HKB Uncut | A Cosmetic Surgery Podcast

25. Modern Facelift Guide with Dr. Richard Kao: Deep Plane, Recovery, Scars & Natural Results

• Dr. Bill Kortesis & Dr. Gaurav Bharti • Episode 25

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 44:46

Facelift conversations have changed. Today’s patients are asking better questions: Am I ready for surgery, or can non-surgical treatments still help? What does a deep plane facelift actually do? Will I still look like myself? What should I expect from recovery, scarring, and long-term maintenance?


In this episode, Dr. Kortesis and Dr. Bharti sit down with Dr. Richard Kao to talk through the modern facelift experience: from deep plane techniques and natural-looking results to revision facelifts, men’s facial surgery, direct neck lifts, buccal fat removal, and the treatments that can support results over time. It’s a conversation about what facial rejuvenation can do, what it cannot do, and how surgeons think about creating balance across the whole face.


Dr. Richard Kao is a facial plastic surgeon and facial plastic surgery leader at H/K/B Cosmetic Surgery, bringing expertise in facelift and neck lift surgery, facial rejuvenation, and individualized treatment planning.


Connect with Dr. Kao:


In this episode you’ll learn:

  • What is a deep plane facelift, and why does it matter?
  • How do you know when you may be ready for a facelift?
  • What does recovery really look like?
  • Where are facelift scars placed?
  • Can you have a second facelift later in life?
  • How are facelifts different for men?
  • When are non-surgical treatments still the better option?

Welcome to HKB Uncut: the Health, Knowledge, and Beauty Podcast. On this show, Dr. Bill Kortesis & Dr. Guarav Bharti unpack the newest techniques and trends in cosmetic surgery, how to tune out the social media noise to make empowered decisions about your appearance, and what you need to know before you book a procedure. 

Dr. Bill Kortesis and Dr. Guarav are board certified plastic surgeons and Co-Founders of HKB Cosmetic Surgery, an award-winning practice with eleven locations across six states. 

Connect with HKB: 

SPEAKER_03

Yeah, have you ever had a single patient? Because we've all done a lot. I can only tell you, all of us have done a lot. Have you ever had a single patient unhappy with the removal? None. Not a single one.

SPEAKER_02

I've had one or two say, you know, we should take a little more simple disal asymmetry here.

SPEAKER_03

But never has it been. You took too much. Welcome to HKB Uncut, the health, knowledge, and beauty podcast.

SPEAKER_02

On this show, we unpack the newest techniques and trends in cosmetic surgery, how to tune out the social media noise to make empowered decisions about your appearance and what you need to know before you book a procedure. I'm Dr. Bill Cortesis. And I'm Gorfarty. We are board-certified plastic surgeons and co-founders of HKB Cosmetic Surgery, an award-winning practice with 11 locations across six states.

SPEAKER_03

In other words, when it comes to aesthetics and cosmetic surgery, we've pretty much seen it all and we want to share our knowledge and unique approach to aesthetics and beauty with you. Whether you're interested in cosmetic surgery for yourself or want to separate fact from fiction in the plastic surgery world, we hope you'll tune in each week. Love me some Dr. Cow. I'm excited to have you on the show, bud.

SPEAKER_02

Thanks, guys. Appreciate being here.

SPEAKER_01

It's been great.

SPEAKER_02

He's the he's the he's the cow cowboy, and so for the girls, he's the cowgirl man.

SPEAKER_03

Oh, I don't know what you're talking about, but I think I would I would really like to dive in deep here. Take a punch intended on uh facelifts and all things facial surgery. Um honestly been a really big boost to the practice. We're we've enjoyed um obviously getting to know you being a colleague and you taking care of all these wonderful patients. But gee, I really want to dive in deep on these facelifts. And I think the first thing I want to hear, because everybody's talking about it, deep plane facelifts. Should we do it? Should we not do it? Is it is it just you know a fad or trend, or is it here to stay and what are the advantages, disadvantages, and why would somebody do deep lane versus traditional?

SPEAKER_01

Yeah, and I think this has been kind of present the entirety of my career here, certainly, is talking to everybody. The patients ask about what the deep lane facelift is and what's involved with that. And you know, it it's it does take time, but I think it's worth kind of explaining to them like the reasons why we do it and the risks associated with that. Um, I think these days it's kind of just thrown around a lot too, you know, like, oh, I'm doing this. Are you really doing all the surgery that's entailed with the deep-plane facelift and neck lift and so forth? But you know, I think it it always starts with talking about the retaining ligaments of the face, um, which are in the SMAS, underneath the SMAS, I should say, and releasing those ligaments in the cheek by the masseters, uh, the retaining ligaments in the neck, um, and then certainly the mandibular cutaneous units too. So um, these are the areas that are important to release, you know, actually get you that nice elevation of the fat pads, um, help smooth out those nasal labial folds.

SPEAKER_03

For all the layman out there, when you're talking about the retaining ligaments and the structures in the face, you know, let's let's talk, you know, specifically, you know, right. What are you what are you referring to and what does that mean to somebody coming in in kind of layman's terms?

SPEAKER_01

Yeah, it's tough. Sometimes patients already come in and they're already like honed in on the questions of like what are the retaining ligaments in the case.

SPEAKER_03

Yeah, let's say let's start like you're talking to Dr. Barty who doesn't know a whole lot about the subject. But no, let's let's accurate. But but let's let's start with somebody who doesn't know a whole lot, and then let's kind of fast forward to kind of the um more advanced stuff.

