#13 – Brett Kotlus, M.D.: How to look younger while we live longer

1. 0:00 – 0:04

   Intro

   1. PAPeter Attia0:00

      [upbeat music]

2. 0:04 – 5:25

   Episode setup: subtle, long-term aesthetics and how to choose a provider

   1. PAPeter Attia0:04

      Hey, everyone. Welcome to The Peter Attia Drive. I'm your host, Peter Attia. [upbeat music] The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top-performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peterattiamd.com. [upbeat music] In this podcast episode, I'm speaking with my friend Dr. Brett Kotlus. Brett is a New York City-based eye and facial plastic surgeon who specializes in cosmetic and reconstructive surgery of the face, but particularly specializing around things to do with everything with the eyes, including the skin around the eyes. He's trained both in general oculoplastic surgery and general cosmetic surgery. I met Brett about three years ago, and I still remember our first meeting. We met for the first time when he just came by my office at some point, and we sat around having coffee. And as he walked me through not just his training, but-- which, which is actually quite unique, but also his particular approach, I realized we were kind of kindred spirits in our appreciation for nuance. As you'll learn in this episode, I know pretty much nothing about looking good and skin and eyes and all that stuff. And in many ways, to spend time with Brett is to spend time with someone who thinks a lot about how to make small and subtle changes over time that lead to long-lasting effects. And I think the reason that resonated so much with me is my belief in longevity, of course, is that it's a compounding issue, and therefore making small but consistent changes that lead to seemingly small improvements over the short run is actually what leads to amazing results over the long run with respect to the reduction of risk of disease, et cetera. Brett's approach to cosmesis is the same way, and I suspect that my bias is probably what has me thinking that that's really the right way to do it. And once I got to know Brett better and we started to collaborate and work together, and I've sent a number of patients to Brett, I was always amazed by the responses because to me, the right way to, for example, do botox is to be able to look at a patient after the procedure and say, "I didn't know you had botox." And so things that we talk about here are a bunch of things that you can do to make a huge impact on the health and vitality of your skin. And he does get into a number of these things, specifically around botox. He also gets into a growing list of sort of all the facial treatments and cosmetic proc- procedures that are out there, lasers, peels, all of these sorts of things. And most importantly, I think he also helps you, as the listener, think about how to pick someone because again, you know, many of you listening to this might find this stuff interesting, and sure, if you happen to be in New York and you wanna meet Brett, that's great, but most likely you're not. And so the more important question is: how do you sort of separate the good from the great or even the great from the not so great in this space? So again, like I said, I don't think a lot about this personally. I realize I should probably think about it more. When I look at pictures of myself today versus pictures of myself when I was 30, I am sort of surprised at how much I feel [chuckles] like I look like I've aged. And I guess part of this was a bit of a wake-up call for me that I might need to pay a little more attention to that, if for no other reason than just to have the optionality to look a little better when I'm 80 than I'm probably on the course to looking. Brett does a great job here explaining why our faces change over time, what he considers the three most important tools for skincare and rejuvenation. He gets into all the procedures, as I mentioned, the lasers, the peels, the needles, the devices. Um, I really enjoyed his discussion of the right way to do botox because I'd heard this before because, of course, Brett and I had discussed this a lot, but I, I'm glad we were able to sort of revisit that for people here. And he also talks a little bit about the current trends and future trends of cosmetic and plastic surgery. You can follow Brett on Instagram. He's Dr. Kotlus, D-R-K-O-T-L-U-S, where he puts up lots of before and after photos, especially around the eyes, which I find particularly interesting. That's something about myself that I've always been curious about making better. And his website has the same URL. Lastly, you can see some stuff in the show notes here. I asked for Brett to give us kind of his recommendations on products that he suggests that his patients get, that if anyone is interested in, they'll at least be able to sort of get that, and you can see that at peterattiamd.com/podcast. So without further delay, here's my conversation with Dr. Brett Kotlus. [upbeat music] Well, I'd like to welcome to the show today Dr. Brett Kotlus, who is an oculoplastic guru and also a close friend of mine. Brett, we met, what, about three years ago?

   2. BKDr. Brett Kotlus5:14

      I would say. Maybe it's two.

   3. PAPeter Attia5:15

      Okay.

   4. BKDr. Brett Kotlus5:15

      Yeah. It just seems like we've known each other a long time.

   5. PAPeter Attia5:18

      The first time we met, I remember being really impressed by kind of the nuance of your training.

   6. BKDr. Brett Kotlus5:25

      Thank you.

3. 5:25 – 8:41

   Kotlus’s training path: oculoplastics, cosmetic surgery, and med-spa technology exposure

   1. PAPeter Attia5:25

      I tend to think and talk a lot about longevity, but I don't tend to think and talk a lot about or know anything about looking younger, and you have learned an awful lot about that. So remind me, how, w- how did you train? What was your medical training?

   2. BKDr. Brett Kotlus5:40

      When I was in medical school, I was drawn to this specialized field that was sort of a cross between ophthalmology and plastic surgery, and it's called oculoplastic surgery. I was watching this doctor do, uh, an orbital tumor resection, and so I decided this is what I wanna do. And I learned that I needed to do a residency in ophthalmology before I can do a fellowship in oculoplastic surgery, which the field basically revolves around the eyes and the face and plastic procedures related to that. So I found out that I had to do an ophthalmology residency first. So I did that, and then I matched in this training program. The match process is sort of like a, the medical matchmakers, and you are assigned to a program based on a ranking system, which you've been through that as well. And, um, I matched with this doctor in Tucson who happened to have transitioned his practice into cosmetic surgery. And so when I arrived, I thought I was gonna be doing mostly orbital tumors and tear duct surgery and eyelid reconstruction, and that was part of what we did. But we were also doing a lot of facelifts and fat grafting and liposuction and lasers. And so my fellowship training qualified for two different organizations, the American Society of Oculopla- Ophthalmic Plastic and Reconstructive Surgery, and then also the American Academy of Cosmetic Surgery. So when I finished my fellowship, I ended up working in this practice in Michigan that was the largest medical spa in the Midwest, and it was an exposure to even more lasers and more technology that was on the cutting edge of what doctors are doing for our appearance.

   3. PAPeter Attia7:35

      I remember one of the things that really surprised me when we spoke was just understanding that basically anybody with an M.D. can hang a shingle and do kind of whatever the heck they want with respect to facial plastic stuff. I mean, anybody can be injecting botox and fillers and all of these things. And of course, not everybody's doing this stuff well, and not everybody's doing this stuff with the eye towards how will this look down the road?

   4. BKDr. Brett Kotlus8:01

      Right.

   5. PAPeter Attia8:01

      And I think, um, your approach seemed very nuanced and sophisticated, so I hope to certainly touch on that today. But I kinda wanna start with some just fundamentals. So I saw a picture of myself 20 years ago, meaning I recently saw a picture of myself from 20 years ago, and I was like, "God, you were, like, a better-looking dude back then."

   6. BKDr. Brett Kotlus8:22

      Huh.

   7. PAPeter Attia8:22

      Why is it that at 25 I looked better than 45? And part of it, I think, is just my skin looked so much better. So even though by most people's standards I'm not an old guy today-

   8. BKDr. Brett Kotlus8:36

      Right

   9. PAPeter Attia8:36

      ... clearly my skin doesn't look like it used to. What has changed?

4. 8:41 – 10:12

   Why faces age: intrinsic vs extrinsic changes, layers, and sun-driven damage

   1. BKDr. Brett Kotlus8:41

      It's interesting because there does happen to be a double standard for men and women, and we have the benefit of looking more distinguished as we age. So it's-- I don't think all men feel that way, that we're looking worse as we age, but we certainly, we're, our faces are changing. And there are some aging changes that are intrinsic and some that are extrinsic, right? So your genetics, you're programmed to have certain changes over your lifespan, right? Your, we lose bone as we age, which happens in our faces. We are losing facial fat as we age, and in some ways we're losing it in maybe the wrong places. And the sun that we're exposed to over many, many years causes something called solar elastosis, so we are losing collagen and elastin. The thickness of our skin is decreasing in many areas, and we're also gaining small blood vessels, the telangiectasias, and we are gaining brown spots, and the combination of these things on every layer, your skin, your fat, your muscle, your bone, the ligaments that connect the interplay between these layers are all losing support, and they're getting thinner, and they're degrading. So from the time that you're born until now, you started off with really chubby, round cheeks. You look at your one-year-old son, and it's all downhill from there. [chuckles]

5. 10:12 – 11:36

   Why sun seems to “show” more on the face than the body: tension, glands, and movement

   1. PAPeter Attia10:12

      Now, there seems to be something about the face in particular. So I used to swim a lot, and I used to swim outdoors, obviously. So I'd spend, uh, sometimes six or eight hours just swimming in the, out in the ocean, and I didn't even bother putting sunscreen on 'cause, you know, I have dark skin. I have olive skin. I never get sunburned. So I'm pretty used to being the guy that's getting a ton of sun. And, and while I accept that that's probably caused some damage to my face, why does it not seem to have caused that same damage to, say, my back, which was even more exposed to the sun when, you know, I'm swimming in a prone position?

