EP 12: Laser Specialist Reveals the Truth About Anti-Aging Devices | Dr. Ryan Kelm

In this episode, Dr. Ryan Kelm, Harvard-trained laser specialist and cosmetic surgeon, breaks down what actually works (and what doesn’t) when it comes to devices, longevity science, and modern facial rejuvenation. We explore cellular senescence, regenerative approaches like fat transfer, and how surgical thinking is evolving to integrate technology without compromising outcomes. If you want a clear, evidence-based perspective on the future of aesthetics, and the biggest mistakes to avoid with devices, this episode delivers.

CONNECT WITH RYAN KELM
Website: https://clinic5c.com/providers/ryan-c-kelm-md
Instagram: https://www.instagram.com/kelm_md/
 
CONNECT WITH HOST 
Website: https://clinic5c.com/ 
Instagram: https://www.instagram.com/chesnut.md/ 
YouTube: https://www.youtube.com/@chesnutMD 
LinkedIn: https://www.linkedin.com/in/cameron-chesnut-a6910baa/ 
 
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TIMESTAMPS 
00:00 - Intro
02:28 - Lift vs Tighten
06:50 - What Devices Work
13:50 - Microneedling vs RF Microneedling
16:58 - How to Tell If Microneedling Is Done Well
18:57 - CO2 Lasers
22:14 - Fractional vs Continuous Lasers
24:10 - Top Devices Ranked
25:23 - Light Devices vs Lasers
30:56 - Downtime From Lasers
33:08 - Aging and Cellular Senescence
36:56 - Can Devices Impact Cellular Senescence?
40:01 - Surgical Practice Tie-Ins
41:30 - Red Light and Other Recovery Tools
50:09 - Psychotropics
54:11 - The Surfer’s Mindset
58:07 - Co-Writen Paper
1:09:20 - The Future of Fat Transfer
1:15:37 - Future and Evolution of Facial Surgery
1:26:53 - Outro
 
ABOUT HOST 
Dr. Cameron Chesnut is the host of the 5 Codes podcast and the founder of Clinic 5C, where he leads a team dedicated to integrative cosmetic surgery, regenerative medicine, and functional health. An internationally recognized facial plastic surgeon, Dr. Chesnut is known for producing natural, refined results that enhance rather than alter one’s appearance. His approach blends surgical precision with biological optimization and disciplined restraint, drawing patients from around the world who value excellence, longevity, and holistic care. On 5 Codes, Dr. Chesnut uncovers the mindsets and evidence-backed strategies he lives by, helping high performers perform better, recover smarter, and feel their best in every area of life. 
 
DISCLAIMER 
The views shared on this podcast are my own and are not associated with, affiliated with, or representative of my clinical teaching role at the University of Washington School of Medicine. This content is for general educational purposes only and should not be considered individualized medical advice.

Transcript

Intro

SPEAKER_00 0:00

Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level through optimizing the way you look, move, perform, feel, and connect. In this episode, we get to sit down with Dr. Ryan Kelm. And Dr. Ryan Kelm is a double unicorn. The reason I say that, he has a Harvard Laser Fellowship. This is the quintessential laser fellowship. Every device that we know, I think I can say that blanket statement, comes through the doors of this fellowship, this group, this brain trust. And he did that fellowship and has been part of it. And he also trained with me, which in our field is the other sort of unicorn fellowship that you can do. So he's kind of got both of these things down. So hence the double rainbow of play of him being a double unicorn a little bit. He's young, he's innovative, he's creative. I see a lot of myself in him at that age. I really get after him on devices. I pin him down on a couple of key things. We get into longevity science. So there's some nerdy stuff in there for you, cellular senescence, how that plays into things. And then we really get into surgical mindsets, how we can apply all those things to what we're doing in the operating room, how that fits into the whole surgical paradigm, surgical planning. And then we get a little bit into the future of fat transfer, what that is and what that looks like, the regenerative aspects of it, and then of course into the future of facelifting as well. And so we really get into those things uh in a very deep way. And I really hope you're gonna enjoy this episode, and I think you're gonna have some really nice take-homes out of this. Dr. Ryan Kell, thank you for being here today. Thank you for having me. Yeah, very excited to have you mostly to uh really play on your double unicorn status. What I mean by double unicorn status, I'm gonna call you that. You did the Harvard Laser Fellowship, the device fellowship of all fellowships, where everything comes out of quite literally the brain trust for all of plastic surgery and dermatology and where everything comes from. You were there, you were part of it, literally in think tanks about it, brainstorming sessions, science mechanisms, thinking about it, you specifically thinking about it from a longevity standpoint. I cannot wait to pick your brain on devices. I get a lot of questions about them, and nobody's better to answer them than you are. Uh, your other unicorn status is having done my fellowship, our fellowship, which is uh super unicorn status in our world, of course. Uh so you have two very incredible, uh honorable, unique types of training coming and overlapping. And and uh that's gonna lead me right into my question about devices, right? Um when I'm talking about devices for everybody, I'm thinking of anything delivering energy to the skin, whether it's light or radio frequency, anything that is intended to have a cosmetic benefit, right? And so I tend to take a very um firm stance on these, but I want to know from you. Million dollar question. Are there any devices that lift and tighten and have a facelift-like effect without doing a facelift?

SPEAKER_02 2:57

So I would say absolutely not. Okay. Yeah. I do agree with you. I didn't know what you were gonna say there. Okay. I do agree, I do agree with you there, where I don't think these devices are actually providing lift. I do think they can tighten, though. It just depends what device you're using, kind of, and also depends on what setting you're you're using and also the patients you're using them on. A lot of times I think people can overpromise what these devices can actually do. And then they see someone with significant laxity and they're like, hey, we're gonna get this really tight with this device. And then after two to three treatments, really no change happens, and then a lot of patients are like not really satisfied. So I think it's a messaging problem. Okay, but it's it's um it's it's not a lift, it's it's more of a tighten and it's more of the surface changes that I think you get.

SPEAKER_00 3:39

Well that could be confusing, right? Like the difference between lifting and tightening. What? Um, let's just get a little bit like uh I want two parts to this answer. Let's get the scientific answer and then the clinically meaningful part of what is tightening? What does that mean?

SPEAKER_02 3:53

So for a tightening perspective, you can think of it in layers. So I first think about the top layer of the epidermis or the skin. And from a tightening perspective, it's more of the ablative lasers that are creating small columns in the skin, and then it closes up and can tighten just a little bit. And then the second part is the dermis, where you have collagen, fibroblasts, and tightening, in my view, is that you're using heat or thermal damage, controlled wounding basically, to heat up the collagen, it denatures or it kind of breaks apart and then congeals or comes together, and then that kind of tightens the skin. So that's in my view, that's how skin tightening can work from a dermal or dermal collagen perspective and also the top layer of the skin.

SPEAKER_00 4:31

Gotcha. So what does that look like clinically for people then?

SPEAKER_02 4:34

So we're what you're looking for is just reducing the signs of like aging, wrinkling, softening those wrinkles like that you see on the face, primarily, you know, cheeks around the eyes and stuff like that.

SPEAKER_00 4:44

So it's like an envelope tightening down, basically. Correct. Yeah, exactly. And so this is where I think we get into the differentiation of lifting and tightening, right? Because even with old, I wouldn't I would argue with old school facelifts that are very focused on skin and subcutaneous tissue, let's call that the superficial envelope, that a lot of times those lifts that are actually kind of lifting that tissue and maybe tightening it in that sense of taking some of it away over a specific surface area, um, they still leave laxity in the deep tissue, which is we'll probably get into later, one of our probably the future targets of where facelifting procedures are going is it's tightening all the layers or lifting all the layers appropriately and in in unison instead of just tightening one layer and leaving another one going. I see that in revision facelifts all the time. Surface is tight, the deepest section is lax a little bit. So maybe that's a little bit of where we're getting confusion on uh some devices that do actually have a clinically meaningful benefit of tightening, uh, but that being promised as lifting that confusion. I don't know. What do you think about that?

SPEAKER_02 5:47

No, I agree. And I think there are different levels, right? So when I think about tightening, it's more the surface level changes, more like you know, the sub two, you know, two millimeters or so. And then the lifting is you have to do that from the bottom, bottom up, basically, the deeper structures and you have to lift because you see that with the old style facelifts when you just try to lift by just pulling the skin, that's when you result in all of like the stigmata facial surgery. You have the doweling, the deeper structures that are still falling down, you have the you know, the lateral sweep deformity, all those different stigmatas. It's because they're just pulling that skin too tight.

What Devices Work

SPEAKER_00 6:20

Yeah, it's interesting too, because as you say that, I'm thinking like, yeah, our current facelifting strategy is focused so deep that I still use laser routinely on the surface because I'm not focused on the surface at all. I'm focused on the deep structures of then devices are my answer to the surface tightening, like to changing the surface. I'm thinking of it qualitatively more than quantitatively, usually. Uh, and I'm thinking about elastin changes and things like that, which we'll talk about how we can use regenerative signaling to increase those things at some point. But I wanted to pick on this because everybody wants to know what devices work. You mentioned ablative lasers specifically for skin tightening, not for lifting, that's where the confusion lies, but for skin tightening, you mentioned ablate of lasers. Okay, let's run through this. Harvard-trained laser, knowing every device inside out that exists from punching holes in the skin to treating it with magical, superficial magic wand heat. What devices work?

