355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance

1. 0:00 – 8:50

   0:01:18-Evolving field of aesthetic medicine

   1. PAPeter Attia0:00

      Why did I look better at forty-two than fifty-two? Start the discussion through the lens of preventive care.

   2. SOSuzan Obagi0:06

      The absolute minimum thing I should use on my skin every day, it would be sunscreen. I tell my patients they have to use mineral sunscreens as opposed to chemical sunscreens.

   3. TNTanuj Nakra0:15

      Cheapest trick in skincare, you can go to Walgreens and spend six dollars on Aquaphor, and your skin will look better in thirty days, guaranteed.

   4. PAPeter Attia0:24

      How much do you see trends that dramatically change what people are asking for?

   5. TNTanuj Nakra0:31

      The images that are being posted are not real.

   6. SOSuzan Obagi0:34

      I try to really educate my patients to stay away from things that are trending and really do things that make them look and feel better but natural for themselves.

   7. PAPeter Attia0:42

      So, so what is it that you see, Tanuj, that is most disconcerting?

   8. TNTanuj Nakra0:45

      I think overfilling is a serious problem. Um, whether it's the lips or the cheeks, the companies will tell you that filler only lasts one year in the face, and then you have to refill it. That's definitely not true.

   9. PAPeter Attia0:56

      Really. I show up in your office. I can't tell you what's wrong, but I show you a picture of me ten years ago, and I say, "I wanna look like that." [upbeat music] Hey, everyone. Welcome to "The Drive" podcast. I'm your host, Peter Attia. Tanuj, Suzan, great to have you here both. Um, you're obviously in Austin. You traveled from Pittsburgh, right?

   10. SOSuzan Obagi1:26

       Yes.

   11. PAPeter Attia1:26

       Awesome. Well, um, this is a topic we get asked a lot about, and sometimes when we get asked about topics, I already know quite a bit. Um, and this is absolutely an example of the opposite of that. This is a topic we get asked about a lot, and I would argue that my knowledge is even below that of the general public. So I, I can't think of a time when I've, uh, done a discussion on the podcast on something where I know less than, than all things related to the health of, of one's skin and appearance. Um, a- and, and so yeah. Uh, thank you very much for both being here, and thank you for, um, helping me even think about how to structure a discussion on this topic. Um, maybe before we jump into it, just give us each a little bit of your backgrounds. Uh, I think it was, um, helpful to have not one but two experts here because you guys have sort of a different specialty. Obviously, within medicine, you have a different specialty. You overlap in things but, but obviously do some things different. So, so Tanuj, tell us a little bit about your training, your background, and what you focus on.

   12. TNTanuj Nakra2:35

       So yes, uh, thanks for having us, Peter. Uh, it's a pleasure to be here, um, to talk about something I'm quite passionate about. And I know it's very confusing for a lot of listeners to understand aesthetics, and, and we'd love to demystify it a little bit. Um, so my background, my core specialty is oculofacial plastic surgery. Um, I trained in eye surgery and in facial surgery mostly at UCLA.

   13. PAPeter Attia2:59

       But did you train in plastic surgery first?

   14. TNTanuj Nakra3:03

       My original background is ophthalmology.

   15. PAPeter Attia3:04

       Ophthalmology, okay.

   16. TNTanuj Nakra3:05

       And then I did fellowships in ophthalmic plastic surgery, and then another fellowship in facial cosmetic surgery in addition to that. Um, my practice is limited to eye and face plastic surgery, basically, and, um, that ranges from reconstruction of children, cancer reconstruction for e- elderly, and all the cosmetic surgeries that we can perform on the face, including-

   17. PAPeter Attia3:31

       Including nose, neck.

   18. TNTanuj Nakra3:33

       Including nose and neck, yes. And, um, I moved to sixteen-- moved to Austin sixteen years ago after training at UCLA and, uh, joined a large group here, and we're also all on the faculty of the Dell Medical School. So we are actively involved with, uh, academics, teaching residents. We have a fellowship program, two fellowship programs in our practice. Uh, y- and, um, it's a real pleasure to be involved in academics because it's the cutting edge of science, and, you know, we like to perform clinical research and, um, in the academic community, which is how I know Suzan. Um, we-- there's a lot of collaboration among specialties, and we have an opportunity to dialogue and, and further this specialty that we care so much about.

   19. PAPeter Attia4:19

       Awesome. Okay. And Suzan, you are a dermatologist by training?

   20. SOSuzan Obagi4:23

       Yes. And then I did a cosmetic surgery fellowship, and I am in academic medicine as well. I'm at the University of Pittsburgh, have been there about twenty-four years. So I got to see the evolution of this entire field, starting with what we used to do at the time was, uh, surgeries and then maybe a, a few collagen injections, and now we have the plethora of all these tools at our disposal. And I train residents, medical students, and I have visiting physicians from all over the world that come in. And I love the multi-specialty collaboration that we have because we both belong to the American Academy of Cosmetic Surgery, and we hear a different approach from different specialists, maybe on the same procedures. In my practice, I focus on everything, uh, with regards to skin rejuvenation, peels, lasers. I also do a lot of fat grafting. We do body liposuction, mini facelifts, eye lifts. But everything when it comes to the face is about really enhancing the appearance of the skin first-

   21. PAPeter Attia5:25

       Mm-hmm

   22. SOSuzan Obagi5:25

       ... because my feeling is that's the most important thing that everyone sees. So when a patient comes in like you, who has not had anything done or doesn't know about the field, I actually like that because I can take that opportunity to really educate them and pick the right things for them.

