Latest / Rebellious Aging Podcast / Rebellious Aging: Face
Transcript
- speaker-0: So today we're gonna be talking about the face, and of course this is one of my favorites because it's a plastic surgeon. It's something I've been doing for a long time and I have a lot of advanced training in. Yeah, so let's start with the the elephant in the room, which is this is a rebellious aging podcast. This is not the plastic surgery athena clinic facelift podcast. And we're gonna be talking about the face, and the face is really, really interesting from the aging standpoint, because with aging, there are a lot of changes in the body that are unseen, and then there are some that are seen. The thing that everybody focuses on is aging of the parts that they can see. the changes in hair color, wrinkling in the face, sagging of the face, things like that. And actually sagging of the face and aging and looking older doesn't really reflect necessarily what's going on inside. And aging of the face doesn't change your lifespan that much. A lot of the things that happen inside in your kidneys and your liver and your heart and your lungs don't really show up when you look in the mirror. So today is important from a cosmetic standpoint and from a social standpoint and of course from the plastic surgery standpoint. But in terms of actually aging and determining your health status, it's not as important as a lot of the other unseen things. But given that caveat, let's get into it and let's talk about some interesting things about the face. Yeah, so this is one of the things that that surprises a lot of people. Your face from our standpoint, plastic surgery, has five layers. The deepest layer is the bone, the next layer is the muscle, the layer that everybody is confused about is called the SMAS. That stands for superficial muscular aponeurotic system. Because that's such a mouthful, we just usually say SMAS. Yeah, S A S. And that layer is the fibrous. connective tissue that's in between the muscles and the skin and then there's a subcutaneous fat and the skin. But the surprising thing is as you age you actually lose bone structure that the bone resorbs your orbit increases in size and that sometimes will cause the eyes to have more room in the orbit, in the orbital bone, so they'll fall into the orbital bone. You have that sunken eyelid look. Yeah. Yeah. Mm-hmm. And that's a that's that's a giveaway of either age or infirmity. And so people don't like that look. you also lose bone in your jaw. So as you age your you lose some of the bone and that bone loss is extremely important to then what shows up on your face because As you lose bone, it deflates the tissue overlying it. And so because the bone is smaller, your face it kind of sags down, it gives you that melted candle look. And there are certain places where the the skin is kind of stuck to the bone. Those are called the ligaments. There's a there's a ligament here, and there are ligaments along here, and so Because the skin is stuck to the bone here, when the bone deflates and the skin is too big, it falls down and it falls down onto this ligament where the skin is stuck to the bone and then it falls over that, just like your shirt will fall over a belt. Yeah, and it makes a crease. And we call this one the marionette line because marionette will have a a line there with movement. We call this one the nasal labial fold, and then there are the malar ligaments here that attach that kind of hold the skin onto the front of the of the of the master muscle. Yeah, that's right. That was actually that's that's something that's new since I was in training. We used to think of the fat as one continuous, like you said, just a layer, like a sheet. And it turns out that if you do careful anatomic studies, which they did at UT Southwestern in Dallas, that there are individual fat compartments. So there's a little one here, a little one here, a little one here, a little one here. And they're separate. And the interesting thing is that they don't all lose volume at the same rates. So your facial aging is determined a lot of the the appearance of facial aging is determined by loss of that fat. and so fat gets less in the face and as I said, deflates both because of the bone and also because of the fat. And so if you look at little kids, you know, they have chubby cheeks, they have full faces and they're full because the bones are actually still growing and so the skin is under tension. And then They they have a lot of fat and the fat actually gets smaller. It's not that it just gets diluted out by the fact that the face is bigger. The fat layer actually is smaller in an older person than it is in a child in in actual volume. and then in addition, of course, it it spreads out more 'cause the facial bones get bigger and and the fat gets, you know, pulled out. But but yeah, you lose fat there and it's the loss of fat in the face is one of the things that separates the look of an old person from a young person. And it's one of the things that we that we need to address when we're doing facial rejuvenation to make people look better. And it's actually surprisingly and amazingly effective at rejuvenating somebody's appearance by restoring some of the fullness in the areas that they've lost from fat. Yeah. So if you look at people that have never really been in the sun, their skin is oftentimes really nice, even if they're old. And so one of the things that's a major contributor of the appearance of facial aging is sun exposure. And the sun exposure, there's UVA and UVB. UV Ba is the longer wavelength that's ionizing radiation. And that causes changes in the in the DNA and in the proteins. And and then the other thing is that the UV radiation will break the elastin. And elastin in your skin, you know, that's what makes it flexible. So it's gonna bounce back and and and have it have it return to its normal position after just displacement. And and elastin is very, very difficult for the body to make. And most of the elastin that you have you have already in childhood. Your body doesn't really make significant amounts of elastin after that. So if you break the elastin, then you just have less. Yeah. It's gone for good. So the sun does that. The sun also causes irregular