SPEAKER_02 7:16

So ablade of lasers are by far the best device that you can use from a cosmetic standpoint, and kind of go back to your point from the tightening and lifting. So, all these energy-based devices, lasers, they're working pretty superficially, like, you know, four, three millimeters and up, and that's just more of the tightening effect. You're not going to get a good lift from these devices because they're not going deep enough. And you don't want to go deep enough because if they do, the all that heat is probably melting away your fat and causing all these different complications and problems. So think of devices, top layer of the skin, and then lifting from like a surgical perspective, pulling things up and moving things around. Um but back to your question. So a blade of lasers, yeah, by far. Um CO2 is more aggressive and stronger, I think, better than erbium. Erbium's great as well, but that's more surface level change, more like tone, sometimes pore, some texture. But if you want, if you have strong deep wrinkles, ablate of lasers, CO2s are the best that you can use. And then I know where you're going with this questioning. So I think everyone agrees that CO2 lasers and ablative lasers are very effective. I don't think anyone's going to really argue that. But it's where we get into these other energy-based devices. So the wave on our hands are there. Yeah, the radio frequency, micro needling, the um the ultrasound-based devices, microfocused, um, high frequency stuff like that. Um there's another device that was out called Elicor, it was more like basically similar to a bladder, but you're just taking columns of tissue without the thermal cuff. So punching holes in the skin. Yeah, punching holes in the skin. Taking those little, like, you know, the the when you if you gauf like the the whole microcore. Yeah, the micro cores. Um so I think we have to think about these devices and like what they're actually doing. Um I think historically, a lot of papers they focus too much on collagen. It's like, oh, they increase collagen, so that's like the benefit we're gonna get, but just like how much collagen, how is it organized, X, Y, and Z. There's other other things besides just collagen. Um patient selection is also really important for these devices because, like I said, it's like you can overpromise that this is gonna lift, this is gonna tight, this is gonna treat this type of you know, sign of aging, and it's it may not do something for this patient because a lot of times these patients will come in with like significant laxity, and they're like, hey, this is an ultrasound-based device that's supposed to improve or tighten tighten the skin, where it may, but I think these patients are too far gone where they're not gonna really notice a benefit despite having you know multiple four or five treatments. So that's that's one point. The second point where I think these devices actually will start to be utilized more is more for like prejuvenation and to to minimize the signs of aging before they actually occur. And so my my co-fellow and I last year wrote a paper that was published in Aslums. We're looking at, and we'll probably go into this more detail later about senescence and cellular senescence, it's a homework of aging. And because I'm I was a little obsessed with senescence, and I was trying to bridge these two fields together. And I um so we looked at all the data, all the literature, made it or we wrote a systematic review about every every paper that's been published with an energy-based device and their effect on senescence. Does it mention senescence and like how does it change senescence or whatever, or these biomarkers of aging? And every single paper show that from RF microneedling, ultrasound, Q-switch indie Agase lasers, uh 2790 ablative, some non-ablative stuff. And what that's doing is actually making an impact on cellular senescence. So it's reducing these biomarkers of aging. And what that what what occurs following that is like decreased inflammation down the road. And I think it's gonna actually decrease the rate of aging if you do these devices. So I would say maybe you're not gonna get that impactful wow factor that you get from a facelift or surgery, like immediate see. But over time, throughout the years, if you do these, like I'm not saying that's a problem right now, we don't know the protocol. Like, how long do those effects last for once this happens? So we need more research. But like the signal now is that it does affect senescence and it does reduce these cells that cause or that are associated with aging. And so if you can reduce these biomarkers of aging, the the implication is that you can reduce the rate that you're gonna be aging in the future. So yeah, so it's exciting, and I that's so that's where I think these devices are gonna be used more in the future. Um we just need need more information, basically.

Microneedling vs RF Microneedling

SPEAKER_00 11:37

I just learned something from you there, at least had a little thought paradigm shift because I've often answered these device questions. I had a confirmation bias and a paradigm shift, I'll say right there. Because I've always answered these device questions as to these are really good post-operative management strategies after we've done our procedure, we've got you to a new place, we've already blunted your aging curve moving forward just from the procedure and the regenerative aspects itself. But then now we're on your you know new curve forward, and our next way to blunt it is with device-based things, you know. Um, and my mindset with them has always been like if the device is intended for superficial use, if that is what the person firing that device is intending to do, they're not promising you lift, they're not promising you, you know, the moon and the stars, it's like we're gonna make the surface of your skin better. That's a great use for that device. The confirmation bias came in, like, oh, a mechanism as to like reducing cellular senescence. That's what's happening. That's why it's such a good maintenance strategy afterwards. My thought paradigm shift comes a pre-juvenation with it, right? Which I kind of know to some level. And the most common thing that I question I get is like, well, what should I use before surgery? And my usual answer is like, I would just not do anything leading into surgery if that would be my ideal world. There's two parts to that. One of them is just from a financial standpoint, is like I view that what I'm gonna do is so much more powerful than what the device kind of set me up for that I can kind of make up for what it would have done, number one. And then number two is the bigger deal, so many people that have been on the device train are so anatomically damaged in their deep structures when I do surgery, that it's uh it changes everything about their surgery and recovery. Any surgeon who says that these types of devices don't affect future surgical outcomes is not getting granular enough with it, that they're not detailed, they're not paying attention, or they just don't recognize it, right? The mechanisms and the anatomic and physiologic changes that happen, even at like the microvascular or lymphatic level, change the way that the surgery recovers. There's no question about it. So I tend to steer people away for that reason. But if it is a superficial, like I would say microneedling with your own growth factors, PRP, great option because I know there's no chance that that person's gonna do any damage, and it probably has some of the cellular senescence benefits. Which leads me to my question about okay, what about microneedling, which I'm you know a fan of, I guess, in that sense, versus like radio frequency microneedling. Yeah. What's the difference between these? What does it do? Um, and you know, is one more beneficial than the other?

SPEAKER_02 14:04

So uh so microneedling versus RF microneedling. Microneedles are just small little pins going into the skin, causing mechanical damage, no thermal damage at all, which I think is important. So usually when people are doing microneedling, you're not gonna notice any beneficial change for one, two, three, four. It's usually if you're doing like eight, twelve, twenty treatments of these microneedalines, that you can notice some benefit, but it's not gonna be anything substantial, in my view. I think you the heat is a critical component of treatment to cause like the hormetic effect that that stress-induced damage where you can elicit some beneficial change and adaptation. So that so that's what RF microneedling comes in. So it adds like this radio frequency, generate heat with the microneedling. So I think that's the key differentiator there. And in fellowship, we did do a lot of RF microneedling. There's a lot of different types of RF microneedling devices. Is it monopolar, bipolar, what frequency are you using? Like, you know, we can get into the weeds, but um it's just basically what depth are you generating that heat and how much heat are you um putting out? So, like how big is that coagulation cuff? So, and that kind of correlates to how much tightening you can get. And that goes back to the what patients should we be doing these treatments on? And during fellowship, there are some patients that didn't really notice much difference after one, two, three, but then there are some patients that did have a meaningful change from RF microneedling from a tightening perspective from their skin. It also can help pigmentation, skin quality, and I this all goes to the the controlled wounding, where if you're focusing on that dermal layer, in my view, the like to get off sciencey with with nerd out for a little bit, the fibroblasts is the main cell in the dermis. And I think that's like one of the main cells that are contributes or influences skin aging in general and also like the underlying structures. And there's a significant data that supports that. And so what these devices, I think, are doing back to the prejuvenation, is it's kind of reinvigorating these fibroblasts to become healthy again, reducing senescence, and that's that's re-establishing these cell communication structures because as cells get older, they get old, tired, they don't really want to communicate effectively. So the signals are like, you know, maybe one will go there, one will go one will go there, but it's not like a uh efficient highway system, basically. And so with these treatments, I think you're actually rejuvenating those cells to re-establish that communication. And that goes for like from the fibroblast to the top of the skin with the melanocytes, which is why you can get improvement with like sinile uh lentigenies or those like um uh dyschromia, melasma, stuff like that. Um, yeah.

How to Tell If Microneedling Is Done Well

SPEAKER_00 16:40

So I'm gonna ask you like a very practical pretend I'm you know kind of new in the space, and I'm a patient, basically asking you like, okay, so I heard there like radio frequency microneedling can be okay. Um microneedling, I get there, there's a difference between them. How, what, what do I look for in my radio frequency microneedling, or how do I not get in trouble? Because you mentioned that there's so many nuances to it. I'm showing up to the place on the corner. How do I know that this is gonna be okay? Because my personal bias, which is a sampling error of a lot of negative outcomes of radio frequency microneedling, is driven by I think a lot of what your answer is gonna be here. How do I not get in trouble with how do I get a benefit and not get in trouble with radio frequency micro?

SPEAKER_02 17:24

And so, yeah, this goes to the from a surgical perspective, like what you see, how much fibrosis is there? Is there a lot of scarring or not? It just depends on like depth of delivery of the energy, basically. And so usually you want to stay, you know, three millimeters and above, or just within the dermis. Like obviously that's dependent upon what area the face you're treating, because you want to change it based on that area. Um, so I would say that's one of the main points, just like the depth of treatment. Because if you're too deep, you can melt fat. If you're too superficial, you can burn the skin. And so an advantage that some of these companies um have come up with or like, you know, is these insulated needles where you can protect that top layer of the skin. So, you know, if you're an ethnic patient, you have darker skin types, you want to make sure you have an insulated micro needle or RF microneedle in device because that's when you can get scar and that's where you can get into some trouble, and it's like quite difficult to treat some of that hypopigmentation once that occurs.

SPEAKER_00 18:17

I feel like the insulated needles can give a false sense of security too and force people to go deeper. They can. Which is problematic. Yeah. Yeah. So I you know, I always kind of approach this with just like the mindset of the provider. You know, if their mindset is like superficial skin improvement, all the things you said it can do, which are totally in bounds and absolutely what it does, yes, do it. If they're promising you anything that has to do with like a non-surgical facelift, run, don't walk away.

SPEAKER_01 18:42

Yeah.

CO2 Lasers

SPEAKER_00 18:43

You know, that's that's sort of my mindset around it. I want to go back to you. You talked about uh ablative lasers. I'm gonna ask you the same question. You said that was seems to me like that's maybe the top of your hierarchy. I'm gonna still nail you down on a couple things with devices here, but same thing. Pretend I'm a patient, you know, early exploration figuring it out. Tell me about like, okay, what's a CO2 laser? Give me the nuances. What are the different types? What does that even mean? How do they get used? Like, give me the basics of ablative lasers.

