#1 Plastic Surgeon: Breast Implants and Brazilian Butt Lifts (DON'T DO THIS)

Summary

Podcast Summary: The Neuro Experience Episode: #1 Plastic Surgeon: Breast Implants and Brazilian Butt Lifts (DON'T DO THIS) Host: Louisa Nicola
Guest: Dr. Charles (Plastic Surgeon)
Date: July 25, 2024

---

Overview

In this episode, Louisa Nicola sits down with Dr. Charles, a board-certified plastic surgeon, to discuss the nuanced realities of plastic surgery. The conversation explores breast augmentation—addressing cancer myths, breast implant illness, and screening—before turning to the evolution, risks, and psychology of aesthetic and reconstructive procedures, including Brazilian Butt Lifts (BBLs), liposuction, body dysmorphia, social media's impact, and transgender surgeries. The episode aims to debunk persistent myths and provide a transparent, evidence-informed view into the world of plastic surgery.

---

Key Discussion Points & Insights

1. Breast Implants and Breast Cancer Myths (00:54)

• Myth Debunking: Breast implants do not increase the risk of breast cancer.
  • “Breast implants do not give anyone any increased risk of breast cancer. Completely unrelated.” — Dr. Charles [02:18]
• Rare Complication: Some textured implants (no longer used) were linked to lymphoma, but it’s rare and treatable.
• Screening Nuances: Implants may make traditional mammogram readings more challenging, but specialized displacement techniques and notifying the imaging center solve this.
  • “In 1986 or 1988... Dr. Eklund... showed this displacement... you can have adequate screening even with implants.” — Dr. Charles [03:45]

2. Breast Cancer Screening Guidelines (04:26)

• Screening Age: Standard mammograms begin at 40 because breast tissue is denser at a younger age, making detection harder. Earlier (35+) or alternate screening is needed for high-risk individuals (BRCA gene, family history).
  • “If you have a first-degree relative... diagnosed at age 40, you should start your screening five years before their age of diagnosis.” — Dr. Charles [05:19]
• Self-Exams: Still important; many lumps are benign, but vigilance is crucial.

3. Full Body MRIs for Cancer Detection (06:51)

• Limitations & Cautions: Not currently recommended for healthy individuals due to low yield, high false-positive rates, and potential over-treatment.
  • “Is it something that we’re going to get to the point where we recommend for everyone? Probably not, for the reasons you mentioned. False positives...” — Dr. Charles [07:31]

4. Misconceptions about Plastic Surgery (09:18)

• Training Scope: Aesthetic surgery is just a fraction of comprehensive plastic surgery training, which includes reconstructive work for trauma, cancer, burns, congenital deformities, and more.

  • “Aesthetic surgery is a small part... you're doing craniofacial fractures, free flap reconstruction, pediatric hand, etc.” — Dr. Charles [09:56]

• Reconstructive Impact: Plastic surgery helps restore function and confidence; its psychological effects are profound.

  • “It's almost like psychology with a scalpel... They’re rarely talking about what they look like... they’re talking about how they feel.” — Dr. Charles [11:27]
  • Memorable Moment: Story of a mother who regained confidence through surgery and became “more present” for her daughter [12:30].

• Burns: Plastic surgeons play a critical role in burn care, grafting, and reconstruction.

  • “...devastating injuries... plastic surgeons remove damaged skin and do skin grafting.” — Dr. Charles [14:38]

5. Breast Implant Illness (BII): Controversies & Evidence (16:36)

• Origins: BII describes nonspecific symptoms (fatigue, brain fog, rashes, etc.), with no objective findings in testing.
• History: Silicone implants were pulled off-market in the '90s following autoimmune concerns; epidemiological studies failed to show causation.
• Recent Research: The best study (prospective, randomized) found:
  • No difference in inflammatory or immune markers among those with/without BII ([21:20]).
  • The only predictive factor was pre-existing anxiety/depression—suggesting a psychosomatic component.
  • 90% of patients reporting BII improved after implant removal, regardless of technique; placebo effect can’t be ruled out.
  • “The science doesn’t support it yet. The only predictive factor... history of anxiety/depression.” — Dr. Charles [23:31]
• Takeaway: “Is it possible that... science is missing something? ... If it exists, it exists on a much smaller scale than I think is being perpetrated.” — Dr. Charles [25:39]

6. Social Media & Misinformation (27:29)

• Dangers & Skepticism: Social media accelerates pseudo-expert claims and spreads inaccurate fears (e.g., BII, nutrition myths).
  • “We have seen this explosion of pseudo-experts... having never tested... there’s a good part of the public that will grasp onto something and call it fact.” — Dr. Charles [28:29]
• Critical Thinking: Both encourage consumers to demand evidence and check study methods, especially in wellness trends.

7. Regulation & Safety in Aesthetic Procedures (32:44)

• Provider Qualifications: Many non-specialists perform cosmetic surgery and injectable procedures due to weak regulation; patient due diligence is key.
  • “As little as 30-35% of plastic surgeries in California are done by plastic surgeons. The rest—people doing operations that don’t have accredited training.” — Dr. Charles [33:53]
• Risk of Complications: Inexperience leads to serious risks, both in surgery (liposuction) and injectables (Botox, fillers).

8. Liposuction vs. Fat Loss & Medical Tourism (35:35)

• Difference: Liposuction permanently removes fat cells but isn't a weight-loss procedure; remaining fat cells can still grow if lifestyle changes aren't made.
  • “When you do liposuction, I am permanently removing a fat cell from your body.” — Dr. Charles [36:49]
• Medical Tourism Dangers: Cheap options overseas often result in poor outcomes, infections, and sometimes fatalities.
  • “You might get a good result, but you’re paying for a probability of 50%... or you might die.” — Dr. Charles [38:09]

9. Social Media’s Impact on Patient Decisions (40:34)

• Cosmetic Surgery as Routine: Procedures becoming normalized; heightened by “before and after” social posts and influencer marketing.
• Expectations Management: Many patients request results copied from celebrities, not realizing the imagery is manipulated.
  • “It's like a dream within a dream sometimes... You're trying to be someone who's not even that herself.” — Dr. Charles [42:26]

10. Brazilian Butt Lifts (BBLs): Risks, Myths & Mortality (43:25)

• What is a BBL: Liposuction with fat transfer to the buttocks; not an actual “lift.”
• Mortality Rate: Earlier studies (2016) reported 1 in 3,000 death rate, primarily due to improper technique (injecting into the muscle, causing embolism). Updated guidelines and practices have since reduced the risk 5-fold (1 in 15,000).
  • “If you're in the hands of someone... it's a safe procedure. If you hear someone saying, ‘I don’t do this because it’s not safe,’... they’re not familiar with the data.” — Dr. Charles [45:41]

11. Body Dysmorphia & Patient Psychology (48:13)

• Body Dysmorphia: A spectrum; up to 20-40% of those affected seek cosmetic surgery, but 80-90% won't benefit post-surgery unless severity is low and motivations are healthy.
  • “You have to have a little humility, even in the context of the science, and say, hey, it's possible there may be an issue.” — Dr. Charles [26:54]
• Approach to Screening: Providers screen for unrealistic expectations/psychological distress (often by simply saying, “I don’t think I can meet your expectations.”).

12. Lifting vs. Tightening & Surgical Realities (51:43)

• Tummy Tuck Definition: Lower abdominal incision addressing loose skin, muscle separation (rectus diastasis), and fat deposits—most common after pregnancy.
• Lifting vs. Tightening: Often synonymous (e.g., breast lifts), but tightening also refers to non-surgical skin tightening modalities; true “lift” generally requires incisions.

13. Reconstructive & Transgender Surgery (61:48)

• Gender-Affirming Procedures: Surgical interventions in transgender care are preceded by psychiatric assessment. Bottom surgery (neogenitalia) is complex and largely irreversible.
  • “The only treatment is surgical—to grant you the physical identity that matches the identity you feel.” — Dr. Charles [62:14]
• Age Criteria: Surgical interventions generally require adulthood (18+); hormone therapy for minors remains a contentious issue.

14. Cosmetic Intimate Surgery (Penile Implants & Fillers) (67:42)

• Penile Enhancement: Fillers (hyaluronic acid) can add girth, not length; surgical options are more invasive and seldom done for purely cosmetic reasons.

15. Skin Health and Youthful Aging (69:45)

• Evidence-Based Skincare: Collagen supplements likely beneficial; fundamental routines include sunscreen, retinols, vitamin C, and daily cleansing.
  • “If you just follow those, it’s not too complicated... Did you see the twin study? The one who got Botox regularly—10 years later, dramatic difference.” — Dr. Charles [71:23]
• Role of Genetics & Prevention: Acknowledges much of skin’s aging is genetic, but prevention and consistent routines matter.

---

Notable Quotes & Memorable Moments

• “It’s almost like psychology with a scalpel.” — Dr. Charles [11:27]
• “The science doesn't support [breast implant illness] yet. The only predictive factor... history of anxiety/depression.” — Dr. Charles [23:31]
• “If you go get liposuction and then go eat an in and out burger three times a day... you can kind of ruin the result.” — Dr. Charles [36:51]
• “You're paying for the probability of a result... It's not like buying a TV where you know exactly what you're going to get.” — Dr. Charles [38:09]
• “If you hear someone saying, ‘I don't do this because it's not safe,’... they’re not familiar with the data.” (On BBL) — Dr. Charles [45:41]
• “In a perfect world, no one would come to see me. They’d be happy with the way they look and living a full life.” — Dr. Charles [57:38]

---

Important Timestamps

• 00:54: Debunking breast implant and cancer risk
• 03:45: Adequate breast cancer screening with implants
• 05:10: Screening for high-risk populations (BRCA, family hx)
• 09:56: Breadth of plastic surgery training and misconceptions
• 11:27: Psychological impact and reconstructive stories
• 16:36: Introduction to breast implant illness (BII)
• 21:20: Scientific evidence about BII
• 25:39: Summary on validity of breast implant illness
• 28:29: The role of social media in spreading health misinformation
• 33:53: Lack of regulatory oversight in aesthetic medicine
• 43:20: BBLs, risks, mortality, and technique evolution
• 51:43: Tummy tucks, lifting vs tightening
• 62:14: Overview of transgender (“gender-affirming”) surgeries
• 69:45: Science of skin health, basics of anti-aging
• 71:23: Botox as prevention—evidence from twin studies

---

Final Takeaways

• Plastic surgery is more nuanced and impactful than often portrayed, encompassing both life-restoring reconstructive procedures and well-chosen elective interventions that can profoundly improve confidence and quality of life.
• Patient safety, realistic expectations, and self-acceptance are paramount. Regulation lags behind, making patient education and due diligence crucial in choosing practitioners.
• Social media is a double-edged sword, fostering information but also elevating myths, influencing expectations, and lowering the emotional threshold for pursuing surgery—sometimes unwisely.
• Dr. Charles emphasizes humility, data-driven practice, individualized care, and open dialogue as the best antidotes to both outdated stigma and modern misinformation in the evolving field of plastic surgery.