activation of the pigment cells. That's right. So everybody knows that you can get a sunburn from the sun. Well, clearly if it's a burn, that's probably not a good thing. and in addition it's it's uncomfortable. And it's red and it's inflamed. And and then that inflammation that's that will then stimulate the melanocytes, the ones that produce pigment, and that's what makes a tan. Mm-hmm. Now Melanocytes are designed to be free radical scavengers. That's actually one of their jobs. And so that inflammation, the melanocytes are doing their job by sort of soaking up the inflammation and containing it, but in the process, they're getting stimulated. Right. And that makes melanocytes, makes melanosomes, which is the pigment band, and that's how get a tan. And one of the dermatologists here always used to say, There's no such thing as a healthy tan. Because everybody says, I want to go to the beach, I want to get a healthy tan, I want to look you know, I want to look healthy. I don't want look pale and pasty and and and somebody who doesn't, you know, get out and be vigorous. But actually from your skin standpoint, if you just only think about the skin. The skin is saying, Whoa, that's not good. and there is no such thing as a healthy tan. And you know, some people are really good about avoiding the sun and their skin looks good. And if you look at your own body, if you look at places that didn't get so much sun, the skin there is oftentimes way better than the places that got a lot of sun. And so the the sunlight causes you know increasing damage and over time you lose elastin and and then it it you know leads to wrinkling and and what we call dyschromia, the hypo and hyper pigmentation, the brown spots, the white spots, the red spots that you talked about earlier. Yeah, that surprisingly you know, everybody worries about wrinkles and they think that that's a that's a sign of aging and that that's what's gonna really show you know, that they're old. And th they they do give that that impression as well. But the dyschromia, the difference in the skin color from one place to another actually is a better marker of skin damage, sun damage and age than the wrinkles are. So A wrinkly person with no dyschromia, the the wrinkles aren't so noticeable because they're all the same color. But if you have dyschromia, that that shows up. And in Caucasians, you frequently will get red spots, you'll get some brown spots, you'll get hypopigment, you'll get pale spots. And so you have a mottled pigmentation. in Asians, typically what you'll get is you'll just get more brown spots and the the brown spots will show up. if you go to the nursery. When you look at all the babies, none of them have brown spots. Their skin is all perfectly the same color. And if you didn't go in the sun, they would stay that way for a long time. Absolutely. one of the things that's nice about being in Hawaii is that we take care of people of all different, you know, ethnicities and skin tones. And you know, Chinese, Japanese, East Asians, the dermis is actually thicker, the skin is is physically thicker. And they're less prone to wrinkling and they don't get as much dyschromia as Caucasians do, and And they get brown spots and that's that that's a sign of aging and that's how in the movies and television in Asia they will show somebody's older by making you know putting little brown spots on them. and then you know, people of African descent. Africa has many, many different ethnicities. It's amazing. It's a it's a very, very diverse population. So lumping all of Africa together is really not fair because it it varies tremendously. But a very dark skinned African, is their skin is is remarkably resilient and resistant to photo damage because they're designed for that. The the skin is designed exposure. Right. Right. That they've evolved to live in a place that has constant dark you know strong sunlight. Conversely, Caucasians migrated out of Africa and then into you know northern climes and one of the big selective pressures for northern Europeans was the fact that there wasn't much sun. And so if you were darker skinned, it was hard for your skin to make enough vitamin D. So people that were lighter skinned, were selected out in the northern climes. And and so there's a there's a tremendous variation from from person to person ethnically. but then also of course you're taking that ethnic baseline and then you're exposing it to the sun or to cigarette smoke or other things that are gonna have a huge impact as well. a darker skinned person does better in sun exposure than a lighter skinned person just because they have melanosomes, they have pigment in the upper layers of the skin. And the pigment in the upper layers of the skin will absorb the sun that's shining down on it before the sun shines through into the into the active growing layers, the dermis and the the top layer of the epidermis, the basal layer. And so the the part that's really living in the tissue gets more exposure. Whereas the the keratin at the top, if it has a lot of pigment in it, will will absorb a lot of that sun before it gets down into the deeper layers. And so for a given amount of sun exposure, less of it will get through to the deeper layers than a darker skinned person. Yeah, yeah. And then you can choose to expose it or not expose it. That's that's up to you. Yes. The genes you were born with, but the what you do with them is up to you. Yeah. So the neck skin really has a hard time because if you feel neck skin and you feel face skin, the face skin is considerably thicker than the neck skin. So neck thinner skin, the separate fat in the neck is much less. and then in addition, the neck has significant excursion of movement. Right. That the neck has to be able to do this and this and this. So it moves around a lot. And so it has to have enough skin. To do all of these things. And and so when you extend it, it stretches out, and then when you come back, if the elastin has been degraded, as it is by sunlight and by tobacco smoke, then it won't return. It won't snap back. Yes. And because the neck skin is thinner and it's out, you know, in the sun pretty much just as much as the face, the neck skin will will suffer the photo damage and show it a lot