Can MITs Compromise Future Facial Surgeries?

On today's episode of AP Class, we're diving into one of the biggest conversations happening in aesthetics. Can non-surgical treatments impact future facelift surgery? From filler and Sculptra to threads, lasers, and RF devices, there's been a lot of debate about whether these minimally invasive techniques can have impact on future facelift procedures. But what does the evidence actually say? Today, we're breaking down a major consensus paper from leading plastic surgeons and dermatologists that explores how these treatments may or may not affect surgical outcomes, healing, and facial anatomy, and why this conversation is way more nuanced than social media makes it out to be.

Episode participants:
Radiance Wellness | @radiance.well
Megan Ucich | @the.skin.practitioner
Aayesha Patel | @aaestheticsbyaayesha
Sarah Pertschuk | @beautyinjectorsarah

Disclaimers & disclosures: Link

Transcript

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Today we are bringing in a topic that has sparked some serious debate in the aesthetic community and for patients too. Can your nonsurgical tweakments actually compromise your future facelift? Welcome to AP Class, your virtual journal club for all things aesthetic medicine. Created by injectors for injectors. This is where we take a clear evidence-first look at the research shaping modern aesthetics. Each episode we'll unpack a study. What's solid? What's questionable? And how the evidence informs natural refined results in real practice. Class is now in session. Welcome back to AP Class. On today's episode, we're diving into one of the biggest conversations happening in aesthetics. Can non-surgical treatments impact future facelift surgery? From filler and Sculptra to threads, lasers, and RF devices, there's been a lot of debate about whether these minimally invasive techniques can have impact on future facelift procedures. But what does the evidence actually say? Today, we're breaking down a major consensus paper from leading plastic surgeons and dermatologists that explores how these treatments may or may not affect surgical outcomes, healing, and facial anatomy, and why this conversation is way more nuanced than social media makes it out to be. Class is now in session. Do you want to give us a clap or are we just going for this? Maybe that's what we should do. When's the last time you've yodeled? I don't think we have. Yeah. Okay. I don't think I can. There was no first time, but this can be our first time. Yeah. I think we're all going to start saying that in the office. I know. Hello. You know who it reminds me of? Um, the nanny from Yes. The nanny. Hello. Fran Drescher. Yeah. Yep. All right. Welcome back AP class coming at you. This is episode six. I am Megan Ucich, nurse practitioner. I'm Aayesha, physician assistant. And I'm Sarah Pertschuk, physician assistant. And we are the providers at Radiance Wellness. Thank you for joining us for another episode of AP Class. Today we are bringing in a topic that has sparked some serious debate in the aesthetic community and for patients too. Um, can your nonsurgical tweakments actually compromise your future facelift? We're diving in. It's a landmark study or a con consensus paper I should say from the Aesthetic Journal Open Forum titled Optimizing Aesthetic Facial Surgery Outcomes Following Minimally Invasive Treatments. And for the purpose of this podcast, we're going to call those MITs. Yeah, minimally invasive treatments. And that's basically everything that we do in aesthetics. So whether it's injectables, lasers, microneedling, etc. So this topic first caught my eye. I was at the Cult Conference last year and Dr. Saadat was there. He was on podium speaking and we were talking about biostimulators and facelifts because there's been a few outspoken surgeons out there that have kind of sparked some fear in people in patients and some kind of outrage in providers. Fear mongers. Fear mongers. Clickbait. I tell you it gets you every time. Every time. Mhm. um that they were saying bio stimulator biostimulators can make future surgeries really risky um and hard because of scar tissue. So Dr. Saadat was on stage and he was like you know what we are publishing a consensus paper that will be coming out shortly. It was a group of, and we'll get into it, surgeons and dermatologists who all sat down together to kind of talk about just what are the recommendations, what are the risks, and do they have any impact on surgery? And so that's what we're uncovering today. This has been a hot topic in the aesthetic community, and rightfully so, because about 80% of cosmetic procedures are minimally invasive treatments. And previously it was injectables or surgery and now they're more synergistic and really a spectrum of care now that we're managing together. Yeah. I think people our brains like to be so black and white like you can either have one or the other and the reality is both happen and that's really the reality of aesthetics. People are going to do injectables and then likely get some sort of surgical procedure down the line and both can happen. Yeah, I think the mindset has changed from correction to now like prejuvenation and the goal isn't to replace surgical facelifts. We're ideally pushing back that timeline. To provide a clear road map. This paper uses a framework to answer three questions. What should we consider as providers when doing minimally invasive treatments for our surgical candidates? What