SPEAKER_01

So facelifts and even D-plane facelifts have been around for a really long time. That's actually the truth of the matter. Um and so we have the skin, obviously, of the face and the neck, and then as you go deeper, the SMAS layer, the superficial muscular apode neurotic um system, that's actually the next layer of the SMAS. You know, underneath that you have the other tissues of the face and the neck, right? So you have other fascial layers, you have deeper musculature of the face and neck. So um for facelifts, when we are these days, usually somebody's doing something to the SMAS layer, which is a certain, you know, the layer that's underneath the skin. Okay. So obviously different methods to uh perform facelifts with the deep plane, you're actually going underneath that smaz layer underneath the platisma and lifting the units of the skin and the SMAS and the platisma together. And so, you know, the idea behind that is a couple different things. For one, you know, does it give you a longer lasting result? I think the answer there is it certainly can. You know, you're releasing a lot of those areas that we just discussed, the retaining ligaments, and that can help give you a nice smoother approach, uh, smoother results. Um also, you know, it gives better vasculature. So it maintains the vasculature to the skin, and you should have a you know, better result overall, less issues of scarring overall, and uh, you know, tissue loss and kind of the unfortunate things that can happen if you stretch the skin too tight.

SPEAKER_02

You know, that's a great point that you make, and it's is to remember like some of the initial facelifts that were first described and done were, you know, skin was loose, things have dropped, pull on the skin. Well, we all have learned that you know skin is just not sufficient, right? And you have to you have to handle kind of the underlying soft tissue network. And then there was this kind of movement towards you, okay, so you you move the skin and you move some of that deep underlying soft tissue network, but as you're describing these these ligaments and releasing those ligaments, that leads to better excursion, better movement of all this kind of facial construct. So you literally take what's dropped down and you all are able to reposition it to where it should be, and then the skin just follows, right? The thing is, isn't it's it's sort of a skin surgery, but it's not really a skin surgery in and of itself. So I think that's a big thing that you know a deep plane approach and some other approaches can uh can afford patients. Yeah. You know, w one of the things that I I get asked about, and I know me and you've had this discussion, but I th I'd love to get your your thoughts on this on the philosophy of like, all right, so this is a super popular procedure now.

SPEAKER_00

Yeah.

SPEAKER_02

Um it's always been a popular procedure.

SPEAKER_00

Yeah.

SPEAKER_02

When when should a patient start thinking about it? Should they come see you at 3540, or should they just do fillers and Botox and just wait till they're 50 or 60?

SPEAKER_01

Yeah, and I I think that, you know, for all of us that have been practicing for some time now, um man, it's so hard to put a certain number on when someone's appropriate. You know, I just talked to somebody the other day, massive weight loss patient, 32 years old, and you're sitting there looking at her, you're like, yeah, I actually think you would actually benefit. Um, that's something that I never honestly imagined prior to working here and in this current, you know, 2026 era of uh massive weight loss, GLP1s, et cetera. Um, but that's the reality of it. And then other times, you know, I'm seeing patients in their like 80s, and I'm like, well, yeah, we could definitely do something here to help you, but you don't have the worst findings. Maybe we work on your skin, you know, do do the do the other things. Naturally, at that the older age is gonna have some volume loss, reposition those tissues as well. But yeah, there's there's it's becoming less and less a number. I don't know what you guys think about it, but you know, that's my my practice has definitely shifted, certainly younger, with respect to considering facelifts, which has been crazy.

SPEAKER_03

I think the trend is to do it sooner. You know, I I think a lot of patients don't necessarily want to wait until things are too far gone, and then they look back and go, wow, that's what a dramatic difference. I think people don't want to age gracefully. I mean, they really want to age not at all, right?

SPEAKER_02

And reversing you want to like preserve your prime. You know what I mean? It's like you want you you you're at a place you just want to stay there. And like the truth is, I don't know about you all, the the facelifts that you do and we do patients look elegant and natural. If someone's trying to get like a lift result or a volumization result, if you're too heavy-handed with you know, fillers and neuromodulator, like it doesn't look natural. You get a look. Now listen, you can do filler in an amazing way. And our our our like our injectors can do some amazing things with fillers and biostimulators, so I'm not knocking them at all. Matter of fact, they're very important, and actually they can be used with you know facelifting procedures subsequently. But like the results, I mean, are just better. Like facelift results are awesome. I'm gonna get a facelift. I don't know about you. It's in my future for sure. Right? I'm kidding. Um, but like, you know, at some point, like it's not a bad surgery. Like, I'm gonna ask you, you're you're you do a ton of facelifts.

SPEAKER_01

You're gonna get a facelift? Uh if it's if it's the time, it's the time. I mean, I have patients all the time ask if I'm 14 years old, so it's hard to kind of tell people to yeah, boogie or age or something. But um, yeah, I mean, you know, what I'm also finding there is some benefit to having a lot of information out there now as far as facelifts go. Obviously, the celebrities doing it too, and uh I'm sure we'll talk about that, but um there's just more awareness of it, and I feel like the population, the the generation, I guess, of people in their 40s currently and you know, so forth, they are more comfortable with it and they know what to expect. And like you said, they're gonna heal best right now. They don't want that change where they can't recognize themselves or you know, they just want to be in their prime. Maybe they have social things that they want to, you know, perk up for whatever the word is, but um, it's it's been awesome. Um, these are some of the most rewarding patients for sure.

SPEAKER_03

How do you talk to patients about the fact that they're they're unhappy with how they look? They're already starting to see laxity in their neck and their jaws, they're scared of facelift, they come in talking about non-invasive stuff or minimally invasive, you know, like Illicor, skin tightening, Renuvion, which are all great devices, but how do you differentiate between who's gonna be a you know needs to go down the road of a surgical candidate versus, hey, I'm okay doing these minimally invasive stuff?