SPEAKER_02 19:13

Yeah, okay. So basically a blade of lasers vaporizing the top layer of the um like columns of tissue in the skin. The chromophore for a blade of lasers, the wavelengths are different, but the CO2 is the one we most commonly use, 10 10, 600 nanometer wavelength, the targets water. So it's basically vaporizing this water really quickly, removing this tissue, and then around that vaporization channel is the coagulation cuff. Um, quick overview of like how they work. So when we're selecting a CO2 laser, it's like, what are we using it for? And it's usually for patients that have significant photo damage, um, you know, deep coarse wrinkles, think people that want to improve their texture, sometimes their tone, even though there are a little bit, there are some better lasers for a tone, in my view. What is tone? Or like um the color of their skin, like the pigmentation issues if there's like like darker browns, lighter browns, like you know, whiter beige areas. So just kind of homogenize the tone, help everything look um uh look look nice, basically. Um so basically, so wrinkles, coarse wrinkles if they're really deep, that kind of changes the way you operate the laser, what settings you want to use. I don't know how how nerdy you want me to get with these CO2 lasers, but you know, there's settings that you change, and that's why I think it's very important to go to people that are properly trained, especially with these devices, because you know, the other lasers, if you do like a non-ablative laser um that you can see at a med spa or something, they're usually not as aggressive, but some of these really aggressive lasers can completely disfigure people. Right. And I would say during my fellowship uh at Harvard last year, we or two years ago, we saw a lot of these cases where patients would come in from med spas and they would have like scarring disfigurement because people would just wouldn't they they didn't know how to use this laser appropriately. And it was quite sad, and you know, you do everything you can to help, but the best thing to do is just go to someone that knows what they're doing and then just prevent it from happening. Um but back to your question. So wrinkles are by far the best thing to do and just help restructure their skin exactly and like completely rejuvenate too, to be honest. And another benefit that people need to realize from the CO2 lasers is not just a cosmetic aesthetic benefit, it's the skin health um perspective and also like impacts on skin aging. And like I mentioned from a senescence standpoint, completely uh helps rejuvenate the skin from a senescence standpoint. It also reduces your risk of skin cancer. So there's and there's and the pathways or the mechanism to that is goes back to the senescence because, like, you know, quickly it's like you know, the dermal fibroblast gets really old, it can't send a signal to the skin above it, the keratinosite. And so that can't respond to sun or the UV damage. And so when the skin that cell can't respond appropriately to That UV damage, the mutations occur, and then skin cancer can happen. So once you do these CO2 lasers and kind of rejuvenate the skin, it reduces your risk of skin cancer down the road.

Fractional vs Continuous Lasers

SPEAKER_00 22:08

So yeah, it's been an interesting. We've always known that it did it, but it's defining the mechanisms as to how it's going to be. Exactly. What about a fractional CO2 versus a continuous CO2? And there's with all the devices, there's a million brand names, so we don't need to get into those, but one of the brand names has plays on this fractional aspect to it. So what does that mean? Fractional versus continuous? Yeah.

SPEAKER_02 22:29

So when CO2s first came out, um they were doing like a continuous or fully ablative uh uh procedure, which is the entire top of your skin is just gone. It's just gone. And they started like noticing problems with that. Uh primarily, you know, you would have patients that would have this porcelain white appearance and like just like really scarred, and the there's a kind of an interesting phenomenon how that occurs. It's because it was causing too much scar tissue, the skin couldn't heal really over it. Right. And so, like, you know, you have atrophic scars or any type of scars that can have like the red or the the white slash blue hue to it.

SPEAKER_00 23:03

Too much of a good thing.

SPEAKER_02 23:04

Yeah, too much of a good thing. So they were just taking off that whole entire top layer of skin. And then they're like, well, this is a problem. Maybe we should try to innovate. And at my fellowship with Dr. Um Anderson and um Dieter, what they came up with this fractional type of technology where instead of doing the entire skin, they're just poking like just little small channels within within the skin and deliver that treatment. And it was wildly successful, wildly um effective. The complication rate went down. And so that's primarily what's used today.

Top Devices Ranked

SPEAKER_00 23:35

Back to like the area in the lawn, you know, the micro um thermal zones. You know the story about how Dr. Anderson thought of it. Actually, uh reading a newspaper and noticing that the print on the newspaper was a bunch of pixels. Yeah. Like that made the actual letters, like looking really close and being like, oh shoot, at like the close level, it's pixels. At the faraway level, it looks like a complete letter. That was sort of the original idea for fractionation from the wow, that's interesting. I need to I need to I need to reach out to him after the question. Tell me about how the idea with the inception. The legend stats story right there. Um, Dr. Kelm, I'm gonna nail you down. Harvard Fellowship trained, mixing that with facial plastic surgery. What are your top devices?

SPEAKER_02 24:19

Okay, in order, top devices. One, CO2 laser, two, erbium laser, two ablative lasers, three is a 1927, and four would be a 1550 nanometer laser. Those are both fractional non-ablative lasers.

unknown 24:35

Okay.

SPEAKER_02 24:37

Five would be a pulse style laser, vascular. Six would be a 532 nanometer laser. This is pigment and vascular. Then I would go seven, maybe an IPL, pretty good at most stuff, so you can use it for a lot of different things. Eight, I would go with picosecond lasers, good for tattoos, good for some skid rejuvenation. And then nine would be radio radio frequency type devices, ten would be ultrasound. Nice.

Light Devices vs Lasers

SPEAKER_00 25:04

Yeah, very nice hierarchy there. Um and that goes from efficacy to maybe maybe negative effects to no effects, in my opinion. Yeah. I like that spectrum. You mentioned um IPL, a light-based device. So tell me, just give me a little rundown from an expert um perspective here on light-based devices versus lasers. What are the differences between these?

SPEAKER_02 25:28

Okay. So lasers um typically just have one wavelength of light. By definition. That's an acronym. Yep, that's an acronym. Laser amplification stimulated. Light amplification stimulated mission regardless. Yeah, yeah. I didn't really do the fellowship. So uh and then IPLs, intense bolts light. Um you can it's been branded as like BBLs or broad base light, stuff like that. Those are just multiple wavelengths that that are used from a filter. Or the it it's a basically the flash lamp that sends out a big pump of energy for light, and then there's filters that filter out the wavelengths that you don't uh do not want. So anything above that filter cutoff point sends out uh um those wavelengths to the skin. So in doing so, the IPL can be good at a lot or pretty good at some things, like you know, pigments, some reds, but it's really not the best for anything, in my opinion. There's I think it's more effective to use a laser with the wavelength that you want to use that targets a chromophore that you want to target. So it's but you know, I understand because practices are just starting out like you know, capital limitations, X, Y, and Z. So it's more useful and you could probably utilize it a little bit more, but in my view, it's the lasers out.

SPEAKER_00 26:41

The answer to my question is why we see so many IPLs, BBLs. Why do we see so many? Yeah.

SPEAKER_02 26:46

Because the capital requirements for to have so many different lasers to address one specific problem is a little bit um restrictive to most practices. Yeah. But and that's why you you see these practices start off with like just a V beam, because I can tackle most red stuff, and then they'll like, you know, they'll get another laser, a fractal, then as they progress, as they develop, as they you know, bring in more revenue, they'll get, you know, bring on a new laser. Yeah. But then other practices where if they want to, if they're concerned about what other devices they're getting, they'll just get an IPL, you know, can tackle some reds, some browns, but you have to be careful though, because with have with having such a broad range of wavelengths, you're you're also hitting those other chromophores or those other targets. Yeah. So you can cause side, yeah, you can like cause side effects, adverse effects, you can scar people. And that's why you see those. I think it's one of the most heavily um like litigated devices is because of the scarring and what's going on, like some of these med spots. And that's you see these photos on social media where you have these like you know, these footprintings of of of these rectangles on these patients, and it's it's it's sad because they don't know what they're doing.

SPEAKER_00 27:50

But yeah, one of your fellowship directors outlined that he was an MD and a JD. Yeah, and he didn't have Dr. Matt Avram. Dr. Matt Avram. Yes. Um, also a UCLA fellow, like I was. Um we share a fellowship there. Um, but yeah, he you know looked at that and it it's the it's a recipe for disaster. It's a laser that a lot of new clinics get because of what you said, like it kind of does everything. So they're like, great, one laser to do everything, but they also have no idea what they're doing with it. And this is one of my big cautions to patients. There's this miraculous effect that whatever clinic you go to, what you have is perfect for the laser that they have or the device that they have. It's this miraculous phenomenon. And so one of my pieces of advice to patients is like, look at what they actually have. Like a practice like ours has multiple options. You know, we have options for red and brown and tattoos and resurfacing. Like we have multiple things to choose from, non-ablative fractionals, ablative fractionals. So, truly, when I make my laser cocktail, I can kind of choose. Like, I have a strong base that I like in my cocktail, but um, I can I can make it whatever I want. Um, and interestingly, my strong base gets into the other part of the thing is like you and you hinted at this earlier, which is like something like a fractional CO2 is a high capability laser. This thing is not idiot proof, or it shouldn't be in the way that it's used. And things that I see with it, I view this as like a fighter jet. Like you don't just put some random, even pilot in a fighter jet. You that's dangerous, right? Or I always talk about like putting grandpa in a formula one car. It's not, it's like that that's you know, number one, he's probably just gonna drive it slow, not do much with it anyway. Because when I see a lot of people doing getting CO2 laser, like I hear this in console. Oh, I had a CO2 recently, instantaneously. Okay, cool. What type of anesthesia did you have? Oh, topical? Okay, great. Grandpa drove the Formula One car at 10 miles an hour, right? Um, he didn't do what it was like the laser did not do what it was capable of. If you had two days of redness, local, you know, topical anesthesia, like it's yes, you had a CO2, but you didn't have it doing what it can do. And so there's a lot of nuance that goes into the devices and choosing, you know, like getting a CO2 is not equal across all spectrums.

Downtime From Lasers

SPEAKER_02 30:02

I it's funny you say that because I just had a patient uh yesterday or during a console talk to me about, oh I was like, what have you done before? CO2. And I was like, okay, let me let's go into the the details of that. I was like, because I because I brought up numbing. I was like, yeah, I have to inject the numbing and another shout to Mount Avram, because during fellowship, I would have to numb all the patients' patients, patient, all the patients' faces, and I hated it because it's like I was doing all the part that sucked for the patient. And so I talked to them because it's it's if you're using the CO2 appropriately, it can go really deep, dense, you know, it's it's painful. And so when I was talking to this patient, she's like, topical numbing. And I was like, okay, that's odd. And then how long was your downtime? She said three days downtime. I was like, okay, so it wasn't that aggressive. So I was, you know, you have to kind of guide them, instruct them that this is gonna be a lot different. This experience is gonna be a lot different than it was for that previous CO2. Um, but the effects were gonna be much better. Right. Yeah.