   23. PAPeter Attia5:41

       I appreciate you noticing I've had nothing done. Um-

   24. SOSuzan Obagi5:44

       [laughs]

   25. TNTanuj Nakra5:45

       [laughs]

   26. PAPeter Attia5:45

       Uh, you know, we were talking before the podcast, but it's worth me stating this now again for everybody to hear. There is something about this field of, of medicine that I have such a, a block in my brain to understanding. And, um, y- you know, uh, w- Tanuj and I have met before. Tanuj helped me with a scar. So Brett Cotless, a friend of mine who's actually been a former guest on the podcast, introduced us. Um, I face-planted one morning, uh, due to some hypotension, and, um, sustained a pretty nice scar here that, um, I think for the most part is largely invisible today, probably in part because my face is leather to begin with, but I think in part because, um, we did some 5FU microabrasion. We did a whole bunch of stuff, and I was actually pretty diligent about staying out of the sun for the period of time after it, et cetera. And, um, so, uh, I think we've also done a Botox treatment, which, you know, I-- It certainly reduced the wrinkles. Obviously, it's long gone, but I'd love to talk about that. Um, my wife and her friends are like... It's almost like they've done fellowships themselves, the way they talk about this stuff. And maybe that is just true of women in their 40s, but the way they go on about these techniques, it must sound like that when I talk about cars in front of them. Like, [laughs] it's so foreign.

   27. SOSuzan Obagi7:15

       Mm-hmm.

   28. PAPeter Attia7:15

       So as I was saying earlier, I have taken a strategy towards my appearance that is, uh, probably illogical, which is I'm just going to ignore it because I don't understand it, and I'm going to focus on things I understand. I would, I would view it as an enormous win of this podcast if in a few hours I decided to do something that was sustainable and, y- you know, gonna, gonna help me look a little better at sixty-two than I should look. I'm fifty-two today. I looked at a picture of myself ten years ago before this podcast. What a difference ten years has made. I, I look so much worse today than I did ten years ago, and I, I guess that's not uncommon, right? It, it-- I would guess forty-two to fifty-two is a big reduction in appearance. But it also made me realize, wow, the next ten years, that reduction will probably be greater if I don't do something proactive. Um, and to just fi- make one final point about my abject laziness on this topic, I can't even bring myself-- This is going to sound so disgusting. I can't even bring myself to wash my face before bed, which my wife is like, "You are so disgusting. Just wash your face."

   29. SOSuzan Obagi8:31

       [laughs]

   30. PAPeter Attia8:32

       But I'm like, "Eh, it's not like I'm that greasy. Who cares?"
2. 8:50 – 15:27

   Biology of the aging face

   1. PAPeter Attia8:50

      Let's start a little bit-

   2. SOSuzan Obagi8:51

      Well, yeah

   3. PAPeter Attia8:51

      ... uh, with the biology of the aging face. And again, we're going to limit our discussion today to the neck up, not that there isn't other things that, that, that are completely relevant around cosmetics. But, um, th- but that's just a big enough topic, right? Um, I told you that when I looked at myself ten years ago, I couldn't believe how much better I looked, but I'd have a hard time telling you why. Like I, I can't put my finger on it. But I bet you can without me showing you those pictures. Why did I look better at forty-two than fifty-two?

   4. SOSuzan Obagi9:24

      That's such a great question, and that's exactly how my patients come in. A lot of times they'll come in, and they'll say, "I feel like I look tired."

   5. PAPeter Attia9:32

      Mm-hmm.

   6. SOSuzan Obagi9:32

      "I don't know exactly what's going on, but I feel like I look tired." And I have these beautiful diagrams in my office, and I show them the face of someone who's twenty.

   7. PAPeter Attia9:43

      Hmm.

   8. SOSuzan Obagi9:44

      The face of someone who's in their late sixties, and I walk them through the changes. And the first thing I do is we show them the diagram with the skin peeled off, and you see about eleven different fat compartments in the youthful face that, on each side of the face, that are plump. They're robust. They're giving volume, and they're giving a padding between the skin and the muscle and the underlying bones. And then you look at someone who's in their late sixties, and you peel the skin away, and you see a dramatic atrophy in all those fat pads. So a few might increase in size, but the vast majority undergo atrophy.

   9. PAPeter Attia10:21

      Hmm.

   10. SOSuzan Obagi10:22

       And then in addition to that, I show them what the bones are doing at that age too. So we look at the vault, the bony vault of a twenty-year-old, and the opening around the eyes are nice and tight. The cheekbones are nice and wide. The jawline has a really good definition. And then you look at someone who's in their sixties, and all of a sudden, the opening around the eyes are wider.

   11. PAPeter Attia10:43

       Really?

   12. SOSuzan Obagi10:44

       The cheekbones are less wide, jawbone is less wide, less height. And so now you've got that scaffolding that's diminished, and all the skin f- looks like it's just hanging. And that's what's happening. But it starts early. So what I see on most of my patients when they come in and say, "I look tired," and you said it. You look at your pictures ten years ago, and you look now, and you don't know what's different. The first change is around the eyes.

   13. PAPeter Attia11:07

       Hmm.

   14. SOSuzan Obagi11:08

       And I'm sure Tanuj can add to that. But basically, what's happening is you're getting more bone loss around the eyes, more fat atrophy around the eyes. So you're starting to see the underlying anatomy, which was padded before.

   15. PAPeter Attia11:20

       So first of all, this is completely news to me. Is this loss of bone comparable to what we would see in the reduction of bone density in a person's hips as they age?

   16. SOSuzan Obagi11:33

       So a lot of it is hormonal. A lot of it is hormonal, and you see it especially in women. If they start to see the aging changes, they'll, they'll start to identify that in their early forties.

   17. PAPeter Attia11:46

       So this, in other words, is probably another reason why women would benefit from hormone replacement therapy because maintaining estrogen levels would maintain bone health.

   18. SOSuzan Obagi11:53

       Absolutely. And actually, that's something we need to stress more and more to them because it starts in their probably early forties.

   19. PAPeter Attia12:01

       Yep.