SPEAKER_01

Yeah, and I think this matters a lot your conversation with them, understanding their motivations and the kind of results that they're looking for. Um, we do a lot of Elochor here, obviously, and the other non-invasive or minimally invasive things as well. Um, yes, you know, it's natural for people even in their 30s to start noticing some laxity, especially a lot of women, you know, they've had kids and kind of lose a little bit of volume here and there, um, or others are kind of noticing a little more hanging of tissue, you know, in their jowls and their cheeks. So I think that, you know, you definitely want to understand their goals and understand if they want, you know, more definitive change, you know, doing a surgery that for one time might actually give them that result they're looking for a more you know significant amount of change. If you're doing non-surgical stuff, you know, obviously sometimes it takes multiple sessions. I mean, you know, the all these products are sold to us, and you know, we gotta do multiple sessions of them so they have multiple downtimes, and that's not all bad. You know, if it it suits their lifestyle, that's a good thing um for them to pursue. But I try to just tell them look, like, you know, there are things like that I do recommend if you do just have a little bit of neck skin laxity, Melcor could be a great option. Um, radio frequency micro needling can also be a great option for those people too. Um, certainly lasers have a role. Um and then yeah, just kind of small stuff, right? Like volume. We talk about fat grafting today. I just did a case today where we did fat grafting on somebody who I didn't feel like was quite ready for a facelift per se. Um, just had some volume loss over time. So just giving them different options, and I think they'll be good. You know, I think these are all intended to kind of buy them some time before they're maybe more ready for you know the big surgery.

SPEAKER_02

You know, one of the things that you know I know when I when I see you you doing a facelift or you're doing a facelift, or I'm doing a facelift, like very rarely is it just a facelift, right? And so there are often other other interventions that are being done simultaneously. There might be just one thing or there might be multiple things. Um walk us through why it's super valuable to be in to consider combination interventions when approaching the face in general and how that I mean is that gonna make them look more operated on, or they actually look better. Like what's your philosophy on on facial rejuvenation from a surgical standpoint? Like, what do you do? What do you look at? How do you you know explain to a patient, like, all right, yeah, you're coming in for this, but you know, what about the rest of this? Yeah.

SPEAKER_01

It's funny. Sometimes patients come in and they say, you know, all I want done is my neck, and like that's it. And you start pointing different things out, not to kind of make them think that they need to do these things, but you you also show them, well, you do have some gowls, and then you know, you have some hollowness around the eyes, or maybe you have excess hooding around the eyes. And whether or not these things bother the patient, I think that's the first thing to ask about, is like, are these things bothering you? But when patients often say, you know, I just feel tired. So you really have to peel through that. And then when you peel, when you peel through that kind of feel tired, I just don't feel the same, I don't look the same anymore. That's when I think you actually have to address so many more things. And that can be kind of like overwhelming for some people if they're not ready to kind of like embark upon doing eyelids, brows, fat transfer, facelift, necklift, whatever it might be. Um, but you know, I try to tell them look, you can certainly split some of these things up if you don't really feel like you want to do them all at once. And there's reasons for that. People have sometimes they have concerns over general anesthesia, even though we have a great facility here. We have, you know, multiple surges, multiple anesthesiologists, et cetera. So it's a super safe place to do surgery, actually. Um and you know, one of the best parts. But um yeah, I I think it really depends on the kind of downtime that they're expecting. And you know what's funny is like with the face-of specifically, there are certainly some like swelling, bruising to encounter, but I feel like sometimes with things that they might think are smaller, lower eyelid surgery, you know, you can definitely see a lot of bruising with those kind of procedures too, unfortunately. So sometimes it does make more sense to put it all together so you kind of get that done. Yeah. Um, but you know, I think everybody does have an approach with that.

SPEAKER_02

Yeah. You know, one of the things you and I have talked about um when you're approaching the face, if you're gonna look, and Bill and I have talked about this for the body, like when we talk about somebody when they come in for a tummy tuck, like you you see their anterior part of their torso, but when we see them, you're s we see them all in 360. So it's like same with us when we see somebody's face, you're not looking at binoculars, just at their, you know, lower face and neck or just their eyes. And so um it's interesting when you approach it kind of as a panfacial thing and do multiple little things, and even you know, you're you're a big proponent of of CO2 laser as well, and uh maybe we can chat about that. But like it has a it has a unique effect. So when they come back in, their faces in kind of harmony. And um, I don't know about you, but every time I I'd love for you to tell us like your patients' reactions when they come in like two weeks or four weeks afterwards, like what are they like? Like, what are these patients like?

SPEAKER_01

Yeah, the vast majority of them after two weeks, you know, they're they we've all their sutures are removed at that point. I think they're all pretty much free to do mostly what they need to do. You know what I mean? Our incisions heal really well. Um, they're not dealing with kind of really bad scarring at that point. Um, I tell most patients by like, I don't know what you guys say, but after that two week period, it life life just gets more a lot more normal. Um by four weeks, you know, you should really be pretty prepared for an event or like go out and things like that, not feel like you're gonna be like stared at or anything. What are their comments to you when they come in? You know, their swellings are gone. Yeah, I mean they they I mean the most common things obviously, I think this is, you know, like I should have done this earlier. Um I I really felt like the swelling would last longer. I didn't think it would be this easy, I didn't think it'd be this, this, this, you know, painless. Uh I didn't need to take any pain medication. A lot of our patients, you know, these days are not trying to take a lot of narcotics anyway. But yeah, the recovery's overall pretty fast. Um, and and I think what really helps is like being aware. Obviously, it's our job to kind of educate them, but also like I really talk to the patients like you know, really have faith in the process, like be positive and know that, you know, I just talked to a patient today, like, you're gonna be fine, you're gonna do great. But we also have to be on the same page with that and know that we're gonna take care of everything and as it comes up, you know. But the key is to kind of stay positive and know that you're gonna look great.