   2. BKDr. Brett Kotlus10:45

      Well, if you think about the tension at play and based on your face and your back, I mean, they're, they're different. So your face has more movement, but there's also, because you need to move in certain ways, there's also more areas of laxity. Whereas your back, the skin is stretched, and it's taut, even though you can certainly get brown spots and wrinkles on your back. Think about scars on the back tend to spread.

   3. PAPeter Attia11:10

      Mm-hmm.

   4. BKDr. Brett Kotlus11:11

      They look wide and stretched, and they don't heal well because it's under constant tension. But I think that tension makes the back skin look different than the facial skin. But you also have different oil glands in different parts of your body. So you have a higher density of sebaceous glands in your face, and the muscl- muscular expression, I think it affects the way that you age more than it does in other areas.

6. 11:36 – 13:35

   Facial fat loss, gravity, and contours: why “deflation” changes the look

   1. PAPeter Attia11:36

      Now, I, I read once that, um, by about the age of 35, you've, you'll lose about 10% of the fat in your face.

   2. BKDr. Brett Kotlus11:43

      Yes.

   3. PAPeter Attia11:44

      Which is kind of amazing to me, given that by the age of 35, I probably gained 10% of the fat in my body.

   4. BKDr. Brett Kotlus11:50

      [laughs]

   5. PAPeter Attia11:50

      What, what is it about the face that doesn't do what the rest of the body does, which is accumulate fat?

   6. BKDr. Brett Kotlus11:55

      Yeah, well, I think there's probably local hormone effects that are making you accumulate in other areas. And in the face, we have the fat cells come from different embryologic origins. And for some reason, that's what's happening there. And you're-- we're talking about very small amounts of fat. So you'll see those small differences. But think about your facial fat as insulation, and as you lose that insulation, you start to see the structures that are underlying the surface. And so you can see where the ligaments are tethered, and you can see the places where they're not tethered, which would be an out-pouching.

   7. PAPeter Attia12:31

      Mm.

   8. BKDr. Brett Kotlus12:31

      And so all of those tight areas, uh, opposed and just directly next to the areas that are not tightly attached, you see these contours. And so as you age and you deflate and you have gravity pulling down, I mean, the effect of gravity is real. Have you ever seen a, like, a slow motion video of a runner, and you see their face and the way that the face bounces up and down, and there's so much force on those facial ligaments? And so you can imagine what happens as you're just walking and running up and down the stairs and ov-- and you're smiling, and you're doing all these things with your face. So there's wear and tear. Just like it happens on our joints, it happens on our facial ligaments. Have you ever lied down on your back and take a picture, and then stand up and take a photo? That lying down image, that eliminates the effect of gravity on your face, and that shows you what is gravity doing in combination with the deflation. So that's how you take a selfie is when you're lying down on your back.

   9. PAPeter Attia13:29

      Take a lying down selfie.

   10. BKDr. Brett Kotlus13:31

       Yeah.

   11. PAPeter Attia13:31

       There's tip number one, guys.

   12. BKDr. Brett Kotlus13:32

       It's called the anti-gravity selfie.

7. 13:35 – 16:58

   Genetics, skin type, and UV: what seems inherited vs what lifestyle can change

   1. PAPeter Attia13:35

      In longevity, I used to-- used to, I still do, and I certainly don't, uh, des- don't deserve credit for this. Smarter people than me have said this first, but the, the joke is the most important thing you can do to live longer is choose the right parents.

   2. BKDr. Brett Kotlus13:46

      Mm.

   3. PAPeter Attia13:47

      So there are lots of things that you can do to live longer, but genes really play a role. Now, in the longevity space, we have a pretty good sense of what those genes are. There are somewhere between about eight and 12 genes that offer pretty remarkable protection in delaying the onset of chronic disease, and therefore centenarians, people who live to be 100 or longer, tend to be bestowed with a greater proportion of those genes. But you mentioned a second ago that genetic factors can also influence these sort of intrinsic changes that occur. Do we have a sense of what those genetic factors are? Clearly, there are people who just have remarkable skin, and they age with remarkable skin and, you know, you'll see a woman who's 40 who looks like she's 20, and her mom is 65, and she looks like she's 45.

   4. BKDr. Brett Kotlus14:37

      Well, we know that there are some correlations between certain genetic types and certain traits and the way we age. I mean, if-- You know, I see a lot of people for under eye-bags, and it's almost everybody says, "Hey, this is, this is genetic." Well, yes, I know it's genetic. I mean, their-- your parents have it. You came in with your mom, and y- she has it, too. So the structure of your face obviously comes from your parents. But when we talk about skin types and the skin color, darker skin types tend to have more connective tissue or denser connective tissue and tend to look better as they age. So maybe it's a generalization, but a lot of the Asians in my practice tend to look better longer. Darker skinned individuals, the same thing. And so the darker pigment in skin does give you some UV protection. Doesn't mean that you don't have to wear sunscreen, but it offers photo protection. And I, I theorize that UV exposure from sunlight causes fat atrophy over many, many years.

   5. PAPeter Attia15:42

      Wow. What do you base that hypothesis on?

   6. BKDr. Brett Kotlus15:45

      We use heat, and we use laser procedures in a very highly focused way, and we know that it destroys fat cells. So these externally applied devices that are available now, and they effectively remove subcutaneous fat, and I believe that UV radiation does the same thing over a long period of time. And if you've seen people that have always protected themselves from the sun, they look like they have white porcelain skin.

   7. PAPeter Attia16:12

      Mm.

   8. BKDr. Brett Kotlus16:12

      They have less wrinkles, and they have younger looking faces. I know we're moving away from the genetic question you're asking me, but I think you can often overcome many of the genetic things, just like with chronic diseases or with your lifestyle modifications. But I think that there is also an internal drive that we have to perpetuate our gene pool, that we each have our own internal motivation to do that. That's just our evolutionary goals, and I think some of the more favorable genes become selected over time. And so I think there's a genetic motivation for people to want to look good because they want to present themselves in their best possible way to a possible mate.

   9. PAPeter Attia16:56

      Kind of like a peacock. [laughs]

   10. BKDr. Brett Kotlus16:57

       [laughs] Right.

8. 16:58 – 22:29

   Avoiding the overdone look: why it happens and what “natural” requires

   1. PAPeter Attia16:58

      But we don't have feathers, so... One of the things that I'm sure anybody listening to this, and certainly I've always found a little bit, um, I don't know, worrisome is, God, if I had a dollar for every time I saw someone walking down the street and who'd looked like they'd had a million procedures done, and you just feel bad for them. You feel like, "God, something went wrong there. I'm-- You don't look natural or normal." And I think for many people, it becomes off-putting, and they think, "Well, gosh," like, "I don't want to do anything." So it, it begs the question: Are there strategies that one should take to consider gracefully aging in as much as one cares? I mean, look, I think in the end, some people are gonna say, "I don't care about any of this stuff." But presumably, if someone is still listening to us talking now a few minutes into this, they probably care.

   2. BKDr. Brett Kotlus17:46

      Right.

   3. PAPeter Attia17:46

      How do you think about this, and maybe how does that differ from what other docs think or, you know, what, what would be a traditional point of view?

   4. BKDr. Brett Kotlus17:53

      Think about all the people that are walking by you on the street that have had work done, and you haven't-- you don't notice it because it's done well. So I think you're seeing that every day, but you just don't know it.

   5. PAPeter Attia18:04

      Yeah, I only see, I only see the, uh, the numerator. I don't see the denominator.

   6. BKDr. Brett Kotlus18:08

      What are the reasons for the unnatural appearance? Why do people get to that point? I think in some cases, maybe it's unlimited access or unlimited resources. I think there are forces that push people in that direction.

   7. PAPeter Attia18:23

      Yeah.

   8. BKDr. Brett Kotlus18:23

      Your appearance is a very emotional subject, and I think we tie ourselves to that, maybe an age that we feel like that was our best age. Think about the actress that everyone knows for the role that they played when they were 20 years old, and in our minds, we think of them as that person.

   9. PAPeter Attia18:44

      Mm.

   10. BKDr. Brett Kotlus18:44

       And it's almost hard for us to imagine them aging, and you see them and you're like, "Oh, look how old they look." And it's, it's... I think it's a natural tendency to think that because you're remembering that favorite movie that you saw them in. But think about the pressure they feel in that situation, like, "My career is based on my image." And so if you try to hold onto that 20-year-old version of yourself, at some point, you're going to cross the line into an unnatural, distorted look. So there's probably a rough guideline. Your goal should-- You know, if you wanna look your best, maybe I'd like to be, look a little, s- like seven years younger than where I am now.

   11. PAPeter Attia19:23

       Mm.