---

For more insights, follow Dr. Charles on Instagram or visit his clinics in Beverly Hills and Dubai.

---

End of Summary

Transcript

[A]

Doctor Charles, welcome to the Neuro Experience podcast. So excited to have you. This area really interests me and I think you're going to be able to provide not just a helicopter view of the entire world of plastic surgery, which I think is more nuanced than what people see it as. But we're going to deep dive into many areas and I'm going to start by understanding breast augmentation. And this came about because something that you actually put up on social media and it was around the breast augmentation procedures, misinformation thinking. You know, a lot of people thinking that getting breast implants may increase your risk of getting cancer. And you debunked that and said it doesn't increase your risk of breast cancer, but it may interfere with the screening of breast cancer. So I would love to talk about breast cancer screening and how breast implants may interfere with that process.

[B]

Sure, A pleasure to be here. So, you know, obviously breast cancer is a, is a topic relevant to just about all of us. I mean, you're talking about the number one killer of women in cancer, number two overall behind lung cancer. And one in eight women in the US in their lifetime will be diagnosed with breast cancer. So the numbers are staggering. And really early detection is our, is our, is a primary weapon we have. In fact, if you detect cancer early, if it's a local disease, your five year survival is 99%. If it's spread of the lymph nodes, it goes down to the 80% at five years. If it's regional, if it's distance spread, you're talking about a five year survival of 30%. So early detection is critical. Now we're talking about breast carcinoma or breast cancer. One of the things when it comes to breast implants that can be confusing for patients is something that came out in the news some years ago. It was a breast implant associated lymphoma. And what they found is in a particular kind of implant, meaning a textured implant primarily, which is the surface of the implant, which isn't really used in the United States anyway. And now that implant that was kind of exposed is no longer available. But they found a very, very rare cases. Patients would develop a localized lymphoma. So it was a cancer of the lymphatic system. Cancer cells would be found in the implant pocket and the patients would present with some breast pain, maybe some swelling. Now the good news is the cure rate was greater than 90%. But nonetheless, this created this panic that breast implants are causing cancer. But that's not the breast cancer that we think about every day, and in fact the breast cancer we think about every day, the risks for that are age, obesity, smoking, age at menopause, hormone replacement therapy, not breast implants. Breast implants do not give anyone any increased risk of breast cancer. Completely unrelated. So back to what we're talking about with screening. So screening is critical, obviously, because the earlier we detect it, the better chance of a cure. Now, one of the concerns that came up with breast implants is, well, are they getting, are they going to get in the way of how we can screen for breast cancer? In other words, if we have these implants, great. Now are we still able to detect the cancers when people have implants? So the mainstay since 1976 has been the mammogram. That's the thing that women starting at age 40, sometimes earlier, if you have high risk, get a yearly mammogram. That's our mainstay of screening right now. There's other tests available, but mammogram is still the kind of the primary one. And the concern was with an implant, you wouldn't be able to see all of the breast tissue and therefore you could miss some occult cancers. In 1986 or 1988, there was someone who introduced a distraction technique, Dr. Eklund, he's a radiologist, who showed this displacement or distraction method where they pull the breast tissue in front of the implant and they're able to show that you can have adequate screening even with implants using this method. In fact, there was a study out of Korea just last year that showed if you just use those views, meaning you don't even need the standard views and you just show those views, you, you have adequate screening. The things that. There's a few caveats. I tell people if you have breast implants and you're going to go for your mammogram screening, make sure when you call for your mammogram, you tell them you have implants and make sure that they know how to do that method and that they have experience with it. And there are some other nuances too. There are certain situations where they may not be able based on, let's say if you have a contracture or some scar tissue and they can't see all the tissue, you may need follow up studies like an MRI or an ultrasound. There's a newer technology known as thermography that people are investigating as another way of, for looking for cancer. So the basic answer is yes, you can screen for breast cancer if you have implants. It's not going to increase your risk of breast cancer, but you still need to have screening.

[A]

I think I would love to understand breast cancer screening because you mentioned that age, obesity, postmenopausal women. Why is a mammogram only set for 40 years and above?

[B]

So, you know, I think when you think about the fact the majority of cancers are diagnosed after age 50, so in the normal risk population, the majority of breast cancers are present after age 50. So the American Cancer Society sort of settled on the age of 40, sort of the way to start. And the other thing is when we're younger or when women are younger, the breast tissue is more dense, making it a little bit more difficult to screen. If you're a high risk patient, let's say, and you have to start Screening at age 35, a mammogram may not be the test that they elect to.

[A]

Use by high risk. Are you talking about the broca gene?

[B]

Correct, the broca gene. Gene. Genetic. Various genetic mutations which increase your risk of breast or ovarian cancer. You know, strong family history. So in those situations, for example, a lot of times one of the, one of the simple rules of thumb is if you have a first degree relative, sister or mother, who is diagnosed, let's say, at age 40, you should start your screening five years before their age of diagnosis. And in those cases, a mammogram may not be the best study because the tissue may be too dense. So that's where things like MRI or ultrasound may be more appropriate. In addition to physical exams as well. Self breast exams is still something that every woman should talk to their provider about how to perform a self breast exam, because it's not uncommon for a woman to present with, hey, I felt something. Yes, can we work this up? And then that's, you know, then they get the appropriate workup.

[A]

I've had a lot of my friends who have had, they felt something, but it was just a cyst or a benign cyst.

[B]

Yeah, yeah. And most commonly, that's what it is. Most commonly it's a fibroadenoma, which is a benign cyst or benign disease. But nonetheless, you don't want to be that one person who just blew it off and sure enough, it was something more serious. You know, unfortunately, a lot of cancers, whether it's breast or something else, tend to be more devastating for younger people because we don't think it's cancer and we just sit on it until it's too late.

[A]

That's the problem with most cancers.

[B]

Absolutely.

[A]

Yeah.

[B]

So, you know, it's the the cancers that are the most lethal are the ones that by the time they're discovered, they've spread. You look at pancreatic cancer, which is a horrible killer. The reason that one is so lethal is that 95% of patients are non operable candidates by the time it's discovered, by the time it's disc discovered because of where it's positioned in the body, it has already spread. It's not symptomatic until it's too late. So, you know, fortunately with something like breast cancer, which is more at the surface where we have good screening methods, it's not quite as lethal as long as we stay on top of things.

[A]

What's your view on the new full body MRIs in cancer detection? Because I think they are claiming some places where you can go that Maybe there's a 300 different types of cancer that could be picked up on. I asked because I'm actually getting one and I thought it was quite interesting and I was like, oh, I can have my brain mri. That's great for me, that's great publicity. I just want to show the world how amazing it looks. But it's also quite scary because I understand that there are so many false positives that can come about and it's probably going to send me on a wild goose chase. But what's, what is the prevalence of detecting cancer in a full body mri?

[B]

So definitely out of my realm of expertise here as I'm not an oncologist. But if you look at any of this cancer screening methods that we use across all diseases, prostate, colon, breast, which are the three biggest ones where we have great screening technologies. Now if you look at lung cancer where they've looked at just giving any smoker a CT scan or doing, you know, look, trying to select even some people who are somewhat high risk and just doing a bunch of scans, it's not a cost effective way or particularly the studies haven't borne it out to be. This is a great way to screen for disease. So if you extrapolate that to a situation like you're talking about a healthy individual going for a whole body scan, is it something that we're going to get to the point where we recommend for everyone? Probably not for the reasons you mentioned. False positives, an MRI maybe is okay, but some studies are exposing people to unnecessary radiation. So I don't think we're there yet where it's something we're going to tell everyone to do it. You know, I think if you look at, if you conduct any study that's looking at an analysis of, you know, decreases in mortality, cost effective. It's probably not going to cut the mustard on most any of those because the N would be the numerator, would be so small that you'd have to test probably tens or hundreds of thousands of people to help one.

[A]

Yeah.

[B]

You know, when you're looking at a mammogram, you're talking about a decrease in mortality of one in one. One in, excuse me, one in 1,000, which seems like a small number, but when you consider that tens of millions of women are eligible for mammogram screaming, you're talking about tens of thousands of lives you're saving. So it's a different, different animal. And that's one in thousand. Now you take something like whole body scanning and someone who's healthy, you're probably talking about one in a hundred thousand. Yeah, you know, I'm just shooting a number out there, but it's probably extremely rare that you're going to find something.

[A]

I want to talk about you and plastic surgery. I just did that because I think, you know, we were sharing offline. So I've been in a hospital setting and I think plastic surgeons get the bad end of the stick when it comes to specialty is meaning that a lot of people, public, the public probably just view you as botox guy, sorry, correct me if I'm wrong, or the guy who's going to give me a boob job.

[B]

It's not even just outside of the medical field. You'd be surprised at how many clinicians have no idea what it is that we do or what our training is. It's wild. So it is, you know, I'm not trying to woe is me and you know, poor us.

[A]

Yeah.