   20. SOSuzan Obagi12:01

       And then it just accentuates over time. But by the time they hit fifty, all of a sudden, now if we're looking at them cross-sectionally, a group of fifty-year-olds compared to guys who are fifty, the men are holding up pretty good. Their facial bone structure is good. Their fat volume's good. Their muscle thickness and skin thickness is good. But from 50 to 60 or 70, women will age about 20 years faster than men, in the lower face especially. They will get so much atrophy in the mandible that they'll start to get that-- That's why women start to say, "I hate my neck, and I hate the loose skin in my neck."

   21. PAPeter Attia12:36

       And if the n- 'cause if the mandible's retracting, the neck becomes looser.

   22. SOSuzan Obagi12:39

       Yes.

   23. PAPeter Attia12:41

       Again, this is remarkable because if you, bringing it back to the one thing I know about bone, it's when you look at men and women aging from a skeletal system, they're both going through a comparable decline starting in their 20s, uh, 'cause we both peak, both men and women peak in the early 20s. And, um, but at about 50, women fall off a cliff, uh, whereas men just continue a linear decline. And, and, and so the gap really widens. Interesting to realize that the exact same thing is happening in the face.

   24. SOSuzan Obagi13:12

       That's exactly it, and that's why women come in, the first thing they say when they're 50 is, "I hate my neck." And I think we jump to try to surgically correct it-

   25. PAPeter Attia13:20

       Mm

   26. SOSuzan Obagi13:21

       ... or to augment it with fillers or neuromodulators to keep the muscle from pulling down. But I think we have to have a talk about hormone replacement. You have to catch those women before they're far along into menopause.

   27. PAPeter Attia13:32

       A- a- again, I'm blown away by that fact.

   28. TNTanuj Nakra13:35

       And if I could hop in for a second, I, I mean, I love the direction of this conversation because, um, I don't know if people realize how much science there is about the aging process. Uh, there were some seminal studies by Rorik and Pessa in the '90s and 2000s that kind of delineated a lot of what Suzan's talking about, where they looked at, uh, CT scans of similar in, uh, the same individual over time. I think some of those studies had a 50 to 20 year span, and there was, uh, quantitative calculations of bone density and bone projection of the mandible, the maxilla, the frontal bone. Um, and these bone structures all recede with aging. Uh, and the bone is the foundation for the face. And so when we're talking about youthful fullness of a face, a lot of that is the bone structure. Uh, and then as Suzan said, of course, the fat compartments are a critical component of our facial aesthetics. And as we lose all that volume, the reason why people start to look more skeletal as we age, one of the most common areas that I see in my practice is people talking about their under eye bags and their, you know, the lines that are showing up in their eyelids and their cheek area. It's because we have ligaments that attach the skin down to the bone. It's called the osseocutaneous ligamentous network of the face. And those ligaments are, um, the same for every single individual, no matter what your ethnicity is. Of course, there's variations on the theme, but the orbital retaining ligament, the malar ligament, the temporal ligament, the mandibular ligament, the masseter ligament, these ligaments are always present. And then as we lose that facial volume from fat atrophy and the bones move backwards, these ligaments are tugging on the skin, and these l- these deep lines start to show up. And that's, that's really, I would say, one of the fundamental changes we see with aging of the face.

3. 15:27 – 19:15

   Why facial fat atrophies with age while body fat tends to accumulate

   1. PAPeter Attia15:27

      What I guess I don't understand is the following. Again, I'm just gonna use myself as the example because I think I'm probably reflective of many people. Ten years ago, I was less fat than I am today. Same body weight, by the way. I, I, almost to the pound, I'm the same as I was 10 years ago. Um, but I would bet my body fat was two or three percent lower. In other words, I have accumulated fat in my body. Why am I losing fat in my face? What is it about facial subcutaneous fat depots that atrophies when for virtually every person, the opposite is happening when they age? They're actually adding adipose tissue subcutaneously and unfortunately, often viscerally.

   2. SOSuzan Obagi16:16

      So if I may answer that one, it's interesting because I s- talk a lot to my patients about that. Now, the vast majority of my patients are female. So they'll come in, and they'll see me, and I can look at their face, let's say they're in their late 30s, early 40s, and I can guess how many kids they've had.

   3. PAPeter Attia16:33

      Hmm.

   4. SOSuzan Obagi16:34

      Because what happens is you gain weight in pregnancy. It doesn't have to even be a lot, but then most people, if they're fit, they lose that post-pregnancy weight, and-

   5. PAPeter Attia16:44

      I've had none, by the way.

   6. SOSuzan Obagi16:45

      Yeah. [laughs]

   7. PAPeter Attia16:45

      Just in case you were wondering.

   8. SOSuzan Obagi16:47

      That's good to know.

   9. PAPeter Attia16:48

      [laughs]

   10. SOSuzan Obagi16:49

       Um, and then they lose that post-pregnancy weight, and what happens is they go back to being the same weight that they were before they got pregnant, but their face is thinner.

   11. PAPeter Attia16:57

       Mm-hmm.

   12. SOSuzan Obagi16:57

       Second baby, more so. By the third baby, it takes a significant toll on the face, that weight gain, weight loss. So you can tell, looking at a female face, almost how many times they've gone through that weight gain, weight loss. And so what happens, the facial fat pads are very unique metabolically. Like I mentioned, most of the time they're just atrophying as we age.

   13. PAPeter Attia17:18

       Yeah.

   14. SOSuzan Obagi17:19

       There are a couple compartments that might, in time, get thicker, such as the nasolabial fat compartment, which is why some people have that deep fold.

   15. PAPeter Attia17:27

       Yep.

   16. SOSuzan Obagi17:28

       But for the most part, they atrophy, and so if you go through this yo-yo change with your weight, and you're progressively getting thinner and then gaining some weight back, it doesn't go to the face. It goes to parts of the body we don't want. But the face continues to undergo that weight loss or the volume atrophy.