   12. BKDr. Brett Kotlus19:23

       Or 10 years. But if you go beyond that, it's a little too much. That's one part of it. I think the images that we see around us, if you look at some of, uh... This is part of, like, what I call the Instagram effect, where you're scrolling through and you see these photos of celebrities that have blown up their lips and their cheeks are over the top or whatever it is. And some of it is Photoshop, but some of it is from medical augmentation. You start to think that that's the new normal, but it's overdone, and that exaggerated appearance, it-- people around you in your circles might be doing some of these procedures, and so you all see each other like that, and then you wanna get a little bigger and just push it a little more. And then before you know it, you've gone too far. And it can be a slippery slope. So I think people start to lose sight of where they started and what their goals were. Your goals maybe change, and maybe you've found a provider that's a doctor or a nurse injector that said, "Okay, you know, let's take this a little further, a little further." And then they say, "You know, I think you're good here. Let's stop it." But you wanna go further, so you'll find somebody. And so you'll, you'll get to another provider, and they'll do it. I personally feel this way. If someone comes into my office, and they've had something done, I think I can fix them. But maybe you can't or maybe it's time to say, "Okay, let's put the brakes on." So I think there's different reasons why people get to that point, but the technical reason that someone looks unnatural is when you either try to enlarge something beyond its natural dimensions. There's only a certain point is how far the skin will stretch before you start to lose the contours.

   13. PAPeter Attia21:00

       Mm.

   14. BKDr. Brett Kotlus21:00

       And we say, like, you can't have light without dark. So the goal of your face, the goal of a natural-looking face is not to be totally smooth and to have no curves and no shadows and no lines. When you smile, you're supposed to-- You see my brow elevate, and you see some lines in my forehead. You know, I'm, I'm, I'm conveying expression. I'm conveying a message to you that I'm surprised or that I'm angry. And so if you lose those expressions, if you lose the shape of your lip, you have a Cupid's bow where it looks like it dips down in the middle, or you have two pillows in the bot- lower lip. And if you distort that by just blowing past all of that and filling it up, and so you have a sausage now for your lower lip, I mean, your eye will pick up on that very quickly, that that's not natural. You might not know how to describe what is natural, but you know what isn't.

   15. PAPeter Attia21:48

       Yeah.

   16. BKDr. Brett Kotlus21:48

       And so you distort the natural dimensions, and pulling will achieve the same type of distortion if you go too far. Facelifts, when they're pulled back too tight because someone is being too aggressive on the surface of the skin, you see the windswept look. Those type of things where, you know, you see it in older actresses or even actors. Maybe they feel like, "Okay, I can spend this much money to look like this version of myself." Well, there's no amount of money that will make you look naturally 30 years younger than where you are.

   17. PAPeter Attia22:20

       You know, if you compare, I think, people's bodies today to people's bodies 30 years ago, uh, based on augmentation, there are some inevitable trends. Now, I don't have any data to back this up-

9. 22:29 – 26:48

   Fillers and facial balance: lips, swelling, reversibility, and how long results last

   1. BKDr. Brett Kotlus22:29

      Mm

   2. PAPeter Attia22:29

      ... but I can only imagine that breast size is larger today. I think breast augmentation must be more common than it was 30 years ago. When it comes to facial augmentation, what are the trends? And I'm not talking about the, just the extremes where people have, like, gone too far, but it, it would seem to me that people tend to have fuller lips these days.

   3. BKDr. Brett Kotlus22:49

      Mm.

   4. PAPeter Attia22:49

      Is that-- Would that be true?

   5. BKDr. Brett Kotlus22:51

      I would say yes, and for good and bad reasons. I think we recognize now more and more that global volume loss is something that's happening to our faces as we age, and that includes the lips. So lips can be reinflated because they've lost volume in a natural-looking way that you wouldn't know about. I think that there is a tendency now to focus on these areas. So look, when you come into my office and you say, "Hey, look at my face. What should I do?" I'm probably not gonna just say, like, "Okay, you should do this, this, and this." I'm gonna focus on what you're seeing. But I might point out certain things like, "You know, you've lost a lot of volume in this part of your face, and I know you're focusing on your, your brows," for s- may I say. But, um, but I, I see-- You know, I wanna maintain a balance. So it's been, you know, popular to fill these nasolabial lines next to the lips, you know, the lines that go from the corner of your nose to the outer corner of your mouth, or to inflate the cheeks. But we have to look at the neighboring areas. Like, you're a car guy, and you get a scratch on your car. Well, you have to paint the panels next to it in order to make it look good.

   6. PAPeter Attia23:59

      Mm.

   7. BKDr. Brett Kotlus23:59

      And so a good provider, a good physician will look at you and say, "Okay, your concern is your, your nasolabial lines, but I think we should also just at least consider your lips because let's look back at your photo from 10 years ago and, and look what your volume status was then, and let's look at it now." So I think in a good way, people are focusing on lips, but also I think the negative is that, uh, there's always gonna be some people that are over the top. And I see it a lot when, you know, when you have a lip injection, you know, typically we're using hyaluronic acid fillers, which is something that's a constituent of our skin to begin with. So these are very safe in terms of that they're not-- they're biocompatible. There's no allergic reactions to them in general, and they're reversible, so we have an enzyme that can take them back if there's something that doesn't look right or there's an issue. But with these gel fillers, they tend to be hydrophilic, meaning that they absorb water. And for the first two or three days after you do it, your lips look like that person that you're trying to not look like. They get pretty big. So most people, for about two days, they're sort of like homebound or at least-

   8. PAPeter Attia25:09

      They're freaking out.

   9. BKDr. Brett Kotlus25:10

      Yeah.

   10. PAPeter Attia25:10

       They're wondering if they overdid it.

   11. BKDr. Brett Kotlus25:12

       Yes, but it's almost 100% of the time, the first time someone does lip filler and they come back, and I said, "Okay, you were pretty swollen, I bet, for the first two days." And they say, "Yeah, but I sort of miss some of that swelling."

   12. PAPeter Attia25:25

       Hmm.

   13. BKDr. Brett Kotlus25:25

       And so the next time around we do a little bit more. And that's sort of like where you have to determine... And that's, that's, um, it's a personality thing. It's a personal decision in terms of like what is good and, and it's a discussion between, you know, myself and my patient and, and we don't always agree. Like, my patient might say, "You know, I hear what you're saying. You're telling me this is natural. I want to go a little further, and, you know, I'm open to that."

   14. PAPeter Attia25:51

       Now, that's something that doesn't l-- like a facelift, once you get a facelift, you're kind of stuck with it, right? I mean, a redo procedure there is gonna be cumbersome.

   15. BKDr. Brett Kotlus26:00

       It depends on, you know, what the reason is for doing... You can-- there's a big, I think, role for revision facelift surgery. But you're right, when you take something out, right, or you over-reduce a nose or you overstretch someone, that can be very difficult to, um, to repair.

   16. PAPeter Attia26:15

       But obviously the hyaluronic acid doesn't last forever, right?

   17. BKDr. Brett Kotlus26:18

       Right.

   18. PAPeter Attia26:19

       So if someone is doing, whether it's an extreme or incremental strategy of filling, uh, how often do they have to do that?

   19. BKDr. Brett Kotlus26:26

       It depends on the area. So, you know, l-lips tend to not last as long as other parts of the face. Like I, I do a lot of under-eye filler. Under your eyes, you don't have a lot of movement there, uh, even though you're blinking. Under-eye filler lasts, you know, a year, two years. I've seen it last four or five years in some people. Whereas the lips, you're always talking and pursing your lips and eating, maybe six to eight months.

10. 26:48 – 31:52

    Under-eye rejuvenation technique: cannula filler, tear troughs, and anatomy-driven placement

    1. PAPeter Attia26:48

       Now, you have a very interesting technique of doing the under-eye filler, which I've sent a number of patients to you because I've been so impressed by just how amazing it looks and how minimally invasive it is. What, what do you do different there?

    2. BKDr. Brett Kotlus27:03

       So this has sort of become my niche in my practice, and I probably do that one procedure more than anything else, and it wasn't by design. I didn't plan for this to happen, but it was definitely an interest of mine. And, you know, when you look at someone's face, the first thing that starts to age is-- or would be the eyes because that's where we have so much movement. We're blinking all the time, and we have the thinnest skin in our body. And combine that with the fat pads under your eyes, which can enlarge with time because they have a different embryologic origin, and we're losing fat in our cheeks, in the upper part of our cheek, which that groove where you get that shadow is called the tear trough, which I don't really like that term. It makes me think of like pigs eating at a trough. But that trough would be if you were to cry, it would sort of spill down that kind of slide in the inner corner of your eye.

    3. PAPeter Attia27:54

       This is what makes people look like they have almost a black eye sometimes-

    4. BKDr. Brett Kotlus27:57

       Right

    5. PAPeter Attia27:57

       ... from this shadow.