SPEAKER_02

Uh it's always fun when you you you see patients like I've seen your patient, I've done some follow-ups for you, and I see our own, and then when they're when they come in that you know, one to three month to six months, even like you're out and they're just like they're just happy and they come in to see you, and it's just like it's a fun social visit, and you know that you made that impactful change and they look great. What about scar? You know, how visible are these scars? Because I always feel like they're just I mean, you really have to look. Yeah. But give us some of your your thoughts and explain kind of scar and and and and how dis disguised are they?

SPEAKER_01

Most of the face-up scars are kind of hidden in shadows, right? And by the hairline, so I position it in the hairline itself. As it's healing, the scar will usually kind of you know, the hair is gonna heal through the scar itself, so kind of further obscures things. And then it travels along the ear, a little bit of area right there in front of the um helix, root of the helix there, which is you know a fancy word for in front of the ear. Then I usually go behind the tragus. I know there's some people who like to go in front of the tragus, which is this little area here, and then behind the earlobe. So essentially all this stuff is hidden, you know, in in most most women, I should say. So when you have your hair down, obviously they won't see anything. Um but I find that our incisions heal super well, you know, we we get them on the right regimen, you're not pulling too tight, et cetera, on the skin. So um scar is definitely one of the most common questions for sure. Like, you know, are you gonna be able to see or are you gonna be able to tell? I think if we're taking care of the tissues properly, you know, during surgery, not putting things under tension too much, you should have a really nice, you know, nearly invisible scar uh once you're all healed up. I mean we also do things like lasers and things like that if we need to kind of further augment things, um make it even more invisible, which you know takes a few efforts sometimes, but it's definitely worth it.

SPEAKER_02

And what about, you know, someone who's had a facelift 10, 15 years ago? I mean, are are they are they hosed? They just there's nothing to do. Are they gonna look like they if they have something else done, are they gonna have a negative outcome? I think it's a misconception. Walk us through secondary, tertiary, ordinary facelifts, because we I know you've done them all.

SPEAKER_01

These days it's like I know mo I feel like half of our patients have had some form of facelift done in the past. And look, that's just kind of the time course, right? We're all aging even at the time of surgery. You know, we're healed up, but then in a number of years you're gonna have signs of facial aging. This is normal. Um, so no, you're definitely not hoes if you've had a previous surgery and you want to have further improvement. Um, we see this all the time. Um, you know, and I think it's actually important to kind of like we have to accept that too, because moving forward, if people are starting to do this younger, you know, we're just gonna have to get better and understand where we are and the anatomy and what the prior procedures were to really give them the results um that we want, you know, second surgery, third surgery, and so forth.

SPEAKER_03

So how long will it last? Yeah. You know, a patient comes in, you know, and they they have their first procedure done. They always ask, how long is it gonna last? Always ask that.

SPEAKER_01

They really do. Yeah, and I mean the studies, you know, that have been shown, it's like eight, ten years is the idea here. And I think often patients, when we do surgery on them, especially when you combine the other things we're kind of talking about before, you know, sometimes they feel like they're younger, 15 20 years. I don't make these numbers up, they they're the ones saying it. So I think that's a pretty great return on, you know, if you're calling it an eight, 10 year surgery and you feel like you're you wind it back 15 years, that's great.

SPEAKER_03

Yeah, it's usually what I tell them. It's like we're just turning the clock back, but the aging process will continue. Is there anything that you see or that you know patients have done previously that make a facelift more difficult that you would uh knowing what you know now would tell patients, hey, think about this before you do it. I know a few that you're gonna say, but uh you know, I I think this is a key point that a lot of patients are really gonna want to hone in on of things to avoid to make your facelift better in the future.

SPEAKER_01

Yeah. So one important maybe the most important thing I think is timing. So doing some procedures, if it's within three, six months, I really don't think that's a great idea. Even something as minor as certain lasers, I would say, are not a great idea. I've I've done some face of some people that had laser within the three-month span. And maybe we didn't do it, you know, in in our practice. But like when you're dissecting that tissue, trust me, like this is why I know lasers work, is because you can see that change in the skin. You can tell in the ears that they didn't touch, like, wow, this is elevating just fine. Um, that collagen production is real, and it certainly can, you know, disrupt the planes. But, you know, we are experienced surgeons and we're able to get through it. Um, it's just knowing about the timing. So I generally try to tell patients, like, look, like if you are planning having surgery, try to avoid things maybe up to that even that year. And what I mean by that are things like you know, RF microneedling, um more invasive things like I face tight if people are doing that at this point. Um Renevion. I mean, ideally, these are not things you're doing in the months beforehand, sculpture. Um threads, threads, certainly. So these things can be put in the, you know, you try to put it in the right plane um when people put these things, but sometimes they can get a little bit weird and cause some scarring, and that can certainly make you know surgery more challenging. Um, so yeah, you know, it starts with timing now. I do have patients that have had these things done before, and I'm sure you've guys have seen when you've had surgery and even surgery in someone facelift like 10, 15 years ago, usually by that point that skin has remodeled pretty nicely. So when you're elevating things and And you know, if if that smazzer is still intact and things like that, you know, it's really not that bad. Um so if someone's really like maybe not a surgical candidate, I think doing non-surgical stuff is actually great. Um you're not gonna disrupt anything. But yeah, I would avoid doing it too soon prior to surgery. I think that's a key.