   17. PAPeter Attia17:44

       But do we know biologically-- 'cause it's almost like a lipodystrophy, where-

   18. SOSuzan Obagi17:47

       Mm-hmm

   19. PAPeter Attia17:48

       ... the fat cell becomes defective and can't re-accumulate, uh, uh, tri- triglyceride or whatever it is, whatever form it's gonna store it in.

   20. TNTanuj Nakra17:57

       I, I think this is a, um, the edge of our-- W- uh, like so many things in medicine, there are things that we know and a lot that we don't know.

   21. PAPeter Attia18:05

       Yeah, so we know that it's happening.

   22. TNTanuj Nakra18:06

       Mm-hmm.

   23. PAPeter Attia18:06

       We don't actually know the biochemical mechanism necessarily.

   24. TNTanuj Nakra18:08

       We know some. I think we're just starting to understand the individual, um, uh, you know, receptors and specific nature of different areas of fat. So for example, even in the eyelid region, when we're doing surgery on the face, and we're, we're doing surgery on the upper eyelid, we will see that the fat pads have different colors. So the medial orbital fat pad is lighter substantially compared to the much yellower and more orange lateral fat pad, and that color will be different than the buccal fat pad. And one of the differences, there's beta-carotene differences in the fat pads, and that's probably just one of maybe a hundred that we'll eventually find out-

   25. PAPeter Attia18:48

       Mm-hmm

   26. TNTanuj Nakra18:48

       ... is, is contributing to the differences in the fat population. So we know that facial fat is different from abdominal fat, which is different from lower extremity fat. Um, and we know this also practically speaking because when we're doing fat grafting procedures, the source of the fat can have a different long-term effect when it's injected into the face depending on what the source was. And so, um, so we know that fat is not the same throughout the body, and it's not the same in the face.

4. 19:15 – 24:49

   How chronic stress accelerates facial aging

   1. TNTanuj Nakra19:15

      Um, w- there is a general, uh, consensus that beta carotene is an anti-inflammatory mediator, um, and higher concentrations and lower concentrations of beta carotene can have some effect on the metabolic health and s- of, of fat, especially how it responds to stress. And so in the world of longevity, there's a lot of discussions about, you know, man-managing cortisol levels.

   2. PAPeter Attia19:41

      Yep.

   3. TNTanuj Nakra19:42

      Like sleep is helpful. You know, uh, having lifestyles that reduce your overall stress level is good for your overall health in, in numerous ways. That's also true for the fat and the skin of the face because, uh, a-again, a lot of this is not fully explained, but we're starting to get more and more details as basic science progresses in this area that these fat compartments and the skin, which we can talk more about, um, is exquisitely sensitive to stress that the body is experiencing cumulatively over time. So, you know, a lot of times people feel like they're really aging in their forties. You know, people have midlife crisis. They're, they're-- crises. They're probably experiencing the maximum stress in their life at that stage typically, and I'm just generalizing here, but, you know, people will have a busy career. They've got kids. They've got financial worries, and so people are under a lot of stress in their thirties and forties, and that contributes to some of the more rapid facial volume loss changes, some of the skin aging changes with elasticity, collagen, elastin changes that occur over time. Um, and so that's where I think that, um, you know, this conversation really plugs in quite well into the line of, um, you know, education that you're providing your followers in terms of longevity benefits because the-- it overlaps here with cortisol stress and inflammation.

   4. PAPeter Attia21:08

      And what's interesting is that chronic elevation of cortisol in the body is actually anabolic to fat, right? You accumulate fat. It's catabolic to muscle. Muscle decays, uh, fat accumulates. It sounds like you're saying, "Okay, that's, that's true from the neck down," but above the neck, chronic elevation of cortisol might have the opposite effect. It might actually be catabolic to fat, and therefore-

   5. TNTanuj Nakra21:34

      Mm-hmm

   6. PAPeter Attia21:34

      ... it accentuates the fat loss. Is that-- Am I hearing you correctly in that?

   7. TNTanuj Nakra21:37

      Yes, I believe that's correct. And, and just yesterday in my clinic, I had a perfect example of this. I had patients back to back. One was sixty-eight year old. She was a sixty-eight-year-old woman who has lived a very comfortable life. She comes from affluence, hasn't really had to work too hard in her life, and has maintained things. Of course, she uses skincare products, and, you know, she's had a little bit of fillers and Botox but no surgery, and she looks ten years younger than her stated age because of the kind of life she's been living. And then the next patient I saw was from rural Texas, has been in the sun, has never been taking care of her skin, you know, was working a, a kind of a blue collar job, difficult life, couple marriages failed. She looked like she was ten years older, and, and this is common. I'm sure you see this all the time as well, Suzan. So, so l-lifestyle stress factors clearly have a, an effect. Um, and one of the reasons why, Peter, perhaps this is not an area that you've kind of delved into in your vast, um, experience in medicine is because the quality of science and aesthetics has historically been pretty poor.

   8. PAPeter Attia22:46

      You're, you're giving me way too much credit.

   9. TNTanuj Nakra22:48

      Mm-hmm.

   10. PAPeter Attia22:48

       I wish I could say that was-- I have delved into plenty of things where the science is poor. There is some other [laughs] mental block I have. It might be that I'm not smart enough to understand it all, but we'll continue, and I appreciate your... [laughs]

   11. TNTanuj Nakra23:00

       And another reason, uh, why it becomes very murky to sort through the science, and I'm sure this exists in other areas of medicine too, but a lot of the individuals, corporations, you know, factor-- forces that are delivering science to the masses and to physicians who are eating it up and, and, you know, regurgitating it to their patients, um, these sources are questionable. They're, they're-

   12. PAPeter Attia23:24

       Yeah

   13. TNTanuj Nakra23:24

       ... corp-- they're profiting. You know, uh, as you I'm sure realize, the aesthetic industry is a very, very lucrative industry worldwide, especially in the United States, and all the forces that are delivering the science-- I'm sorry, not-- I shouldn't say all the forces. There's a lot of forces where, uh, those that are delivering the science have a vested interest in receiving monetary benefit from what they're pushing out.