more. So sometimes people's faces are not too wrinkly, but the neck can be really significantly wrinkly because of the combination of those factors. Well yeah. Yeah, so that's we were talking about the layers of the face earlier and the bottom most layer, the deepest one is the bone, and then the next layer is the muscle. Now, when we think of muscles, a lot of the muscles will connect one place on a bone to another place on a bone. So like your biceps will connect two bony areas and then they will pull across it and and and will hinge across a joint and that'll cause movement. In your face, none of them connect one bone to another bone. Their muscles and the muscles either connect to each other and pull on each other like a like a trampoline or like a tug of war, or they'll then pull on the skin. So that allows the muscle contraction to cause the skin to move. That's why we're so expressive, because the muscles can move the skin in a million different ways. And that repeated muscle movement and contraction will cause the skin to bend in the same place. over and over and over again, thousands of times a a day, and then you know over the course of a lifetime, you know, hundreds of thousands or millions of times. And if you bend the skin always in the same place, that kind of breaks up the the the collagen a little bit and maybe will pleat out a little bit of the glycosaminoglycans and the the intracellular matrix. and especially if you have loss of elastin. So That when you bend, it won't spring back and it won't return to the state that it was in before the contraction. then eventually you'll get you'll get creases in the places that have bent the most. And Mark Twain said it beautifully. He said the lines should show where the smiles have been. And I love that way of of phrasing. Yeah. Right. The genetics? well there's there's a variety of different things. We talked about the pigment earlier. Mm-hmm. And then actually people have different collagen and elastin genes as well. Some people are extremely flexible. There's a thing called ailers' dandlers where the people, they're double jointed. Yes. and there are other differences in the collagen expression. And the extracellular matrix, the the the part between the cells. i in the face is extremely important and that's something that's a relatively recent understanding that that is its own organ and the extracellular matrix is really, really important in in how tissues interact with the with each other and the cells attach to the extracellular matrix and then that signals them to produce more collagen or less collagen and and things like that. So all of those things are important. Now the fact that it's only forty to sixty percent means that there's forty to sixty percent that's not and the not genetic part, that's what we talked about earlier with the sun and that that's really important. The other one that's a killer is smoking. absolutely true because smoking stimulates smok what's called matrix melanoproteins matrix metalloprotein sorry and and those mmps break down the elastin and if you remember you get a certain amount of elastin when you're a kid and that's it it degrades with time and there's we don't really have anything that restores elastin so all of the skincare products all of the supplements, all that stuff. If they claim that it produces elastin, either they've measured it super, super, super carefully and it made.001% difference. or they're perhaps overly optimistic. Yes. yes, exactly. and so there's nothing you can rub on your skin that's gonna make it more elastic and there's not really anything you can eat that will make it more elastic. So that whole industry of trying to s make more elastic, the the best it can do is minuscule. Whereas smoking absolutely a hundred percent degrades the elastic. We know that. And so there's nothing that's gonna counteract the smoking. You can't like smoke a cigarette and then take a pill and they cancel it out. So the b absolute best thing you can do for your skin is stop smoking. Mm-hmm. And then that also allows more circulation back into your skin because the nicotine is rhizocstrictive and and the body loves circulation that helps it bring in more nutrients, helps take things away. So the environmental part is predominantly sunlight and smoking. Those are the two biggies. and then there there's some other factors. If I mean some people are exposed to ionizing radiation as part of their job or toxins or air pollution, things like that. But they're but they're a much smaller component. of the skin aging than than tick cigarettes and and some like Right. Yeah. So I think that that's I mean that's part of the problem is that aging of the face is probably the least of the smokers concerns or reasons. Although, the cigarettes are terrible for your lungs and your bladder and your kidneys and your heart and your blood vessels. Exactly. Yeah, and if that were the case then that would be great. They should put that on the warnings of the cigarette pictures. Will cause wrinkles. Okay, and then so to intro to our next segment, let's talk about some frequently asked questions, things that we would say, but what about this and this and this? starting off strong, building off of what you were saying last topic about you know your elasticity and some of the other things that you can do to be in control and have kind of a factor in how your skin ages. what should we do about collagen supplements and sunscreen and things like that? speaker-1: there are two long chain molecules in the skin and the in the X cellular matrix that are made from collagen like substances. There's collagen, which is strong, it's ropey, and that's deposited by the fibroblast. and then there's elastin. Now the elastin is also made by the fibroblast and it's a big it's like a trampoline molecule. It's four molecules put together with a a central core. And it's it's hard to make. And so the body makes it when when you're young and puts down elastin, but more or less it it doesn't really make very much after that. Now you can stimulate it to make some elastin by by fillers and things like that, and that'll that'll make a little bit, but not significantly. Collagen, on the other hand, is the way that the body heals