are the surgical implications and what are the risk mitigations? And hopefully this kind of opens the door where we as aesthetic providers and surgeons can work collaboratively rather than pitting each other against one another. Totally. And we were talking about this before we started filming, but I think it's also important for our patients to understand that what we do are medical procedures and it is a part of your medical record in the same way that we need to know your medical record when you come in here. We need to know your surgical history and your non-surgical history because it does impact the way that we think about your face when you're sitting in our chair. That your anatomy is not going to be textbook. Not that it ever was, but that it is riskier. And in the same sense, plastic surgeons need to know what type of MITs have happened before they go in and dissect someone's face. So for consumers listening to just know that these are medical procedures. They're not just beauty treatments. And it's important for both your plastic surgeon and your aesthetic provider to have all of that information so that we can work together and for us to be able to treat you as a whole. Yeah. If we don't know what medications you're on or what your past medical history is, then we may not be considering something that is important to us, but you may not deem important because you can't see the whole picture. Yeah. So, yeah. Yeah. It's like when we're doing our good faith exams and we start asking like, okay, like any medical conditions, what medications you are on? And you start sensing the patients like being like, uh, yeah, why are you asking me this? Like, get on with it. or they wrote no for everything and then you ask them again, they're like, "Oh yeah, I'm on this, this, and this. Oh yes, this." Or like, "Oh yeah, I do have this autoimmune condition." It's like, "Okay, good to know. That is important." Or then you're like needle deep in their chin and you're like, "Do you have a chin implant?" They're like,"Oh my god, I forgot to tell you about that." Like, "Oh my goodness, I can't." Yeah. The more thorough the better for both. Yeah. For both sides. Yes. Um, so brief synopsis on this article. It brought together eight members, eight I shouldn't even say members, amazing physicians, plastic surgeons, and a dermatologist. Um, so seven plastic surgeons, one dermatologist. Combined, they have over 75 years of experience. They are published in hundreds of journals. They are considered key opinion leaders. They are practicing daily in their office, plastic surgery, and MITs at the same time. So these aren't just like random people, experts in the field that are putting together this consensus paper. These are people who are dissecting back faces and doing plastic surgery but also delivering injectables and non-invasive treatments or MITs. So I think that's important to know and I want to name who they are because I think for our providers listening to hear those names also kind of gives you the weight of that too. We have Dr. Shridharani, we have Dr. Palm, Dr. um Jarmuz, Dr. Somenek, Dr. Nayak, Dr. Saadat, Dr. Indeyeva, and Dr. Sykes. Hopefully, I'm not saying any of those wrong, although I might. Um, those are big names. Those are people that we really look up to in the field to kind of tell us what is safe, what is clinical excellence. So, those are the people that came together. They reviewed um all of the existing literature that we have about MIT's and plastic surgery outcomes. They did case-based reviews. Yeah. Reviews together. Yeah. Um and they basically combined all of that along with some surveys for for everyone to do. And they used a Likert scale. And that Likert scale, they basically had to get more than 75% agreement threshold to determine what the consensus was. So for every MIT that they go through, they had to get to a 75% agreement that their um considerations for that treatment are on the same page. So which is huge. Yeah. Because for multiple people to agree Yeah. is difficult, but it's clear that the science points in that direction. So it's nice to have that. That's comforting when you read this paper that you can really trust in it. Yeah. With that being said, it's level five evidence, right? So, we're at the bottom bottom of the pyramid because it's not a randomized control trial. We're not running an experimental study. This is a consensus paper. So, these are um the author's kind of subjective thoughts about it based in evidence, their expert opinion. Yeah. So, the main takeaway is incredibly positive. You can get surgery. Now, tune in to the end of the podcast to find out. Exactly. So, MIT patients are still excellent candidates for surgery. It's just that there's unseen effects from these minimally invasive treatments that can create a more complex surgical environment. And so, these patients need to be treated appropriately. And we need to know about their entire history before creating a surgical plan. Totally. Yeah. And they kind of come up with this risk hierarchy. So not all treatments are created equal. And they kind of looked at two main concerns really three. Is there are the MITs causing any plane distortion? So making it difficult for the surgeon when they're in the operating room to dissect back the different planes, the facial planes. Um, is there any vascular compromise? So, when you're thinking about a tissue flap or you're dissecting and causing a flap in the skin, is there concern that there's