   14. PAPeter Attia23:51

       Fair.

   15. TNTanuj Nakra23:51

       And that makes things murky.

   16. SOSuzan Obagi23:53

       But I think going back to the fat compartments, think about it with our patients in general, you know, the, the role of the fat compartments in the face are to allow muscle glide So the muscles can move over each other when you smile, talk, eat, chew, all of that. And I don't understand why they should undergo such atrophy over time for such an important function. But then we look at the metabolic activity of the fat in other areas of the body, and it's very different. So when we do fat grafting, for example, and we take fat from the abdomen, which has the highest concentration of stem cells-

   17. PAPeter Attia24:26

       Yeah

   18. SOSuzan Obagi24:26

       ... pre-adipocytes there, and put them in the face, the fat starts to behave more like the fat from the abdomen when you put it in the face. And if they gain weight-

   19. PAPeter Attia24:35

       So it retains its source.

   20. SOSuzan Obagi24:36

       Yes.

   21. PAPeter Attia24:37

       Okay.

   22. SOSuzan Obagi24:37

       And then when they gain weight, you have to tell your patients specifically, "Don't try to gain more than a few pounds," because it will hypertrophy like it would in the abdomen if they gained weight.

   23. PAPeter Attia24:48

       Interesting.

5. 24:49 – 37:20

   Evolutionary biology of beauty, & how modern lifestyle, culture, & medicine interact with ancient instincts

   1. PAPeter Attia24:50

      Um, is there an evolutionary explanation for any of this? I mean, I, I don't know if aesthetics, if you think about this through an evolutionary lens, but I mean, historically, we didn't need to look good beyond our 20s if looking, if the purpose of looking good was to attract a mate. So again-

   2. TNTanuj Nakra25:09

      Yeah

   3. PAPeter Attia25:09

      ... none of us sitting around this table need to look good in Darwinian terms 'cause we're not reproducing. Do you think that factors into any of these observations?

   4. TNTanuj Nakra25:18

      100%, yes. And so I, I think it's also good, uh, for the sake of, um, the overall podcast for us to talk about the evolutionary aspects of beauty for just a moment, which could be a whole separate podcast. You could invite Nancy Etcoff from Harvard to come talk to you about the psychology of beauty. She wrote the definitive book on it, um, and summarizes all of, um, evolutionary beauty science. I have all of my fellows read her book because I think it is just a, a beautiful compendium. And, um, evolution- ev- the evolution of beauty is a fascinating topic because when you think back to the evolution of humans, you know, why do we even care about beauty? And so the interesting fact is that we're actually genetically hardwired to appreciate beauty. Um, and so there's this famous study from the University of Texas in the 1980s. Judith Langlois, um, is sort of a, a, a well-known name in psychology. She did what's called a preferential looking study of infants. I don't know if you've heard of this study-

   5. PAPeter Attia26:23

      No

   6. TNTanuj Nakra26:23

      ... but it's fascinating. She took newborn infants who were literally weeks old, barely able to see, um, you know, six inches away from their face, and she showed them pictures that are considered beautiful, faces that, that are beautiful, and faces that are less beautiful. And these newborn infants who've not yet been influenced by society preferentially were looking at the beautiful faces. And so that, that natural drive for us to appreciate beauty is present even at birth.

   7. PAPeter Attia26:54

      Does that suggest that b- that there is a definition of beauty that arcs time? Because I was actually going to ask a question, which would be a great, you know, detour for us to take after this point, about how much is the definition of beauty changing. In other words, if you took Matthew McConaughey and transported him back 10,000 years ago, would he still be a hunk, is sort of where I was going. But continue with this point, and then let's come back to-

   8. TNTanuj Nakra27:22

      Yeah, I think that's a-

   9. PAPeter Attia27:23

      ... the evolution of beauty

   10. TNTanuj Nakra27:24

       ... that's a great, um, that's a great question, and I would say that the answer is generally yes. There's two layers here. The first layer is the genetic, biologic, um, drive that we have to appreciate beauty in men and women. Um, and then, of course, there is a societal impact that conditions us to appreciate certain versions of that beauty. But the fundamentals are, uh, have been studied in the '90s, um, and the fundamentals are that all humans across ethnicities all over the world have been studied, and they appreciate certain features of beauty. So there's symmetry of the face, um, facial proportion, and then, um, they also appreciate, uh, sexual dimorphisms. Those are kind of the three categories. And so, um, symmetry, when, when a face is symmetric, it sort of connotes if you're out there in the reproductive world looking at the pool of your options, symmetry means that this individual most likely has had good development and nourishment and is most likely going to have good genetics for me to potentially connect with and pass on genetics together with. Um, facial proportion is similar. Um, in fact, um, to, to go a little deeper into that, um, averageness is really what people are looking for, and that doesn't, on the surface, that doesn't sound so attractive to be average. But if you take 100 faces of men, 100 faces of women, and average them all down to a single composite, you will, um, average someone who has a little bit of a big nose or a small jaw or some aspect of their f- their forehead shape, and all that gets averaged down into a composite that is considered universally beautiful across cultures. And again, that sort of unconsciously in the mating pool from an evolutionary standpoint is connoting healthy genetics, um, again, to be able to pass on gen- uh, your, your genetics with. And then the third area, which is sexual dim- dimorphism, we're talking here about strong jaws in med, full lips or big eyes in women. These tend to connote either higher estrogen levels or higher testosterone levels, depending on whether you're looking at women or men. And again, that's fertility. That's subconscious Communication of fertility. So those are the genetic absolutes that exist in all of us on the planet, and then on top of that, as you're, um, kind of bringing up, you know, social media, you know, in this culture, this particular way of, you know, uh, wearing your hair is considered beautiful, those are conditioned upon us-

   11. PAPeter Attia30:05

       Yeah

   12. TNTanuj Nakra30:05

       ... based on society, um, but it overlaps on top of that, that underlying genetic basis that we all have.