pretty much everything. So there's collagen, as I said, everywhere in the extracellular matrix in the the space between the cells. So we have historically thought of the tissue as a bunch of cells next to each other, touching each other, and and that was it. But actually the cells are sort of noodles in a soup. There's this big broth in between them that's the extracellular matrix and the interstitial fluid that's really important for communication between the cells, for them to be able to move and and then actually the cells determine what they need to do by their connections to the extracellular matrix. So when the when they're being tugged on, the fibroblasts say, there's stress. We need to make more collagen to help combat the stress and get us back into a homeostatic state. And so the body will make collagen response to a lot of different signals and makes different kinds of collagens. There's type one collagen, there's type three collagen, and then there's a there's a Handful of others that are on the basement membrane and have specialized purposes. But for the most part, there's type one and type three collagen, and the body makes them response to stress and signals like that. Now, because of that, increase in the body's collagen is kind of a cosmetics industry's signal for this is something that's going to do something good for your skin. And so anything that will even remotely increase collagen is promoted as doing so. Whether it does it very much or not, or whether it's a good kind of collagen or bad kind of collagen, scar is made out of collagen too. Yes. So it's not always the something that you necessarily would want to have. but it's something that the body needs 'cause I mean given choice between a scar and an open wound, clearly the scar is a much better choice. speaker-0: Yes. speaker-1: and and so so collagen is is you know sold. it it has a good rep and there are lots of products that try to increase collagen. Now if you rub collagen on your skin, collagen's a very, very big molecule. Yes. And if your skin isn't damaged, the skin's keeping out all those big molecules because some of them aren't good for you, you know, poisons and things like that. So The skin is designed to keep the outside outside and keep the inside inside. And there's a edge. And if the skin is doing its job, it wouldn't let something as big as a collagen molecule penetrate in. It just won't do it. So rubbing collagen on your skin, no matter how great the collagen or how wonderful the the skincare product, the collagen's Not getting that. It'll sit on top of your skin and it'll maybe hold water there or maybe be somewhat protective in some way, but but it's not going to get into your skin. On the other hand, your skin needs to make collagen all the time. Yes. So it needs the building blocks. And and so if you give the skin more building blocks then the skin will make more collagen by itself. And one way to do that is by eating hydrolyzed collagen, you know, or it broke so it's the the collagen is broken up into small pieces and when you eat it it's the absorbed and the small pieces will give the body the the raw materials that it needs to make new collagen. And and it can help a little bit. But again, know, jello is collagen, you know, meat is collagen, you know, plants are collagen. There are lots of things that have collagen in them. And they're pretty much all broken down into the building blocks that the body uses to make collagen. It's just that the hydrolyzed collagen happens to have a little bit more of some of the rarer ones. Right. So, that it it is somewhat helpful. and then the other thing you can do to stimulate collagen is you can cause a small injury to the skin of some kind. So if you put a needle in the skin, then the body will react by making a little bit of collagen. If you inject filler into the skin, that will distort the extracellular matrix in a way that will cause the body to make collagen. If you laser and make little holes or you heat up something deep down and make a little injury then the body's response to most injuries is to make collagen to plug the hole. Mm-hmm. So there are lots of ways of making the skin make more collagen. Mm-hmm. Some of which are, you know, sort of working with nature and the others are causing small injuries, which may or may not be a good thing. Mm-hmm. speaker-0: Yeah, microneedling, I think, and micro like laser treatments, all are supposed to promote, you know, collagen stimulation. outside of treatments though, and supplements, we should talk about vitamins because I hear a lot of things about vitamin C and vitamin A. can you kind of tell us maybe if there's any merit to taking these? speaker-1: So they're both interesting and they're both good for the skin in different ways. Vitamin C, taking vitamin C, eating vitamin C is is good because vitamin C is a cofactor in the body making collagen. So if you eat vitamin C, then the body will use that to you know help make more collagen. There's a limit to how much vitamin C the body can absorb. And for most people, if you take a lot of supplemental vitamin C, a lot of it just ends up in your urine. And so if you're deficient, vitamin C makes a huge difference. and and if you're vitamin C deficient, that's called scurvy and you have problems with collagen all through body. Yeah. And a small amount of vitamin C will will make a huge improvement in your ability to fight that off. So that's That's the taking the vitamin C orally. Vitamin C also is interesting because vitamin C is a small enough molecule. It's not like collage not a huge molecule, it's small enough molecule that it will penetrate the skin. And when it penetrates the skin and gets into the deeper layer of the skin, vitamin C will downregulate, will quiet down the body's production of melanosomes, the pigment particles. And so if you take vitamin C, it will help. to correct brown spots and pigment spots. And as I said, it it seems like it helps to quiet down the melanocytes. And so topical vitamin C is also good. And then there are some there were some treatments where you'll do microderm abrasion and then apply vitamin C crystals and they'll penetrate in. And then that gives you a higher dose of vitamin C penetrating in through