[B]

But it is misunderstood. There's no question. And I think in, in a general sense, when you're talking about a plastic surgeon and what it is to be trained in plastic surgery, aesthetic surgery is a small part of what the training incorporates. When you're in plastic surgery training, you're doing craniofacial facial fractures, free flap reconstruction, post cancer, post traumatic reconstruction. You know, you're doing. There's pediatric hand. There's a lot of different fields that deal predominantly with reconstructive efforts. Not necessarily anything to do with aesthetic. Unfortunately, the thing that. Well, fortunately or unfortunately, the thing that gets a lot of attention in the media, whether it be, you know, social media, news outlets or TV and film, is the aesthetic world. And it's an easy target. So I get it. I think some of the criticism Especially in the age of social media where you see a lot of quackery out there. I think a lot of the criticism might be warranted, but I do think it's misunderstood. And I, you know, one of the things, because I started in reconstructive surgery, you know, when I came out, 80% of what I did was breast reconstruction, post mastectomy reconstruction. So I was on both sides of this before I kind of went into more of the aesthetic world. And like what we were talking about earlier, you know, I saw aesthetic or I saw reconstructive surgery as this noble and fulfilling pursuit that, you know, you're making people whole after something robbed them of some form or function. And I was always worried about that transition to cosmetic surgery, that it's, oh, it's just going to be dealing with these wackos who are just completely, you know, delusional about their appearance or dysmorphia and their vanity projects. And I had that concern going into it and I was pleasantly surprised to find that is not the case. The vast, vast majority of the patients that I'm taking care of are normal, confident, well adjusted men and women where there's just something that's impacting their confidence and their ability to live a full life. Yeah, it's simple as that. And if you talk to these people, if you look at reviews of when they're talking about their results or where they end up, they're rarely talking about what they look like. They're talking about how they feel. I feel great. I can wear these clothes now. I'm so much more confident. So what we're, it's almost like psychology with a scalpel. And I know that there's a fine line where we're, where are we perpetrating or where are we supporting insecurities versus where were we helping people? And I get that there's a gray area there, but I think what's not really appreciated is the positive impact it can have. And I'll tell you, I'll digress a little bit. There's one story I would tell you that I always go to that was it happened maybe a year or two ago, a couple years ago, that was the best, like one of the most powerful experiences I had in my clinic once. And it was a patient who I had treated. She had a mommy makeover surgery, had breast surgery and abdominal surgery. She had two kids. She was, she lived on in Hawaii, she's Polynesian. And so they would have, her family would have these events where her daughter was, would be playing in the water. Would be doing something in the water. And the patient related a story to me. She was six months post op, and she was with her daughter at one of these events. And her daughter ran up and grabbed her leg and hugged her and said, mommy, you come to all my events now. And she was crying when she was telling me this, or the mom was tearing up. And I'm not the emotional type, but I was just kind of caught me off guard because she had never gone to those things because she didn't feel confident in her body anymore. And she had this operation and now she felt confident and she was more present for the people around her, including her own daughter. So for people that think it's a selfish enterprise, I challenge them on that in another way of looking at it. It's a form of self love, and you become more present for those around you if you're no longer perseverating or held back with something that may not be your own fault. You had kids and your body changed and you're just hung up on that, and it's causing you to withdraw. You may not be there as much. You're not yourself or not your best self or on those you even care about. So to me, it was a really powerful example of what plastic surgery in its ideal form can accomplish for people. And that's not the stuff you hear about. That's not the stuff that makes the news or the nip talk or the bot shows or things like that. So there is a lot of misunderstanding around plastics. I think there always will be. And it's not to say there isn't a dark underbelly to it. We've talked about that. But, you know, in as much as I try to show people that it's more ubiquitous than they realize, more people are getting it than you think. And they're not crazy people that are doing this.

[A]

Yeah, there's levels to it as well. And one thing that you didn't mention is burn victims as well. Have you seen that? Because I know that I've. I've. I've been involved in a case with that. And I remember it was the plastic surgeon that was actually taking the case and being the chief of that case. And I saw that was my first instinct. I was like, wow, yeah, we're recruiting plastics for this. I didn't. You know, it's the skin.

[B]

Absolutely. So, yeah. So burnt. You know, when I was at Johns Hopkins. Right. We did work at the burn unit in Baltimore. And then when I was in plastics training at ucla, we Also we would work at the USC burn unit, level one trauma centers that are burn units. And they're devastating injuries. And I'd love to say that we've can, we've turned the corner and you know, we've, we've, we've addressed the problem and it's no longer an issue, but it's just they're devastating injuries and you're talking about people that are, you know, there's high mortality rates when you're, when you're looking at burns that are 80, 90% of the body, which, which I've seen. And at a minimum you're talking about people being in the hospital for months in an icu. You know, what people don't realize is the importance the skin plays in terms of our basic levels of function as a protective barrier. Whether it's our temperature control, you know, fluid status, preventing, you know, the egress of fluid from our system. And when you lose that barrier and not only the scars that form in its place, there's significant limitations, massive fluid shifts that compromise the system. So I've seen some pretty awful cases. I mean, I had a, I remember I had a 21 year old who he was standing on top of, he was a tanker truck driver. I don't know why, I don't remember the circumstances what caused him to do this, but he was on top the tanker opening up the lid and he had a cigarette and it lit him. He had 95% burn area. In fact, the only area that was spared was his perineum was basically scoring. That was it. Everything else was burned. And he was in the hospital for months. Actually when I was with him, I think he was been in the ICU for six months still alive, which was a miracle in and of itself because usually that level degree of burn mortality approaches 100%. But you see that and the devastating consequences after in terms of disfigurement, it's wild. So yeah, that's not something people think a plastic surgeon is involved with. But in terms of the removing the damaged skin and kind of doing skin grafting, full thickness skin grafting, partial thickness skin grafting, those are things that part plastic surgeons do.

[A]

One thing that I didn't bring up is earlier when we're talking about breast augmentation is breast implant illness, I want to know what it is.

[B]

So it's funny, I've never talked about this publicly and the reason I haven't is because it's such a hot button topic with very controversial, it's like bringing up vaccines and just Looking in your comments. Well, because you'll have people that are very convinced it's real, that think that physicians are. And I'm not saying it's not. We'll get into that. But they will go into. They'll say things like, you know, you're, you're just a money hungry plastic surgeon putting these toxic bags into women. And how dare you? I mean, so it gets, it's pretty treacherous terrain to navigate, but I'll get into the patient.

[A]

It's a patient's choice.

[B]

Correct. But you know, they'll, they'll say you're not giving them the full story. You're lying. You know, it's bad for people and you're still doing it. But we'll get into it. There's a lot of information here, so.

[A]

Because I don't even know what you're actually placing. I've never had plastic surgery, so I don't know what you're. I've never had a nose job and done eating.

[B]

I'll give you a quick history of breast implants. Okay, so the first breast implant, the first silicone breast implant was in the 1960s in Texas. It was in the early 1960s. And this is after really a century of them of people playing with different things. I mean, they used everything from paraffin oil to sponges, all kinds of things, pieces of wood. People tried everything to try to augment breasts. And it was in the 60s that a doctor, he was actually, the story is he was holding a bag that was filled with blood and he thought, oh, this kind of feels like what a breast would feel like. And so he came up with the idea of, let's make a sac. And they used silicone gel initially to try to augment the breast. And they found good results with this. And so this kind of started this trend in the 60s of breast augmentation. There's also a saline implant. So both of them have a silicone polymer shell. Whether you're talking about a silicone implant or a saline implant, the difference is what's contained within a saline implant is just salt water. A silicone implant has silicone gel on the inside. Now, fast forward about 20 years. In the late 80s, early 90s, a lot of women came forward saying, these implants are making me sick. Women came forward with autoimmune disease and said the breast implants were the culprit. So in 1992, under the sort of mountain of all these complaints and lawsuits, the FDA started to pull silicone implants off the market. In fact, from 1992 to 2006, they were severely restricted. You could not get a silicone implant for cosmetic surgery for 14 years in the US you could still get them for reconstructive, but not cosmetic. Dow Kornig, which was the largest implant manufacturer in the late 80s 90s, went bankrupt, so it was not off the market. Now, during that period of time, studies were performed and essentially every epidemiologic study could not find any link causative or correlative between implants and illnesses. So in 2006, the FDA said, okay, we can start doing silicone implants again. So we do about 300,000 cosmetic augmentations a year in the United States. About 400,000 cases. Probably a year is accurate when you incorporate reconstructive cases. Worldwide, there's well over a million. So we have a tremendous body of information now about breast implants, and the satisfaction rates are consistently 85 to 95%. So women are very happy. You know, it could be they want to be a little bit larger, could be there's an asymmetry. There's any number of reasons people pursue cosmetic augmentation. Now. What started happening a few years ago in Facebook chat groups is people started coming forward saying, I'm sick and the implants are making me sick. And what they talked about were what we call non specific constitutional or systemic symptoms, meaning it wasn't a symptom of the breast. It was things like memory fog or brain fog, memory loss, you know, joint pain, fatigue, rashes, hair loss.

[A]

When you say that, it kind of makes me think you just said brain fog. So you've opened up the gateways in, I think, is that an inflammatory process that was happening?