SPEAKER_02

Yeah. And also, you know, I think one of the things is it's great when you know, like as a surgeon, you know you're you know that they've done stuff so you're kind of prepared because otherwise you still can do it. I mean, I I've I know we've been in each other's rooms where we go and we're like, oh man, this patient must have had X, Y, and Z because it's wood. It's like dissecting through wood. But the thing is you can do it. And it does take a level of experience because if you don't have that experience, you could potentially create a tissue flap that's too thin and have a healing issue, or you could, you know, get into a structure you're not supposed to be in. Um but I've seen I've seen you go through, you know, all kinds of different um, you know, terrain and territory, and it it ends up working out, but it's really nice when you know. It's like you know, having a roadmap to what's going on like helps so much. Um, or when you go into someone who's had like multiple rounds of liposuctioning in the neck and then RF micro, whatever it's it's like literally dissecting through wood. You can get through it, but it just sometimes we need to know because we need to add an extra hour to the surgery or something just so that you can go a little slower.

SPEAKER_01

If someone's had radius in certain areas of the face or neck, I'm already like, okay, let me think about my approach. Maybe we do this preservation approach now, right? Where I go all the way, limit my skin dissection, and just go into the subsmas subplatisma, and that way you just kind of bypass all that. And you know, we're already doing so much of the subplatismal dissection, it's not that much different of a surgery, honestly. And I've been doing that a lot in in certain patients, trying to, you know, do the non-delamination kind of thing. So not having to open things up in the midline, correct? Yeah, I mean you if it's indicated, it's indicated, but sure. Yeah, just trying to kind of keep the skin and the muscle together. Sometimes that actually gives you more snatch results than really interesting. Very interesting.

SPEAKER_03

Let's throw the counter question. Anything you would recommend ahead of time that you're like, oh, that actually makes things better or looks better.

SPEAKER_01

Yeah, I mean, I think, yeah, so you know, when you do surgery, often patients are like, you know, I don't have to get Botox anymore, right? Like, we're good, right? And the answer is of course not. I mean, I think Botox is amazing. Neurotoxins in general, I should say, are amazing adjuncts and tools that we can use, right? Um, helps with obviously wrinkle formation and you know, helps with kind of smoothing things out in general. There's just things that surgery doesn't do well, right? We were just talking about like do you cut all the muscles in the eyelid to make things smoother? And you know, that's been described, but I don't generally think that's a great idea. Um, so um things like Botox and you know your fillers when they're used appropriately, which like you said in our med spas, like they they do a good job of kind of keeping things, you know, at a good natural spot. Sculpture, you know, those are good good products um to kind of consider as well. You know, when they're placed appropriately, it really is not that much of a problem, but it's good to tell your surgeon, obviously, yeah. I've done this a few times. That that's a great great point, you know, uh Rich.

SPEAKER_02

So what so patient gets uh a facelift, neck lift, maybe they get other stuff too. But what should they do to maintain their results? Is there, you know, and and this is kind of dovetails into the neuromodulator discussion, but what what what's your regimen? Like you're seeing them at six months a year. What would you say here, hey, here's what you need to be doing, here's how you here's how you make this last longer.

SPEAKER_01

It's such a broad spectrum of people. You know, I in the ideal scenario for us, it starts with skincare. I think that's really the key thing, being on a good retinol, tretinoin, taking care of your skin with SPF products and your antioxidants, your vitamin C's, etc. Um, and then you know, after that, it's kind of maintenance, you know, neurotoxins. Like I said, if you need a little boost of volume here and there, you can always do fat grafting, fat transfer. You know, fat transfer is super popular these days.

SPEAKER_02

Um is that a down and out procedure? Get in general anesthesia, or or can that be how how is that? Like if someone's like a micro surgery again?

SPEAKER_01

It can be either way. Um, some patients prefer to go to sleep, but today we did it today, and perfectly awake, uh well tolerated around the cheeks, tear trough area. Um, and you know, we we spin it down, make sure it's nice and fine, the microfat, the nano fat, these are different, you know, tools. But yeah, I mean, in terms of maintenance, then we talk about lasers and you know, certainly things there's a role for things like Elicor for sure. You know, I use it around the mouth a lot for kind of the lines around the mouth, combine that with CO2. Uh that's been pretty nice for our patients and you know, trying to give them that whole you know, just rejuvenation, you know, a total rejuvenation. But that but that does mean we need to take care of the skin at the same time. You know, you can have no gowls, but for some people they might have really bad sun exposure, uh just like leathery skin sometimes. So it's it's hard to kind of tell everybody, you know, to be on the same regimen. Microneedling, also really good. Yeah, nothing wrong with microneedling. All skin types are fair game too, which is sweet. Yeah, I did that the first time.

SPEAKER_03

It's good. Well, I think you bring up a really good point. You know, some facelifts, it doesn't take care of every you know, some patients come in and they assume, hey, I'm gonna face a neck lift. They think it's gonna cover all the stuff around the mouth, which is not. So, and perioral rejuvenation is a big deal. You know, the signs of aging are huge in that area. And so we ultimately have to you do these adjunct procedures to address those things, right? Like ELICOR, microneedling, CO2 laser. You have to address it, otherwise they're gonna have a really nice face and neck, but then they have all the signs of aging around their mouth.