SPEAKER_00 30:56

So let's talk about downtime from lasers because that you're right. Like you can, like those of us that are masters with the device can kind of almost tailor the downtime to what the patient has available, which is I don't really do that to be honest. Like, there's been a few situations where they're like, I have five days and I got to be back on camera or something like that. It's like, okay, well, I can tailor it to that, but you're not gonna get optimal results. Most of the time, my patients are seeking optimal results from the device and they're usually having surgery at the same time. So the downtime lumps beautifully together. But let's talk about downtime from lasers and can it be decoupled or can it be optimized? Because you know, you're talking about a controlled wounding effect. We also have a wound healing cascade or wound healing phases that we have to go through. What should downtime from your laser, let's talk about a fractional ablative laser, what should it look like and how can we make it better? I guess there's two big points to that.

SPEAKER_02 31:47

The downtime from a CO2 laser, what that looks like, day one and two, swelling is typically the greatest. You have a lot of oozing or the serous fluid that can come out from those channels that you create with the ablative laser. You're red, it's pain is tolerable typically afterwards. Um day three, four, you can start developing all these microcrusts or we call like peppering of the face. And that's why it's why it's really important for you to uh follow some of the recommendations that whoever did the CO2 should be giving you in terms of how to minimize that because you don't want to, you know, rub them, don't scrub them, you want to make sure you try to prevent them from even happening. Um, and then by day six to seven, those typically fall off and you have a you know faint redness, faint pinkness. And then over day seven and ten to maybe a few weeks, it just depends on the settings, but the the pink typically fades. Um, but this goes into the the what who's operating the laser and like how aggressive do they want to be. Because you know, if they're doing a really aggressive treatment where you know the depth's really deep, you know, two millimeters or so, the density's not as much, but you're still really deep, you're gonna be swollen in red for a long period of time. Yeah, yeah.

Aging and Cellular Senescence

SPEAKER_00 32:57

So let's uh I'm gonna transition that because you know, talking about healing from that is like talking about healing from surgery. And you sort of mentioned your uh obsession and fascination with um signaling molecules, cellular senescence, cell like uh controlled wounding, which really gets into I think how we both approach surgical recovery as well. So I'm I'm wanting a little education from here, from you here. Nerd out on me for a second and talk about not just laser, but I want that that you know lens on it. Injury, cellular signaling and senescence, and how that process can lead to a long-term blunting of our aging curve, whether it's with laser or whether it's postoperative, how does that cellular senescence change? You mentioned it with skin cancer. How does that affect? Because I talk about this all the time. After your surgery, not only are you in a better place, but you're gonna age better. Give me the mechanisms of that.

Can Devices Impact Cellular Senescence?

SPEAKER_02 33:57

Okay, so um, big topic. Get nerdy. Yeah, trying to figure out how to distill this down uh in a a few a few minutes. So cellular senescence is basically a state of cell cycle arrest while the cells are still metabolically active, meaning that they don't uh replicate, they just linger around, they stay around when they shouldn't, and they just sit there. And the metabolically active means they're just releasing these pro-inflammatory satochines, these inflammatory signaling. It's called zombie cells. Yeah, the zombie cells. So it's called the SASP, senescence associated secretory phenotype. And that um causes a lot of problems. And in my view, it's one of the major causes of something called inflammaging or like you know this chronic low-grade inflammation that people get as they get older. And that's associated with so many comorbidities from a skin perspective. You know, when your skin's really inflamed, psoriasis, uh, atopic dermatitis, these things are associated with other diseases like cardiovascular disease. And I think from an aging perspective, when you have all these senescent cells that are causing this chronic inflammation, that's also why the skin aging is associated with some of these other comorbidities, uh, chronic um uh cardiovascular disease. And there's actually pretty interesting studies that have looked at in mice where they transplant senescent cells in young mice, and it causes distal organ dysfunction. And uh, you know, I'm gonna do a post on this later, but it's like you're like, what? Distal organ dysfunction in a young mice because of senescent cells transplantation in there. And the distal organ functions like liver, the muscle, the hippocampus uh was affected as well. Yeah. There's yeah, increased frailty, the grip strength was reduced. And it wasn't just like nearby skin that got old as well. It was like these distant organs, and it's like, okay, so this after like obviously is a signal that these senescent cells are playing a big impact, right? And so kind of going back to these devices of like how what are they doing, it's like, what if these devices are actually making an impact on senescence and it's actually changing the trajectory of these other diseases? You know, these are just more a big hypothetical question. And like this is not feasible, but you know, what if like, you know, if you're aging, when when you age, you get your skin is the largest organ in your body. Sure. And as you age, you get more senescent cells in your skin. And so I think that's one of the main contributors of inflammation and also the circulatory pro-inflammatory milieu that's going around circulating all throughout your body, affecting all the other organs, especially your skin is getting insulted daily by um the sun, pollution, microplastics, you know, you name it. So I just like thought, I was like, you know, just you know, proof of concept experiment. So what if you you could do a full body treatment of, say, like a fractional or a CO2 or something like that, and you can drastically improve skin aging in general, would that have an effect on you know, distant organ dysfunction, distant organ aging even? And you know, maybe it was just like a kind of a thought experiment.

SPEAKER_00 36:56

Aaron Powell Is there any evidence on any devices affecting cellular senescence?

SPEAKER_02 37:01

Yeah. So that's the paper that we wrote when we looked at all those different devices, how that impacts cellular senescence. And yeah, every single one had an impact, like the CO2 lasers, uh 2710 ablative lasers, non-ablative lasers, the night uh the 1550. And that's kind of a side note, and that's a lot of the some research came out of Harvard about looking at people that had non-ablative lasers and even a V beam, like the pulse dye uh pulse dye laser, and there was a reduction of reduction in future development of skin cancer for those. And that kind of goes back to the wounding. And then the next step would be I think it's because it's reducing senescence in the skin. Um Q-switch lasers, RF microneedling, ultrasound, they all kind of point to that same direction. What about IPL? Yeah, so IPL is actually another one that does affect senescence. And what's cool about IPL is that it's one of the only studies, or it's it is the only study that I can think of that actually they looked at the gene expression profile like after the IPL treatment, and it it restores like this useful gene expression that um um that that resembled more uh younger patients. So you're getting like this the skin health benefit, this aesthetic benefit, but or you're getting this aesthetic benefit, but you're also getting this skin health and it's changing these like gene expression patterns. So I think as things progress, as we like, you know, the the the cost of all these studies start to decrease, decrease, and people start utilizing these tests more, hopefully we have like a better understanding of how these devices work and can actually impact skin aging. And you know, like my ultimate goal, kind of how I started on this quest of like my obsession with you know regenerative medicine, kind of these technologies was, you know, I I guess you can go all the way back to my medical school interview, actually. Um, you you prepare for those interviews, right? You're like, okay, what can I talk about? And then I remember watching this TED Talk, uh his name's like Anthony Adala or something, and he talks about 3D bioprinting uh kidneys. And I was like, holy crap, like you can do that. And then just kind of started this cascade where in medical school residency, I paid attention to like these innovations that there's like you just they're very intriguing. And then, you know, like started getting to the hallmarks of aging, like, oh, can we reverse aging? Or first, can we can we um like delay it or then or can we stop aging and then can we reverse aging? And then this kind of got me on this quest of, oh, can I do that for the skin? Yeah, and then that's why I kind of started all this whole technologies that are coming up are really exciting, actually.

Surgical Practice Tie-Ins

SPEAKER_00 39:39

And that innovative mindset is why I love you, why I wouldn't pick you for medical school, just like I picked you for fellowship, honestly. Um, I knew that then. And that carries into part of my next question is okay, so now we've established this like your dream in medical school, can we reverse, can we slow, stop, or reverse aging in the skin? The answer is yes. We've shown that through gene expression and through like cellular senescence. Okay, so here's our next step. You're a surgeon. This is what you do now. You use devices as a supplement to your main practice, basically. How can we apply that same innovative mindset to our surgical practice? Can we plan and execute our surgical procedures in a way that is not only immediately um improving their baseline, but also has these changes to their long-term cellular signaling, cellular senescence, gene expression. Can we extrapolate any of that information to our surgical practice?

Red Light and Other Recovery Tools

SPEAKER_02 40:34

Yeah, definitely. And I think that's why I think this you know relationship works out so well and like perfectly, because I was like, oh wow, this fellowship director has this weird obsession with you know regidive medicine and like longevity-based stuff and like biohacking like I do is like super cool. And so, and that's what we talk about in the OR all the time. Um, it and this also kind of plays into a recent paper that we just wrote. The um we're talking about like what is the best ways we can optimize a patient before surgery and after surgery. Because, you know, I think traditionally or you know, historically, uh, you know, technical execution has been the the only thing that people have cared about, which you know that's the the most important part, but like they're just forgetting the pre and post of the whole recovery standpoint. So to answer your question, I think we can definitely use some of these regenerative principles and these modalities to help improve our recovery and improve our results from a um surgical perspective. Um some devices that we've talked about, even going back to light-based devices, like photobiomodulation, like red light, infrared light, how do we utilize that like perioperatively to improve patients' outcomes, basically? And even intra-operatively. So, you know, there's there's evidence that when you when you use photobiomodulation, like see say post-blephoroplasty, post um CO2 laser, using that photobiomodulation, like using red light reduces the duration of those um uh reduces the duration of the like the side the side effects or the like what you can expect from the surgery or from the um laser, meaning reduces the redness, uh, how or how long the erythema lasts, it reduces the risk of um post-inflammatory hyperpigmentation or PIH, um, reduces bruising. And you know, there's that doesn't even go into the like this is just recovery. Like, if you wanted to go look into the literature of like how does it even improve skin aging in general, right? From like collagen, elastin, the skin quality, skin health metrics, for sure. Hair. Like you can you can go into so many different avenues of photobiomodulation. It's like these, because and now we're starting to understand why and how that happens. So it's like it's it's powerful now that we have the, oh, we see it in effect, and then now we understand the why.