[B]

So this is where this kind of debate started. Is it an inflammatory process? Is it an immunological process? Or is our immune system attacking the implant and attacking us? And so this is these. All these symptoms got lumped into breast implant illness. Now, it's important to know these patients would have a normal exam and normal labs. There would be nothing that we could find. And the other thing. And so this is kind of this breast implant illness. So let me talk about the data first. There's. Because of these complaints, this started getting looked into heavily. Now, the problem with studying this is, number one, the symptoms are present in the general population. So it's very difficult to weed out symptoms specific to this disease because there's no. There's over 100 symptoms now listed. There's no unique combination that seems to match everyone. And these are symptoms that you can find in fibromyalgia chronic fatigue syndrome, or other diseases that, you know, it's difficult to sort of weed out what is truly this, what is truly that. The other thing is any study, particularly epidemiologic study, is going to rely on self reporting, which anyone in science knows. If you're relying on self reporting, it's a dagger to any statistically valid study. So we have a host of epidemiologic studies. The best study to date started coming out in 2022, and it was released in four parts, and it was the only prospective randomized trial. And it was done by the Aesthetic Surgery Education and Research foundation, which is a nonprofit. This is not something that just pumps out data supporting plastic surgeons. In fact, they had another study we can talk about later that was damning to plastic surgeons. So it's pretty impartial in terms of just trying to be. Just look at the science. And they took three cohorts, three groups. They had one group that were women that had breast implant illness, and they were going to surgery to have their implants taken out and their capsule taken out, because the prevailing theory among the population is you got to take the full capsule out, too. The capsule is the scar tissue on the implant. The second group were people that had implants but had no breast implant illness, but were going to surgery to have their implants taken out. Maybe they didn't want them anymore, whatever. And the third group was a control group where they were having a breast lift. There was no implant before, no implant after. They looked at immunological markers, they looked at inflammatory markers in these patients. They did blood work for all these patients, looked at crp, interferon, every interleukin you can think of. They looked at hormone levels, and they took tissue samples, looked for heavy metals, they looked for fungus, they looked for bacteria. They looked for everything that would possibly be indicting immunological response or inflammatory response. And then they follow these patients at least through six months, and they follow their symptoms. So I'm going to go through four questions about breast implant illness, and that's most of where I'm going to pull the data from and what it shows us. So the first question is, is this real? Is this real? And is there a diagnostic, an objective thing we can point to to say you have this disease because this is abnormal, this level is abnormal. The study showed there was no difference between the three groups in terms of any of the inflammatory markers, any of the immunological markers, heavy meta levels. Everything was the same across all three groups. So there Was nothing in an objective test that we could point to to say surreal thing. And the same thing is true in the previous epidemiologic studies which weren't that great anyway. In fact, I found one study that tried to show the existence of breast implant illness, but that same study showed that breast implants would protect you from lung cancer. So it suggests that the data probably isn't the best data, it's just not great. So I'll give you my final thing at the end. But so the question one, is it real? The science doesn't support it. Science says no, science is not supporting it yet. So the second question is, what is the risk factor for someone getting it if you have implants? We know not everyone's getting it. We have millions of women walking around with implants. If it was causing, if it was a true causative agent, millions of people would be flooding the hospital sick. And that's not the case. So who's at risk of getting it? Well, interestingly, one of the only predictive factors that we found scientifically in the studies is a history of anxiety depression. So does that suggest it's an organic disease or that may be super tentorial and maybe something psychological, who knows? But that's what we don't have exposed by the implant. No, no, they had pre existing oxygen depression, then they got implants, then they got bii. So it suggests maybe there may be a psychological component, maybe it's not organic disease, but who knows if you have a pre existing autoimmune disease, you have lupus, you have rheumatoid arthritis. Those people do have a higher incidence of issues with implants. But that's true with any implant. If you look in the orthopedic literature or any. Anyone with autoimmune disease who has an implant has a higher risk of issues. Makes sense.

[A]

But why does it exasperate?

[B]

We don't know. Because really silicone is seen as an inert substance. It's not something that should inspire an inflammatory response. But people who are of autoimmune disease, they don't have normal immune responses. So in those people, for some one reason, another, they may have some kind of reaction.

[A]

But how does that go unrecognized? Don't you do every test under the sun?

[B]

Well, yeah, if you go back to point one I was making, doesn't seem to corroborate immunologic response. But again, we'll get back to that. Maybe the data is missing it. So anyway, risk factors, that's all we really have for risk factors. The third question is, what is the treatment? Someone comes to you and they have breast implant illness or they think the implants are making them sick. What is the treatment? Traditionally, what the population was trying to perpetrate is you need to do this, what they call an unblocked capsulectomy, which takes a bigger incision and takes all of the implant and the scar in one sort of in one fell swoop. It can lead people disfigured, increased risk of hematoma, longer operative times. What the study showed is there was no difference if you just took the implant out versus took a piece of the capsule out versus the whole capsule. So the treatment should be just removal of the implant, based on that study, which gets us to our last question. Is the treatment effective? And in that study, greater than 90% of patients had improvement in their symptoms when their implant was removed. Now, that doesn't necessarily mean the disease is real. It could be placebo, we don't know. But when they had the implant removed, they felt better. So this is the final analysis that I give patients. Putting all this stuff together. Is breast implant illness real? And what I tell patients is this. Listen, is it possible that to date, science is missing something that shows that certain population of patients have a reaction implants? I think it's possible. The study I'm citing, the cohorts were each 50 patients. Now that should be enough to show at least a correlation, if not causative effect, at least should be able to see something that's statistically significant. But it's possible it's missing it because I don't want to label all these people as crazy. I think there can possibly be some link. However, if it exists, it exists on a much smaller scale than I think is being perpetrated.

[A]

Of course.

[B]

And I can tell you anecdotally, I've had patients who come in with breast implant illness, removed the implant, did all that. They came back a year later and had the implants put back in. They said, it turned out I was just tired. So I think there's a lot of gray area here. But rather than sort of ostracize all these people and say, you're all nut jobs, I think you have to have a little humility, even in the context of having some signs and saying, hey, it's possible there may be an issue. If it's going to make you feel better, let's take the implant out. But I do tell them this en bloc capsulectomy nonsense is not supported. It does not make Sense, you're risking yourself in very real ways, and I think you should just take the implant out. It's their body, their choice. At the end of the day, if they want to accept the greater risk of doing all the unblocked, that's fine. But that's something I have a very real conversation with them about.

[A]

You know, when you, when we said breast cancer, breast illness, breast implant illness, I immediately thought flu. Like symptoms, you know, like an actual illness. And you just mentioned really subjective symptoms like brain fog, which can literally occur from a bad night's sleep.

[B]

Yeah.

[A]

I don't know how it got to that place, but it, it reminds me of one of the devastating things that has happened in medicine, which was the Women's Health Initiative, which really changed the way that women postmenopausal started to reject hormones due to this big phenomenon. Everyone started thinking, well, I'm not going to take hormones because it's going to increase my risk of getting breast cancer. It's like, how did we get to this place? I think it's because somebody hears something on social media and then.

[B]

Exactly.

[A]

Rampage.

[B]

So, listen, you and I are involved in social media. I mean, you have a bigger platform than I do, but we both know the dangers inherent to social media. There's great things positive that can come from it. It can be a great platform to exchange information, create connections. I'm not sort of saying social media writ large is terrible, but without question, we have seen this explosion of pseudo experts or people espousing things as truth or with zero scientific basis, having never tested. There's no method behind it. It's just someone's opinion. And unfortunately, there's a good part of the public that will grasp onto something and call it fact. And I think all of us, myself included, I mean, listen, you have to approach things with a degree of skepticism and humility and not just sort of take things at face value every time. And I think it's a real problem that we have to navigate. And the only way I can do it, or I try to do it, is just giving people facts. So I don't. I try to stay away from anecdotes or conjecture or I think or feel and be like, listen, this is the data we have, these are the facts. And take with that what you want. If you want to continue to run with whatever conclusion you have, that's your right, it's fine. But it's something that I think, you know, we deal with in all of healthcare right now, you know, whether it's with vaccines or with hormone replacement therapy or anything. And it's, you know, I, I fear it's getting worse rather than better because there's just more and more people getting up there. I mean, look at, look at the diet industry, look at what people are.

[A]

Telling me on the nutrition space.

[B]

Right? It is, I mean, it's insane. Everyone's an expert and everyone's like, you got to eat this. I mean, it's craziness.

[A]

Yeah.

[B]

And you'll have people that have no training but consider themselves experts now because they watched a podcast or watched a YouTube video or it works for them and, and it just creates this just hodgepodge of misinformation.

[A]

Listen, you're, you're preaching to the converted and the choir because I, I don't know how many times, like I stick to my field, which is Alzheimer's disease. You know, I have a vast background as well. I see a brain, a live brain very frequently during surgery. I don't really talk about that, but I like, whenever I say something, there is so much back background. There's 15 years of knowledge that goes into just that one minute reel. And I hear so many people now on social media, just in my space, maybe talking about the brain. And one of the, my distaste is when I hear people combining nutrition with the brain claiming that, for example, oh, the brain is made of fat, therefore if you eat cholesterol rich foods, then it's going to be good for your brain. I think to myself, how did you come to that conclusion that dietary cholesterol can pass through the blood brain barrier and have any sort of effect? I mean, if you believe that dietary cholesterol can enter the brain through the blood brain barrier, you've got more problems than, than that. That means you've got a compromised blood brain barrier or a leaky brain, if you will, which needs to be addressed. And so these are, these are the nuances that I think to myself when I hear somebody speak, I would love to know, can you back up, can you describe the enzymatic processes that occurred to get to whatever it is that, that you have just concluded in this.

[B]

One minute read or make it simpler. You know, can you tell me, can you show me the study you're talking about and not just that you're reading the abstract. Did you look at the methods? Did you look at what the flaws? Was it an animal model? Yeah, one of my favorite ones that I think is, seems to be accepted as gospel, but I don't think it is, frankly, when I look at sort of what the research is, has to do with seed oils and how people just demonize accepting it as fact that seed oils are this thing that cause inflammation, whatever. When you looked at what the origin study of it was, that it's a terrible study and it was an animal based study. Like it's so there's so many things that are just sort of, not only do we have the problem of people bringing up new things that are wrong, but they just accept they've moved past accepting some things as fact and now they're taking it to the next level. So, you know, I, at the end of the day, just do the best you can in terms of, you know, when I'm dealing with my patients, I just try to speak from a position of hey, these are the things I know about, this is my experiences, this is the information I'm providing. I'm not taking the choice away from you, but I'm just trying to inform you. But it's an uphill battle. I mean, it's tough.

[A]

And I guess, are you, how do you feel now with the rise in cosmetic surgery and not cosmetic. I'm talking Botox and fillers, which are now you can do it. I'm guessing anybody who is certified in the United States of being able to hold a needle, that is dentists, nurse practitioners and MDs can now give you Botox. And there are just so many people going out there saying it's completely safe. It's, you know, it just blocks the neuromuscular junction.

[B]

Oh my God. I just, I just got, I just got you. You're very neuroscientist.

[A]

Junction. Yes, in Botox, which inhibits the action at the neuromuscular junction. So that means that anyone can just go around and just poke around.