poor profusion to that area which would impact wound healing? And then fibrosis when they pull back, are there granulomas or scar tissue that are adhering down that could also lead to plane distortion. So, those are the things they were thinking about when they looked at each MIT to determine, okay, what are the risks? could they cause plain distortion or vascular compromise or any risk of fibrosis? And they started off by discussing Botox briefly or neuromodulators and because that is the mainstay of a lot of people's aesthetic practice, but they didn't really include it in the paper because it is so transient. It's short term and it doesn't cause any deeper distortion. So they mentioned that it's one of the most common procedures, but they didn't go into it in this paper. Yeah. And we'll get into it later. But it's interesting you say that because patients will come in and think, okay, well microneedling is not that big of a deal um compared to Botox. But we'll get into like, well, no, it does actually cause, you know, inflammatory response which can also, you know, introduce other things. Yeah. Um but back on our risk hierarchy at our lowest risk is our HA fillers, our bread and butter in aesthetics. We love them. Um, these are foundational for volume and when used correctly, um, they do pose minimal risk. And I think patients might be happy to hear that actually surgeons are using them in collaboration with their surgical facelifts because yes, you can pull back the tissue, but you can't replace that volume, right? And we hear that all the time from patients when they come in and they're like, I'm just going to save it for a facelift. And the reality is you're going to need both because a facelift doesn't impact any of the volume loss that's happened. So you're either picking from a fat transfer or from HA filler. Yeah. And HA filler is reversible. Right. That too. Right. And so around these treatments like HA filler, the negative effects are usually due to administration error. So overfilling large boluses um injecting into multiple planes or across planes that is what's going to cause fibrosis, granulomas, nodules, inflammation that can turn into impinged vascular or you know put pressure on surrounding structures. And that's when it gets more complicated for a surgeon going in. And that's why it's so important to mention every single minimally invasive treatment that you've had when you are discussing your aesthetic history. Yeah. And HA fillers were the lowest on the on the list. But not all providers are the same, right? Like that's true. We'd like to think everyone is like us at Radiance Wellness. Um but it's unfortunately just not not everyone um educates themselves as much and so they even think that they're injecting in the right plane and they're not. I feel like injection techniques have also changed so much even just over the last 5 years. Totally. Like 5 to seven years ago we were injecting lips completely differently or injecting midface completely differently. So there's probably residual filler in different planes for sure that has just been loculating there and now you know we might run up on it later but and the reality is the we're going off topic but the years of experience doesn't necessarily matter. It's how often are you keeping up with changes in education and skill that really matters. Like it doesn't matter if you've been going to an injector and they've been doing it for 20 years. if they haven't opened a textbook or gone to a conference in 20 years, like not great, right? Yeah. Yeah. So, anyways, moving on. So, HA fillers lowest. We love that. We know that. We use them all the time. Biostimulators was really what kind of like shook everybody up. That's what you were hearing on social media. Oh my god, you can't do Sculptra and get a facelift. And there was really two prominent surgeons who were kind of pushing this idea. Um the authors affirm over and over again biostimulatory treatments rarely result in complications that cause challenges in performing sub subsequent surgery. So what they are biostimulators are like Sculptra, PLLA or rads or CaHA um the risk is generally low because they favor type one collagen and we know that type one collagen is soft it's organized rather than fibrotic scar tissue collagen which is type three. So baseline just based on like what the mechanics of Sculptra or um biostimulators are it's collagen type one it's really not a problem when there has been problems it's again the same thing like filler it's been injected in the wrong plane or in large boluses or too many treatments back to back. Those are the things that surgeons have then gone in and been like, "Oh yeah, I've noticed there's some changes um in trying to kind of dissect back tissue, but not that it is making surgery impossible or that it's really that much riskier. It's still doable." Yeah. The good thing about Sculptra, too, is that we literally try to inject it into the most superficial layers. Totally. Like that's the even potentially hard part about it is injecting it so superficially. Yes. So that really takes away a lot of the risk if you're having a deep plane. Yeah. Face lift because our Sculptra isn't placed. It's not in that plane where that face lift is happening. Exactly. Now well there are some who do and and there is some evidence that's coming out about how Sculptra works in different planes. And I was having this conversation with Dr. Saadat at another conference because I was asking him about