    6. BKDr. Brett Kotlus27:58

       Right. And people think, you know, th-- everyone says, "I'm tired, but I'm not." And so when you combine the puffy under-eyes with the tear trough area, you look tired, and you might not be, or maybe you are, but you just don't want people to know it. So what I do with fillers, I use a hyaluronic gel filler, and I inject it there, but with a cannula. So a cannula-

    7. PAPeter Attia28:19

       So what's a cannula for people who don't know?

    8. BKDr. Brett Kotlus28:21

       It's like a needle, but the tip is dull. It's a blunt tips needle. So what I do is I approach that area from the cheek. We make a little needle hole in the cheek, and then I introduce this cannula through that little needle hole so you have no needles under your eye. And I can use that cannula in a very accurate way. And at this point, I know exactly where my tip is all the time. Even though I don't always see the tip, I know where it is. And when I'm doing this, I'm, I'm imagining the surgical procedures that I do very frequently, which is blepharoplasty. And so because I know the eye-

    9. PAPeter Attia28:54

       Which is what?

    10. BKDr. Brett Kotlus28:55

        So that's-- blepharoplasty just means a modification of the eyelids through surgery. And so cosmetic blepharoplasty is often either removing the fat pads, the bags, removing skin from the upper lids, or shifting the fat, what-whatever I have to do to make your eyes look younger or the way that they used to look. So I do a lot of blepharoplasty, and because of that, I know what it looks like inside. And so I imagine that in my mind when I'm placing the filler, and I'm placing this gel that takes up space, and it's replacing the fat that you've lost, or it's also disguising the fat pad that might be bulging. And so by putting it in the right place and using the right filler, because there's certainly-- there are hyaluronic gel fillers that are incorrect for that area because they just have the wrong properties, the wrong stiffness, the wrong amount of water attraction. But placing it in the right area and the right amount.

    11. PAPeter Attia29:48

        Is Restylane a hyaluronic acid paste filler?

    12. BKDr. Brett Kotlus29:51

        That's one of the fillers that I use, and it's also amount of ha-- it's having restraint. So I understand at which point that this will become puffy or look unnatural, and that's where we stop, and sometimes we stage it. But this procedure will brighten up people's faces who look like they have bags and look like they're tired, and it's really gratifying to see w-- you know, people's reactions to this when they look in the mirror, especially when you do one side and you look in the mirror and then you see the difference. It's pretty remarkable. And so it's one of the things I really enjoy doing, and I think that there's a lot of doctors that sort of stray away from it, either because they're not comfortable with the idea of injecting under the eyes. There's risks with everything we do. To me, that's not a high-risk procedure, but I think it's perceived as one.

    13. PAPeter Attia30:35

        I think part of it, too, is this gets back to your unique training. I mean, you trained first as an ophthalmologist, which, you know, if I think about it, like I trained in general surgery, like my, my scope of what I needed to know was so broad.

    14. BKDr. Brett Kotlus30:49

        Right.

    15. PAPeter Attia30:50

        But when you look at someone who's training in ophthalmology, like you get to focus five years on like two inches of a person's body.

    16. BKDr. Brett Kotlus30:57

        Right.

    17. PAPeter Attia30:57

        So your knowledge of that anatomy is, is, is unparalleled.

    18. BKDr. Brett Kotlus31:01

        Right. I was narrow to begin with, and then I became even more, yeah.

    19. PAPeter Attia31:03

        And then you become even more narrower. So it seems to me that the advantage that you have, and this is certainly why I've always felt very comfortable sending people to you, is I know that people who understand the anatomy because they've operated, they've actually been beneath the surface, can do exactly what you describe, which is they're sort of-- they know what the art is. Put it this way, when I was in residency, there was never any confusion that I would go into plastic surgery-

    20. BKDr. Brett Kotlus31:25

        Mm-hmm [laughs]

    21. PAPeter Attia31:25

        ... when I was in medical school. Like, I just don't have that artistic capacity.

    22. BKDr. Brett Kotlus31:29

        But I would say, you know, at the same time, you know, I like to talk about my skills, but I, I don't-- and I think there's like a political part of this conversation where the question is like, who do you go to and who's the right kind of provider if you want to do something like this? I don't think it has to be a certain person or a certain kind of person. I think that there are good injectors and bad injectors. I think there's good doctors and-

11. 31:52 – 37:43

    Choosing the right practitioner: credentials, photos, consult fit, volume, and complication planning

    1. PAPeter Attia31:52

       How can people distinguish? So if you're-- if someone's listening to this podcast and they're saying, "Well, you know what? These bags under my eyes are driving me crazy." Let's say they don't live in New York, so that you're-- coming to see you wouldn't even be an option.

    2. BKDr. Brett Kotlus32:03

       Well, people come from other places or countries to see me, but I think when-- if you're looking for a provider for anything, obviously everyone, everyone says, "Oh, I did my research and I looked on the-"

    3. PAPeter Attia32:13

       Put, put it this way. If your wife needed a procedure and you decided, you know what? I don't wanna be the one to do it because there's an emotional connection to this person, and how would you pick the person that would do this to your wife or your mom?

    4. BKDr. Brett Kotlus32:24

       I think you have to find out first what are the organizations that certify people. For my field in, let's say, talking about blepharoplasty, I think there's a handful of specialists that would be competent. You could be a plastic surgeon, a facial plastic surgeon, an oculoplastic surgeon. I have-- I'm biased towards oculoplastic surgeons because that's a big part of what we do. I would look at that first. References, like referrals from other people, obviously. You know, look, if you wanted to find out the best surgeon in your-- in the hospital, you'd probably ask the nurses or the scrub techs and say, "Tell me," or the anesthesiologists, because they have firsthand knowledge. So I think referrals go a very long way. And if you know somebody that had a great result or you know someone who's done something... But you have to meet with a few people because you might have the best surgeon or the best under-eye injector or lip filler person, and, and that person could also be a physician assistant, it could be a nurse. I mean, I've seen some amazing physician assistant injectors that I would have inject myself, you know, without, uh, hesitation. But it's like, are-- do you have a, a good rapport with that person? Do you think you're on the same page? Do you have the same goals and style? So it's almost like an interview when you go for a consultation. Sometimes you have to pay for a consultation fee, but I think it's worth doing that at least for two or three or four doctors to meet with someone and say, "Uh, I get the wrong feeling here," or, "This office seems frantic," or, "The doctor just didn't even really look at me or listen to me." I mean, those things I think are all really important. So I know doctors that are family practice doctors that are exquisite botox injectors. And so I think it's wrong to fall into the political trap of you have to have this label next to your name, or you have to be this kind of, like, training. I, I think that a lot of the training that I've done was post-

    5. PAPeter Attia34:17

       Post your formal training, yeah.

    6. BKDr. Brett Kotlus34:19

       Right. And some of the training is-- are things that I developed on my own. But for blepharoplasty or eye procedures, I recommend looking at the oculoplastic organization. But for things in general, I think you should look-- you look at photos of people who all have their galleries online. They're gonna show you their best work. So you look at those pictures and you say, "Oh, those look good," or some... I look at some well-known doctors and surgeons, and I look at their photos, and I, I think, "This does not look good to me at all. I don't think this is natural," and they're promoting it as their best work. [smacks lip] There are a lot of things that I see around the eyes where, you know, I preserve fat, and sometimes I'm often adding fat, which a lot of people don't like to do because they don't maybe have the same philosophy that I do. But I see hollowed-out eyes, and people are pushing that-- putting that forward as the-- their, "This is my best blepharoplasty." Maybe for someone that is, maybe that's the look they're going for.

    7. PAPeter Attia35:08

       Should one ask how many procedures the person has done? Is there a certain number above which you sort of hit that threshold of, okay, now I've really, uh-

    8. BKDr. Brett Kotlus35:17

       You should ask all of these questions, like how many procedures. I mean, look, I've done well over 1,000, 2,000 of under-eye fillers, uh, blepharoplasties. Like it's thousands, so. But in-- early in my career, I did lots of procedures, and it was probably hundreds, so you should ask, and, and your doctor shouldn't be, um, defensive about those questions. You can say, "Hey, can I talk to somebody who's had this with you?" And we do that all the time. We connect patients with previous patients who are, who are open about it and say, "Hey, what was your experience?" Or s- then you say, "Well, tell me about the complications you've had. And if I get one of those, what are you gonna do for me? How do you-- how do I manage that? Do I have to pay to fix the complication?" Those are questions you should be asking.

    9. PAPeter Attia35:58

       [chuckles] That's such an important thing in medicine in general. It's amazing how easy it is to gloss over consent forms.

    10. BKDr. Brett Kotlus36:05

        Right.

    11. PAPeter Attia36:05

        And you just sort of list a whole bunch of generic complications, but you don't actually talk about what probabilistically or expected complications could look like. And to your point, what are the next steps? So, for example, you know, with breast augmentation, I know a woman who had these, uh, really horrible contractures develop, and I was like, "God, I've never even heard of that."

    12. BKDr. Brett Kotlus36:27

        Mm-hmm.

    13. PAPeter Attia36:27

        You know, I didn't even realize that was a complication. Obviously, I'm not in the loop in that space.

