't
fully understand and it's not a real stem cell. I
tell them, I say, it's this plurry potent type of

(55:16):
progenitor cell, whatever it is, and it improves your tissue
quality because there's a lot of damage that happened with
the heat treatments that you did with the filler and
dissolver that you did, and whatever else and the nanofat
or the broken down fat cells, whichever way you look
at it, that you do it is going to improve
your tissue quality.

Speaker 1 (55:30):
Yeah, there's no question about it. It's just it's just
the understanding of the amounts, the nuances, how to apply
it in what many planes and all. But just like
any other procedure, it's fat transfer is no different than rhinoplasty.
It's a procedure that needs you know, needs expertise and
knowledge and just shoving the fat in and calling a
day's definitely not.

Speaker 3 (55:49):
But I think we throw that in the Big five
over there just because well.

Speaker 1 (55:53):
I look because for me, when I can I communicate
to the patients, I throw that in facelift the way
I the way I process is when I tell them
you can you have a brow an upper eld, lower eyelid,
and your lower face and neck of some variation fat
transfer you. You can't separate the you And whereas you say,
if they can't do the brow, I just do the
fat anyway. If they're like, oh my god, it's how

(56:14):
much the fat, I was like, it just it's part
of it. Forget about forget.

Speaker 3 (56:19):
I have mentioned it, SAM for lips, SAD for upper eelids,
upper eyelids, simplicity, upperies age from this major involutional change,
It's not that we grow that much extra skin, so
you have to partly improve right exactly the uppers and
the infra brow perri orbit on all that. So I
do throw it in routinely as that stuff if I
need to do it anyway, Yes, it's important.

Speaker 1 (56:40):
Anything else other than the fat and the lips that
you're kind of feeling that are. And then the last
thing I throw in there because I usually this is
I'm very methodical in my thought process with these patients
because I think it helps them process what it is.
The last is your skin texture. So there are instances
where it's indicated, their instance where it's not. But you're down,
you're out of your grandessthesia, you're out for a week

(57:01):
or ten days or whatever. So depending on the patients,
I obviously offer lasers as well, whether that's a CO two,
an erbium, a mild one, a moderate one, whatever your
philosophy is on it. I'm assuming you're doing resurfacing when.

Speaker 3 (57:15):
Indicated, yeah, yeah, And there's the resilient areas that I
do on everyone if needed, is the eyes in the
mouth where they're a little less sensitive, versus the forehead
and lateral cheek neck of you know, severe pigmentation issues sometimes,
so I throw those in pretty commonly. Every patient I
do a facelift on. Every single one that I consult on,
will consult with my skincare person. So I send them

(57:36):
over to Cupid Lips and they look at their skin
and they say, Okay, we need either need to prep
you for something or he's not lasering you because of
your skin type. I'm going to optimize you afterwards, because
he's going to go through all this trouble to make
your face look better and you can't have the surface
look like ysh.

Speaker 1 (57:49):
Of course. Yeah. I always say to patients, you know
you've you've bought this Bugatti. It's gunning, but it's dirty.
It's dirty, dirty Bugatti, Like what the fuck? They just
pay for the detail. Bro Okay, well that's amazing. I mean,
obviously we could go on for days and hours and
months and whatnot. I think for all of you who
are listening, this is a real treat because Ben, obviously

(58:11):
you have spent your life's mission, you know, sort of
hyper dissecting this area, and you know, you've come up
with a lot of thought processes and analyzes and things
like that, and it's a real pleasure to be able
to talk with you about it, albeit on a superficial
level and sort of very broad any parting information that
you think, Okay, well, you know this is a bunch

(58:34):
of people listening and this is you know, I don't
want to get into a whole bunch of other things
or what are the trends and all that other nonsense.
We could go for days on this, but is there
anything that you would say is like sort of your man,
for lack of a better word, parting recommendations or suggestions
or things like that, because at the end of the day,

(58:54):
you know better than anybody this is. This is not
going anywhere. It's bigger than it's ever been.

Speaker 3 (58:59):
Yeah, I mean the most important thing for people just
exploring this world and starting to get interested in it,
and especially with like social media, you know, becoming your
new news source and algorithms feeding you things is you know,
never be the guinea pig, and anytime you're following a
trend that just started, you are the guinea pig. Yeah,
it doesn't matter if the person did one hundred of
that thing in a row. You are the guinea pick.

(59:20):
Never be the guinea pig. As you said, ten percent
trends are fantastic because ten percent of them lead to evolution.
Ninety percent of them are pure trash or regurgitation of
prior things that failed. Direct liplift all this stuff there,
regurgitation of things that failed and people who were too
stupid to read the old literature. Yeah, so it's been
around forever. You just got to know your history. So

(59:41):
don't ever be the trend. Don't ever be the story
on Fox News exactly.

Speaker 1 (59:46):
You don't want to be the Daily mail article. Yeah.
My always suggestion to people is I think that there's
too much onus on the patient today to know more
than they ought to know. So when I meet with
my account I know very little. In reality, if you
think about it, I don't know that much. But what

(01:00:07):
I know is I really trust him and I rely
on his professional opinion and advice to guide me in
my financial world. When I hire a lawyer, I really
don't know that much and I rely on his or
her advice, and I think there's no area more than
when we had my wife had six fine surgeries. I'm

(01:00:30):
a plastic surgeon who's incredibly bright. I didn't ask too
many fucking questions because at the end of what am
I going to ask you that's a relevance, like oh,
are you using a two point eight millimeters disc? Or
like we didn't decide the company or style of disc
or the size or whatever. We identified an individual who
we believed, to the best of our knowledge, was capable,
and then we kind of defer to them. And I think, unfortunately,

(01:00:52):
because of the direct consumerism and marketing that it's happening,
patients are little bit overwhelmed and are kind of a
little little bit of a tough place because they're trying
to arrive with more knowledge than they can ever process.
So I always try to push towards finding that provider
and believing in that provider. Like my patients come to
me and I'll tell them, no, this is a terrible idea,

(01:01:13):
why the hell would you do that? And well, this
is a great idea. And at the end of the day,
you know, they have to trust me because I'm their professional.
So you know, I think, definitely, don't be a trend
and definitely try to find someone who you believe in
and then let that person guide you, because I think
you'll never out, You'll never know enough. There's no chat
GPT or Claude that's going to help you with this shit.
All right, guys, that's a wrap. If you guys like

(01:01:37):
the show, which I know you will, and you want
Ben to come back, and I can ask him a
million more questions, we'll have to send them aget another
invitation because we can do this for days at any rate.
As always, thank you so much for tuning in. We
have two requests I do and at the end of
every episode. Number one, if you like the show, share it.
Share it, just like forward the shit to everyone you know,

(01:01:57):
because they're gonna come back one day. They're gonna be
like all lopside and you were like, what the hell
did you do? Oh? I got a facelift? You gotta
what where? And you wish that they had red you
had heard this, and it's too late at that point.
And the other is, if you enjoy the show, go
write a review, Go write something positive. There's so many
people that come to put this show together, and we
love hearing nice things. All right, guys, that's a rap.
We'll see you guys next week. On plastic surgery on

(01:02:19):
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