SPEAKER_01

Yeah, and and and you know, with all the information that's out there too, there's certainly you know some patients who are like really anti-certain procedures, and that can be tough too when you know that well, this is really the best thing for you. So really have to develop that relationship with the surgeon or the injector, whomever. Like, yes, it's okay sometime to do back rafting or sculpture or filler, whatever it is. There's a reason why they're really useful, you know.

SPEAKER_02

Um, and not to be afraid of that. But you know, one thing I was just thinking about is because you know, today our topic is is facelift. And uh you tell me, I mean, I I feel like I get this a lot where patients come in and say, Doc, you know, I want I want a facelift. I want I want I want a full facelift, or I don't want a full facelift. Can we talk about what it means just so we we've really kind of I think discussed what a lower face and necklift is? But talk to us about this part of the face, you know, you know, above cheeking up. Like what what does that mean when a patient says I want that kind of facelift? What does that mean actual from a technical standpoint? And what procedures would that be? And could you do that with a lower face and necklift?

SPEAKER_01

Yeah, right. The full facelift, you know, you're taking the brow traditionally as well, and sometimes that's like a complete incision across the forehead in the hairline, I should say. And that's to kind of elevate the brow, the middle of the forehead as well. Sometimes you can manipulate the hairline as well. Um, obviously position the brow as well. Okay. So you mean you mean lower the hairline, right? Oh, sorry, yeah. You can lower the hairline, you can also take it up if you really wanted to, I guess. But some people do have a really, you know, short hair hair forehead, but um, yeah. And then as you move down, you're kind of touching the mid-face area, and you certainly lift those areas as well. The temporal brow lift as well is a huge role these days. Um, you know, brow aesthetics changes so much over time, and you really want to listen to the patients um about what they want. But yes, a full facelift would include all these parts the the the upper third, the middle third, the lower third of the face. And um, you know, I feel like these days, certainly, when we, you know, talk about facelifts, sometimes patients think it just kind of applies to the whole head, the whole forehead and everything else. And I do think most patients these days are thinking, okay, we're we're we're talking about the lower part of the face for the most part here. We're addressing the jowls as well. So um yeah, sometimes they think that you know it also includes the eyelids and things like that. So we kind of have to clarify that. Um, but that's that's that's easy to kind of redirect people on that for sure. Favorite approach for brow lift? Ooh, um endoscopic or temporal. Yeah. Yeah. I I you know, I think the you know, the the trichophytic incision, the one in the hairline, is very powerful. Um it's just yeah, it's certainly quite an incision to to go, you know, make.

SPEAKER_03

General versus local, gentlemen. People going to sleep for this procedure, or can they do it awake? And what is your preferred approach? And what if somebody's like, hey, I just don't want to go to sleep. I want to hear it all.

SPEAKER_01

Yeah. So my preferred approach is definitely general. Um I think it's this, I think it's the safest, most efficient for sure. We can certainly ensure the best possible result, in my opinion, as well. Um there are cases where I've done them with patients being awake too, you know, for various reasons. If it's anesthesia, um, mainly being the main one, if they can't undergo general anesthesia. Um sometimes if we're doing like a unilateral surgery for some reason, that might be fine too. Um, but yeah, I mean, I think it's it's just much better. You know, modern anesthesia's made, you know, huge improvements. You know, there certainly are risks of general anesthesia, but um I think that you know, we've got great people here with work with us routinely. Um, like I said, anesthesiologists, CRNAs who work with us daily, right? And so huge amount of support um in the OR, which is great at our practice. Um, I've personally talked to patients who underwent a lot of procedures under local and have had discomfort and you know, maybe had like, you know, results they didn't really like as much out of other practices from from doing it under local. So not to say you can't do it, but just know that that's the risk that you can't get the result, you know, that you maybe want just because you're uncomfortable, which you know that's not worth it. You know, this is your face. You want to make sure you you know, here's the deal.

SPEAKER_02

I would tell you that for me it's very much patient-driven. Like I can tell, like if I'm like, listen, you know, if they if they're like, I don't can you do this under local, I'm like, well, how do you do with things? Do you like do needles bother you? Do you get queasy? You know, are you an antsy person? How are you gonna do hearing sounds, vibrations, feeling things? Because they're you're gonna feel those things. And I think if they're like, no, I'm good, and like I I want to do it, and then I will do, you know, fairly decent facial process under local, I'm gonna do full face and neck and do some lids, do other stuff. But the thing that it's is super important is that a patient has to be like fine and bought in front of and be able to get to a state of being calm. We still give them oral relaxation, we do it. But I'm I I agree with you, Rich, because one of the things that people don't realize is so they'll say, Well, how about Twilight, Doc? Do Twilight on me. And what happens is, and and I think twilight, quote unquote, or or these kind of total intravenous anesthesias, there are a lot of surgeons who do some of these things, they work out pretty well. But I'm gonna tell you something having control of the airway is one of the safest, best things in in my personal opinion.

SPEAKER_03

I don't think I don't think you should do anesthesia without a controlled airway. It's like it's all choke.

SPEAKER_02

Patients can choke out of the case. It's all crazy.

SPEAKER_03

It's all considered general anesthesia. Yeah. That's the thing. And it's either whether or not you have a protected airway or you don't. Right. And for us, it's like, hey, you got to have a protected airway.

unknown

No.

SPEAKER_02

But I think it can be done well with it, but it's like patient selection. And I'll be honest with you, most patients don't want it. Most patients want to have a good experience, they want to be comfortable, they don't want to feel things. And also, like as a surgeon, like you just want to you want to be comfortable too, right? You know, and if someone's really chatty, it can sometimes be a little bit of a micro nuisance, not a big one. And then the other is like, you know, if there's something, if there's something happening, you're worrying, you're doing stuff, like you don't want to get a patient all nervous either. Like you just want everybody to be calm. So I think it's just there's it's like everything that we do. We don't do you don't do the same thing on three patients that come in, every one of them has something different, right? I mean, it just is what it is.