the skin. And that can be helpful as well. So that's vitamin C. Vitamin C is a water-soluble vitamin, and and and it works on on the cell surface receptors. Vitamin A is an entirely different story. Vitamin A is a vitamin that is a fat-soluble vitamin. And vitamin A is a cofactor in the skin, in the normal regulation of skin. maturation. So the skin making the dermis and making the epidermis. Vitamin A is also what we call photolabile, that the sun shining on the skin will cause the vitamin A to break down. So if you live in Hawaii and you're fair skinned and you go out in the sun, the vitamin A in your skin will be broken down by the sunlight and your skin will be relatively vitamin A deficient. So if your skin is vitamin A deficient, then you're gonna have the all of the signs of vitamin A deficiency. You're gonna have dry, flaky skin and and it that's not good for you. If you want to replace the vitamin A in your skin, you could try eating it. You know, eat a bunch of vitamin A and some of it will get to your skin eventually. But it won't get to your skin nearly as fast as it needs to because the sun breaks it down quite quickly. Yes. So if you eat vitamin A to try and get it to your skin, there are two problems. One is it's it's slow to get there. The other problem, it's a bigger problem, is that vitamin A is fat soluble and it stores up in your liver. And before you get enough to get to your skin, you're gonna have a ton of it in your liver and it's not good for your liver in in large doses. So we generally don't recommend that people try and replenish the vitamin A by eating it. On the other hand, rubbing vitamin A on your skin works great. Except that we don't usually rub vitamin A, we rub another similar type of molecule. And that whole class of molecules is called retinoids. speaker-0: Yeah. speaker-1: And the most famous of the retinoids is retin A. And and but it has friends, it has retinol, has retinal, has retinal sulmitate. and that whole class of retinoid molecules, if you rub them on the skin, some of them will get into your skin. And will help to relieve the vitamin A deficiency in your skin that's related to sun exposure. So vitamin A is great for making the skin better, making it healthier. what we do is we try to combine that with ways of getting more vitamin A into the skin by either microneedling or by doing you know a fraction fractionated laser or something like that to allow the vitamin A to penetrate into the skin better because. Once the vitamin A makes the skin healthy, of course it makes it not so easy to get in. Mm-hmm. And because it's lipid soluble, it's it it's a little bit harder for it to get in than the vitamin C. speaker-0: Yeah. Mm-hmm. Okay. And then to also add on to what we can do to take care of our skin, exercise is another big thing that could be beneficial, right, to our facial anti aging. speaker-1: Yeah. So it's funny 'cause you think, how could exercise help you? speaker-0: Time, yeah. speaker-1: Yeah, 'cause the exercise you're gonna grimace, you're gonna be moving, is you know, you're gonna be on the sun. All of those things sound like they'd be not good. But remember we talked earlier about the extracellular matrix and how the cells are floating in the extracellular matrix noodle soup. Yes and they're attached to it. And when you exercise, that causes the matrix to shift. And that shifting of the matrix then stimulates the cells to to react differently. So if skin is being, you know, moved, the body will then try to make the skin stronger in response. And it'll actually thicken your dermis a little bit. It brings in more blood flow. Yeah. And and the blood flow will then allow the cells to proliferate and the skin to grow and to be healthier and to and and also to clear out the, you know. clear out the trash. so exercise is actually surprisingly effective at at making your skin healthier. And it doesn't have to be facial exercise. You you know, you can go to the gym and do lifting or aerobics or Zumba or whatever. and and it's your whole body exercising, your face kind of goes along for the right. Yes. Facial exercises by themselves, you know, that kind of thing. Less evidence for that. And then also you get into the problem of the if you're bending the facial mimetic muscles all the time, you're gonna be pleating the skin in the same place over and over again. And since that sort of causes wrinkles, it may make your skin healthier but more wrinkly. Mm-hmm. speaker-0: And for the aesthetic side of it. speaker-1: Yeah, and so th that may not be the trade that you were looking for. speaker-0: Yes. We didn't bargain for that. speaker-1: Yeah. speaker-0: and I know we always touch on this topic, but sleep and the meditation is super, super important, right? For your anti-aging journey. speaker-1: Yeah, absolutely. sleep was very much underappreciated when I was in medical school and in fact when I was a resident we were forced to Right, exactly. Which is which is just Yes. speaker-0: Not have any sleep. Crazy now as doctors. speaker-1: but that was just the way it was and and so I think things are a lot better now than they were, but it it's still a stressful job and people still it's hard to get sleep when you're you know. speaker-0: Training. speaker-1: But sleep is really important because during sleep you have a sp a spike, a circadian spike of growth hormone, and that helps the body to make more collagen and and assemble things and process all the signals that it's been getting all day and sort of catch up on its email metaphorically. And then also in the brain, the sleep is is the time when the lymphatic circulation lets the brain you know, clean up the trash. and so yeah, sleep is sleep is i is really important for you know, skin health and and of course the the health of the entire body w as reflected in the skin. speaker-0: I also just feel better when I have sleep and I feel like it glows in your skin. It really shows when you don't get enough sleep. speaker-1: Yeah, that's right. Your skin gets dried out and speaker-0: All the all the all the bad things. Yeah. and there are treatments that we offer here, right? So patients will come in to kind of consult with you and say what can I do to help these aging lines that I haven't