it. Why do people inject it deep? Like I don't understand that if we know that we're trying to stimulate collagen and it's in a superficial layer, why are we injecting it on bone, right? Um why am I blinking on the injector who does this? No, it'll come to me. He he's been injecting it on periosteum for a long time. Oh um no um it's come to us. It'll come to you. It'll be on the tip of your tongue. Um but that there is something happening on the deeper layers that you can stimulate fibroblasts on the deeper layers that then affect the more superficial layers. But then that's going to lead to another conversation about surgical implications. So we don't we don't inject Sculptra deep. we stay superficial with it. Um, and and I think that's safest. One, we know that's where it's most effective, and two, we know there's least impact for surgeons down the line. Yeah. When they're doing. When Aayesha and I were just talking about it earlier, too, when we were reviewing this. Oh, we should do our next AP Class on Sculptra and depth. Yeah. And then, but then we realized, wait, there's not a lot of conclusive paper on it. So if anybody's you know wanting to put out some information on that exclusive please let us know so we can learn. Dr. Saadat said that when he does inject sculpture deep on periosteum tiny little boluses and he moves it around because I said to him okay well we know that it's going to travel path of least resistance. You're putting liquid on bone. It's going to travel right up through all of the planes of the needle path. Right. Interesting. So you know Yeah. Huh. techniques techniques. Yeah. Uh so after the biostimulators they move on to the more permanent fillers and at the permanent fillers this is where risk skyrockets. So you've got silicone, PMMA. This is where you're going to get encapsulation. You're going to get granulomas. You can even get malposition of your eye or your eyelid. And this is they're not dissolvable. So these are going to cause real issues if you're trying to go in for surgery later. Yeah. Um and we see some permanent filler in practice. And it's also unpredictable because there is chronic inflammation. It is riskier to even do other types of MITs when you know that there's permanent filler there because you don't know how it's going to react. Is it encapsulated? You know what's going on with it. Yeah. Yeah. Um, okay. Next one. Threads, dun dun dun. I feel like threads are all over the map. People either love them or hate them. My personal preference. I'd love to hear you guys, but I think they're expensive, they're painful, and they don't last long. Yeah. I've just seen that the results are not long-term. Like, it looks amazing once it's done right after and then it just kind of goes back to baseline. Yeah. I've seen really gentle thread procedures and then I've seen really intense fast aggressive thread procedures. Yeah. So, I mean obviously if there's something significant that you're trying to maybe lift or do something on one side or maybe even on both sides and you're not ready for a facelift or surgery, I could see where they can fit in, but the risk for user error is, it's big. Yeah, I think the promising image to maybe consumers is when they put out those videos and they're like really tugging those threads back and they get like, "Oh, that's what I need. Yeah, that's what I need and I can get that without surgery." Yeah. But there's nuances to it. Yes. And unfortunately for um plastic surgery, it does become a lot more risky. They broke it down into dissolvable and then permanent threads or non-dissolvable threads. The dissolvable threads less risky. um they don't seem to be in the way of plain distortion by the time the surgeon gets into which we'll break down Aayesha like timing of all of that if you are going to get threads um but they do see that in patients over the age of 50 there are more complications in terms of like tethering or induration kind of seeing like distortion of the skin of the soft tissue because if you just think about a 50-year-old's skin it is thinner there isn't a whole lot of forgiveness there so um it can make it difficult it also kind of locks the tissue down. So then when they're trying to dissect back or pull in a glide plane, that can make it a little bit trickier for them. Yeah. Yeah. Uh, next we have Kybella. We can't forget that. We don't offer it here in our practice and I feel like it's becoming less and less maybe offered. We have it. Yeah. But yeah, we don't use it as often. Yeah. Yeah. It's one of our least um done procedures, but it works great for the double chin, but it does trigger significant inflammation which can make it difficult for when surgeons go in for maybe that neck lift, that long-term fibrosis um can alter those planes and make it more difficult. Yeah, that one surprised me, I guess, just cuz it wasn't on my radar. But when we talk about the like post-operative or perioperative timing with Kybella, that makes sense. You have to let any of that inflammation pass, especially if you're doing a neck lift. Yeah. And there's a bunch of inflammation in the neck. That makes total sense. Yeah. And this paper really leads you to it really shows you that inflammation leads to fibrosis. Yeah. Mhm. Like and the length of time that the inflammation is happening that kind of can tell you what your fibrosis is going to look like. Yeah. So, it does make sense because it's such an inflammatory response. Yep. Mhm. Yep. But the greatest risk goes to