    14. BKDr. Brett Kotlus36:31

        It's actually a common complication.

    15. PAPeter Attia36:33

        Yeah, it's about 3%, I've learned.

    16. BKDr. Brett Kotlus36:35

        Yeah. I think it could be even higher, depending on the type of implant and the placement. So those are things that surgeons should be saying to every patient, that 3% is a, you know, relatively high rate.

    17. PAPeter Attia36:45

        Yeah, and you're right. It could be-- I mean, it depends on the implant, so if you're using the different textured implants, it could be as high as 5%. I mean- 5% complication is, is really high, right?

    18. BKDr. Brett Kotlus36:55

        Yeah.

    19. PAPeter Attia36:55

        One in 20-

    20. BKDr. Brett Kotlus36:57

        Right

    21. PAPeter Attia36:57

        ... people who do this is going to have this, and a lot of times on redos it still happens. Um, which is not to say one shouldn't have an augmentation, but boy I'd, I'd be very upset if someone I cared about had that procedure, wasn't told about that complication, and then developed it.

    22. BKDr. Brett Kotlus37:13

        Well-

    23. PAPeter Attia37:13

        Especially if they required redo, redo.

    24. BKDr. Brett Kotlus37:15

        Of course, and so that going into it, you know, let's say this busy surgeon's doing 20 breast augs a week, and so one, one patient every week is going to have potential reoperation, so going in you should know, "Hey, I might have to do something else." And that's with, I think, any procedure. The risk is relatively low with cer- with many of these things. And we ta- sometimes we're talking about one... Certain complications might be one in a million, and so you don't have to put that as like, this is likely for you to hap- But yes, th- that's part of the discussion.

12. 37:43 – 41:32

    Botox done well: common forehead mistake, better targets, and timing to prevent etched lines

    1. PAPeter Attia37:43

       So let's go back to botox for a second. I think about, like, six years ago, one of my good buddies from residency who's a plastic surgeon, I was just hanging out with him. We were just sort of playing patty cakes one day, and he was like, "Hey, dude, why don't I throw some botox on your wrinkly forehead?"

    2. BKDr. Brett Kotlus37:57

       Yeah.

    3. PAPeter Attia37:57

       And I was like, "All right, fine." So I, like, sat down in his little chair, and he whipped out some botox and put, like, what felt like 3,000 injections into my forehead. And, uh, you know, put an ice pack on it, went home.

    4. BKDr. Brett Kotlus38:09

       Classic mistake, though, I think is what you're starting to describe.

    5. PAPeter Attia38:14

       Yeah.

    6. BKDr. Brett Kotlus38:14

       Is treating your forehead directly.

    7. PAPeter Attia38:16

       Well, let me tell you, oh my God. Uh, I don't remember how long it took to wear off. I think it was about two to three months.

    8. BKDr. Brett Kotlus38:22

       Mm.

    9. PAPeter Attia38:22

       The most miserable two to three months of my life, because this was at a time when I was a, a very active cyclist.

    10. BKDr. Brett Kotlus38:29

        Mm.

    11. PAPeter Attia38:30

        And I didn't realize it until, of course, I lost the ability to do so. But not being able to lift my brow-

    12. BKDr. Brett Kotlus38:36

        Yeah

    13. PAPeter Attia38:36

        ... meant I had absolutely no way to keep the sweat out of my eyes, even when I was wearing my kind of do-rag under my helmet. So I couldn't believe how miserable I was not being able to lift my eyebrows.

    14. BKDr. Brett Kotlus38:48

        Yeah. So it's uncomfortable, and then it's also a dead giveaway. So when you look around, uh, let's say you're watching the Oscars on TV or something, and you want to know which people have had poorly done botox, and it's a lot. It's when the, the frontalis muscle, right, which is the only-

    15. PAPeter Attia39:03

        So where is that, for the people who are listening?

    16. BKDr. Brett Kotlus39:05

        That's the forehead muscle, right?

    17. PAPeter Attia39:06

        Okay.

    18. BKDr. Brett Kotlus39:06

        Between the eyebrows and your hairline.

    19. PAPeter Attia39:10

        Okay.

    20. BKDr. Brett Kotlus39:10

        Okay? So for some of us it's further back than others. But the frontalis muscle is the only muscle that raises your eyebrows.

    21. PAPeter Attia39:18

        Okay.

    22. BKDr. Brett Kotlus39:18

        So you get those transverse, those horizontal lines across your forehead, and your instinct is like, "Oh, I should do botox to get rid of these." Well, if you inject the frontalis to the degree wh- to, to the degree where you smooth those lines, because, you know, those lines are formed by the muscle contraction, so your muscles don't contract anymore. And I said they're the only muscles that raise the brow, so now you can't raise your brows. In fact, they drop, but your forehead will be shiny smooth. So if you see somebody and they can't raise their brows at all, you just see smoothness, they were over botoxed in their forehead. And we say botox a- as a generic term. It's actually, that's a trade name, and there's other-

    23. PAPeter Attia39:54

        That's the Amgen product-

    24. BKDr. Brett Kotlus39:55

        Right

    25. PAPeter Attia39:55

        ... right?

    26. BKDr. Brett Kotlus39:55

        That one is, um, Allergan.

    27. PAPeter Attia39:57

        Oh, it's Allergan. Okay.

    28. BKDr. Brett Kotlus39:58

        Currently FDA approved is botox, Xeomin, and Dysport. So those are all types of botulinum toxin Type A. There's slight differences in the molecules, but they all have the same effect. So the mistake that was made for you was going after the horizontal forehead lines. And in fact, what-

    29. PAPeter Attia40:15

        Which seems like a common mistake, given on the frequency with which we see this.

    30. BKDr. Brett Kotlus40:19

        Yeah. I think people know a little bit more about it now, but still I think they use too many units up there.
13. 41:32 – 46:29

    Cosmetic procedures and psychology: confidence, unrealistic expectations, and saying no

    1. BKDr. Brett Kotlus41:32

       So I think we have to think from the beginning that you don't have to do anything, right? Nobody has to do botox. Nobody has to even spend this much time thinking about their appearance, right? Th- people do it because it's important to them, and what's important to you might not be important to someone else. So with that aside, let's say your goal is to look your best as long as you can. You should probably first start focusing on the preventive things, which can include neurotoxins like botox, but it should start with sun avoidance at a young age. You should do botox or something like that before you start to get etched lines.

    2. PAPeter Attia42:13

       Is an etched line one that means when your forehead is relaxed, the line still shows?

    3. BKDr. Brett Kotlus42:18

       Right. And I think it's okay. You know, I have some etched lines and tr- horizontal f- etched lines in my forehead, and I think it's acceptable for me, and I'm okay with it. I mean, look, there's a range of what's acceptable. I used to look at Bill Clinton on TV all the time, and I'd see his big eye-bags, and when I was in my training I'm thinking, "Oh, I would just die to be able to take out those nice juicy fat pads." But he doesn't care about them at all, right? And so it's meaningless to him. Or maybe he thought about it, but, you know, he obviously didn't pursue it.

    4. PAPeter Attia42:45

       Mm-hmm.

    5. BKDr. Brett Kotlus42:46

       So doesn't really matter if it doesn't matter to you. And I think, you know, what's interesting at the root of all of this is, you know, why do we do cosmetic procedures, and why do some people think it's so important? Why do people think it's nonsense? It's about your confidence. It's about how you feel about yourself, your self-image. And I think that there are some people that will chase after confidence and may never be able to achieve it, and it's because of what happened to us in our childhood, our upbringing, the, I guess, the stability that we had when we were growing up, and it's being able to experience love in your family, experience acceptance, people that were proud of you. People can say that they love you, but, and if you didn't experience that, it's much harder to be self-confident and to have a good self-image. And so I think it all goes back to that. I think there's a healthy way to do it, and I think it's not something that we should frown upon. I think it's becoming more accepted in our society to, to have a focus on how we look and how we project ourselves, and I think the best way to do that is to have a healthy attitude about it in terms of, "Look, I'm doing this for me. I'm not trying to impress somebody. I'm not trying to fit in with somebody." And what's amazing is sometimes a little tiny thing that you wouldn't even know, you wouldn't notice it, but I see people walk out of the office with a different gait, or they're smiling when they weren't before, and we barely even did anything, but it's a, a little shift in the way that they were thinking about themselves. And so it's not so much exactly what you do, but how you help somebody to feel better. So in terms of doing, like, a neurotoxin inject-- like, doing your first Botox injection, if you're looking at your parents and you see these lines and you think, "I don't really want those lines," so you do it before they start to become fixed lines, those etched creases.

    6. PAPeter Attia44:36

       Mm-hmm.

    7. BKDr. Brett Kotlus44:37

       You do it before you get that. So there's not really an age. I mean, I've, I've injected people in their 20s. I've injected people in their 80s. I think it's never too late, but i- there's certainly times where it can be too early.

