Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / Thirty-ish: Best Anti-Aging Treatments for Your 30’s
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis. Kirstin (00:08): Hey, Dr. Koehler. Dr. Koehler (00:09): Hey, Kirstin, Kirstin (00:11): Do you want to know what's on the agenda for today? Dr. Koehler (00:13): Sure. What's on your agenda today? Kirstin (00:16): Well, do you remember the first time you got Botox? Dr. Koehler (00:20): No. Kirstin (00:21): You don't remember how old you are, you were? Dr. Koehler (00:24): I remember how old I am now. Yeah, I don't know. I was probably, I was in my thirties. Kirstin (00:32): Do you get Botox now, still today? Dr. Koehler (00:36): Yeah, I still get, it's the one thing that I really do consistently. Kirstin (00:41): How often? Dr. Koehler (00:42): I don't know. I don't count it by the calendar. It's about every three months. Kirstin (00:45): Okay. We're going to talk to the 30 ish people today. You know who you are. So we're going to do a little mini series on how to face each decade of your life. At the age of about 30, what are things that you should be doing every day, every month, every few months? Dr. Koehler (01:04): I think most people are pretty fortunate in their thirties and don't have problem skin, but you still want to do things to obviously look and feel your best. But I think the key in your thirties is just maybe just getting a regimen together that you're good about doing and you're consistent with. I think success in anything in life, whether it's in your career or in your progress in the gym or any of these things. It's all about consistency. You got to do something and you do it on a consistent basis, and when you do that and you're consistent, you're going to make progress. I think the big thing that people do is they'll get into a little mode where they're like, okay, I'm going to get in shape, and then they work out for a brief period of time and then they quit doing it, or I'm going to really focus on my skincare, and then they do something and they do it for a few weeks, and then they either quit or they switch skincare products, but they don't do anything long enough to really see the benefits of it. Dr. Koehler (02:01): So I think the thing that you should be developing in your thirties is probably the habits that you can carry forward to when you do get older because things creep up on you. When I see older patients and they've got really bad sun damaged skin, that didn't happen this last summer. That's years and years of being out in the sun, not protecting your skin, not doing things that you should. So it's like the cumulative damage. So in your thirties, it should be, okay, what would be the easy, simple things that I can do on a consistent basis to keep myself looking young? And probably the simplest things are wearing sunscreen, especially like here in the south, we got some hot summers and lots of sunny days, and just protecting your skin with at least SPF 30 on your face and wearing a hat, wearing stuff to protect your skin. Dr. Koehler (02:54): It's fine to be out in the sun, but you can't just be sun worshiping. You can, when you're young and you might get sunburned and then you'll think, oh, then it turns to tan and I'm great, great for the rest of the summer. But again, you're going to pay for these days in the sun later in life. So if you want to do something, that's the simple thing to do. So first would be protect your skin. And then secondly, I think is for women, especially if you put on makeup at the end of the night, have your little routine, take your makeup off, wash your skin really good, moisturize. And then if you can, maybe not so much in the thirties, but definitely maybe late thirties and certainly into the forties, think about starting to use a Retin A, which I think is beneficial. In thirties, you probably don't really need to use a Retin A, but just good skincare cleanser, moisturizer, that's probably sufficient. And then skin protection. Kirstin (03:47): Awesome. I love it. I'm the worst at washing my face at night. Hate it. Dr. Koehler (03:51): Yeah. Well, falling asleep with your makeup on and all that stuff. I mean, every now and again, it's not a problem. But I mean, I think, again, keeping your skin healthy, you got to do things consistently over time. Kirstin (04:05): Well, let's talk about Botox and filler in your thirties. So if you have never had Botox before, what do you need to know? Or when should you start? Dr. Koehler (04:16): So when should you start is probably a really good question, and it's not a good answer. It's different for everybody. I had a girl in the other day, she's like 22 years old, and she says, well, I want to start Botox and her skin looks great. And I'm like, well, why? And she's like, well, I just don't want to get wrinkles. I'm