   13. PAPeter Attia30:11

       And how much can those things override? Again, I'll just use examples that we can all appreciate. Like, you know, I- my, my... I was talking with my daughter about Cindy Crawford. We were, you know, going, and I was like, "Look," like, "look at a picture of Cindy today, look at a picture of Cindy in the mid-1990s." I mean, there's simply no way to describe beauty in any other way. Like, you, you-- It doesn't matter what your type is, everybody would acknowledge Cindy is absurdly beautiful. And so you're saying she is hitting it out of the park on those three things independent of what the in vogue look of the moment is, right? So if, if, if it becomes the case that blondes are really attractive, it doesn't matter. Like, Cindy will override that. If it becomes the thing that women who weigh thirty pounds are attractive, it doesn't matter. Cindy will override that.

   14. SOSuzan Obagi31:00

       Yeah, I think if you look-

   15. PAPeter Attia31:01

       Is that kind of what you're saying?

   16. SOSuzan Obagi31:01

       If you look at even different races-

   17. PAPeter Attia31:04

       Yes

   18. SOSuzan Obagi31:04

       ... and look at a beautiful person in each of those, they actually all have similar measurements. So there are these masks that you can superimpose onto any image and really dissect down every single angle, whether it's the cheek angle, the jawline angle, the shape of the nose, the eyes, and all-- If you look at that across different races, they all have that same kind of measurement that they hit, talking about those same, the symmetry, the upper third, the middle third, lower third of the face, the fifths going across the face. All of that, if you look at a beautiful person, no matter what race they are, they all kind of hit those measurements. Now, then there are nuances. Like you said, you change your hair, you change your makeup, you can transform yourself. But if you take someone without makeup and just look at them that way, they all kind of conform to those measurements.

   19. PAPeter Attia31:55

       Doesn't this apply, imply that over time beauty should be one of the most preserved, concentrated traits of our evolution, given the, presumably the difficulty in acquiring a mate absent beauty? In other words, does it suggest that if you compared what we as a population look like today in twenty twenty-five to what we looked like two thousand years ago, ten thousand years ago, a hundred thousand years ago, are we monotonically getting more attractive as a species?

   20. SOSuzan Obagi32:26

       Can I jump in on one thing on this?

   21. PAPeter Attia32:29

       Mm-hmm.

   22. SOSuzan Obagi32:29

       You would think so, right? Because we're selectively-

   23. PAPeter Attia32:32

       Because the selection-

   24. SOSuzan Obagi32:32

       Yes

   25. PAPeter Attia32:32

       ... should be ramping it up.

   26. SOSuzan Obagi32:33

       Exactly. So we should be marrying someone that looks better or mating with someone that looks better and having our progeny look better. But what's different is our diet. So ta- go back a hundred years, two hundred years, a thousand years, we had to chew a lot more-

   27. PAPeter Attia32:51

       Mm

   28. SOSuzan Obagi32:51

       ... to really digest our food. We were working our masseters, we were working our jawline, our palates were not as high, our jawline was a lot wider, our teeth were stronger. And then as we have changed our diet and everything is cooked and we don't have to make as much effort to chew it, you actually get more crowding in your, of your teeth, your jawline is a little bit less strong, your palate changes, more people become nose breath-- uh, mouth breathers as opposed to nose breathers. That changes the shape of your face, and that has been measured anthropologically. And so it's interesting because there's a whole book on breath-

   29. PAPeter Attia33:30

       Hmm

   30. SOSuzan Obagi33:30

       ... and they go through the anthropology of all that and the changes in the skeletons that they've gone back and studied. And so that does fundamentally change. Now we have kids that have to have teeth extracted or we have to have palate expanders now because we realize when we extracted teeth before, we made the faces more narrow. And so now the thinking is let's preserve the teeth, expand the palate when the child is ten, allow those teeth to come in so there's less grinding, uh, I'm sorry, crowding, and then that face will be better and a stronger jawline. So it is something that we've changed.
6. 37:20 – 43:10

   How social media has shifted aesthetic trends toward exaggerated features/unrealistic beauty standards

   1. PAPeter Attia37:20

      How much do you see... Even, even just speak about it through the length of your actual careers. How much do you see trends that dramatically change what people are asking for? In other words, Suzan, you know, 25 years ago, did men or women come into your practice significantly looking for something different in terms of an appearance and an outcome that they wanted you to shape?

   2. SOSuzan Obagi37:48

      Yeah, I would say that's such a loaded question because 25 years ago, if we think back, there was no social media.

   3. PAPeter Attia37:55

      Yep.

   4. SOSuzan Obagi37:56

      Um, television was, you know, very basic. Um, they talked-- Maybe there was some shows that had live people on there on different shows where they would talk about beauty or fashion, but you had to actually tune in and watch those shows to be able to see the trends. Magazines came out, and that was the extent of it. Now you have social media and various channels on social media, and then you have what we now know as influencers, and they're changing what our patients are seeing and what's driving them. And the biggest one that I can talk about is basically that very well-known family in California that has monetized their appearance and set a lot of trends, for better or for worse. It's great to see that they're making it okay to talk about enhancing your appearance or fixing something that bothers you. But where I draw the line is when they start putting out their transformations, and this trend now is something that everyone wants to emulate. And you're talking about young women changing, physically changing their body drastically to conform to what you said is a trend, which is exactly it. And trends, as the word says, are not permanent. So what happens when that trend ends? The celebrities have the money to go to the doctors and reverse all that. Now, it will take surgery, and they will have scars to show for it or hide for-- from that. But the patients, uh, that follow them, these young women don't have all of that income to go back and then retransform their body, and they don't know the implications of that. So I think it's-- we have a duty as doctors definitely to try to educate our patients about not following trends so strongly and look beyond the monetary aspect of it. And so from that standpoint, I try to really educate my patients to stay away from things that are trending and really do things that make them look and feel better but natural for themselves. Because, um, I, I don't know in your practice, but I know people want to come in for the enhanced buttocks, the, uh, Brazilian butt lifts, and the small waists, and, you know, that's something, again, that's being undone by that family now, and you're gonna see a whole trend that's coming out that doesn't look like that.