SPEAKER_03

Yeah, um, shifting gears to to male facelifts. Um let's talk about some of the nuances. Dr. Cow, what what some of those nuances for you and and then specifically let's talk about a direct necklift for guys who don't want to the traditional approach.

SPEAKER_01

Yeah. Um men are definitely getting facelifts uh more and more these days. Many of them, you know, don't like to share their photos. It's been certainly a challenge. But uh they, you know, at the same time, they heal great. Um, especially most of my our population, you know, they're able to have some level of bearded skin, which really helps me not so much. But when they're healing in the hair area, that heals super nice. I try to line up their sideburns nicely, okay, and they're able to carry that up. I typically will make a pre-tragle incision which kind of goes in front of the ear. It heals great because again, you're bringing that hair into the area. Um, and also, you know, technically you don't want to bring that hair into the ear canal for what it's worth. But um, other than that, you know, men are bigger, they have bigger heads, bigger vessels, maybe they have a little bit higher risk of bleeding. Um, so important to kind of be prepared for that. It doesn't really change anything technically during the approach is the same, approach is largely the same. I think men are usually looking at specific things um that they want to adjust. And that's usually, you know, for me, the procedures and are either the eyelids, you know, so usually where they start, or in the jowls and the neck, right? So those are kind of the two main things. So yeah, I mean, everybody has a different taste, you know. Maybe the thing about the hollowing around their eyes as well. So you gotta think about volume. Um, I I kind of change it up a little bit based on their everyone's anatomy. You know, men often have a more square jaw, so you're thinking about the way you're gonna lift. The vectors are a little bit different, um, just to get a nice jawline, which is what I think men are largely looking for. Um, yeah.

SPEAKER_02

You know, the nice thing for men is that it is a it definitely is it is something that is a masculinizing procedure. Like it's there's nothing about it that feminizes them. Like so a a male getting um facial risk restoration, like lower face and necklift, or eyelid surgery, or fat transfer too. Men, men sometimes men, you tell them, hey, I'm gonna need to add a little volume, and they'll kind of look at you sometimes. But the the truth is almost every man has has infraorbital hollowing, oh yeah, has a little bit of cheek loss. And so when you restore that and combine that with, you know, upper lid, lower lid, the effect is so powerful. I mean, these, you know, guys come back and and and I would say some of them are like even more impacted than their female counterparts because they're just like, man, all right, I'm here. And there's guys who are working longer, they're in big positions, or they're competing with younger guys for positions, and women are too, but I I get this more from guys. Hey, I gotta I gotta be able to compete. I gotta be able to, you know, look, I want to look as good as I feel. And it's crazy how what you can get with them. And what you're saying is really interesting. When they heal, the scars are almost invisible. And it's because they got this, you know, ruddy pilo sebaceous skin. So it's like I I mean, you've done it, I know I've done it, and I think you have too. Like even guys who wear their hair real short, i.e., you know, ball patients, will do this all day long because the change is so significant. And even after things heal up, the scars actually are not super visible. So it's a pretty remarkable thing for guys.

SPEAKER_01

Yeah. And I think like, you know, a lot of men, they, you know, to talk about the fat transfer aspect, they they definitely don't like the concept of it because they're like, I don't want to look fat, you know, where I don't really need to take that from my belly and put it up there. But yeah, you're absolutely right. With uh especially with the eyes, you know, they are always kind of surprised, like, oh my gosh, that was the best thing. And most men haven't maybe played around with fillers and things like that, so they don't really know what the role is of volume in their surgery. So that's why it's huge to kind of talk about that, you know. Direct neck lift though, certainly an option for people that who is that ideal candidate for the yeah. So the ideal candidate for that is someone that you're you know, you're largely looking at just problems with the neck. You know, we're talking underneath the mandible itself, just in the area underneath that area instead of addressing the jowls. Maybe they don't care for it.

SPEAKER_03

Maybe they can't really have, yeah, maybe they can't have like I mean the the last few that I did were individuals who said, Doc, I'm not going to sleep. I'm not doing general anesthesia. This is the only thing that bothers me. And or they have medical issues that you know prohibits them from doing general anesthesia, and they're like, just take care of this. And and and they're all happy.

SPEAKER_01

Yeah. And some subtleties on that. Yeah, I just actually saw a patient who I did this on, especially if they just have like, you know, really good anatomy for one, but if it really is largely the skin and it's pretty high up, you can actually carve a really nice angle.

unknown

Okay.

SPEAKER_01

You know, certainly better than in honestly in this traditional approach sometimes. It is under local.

SPEAKER_02

What's the biggest drawback?

SPEAKER_01

Scar. That's the deal. The scar runs, you know, we try to make it irregular purposefully, so you don't, you're not, you know, your eye isn't drawn to that linear scar. You don't want scar strictures. You kind of put a little Zoro in there. Can I put a little Z in there? The Grecian urn. Shout out to the Greeks. Um, but we invented a lot of things. Yeah, obviously. Yeah, because we're urns specialists. So yeah, I mean it's it's a great procedure for the, you know, especially for men for the most part. I I I tend not to offer it to females. I don't know about it. Yeah, I can only count like one that I've done on a female. Yeah.