[B]

Well, I think you, you sort of tickle the tiger with. One of the biggest issues we're dealing with right now in aesthetic medicine as a whole is that, and I talked about this recently because there's been a series of deaths around like a dentist doing liposuction or people doing things like a dentist doing liposuction, pediatrician doing a breast augmentation. There's a whole lot of people out of the scope of practice doing things.

[A]

How is that allowed though?

[B]

So this is the problem. So when I tell people the regulatory bodies have failed you, the regulatory bodies who should be monitoring this have failed. Because at the end of the day, if you have an md, you can open up a cosmetic practice somewhere in the community. Now you're not going to get hospital privileges, but it's not going to stop you from opening up a shop, building something. Building an. Or bringing people in your office, doing whatever you want to them. So there's nothing that prevents that person from doing it. Now if they get exposed or they have a complication, could they lose their medical license? Yeah, that's after the fact, but that's not protecting people proactively. There's as little as 30, 35% of plastic surgeries in California are done by plastic surgeons. The studies vary. I mean, one of them showed it was 70, but some of those lowest 30 and the rest.

[A]

Are you talking about the bit like am I going to see a general practitioner doing a nose job?

[B]

Yes, I'm talking about people doing operations. So it's that don't have a full fully accredited plastic surgery training.

[A]

So they're not board certified.

[B]

No.

[A]

Yeah.

[B]

And so the onus is unfortunately falling on the patient do their research about what someone's qualifications are. And the problem is even worse for injections because injections, to your point, anytime Dick and Harry can, you know, start, start setting up and injecting Botox. Now, the mass majority, the consequences, the negative consequences may be less significant as a surgical complication, but nonetheless you can cause serious problems. With fillers, you know, you can, you can cause a vascular occlusion.

[A]

Yes.

[B]

With Botox, if you're injecting the wrong place, you can in theory, you know, they can have a droopy eyelid or you can, God forbid, affect their muscular, their eyes in more serious ways. So there are potentially dangerous complications of these things. And it's kind of like buyer beware. You just have to do your research about what are the qualifications of this person. You know, a simple way to say it with surgery is find someone who's a board certified plastic surgeon. It's not hard to figure that out.

[A]

Yeah, I actually know that there are several people who are, you know, DOs or MDs who are performing liposuction. And it's a different form from what I'm used to. Actually. I want to get into liposuction and understand the difference between a fat cell and like literally removing that fat cell, what it entails, as opposed to shrinking the fat cell through diet and exercise. And I want to understand the different procedures because I see it on your Instagram and then I know that people are doing this pumping. I'm not, I'm seeing this pumping thing and I'm like, that doesn't look safe. And so what, what is the pumping thing?

[B]

So listen to your point that ideally the first thing is diet and exercise, lifestyle modifications, the best way to lose weight, lose fat, lose fat or, you know, optimize, get to get to a lean body weight and lose fat. However, liposuction should never be misconstrued with a weight loss procedure. It's not. It's a body countering procedure. Okay. So it's intended to shape the body or target specific stubborn areas where there's fat cells. And to your point about removing fat versus shrinking a fat cell. Yes. When you diet and exercise, the fat cells you have shrink. When you do liposuction, I am permanently removing a fat cell from your body.

[A]

I mean, you can get them back.

[B]

There's some studies that show you can grow new fat cells, but what can happen is the fat cells that remain behind can grow. You're not getting every last fat cell. So if you go get liposuction and then go eat an in and out burger three times a day for the next six months, you can kind of ruin the result. And the fat that you have can still grow, but the liposuction. So to your point. Yeah. You take, fundamentally, at the end of the day, when you're doing liposuction, you're taking a metal rod or metal straw and you're sticking it under the skin and removing the fat. Targeted. Now, this does require a layer of. This does require expertise in knowing anatomy, knowing techniques so that you don't damage a neighboring structure. You know, people that don't know what they're doing, can they stab an intestine or stab the liver or get into the lung? Absolutely. If you don't know how to, how to do this, it's dangerous. You're stabbing someone.

[A]

Essentially, I'm seeing people doing it just in day surgeries.

[B]

You can't know, listen, it's possible to even do it awake. It is, yes.

[A]

I've seen that.

[B]

And it is possible. I don't like doing that in my practice because I feel like I can be a little bit more targeted and aggressive. And I think it's more comfortable for patients than being just asleep. But it can be done awake if the provider knows what they're doing. Yes. But, you know, again, it comes down to knowing that someone knows what they're doing. It's not someone who's some kind of cowboy doing this as a side gig or one that's not the foundation of their training. They don't know the anatomy, they don't know the technique because it is dangerous. It's an operation.

[A]

Yeah.

[B]

And I think the Other. The other area where we see this being a problem, which is, listen, I know cost is a concern for anyone. I know it's a factor going into selecting a provider, selecting a procedure. But it shouldn't be the first one. It shouldn't be. I mean, it can be the first one if you're deciding yes or no to doing something at all. But when it comes to looking for a provider, if the first thing you're looking for is the cheapest option, you are, you are putting yourself at risk. One of the things I tell people is that's kind of an uncomfortable reality about plastic surgery. When you pay for plastic surgery, I tell people you're not paying for a result. It's not like buying a TV where you know exactly what you're going to get. The analogy I give people is, or the metaphor, analogy, whatever that tell people is it's more you're paying for the probability of a result. So you can go to someone who's the best surgeon in the world, best training, best accolades, great reviews. And the probability of a good result might be 99%. Maybe it's not 100, though, because there's always complications, always risk, but it's 99%. You're paying for that 99% chance of a good result. Or you could go to the Dominican Republic or some countries or even South Florida, some areas where they have these basement prices. You might get a good result, but you're paying for a probability of 50%. So what do you want to do when it comes to your body? Do you want to pay for a probability that you have a 50, 50 chance of a good result or of meeting harm? Or you want to pay for a higher probability of a safe procedure? And a good result doesn't mean it's 100. Good surgeons have bad results, too, but it's about your probabilities. And when you sort of try to get the cheapest option, it might work out or you might die.

[A]

Yeah. How many people are, like, going to Mexico?

[B]

Oh, it's a lot, certainly. And listen, it's not to say that all Mexican surgeons are trash. I mean, I have some colleagues on. There are great surgeons, but they're not the ones charging pennies on the dollar for the operation. Yeah, they're not doing it out of a apartment or a garage or whatever. So, you know, here in Southern California, there's a lot of that. And I think on the east coast or in Florida, you have people going into the Caribbean or some countries where they have some clinics not being regulated there was a rash of these horrible infections of patients going to Dominican Republic, getting surgery and coming back to New York, going and ending up in ICUs with horrible necrotic infections. So, you know, there's just. It's a dangerous world out there if you're not taking time to pick your provider, do your research and find someone who puts you in a safe place.

[A]

I think. I don't know if you agree, but the world of social media now is changing the way that we probably choose a provider. Because now everybody believes that plastic surgery is just part of their skincare routine, which is scary. I think, you know, 20 years ago we didn't. I didn't really see so many people just going to the plastic surgeon, just getting. Yeah, I think I might get a boob job. Today we're going to get into the Brazilian butt lifts. But there's just so many different procedures that can be done now. And it's just like, you know, what, what, what sweater am I going to buy today?

[B]

You know, you're right. I think that in some ways we're a victim of our own success in terms of being able to do these procedures safely now that now people look at it like they're getting a haircut. It's not a haircut. You're changing your body. It's an operation. There are risks. And I see it a lot, certainly in celebrity culture and the influencer culture. It's a big problem. I've seen patients who are 22 years old, had six operations, you know, and so there is a part of that. And I think, you know, social media does good in terms of educating people, but there's danger in it too, in terms of, you know, I think one of the issues too is expectations. There was something that made the rounds. I don't know if you saw this. Did you see that, that ridiculous before and after that made the rounds on social media recently? That came out of Turkey and it wasn't the same person, but people thought it was a real before and after. No, it was clearly two different people. What? Yeah, it was wild. And so it was just this.

[A]

Oh, yes, I did see that.

[B]

Yes. Where it was like you almost could believe it, but if you really looked in, you zoomed in on the ears. It was a different. Like, it was clearly a different person. Yeah, but this is the, this is the landscape we have to navigate now on social media is there's really not a good check and balance system in terms of a result. But, you know, like I said, a lot of this too comes to expectations. When I see a patient comes in, I think any good provider will have a very real conversation with them about what your expectation is. I've had patients who come in where they have a. They bring me a picture of an influencer or someone famous that they make.

[A]

Me look like Kim Kardashian or something.

[B]

Like, along those lines. And I can tell you, some of these patients I knew, either I'd operated on them or I knew them. And I'm like, I can tell you, and I wouldn't say this to them. I wouldn't, you know, give up that person's identity or whatever, but those people don't look like even what they're posting. So it's a manipulated picture or it's, you know, they want to look like someone, and even that person doesn't look like that. So it's just become such like a. We're like, you know, it's like I feel like I'm in the movie Inception. Like, it's like a dream within a dream sometimes where I'm just dealing with. Know that you're trying to be someone who's not even that herself. So, yes, it's like, so you really have to be candid with patience and say, listen, I'm going to give you the best possible result to move you in the direction that you want to move to within the confines of what your anatomy will allow me to do and do safely. And I think if you promise them the world or they see these images on social media, that's not them. And it is even that person they're looking at. You got to be careful.

[A]

What are some other myths around plastic surgery that you're trying to debunk?

[B]

Well, you know, you brought up bbls.

[A]

Oh. So I want to talk about that before. Okay, we will talk about that. So I found a study, guys, and it stated that 1 in 3,000 mortality rate associated with BBL. BBL stands for Brazilian butt Lift. Can you talk to me about what a Brazilian butt lift is? Why is it called Brazilian in the first place? And is this true? The 1 in 3,000 mortality rate?

[B]

So the Brazilian butt lift procedure is not really a lift. What it is is you do liposuction, remove fat from one part of the body and use that fat to revolumize the butt, and therefore, it can give it the impression of being lifted, but you're just making it fuller. That's what a Brazilian butt lift is.