   5. PAPeter Attia40:08

      So what are, what are kind of the top above-the-neck trends? So, so what, what I see as I look around is I see lip size being something that's getting bigger, smaller, bigger, smaller. Where are we today, by the way, in lip size?

   6. TNTanuj Nakra40:24

      So just to, um, continue Suzan's lines of-- line, line of thought there, um, we're in this, again, unusual era where the influencers that are affecting society are much more in our faces than they have been historically, and they're affecting young people at a much younger age, which is why we just let my 16-year-old daughter have a social media account. Um, and that influence of these influencers is, is quite powerful because what happens is on social media, which is the primary exposure that people are receiving these days about beauty, um, the, the, the images that are being posted are not real. They're filtered. They're, um, unrealistic, uh, exaggerations of some of those three original factors that we're talking about, the symmetry proportion. People will photograph themselves in such a way where they look, they look more proportionate. They will, uh, you know, they'll pull their jaw in a certain way to make their proportions look, uh, look better.

   7. PAPeter Attia41:23

      Someone has to teach me how to do this because-

   8. SOSuzan Obagi41:25

      [laughs]

   9. PAPeter Attia41:26

      ... anytime I see a video of myself, you know, I'm like, "That is the worst-looking thing I've ever seen."

   10. SOSuzan Obagi41:31

       Mm-hmm.

   11. PAPeter Attia41:31

       Like, I need to learn these tricks.

   12. SOSuzan Obagi41:32

       You need a 20-year-old.

   13. PAPeter Attia41:33

       [laughs]

   14. TNTanuj Nakra41:35

       And a lot of this is subconscious posing.

   15. PAPeter Attia41:37

       Interesting.

   16. TNTanuj Nakra41:37

       That's a term that I have, you know, have used for this, uh, concept where people are subconsciously posing. Like, for example, if you-- Like, a lot of people when they walk past a shiny building will stop and look at themselves and kind of, like, adjust themselves a little bit.

   17. PAPeter Attia41:51

       And by the way, is that new, or is that something we would've alwa-- Like, in other words, did our ancestors walk by a stream where the water was still and look at themselves? Do we-- I mean, not that we can know that, but...

   18. TNTanuj Nakra42:02

       Possibly. I think so.

   19. PAPeter Attia42:03

       Mm-hmm.

   20. TNTanuj Nakra42:03

       But I think the, the-- it's becoming so much more exaggerated now, um, to the point where we can, you know, confidently state that social media influencers are selling exaggerated forms of beauty ideals, like the sexual dimorphism. So we talked earlier about, like, larger lips or bigger eyes. Um, one of the most popular procedures in, uh, Northeast Asia is surgeries to make the eyes wider. You actually cut into the canthus-

   21. PAPeter Attia42:31

       What?

   22. TNTanuj Nakra42:31

       ... and perform ptosis surgery to make the eye look bigger. And then, of course, this trend to have bigger lips, um, you know, fillers are being used left and right, unfortunately, to overdo lip volume and plump up lips. And because the social media influencers are, are posting it, it's becoming more exaggerated because these exaggerated gender traits are becoming normalized. And so again, the family that Suzan's mentioning in, in California, they normalized over, overdone lips. To the point where people come in asking for it, and we have to say, "No, I'm sorry. This is not a good direction for us to take you in."

   23. PAPeter Attia43:09

       So where, where do

7. 43:10 – 53:52

   Ethical challenges, financial incentives, & social pressures shaping modern aesthetic medicine

   1. PAPeter Attia43:10

      you-- Sorry to interrupt, Tanuj, but-

   2. TNTanuj Nakra43:11

      Yeah

   3. PAPeter Attia43:11

      ... where do you put, 'cause, 'cause clearly both of you seem to be more on the, um... Well, let me take a step back. I was talking to somebody yesterday where I said, "One of the marks of a great surgeon is a person who is happy to say no, is happy to say, 'I'm not gonna do this,' because I'm so good that I don't need your business. Like, I can be as selective as I want about what I do." Um, that allows two things. That allows the right patient selection to get a good outcome. So the, the discussion I had with a patient yesterday was about a, was about, uh, a orthopedic surgery issue. And, you know, the, the, the, the doctor said, "Yeah, I think it's time to do the surgery," and he was, the patient was saying to me, "Well, he does sort of have a vested interest in doing the surgery. After all, he's a surgeon." I said, "Yes, but I can speak about this surgeon in particular. I've watched him say no to 100 patients because patient selection is the most important thing for him to drive amazing outcomes, and he'll say no until it's time." In, in, in, in the cosmetic world, you add another layer to that decision, and clearly you guys are both on the spectrum of you're both, you're both, you know, you're both the top of your field, so you don't need an incremental patient. You're happy to say no. There's also, it sounds like, an ethical reason for you to say no. My, where I'm going with my rambling question is, where do you think the field is on the whole? Are you guys the outliers, or are you guys the majority? Is there, is there a handful of bad actors out there that will take any money from any 17-year-old who's, you know, being duped into thinking this is the way they need to look? Um, I'm trying to get a sense of the scale of this problem.

   4. SOSuzan Obagi44:52

      I would say the vast majority of physicians are ethical. Um, I do think there are some out there, though, where it is something that's monetized, so they will mass treat patients. You know, their goal is to have surgery after surgery coming in, and basically letting the patients make their own informed decision about it to an extent. But I always look at it akin to managing hypertension or diabetes. We never let the patients determine how much insulin to use or how much antihypertensive medication to take, and I don't think we should let the patients say that they want to transform themselves to some completely different person. I just ethically think that's wrong. I think that brings to mind a whole bunch of other psychological issues that might be playing there, including what we call social media dysmorphism, where people h- come in with pictures of themselves with a filter and say, "Can you make me look like this picture?" And so there's a disconnect.