had before? Right. My fat pads are falling forward in my face, I look gaunt. What can we offer these patients to try to help them, you know, kind of rejuvenate their face? Yeah, so people come in with a variety of complaints about their facial aging. And as we talked about, the face is extremely important for social interactions. And people make judgments about you within a a second or two just by looking at your face and even from a distance. And they'll they'll make judgments about your age, about your state of health, they'll judge your lots of different things, your occupation, your you know, your likely you know, personality, things like that. So the face is really important and because people really do judge a book by its cover. They they judge you by how your face looks. even though it's not as important for your you know, longevity in terms of w you know, the the other systems, it it is extremely important for the social aspects of of fitting with society and where you want to be and and how you want people to judge you. Yeah. So people come in with a variety of different complaints. So of course wrinkles is one. And for wrinkling, there's three things you can do for wrinkles. One is you can tighten the skin. Mm-hmm. The other is you can f fill up the bottom of the wrinkles. And we do we we do that with filler or other biostimulatory things that to cause the bottom to come up. The other thing you can do is sand down the top of the wrinkle. And you can do that with lasers, with chemical peels, with derm abrasion. Yes. and and depending on the wrinkles and where they are and how severe they are, one or another or all three treatments together might be the may be the right thing. So wrinkles are one thing. Another thing that bothers people, of course, is the dyschromia we talked about initially. Yes. The the changes in the skin will be different colors in in adjacent areas. And so for that, retin A actually is is very effective. Vitamin C, topically or or orally, is very helpful. And then there's some other mild peels and things like that that can help cochic acids one. And then we also can do laser and the lasers either work by Making little holes in the skin like microneedling does. and of course microneedling also is can can work. and making little holes for some reason that causes the body to heal It makes a stimulation of collagen and it stimulates the melanocytes to even out their pigmentation. But the other thing that it allows you to do is it allows you to put put product well then penetrate better into the skin because you've made the skin go from a a very good barrier, you know, like a bowl. Into a sieve where it's got lots of holes and stuff can get through. obviously we don't want it to be like that all the time, but yeah, we take advantage of it while we do the treatment to allow us to put in stuff, the vitamin A, vitamin C, other factors, exosomes, things like that. We allow them to penetrate in better at that time on purpose. Exactly, exactly. And then that that helps. And then of course, you know, if you use a a pigmented a pigment laser that that targets the dark the darker pigments, what will happen is the darker things will absorb more of the incoming light and the other the other tissue will reflect it. That will that will heat up the darker things more so than the other skin. So you can target blood vessels or you can target dark, you know, pigment spots. and heat them up and if you heat them up enough, y you can, you know, damage them, you can kill them and then the body will will kind of repair it. Right. So you can yeah, you c either shatter it or heat it up or whatever. Now obviously if it gets really hot that can be uncomfortable. So sometimes you have to use topical anesthetics or you put cooling or something like that. But but those are those are reasonably effective. Now and on a person who's easy to tan, what happens frequently is that you'll get the pigment will heat up and then That'll cause an inflammation and the body will get rid of that pigment. But inflammation will then cause a tan. Yes. We call that post-inflammatory hyperpigmentation. and a lot a lot of people in Hawaii are prone to that. So the bronze spot will be a bronze spot that'll never go away. You turn it into a pink spot, which then turns into a tan, and the tan will eventually fade, but that process takes months. Yes. And then the time when it's tan. The people are concerned because their bronze spot came back. Yes. And it's actually a different bronze spot because it was a a subrecatosis now has turned into a tan. And tans do eventually fade. the darker your skin, the longer it takes for the tan to fade, usually, but it will usually eventually fade and it'll come back to a a more even skin tone. which brings me to melasma. Melasma is so difficult. Yeah, melasma is a different thing altogether. There are a lot of brown spots that are on the surface of the skin, like stick-on things, and and if you if you blast them and they fall off, they stay fallen off. Yes. But melasma is deeper in the skin, it's in the deep dermis. And a lot of melasma is is responsive to hormones, you know, especially estrogens, will cause melasma. And and and because the estrogens are stimulating the melanocytes. And then if you actually if you add more stimulation to melancytes with sun exposure with light, then the melanocytes get doubly, doubly bad combination. Yeah, and they and they get dark. So melasma is not uncommon with pregnancy because the estrogen levels are quite high. and and of course, here the combination of the estrogen levels and the sunlight causes people to get melasma. And then once you get it, it's in the bottom of the skin, and the the top of the skin. grows and falls off all the time. It it's it's like a conveyor belt. It's just growing and falling off, growing and falling off, going off and off. But the bottom, the deeper layer, anything deep to the basal membrane, doesn't turn over. So if you have pigment that's embedded in that, then it it's gonna be there and it's basically your body's own natural tattoo. if you put ink on your skin, it'll wash off eventually. If you put it in the dermis, It's there for a long, long time. Wow. And so melasma is like your body's, you