SPEAKER_00 42:44

Yeah, lots of grade 1A evidence for um photobiomodulation, which is actually a great example of, I think, something that we both adhere to a lot, which is that uh sometimes it takes the literature a decade or two to catch up to what we're seeing in clinical practice. Funny story about that. Um, I carried a similar curiosity into my training uh of like innovative and progressive thinking. And um I was very keen on photobiomodulation, red light, near infrared light in my for my athletic background, honestly, knowing without question that it improved athletic recovery and that application for whether it was muscle soreness, whatever it may be. And when I got into, you know, looking into like now I'm in my sub specialty and subspecialty training, and you know, photobiomodulation is kind of like making its first little splash in skin-based things. And it got its first little nod at a conference, and one of the Harvard guys poo-pooed it. Really? Yeah, poo-pooed it and said, it's pseudoscience, it's junk science, it's not real. Um, and that crushed it for a while, interestingly. This is like right before I started training. And um, it the guy was persistent who had all these in hindsight really great studies and kept at it and then eventually kind of broke through. Again, but it got, I think it's a just a big interesting thing that like one big thought leader in the field could skew everybody so much to be ignoring this thing that now we know a decade later, two decades later, has like boom, caught up. No question about it. High great evidence of how beneficial it is, but it got stifled for a while because of a key opinion leader. Um, and you know, in the same sort of like we know it's beneficial, we know it. Um, it probably has all these other benefits that are being studied and there's positive literature behind it, but it gets crushed, takes a while to catch up, and now we're back, and like, oh wow, that's really, really, really, really, really helpful on the bottom. Like, to the sense it's like probably bad for you not to get it, yeah, you know, on the other end of the spectrum a little bit. So uh kind of a funny little tie-in to that. But I think that there's a lot of aspects of our practices that, you know, kind of get into that, like probably a little bit ahead of the curve. Um, and but doing so in a safe, reasonable, and uh honestly very mechanistically driven way. There's either a very plausible mechanism, there's strong animal data. I mean, for example, we're using red light to treat our stem cell-rich fat before transfer. Yep. Are there any human studies that show any benefit in that?

SPEAKER_02 45:12

Uh not human. I think it's primarily all animal data.

SPEAKER_00 45:15

So but it's like, okay, so we know that the mesenchymal stem cells respond positively to this red and near-infrared light in vitro in animal studies. And it's so simple to do, and it's not causing any harm. So something we're applying in our practice and and the literature will catch up at some point over time, right? Yeah. One of our one of our multiple interoperative uses for red light.

SPEAKER_02 45:41

Yeah. And like in my view, I think, you know, people like ask, you know, is this regenerative medicine stuff all fat? Is it just a trend? Is it just all gimmicky? And like certainly some of it is, but I think you have to be able to look at the literature and distill it down. And like for me, the way I kind of practice of like one, it's just like it can't be, you know, it can't be like detrimental to the patient, like I said, a neutral or positive, right? So like the worst case, it doesn't do anything, but sure it could work, and I don't want to wait for 20, 30, 40 years, or it it maybe they won't even like ever do it, right? And so it's like I think it's for me, is like this regenerative stuff that we're doing, is this is the is the like the clinical translation and um like implementation of these mechanisms, like these mechanistic justifications that we see all over the literature. It's not just like one study, it's multiple different studies corroborating each other. And then you can see, okay, it cell data, then animal data, and then there's clinical evidence out there too. I mean, this it may not be the most robust, you know, randomized controlled trial, but there are definitely signals there. And I'm not I I don't think we should wait for the signal to like do some of these things for like a red light, you know, all these other recovery modalities that we that we're using. But but those also have substantial evidence behind that. Right.

SPEAKER_00 46:55

And I've seen that evidence build over the decades too, for from since I've been using them to now. Like, yes, I've known this the whole time, I've been screaming this from the hilltops, and then the evidence starts to do a little bit.

SPEAKER_02 47:06

You know, if there's one study that like negates it or doesn't support that data, they people just try to cling on to one piece of information with like completely disregarding everything else. Yeah. And so I think it's important like kind of evaluate everything in totality, right? And then, you know, some people that don't agree with it now or don't really, it's one I think they just haven't really looked. I don't and and usually by looking, it's limited to clinical stuff, which usually is the most impactful and important. But I think you're missing a lot of other useful information in terms of like, you know, sell like in vitro animal data, because that's how that's what kind of gets there, gets you to the human stuff. So, like, how about we understand, like, is this stuff working to see if it's gonna work on humans, right? And eventually I think these people come around once they understand more of the basic science, more of the animal model stuff, more of the mechanism justifications, the thing they come around. And like it's what you said about the the photobiom modulation, like the Harvard guy, I don't know who it is, but I will say, like, at so the the lab at Harvard for what associated with the um the dermatology department is uh called the Wellman Center of Photomedicine. And that there's a lot of research going on with photobiomodulation, and a lot of stuff comes out of there with red light therapy. And I remember uh so my previous one of my pre previous fellowship directors, Dr. Anderson Rox, we call him, who basically invented everything on the planet from uh cosmetic standpoint. But anyway, we used to have these sessions, and my co-fellow uh Morgan was uh preparing for the marathon. And he was like, what you should do is just photobomb modulate all of like your legs with you know red light, you have to get five joules per centimeter squared, and it's gonna increase your efficiency, it's gonna reduce your time for the marathon. I was like, damn it. I should have thought about that before I uh before I ran my marathon, like the year or two before. Um, but it's just like to your point where like, you know, some some people if they don't believe, but it comes around used with further evidence, and there's like like real use cases for this technology, and people like people are utilizing it, you know. So quick tip if you're gonna run a marathon, use some photobomb modulation. Absolutely.

SPEAKER_00 49:05

That's that was what drove me to it originally using it as an athlete in the past. And it's funny with this, like our drive to practice evidence-based medicine, what is beat into us quite literally. Um, I think that gets confused with evidence-based medicine being solely randomized controlled trials and not looking at more granular, um, trying to like find the essence of what's in a lot of studies, or you know, because like you talked about, like someone finds one non-superiority study and that's all they talk about, even though there's a bunch of other ones that show a benefit or trending or whatever, and there's just the one that said, oh, there was no difference between these two. Yeah, well, you're looking at like a three-point scale and something that's like, you know, like uncomprehensibly nuanced, basically.

SPEAKER_02 49:46

Um, and so the other's complaining, lack of evidence for a lack of uh efficacy.

Psychotropics

SPEAKER_00 49:52

Yep, exactly, which is rampant, you know, in my opinion. But on the other end, is like being safe about it, right? Because we both we're kind of talking about this offline, we both live in this um wellness and longevity space with that mindset where we're using that uh clearly to optimize our patients and their recovery, but also ourselves going into surgery. And this was a funny offline conversation that we just had a second ago about psychedelics, which falls into this, like maybe a potential benefit to your cognition and psychiatric state and emotional health and things like that. Um, but then there's also this other darker side that could be a detriment, even though it's a small chance of it, it's a detriment. And, you know, I will openly say that I have never done a psychedelic, I've not done a psychotropic, I've not been on a journey, I've not done ayahuasca or 5MML DMT or psilocybin or even marijuana. Like I've never smoked weed in my life. Um and you know, there's but there's this other like curious part of me, which I think is just one of my traits of being very curious, that like sees all of these, like I've talked to a lot of friends, even who are like, this is the most incredible thing I've ever done. This like journey changed my life. And so I'm like, should I do that? But then I think like, if I'm a patient, yeah, do I want my surgeon on psychedelic journeys? Probably not. And then I was telling you about this one Alaska Airlines pilot, very famous case where he did psilocybin, mushrooms, two days prior, gets on a flight, they're long gone. He's sitting in the jump seat of this flight in the in the cockpit, and then he has this break basically, and he like tries to take the plane down, like cut the engines, blow them out from a fire thing, basically, you know, be death to all the passengers. And they rescued it and whatever, and it turns out that yeah, he had done mushrooms a couple days prior and a couple days prior and broke. And I'm like, yeah, that really reinforced me. Like, yep, nope, not doing that, you know, not my thing a little bit, but it I thought that was an interesting like tie-in to this like a potential for harm. Even though there's this very curious, like sexy, interesting, like, oh, I wonder if that would be beneficial. I know that there's a mechanism of harm, and so I won't do it. And I apply that to my how I treat my patients too. Like, I know that treating their fat with red light does not have that potential for harm to that degree. So, you know, an interesting mindset with that.

SPEAKER_02 52:07

I think the research around them has been stifled, definitely, with over the past decades. But and hopefully that's changing. Um with RFKs, making some changes, allowing hopefully allowing some studies to move forward. Um, because there is significant data and support that some of these medications are really effective for depression and like PTSD trauma, like you know, military, police, like all these people that are you know like just left for the wayside and just have to go deal with their, you know, they're taking all these SSRIs. And I would I would do a uh like psychoactive over an SSRI every day, any day. Yeah. So I think, you know, certainly I wouldn't want like you know, my surgeon or my doctor to be doing these like actively during or you know, maybe like during before apparently too, they that that is a little unusual, I will say. Um but uh but you know, what if your surgeon is going through something or like depressed or has some trauma that they can think about? I think there it could be effective in certain situations.

SPEAKER_00 53:01

So yeah, that's not my situation. I just think I mean honestly, it's like there's this strong curious draw to them because I've heard so much positive feedback. And there's certainly evidence to back it up. No question about that, too. Trevor Burrus, Jr. Yeah.

SPEAKER_02 53:14

There was actually a paper back to my whole cell senescence, like a weirdly obsession, uh, that psilocybin uh can extend, I think it was median lifespan in mice and reduces cellular senescence. And so you're like, okay, interesting. And then you have these people that are doing like in of one studies where you know Brian Johnson famously just did a you know five grams or something, like a heroic dose of psilocybin, and they they were like, you know, they did all these metrics and testing, like biomarkers and stuff. And it was, it was um, it was very like impactful for him, like and also this the effects that it had from like a neuroplasticity standpoint, inflammation, things like that. So I think there's definitely things that we don't know about this, and there I think it should be investigated. I think it's maybe a new frontier.

The Surfer’s Mindset

SPEAKER_00 54:01

You're just highlighting all the curious, sexy things I'm talking about. Yeah. So still not gonna do it. We should do it. Still not gonna do it. We gotta go, guys. We gotta do it. Oh, yeah, right, right. Um, well, and you know, this it's this is a fun like kind of banter because again, highlighting the mindset of trying to be at our best for various things. And um you at one point, I kind of like asked you a little bit about your mindset. I really put you on the spot, actually. And you gave me one of the coolest, slash, best, slash, most impactful, resonating answers I've ever heard. And it was just like about your mindset around surgery. And uh, somebody who grew up in Hawaii and you like tied this in together for me with this like surfers mindset. Yeah.