    8. PAPeter Attia44:48

       Now, have you ever found yourself in a situation where you felt it was unethical to participate in the care of a patient because you felt that they were just being too neurotic, or they were asking for something that you felt was too much? I mean, did you find yourself in that situation?

    9. BKDr. Brett Kotlus45:01

       It happens all the time. All the time. I, I think that's the nature of what I do, right? It g- it goes along with it. And so the way that you look is tied in very closely to your emotions, and when you-- especially when it's your eyes, and I see people all the time that have had poorly done procedures, and they're tearful when they're talking to me. Um, and I see people, I think they're unrealistic, and I try to guide them. I, I-- my goal is to be on their side all the time. So in order to sort of focus on overall wellness, not just appearance, but, but there's-- I think there's a connection between appearance and wellness. And if you seem to me like, you know, "There's something else going on here. Why are you chasing after this, this one line when you look-- anyone who would look at you objectively would say, 'Oh, yes, you look younger. You look more relaxed. You look refreshed.' Like, what are we really talking about here?" Well, maybe there's something else to talk about.

    10. PAPeter Attia45:59

        So you're almost having to try to be a psychologist, psychiatrist at the same time.

    11. BKDr. Brett Kotlus46:03

        In a way. I mean, maybe it's also my-- my wife is a therapist, and so some of that probably, um, has brushed off on me in terms of how important it is, having somebody to talk to that's outside of judgment. And so, um, I think sometimes people need to-- maybe it's not just one thing, it's both. It's having someone to talk to. Maybe there's some other issues going on. And, um, you know, what is your goal in doing this?

14. 46:29 – 1:09:07

    The skincare “trifecta”: sunscreen, retinoids, and topical vitamin C

    1. PAPeter Attia46:29

       L- let's go back a little bit further. Let's say someone's listening to this, and maybe this is a lot of people, and they think, "Look, it's really good to know that there are people out there like you who can do the most nuanced, complicated grafting, injecting techniques above, below the eye, the forehead, et cetera." But what if they say, "Look, I don't want to do anything that I can't do as the patient myself," meaning lotions, potions, behavioral changes.

    2. BKDr. Brett Kotlus46:57

       Yeah.

    3. PAPeter Attia46:58

       Uh, let's start-- you, you alluded to sun. Let's start there. I get asked all the time, and I'm kind of embarrassed 'cause I just don't know the answer, and I have to say, "I have no clue." I get asked all the time, "Peter, what sunscreen should I be wearing?" Like, I feel like it's easier for me to answer, like, how would you solve the, uh, Iran nuclear missile crisis or, you know, before-- like, I don't have a clue what sunscreen to wear.

    4. BKDr. Brett Kotlus47:20

       It's a complex marketplace, let's say, because the way that sunscreens are marketed, the way that the, um, labeling is done can be a little bit confusing, and there are technologies that are being employed now that are newer that we don't fully understand. So let's talk about-

    5. PAPeter Attia47:38

       So let me start with the first question, which is there are some people out there who say sunscreen is horrible, you should never wear it. I'm assuming you don't think that that's the right approach.

    6. BKDr. Brett Kotlus47:46

       It's absolutely untrue. I mean, I can't feel strongly enough about-- look, I see a lot of, uh, skin cancer, and I treat skin cancer, and it's, like-- it's obvious, and it's been well scientifically proven that there's a correlation between UV radiation and skin cancer, right? So I have to reconstruct people's eyelids, their faces, their noses because they've had basal cells, which-- basal cell carcinoma, which is related to sun exposure. My wife has had several Mohs procedures where-- which means a dermatologist with special surgical training has to remove pieces of skin, and then that has to be reconstructed, and, you know, s- I don't think anybody wants to go through that. Look, the recommendations of the American Academy of Dermatology is to protect children from sun, and there's recommendations about levels of sunscreen, so you can get your vitamin D even if you're using sunscreen.

    7. PAPeter Attia48:40

       So when we talk about UV, they talk about UVA and UVB, and you'll see these things on sunscreen. Can you explain what UVA and B are?

    8. BKDr. Brett Kotlus48:50

       Traditionally, UV-- you can think about it as, um, UVA, the A might stand for aging, and the UVB is for burning. UVB is what's responsible for your skin turning red, okay? They're just different w-

    9. PAPeter Attia49:02

       It's different wavelengths

    10. BKDr. Brett Kotlus49:03

        ... wavelengths of ultraviolet light. And when you're looking at SPF, they're talking about UVB. The way that they determine SPF is They will take a subject, they'll do it probably, I think you need to have 10 subjects. This is just done on a person. It's not like a laboratory test that works well for this. They still use it on people. So they would put you under a light in a laboratory with UVB, and they would wait and see how long it takes for you to turn red. And then an SPF... And so that's UVB radiation. SPF 15 means what do we need to put on you that will make you turn red 15 times longer?

    11. PAPeter Attia49:40

        Take 15 times longer.

    12. BKDr. Brett Kotlus49:41

        It'll take 15 times longer to turn red. And 30-

    13. PAPeter Attia49:45

        And, and this is, might sound a silly question, but is there an, an objective metric for what redness is? Like there's a color, you know how like you can define colors by the percent red, green, blue?

    14. BKDr. Brett Kotlus49:55

        Right. You can measure the redness. Yeah.

    15. PAPeter Attia49:57

        You, you can measure the color. Got it. It's a purely objective measurement. So it's interesting, SPF 15, which seems like very mild sunscreen, still gives you 15 more times. So if it takes you 10 minutes, this is gonna take you to, you know what? 150 minutes is like two, two and a half hours basically.

    16. BKDr. Brett Kotlus50:14

        If you look at the difference between SPF 30 and SPF 50-

    17. PAPeter Attia50:18

        Mm

    18. BKDr. Brett Kotlus50:19

        ... you're getting a difference of, I think it's like a 96 or 90, 96% protection against UV during that time, versus 98% protection. So it's, it actually becomes less of a difference in protection from those rays as you go up higher. So over 30 you don't get that much more benefit. So at l- but you should be at using at least a 30, but that's talking about UVB. If you want to protect yourself from UVA and UVB, which you should, you should be using a sunscreen that says broad spectrum.

    19. PAPeter Attia50:51

        Okay. And it's still the same SPF system?

    20. BKDr. Brett Kotlus50:54

        Well, no. SPF does not apply to UVA. It doesn't measure UVA. In fact, there's no measurement of UVA.

    21. PAPeter Attia51:00

        So if you buy a broad spectrum sunscreen, it will not have an SPF number on it? Or if it does-

    22. BKDr. Brett Kotlus51:05

        It, it has an SPF, but it relates to UVB

    23. PAPeter Attia51:06

        ... it's in reference only of a B. Okay, got it. So you-

    24. BKDr. Brett Kotlus51:08

        Because UVA doesn't cause redness, so you can't use that test.

    25. PAPeter Attia51:12

        Which of the two is more responsible for vitamin D synthesis?

    26. BKDr. Brett Kotlus51:18

        That's a good question. I don't have the answer for you.

    27. PAPeter Attia51:20

        All right. We will-

    28. BKDr. Brett Kotlus51:21

        [laughs]

    29. PAPeter Attia51:21

        ... we will find out the answer to that question at some point. That should be known. My I, my intuition is it's UVA, but I, I, uh, I don't know.

    30. BKDr. Brett Kotlus51:29

        But, um, both are responsible for skin cancer.
15. 1:09:07 – 1:33:04

    Procedures beyond injectables: peels, resurfacing lasers, tightening devices, and PRP skepticism

    1. PAPeter Attia1:09:07

       One of the things I get asked about a lot by patients, and this is why I'm really glad I know people like you, because I obviously don't know the answer to any of these questions, is, "My friend got such and such a laser treatment on his or her skin, and I want to do that," and all these different types of lasers and these things. Can you give us, like, kind of the 101 on laser treatment for skin?

    2. BKDr. Brett Kotlus1:09:30

       I think lasers are effective in many ways, right? And the lasers are getting better. The technology's getting better. There's fractional technology. There's different types of energy. And it's confusing, though, to consumers because you don't know, are you selecting a doctor? Are you selecting a device? Anyone can buy a laser if you have a certain amount of money, and you have a certain amount of patience. And how much of the work is being done by the laser by itself? You just turn it on and it just happens, or is it the provider selecting the right patients and changing the settings? So there's a lot of variables. There are some devices that doesn't matter who does it, for the most part, like the cryolipolysis, right? CoolSculpting. It's a device that suctions your fat, and it freezes it at a certain temperature, and it uses, you know, an algorithm to figure out what temperature it needs to stay at for how long to adequately cause apoptosis of those fat cells, right? And so basically someone just has to say, "Okay, this is the area we're gonna do it," and they stick the machine on you. There's a little bit of, you know, understanding and training that goes into it, but once you turn it on, it's done, right? It, you sit there and it happens, and then you-

    3. PAPeter Attia1:10:36

       And is this CoolSculpt procedure effective?