like, well, unfortunately you probably will. You don't have a choice. But I get the idea. We want to prevent things. So I'm glad that she's thinking about it. But early twenties you don't need to be doing Botox, but it's different for everybody. So the things that influence how our skin looks, there's a lot of things that impact it. There's the genetics, which you can't really fight. I mean, you got what you got and you got to live with it. But then there's things like the environment, which we already mentioned. Dr. Koehler (05:03): I mean, if you're out in the sun on a daily basis, day in, day out, if your job is outside, you've got to be more careful because sun damage over time is a real thing. So environment, things like smoking, that's another thing. If you're a smoker, you're going to prematurely age your skin, no doubt about it. Nutrition, what you eat, that also has an impact. If you don't eat healthy, your skin's not going to be healthy. So there's a lot of things, some of which we can control to a certain extent and some which we can't. But depending on all those factors, those combined factors that will determine when you would start. So really once you start to get dynamic lines that are very noticeable to you. For instance, the three most common areas we treat for Botox or any of the neurotoxins is forehead, glabella, and crow's feet. Dr. Koehler (05:56): And those lines may not appear all at the same time. You may start to notice first forehead lines, and then maybe the crow's feet are a little later. You don't necessarily start treating all three areas all at once. But when your skin starts to lose its elasticity, when you're young and you raise your brows, you might form a few little minor creases or lines on your brow and your forehead when you animate, but they might not be very deep at all because your skin's very elastic and it'll stretch and bend. As we get older, the elasticity is not as good. And so that's when we start to form creases. And so when those creases are starting to form with repetitive facial movement, that's when you want to start targeting them with the toxins, the goal is, well, one, we don't want to see those prominent lines. Dr. Koehler (06:42): We would rather see smoother skin. It looks good, but also what we're trying to do is to prevent the permanent creases that occur over repetitive movement. Over time, you're constantly raising your brows or you're constantly frowning the dynamic lines you can treat with Botox, but once they become a permanent crease in your skin, so when you're totally relaxed and you look in the mirror and you see that crease, you're kind of stuck with it at that point. And so that's the preventive part of using the neurotoxins. So you want to get to those creases before they're too deep and you can't reverse them or slow the progression down with one of the toxins. So for many people that's in their thirties, and it could be early thirties or late thirties. And sometimes I've seen people who are just now starting to do their first sessions of Botox and they're in their forties and their skin looks fabulous, and they can totally start in their forties because their skin is that good. So again, it's not an age when it gets to where it's starting to bother you. And definitely well before you start to get those creases at rest, you should be considering that if you want your skin to look the best. Kirstin (07:48): Are other name brands like Dysport and Jeuveau, are they as good as Botox? Dr. Koehler (07:54): There's lots of different brands out there now. They're all botulinum toxin A, so they're the same drug, but the molecules are a little different. And so there's some subtle differences in terms of the onset of action and maybe the duration of action between some of these neurotoxins, but they all kind of work the same way. Some people will say one works better for them than another, and that's fine. A lot of times I jokingly say when the two main ones that we typically use are Dysport and Botox, and I'm like, well, that's Coke or Pepsi. They're the same. They're both botulinum toxin A. They both really, the clinical studies show that the duration of action is the same for both. And if I didn't tell you which one we were using, you probably wouldn't notice the difference. However, there is a subtle difference that Dysport tends to have. Dr. Koehler (08:48): Its onset is a little bit quicker than Botox. So the one time where I'm like, if I'm going to recommend something, I'm like, they're both good. I've used them both personally. I think they both work great. But if somebody says, oh, I've got a wedding coming up and it's in six days, I'm like, okay, then do the Dysport, because we want to try to get that action as quickly as possible. If it's in two weeks, doesn't matter. Either one would be fine. But if you're