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Peter Attia MD#13 – Brett Kotlus, M.D.: How to look younger while we live longer
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CHAPTERS
- 0:04 – 5:25
Episode setup: subtle, long-term aesthetics and how to choose a provider
Peter Attia introduces Dr. Brett Kotlus and frames cosmetic work as a “compounding” game of small, subtle changes that hold up over time. He also tees up a practical focus: understanding common procedures and how to distinguish high-quality providers from poor ones.
- •Peter Attia describes Brett Kotlus’s specialty around the eyes and facial plastics
- •Emphasis on subtle results that don’t look “done”
- •Overview of topics to come: Botox, fillers, lasers, peels, and selection of practitioners
- •Peter highlights the importance of picking the right person, not just a procedure
- 5:25 – 8:41
Kotlus’s training path: oculoplastics, cosmetic surgery, and med-spa technology exposure
Kotlus explains how he entered oculoplastic surgery through ophthalmology residency and a fellowship that included significant cosmetic surgery experience. He describes subsequent work in a large medical spa environment that deepened his exposure to lasers and aesthetic technology.
- •Oculoplastic surgery as a cross between ophthalmology and plastic surgery
- •Fellowship included reconstructive work plus facelifts, fat grafting, liposuction, and lasers
- •Training qualified him for multiple professional organizations
- •Early career experience in a large medical spa expanded device and laser familiarity
- 8:41 – 10:12
Why faces age: intrinsic vs extrinsic changes, layers, and sun-driven damage
Kotlus outlines the main drivers of facial aging, separating genetic programming from environmental exposure. He describes aging as a multi-layer process involving bone, fat, skin thickness, collagen/elastin loss, and pigment and vessel changes.
- •Intrinsic changes: bone loss and shifting fat with age
- •Extrinsic changes: sun exposure causing solar elastosis and collagen/elastin loss
- •Skin gets thinner; telangiectasias and brown spots increase
- •Aging reflects changes across skin, fat, muscle, bone, and connective support structures
- 10:12 – 11:36
Why sun seems to “show” more on the face than the body: tension, glands, and movement
Peter asks why heavy sun exposure appears to age the face more than areas like the back. Kotlus attributes differences to skin tension, movement patterns, laxity, and oil-gland distribution, noting how expression and repetitive motion influence visible aging.
- •Back skin is taut and under tension; facial skin needs laxity for expression
- •Scars and healing patterns differ in high-tension areas
- •Facial sebaceous gland density differs from other body areas
- •Muscle expression and constant motion shape how facial aging appears
- 11:36 – 13:35
Facial fat loss, gravity, and contours: why “deflation” changes the look
Kotlus discusses how small changes in facial fat alter contours by revealing underlying tether points and bulges. He connects deflation with gravity and repetitive mechanical stress on facial ligaments, using the “lying down photo” example to illustrate gravitational effects.
- •Local facial fat loss reveals ligaments and creates shadows/contours
- •Gravity compounds deflation and support loss over time
- •Mechanical wear from everyday motion and impact affects facial ligaments
- •Comparing photos lying down vs standing shows gravity’s contribution
- 13:35 – 16:58
Genetics, skin type, and UV: what seems inherited vs what lifestyle can change
Peter asks about genetic factors behind “aging well.” Kotlus points to inherited facial structure and correlations with skin type/pigment, then suggests UV protection can offset many “genetic” outcomes and shares his view that long-term UV may contribute to fat atrophy.
- •Under-eye bags and facial structure are often familial
- •Darker skin types may show UV protection and different connective tissue density
- •Kotlus hypothesizes UV exposure may contribute to fat atrophy over time
- •Lifestyle choices (especially sun protection) can mitigate appearance outcomes
- 16:58 – 22:29
Avoiding the overdone look: why it happens and what “natural” requires
Kotlus explains that well-done work is often invisible, while overdone results stand out. He describes social and psychological pressures (including “Instagram effect”) and gives a practical boundary: aiming to look modestly younger rather than decades younger to avoid distortion.
- •Most noticeable “work” is the poorly done subset; good work can be hard to detect
- •Emotional attachment to a younger self and career/image pressure can drive excess
- •Social normalization via curated images can shift expectations
- •Unnatural results come from distorted dimensions, erased shadows, and over-pulling
- 22:29 – 26:48
Fillers and facial balance: lips, swelling, reversibility, and how long results last
The conversation turns to trends like fuller lips and the rationale of restoring age-related volume loss. Kotlus describes hyaluronic acid fillers, temporary swelling, reversibility, and why longevity differs by area—contrasting under-eye longevity with shorter-lasting lip filler.
- •Volume restoration can be natural-looking when guided by older photos and balance
- •Hyaluronic acid fillers are biocompatible and reversible with an enzyme
- •Hydrophilic swelling makes lips look temporarily larger, influencing repeat decisions
- •Duration varies: under-eye can last years; lips often shorter due to movement
- 26:48 – 31:52
Under-eye rejuvenation technique: cannula filler, tear troughs, and anatomy-driven placement
Kotlus details his approach to under-eye filler using a blunt cannula introduced from the cheek rather than needles under the eye. He explains the tear trough shadow, why eyes show aging early, and how surgical familiarity with eyelid anatomy guides safe, precise placement.