    4. BKDr. Brett Kotlus1:10:39

       It's effective, yeah. And there are other ones, too. There's other types of, the SculpSure. There's other devices that also effectively non-surgically can reduce fat, and, but they don't require a lot of... It's not an operator dependent for m- for the most part, right? So you turn them on, and they're good. And so you can probably go to most places, and they'll do a good job for that.

    5. PAPeter Attia1:10:58

       There's a procedure where they use heat, and then there's a procedure where they use cold.

    6. BKDr. Brett Kotlus1:11:02

       Right.

    7. PAPeter Attia1:11:02

       What is more effective?

    8. BKDr. Brett Kotlus1:11:03

       They're both effective. There's a lot of devices, but the two main leaders in the market are both effective, and they're probably equally effective. They work in different amounts of time, but usually you get about 20, 20% of subcutaneous fat reduction with that course of treatment.

    9. PAPeter Attia1:11:18

       So if a person wants to take a little bit of fat off, presumably you do this on your belly, or you can do it legs.

    10. BKDr. Brett Kotlus1:11:23

        Even your flanks. Anywhere you can pinch fat, you can do it, right? So it's subcutaneous fat. It's not visceral fat that's under the muscle, but it's the subcutaneous fat, and it works well. As long as you can apply the applicator, there are some limitations, but they both, the main devices have FDA approval for necks as well. So those devices, doesn't really matter so much about who's doing it. Uh, you want to go to a reputable place. You want to make sure it's the real device. There are, like, there are Chinese knockoffs that are not FDA approved, so you want to get the real one. You know, you can go to, there's, like, CoolSculpting is an FDA-approved cryolipolysis device, but I've seen Fat Freeze or something, and it's, and then you look into it, and you say, "Oh, this wasn't even approved by the FDA for marketing." So...

    11. PAPeter Attia1:12:05

        Got it. So at least make sure you're going with an FDA-approved-

    12. BKDr. Brett Kotlus1:12:07

        Right

    13. PAPeter Attia1:12:07

        ... procedure or, or device.

    14. BKDr. Brett Kotlus1:12:09

        There are lasers that work on skin. There are lasers even for-

    15. PAPeter Attia1:12:12

        Yeah, what are, what are the skin laser... Like, people talk about, like, getting their face lasered-

    16. BKDr. Brett Kotlus1:12:17

        Right

    17. PAPeter Attia1:12:17

        ... for skin. I, I've had a chemical peel once a, a little while ago. I was really... I mean, this has gotta be, it's gotta be about five or six years ago. I was amazed at two things. First of all, how quick and easy it was to, for this dermatologist to apply this stuff to my face. That's the first thing. The second thing that amazed me was how red I was for, like, five days and how I had to, like, lather myself up in Aquaphor.

    18. BKDr. Brett Kotlus1:12:39

        Yeah.

    19. PAPeter Attia1:12:40

        And then third, I was just amazed at how many sunspots vanished.

    20. BKDr. Brett Kotlus1:12:43

        Yeah. Well, I mean, that procedure can be very effective. There's lots of different types of peels. There's phenol peels, which can have more risk but more benefit. In fact, for a phenol peel, you have to be connected to an EKG so you don't, so you're monitoring for arrhythmias. There are TCA peels, which can be also equally strong. There's a lot of experience that goes into selecting the type of peel, how they're, how it's being applied, how many layers, what you're seeing. That, that is a very operator dependent procedure. But-

    21. PAPeter Attia1:13:14

        So is there a chemical peel that you would say is, if you were gonna have one tomorrow, that you would preference?

    22. BKDr. Brett Kotlus1:13:21

        I wouldn't say that. I, I think it's, that's more of a Depends on your skin type. There are certain things that are not safe for darker skin types, so that's a very specific treatment plan for each individual.

    23. PAPeter Attia1:13:32

        So what questions could people ask the provider to know that that pro... 'Cause really what you're saying is you have to rely on the provider's judgment to know that-

    24. BKDr. Brett Kotlus1:13:41

        Very heavily. Very heavily, and, and you can get a burn, and you can get a scar.

    25. PAPeter Attia1:13:44

        So how do you screen out for who the right person is?

    26. BKDr. Brett Kotlus1:13:46

        Well, it's asking, you know, "How many of these have you done? Can you show me examples, and is this safe for my skin type, and what are the risks?" So chemical peels are essentially using an acid or a chemical to burn away the outer layer of your skin. That's why you look so red, and they go at different depths depending on how many layers of chemical are being applied, and what type of chemical, and the strength. So I can use a 10% TCA peel on you, and you'll look slightly red, and you'll, you know, look a little better. I can use a 35%, and you'll... your skin will peel off like a snake. Um, so there's a wide range and, and might not be safe for all skin types.

    27. PAPeter Attia1:14:24

        So f- let's look at me right now. I'm kind of a olive skin dude. I've probably got... I don't know where I would rank on the sun damage scale, but I've-

    28. BKDr. Brett Kotlus1:14:31

        I would say for you, either you're looking at a... let's say you wanna just do a skin rejuvenation. You wanna look smoother, less m- less wrinkles, improve texture and brown spots. So we would either talk about a chemical peel, like a, maybe a TCA peel of 20%, and I might recommend three treatments, or we would talk about a laser. So the laser does the same thing that the chemicals do, except it's using energy to burn the surface. Most lasers today are fractional, meaning that they're not taking away everything like a peel would, right? The li- the liquid from the chemical peel is gonna take off a- all of your skin, at least the outer layer, in a continuous fashion, whereas the fractional laser is creating dots and leaving some normal skin in between. So the most common lasers for resurfacing would be erbium and CO2, carbon dioxide, and again, with- within those, there's different levels and different energy settings, and certain patients are not candidates for those, and some are. So that relies heavily also on the experience of the provider. Now, there are some very safe lasers that are very low grade, like a laser like Clear and Brilliant. Very low risk at causing a problem for most people, and doesn't always have to be a doctor provo- performing the procedure. It can, depending on your state laws, can be an aesthetician or a nurse.

    29. PAPeter Attia1:15:50

        And are these painful procedures? Do people need some sedation for them?

    30. BKDr. Brett Kotlus1:15:53

        Usually, no. I mean, it depends on your pain tolerance. The heavier duty lasers, the more powerful, are going to require some type of anesthetic, whether it's an injection, topical anesthesia, sometimes sedation. Uh, often we do them in combination with surgery, so my patient's asleep while I'm lasering them. We're doing one thing, and then we're lasering another. That is something where you need a consultation and someone to evaluate your skin type and say, "Okay, this is my recommendation for you based on my experience and my knowledge, my training." But there are also... I think when you, what you would also lump into that, that category would be the energy devices that are now becoming more rampant, and these are designed for facial rejuvenation in terms of tightening, not the skin surface.
16. 1:33:04 – 1:43:58

    Future directions: stem-cell-adjacent fat work, injectable growth factors, customization, and 3D/bioprinting

    1. PAPeter Attia1:33:04

       What are the step function changes? What are the things that are out there that are not a part of what I do today 'cause they're not ready for primetime or they're still very theoretical, but they're the things I wanna keep enough tabs on because I, I hope that within the next decade or, or maybe beyond, they become relevant. What fits that description in your field? What are the things that maybe aren't ready for use yet but show promise?

    2. BKDr. Brett Kotlus1:33:29

       It sort of makes me shudder to think about the future because I imagine myself 20 years from now, hopefully I'm still practicing, and I'm gonna look back and think like, "Wow," like, you know, we were in Plato's cave at that time. Like, we were seeing the shadows on the wall and not seeing the true objects, right? And I think we are in a sense, right? Uh, I mean, what is our... How limited is our understanding and the things that we, we don't know that we don't know them yet. And so I think there are things n- th- things that we're doing today that I don't fully understand, like things like fat grafting. I use it, and I think there's some predictability to it, but we don't fully understand why it works and how it works, and I think some of that relates to the stem cells, the stem cell effect, and you hear a lot about stem cells being used for all types of medicine, and it's the same with cosmetic procedures, and I do some procedures like-

    3. PAPeter Attia1:34:24

       I think of stem cells like I think of Chevy Chase describing ball bearings in Fletch.

    4. BKDr. Brett Kotlus1:34:28

       [laughs]

    5. PAPeter Attia1:34:28

       You know that scene when he's like, uh, you know, "It's all ball bear-" And the guy's like, "Ball bearings?" He goes, "Ah, it's all ball bearings nowadays."

    6. BKDr. Brett Kotlus1:34:35

       [laughs]

    7. PAPeter Attia1:34:35

       And it's like, that's like stem cells and ball bearings. It's just the same thing to me.

    8. BKDr. Brett Kotlus1:34:38

       That's right. It's the cure-all. It's the PRP of the future. [laughs] So, um-

    9. PAPeter Attia1:34:42

       Which remains to be seen how viable it is, right?