kind of in a pinch, the disport works a few days quicker, and it's not a lot quicker, but it's a few days quicker. And for some people they say, oh, my Botox kicks in three days. I'm like, okay, well that's good. But it's typically seven to 10 days to really get full effect. So if your event is within less than a week, then I would lean you towards the Dysport, but dosing's a little different, which is sometimes confusing for patients. Dr. Koehler (09:36): So when people come in and they're like, I'd like to try that, and they're used to maybe getting 20 units to their glabella, and then I'll say, okay, well, we're going to do Dysport 60 units. And they're like, oh. And they think, oh gosh, that's like three times as much. I don't want to do that now. I don't want to pay three times. Our cost is, it's a third the cost per unit, but it takes three times as many units to get the same effect. It's just the dosing, the way we call it. You might get an antibiotic and one is 500 milligrams and the other is 250 milligrams, and they both are effective doses for that particular drug. So don't get fixated on the numbers. In our office, it's pretty much the equivalent cost. So whether you do Dysport or Botox, the dose will be different, but the cost will be the same. Dr. Koehler (10:23): Now, there also can be some differences in the duration of action, and so you need to just talk to your doctor about that. But the typical standard ones are about three months, so two to four months. And we are typically telling our patients that are doing either Dysport or Botox, that typically we keep 'em on a three month schedule, but then we might start extending it out. So if the way these work is, it prevents the muscle from contracting, so it actually prevents the nerve from getting to the muscle to cause the muscle contraction. Just like if you put your arm in a cast and you took your arm out of the cast after let's say eight weeks, when you look at that, your arm, the muscle will have shrunk down because you haven't been using it for eight weeks. So that's called disuse atrophy. Dr. Koehler (11:13): So if you're not using it, it shrinks. Well, same thing happens with these muscles in the face. So if we are not using them, they will shrink, but they're very, very, very tiny muscles. So once they start to work again, it doesn't take very long for them to get their strength back up. But the point is, if you're consistent with your Botox or your Dysport or whatever, or whatever you use, if let's say you can typically go about every three months, well, if you're really consistent with it, you may find if you don't allow that muscle to regain its strength, that you can maybe start to extend the time between injections because that muscle will have atrophied a little bit. And so maybe at first you only get two months out of it, but over time you might get a little longer between. Now if your toxin is wearing off quickly, some people are like, oh, it's six weeks and it's all back, my movement's all back. First thing that you need to do is make sure that you're getting the appropriate dose. Dr. Koehler (12:11): A lot of people that I see, oh, I had it at this other doctor's office and this is how many units I got for all three areas. I'm like, well, the dose you're telling me is probably effective for one area, not three. So yes, I understand for cost containment, people are like, I just want to use a little bit. People think Botox is like a dimmer switch. It's like, okay, just turn it up or turn it down. I want my wrinkles down. It's not a dimmer switch. It's like an on off switch. Your dose is either working and it's off and the muscles can't move or it starts to come back. And then once they start to come back, it comes back pretty quickly. So if it's coming back too soon, it's probably that your dose is not high enough. Dr. Koehler (12:53): That's the first thing that I'd make sure is that your dose is high enough. And again, some people say, oh, I get better results with one or another, and that's fine. But the only time I've ever had somebody come, I had one patient come in and she said, yeah, Botox doesn't work for me. And I was like, oh, no, it'll work. You probably just didn't have enough. And I said, let's do this. Let me treat you. I want you to come back and see me in two weeks and let's look at it. And I gave her a whopping dose on her forehead. I thought, okay, this is going to work. And she came back in two weeks and she had full movement. So it's the first patient I had ever seen, but she had antibodies. So people who have antibodies to the botulinum toxin, which is rare. It's a very small percentage. I dunno what the percentage is, less than 1% for sure. It's like a low percentage. I'd never, I've actually never, in all my years of injecting, I've never seen a patient with antibodies. And