know, pregnancy tattoo, more or less. And and so when people come in and they want to get rid of the melasma, it's hard. Some of the newer lasers, the the picoshre laser, will fraction you know, fracture the the pigment a little bit. and and they certainly are better than what we've had before. Yes. But I always tell patients that melasma is best thought of as being like the white hair of the skin. Mm-hmm. That if you have white hair, you can treat it and you can make it not white. But when you stop treating it, then it comes back. And the same thing is true of melasma. That we have ways of lightening it and making it less obvious for now. But as soon as you stop treating it. Yes. It it generally comes back. And and as long as you recognize that and say, Okay, well I want it gone for, you know, this month where I got something special on great. But if you say I want something that's gonna make the melasma permanently go away, unfortunately we don't have a treatment that will do that at this time. Yeah, sure. So remember we talked about the skin, that's one of the layers in the subcutaneous fat. Mm-hmm. And and the SMAS, which is the the sort of the mesh work, the hammock that's holding everything up. So if the hammock is loose, you need to tighten the hammock. And we have non-surgical ways of kind of tightening it a little bit, and they work a little bit, but they're expensive, they're uncomfortable. so in that category there'd be thermage, old therapy, and things like that. Then you can say, well, it's let's take that hammock and let's put some strings and we'll, you know, put in strings and hold it up, or we'll put in strings that will sort of help tighten the the the ropes of the hammock. And again that works so so. The problem with strings is that if you're holding something up with a string, it's really easy for it to pull through. And just like we have these, you know, these things are held by a a string at the top. If you pull on it, you can you can pull it through. And so if you're trying to do s lifting with strings, the issue is that you have to be able to open your mouth and eat. So if it's the strings are tight, then either you won't be able to open your mouth, which of course That's not the goal, you know. The or if you open your mouth generally you'll pull through the strings. So the suture lifts you know are interesting idea, but most of the suture lift techniques that are easy fall down by virtue of the fact that you pull through them and they they don't last very long. so that's one set of things that are tightening this mess. Now of course facelifts, we generally tighten the SMAS. We we we lift it up and we we do anchor the SMAS to something strong. So as I said earlier, the most of the facial muscles don't attach to bone. They attach to each other and to the skin. But here we take the SMAS layer which is the hammock that that musculo aponeurotic system and aponeurosis is the the gristle on the muscle that connects it to the other tissue. We pick that up and we we tighten it to the the jawbone here, or the cheekbone, and that gives a a more controlled and longer lasting correction. But of course it's it's surgical. Yes. the other thing that we frequently do is we talked about the fat layer, which is the subcutaneous fat that's that's right under the skin. And that that shrinks with time and that shrinkage makes you look older. So what we do is we re we replenish it. We take fat from someplace else in the body and we put fat back into the face. And that will then restore the volume. and you know it gives a very natural look. And the the nice thing is that it's living tissue, it's fat. It's it's fat once it takes and and gets blood flow in its new area. Permanent. is gonna stay there forever. So fat's really hard to get rid of once it has blood flow. Yes. now some of it of course won't get blood flow, it will die and and be resorbed. And the other thing that's interesting about fat is fat has an enzyme called aromatase. And so fat will actually make estrogens. So you've got a little estrogen patch right next to your skin that's causing the skin to be rosier and healthier and glowing by virtue of the fat grafting. there are areas that are that are challenging nonetheless. The nasal level folds. Yes. If you lift up the tissue to flatten out the nasal level fold, that works fine. But at some point you you have to address the fact that you're gonna run into the eyes. And so if you bunch up too much you're gonna have tissue bunched up under the eyes. Yeah. Hold on like that. Or it's gonna bunch up here lateral to the eyes. And so then you've got to either not lift up so much or smooth it out or have a little wrinkly for a while after surgery or continue going up and then so you lift up to here and you bunch here but then you go higher and you take away that bunching. And so if we do that then we can we can bring the the scar all the way up into the hair where it doesn't show. And then you know with my colleagues in China we've been working on ways of of anchoring this up just right right here and and smoothing out the nasal it be folded. So that that works well. And then the the marionette lines are a real challenge because they're like the perfect storm of wrinkles. There's a they have this really strong muscle, the depressed triangularis, the DAO muscle right here, that causes the skin to bend there. So you've got a crease from the bending. Then in addition, as we talked about earlier, you've got a ligament that pretty much connects the skin to the bone here. And so when the skin is lax, it falls down onto that tissue. And falls over that ligament and it's like s you know, your shirt falling over your belt. And that makes fullness there. and and then in addition, because it's being bent, you know, by the DAO for so many years, it has thinned out the subcutaneous fat in that area. So correcting that requires that to really correct it, you've got to correct all three things. You have to do a lift and you have to do filler and you have to do something to weaken the muscle, you know, like Botox. Mm. if somebody comes in the and they say everything else is good, I just have this one little wrinkle. It's like, well, okay, but fixing that one little wrinkle is really hard