SPEAKER_02 54:44

Will you elaborate? Surfers, the surfer's mentality.

SPEAKER_00 54:47

The surfers mentality. Will you elaborate on that for me and how that plays into your um surgical mindset? Yeah.

SPEAKER_02 54:53

Um the way I like to think about it is how it's like positioning positioning yourself for opportunities. And in this analogy, opportunities are waves. And growing up in Hawaii, I was born in Hawaii, my dad's side of the family lives there. Um, I surf frequently. I love it. It's I find so much enjoyment with it. And when you're out there, it's you know, wait, sometimes waves can be few and far between. Sometimes the sets are rolling in, sometimes they're not, sometimes they're just a lot of waiting. But when you're on the wave, you're you're really enjoying the moment. You're really like that's the only thing you're focused on. You're like kind of in a flow state, really. But you have to be adaptable and you have to like adapt to these moving obstacles, right? These people that may be in front of you, the reef break, the wave itself, is it gonna close out on you? So you need to be prepared and just know how to adapt to those certain circumstances. But then when you get off the wave, you paddle back out, and you have to think, oh, there's there's always gonna be another opportunity coming. Even this wave is over, there's gonna be another opportunities that are that will come. And it's what you do in that interim between that with the first wave you were just on to the next wave that's most important. It's just how you position yourself. Um and it's you know, it's it teaches you a lot about patience, it teaches a lot about like positioning, uh, like strategy, uh, and just knowing that next wave will come. So I it's and I want I I bring that into surgical practice because you're doing the surgery, and obviously that's really important, but like it's the time, the effort, the dedication that you put into it before that surgery, before the operation. It's like not even just knowing all the anatomy, knowing the technical skill, what to do every single step, and specif specifically every single step for that one patient, like looking at the patient before and after photos. It's just all the time and effort that goes into it. And I think that's what gives you the good result and that allows you to enjoy the ride once you're actually on the wave.

SPEAKER_00 56:43

Yep.

SPEAKER_02 56:44

Yeah.

Co-Writen Paper

SPEAKER_00 56:44

Yeah, even with all that preparation, you never know exactly what the wave's gonna look like, no matter how technically skilled you are. Yeah. I've thought about this since then too, and sort of at my level, at a level of mastery, but still striving to be better. Yeah, I was thinking about that service knowledge because I love to surf as well, and thinking about like, yeah, like at my level of mastery, it's really like that now I can read the waves better. And I have all the technical skill and I'm still building that and I love that. Um, and you know, learning new tricks basically. But like when it comes to reading the waves and understanding, I've sort of been there, done that with a lot of things. I get better at sensing when the wave's gonna bowl, when it's gonna barrel, when it's gonna flatten out, when I need to kick out. I've been through all the punishments. I've had the hold downs, I've had the beatings, I've been stuck on the inside, if you will. Um, I know when to paddle out quickly and when I can relax in that paddle. And most importantly, I know where to be and how to be positioned to get in for me my flow state, which is uh I don't think people think about that. So that I think that's when you first told me about your you know surfers mentality and getting in flow state, I was like, Oh, people don't think surgeons don't think about that. You know, maybe they get in it, uh especially more seasoned surgeons, but uh most of the time I think people are like showing up and being like, Are there waves today? What I got going on? Oh, you know, they're not like prepared, they're not, you know, reading the waves as they come in, they're just kind of like riding whatever comes, you know. Um so I really loved that mentality and I've thought a lot about it since then. Um and you know, I think that that plays into the you mentioned this paper that we wrote too, right? Which is gonna be one of the first of its kind, if not the first of its kind in surgical literature that is heavily focused on um surgical preparation and recovery, but at a different level, talking about modalities, peptides, supplements, things that are like hand-wavy and taboo, even to talk about um at the current moment, talking about peptides as a taboo subject, you know, um, but helpful for surgical recovery, right? So, how did we had to navigate this very interesting landscape, even with our colleagues, our like high-level other apex colleagues in this about like we kind of know what they think about some of these things. Um, and some of them are involved in other writing other chapters for this too. And so it's like really massaging this mindset and focusing on the data, positive and negative and neutral, um, about all of these recovery modalities and what they do. But then my negotiation with this when I was like, yes, I'll write this, but you know, it was like a given a day, a little horse trading. Like, I want to write about preparation too. I call it pre-covery. Um, and that was like, well, what are you gonna write about there? Sort of like, oh, don't don't you worry. You know, I got all we got all the things. And so it was fun writing that chapter and getting into it. Of course, I feel like we could have written a book on it and we ended up writing a chapter, right? Um, and you know, I guess getting into that a little bit, what were what are some of your like highlights and favorite parts of that chapter?

SPEAKER_02 59:35

Yeah. So kind of back to your uh we could have wrote uh written a book about it. We definitely could have, because I'm pretty sure the word count was almost double than what the uh recommended guidance was. So guidance, it was you know, all the references. And the references were higher too. The references were a lot. Because, like you said, you know, we have some of these colleagues at you know, Apex top of their fields and very intelligent, very smart, very technically skilled, but you know, maybe they don't have the time to go do the deep dive into the basic science, into the animal models and stuff like that. And so hopefully my goal is to uh hopefully educate with this and like give them some of that background information that shows like, hey, this is mechanism mechanistically justified. And also what does the evidence say from like clinical perspectives of like you know, case series and stuff. So I think hopefully after they read this, they'll maybe they'll come around. But it may take some more convincing on our end when we uh when we talk to them. But uh some key highlights I think from the paper. Um so you know, I think historically I think we start I started the paper, we started the paper with like the era of rest and weight is dead. Yeah, right and weight rest and weight. And so I guess maybe a little brief background. You know, before the like around the 1990s, like people had mandatory bed rest, like you know, uh prolonged fasting before like delayed feeding fat uh after heavy on opioid use, and like people started to realize that a lot of these complications or uh issues post-operatively were due to some of these recommendations. And so like post-1990s, some guy, I think it was like a um like a like a colon surgeon or something, a colorectal surgeon, uh, but he started to like appreciate that like the surgical stress response was actually driving some of these issues that people were having. And that eventually led into this like ERAS or like um enhanced recovery after surgery protocols that's kind of being uh utilized today.

SPEAKER_00 1:01:22

And that's like the first generation, 1.0 of where we were at. Yeah.

SPEAKER_02 1:01:26

ERAS. And that's and that's just very basic stuff. It's like maybe we should get them walking after surgery, don't do bed rests after so long. Maybe we should feed them and not have them being like, you know, in the starvation state and like a catabolic state so long after surgery. Yeah, like how but we don't pump them with so many opioids and so they're getting the constipation, like dependence, all these different issues. So, like, how can we control pain and other mechanisms, right? What about temperature control, glycemic control? So that's like, yeah, step one. So this paper, and I think what we're kind of morphing or trans like transitioning into is the next stage, right? A more advanced stage. So pre-90s, it was like, you know, basically just lay in bed, don't do anything. That's the true, true, true recipe. Yeah, yeah, yeah. And then like right after that, it's like some changes, but now we're actually utilizing technology and our understanding of like fundamental biological mechanisms to how do we engineer the perioperative period for patients to optimize them so that they're in their best high performance state before surgery. Because like people, you know, surgery is like, you know, oh, I have surgery this day, but it's actually like a huge you know, life event if you didn't know this. Like you should be preparing for surgery like a marathon, and then afterwards you should be recovering like a marathon. Like it's a it's a huge physical stressor, right? Um so I I digress. But the main points of our paper is I think um recovery is a modifiable state, for sure. Right. So and to go back to we started the paper with the era of rest and weight is dead because it is, it's transforming. And that's transforming too from like a we say like you know, passive observation to more active optimization now. And that goes pre and post because you know, before for like a pre-operative, you know, you go and have surgery today, you you know, you may get some labs, you may get an EKG, they may ask you some questions like do you smoke, do you have COPD? Do you have heart issues? Like they're asking these questions to figure out are you healthy enough for surgery? Are you gonna die? Yeah, are you gonna die? Like can I do the surgery and you not die, basically. Yeah, and that's which is better than not, dude. Yeah, yeah. But that's the wrong question. Yeah. So I think and that that question hopefully now will become is how can we optimize this patient prior to surgery and get them in the most like high performance state so that they can recover faster and hopefully you know have better outcomes. And so that's the pre-covery pre-covery part. The post-covery part or the post-operative part, that we're now using all these regenerative medicine, kind of these longevity-based uh like devices, protocols, supplements, and that's to help accelerate uh wound healing and improve your uh recovery. And there's substantial and significant data that these things like our protocol that you developed makes meaningful changes into how these patients can heal. So um big points, recovery is a modifiable state. You should focus um the preoperative, the the pre-recovery period is a time for you to kind of get things together. Yeah, focus on nutrition, sleep, like exercise, kind of these basic things that we that everyone knows, but now should understand from a surgical perspective of how that actually can impact your results and how um your recovery recovery stage.

SPEAKER_00 1:04:29

Yeah. I mean, and I've always viewed this from an athlete's mindset personally and for my patients viewing them, kind of like you said, like an athlete, like I want you to prepare for your event, your marathon, your game, your big whatever, and then recover you afterwards. Or even if I always say if a if we knew some famous athlete, Ronaldo or Messi or LeBron James was gonna have an injury on this date, we would be like hyper preparing that high-level athlete for this injury date. Yeah, not to mention recovering them incredibly well afterwards, because that's what everybody thinks of. Oh yeah, LeBron has a knee surgery, what's his recovery like? Well, I'm asking what was his prep like before the knee surgery. I guarantee they were optimizing his stability and muscle mass and whatever around that knee too to make it better and his metabolic state, because uh ERAS was kind of the first thing to like really bring in a metabolic state and be like, oh, metabolism's important here. And now we've probably broken that down even more to be like, yeah, metabolic health's important, but really even down to like the mitochondrial level.

SPEAKER_01 1:05:24

Yeah.