anyhow, people who have, it doesn't matter. You have antibodies to one, you've got antibodies to all of 'em. So if you can't do Botox, you can't do Dysport, Jeuveau, Xeomin, doesn't matter. So fortunately, it's really, really rare. I don't know what it is. It's not 1%., it's way less than that. Kirstin (14:08): That's crazy. So does that mean she was exposed to botulism as a child or something? Dr. Koehler (14:11): No, I mean, well, how your body forms antibodies to it. I mean, definitely the thought is that over time, if you do it for a prolonged period of time, that maybe you'd be more prone for your body to develop antibodies. But why some develop and some don't, I don't. That's something for the immunologist to explain to me. I don't know, but it's really rare. But again, when it happens, then you're out of luck. But it's rare. Kirstin (14:37): Do you do lip filler? Dr. Koehler (14:39): Yeah, I inject lips if people need them. Kirstin (14:42): What is treatment like? Or is it painful? Dr. Koehler (14:45): Yep, it's, I'm not going to lie. It doesn't feel good. I've never had it done, but I've seen enough people squirming and gripping the chair to know that it's not comfortable. So we put topical on, and there's lots of things we've tried over the years to try to make it more comfortable. But ultimately, sometimes you can do dental blocks, but if you do that, you got to get the dental block. So you're going to get a bunch of needles to get your lips all numb, only to get your lips injected. So it's like, why not just get the injections and be done with it? The fillers that we use for lips contain lidocaine in them. So once they get injected, it's not too long afterwards that they should start feeling more numb. And so the discomfort is short-lived. But yeah, lips are tender, but I don't know. I have a lot of women that are champs, like I sit there and they don't flinch, they don't move. I'm like, all right, beauty is pain. You obviously get it and you're doing it, so that's good. Kirstin (15:34): I'm not one of those patients. Dr. Koehler (15:35): No, you're not at all. In fact, I don't know that I'll ever inject your lips ever again. Just kidding. Kirstin (15:42): You're going to have to pry my kiss from my cold dead hands. Dr. Koehler (15:45): Yes. Kirstin (15:46): How can you enhance a jawline with filler? Or is that something that women in their thirties even like to do? Dr. Koehler (15:53): Well, some people like to do it. I'm going to be honest, I'm not a fan of some of this stuff. I mean, sometimes it's not, can you do it? It's like, should you, and if you should, is there a better option? Because there's a place for it. I'm not saying there's no place, but for instance, if somebody wants to enhance their jawline or their chin by using filler, can that work? Sure. And I've done that for sure for people. But you got to realize these fillers, depending on which ones you use, how long do they last? Well, that's a question we get. It depends on the filler, but a lot of them are 12 to 16 months. And I also say with people, okay, it is a really tough question, right? Well, how long does filler last? I always say, well, how long does a tank of gas last you? Dr. Koehler (16:36): So it depends. It depends on your metabolism. But even if you have your car's got gas in it, okay, was the tank filled all the way up, or did you only have a half tank to start with? And at some point you're at a quarter tank, so you don't have a full tank. So maybe in order to get the look you want, you need a full tank. So even when you're not on empty, you've got to fill it back up. So that's the thing about filler that even though they may say, okay, well a filler lasts 12 months. Well, is that clinical effect or to what clinical effect? But yeah, there's still filler there in a year, but you might be on a quarter tank at that point and you need to add to it. So when you need to add, filler is different for every person. Dr. Koehler (17:15): So asking that question, how long it lasts is a tough one to answer for a lot of folks. But let's say you do want to enhance a jawline. Sure, you can do that. Something to really remember though, if we're really wanting to enhance things like jawlines and chins, each one of those syringes contains one milliliter. And to put that into perspective, it takes five milliliters to get you one teaspoon. So if you're thinking you're going to enhance a jawline with one syringe of filler on each side, that's not very much volume. The two of them together is not even a half a teaspoon. So to really get these kinds of changes to enhance a jawline requires sort of a significant amount of filler. And can it be done? Yes. It starts to become a little bit cost prohibitive if you are really trying to enhance that and to get those kind of changes that almost reflect like a skeletal