- •Under-eye aging combines thin skin, constant blinking, and tear-trough shadowing
- •Cannula approach enters from the cheek through a small entry point
- •Blepharoplasty experience informs placement and product choice by tissue planes
- •Goal is brightening and disguising bulges without puffiness or unnatural texture
- 31:52 – 37:43
Choosing the right practitioner: credentials, photos, consult fit, volume, and complication planning
Peter presses on how listeners can pick a provider when they can’t see Kotlus. Kotlus recommends verifying relevant board/organizational training for certain surgeries, using referrals, reviewing galleries critically, interviewing multiple clinicians, and directly discussing complication management and revision policies.
- •Certain procedures (like eyelids) may warrant specialty training focus
- •Referrals from trusted sources and firsthand observers can matter
- •Before/after galleries can reveal a provider’s aesthetic judgment
- •Patients should ask about volume of cases, complications, and what happens if one occurs
- 37:43 – 41:32
Botox done well: common forehead mistake, better targets, and timing to prevent etched lines
Peter shares a bad personal Botox experience that impaired brow elevation, and Kotlus explains why heavy forehead treatment is a classic error. Kotlus describes a more nuanced approach targeting frown muscles with lighter forehead dosing and discusses starting before static (“etched”) lines form—without tying it to a specific age.
- •Over-treating the forehead can prevent brow elevation and look like a giveaway
- •Frontalis is the only muscle that raises the brows
- •Alternative focus: corrugator/procerus with light forehead dosing
- •Start before static lines form; there’s no universal age and it can be too early
- 41:32 – 46:29
Cosmetic procedures and psychology: confidence, unrealistic expectations, and saying no
Kotlus explains that appearance concerns are emotionally loaded and often tied to self-image and confidence. He describes how he sometimes declines treatment or redirects the conversation when goals seem unrealistic, emphasizing an approach aligned with overall wellness rather than chasing minor imperfections.
- •Cosmetic motivation often centers on confidence and self-image
- •Some patients seek changes that don’t match objective reality
- •Providers may need to act partly as counselors to clarify goals
- •Ethical practice includes setting boundaries and refusing inappropriate requests
- 46:29 – 1:09:07
The skincare “trifecta”: sunscreen, retinoids, and topical vitamin C
For those who want self-directed basics, Kotlus outlines three core tools and how to use them. He explains broad-spectrum sunscreen (and physical vs chemical types), retinoids from OTC retinol to prescription tretinoin, and topical vitamin C’s antioxidant role and formulation challenges.
- •Broad-spectrum sunscreen is central; SPF measures UVB, not UVA
- •Physical (zinc/titanium) vs chemical sunscreens; he flags octinoxate as a concern
- •Retinoids promote collagen and skin turnover; start slowly and use at night
- •Topical vitamin C may help reverse sun damage; stability and oxidation are challenges
- 1:09:07 – 1:33:04
Procedures beyond injectables: peels, resurfacing lasers, tightening devices, and PRP skepticism
Kotlus gives an overview of resurfacing options like chemical peels and fractional CO2/erbium lasers, emphasizing operator dependence and skin-type considerations. He also critiques skin-tightening energy devices as often underwhelming and discusses PRP and “vampire facials,” focusing on variability, limited proof, and the risk of spending money for minimal visible change.
- •Chemical peels vary widely (strength, layers) and can burn or scar if misused
- •Fractional lasers leave intact skin between treated zones to speed healing
- •Tightening devices (radiofrequency, ultrasound, plasma) often show subtle results
- •PRP methods vary; outcomes can be hard to verify beyond lighting differences
- 1:33:04 – 1:43:58
Future directions: stem-cell-adjacent fat work, injectable growth factors, customization, and 3D/bioprinting
Peter asks what’s coming next, and Kotlus discusses areas he believes will evolve dramatically. He highlights uncertainty about fat grafting mechanisms, interest in stem-cell–rich fat fractions, mentions lab-derived fibroblast growth factor used in Asia for volumization, and explores how genetic customization and 3D/bioprinting could reshape implants, tools, and even living tissue reconstruction.
- •Fat grafting works clinically but mechanisms remain incompletely understood
- •Interest in “nano fat”/stromal vascular fraction and regenerative signaling
- •Lab-derived fibroblast growth factor injections in Asia for facial volumization are discussed
- •3D printing already enables custom instruments; future may include tailored implants and bioprinted tissues
- 1:43:58 – 1:48:51
Where to find Kotlus and closing remarks
Kotlus shares how to follow his work online and reflects on social media’s role in connection and storytelling. Peter closes by summarizing key takeaways—from provider selection to the basic skincare routine—and ends with the show’s standard wrap-up and disclaimer.
- •Kotlus provides his Instagram handle and website
- •Discussion of the value of stories behind cosmetic decisions
- •Peter reiterates practical takeaways: scrutiny of providers and the skincare basics
- •Episode concludes with podcast links and medical disclaimer