SPEAKER_02

Does she have like some facial hair to help out? Unfortunately, she did not. And so that's the thing. Yeah. And she had redness, she had a little bit of thickening. So sometimes that's the biggest thing of that. I think is you can you're you just need to be prepared for some TLC, but it is a good option. It's really remarkable. I mean, like direct interventions. I mean, what's your thought on some of these other direct surgery, like direct central lip lift or direct lateral lip, direct brow?

SPEAKER_01

Doing a lot more lip lifts now. Um it's obviously very popular surgery. Uh, I think there's a lot of nuance in it, personally. Um, you want to look at the whole face. So you want to look at the length, obviously, of the upper cutaneous lip, which is from the area underneath your nose to the top of the vermilion, right? And that can use the red part, right? Yeah, yeah, the yeah, especially the junction or the red to the to the lip roll. And that's the kind of the area that you're measuring to see if it's long or not. But I, you know, I asked them a bunch of questions, you know, like has this changed over time? You know, have you lost weight? Um, what about your teeth? Um, the role of the structure that's a great point of the teeth.

SPEAKER_02

Because sometimes they want that dental show, and the liplift is actually not the thing that's actually correcting that. They need to have their teeth worked on.

SPEAKER_01

Huge, huge. And then also loss of bony volume, obviously in the mid-face area, you know, that contributes to it as well. And so people feel like, oh, maybe I look frowny. Maybe it's coming with the corners being the issue as well. Um, so and then I gotta ask ask about their teeth. Do you like your teeth? Do you feel like you see a lot of your teeth already when you smile? And if the answer is yeah, I see like too much of it, you know, that can be a tricky surgery to do. It doesn't mean you can't do it, even though you have a long upper lip. But um, yeah, I really take the whole facial balance into the central lip lift because it's it's a very powerful procedure for what it is. You know, it's such a small piece of tissue. And you're taking millimeters out, but it's just kind of takes everything out and puts it in different proportion. Pro or con buckle fat removal? Oh. Pro. I'm pro. So in especially in the facelift, when I am then D-plant, I'm able to pluck that out. It's it's huge to decompress it. Some people are doing it. So what are patients gonna see when they when that it gets removed? Yeah, often the the buckle fat has kind of descended and you know the tissues. How does it hang? It ends up down here in the gel. Exactly, in the jowl area here, and it kind of, especially in the least ladies with really thin skin, you can almost like see it pop out. And you test it beforehand during surgery to make sure you know you're seeing what you're seeing. But yes, decompressing that area is gonna help not drag down the jowl, especially post-operatively. So you can definitely tell a difference.

unknown

Yeah.

SPEAKER_01

And I in a younger patient, you know, there's also some indications for buckle fat removal, you know, yeah, reduction.

SPEAKER_02

So that's a great question. I think it's it's super you hear some people saying, I would never ever do a buckle fat removal, blah, blah, blah, just taking this stance. And then you have others, you know, no one really says I'll do it on everybody, but I think it's it's it's gotta be a unique patient-to-patient thing. But let me ask you this. So when you're doing a buckle fat removal on a young person, what's your approach? Because just because you're doing a buckle fat removal doesn't mean you have to take out every ounce of buckle fat. You can do a buckle pack reduction. And I feel like that's what we actually are doing for these younger patients. You're keeping the volume. So honestly, walk us through that. Just just for what what's your position on it? And what do you think about people say you never ever take somebody's buckle fat because you'll you'll pay for it in the future. I'm wondering what are they talking about? What are you gonna pay for?

SPEAKER_01

Yeah, I mean, patient selection is key here. If you have someone who's really wide, cheeky, you know, just really kind of puffy here, they're just a little bit rounder and you're just trying to help them out, trying to give them a little bit of a carving out for their cheek, their jawline. And um, yeah, I mean, I think people are just trying to say something that doesn't really make sense.

SPEAKER_03

Uh yeah, have you ever had a single patient? Because we've all done a lot. I can tell you, all of us have done a lot. Have you ever had a single patient unhappy with the removal? None. Not a single one.

SPEAKER_02

I've had like one or two say, you know, we should take a little more asymmetry here.

SPEAKER_03

But never has it been you took too much. No.

SPEAKER_01

And like now, someone say I need I need volume put back, Ken. By the time someone has noticed that that buckle fat was gone, let's say you give them 30 years from now. I mean, that's really not gonna change. It's actually not gone, it's just descended. It's still there. But like if you took it out, it's probably just normal skin, muscle, et cetera. So that's yeah, I it's hard to know exactly why, you know, it was trending that you know you shouldn't do buckle fat ever, because I do it all the time.

SPEAKER_03

It just shows you we we have so much to talk to our our our friend Dr.

SPEAKER_02

Cal here about. This has been uh an amazing conversation. I can't wait till the next one. Uh we're gonna we're gonna spend a lot of time talking about noses and um, you know, just cow nose and nose. Um this has been incredible.

SPEAKER_03

He does a lot of odoplasts too. Just noses and faces, but he does thighs also.

SPEAKER_02

Eyes and thighs. Thighs and eyes. But but in all sincerity, this has been a great episode. Um, I think that um we want to thank all our viewers for watching and and listening. And any questions or thoughts you have for us and Dr. Cow specifically, please you know reach out to us on our platform and submit any questions or any other um uh things you want us to talk about next time. Thanks, guys. Awesome. Appreciate it.

SPEAKER_03

Thank you for listening to HKB Uncut. If you enjoyed this episode, please subscribe to us on Apple, Spotify, or YouTube.

SPEAKER_02

To book a surgery consultation or med spa appointment with our team, visit our website at hkbsurgery.com or head to the links in our show notes.