[A]

I don't need that.

[B]

There you go. All right, so now I think the reason it was called Brazilian Butt lift. I think the first patient was a Brazilian woman. I think it was done in New York. I believe that was the reason it got labeled that. It was. It got labeled that. Like a news article. It wasn't. That's. And that just stuck. So the study you're referring to. So we mentioned earlier about the Aesthetic Surgery Education Research Fund, so they did a survey study in 2016, and they sent that study to 10,000 surgeons, and less than 700 responded. And from that data, I think there were seven mortalities reported in that study. And they extrapolated that to everyone that does Brazilian belt lifts and said the mortality is 1 in 3,000. So a terribly flawed study. And if you dive deeper into the data, a lot of the respondents were in South Florida, where they were having a rash of deaths in some of these chop shop clinics that were operating under less than ideal circumstances. Now, nonetheless, in the wake of this, there was set off alarms, understandably, when people were like, my God, we're killing one in 3,000 people doing this. What the hell's going on? And so they. They had created a task force to sort of investigate what was going on. And what they found was these deaths were because people were injecting fat directly into the gluteus muscle, and it was gaining access to the vascular system because there's some large iliac branches in the gluteus muscle, and they're getting a fatal pulmonary embolus.

[A]

They were getting a fatal embolism injecting.

[B]

Into the muscle itself.

[A]

Into the muscle, which is getting into the vascular bed, which is then infiltrating the artery with the fat cell or the vein.

[B]

Usually it gets into a vein that was through the vein. Yeah. Mostly it's into a vein because it's hard to get into an artery because it's high pressure.

[A]

Yes.

[B]

So in most cases, getting into a vein gets sucked into a vein, travels up into the right side of the heart, and the heart pumps it into the lung, and boom, you have a pulmonary embolism. So. And that's pretty much instantly fatal.

[A]

Pulmonary embolism is pretty much a stroke within the lung.

[B]

Exactly. And so, you know, this task force is like, what's going on? They found this was the issue, and so they released a set of recommendations to, number one, say no more. Don't do intramuscular fat injections anymore, obviously. And a host of other technical things to make the surgery safer, including people using ultrasound now to make sure they're in the right plane, things like that. So you don't inject in the muscle you inject in the plane above the muscle. They repeated the study in 2019. The mortality was 1 in 15,000, which is this 0.00006, which is the same as a tummy tuck. So if you, if you're in the hands of someone who knows what they're doing, properly trained, it's a safe procedure. If you hear someone telling you, if you see or hear a surgeon saying, I don't do this because it's not safe, it tells me they're not familiar with the data or they're not really facile with the procedure itself because it is a safe procedure. But that, you know, that got a lot of headlines and appropriately so. I mean, and also it highlights. I always tell people this highlights to me why ACERF is. You can't look at that as just some pro plastic surgery thing because they put out something that was pretty damning to a lot of plastic surgeons, even though the study was, you know, pretty flawed. But it is a safe procedure. Now. It doesn't automatically mean, you know, BBL has also been associated with these really dramatic, overly done.

[A]

Yes.

[B]

Aesthetics. It doesn't have to be that way. Just like breast augmentation doesn't have to be ginormous breasts that are disproportionate whatnot. A lot of BBLs that are done are done in a way that's much more, you know, understated and just kind of helps people feel better in their clothes or enhances their figure in their eyes. So it can be done safely, it can be done without being ridiculous looking. But I think that's one of the big misnomers that it's. Or misunderstandings that it's still dangerous.

[A]

So you don't inject the fat into the muscle anymore.

[B]

Correct. You inject it where it's subcutaneous. So the way to look at it as the plane is there's the skin, there's a layer of fascia, and then there's another layer. So it goes skin, fat, subcutaneous and fascia. Then another layer of fat and then the muscle. Yes, ideally you're between the fascia and the muscle because that area will expand. So I use an ultrasound when I'm doing the surgery.

[A]

I was going to say you would need to use some sort of ultrasound.

[B]

So I use an ultrasound to kind of show me exactly, exactly where my cannula is and that's how I inject. Even without an ultrasound, it can be done safely because if, if, you know, if you inject from a superior Angle, it's really hard to get into the, in the vicinity of the iliac vessels if you inject from the thigh area and coming up, it's a little bit riskier. So there are ways, even technically without ultrasound to make it safe. But ultrasound is certainly kind of the thing that will ultimately enhance the safety.

[A]

Well, how do you feel about calf implants?

[B]

What do you mean, how do I feel about them? Like, do I want one myself? I mean, look, it's anytime, any procedure you're talking about, whatever, however ridiculous it might sound, really what it comes down to is the discussion with a patient and what are we trying to accomplish here, you know, and I think that, you know, I've done calf implants on patients and there are some patients where I had one patient who was a, he's a well known fitness enthusiast and very prominent person and he felt this was one part of his body because, look, there are some parts of your body. No amount of training is going to change. That's just what genetics gave you.

[A]

That's what I tell the world about myself.

[B]

There we go. Perfect. Yeah, it's just what I have. Sorry, this is my genetic gift to you. But so, you know, look, if people have an understanding of what the risks are and it's done within the confines of what's safe, I don't put any stigma on it, good or bad. I think it comes down to what's the patient's motivation. Are they coming from a reasonably healthy place about it? And that's the land we all have to navigate. You know, I talked recently about body dysmorphia and how, you know, body dysmorphia is actually a clinical diagnosis. And it's really what it comes down to is when you're, when you're perseverating so much on a flaw that is either minor or to other people or unrecognizable to other people. But you're persevering on it to the point that it impairs your functioning, whether social or occupational. You're late for your job or you can't, you won't go out at all because of this problem. That's really when you kind of fall into the area of body dysmorphia. And now they have severity scales of how severe it is. Because we all have a component of this. Just as with all psychiatric disease, you know, people, oh, I have a little adhd, I've got a little depression, a little. This we all have. We're on a spectrum of a psychiatric illness. Some of us more than others. But when it becomes a true diagnosis is when it kind of fits those criteria. Now, it's thought that up to 20 to 40% of patients with body dysmorphia will at some point seek cosmetic surgery. Now, you would think it's an automatic disqualification. Body dysmorphia and don't get plastic surgery because greater than 80. 80 to 90% won't be happy after the surgery. But there are others that say, well, it depends on the severity. So there are. There are. There are questionnaires we can give people that will help us stratify if we have that concern. It's usually pretty obvious though. It's usually someone who's coming in where they're talking about something that you. You're sitting there with. I can't tell what you're even talking about. And you know, this goes. What I would do. I tell people you're crazy. No. What I'll tell them I'm not giving myself away so anyone sees this. What I'll tell them is I don't think I can meet your expectations. So it's a way of saying no without being offensive. I don't want to steal your money. I don't think I can meet your expectations. You know. And that's an. You know. And that people like that will fall into that category. Not all of them. I'm not saying anyone. I say that too is crazy. Sometimes it's something where. Yeah, I see what you're saying. We don't have anything available to address that. Or it's someone there. It's like so minor. I'm like, I can't meet your expectations. I don't think you're gonna be happy. But. Yeah. So calf implant would kind of fall in that too.

[A]

Yeah. I think that we're gonna be, you know, as the world gets crazier and crazier on social media, we're gonna.

[B]

Is it possible to get crazier than where we are now? It's batshit crazy out there.

[A]

I've seen AB implants. I don't even know. You've probably seen way more than me. I mean, are there deltoid in place?

[B]

There are. But I would tell you that is.

[A]

That is.

[B]

But that is such a 000. I mean, it's such an outlier. Those are the people you'll see because it's so outrageous. You know, it's not as. That's not something you're seeing kind of standard.

[A]

Well, I think another thing that I wanted to understand was the difference between lifting and tightening. And I think this. You said the word tummy tuck. Okay. I don't know what that is.

[B]

Okay.

[A]

I. Look, I'm nowhere near the age of getting surgery. I don't think I am. And I also haven't had kids. Listen, come to me after I've had a herd of these kids, maybe I'll think differently about doing that. But I'm guessing that tummy tuck maybe is removing some fat in the lower abdomen, maybe, and just sealing it back up. Seems great, by the way.

[B]

So tummy tuck basically is a procedure where it's an incisional operation. So it's a pretty big incision in the lower abdomen, or not lower abdomen, kind of more towards the groin area. And the classic patient getting a tummy tuck is a postpartum woman because she's. And there's three issues they're looking to address. Some of the skin. After the pregnancy, the skin expands. And for some women, it just doesn't retract down well. So they have loose skin. They may have some stubborn pockets of fat. And the other thing they have is something called rectus diastasis. So their rectus muscles have splayed apart, and when the skin comes back down, they stay kind of far apart. And that fascia in between the muscles is really weak. So they kind of have this persistent bulge. Their abdomen isn't flat like it used to be. So in a tummy tuck, you make a lower incision, you re approximate the muscles to the midline. So it's more in a appropriate. Where it's supposed to be placed to help flatten the stomach. You'll remove extra skin. Might do some liposuction as well at the same time. That's what a tummy tuck is. Now to your question about tightening versus lifting. In many cases, they're synonymous. If you're tightening, you're lifting, for example, your breast. If a woman's breast is low, it's because the skin envelope has just expanded and now the breast is just following it down. When you tighten that skin, meaning you make incisions to remove extra skin, and you tighten the skin envelope up, it is going to lift the breast. That's so tightening and lifting the same thing. In other situations, it's not. There are technologies we have now that use radio frequency underneath the skin, that remodel, collagen. They tighten the tissue, the framework underneath the skin, to tighten skin down. For example, if someone has a little bit of loose skin in the abdomen, let's say they can get one of these Treatments that try to tighten the skin, it's not lifting anything. You're not lifting the skin in the stomach, you're just trying to tighten it down. So that's one of those situations where it's different. I think what the general public should know is if you think whether it's your face, your neck, your breasts, something that you need a lift, it's probably going to need an incision. It's probably not going to be something where some fancy technology is going to solve it. Those tend to give you more smaller enhancements or changes versus an incision which is going to do something more dramatic like really pull the skin tight. So that's where people need to be careful when they, because there's a lot of snake oil out there, be like, oh, this is going to lift or shrink wrap your skin without an incision. Well, it's probably bullshit because nothing can really match up to what we can do with a scalpel.