the deeply delivered energy devices. Who would have thought? I don't know. I didn't to be honest. I really didn't think about RF devices or like helium plasma devices like FaceTite Renuvion. Those are the ones that you're really getting into those deeper planes. And what happens is because you're causing collagen maturation and change and reconstruction, it's tethering those planes together with like vertical scar tissue. And then the planes of the face can become stuck. And that's what makes it really difficult. So it makes sense. Yeah. But I did not think that. Yeah. I know. Which is funny because when I see patients and they're like uh a little iffy about injectables, they're like, "But what about lasers?" Like, you know, I can use some like face tightening and then do I saw a patient this morning who we were talking about how, you know, maybe she's she only did Botox. She's thinking about doing maybe some Sculptra um not Sculptra but a facelift in the future and she's like yeah like I've heard about Sculptra but you know I really want a facelift in the future. So she was like I'm going to cross that off but what kind of lasers do you offer? But after reading this paper, we're like, wait a minute, that's actually something you should consider in your timeline if you are looking to get a facelift in the future because it does have some risks that not a lot of providers I myself didn't know about before. Yeah. Well, and to differentiate, so there's the more superficial lasers like the fractionated or the non-fractional lasers, and they added microneedling in there, which was super confusing to me because I did not consider microneedling an energy based device. But I can't speak to that, so I don't know why. But those lasers, like the more superficial ones, really are less of a risk than the deeply delivered ones because the superficial ones kind of stay up in the dermis. It's when you start getting into the subdermal layer with that radiofrequency is when you start to have that plain distortion. Yeah. So, some lasers and microneedling etc. are okay. But it's with RF I think more of the radiofrequency where you just have to be careful. Again, not that it's impossible and like this doesn't mean our brains like mind at least wants to go so black or white like oh my god, okay, that means you can't do it. No, you can. It just is important for there to be guidelines for us to follow and then for surgeons to know, okay, this patient has had these procedures done. Glide planes can be different and so may I may adjust my treatment plan accordingly. And when we talk about glide planes, it's like the movable areas, right? When when surgeons are kind of pulling back, we think about glide planes too, like when you're using a cannula and you get into that glide plane and it just moves, it's butter soft, right? So whereas like if you're in SMAS, you're like you're coming up against that resistance. So that's just what we mean when we say glide planes for those listening. Um, well, and talking about user error as well. So, microneedling, they stated in the paper, if you're going too deep with that, that can get into the wrong layer. Yeah. And so, people come in thinking microneedling is like, oh, I just want like a super mellow treatment, just microneedling, just like two-day downtime. But microneedling is a lot more a lot more involved than I think a lot of people give it credit for. And they were saying that after microneedling, sometimes people are putting on products onto their face or vitamin C serums that are causing granulomas or allergic reactions that are causing inflammation and then fibrosis. So it can still be from superficial things if they're used in a deeper plane, but generally across the board, more superficial is a little less risk. Deeper is more risk. I thought that was interesting. We talked about it in our last AP class about microneedling that one of the risks being and it they said it in this paper granulomas that are caused by delivering certain products too deep into the dermis of the skin that don't belong there. Vitamin C being a big one. Um and there was something else I can't remember. I want to pull it up. But um and we talked about that like aggressive is not always better. And when we tell patients, don't put sh*t on your face. Don't put sh*t on your face. Like, let it heal for like 5 to seven days. Like, we're not saying two days. Yeah. 5 to seven days at least. I feel like there's always this bartering like after filler. Can I just put a little bit of makeup on a little bit? No. Just later today. Few hours. No, I just poked a bunch of holes in your face. Yes. It just happened. I said no. She's like, okay, so you're telling me that tonight? I was like, "Where are you trying to go?" Yeah. So, I should not go to my nephew's softball game later. I'm like, "Not if you're going to wear makeup and a hat." And we just did something up here. No. Yep. All right, Aayesha, we need to know. So, what are we doing? We now know we have these MITs. There's obviously risk associated with everything. I think most important for providers when we're educating our patients if they're talking about surgery and for patients who know that they want to do surgery and are also doing injectables what are the guidelines when can we do things yeah so this paper gives a timing algorithm and this is where we need to bookmark um and maybe this is something we can I don't know if there I know there's a section in our intake form where we do ask about