change. Dr. Koehler (18:15): You need to do skeletal surgery, whether that be an implant or some type of bony surgery to change the contours. And so that's obviously a big surgery. But if you wanted to do something quick and easy for an event, or maybe you just wanted to see what it would look like to get an idea, sure, filler might be an option. I like filler for lips. I like filler for cheeks. I'm not a huge fan of filler and nasal labial folds. You can do it to soften it, but you got to be realistic of what you're trying to achieve there. The biggest problem that I see with fillers is if a little's good, a lot's better, and it's not, it looks, and again, Madonna saw her recently on some awards thing not too long ago, last year sometime, and I was like, her face doesn't even look like it just looks different. Dr. Koehler (19:02): I mean, it's just a lot of filler. So filler should be used conservatively when it's needed and you can enhance things. But definitely there comes a point, and maybe we'll talk about this more when we talk about older patients, but at some point, filler is not your go-to option, and you really need to start looking at surgical or other procedures because the mistake people make is that like, okay, I'm going to put filler in, and filler might be great in your thirties and maybe into your early forties, but then when you start to get to your later forties and fifties, adding that volume is not lifting anything. It's just kind of giving you more volume. And if volume is what you need, then it may be good. But a lot of times people are trying to compensate for descending tissues by adding volume and it just doesn't look right. Kirstin (19:50): Now we're going to move on to my favorite thing. Dr. Koehler (19:53): What's that? Kirstin (19:54): Microneedling. Dr. Koehler (19:56): Microneedling. Yeah, I like microneedling. It's good. Kirstin (19:58): Yeah. Well, we offer two different kinds here. Dr. Koehler (20:01): Yeah. Vivace and the SkinPen one's radio frequency and one is not. Kirstin (20:05): Yes. Okay. So what's the difference? Dr. Koehler (20:07): So the SkinPen is a mechanical microneedling technique. It's less expensive and actually has more downtime. So it's the less expensive treatment, but it has more downtime. It is got little tiny microneedles, tiny needles that we put topical on the skin, numb the skin up, and then this is a mechanical device that the needles kind of go in and out, in and out, in and out through the skin, and it creates this microtrauma to the skin. And in doing so, you'll get some pinpoint bleeding. A lot of times people leave after a treatment with SkinPen and their face looks kind of bloody for a little bit and red. But those micro traumas that are created is stimulates the body to form new collagen, which will help your skin texture and tone and give your skin a little more full appearance. And it will help with fine lines and wrinkles. Dr. Koehler (20:58): And that's the main thing that we're using, whether it's radio frequency microneedling or standard microneedling, it's really just to help with skin texture tone, but fine lines and wrinkles, not deep creases, fine lines. And sometimes it can be used for things like stretch marks and other applications, but that's mainly what we are using it for. And so the SkinPen is less expensive. And again, you do a series of treatments like same as with the radio frequency. You don't do just one treatment walkout, you got to do a repeated series of treatments. And we typically space 'em out about six weeks because it takes time for your body to form new collagen. So no sense doing a treatment and coming back the next day, it would be like doing one treatment because you've created the trauma, even though you did it two days in a row, you're not getting twice the effect. Dr. Koehler (21:43): You're getting one effect, let the body recover, it forms some collagen and then do it again in six weeks. And so usually we recommend a minimum of three treatments. And now for people who have maybe mild, mild acne scarring or other things, then they may benefit from more treatments than that. And acne scarring is a whole nother topic we won't get into. That's difficult to treat. You cannot cure acne scarring. You can improve it to a certain extent, but you can't cure it. So anyhow, that's the regular microneedling, the SkinPen. The radio frequency microneedling, which is my preference, and I've had it done personally. It's not painful. I didn't think it was painful. There may be a few areas that might be a little more tender, but it's really not bad at all. When you're done, you look like you just got a little too much sun. Dr. Koehler (22:30): You could totally go out for dinner and nobody would even think anything about it. And the next day you look fine. So this works a little differently. The