[A]

What I'm hearing a lot of is that this whole world of plastic surgery really is about, it's very individualized, it's about how do you want to feel rather than what we're used to. Like if you were to see a neurologist or a cardiologist, like if we don't, you know, do this, you may end up dead. Whereas in your world it's very much, well, I mean it can still be about life or death, but it's very much like how can we build more confidence in you in the most healthiest way possible, safest way possible, fit to your liking and to make sure that there is no post operative risk?

[B]

Right. So you know, plastic surgery is more about form and function, not about life and death. Usually now burn's different, but for the majority of plastic surgery about form and function, sometimes it is functional hand surgery. You know, there's different things that will affect your function. So we're talking about form and yes, to your point, it's about how we feel. So you're taking healthy people to an operating room. It's pretty wild if you think about it. So I'm taking, when I, in my practice, I take people have no medical issues who are otherwise healthy. Giving them anesthesia and cutting them, it's pretty crazy and I acknowledge that. But to your point, what we're dealing with are people where something is holding them back from living their fullest life. So, you know, whether it's what they see in the mirror does not match with how they feel on the inside. And I say in the purest form, plastic Surgery is trying to bridge how we really think about ourselves and what we see in the mirror, there's a disconnect. And if we can bridge that so that what they see in the mirror is how they feel on the inside, and then they're more active, more present, more engaging in their life, great. You're doing a wonderful service for these people, and no different than someone who has a psychiatric problem that's holding them back or a physical ailment that's holding them back from being present. Their leg is broken or whatever. If you can do something that they can be more present and engaged in life, I'm all for it. I mean, in my personal life, I've always been a big proponent of living a full life. Like, that's always been something that, through the activities I do or what I like to do, that's important to me. And so being in a role where I can help people do that in whatever small way that may seem is fulfilling for me. And I see it. I see it born to life. I mean, I get messages from patients, as a lot of us do, that are, hey, I wore a swimsuit for the first time when I was on vacation with my family. Hey, my relationship with my husband or spouse is better now than it was before because of my confidence. These are real messages, and that's great that I get to be a part of that. I mean, I feel lucky as hell that I get to do that, you know? And that's not the thing that people think about when they think of plastic. They think of someone who's just crazy. You're gonna go fuck up your body to please people, and it's not really what it is in its purest form.

[A]

I would love to get to the bottom of cellulite, and that's because I've had cellulite since I was, God knows, a kid, maybe 12. Right. And there is just, you know, there's a lot of demonization on Instagram regarding cellulite. But then if you actually have a look at what pathophysiology of cellulite, it's a. It's natural. Correct. Why do we demonize cellulite? And what exactly is it?

[B]

That's a great question about the demonizing. Because, listen, in a perfect world, no one would come to see me for anything. They'd be happy with the way they look, and they're living their full life. I get it. You know, where do we draw that line between when it's just. Just love yourself, love the way that you are, and I Get that? And I. And I don't know where that line should be drawn. I really don't. I don't have the answer for that. I don't think anything should be demonized, though. As long as you're doing something safely and it's within what the accepted standard of practice is for what's safe. I don't think anything should be demonized, per se. If you don't want to do it, don't. That's fine. Don't demonize someone else for their choice. No different than you shouldn't demonize them for having cellulite. You shouldn't demonize them for their choice to do something about it. It's up to them. If it's bothering them, great. You know, some would argue it's on the spectrum. I'm not saying it's the same as putting on makeup or picking your favorite outfit for the day, but we like to look our best, to feel our best. There is a correlation. There's a correlation in terms of how we function when we are happy with the way that we look. So getting to your question of cellulite, what is it? There's these little fibroceptal network of bands that are tethering the skin in certain areas. It creates this dimple effect. They're just holding onto the skin from the under surface. There's been several treatments that have come across. There's actually a treatment that's relatively recent, which is probably the most prominent. It's called Aveli. Not paid to say this, but it's a V, E L I. And basically what it does is a little device that goes underneath the skin and just cuts those bands, and it can actually make substantial improvements in terms of the overall contour of the buttock. So there are treatments for it. But, I mean, man, your question of why do we demonize it? Why do we demonize anything, really? I mean, I think there's. I think it's in our nature to want to seek out attractive qualities in each other. It's built into our DNA. We can't explain why, as we're growing up, we're attracted to what we're attracted to. We just are. So, you know, I think there's something in just the way that we're wired that we want to look as alpha, or whatever you want to call it as possible. The question is just when it goes too far, and that's where it's, you know, it's on top of the dysmorphia.

[A]

Issue, but it is normal.

[B]

Yes, absolutely. But I mean, so are small breasts. So is a crooked nose, Is that abnormal?

[A]

Actually, on that, I have a number of friends who actually wanted to talk to. They wanted me to ask you questions regarding nose jobs. Now, I'm not going to draw a correlation between the amount of Persian friends I have and the question, okay, well.

[B]

We'Re Greek, so I'm sure we have fair number of these, too.

[A]

So why. So what is the difference actually between having a nose job with an ENT or do ENTs. Some doctor, plastic surgeon.

[B]

Well, there's. So where ENTs in their training and ENT have. In terms of the airway. So in terms of the sinuses and the airway, they'll have some insight into. So, for example, people presenting with breathing issues or whatnot. But when you're.

[A]

Deviated septum.

[B]

Correct. When you're. But when you're introducing the aesthetic aspects of the nose as well as the airway, it goes a little bit beyond just standard ENT training. There is more to it than that. It doesn't mean that some. There could be someone who went to an ENT training where they happen to get a great exposure to rhinoplasty. But in most cases, you're talking about someone who did either plastic surgery or facial plastic surgery training. And that's where you're restructuring the nose itself for a specific aesthetic goal. So there's the airway issue and there's the cosmetic issue. Two different things.

[A]

And there is no real serious. There's maybe no, like, serious complications with this, like the, the study on the implant illness and Brazilian butt lift.

[B]

Right. So you're not putting. In the majority of cases, you're not putting a foreign body in there. So you're just remodeling the tissue that they have. Are there potential complications? Absolutely. I mean, you can have a poor aesthetic outcome. You can have some airway compromise, you can have bleeding. I mean, there are some things that can happen, but not in the same vein as where you're taking a foreign body, putting a foreign body, and the inherent risk to that. You know, rhinoplasty is complicated surgeries. It's a game of millimeters with rhinoplasty, you know, so it's very technical. So I think with rhinoplasty, very. Among a lot of the things we talk about, very important to find someone who does a lot of rhinoplasties. And even in experienced hands, revision rates are high. With rhinoplasty, people frequently have to go back to get something addressed.

[A]

Okay, I, I want to switch gears now and talk about something that is, I guess, can be touchy for some people, but it's the reconstructive surgery as it relates to transgender surgery. So let's just say there is a. And I don't know if you've been involved in any cases, but a female who is born a female with ovaries in a uterus and wants to undergo transitioning, what does that process look like?

[B]

Yeah. So they're the. These fall under. The diagnosis of body dysmorphia is what was accepted as a DSM criteria. So psychiatric diagnosis of body dysmorphia, where you believe that your gender assigned at birth does not correlate with the gender that you feel that you are. And the only treatment is surgical. The only treatment is to give you. To grant you the physical identity that matches the identity you feel. That's what body dysmorphism with these surgeries are involved in. It's a long process to get to the. I mean, understandably, should be a long process to get to them in terms of you need to have psychiatric confirmation that you're good for surgery and that there's this. You know, that this is truly your diagnosis. It's not just like you're running into a clinic, being like, I want to be a male today, and, okay, let's sign you up. There's more of a process that people should be going through.

[A]

They have to clear it with a psychiatrist first.

[B]

Right.

[A]

Correct. Correct me if I'm wrong, and I know this is not your area. What is the cutoff age?

[B]

So I'm not. This is where this has become a huge debate.

[A]

Yeah.

[B]

And you see this not just with surgery, but even with hormone therapy in kids. And it's. I mean, you see this debated a lot. I have my own opinions on it, to my knowledge, and I gotta check. To be honest, I don't even know the latest when it comes to surgical intervention. You gotta. You have to be an adult. You have to be a consenting adult. To my knowledge, 21. 18.

[A]

18.

[B]

So 18 to be a consideration state dependent. Well, I think. I think for adulthood is 18. Pretty much whatever state you're in as an. You're considered an adult at 18 in.

[A]

The US so that's surgery. But for hormone replacement.

[B]

Right. This is where it's tricky territory because you do see situations where children are being enrolled in hormone therapies at the behest of their families or at the house of their parents. I don't think they can do it on their own. I don't think they were yet at a point where they can do it without parental consent, I could be wrong. But that's where there's a lot of raging debate about, hey, are we going too far with this? You know, I mean, people joke like, my kid wants to be a dinosaur. Does that mean I should give him surgery to give him claws and fang or whatever? And so it's a hot button topic. And I think that it's. It's, you know, like I said, I have my opinions on it, on where I think we should maybe leave certain things toward people older. It doesn't mean that I think people, if they are presenting with that when they're young, they shouldn't talk to someone, a professional, maybe get something sort of spoken about, or if they need to talk to someone and talk those feelings out or talk those thoughts out, fine. But I think when we're talking about modifying bodies, when we're talking about changing hormone profiles of minors, I have concerns about that. I have serious concerns about that. Because we're not entrusting them to drive a car. But you're not entrusting to do that. You're not, you know, there's certain. There's just a disconnect there in what I think is appropriate, maybe for someone who's young. It doesn't mean. I think that all those kids are crazy and they're wrong. They may have a real issue that needs to be addressed, but I think it needs to probably be investigated. What is the right time frame to do that? What's the healthiest way to approach it? What kind of support can we give that person in the meantime? That's where it's tricky stuff. The surgeries themselves are pretty serious, and they're not reversible in most cases. When you're talking about bottom surgery or you're creating a phallus, or you're removing, you know, vagina, or you're removing the penis. Like, you're not really going to come back from that in the way that you were before. So. And you look at suicide rates of these patients, and they're very high. So these are very difficult things to deal with and address in a way that's appropriate and measured. I don't have all the answers for it. And I think, you know, I think our society as a whole has made a real push for inclusion, which I think has a lot of positives. But I think there's also some things we got to be careful about when we're rushing to be inclusive and rushing to accommodate everyone and everything for what they want to do and how they want to do it.