like s past medical surgical treatments But maybe we should add like something about like are you looking to get a facelift in the near future. Um cuz it does impact the treatments we offer and the treatment plan that we give them. Um interesting. So the algorithm here is that they recommend waiting 2 weeks for general, you know, non-invasive inflammatory treatments. They recommend 3 to 4 months for superficial lasers and CoolSculpting. Um, superficial lasers are going to be your MOXI, your BBL. Um, because it takes a while for that collagen remodeling to finish. And also, CoolSculpting has that risk of hyperplasia fat. Um, which can take up to 4 months to show up. Um, 6 months for microneedling or Kybella. Uh because of that inflammatory process going on for so long, um collagen remodeling can take up to 6 months even for microneedling. Um 6 to 9 months for PDO threads because it takes a while for you to absorb that um product and then 12 months for subdermal radiofrequency any type of deep energy based devices to really complete dermal remodeling. Yeah. a year. That was Yeah, that was surprising to me. Yeah. Yeah. Even the micro needling like microneedling surprising to me too. Yeah. And like I said, the Kybella to me was interesting, but makes sense. Yeah. One thing to know and we talked about that Botox earlier. Um, let's say someone's thinking about like a blepharoplasty, they do recommend, you know, not having Botox at least 3 months before any type of eye surgery cuz it does reposition your eyebrows and things like that. And we've seen that here in practice. And um yeah, so people need to be aware of that if if you're getting a bleph. I even tell people who are going to get their brows microbladed to do it before they get Botox. Yep. Yeah. Didn't think of that one. Yep. Exactly. Um they also recommended for surgeons to do a really thorough exam and even for us as providers if we know someone's going in for surgery to do an exam for the surgeon too and then provide that feedback. Um are there nodules? Do they have a chance that they need to dissolve any HA filler when they're in surgery? Um they do recommend if you are dissolving any filler to do it two weeks prior but then there was also discussion in here that they also put hyaluronidase in during the dissection which I thought was super interesting. Yeah, it helps to improve permeability or something within the tissue as well. Um and if they do see any nodules, it just kind of washes it all away as well. Um, and then for those that are high risk, so say you've done a ton of like um RF or something that maybe a surgeon wants to make sure that hyperbaric oxygen therapy is a part of the perioperative treatment plan for them. And I'm noticing that that's happening more across the board in general. I had a patient not too long ago that just had a lower neck lift, healed beautifully, and she really attributed it to um her preop plan, like supplements, the way she was taking care of herself, and then the HBOT therapy after. She did a lot of HBOT after. So, I think that that's also just becoming more kind of standardized for plastic surgeons to use in office. I think people will have them in their office, too. I want one of my I want one in my home, my office. I know. I want to live in one. Yes. Michael Jackson. Yeah. I just wear like nasal cannula. Like do you have do you have COPD? No. Optimizing. Optimizing. Oh my goodness. So, when the surgeon's in there, basically, this is all really important for us to know as non-surgeons that this information is going to the surgeon so that when he's in there or she's in there, they can be able to pivot if they do run up against, you know, tethered planes or maybe a flap that doesn't have as much profusion so that they can maybe make the flap thicker or I think they were saying even using nanofat droplets to help with perfusion and like to mitigate wound healing issues afterwards, which also was super interesting. So yeah, they talked about also if they're worried about perfusion to a wound flap, injecting PRP or PRF at the closure site to improve wound healing there, too. That's cool. So that'd be a cool idea. Yeah, we also have our post-operative recommendations or individualized care that also mitigates the risk. So, you can do more frequent follow-ups with your patients, lymphatic massages to reduce that swelling or like steroid treatment to help with that inflammatory response afterwards, which also helps mitigate those risks. I think lymphatic massage is such an underutilized treatment. Have you had one? Yes. Have you not? No. I've been wanting to Oh, girl. Shout out to Alex Spector. She is a lymphatic. If you're in San Diego. Oh, is it painful? Oh, god. No. It is the most relaxing hour of your life. It feels so good. And it's so soft. Like, don't go in thinking it's a massage because like your lymphatics sit very superficial and you can easily compress them if you press too hard. It's like the most just gentle touch for an hour of your life. Yeah. Highlight. I just feel like I would look like snatched after. Yes, you do. You do. I do a mini one every morning. So, if you want to know the mini one, hit me up on Instagram or at Radiance to learn. Open up your What's this called here? Well, this is part There's a lymph there's a lymph node that sits right here. So, this is part of it. Yeah. There's a special name. It's your like right right above your clavicle. You have to open this up for your lymphatics superior to them to drain. So