    10. BKDr. Brett Kotlus1:34:44

        Right. It's the PRP of today. I think, look, there's something there. We know there's something there. We just can't exactly understand. We can't put our finger quite on it, and there's some good science there now, but I think there's definitely going to be something. And I have colleagues, I have friends that are doing a lot of stem cell treatments, whether it's intravenous, direct injections. I'm in a sense using nano fat as a stem cell. You know, the... Our fat is a rich source of stem cells.

    11. PAPeter Attia1:35:10

        Yeah, this is counterintuitive, isn't it? People have always considered fat to be a totally inert-

    12. BKDr. Brett Kotlus1:35:14

        Right

    13. PAPeter Attia1:35:15

        ... tissue, but it's actually an endocrine tissue.

    14. BKDr. Brett Kotlus1:35:17

        That's true, right? And then why are we going to bone marrow for stem cells when it's l- closer to the surface? It's right there, and it's abundant in, in a lot of people. When I do procedures with fat grafting and I'm thinking, "Hey, I'm injecting fat, and these fat cells are making them look younger," but it might be that the fat cells are not, none of them are surviving.

    15. PAPeter Attia1:35:35

        It might be none of the fat cells at all. It might be the, the adipokines or the cytokines that the-

    16. BKDr. Brett Kotlus1:35:38

        Or maybe it's a combination. Or, or when I do n- what I call nano fat, which is the stromal vascular fraction or the, the soup that's in between the fat cells, and now I inject that with the fat. Am I supporting my fat grafts with these factors? Maybe. I mean, I'm seeing results, and we w- and we sort of look at the literature, which is limited, and we look at large scale studies, which are n- also limited. Um, we're looking for answers in doing these things and, and we try to stay safe, but there's definitely a lot to learn when it comes to that particular area, right? We know that. We look at other types of growth factors. I've seen some promise with fibroblast growth factor, which is also an injectable. Like, I consider that a biologic therapy.

    17. PAPeter Attia1:36:21

        In, in, in FGF world, which is the abbreviation for fibroblast growth factor, we... there are so many numbers to them. Are you talking FGF21 or...?

    18. BKDr. Brett Kotlus1:36:30

        Well, this is something that's not even... it's not approved in the US. We don't have it here. There's been studies in Asia. Actually, I don't even know which version. I probably have it in my notes here because I haven't been able to do it.

    19. PAPeter Attia1:36:43

        But basically, are they harvesting autologous FGF from an individual?

    20. BKDr. Brett Kotlus1:36:50

        No, these are laboratory derived.

    21. PAPeter Attia1:36:52

        Got it. So they're basically making FGF as a growth factor and then just injecting it.

    22. BKDr. Brett Kotlus1:36:56

        Correct.

    23. PAPeter Attia1:36:57

        And is this done in Europe?

    24. BKDr. Brett Kotlus1:36:59

        It's done in Asia.

    25. PAPeter Attia1:37:00

        And what's the indication?

    26. BKDr. Brett Kotlus1:37:01

        Volumization, facial volumization, and it seems to have long-lasting results.

    27. PAPeter Attia1:37:06

        So is the FDA evaluating this stuff now?

    28. BKDr. Brett Kotlus1:37:08

        I'm not clear about that. I don't know. I haven't, I haven't heard of any studies. I don't know of anyone who's part of an IRB. But it, it seems to hold some promise. I think customization, like what you do in your practice, and y- you're going to get down to the specific gene level eventually, right? And hopefully we'll be able to have a full map of everything and each person will know exactly what drug is gonna work well for them, and we'll be like that, I think, with, you know, cosmetic procedures, right? W- how is your skin going to respond to this laser? And what energy setting is appropriate for you versus this other person based on what your genetic screening told us? I think that's definitely in the future. I think ... customization in terms of 3D printing, bioprinting. So we might-- Let's say there's something you don't like, you want to change your ear, we'll probably be able to print ears. We'll be able to print organs. I mean, there's no question that bioprinting is in the future, and we'll be able to replace blood vessels, organs, skin.

    29. PAPeter Attia1:38:06

        That just seems so far out. I mean, as a, as an interesting aside, I remember once being in your office, and you showed me a bunch of surgical instruments that you designed yourself and had 3D printed, and they were just perfect, right? It was like you knew exactly what you wanted, and you were like, "Well, this doesn't exist. I'll just make it."

    30. BKDr. Brett Kotlus1:38:20

        Right. I mean, in the past, you would have to go to a manufacturer, and you'd have to convince this industry person of what you want to make.
17. 1:43:58 – 1:48:51

    Where to find Kotlus and closing remarks

    1. PAPeter Attia1:43:58

       Well, speaking of people contacting you, I follow you on Instagram 'cause I just love looking at your before-after photos, and how can people follow you? What's the best way to follow you?

    2. BKDr. Brett Kotlus1:44:07

       So on Instagram it's @drkotlus, D-R-K-O-T-L-U-S. You can look me up on my website. I have some videos and procedures on my website.

    3. PAPeter Attia1:44:14

       And what's your URL?

    4. BKDr. Brett Kotlus1:44:16

       It's, uh, drkotlus.com, D-R-K-O-T-L-U-S. But yeah, I share a lot of my stuff on Instagram. I think that's kinda fun because people can give me feedback, and my-- I've seen my audience grow, and I'm, I'm following you on Instagram too with your race cars and your, [laughs] your family. Yeah.

    5. PAPeter Attia1:44:31

       [laughs] My nonsense. Yeah.

    6. BKDr. Brett Kotlus1:44:32

       It's fun. I, I think, um, you know, Instagram has connected me with a lot of people that I probably wouldn't have met otherwise. I, I mean, the, the internet and social media has, has made the world a smaller place in a way. Look, there's a lot of garbage to wade through, but it's not all bad.

    7. PAPeter Attia1:44:48

       I don't think there's anything I do clinically that is really relevant to Instagram. [laughs]

    8. BKDr. Brett Kotlus1:44:53

       Well, it's not visual, but it is, right? I mean, I think people are interested in seeing what you're doing in your day. I'm, I'm interested in your routines. I'm interested in like, "Oh, what is he eating? What is he-- What is that indwelling device that you have that's measuring your blood glucose?" Or what's going on in your lab? You posted that picture on your whiteboard of your, like, it looked like your Einstein theories-

    9. PAPeter Attia1:45:12

       Right. Right

    10. BKDr. Brett Kotlus1:45:13

        ... of longevity. I mean, it's actually a very poignant breakdown of your longevity approach. And I've seen you working on the whiteboard, so I'm imagining you writing that and sort of, like, constructing your book that everyone's waiting for. But I think people are looking for insight into your life and into your philosophy, and it doesn't have to be-- I mean, for me it's a little bit easier maybe because I can show a before and after. But that's not-- I think the before and after is not the important thing. The important thing is, like, the story behind the before and after. Like, this is a teacher, and she came to me because she was recently divorced, and she's thinking about finding a new partner maybe or maybe just feeling better about herself because she's surrounded by younger teachers. Like, those kind of stories to me are the powerful things and h- and what's important-- Like, what I love about what I do is that people bring me into their lives in many ways, not just for an injection, but to tell me about why they wanna do it.

    11. PAPeter Attia1:46:09

        Hmm. Yeah. You have a video on your website that you produced, right?

    12. BKDr. Brett Kotlus1:46:14

        Right. Yeah. So that was just, I think, trying to convey my philosophy in a way that I th- I thought was, you know, more powerful about the stories of people who are seeking my help or my advice. And so, um, I'm always thinking about the next one. I think I could do it better. But that, that was a fun project.

    13. PAPeter Attia1:46:30

        Well, Brett, I can't thank you enough for this. I've, I've learned a lot from you over the last couple of years, uh-

    14. BKDr. Brett Kotlus1:46:35

        And I feel the same way

    15. PAPeter Attia1:46:36

        ... but I appreciate you taking the time to sit down today. I hope that people get something out of this. And again, it could be as extreme as they know that they wanna do some of these procedures and now they feel armed to scrutinize the providers out there and make sure they're getting the best care possible. And alternatively, it may be, "I don't wanna do any of that stuff, but boy, if I can just do these three things, you know, put my sunscreen on, use some retinoic acid, and maybe a little topical vitamin C, that's gonna make a 10-year delta."

    16. BKDr. Brett Kotlus1:47:02

        Well, thank you for inviting me to do this and for leading the way for many of us in terms of searching for the answers and, and also sharing those answers.

    17. PAPeter Attia1:47:12

        It's great to see you, and I will, uh, we'll, we'll continue this discussion, I'm sure.

    18. BKDr. Brett Kotlus1:47:16

        Definitely.

    19. PAPeter Attia1:47:16

        All right. See ya. [upbeat music] You can find all of this information and more at peterattiamd.com/podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog and the Nerd Safari at peterattiamd.com. "What's a Nerd Safari?" you ask. Just click on the link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my subjectively non-lame once-a-week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, et cetera. On social you can find me on Twitter, Instagram, and Facebook, all with the ID peterattiamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. And note, no doctor-patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and/or advise, please visit peterattiamd.com/about. [upbeat music]

Episode duration: 1:48:51