[A]

Yeah, I can imagine how, like how much that would place on a surgeon as well. Reconstruct. Reconstructive surgery is a big deal.

[B]

Yeah, it is. And I think that, you know, there's.

[A]

Is that you actually said that. Sorry to cut you off. It's not. You're not getting a penis, for example, from another human.

[B]

Correct. You're not. What you're doing is you. The most common method is something called a radial forearm flap, free flap. So what we do is we take a full thickness piece of skin from the forearm with the blood vessels and the veins attached, we remove it and you kind of wrap it to create a phallus and you attach it to vessels and nerves down there. Believe it or not, aesthetically, you can make it look very real. It's pretty wild what we've been able to kind of accomplish with it.

[A]

What about the testicles?

[B]

So they'll use implants and then urethra. Yeah, so you'll have a urethra because you make a tunnel with this. You'll make a tunnel. They'll have a Foley catheter and they come out of surgery, it'll epithelialize and they'll have a functioning urethra. And then you just skin graft the donor site. So yeah, it's a big operation. Takes, you know, can take 8, 9, 10 hours to do just that. So these are big surgeries. Now the top surgery, like, you know, female to male, where they just essentially have a mastectomy. Not as major of an operation in the sense of kind of the morbidity of the surgery itself, but it's still a surgery you're not going to come back for unless you get an implant to kind of reverse it. Similarly, if you. Male to female is just putting an implant in a male or genetic male or however you want to typify it. But so those aren't quite as involved or quite as irreversible per se. But when you talk about bottom surger, it's a big deal. It's a huge commitment. It's, it's. You're, you're all in at that point.

[A]

I, I've, I've interviewed Dr. Lana Chuck. She's one of my friends. She's a urologist and she has an aesthetic clinic. And she was mentioning the amount of men, and this is in Manhattan, the amount of men that are coming through now who are looking at penis enlargement, if you will. So I guess my question is if I am a man And I want to have a bigger penis. What are some of the things that I can be doing without going too drastic into surgery? Are there different injections that I can be having to increase girth, width, length?

[B]

So there are fillers that providers can use to increase those things. So definitely not in the scope of what I do in my practice.

[A]

Oh, okay. I thought maybe it's, look at its aesthetics.

[B]

I know, you know, it's, it's, it's not something that I, I typically am doing a lot of in my practice, but I know that that is an option. So you, there are fillers you can use to increase the girth.

[A]

Like the fillers you put in your.

[B]

Correct. Similar. Can use hyaluronic acid fillers. Now they will increase, generally those are going to address girth, not so much length, more extreme situations people use. You can use implants, things like that to really stretch things out, but that's a really drastic method of doing something. So I had, I think there was a friend of mine, there was a friend of mine years ago. This is, I think I was a resident. His job, he was a rep for like penile implants.

[A]

Interesting.

[B]

Yeah. Never heard the end of it from us either. We were really mature about it, as you can imagine.

[A]

Oh yeah.

[B]

But, but, yeah, so, but there's a, there's also a purpose for those, in terms of people who have, you know, I was involved in an operation where we had to do a penile reconstruction. A patient who had a cancer down there.

[A]

Yes.

[B]

So he had a penectomy. So it's not all, you know, cosmetic in nature or some, or even gender dysphoria issues. Sometimes it's real reconstruction. So there's, there's things that are available.

[A]

Look, Botox has many uses in. We just saw it there in the genital region. There is everywhere. Including occipital neuralgia, trigeminal neuralgia.

[B]

Yeah.

[A]

So there is. Botox is a multi use product. Okay, that's great. I really want to wrap up by I guess asking a selfish question which is about skin health and your take on it. I'm always trying to stay forever young. Look, forever young. But by the way, my biological age, as per my inside tracker results state that I'm 29.3. Oh God, I'm really happy about that.

[B]

I would be so horrified to take that because I feel old as hell. Like I, it's the mileage. Well, I appreciate it, but it's, it's, it's smoke and mirrors. I am breaking down. I'm telling you, it's like the test like that scares me because it would confirm my fears.

[A]

Well, look, I look in the academic literature it says that everything is downhill at the age of 40.

[B]

So thank you.

[A]

Well past that and I'm not there and I'm just, I'm like looking at it and I'm like, no, but no on that. I know that we now have robust evidence to show that collagen collagen peptides yields great results for skin health. This is non surgical, really easy to adapt. I have my momentous collagen powder. I put it every morning in my smoothie. Is this doing anything good for my skin?

[B]

I certainly think it's only going to help your skin. You know, the extent of which it is, I think as you know, depends on the product you're taking, your mode of, the mode of entry, the product, things like that. But it's only going to help. And I think, you know, without question, collagen is the main thing that's changing. The elastic properties are changing as we get older. So I think collagen supplementation is one of the newer things that I think has shown promise in terms of really overall has a lot of benefits, but certainly skin health I think is one of them. I think that, look, there's some very basic tenets that everyone can accomplish to optimize for skin health. And I think we're doing a better job than we used to overall. If you look at pictures of what people in their 40s look like now versus people in their 40s in the 1980s, there's a huge difference in what people look like now. People are aging much slower than they used to. And I don't think that's in any small part to a lot of different factors, but I do think an appreciation for some of the factors that, you know, like smoking or sun exposure, which unquestionably are two of the worst things that we can do to our skin. A simple SPF is the first step. And if you want to maintain your skin age, okay. The other things that we talk about are we talk about retinols with patients. So, you know, retinols, vitamin C are two things that should probably be in everyone's armamentarium when it comes to skin health and then just cleansing. So for most patients or for most people, I think everyone can benefit from, you know, cleansing their face in the morning, cleansing at night. Women, it's probably even more of an issue because of applying makeup and other things, you know, products to the skin that they probably should wash off before they Go to sleep. But so a daily wash. Most people use some kind of a, some derivative of a retinoic acid at night to help with cell turnover and to help stimulate collagen. Doesn't mean retin A which is pretty aggressive. You know, that's a prescription that people get which will literally flake the skin. Doesn't mean they have to be on that. But a retinol, basic retinols, when there's a million on the market. But I think everyone should look at retinol and some kind of a vitamin C based serum. If you just follow those, it's not too complicated. Now you can go a lot deeper than that. I mean people have 10 step regimens with any number of serums that certainly have benefits. But I think at a baseline people should try to focus on that. And the big thing is consistency. If you're just doing it once a week or twice a week, it's probably not going to do something. It's really something you got to do day to day. And we have pretty compelling evidence to show its benefits in the context of a consistent regiment. And it's really all you got to do. And these other things great. But it does make a difference. And look, Botox does help too. Botox gets a bad rap. But there was a fascinating twin study done years ago where they had two twins. One regularly got Botox, one didn't. And the difference of them kind of 10 years later was not insignificant. It was pretty dramatic in terms of the appearance of fine lines and wrinkles. Because if you use it more as a preventative technique, which is ideally what it's for. I always used to joke with people the difference between being in LA and being in practice in Chicago. In LA you have here in Chicago you'd have a 50 year old coming in saying oh, I think I should start Botox. In LA you have a 20 year old saying let's start Botox. But the reality is that 20 year olds probably more and has the right idea because it's ideal as a preventative agent. So you know, those things are kind of, those are the key things in our armamentarium that work. They do it, you know, I'm not as good as I should be. I, I gotta attribute most of my skin health to my creat genetics. I'd love to say I'm so good with our, so good with my regimen.

[A]

But I'm, I have to say that.

[B]

I'm not, you know, I'm not, I'm not as good as I should be. But being that we have sort of oilier skin that tends to age better. We do better than, you know, some of my dry skin. White friends don't do as well.

[A]

Just.

[B]

They just don't. So. But those are the things that people should look at.

[A]

Well, Dr. Charles, you have provided a very well constructed, no pun intended, episode that has taught me, and I'm sure it's taught everybody about who you are and what the plastic surgery field is. Now you're located in Beverly Hills.

[B]

Yes, so I'm located in Beverly Hills, but I do go to Dubai three times a year, so I have an office there. So I'm in Dubai in the fall, winter and spring. I don't go to Dubai in the summer. It's miserable. But yeah, but yeah, I'm based in.

[A]

Beverly Hills primarily, and people can come and see you. And you also got a really great Instagram page, which you share a lot. I know that you're getting even more, like excited about that now. I'm seeing it.

[B]

Oh, I love it.

[A]

I'm like the rise.

[B]

I think, if anything, it's like I have a love hate relationship with Instagram, as we all do. Look, it's been a great vehicle in plastic surgery and probably in your field too. Patients are much more informed than they ever were. My consults are more efficient. I tell patients it's great for patients because you can see results people have in real time. You know, used to be at a website, used to be looked at 10 results on a webpage. Was that from last week or 10 years ago? Now you can see what a surgeon focuses on week to week, see the reproducibility of results, but you also see their personality. If they're actually themselves, they're not some kind of weirdo on their social media, and they're actually themself on social media. You can get a flavor of their personality because I tell people the other thing, aside from finding a provider, you really like their work, you gotta like them. You want to have a good. You want to be able to vibe with them and have a good relationship with them. And Instagram's been great that way. I. So that's a good part of it. The bad part of it is like the pressure to put stuff up. And there's so much cringy shit out there, especially among doctors. And just like at the end of the day these days, I've just say, as long as I'm not embarrassed by what I put up, I don't care how many views it gets or likes, as long as I think it's just educational or entertaining or showing people a little flavor of my life. Great.

[A]

I love that. Well, you're definitely doing your part in terms of education and entertainment at the same time. So thank you so much for being part of the New Experience podcast.

[B]

It's a pleasure. Thanks for having me.