you have to open this up first and then you can move up to your face. Well, and you can hit this this one too to open it up. So yeah, you have to get these guys opened up in here. Otherwise, if you do all this, it's just going to stop right here. Yeah. And there's some just have a fat neck. Yeah. Right. Which is not what we're doing. No RF on the neck. Okay. So, yeah, there we have a bunch up here and then they go here and then the stomach. So, armpits, stomach, groin, backs of knees. Mhm. Yeah. I think you were telling me and I do it sometimes. You can put a rubber band around your ears and it just like opens up the lymphatics. I'll massage massage at the same time. It feels so good and I swear I can just feel it draining. Yeah. And then you like look at yourself, you're like, "Oh my god, such difference." But post-operatively, heck yeah, you should be doing lymphatic massages. I even have our patients, I refer them over to Alex after like Morpheus or anything that's kind of like high inflammation. And I've noticed some that have like baseline lymphedema, like go get a go get a lymphatic massage, help move this along. So definitely postsurgical. I think after any surgery, people should do it. Very cool. It is the garbage disposal of your body. Definitely not. You got to get that drained. Yeah. So limitations of the study. Um one thing that I wanted to see that I think is important is okay. So and I know this paper was just to compare MITs with surgery but what about surgery with surgery? So say this is your second facelift. How does that impair glide planes or vascular compromise? Like I just I I would be interested to see how that stacks up too. Is that higher risk than some of the MITs were performed? I would assume that it is, but I think again people forget that distinction as well and they're like I can't do Sculptra. I'm going to facelift. Okay, girlfriend. Well, when you get your facelift again in 10 years, are you worried about that? So, yeah. So, just something to keep in mind and it would be interesting to hear that part. Um, and then the authors, of course, most of these authors have sat on boards for a lot of the pharmaceutical companies. Um, it was supported by Galderma. So those are all important call outs to say as well. Yeah, I thought also a small limitation was that they really did not distinguish between microneedling and RF microneedling and why is microneedling being included in the energy based devices and I just didn't understand that. So, it's not necessarily a limitation, but it's a question that I left with, especially since the timeline for microneedling is so significant. So, are we missing some like I just felt like I didn't fully understand what they were saying with that because I didn't know if it was the microneedling that we're talking about, right? Because RF microneedling can also be delivered in a lot of different depths. Exactly. So, yes, agreed. If you're delivering it at like you know 3 to 4 mm or more concern you're in a completely different plane. Yeah. If you're resurfacing microneedling or like 1 to 2 mm where does that land so breaking that down a little bit more could be helpful would have been helpful from a clinical perspective. Yeah. Yeah. So ultimate takeaway MITs in surgery are partners. They're not rivals. They can be used together. They are used together all of the time. It's not one or the other. Um, you know, potentially, could you put off surgery longer if you're doing MITs? Yeah, that's the whole idea, right? Is we're trying to do things to kind of keep you from needing that. But if you do decide that you want surgery or you're planning on it, they both still work hand in hand. It really comes down to communicating properly with your aesthetic providers and with your plastic surgeons what your medical history is. For providers is being able to have knowledge of the perioperative plan and the guidelines and communicate it appropriately to patients. Like if we're doing Kybella or doing something and know that they have surgery in six to nine months like then we need to plan that do that. Yeah. Right. Or do it earlier, right? Yeah. Um, so I think just awareness, timing, and clinical excellence, like that's how we deliver the safest and the best outcomes to our patients when we work together. Yeah. I've already used the information from this paper multiple times when talking with patients. So, it's been really helpful. Yeah. All right. Thanks for joining us, guys. This was a great episode. I hope it was helpful to those listening. If you have enjoyed these, I think it's also important to just let people know, our listeners, that we do have one pagers available that are kind of like a snapshot of the study. So, if you want to have something to to reference back at, that's available. The article is also available and our transcript. So, use those resources, they are there. So, please um please like and subscribe. Let us know if the one pages are helpful. We put a lot of time and effort into them and so we want to make sure if you have feedback for us that you let us know. Yeah. Awesome. Thanks again for joining us and we will see you next time on another episode of AP Class. Thank you. Bye. You've been listening to AP Class, your virtual journal club for all things aesthetic medicine. If you found today's episode helpful, like and subscribe, share it with a colleague, and join us next time as we break down more evidence that helps elevate your practice. Until then, class dismissed.