because you can't just put in Botox or just put in filler. That will give you some correction, but if it's really bothering you, you you really need to do all three. Yeah. Yeah. And it's interesting th there's a there's a significant difference between the way that Caucasians age and, you know, Chinese, Asian and Japanese, Korean people age. And generally the Asians, the East Asians, they their skin is thicker and they they generally preserve pretty good tissue tone in the neck. Caucasians on the other hand, frequently the the neck ages rather significantly and you have a lot of wrinkling and then also a lot of sagging. And the neck is hard because if you think about it, you know, you have skin, you have subcase fat, you have the glands, the submandibular glands, and some muscles. But you don't have really the bone like you have structure. In other places. I mean pretty much every place you touch here, you have bone. If you touch here, there's no bone to really anchor things to. And so You don't really have the the the strong tissue. So you've got skin attached to the fat, attached to muscle, attached to gland, attached to tongue, attached to air. So there's there's not much to really attach it to. So what we have to do is we usually pull the tissue in the middle together like a hammock, take out a lot of the fat and then pull posteriorly on the hammock to tighten the hammock. And so again, if you know somebody comes in and they just say, I you know, I just I hate this band here. the the Botismal bands. Well, the botismal bands have come down because there's no bone to attach to. And so they've fallen loose. And so in order to fix it, you have to kind of connect them to each other and pull everything up. So just to fix this one little teeny thing, it generally requires you know big surgery. There are some patients, it's pretty uncommon, but there's a thing called a nec nephritidy lift, which is Botox, where if the bands are tight, You can put Botox in and relax them and and then that will actually improve the neck and give you a nice neck. Mm-hmm. But it only works if you're typically if somebody that's young that's that grimaces a lot and the muscles are under tension. For people where the muscles are lax and then it's falling down. Botox is just gonna make a lax muscle more lax and it's just gonna fall down even more and then Botox isn't gonna help that much. So you know, Nefertiti was yeah, Nefertiti was young, I guess. Yeah, so th there are a few things that are that are universal and then there are things that are specific. So number one, if you're smoking, stop smoking. The best thing you can absolutely do is stop stop smoking. I I know it's hard. I I know that smoking is very enjoyable and it's just it it's a choice. But if you you are absolutely gonna be weighing, you know, the that the bad effects that it has on your skin and your face. versus the enjoyment and and and you have to make that decision yourself. But from your face standpoint, there is no good part about smoking. There's nothing where this face goes, yeah, but it's fun or it's you know, whatever. It's just no, it's just bad. And you're just you're just saying, you know, it it's you know, so so sorry face, you're gonna have to take this because I I really like smoking. Yes. that's the number one. Number two, similar thing. Stay out of the sun. You know, now that one's not not quite smoking level. Yes. smoking's bad for a lot of other things. and some sun, you need some sun to get vitamin D and being in sun is enjoyable. Yes. And but as we talked about earlier, there isn't really such a thing as a healthy can. as far as the facial skin is concerned, you know, you should live in Portland or someplace where it's north and rainy and cloudy all the time and then your skin will be great. Mm-hmm. or cover it up or and then of course if you don't want to cover it up then use sunscreen sun protection or use some sort of makeup that has sun sun protection in it and a lot of makeups actually are are pretty good for keeping the sun out. and so sun protection is number two. number three, I I recommend for everybody that lives in Hawaii that use a some kind of a retinoid that even if even if you're good at preventing sun damage, you are getting sun exposure. That is depleting the vitamin A in your skin, putting vitamin A back into your skin is going to be really helpful. And so those three are sort of like pretty much for everybody across the board, those are gonna help. Then for the other parts, here in our practice w we just say, you know, what bothers you that you may have a big mole that, you know, is very unsightly and but if it's not if it's not cancerous and it doesn't bother you, then it's your choice. you know, conversely you may have a a little wrinkle right here which doesn't really, you know, affect anything, but it's something that really bothers you and then we'd say, we can fill it with you know with filler. And so we try and individualize it to what not only what makes sense in terms of cosmetically and how it's gonna impact other people, but then most importantly what bothers you because ultimately the thing that's gonna impact your social interaction with other people isn't whether you have wrinkles or you have sun damage or not. It's it's how you feel. Yeah. And if you feel confident and and comfortable and happy, then that's the most attractive thing that we can offer somebody. And and so if if we can get you to that's that's perfect. That's okay. And you know, if you if you have dyschromia or you've got wrinkles or you have sun damage, we can f we can help that too. And especially especially if that will help you feel more confident and happier. That's right, because as much as I enjoy talking to you, and as much as some people apparently like listening to video podcasts, we do have things that have images that illustrate a lot of these points. And and we've prepared that and and that's in an accompanying video. and then if you like to read about things, then of course we have the Rebellious Aging Guidebook, which has a lot of this information and And it gives you the ability to, you know, study it and go back and read it and and it's linked to, you know, some references and things like Okay, thank you.