SPEAKER_00 1:05:24

You know, I kind of say everything meets in the all of these recovery modalities that ultimately kind of meet in the mitochondria at some point. Um, and it's funny with like fasting before and after, like we we use fasting now actually as a beneficial thing, so fast mimicking, but in a more strategic way than just like blanket fast. You know, it's actually the refeeding after the fast preoperatively that drives some of the growth factor release. And we know we don't want to be fasting after surgery because fasting, well, surgery, I view it as a metabolic or physiologic stressor, specifically a metabolic stressor. And we don't want to have any other metabolic stresses happening. So when you know my patients are asking me about when can I get back in the sauna or about In the cold plunge, which I also love. But I'm like, just take a deep breath because those are hormetic stressors, right? Those are making you stronger by recovering afterwards. They're not making you stronger right when you're in the sauna. And we have all kinds of recovery demands going on. Let's not add to the recovery demands with these. But down the road, whether that's a week or a month, depending on the procedure, we can start mixing those in. Also, because you know, there's other like psychological benefits to those things as well. So yeah, you can probably get in the ice bath at day one if it's quick in, quick out, if you need that for your confidence or whatever. But um I view this as a little clarity. Yeah, I view this as an athlete, you know, kind of coming through and recovering. And this is the future, you know, it's whatever, whatever 0.0 we want to call it now, 1.0, 2.03, we're probably 3.0 plus, probably 5.0 in reality. Um, because you know, I would, I would view 1.0 what it was originally, 2.0 ERAS, 3.0, starting to introduce hyperbarics, uh, maybe even 4.0, getting into like some red light therapy, but we're beyond that. We're well beyond that. And for me, it's this mission of like, I want my patients to have this outcome that is aligning them with how they feel on the inside. That's the ultimate goal, right? But I want it to be safe, reliable, effective, fast, right? Everybody emphasizes the fast. And I think I've even been guilty of being like, it kind of takes what it takes to get there, but there's ways we can make it faster. But interestingly, a lot of the ways that make it faster that we're doing are also making it better. And I think that's an important differentiation because making it better means like they're getting a better long-term outcome, which is ultimately my obsession. Yes, I want you to get better faster. I want to be on that page with you, but I want the results to be incredible afterwards. And so that's where my motivation really lies, is in that like let's make the results better, but we can also make it faster in the interim. A contrast to that would be something like post-operative steroids, which I scream from the I literally talked to a friend about this the other day. Why are you putting your patients on post-operative steroids? Because they feel better afterwards. Okay, and so do you, because you're not getting any phone calls about swelling or about this or about that. Um, and because there's those benefits to it that, like, oh yeah, they look incredible immediately. But when you really look at what's happening, you are crushing their recovery. You know, we're going from 5.0 to negative 0.5 or negative 5.0, in my opinion, because we're not allowing any of the signaling, the growth factor repair, the initial phases of healing. We're just blunting them all for the sake of comfort to not make that long-term result last. So, in my opinion, with that one, we are very frankly compromising long-term outcomes for short-term comfort, which is goes against everything that I have with the long-term results, but it makes people feel better right away. So I love our protocol because we can make them feel better right away, make them get better, make get this is like a return to sports and north of the return to activity for an athlete after a surgery. Like, how fast are they getting back? That's a measurable, quantifiable time frame. It's really important if you're LeBron James or Messi or Ronaldo. Like, when can this person get back in the game?

SPEAKER_03 1:08:58

Yeah.

The Future of Fat Transfer

SPEAKER_00 1:08:59

We're doing that faster, but you don't want to put them back in the game on a weak structure, right? So we're really focused on all of those things kind of coming together. So it's a little bit of a different mindset around it. And, you know, this is the future of what we're doing, um, and the future of our specialty. And, you know, I think that this is one of our many mindsets that we share as to what the future of our specialty is. I think I could think of like the way we approach fat transfer, uh, the way we approach uh like lifting procedures, uh, being very much futuristic in addition to um how we prepare and recover our patients from surgery. And I guess, you know, with that, like let's get into it. Let's talk about fat transfer and the future. How what I guess, you know, as I'm teeing you up for this a little bit, but what is to, in your opinion, what's our futuristic mindset around fat transfer? What does that mean to you? What do we do that, you know, what how do you think about it that's like this is very next level?

SPEAKER_02 1:09:53

There is a lot of evidence about like the way you process it, what is the technique, um, where you should harvest it from. And that's you know, I think there's a lot of confounding variables. So there's it's really like there's no clear scientific consensus of those questions. But for me, it's more of like what can we do to the fat to make it last longer, to make it survive longer? Um, and that goes back to our regenerative protocols, and that's just you know, the the photobiomodulation that we do to our fat increases the you know the stem cell viability, how much it survives, how how how much fat retains after you transfer the fat. But this goes into also hyperbaric oxygen. So that's why we use hyperbaric oxygen after the uh the fat transfer because it's it it increases retention. So I think it's just what what are you gonna do to the fat to increase its viability? Because you know, if you look in the literature, people get fat grafted and it's like zero to a hundred percent lasts, right? And it's a huge problem because and so sometimes people try to overfill and then they get stuck in if it retains or it lasts longer, right? Yep. So if we can have more consistency to how much fat is retained, and how do we do that? Is I think it's we like basically I call it like supercharging the fat. You know, we put it under the or I also like to say the rave cabana of the fat because it's like the red light, red light uh um tent where we put the fat underneath. So uh and this it actually does beautiful stuff. So I think like the future of fat is people are gonna more people are gonna recognize that you can use these regenerative medicine type of things to help augment fat to improve its efficacy or improve its retentionability. So yeah.

SPEAKER_00 1:11:32

So you mentioned a little bit of like where we're harvesting it from, yeah. Um which is a really common question at that basic level is like where do you get the fat from? So run I guess answer that question, but also like add a little high-level science onto why with that. Where do we get it from? How do you what is it, what is the fat transition? Pretend I don't know anything about it. Explain it to me, but tell me why on a couple of those basic questions I would have.

SPEAKER_02 1:11:56

Yeah. So um most common areas that we harvest fat from are medial thighs and abdomen. Um, accessibility is probably one and adiposity, but there are some studies that suggest that has a higher density of adipose-drive stem cells in those regions. Um, so that's I would say the primary reason why we take it from the those sites.

SPEAKER_00 1:12:17

Yeah. And I always tell people, I get to control the number of stem cells that we're harvesting based off of where I'm choosing to take it from, usually. Uh, but they get to control the quality of those stem cells, which is part of the pre-covery process. If you want more, we want better stem cells coming in and the more metabolically healthier they are for sure. Because ultimately a lot of the future of uh fat transfer, in my opinion, is driven around like its regenerative potential, you know.

SPEAKER_02 1:12:44

Oh, that's where yeah. Yeah.

Future and Evolution of Facial Surgery

SPEAKER_00 1:12:45

I mean, I was just thinking like that that's kind of where it went from just like adding volume to now uh improving volume. Let's call that quantity, yeah. Uh improving quality, right? A big qualitative change. That's that's probably the piece of literature that's caught the area of literature that's caught up the most to me. Um, because again, something I've been screaming from the hilltops and still pe even to this day, people are like, there's no evidence. This is what I'm like, come on, give me a break. There's like substantial evidence. Substantial evidence, yes. This is this is usually coming from filler injectors, you know, who don't do fat transfer or can't do, I should say can't do it, so it's out of their scope or whatever. They don't get up that high, and then they just like, well, filler's better. There's no evidence to support that, which is not true. Um, but then I think that our our other level is getting so we've got quality, quantity, um, but I think we're also getting into like this functional benefit to it too, like this myomodulation type of idea with it um of you know fat in different layers. Well, I guess getting into like the nuances of what the fat pads are for. Our deep structural fat pads and our superficial fat pads are different from one another, right? One of them is structural and it creates a glide plane for the muscles, essentially. And the muscles of our face are what uniquely make us human, in my opinion. Like half of our communication today has been that way. Um, and we are like so fine-tuned to read it at levels that we can't even verbally, you know, articulate. We know so many more things about how these little muscles and what they do. And so a lot of our job, I think, in uh facial surgery should be to optimize that, you know, like that's let's make you express what you're trying to express and look on the outside quite literally emotionally how you're feeling on the inside, right? Especially if you feel good. Yeah. Um, and so that's like the deep structural fat pads, augmenting them to be the appropriate glide plane. And then our superficial fat pads sit on top of those muscles generally, and those are what are getting moved by the muscles. So we obviously want those to like register the force vectors appropriately to move with our skin. And this is where, in my opinion, filler fails us a lot, like filler being biostimulating fillers and hyaluronic acid fillers, because you're putting a mask on that process, deep and especially superficial though. Botox also can mask that, right, by not making the muscle move. But this gets a little bit into a uh hot territory where I I catch a lot of heat, and I know you do too, as to like uh I don't not not all filler is bad. I don't think that, but I think from an overall anti-aging strategy, we're actually um I don't know if we're making ourselves not human is the right word, but we're blunting many of our very important human features in our face and getting into our neurobiology of how we register those things, you know. Which I think is our facelifting strategy too, right? I don't know if you think about it that same way as far as um what we're doing with our myomodulation with our lifting procedures, right?

SPEAKER_03 1:15:36

Yeah.

SPEAKER_00 1:15:37

Um yeah, run me through your mindset around lifting and like where, you know, I know that you were talking about the evolution of kind of lifting over time and where we're sitting now and where we were at before. Um how does myomodulation fit into that for you?

SPEAKER_02 1:15:53

Yeah, so I think that's like the next frontier of uh like facelifting and like the future of facial plastic surgery is you know, because we first, like you said, we're focused on the skin, just cut the skin, pull the skin tight, reattach it, and then you know, you have all those other issues down the road. Yeah, and then you just kind of get in deeper and deeper and deeper. And then now we're starting to understand like how do these muscles actually function, right? What's required for them to function appropriately? And it's like people just focus just on the muscle, but it's the surrounding structure of that muscle that helps it function the best, right? So, like if you have a muscle here and there's nothing underneath it or there's no support, it's gonna hypercontract or not contract in the vector that it should. And the same thing with the fat pads above it. So I think now we have to having that realization that to improve the muscle function, it's it's to re-establish the surrounding support architecture, and that is through the fat grafting, and that's doing that appropriately because that is a live cell that's gonna integrate with the with the surrounding, you know, the tissue, like a healthy live tissue. And I think that's where the the filler problem or other the issue, like you know, these other biostimulatories and stuff like that, it's because if they, you know, you put it in the wrong plane and they do create a fibro, like inflammatory reaction, fibrotic reaction, that fibrosis is not gonna fully integrate as appropriately or as it should as a natural fat craft uh may. And that's just my view on it. So I think um just understanding that like and another point is that I think in the past people focus on more static, uh like facial expression and like photos, but now it's like the next thing is d uh dynamic movement, right? Because if you you can have a beautiful face like the you know, but then if they smile and there's like you know, there's something going on that's gonna be um demonstrated with the dynamic movement. So the and that's where the muscle function comes into play. It's like now that we've kind of come, you know, we've we've gone top down and now we're going static to more dynamic movement. And so understanding how how can things look the best also with dynamic movement, not just like you know, just looking straight and smiling, basically.