one we have has these gold-plated needles, and the needles go into the skin surface, it goes into the dermis, and then once it gets to depth, and we can control the depth very accurately with this device, but once we get to the depth we want, then radio frequency energy is passed across the different little needles. And it's that radiofrequency energy that actually stimulates the collagen formation, not the repetitive mechanical trauma. So these needles go in, energy released out, move to the next spot, in, release energy, next spot, whereas the skin pen is like in and out, in and out, in and out repeated times in the same location to just create this trauma. So the other one is less expensive because you don't have the expensive device and the gold-plated needles and all that stuff. But I think the results are significantly better with the radio frequency. Kirstin (23:30): We have some patients with significant scarring just because of their heredity or whatever. And then sometimes you would recommend microneedling for them. Could you tell us about that? Dr. Koehler (23:41): Yes. Scars and management of scars is again, a topic all on its own because there's not a one treatment for every scar. It depends what's going on with the scar. Some scars require injections with steroids or other medicines. Some scars have issues with hypervascular or pigment. That's a different treatment. Certain lasers or IPLs will be used to treat those. But one of the things that we will do sometimes to help as the scar is healing is microneedling. Again, it's just as the scar is maturing, again, you're creating this micro trauma just to kind of help in that scar healing in a flat, a manner, not hypertrophic. So early on, usually we try to treat the scars. The first treatment, the soonest would be about six weeks out from healing. And so microneedling, along with, again, some of these other modalities can be used to help improve the appearance of scars. Dr. Koehler (24:37): But scars are a challenging subject because you can take two people if you could do the surgery the exact same way and use the exact same suture. And if nothing was different in terms of how you perform the procedure, you could still see significant differences in how they healed. You know, their genetics and how some people heal with a lot of inflammation, some don't. So yes, using high quality suture, which we use, and doing all the proper dressings after surgery, all these things are very important. I don't want to minimize those things. Those are all very important. But all things being equal, there's some things that're just the way certain people heal. And so some people do not require any other interventions whatsoever, aside from basic wound care, like maybe antibiotic ointment for a few weeks. And then certain scar creams, which I certainly recommend silicone-based scar creams, like the one we use in our office, I'm very happy with. It does a great job. So if people are consistent and use it for the allotted time, which is usually about three months, and they'll see improvement in their scars. But I have some people, they don't do a thing to their scars and they heal wonderfully. So lucky for them, but not everybody's like that. So people who do have difficulties with scarring and healing, then yes, we consider these other modalities like microneedling, IPL lasers. Sometimes you can even inject Botox that's been used in scars to try to help prevent the thickening of scars. Kirstin (26:07): Well, speaking of lasers, is that one thing that you would recommend for somebody in their thirties, or is that later on in life? Dr. Koehler (26:14): Yeah, that's later on in life. I shouldn't say all lasers, but there's like the photo rejuvenation type of devices that they're lasers, but they're not like the CO2 laser, which is an ablative of laser, which really takes the surface of the skin off. It depends on the laser, but there's some milder lasers that are more for addressing pigmentation. So photo damaged skin, sometimes after pregnancy when we'll have things like melasma and stuff like that. So we can use these lasers to kind of help with that. Pigment is challenging to treat because the lasers that we use to treat pigment, they just see shades of gray, like they see different shades of pigmentation. And really the more pigment, the more energy is absorbed by the laser. So the problem is that your skin naturally has pigment. So if you've got an area that's got more pigment right next to an area that has pigment, yes, the area that has more pigment is going to absorb more energy. Dr. Koehler (27:11): And so we can get that to be lighter, but at some point, this pigment that's darker is going to start looking closer to this. And now all of a sudden you can't get it gone. There's still a difference. But if you turn up the