SPEAKER_00 1:17:59

So it's been an interesting evolution, right? Because when you think about um, you know, photos 1.0 and then into more video-based things also that's a topic we haven't talked about, but also probably hopefully a little bit more AI proof, which when I started my career wasn't even something we had to think about, you know. Um, but like, you know, the videos make things more AI proof and had a lot of really interesting conversations with my good friend Ben Talley in our field about this, who you know has talked and thought and worked a lot with myomodulation and you know, these conversations with him talking about his surgical approaches to myomodulation and my super fascinating obsession with um neuroanatomy and neurobiology and how we interpret faces, like we're speaking the same language, you know, in this thing, just think coming at it from different angles, interestingly. You know, he's thinking about, you know, he carries an obsession with his results as well. And I carry an obsession with my results, but I'm looking at it through this lens of like, how is the world interpreting you? How are you interpreting your fellows? What are the levers we can pull? Well, he's pulling some of the levers with myomodulation, and so it's just beautiful. I just gave a nice lecture at a meeting with Ben about the neuroanatomy of facial interpretation and beauty interpretation and choosing mates and nonverbal communication and what surgical levers we are purposefully pulling or should be pulling and are planning to appropriately myomodulate. And so a beautiful intersection with I think what is the future of lifting. And it's so you've got this 1.0, 2.0, 3.0, even in the mechanics of the lifting itself, right? We had, you know, going back to the 19 early 1900s, 1920s, um, Suzanne Noel, a dermatologist, the first person to really be doing facelifts was doing skin-based facelifts, you know, which kind of didn't change a lot for a while, although people wanted it to have changed, like, oh, I'd do this now, but they're all just doing skin-based facelifts for a long time. And then they went one deep, one layer deeper from the skin to the subcutaneous fat, and they were separating the subcutaneous fat from the haponeurotic, the like envelope layer underneath, which probably isn't the right cleavage plane. We know that now, but they were tightening the surface, going back to our original conversation of tightening surfaces but letting deep things herniate. Uh, so that was kind of like 2.0 of lifting, really. Was that? Then we went to deep plane uh procedures, which has been bastardized basically, um, because there's a true deep plane release and deep plane type of a procedure, call that 3.0. But there's lots of people like who might dabble into it but aren't actually really doing it. Well, I did part of the, I did 10% of the deep plane, like, well, it's not really counting, but uh we all the the those of us that know the nuances use that the proofs in the pudding, right? You can see results and see that. Um, but just because someone's calling it a deep plane doesn't mean it's the same as the other person. That but it wasn't that way for a long time. At the very beginning, it was just a few people doing it, and you had a reliability that it was if it was called the people were calling it that, you know, because they were, you know, the the pioneers of frame shift age older than me were meeting resistance for this procedure. Like it's dangerous, you're gonna cause facial nerve palsy. The people who don't do it still hang on to those arguments that are total BS. Um, so far to that by comparison. Exactly. Way, way, but you know, if you can't do it, you if you're in the mid-level, you attack that the top, basically, right? Um, anyway, and then now into the myomodulation onto tightening deeper structures and things, you know. This is again, all these a lot of conversations with Ben about this, but um, you know, this is the next frontier of like, okay, now we've got a way to manage the superficial envelope. How are we optimizing the deep structures, the fascia that sits below the muscles, back to just like the fat transfer? Like things deep to the muscles are also important to how the muscles function. And ultimately, we want those muscles to function on the skin surface the way that they were meant to, which it's very very important to not delaminate their connection to the skin, right? Which is what old school facelifting that's still I shouldn't even call it old school because it still happens today, but like just that previous mindset that hasn't quite faded away. I don't know that it ever will, but yeah. That's uh it's been this interesting evolution through that, you know, like how facelifting has evolved and how it will continue to involve. And it's fun to be involved in the uh the the new frontiers that are moving forward.

SPEAKER_02 1:22:05

Yeah, it's very exciting. I think you know, there's always things to improve upon, always things to advance, and like as like you said, these people that didn't recognize photobiomodulation as an efficac uh um um effective treatment and like they come around with more evidence, and like I think that's just like the natural progression of things. And as you know, people start understanding the mechanisms of aging, you can that's when you can actually start addressing those mechanisms, like you know, from from like from a from a facial plastic standpoint, from a surgical technique standpoint, like that's where we're getting deeper and deeper. Those are the things that are getting taught. Like, like you see that video of that fighter pilot, right? That that ages in two seconds, right? How many G's does she get? Five, six G or something like that, and like it's instantaneous aging, right? And so that just supports, you know, it's more everything just falling down, right? And like you're not gonna bring that up with with the device, but it's just and that goes to the skin envelope because every there's just different layers that one thing, like if you if you do a facelift, it's not gonna treat the skin, right? So there's just like these things are specifically tailored for these purposes, right? And I think it's it's okay that you need multiple different treatments to get the you know what your goal is. Yeah, and now with the evolution um with myomodulation, it's and the fat, the regenerative stuff of fat that we're seeing, it's it's it's incredible to be honest, to see the the potential of these of fat of what we're doing. And if once we start, you know, if if like the regulations change, if we have access to more just like adipose-drive stem cells, and then we can get into the just the specific exosomes from the stem cell, because we may not even need the cells, just like the messaging signaling, right? And and like there's substantial evidence that like you can have these like photo-aged mice, you put in the you know, adipose-drive stem cells, like fat, and like completely restructures their the the skin, like the elastin, which is not talked about enough. Like I said, everyone just focuses on collagen. Right. And all the study, or like, you know, historically in like the laser stuff, they're like, increases collagen, great. Like that's like a mantra that everyone just continues on because they think increased collagen is just um like you know the the pinnacle of like you know results. It's actually not what we want from a realistic standpoint. So yeah, it's like the balance, right? We need we need the elastin, and that's traditionally really hard or it's more difficult to regen rejuvenate or regenerate. Um, like you know, the half-life is much longer, and like you know, it just stays around. And that's why I think some of these devices are working too, is because when the skin ages, you have these elastin like byproducts or these degradation products, and they just they just stay in the dermis. Yeah, we see them. Yeah, and so if you can, with thermal damage help uh the the cells eat them up, take it away, and it helps regenerate, and then you put the fat in, it could completely um restructures your their dermal architecture from like a more youthful level. So I think as you said, it's not just like what you can do to the fat to make it more effective, but also what is what are we using the fat for now? Yeah, and it's gonna be more of a qualitative, like the skin skin quality improvement.

Outro

SPEAKER_00 1:25:01

So yeah, yeah, and there's studies showing that like that fat by itself recycles those elastin byproducts, upregulates precursors. So when used with a laser, um, I mean, again, no question about that. And it's interesting. And for those people that uh don't know the um video that Dr. Kelm just referenced, we'll make sure that you guys see that and a link to it or have it in here. That is um, there's I've seen multiple videos of this now, but it's a pilot with a camera on, and the one you're talking about is a female pilot who's probably in her 30s, maybe, um, and has a camera on her and she experiences some high level of G's, six G's, eight G's, something like that in a matter of like 10, 18 seconds. And if you pause it at the apex of the Gs and look at her, the aging pattern that she's experiencing is not abnormal. It's our exact aging pattern, basically. So a lot of surgeons have used this video to I've seen it at conferences and used it to like illustrate that uh it's a pendulum swing, that so much of our aging change is gravitational because she had no volumetric shifts, no qualitative shifts, which I believe are important to some degree because how your tissue stands up to those gravitational forces is ultimately a part of it. And in her 30s, she probably doesn't have a ton of qualitative change, but some. Um, and but it's been the pendulum shift is like how much of aging is gravitational, why we should be lifting, arguing from a surgeon standpoint, which is swinging from the paradigm that like aging was so volumetric and we should be filling, filling, filling, which that wasn't right either. And it's not all gravitation. I'm a firm believer that most things live in the middle of these extremes, whether it's politics or diet or aging, probably. It's not all volume, it's not all gravity. It lives maybe towards one end more than the other, but um we should be focusing on all those things. So we'll that's a really interesting video. We'll make sure that we have that visible. Yeah, yeah. Um, well, I appreciate your mindset and your curiosity. I think a lot of the things we've talked about with colleagues and friction, it's good to have friction, honestly, from colleagues who um are you know kind of like digging in their heels a little bit more and and uh challenging and things like that. Um, but we also want to move the field forward, which I feel like sometimes I'm pushing a sled. Yeah, metaphorically. Friction, you know, stress is good for systems, right? Right. I get stronger. Yeah. Um and ultimately the sled gets moved. Yeah, you know. Eventually. Yep. Uh, but it's interesting because I think a lot of that the the ultimate lubrication of that friction is usually curiosity, which I think you carry in spades. Um and I love that mindset. And um, yeah, so really appreciate you. And thanks for sharing all your thanks for humoring all the device, the device questions. I know.

SPEAKER_02 1:27:44

I know I'm gonna get some uh some flap for that later.

SPEAKER_00 1:27:48

People love that. That's uh that's there's you're there's nobody better answer than you. So appreciate it. Well, thanks for having me. Yeah, absolutely. If you have any questions or topics you would like me to explore further, please leave them in the comments. I read them all and They often help shape the future conversations here. If you would like to learn more about my surgical practice, you can visit clinic5c.com where you will find additional information on my approach to surgery, recovery, and performance focused care. I also want to be clear that the views shared on this podcast are my own and are not associated with or representative of my clinical teaching affiliation with the University of Washington School of Medicine, nor should this be taken as individual medical advice. Thank you for spending your time with me. I appreciate you being here, and I will see you on the next episode.