energy, now all of a sudden you're going to affect the natural pigmentation of adjacent skin. So there comes a point with pigmentation, with lasers that you can kind of get so far with, and that's why usually it's done in combination with other skincare products that can help with hyperpigmentation. So again, depending on what the skincare need is in your thirties, sometimes we do things like IPL. It's not a laser, it's pulsed light. Those can be helpful. There's just a lot of different things that it just sort of depends on what your needs are. But fine lines and wrinkles, that kind of aging, that's more forties, fifties, sixties. Thirties is going to be basic skincare, maybe some Botox, maybe filler if you want to enhance your lips, but you probably don't even really need filler anywhere else in your thirties. I don't see a need for anywhere else really, for most people. Kirstin (28:15): What about surgery in your thirties? Some people call in for chin lipo, which we know. Well, I'll let you talk about that. Why you wouldn't recommend chin lipo. Dr. Koehler (28:25): Yeah, it's not that I wouldn't, nothing is an absolute. There are some people that are candidates for liposuction underneath their neck, but oftentimes these people that come in, they don't like their neck. It has other issues, the muscles are hanging down and they need the muscles tightened, or they have fat that's below the muscle, which you can't get to safely with a cannula, because you'll end up where all the nerves and vessels are. So sometimes people that have a heavier neck or sagging neck, yeah, those people, we do a surgical procedure, a deep neck lift or platysmaplasty or submentoplasty. There's a lot of different names that are used, but typically it's an incision under the chin, and we still can liposuction some superficial fat., but typically, usually that superficial fat is not the problem. It's usually the deeper fat and the deeper structures. And so we tighten those up or remove what we need to remove from the deep structures to give them a better chin neck contour. Dr. Koehler (29:19): So yeah, in the thirties, if we're talking about face stuff, the most common types of procedures, I'd say for people in their thirties would be rhinoplasty, which that's an any age procedure once you're past puberty and everything. So at that point, if you want fix your nose, that's fine. Not really doing much in terms of things like eyelids and brows, your thirties, that's not an issue. So lip enhancement with fillers maybe. And then yes, I'd say necks are probably just trying to get rid of that, some people have a double chin or just some fullness there. In some people that's a weight thing. In some people, it's a hereditary thing. So if it's a weight thing, then we can still do the surgery. But we're going to certainly recommend that you get your weight more in check to where that'll look better because you can't access all of that area. You can take a heavier neck and make some improvements, but again, there's limitations to what the surgery can do. Kirstin (30:20): Let's say you are listening to us today and in your thirties and have never been to a cosmetic surgeon or a med spa before. What will consultation be like or who does it? Dr. Koehler (30:32): Well, that will depend on where you go, I guess. But here, I would see you for consultation after you've talked to my patient coordinators. But the consultation process, it's a lot of back and forth trying to really figure out what really bothers you and what your goals are. Is it achievable? And if so, what's going to be the best way to achieve that? And so there's a lot of communication there. It's very difficult in a brief little podcast here to describe, because every consults different and people's needs are different. But yeah, if you were to call, you'd talk to one of my coordinators first. They would kind of get a better feel for what it is that you're wanting to do. And then once we kind of narrow it down to what it is we're trying to achieve, ultimately we'll see you in consultation. I'll meet with you, we'll go through everything, discuss the options, come up with a plan, and then carry that through. Kirstin (31:29): All right. Do you have anything else to add for the folks in their thirties? Dr. Koehler (31:34): Yep. Just wait until you're 40, gets better. Wait until you're 50, gets better. Kirstin (31:41): How would you know about that part? Dr. Koehler (31:42): I don't know. Dunno that one. Kirstin (31:44): Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the Beautiful podcast.com. We'd love to hear from you. Thanks, Dr. Koehler. Dr. Koehler (31:57): Thanks, Kirstin. Bye. Kirstin (31:57): Go back to making Alabama beautiful. Announcer (32:00): Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. 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