   5. PAPeter Attia45:52

      By the way, is that a recognized, uh, diagnosis in the-

   6. SOSuzan Obagi45:54

      It is

   7. PAPeter Attia45:55

      ... DSM-5 now?

   8. SOSuzan Obagi45:55

      Oh, in the DSM-5, I don't know if it's made it that far, but-

   9. PAPeter Attia45:59

      Okay

   10. SOSuzan Obagi45:59

       ... it is something that is mentioned at different meetings now. So I don't know-

   11. PAPeter Attia46:03

       Yeah

   12. SOSuzan Obagi46:03

       ... uh, that it's made it into the DSM-5.

   13. PAPeter Attia46:06

       If not, it'd probably be in the six, right?

   14. SOSuzan Obagi46:08

       Yeah.

   15. TNTanuj Nakra46:08

       Um, if I could chime in, I, I think that, you know, S- Suzan's obviously a very ethical, you know, outstanding surgeon and physician, but I, I do have to say I'm an optimist. I have to say that I think the situation's worse than what you're saying. I think that there are, unfortunately, financial incentives for physicians, nurses, and the, the broad spectrum of people that perform aesthetic treatments, including, you know, Botox and filler injections. It's very poorly regulated. There are tons of people out there ranging from hairdressers all the way up to surgeons who will be happy to take your money and find a place to put the syringe of filler because they know it's gonna be money, revenue into, into their practice. And so I, I don't want to be overly negative, but I think this is sort of a cautionary warning to people who are listening to this podcast that when you're delving in the area of aesthetic enhancement, you have to understand that there's an overlay where the person that you're seeking out advice from has a substantial financial incentive to treat you, and it's, uh, I think it's a real issue. I do.

   16. PAPeter Attia47:20

       Yeah. It's-- I'll tell, tell you, one of the things I always caution patients toward in my world is you need to be really careful when you're seeing a quote-unquote longevity doc who is selling tests and selling treatments for the results of that test, right? When you go to see somebody, and they're selling a biologic clock whose treatment is this supplement, and they're monetizing those two things, I just don't see how you can trust that individual. I don't see how even a person with good intentions can't be, can't get conflicted there. And I guess I never thought of it until you said that, but the entire aesthetic industry is effectively that because you're not just selling a procedure, you're often selling a treatment. Like a, you're, you're, you're, you're getting paid on both ends.

   17. SOSuzan Obagi48:12

       Well, and what's happened is, like Tanuj was saying, uh, the m- the providers have changed. So before, it used to be only dermatologists that would do the injectables, and then it became dermatologists and plastic surgeons, and then it became the RNs and the physician assistants, and those are still all medical providers, including dentists who are very well trained can do that. But then you get, in certain states, lack of regulation, so you're seeing unqualified people who are not medical providers doing injectables and laser treatments that they may not be trained for, and all of a sudden, you start to open up a whole Pandora's box of complications there. And this is a shame because Patients might not know enough to ask about qualifications. They might see that it's a nice storefront, the person's wearing a lab coat, they look professional. So from that standpoint, they might go in trusting that this person has their best interest. There might not be a physician overseeing everything. We feel very strongly in our practices that there is a physician overseeing every treatment, whether we're doing it, our nurses or our PAs are doing it, we're overseeing all of that to make sure that if there's a complication, that complication is ours. No matter what, we're going to take care of that patient. So it is a shame, and I do warn a lot of young residents coming into the field to enter the fields if they truly love the field and are passionate about dermatology, ophthalmology, oculoplastics, all of that. Because if they're going into it thinking they're gonna be the next glamorous doctor on social media, then they're not gonna have a lot of treatments that they can offer because at that point, uh, all these other providers are doing those treatments. They're gonna have to find a niche for them- for themselves to make a name for themselves doing something differently. So it- it's really fascinating right now, we're, the times that we're living in.

   18. PAPeter Attia50:06

       And do you see a change in residents today? So when I was in medical school, which is almost 30 years ago now, the people... And maybe that's just, it's such a small sample that it's an irrelevant statement, but, but when I think back to everybody I knew that ultimately chose plastic surgery, they all had a very artistic bent to them, right? Like, they... I'm not gonna say that they didn't pick it because it was also a lucrative field and things like that. Maybe if plastic surgeons made 50,000 a year, they wouldn't have done it. But I never got the sense that that was their primary motivation. When I think back to my friends in medical school that went into plastics, they were artists. They really took an interest in the art of this. Do you still see incoming residents largely o- of that philosophy, where they're interested in the aesthetic component of it, the, the underlying physiology of it? In other words, are they cut from the cloth you guys are cut from? Or do you see a trend towards, "No, this is literally a cash machine," and, um, uh, this, there's [laughs] the, you know. It's one of the, a- again, as, as reimbursements are going lower and lower and lower across the entire field of medicine, um, it is clearly more attractive to be in specialties, um, where, where reimbursements either remain very high and/or there's a, it's mostly cash.

   19. TNTanuj Nakra51:23

       Well, I, I'll take a more optimistic tone here. I think that, um, tho- those who are coming into residency and fellowships in the world of aesthetics, I think really still have that same artistic mindset. People, you know, who are painters or musicians, they have that artistic mind, and it's something we actually look for in our fellowship when we're considering candidates because we know that they have that right brain mentality of being able to handle medical problems. But the, the, the reality is is that, as you said, medical reimbursements are going down. The lucrative nature of aesthetics is high and getting higher as time goes by. And so someone can go through all the training, and then when they see the dollars come in the door, they're just gonna want more of that, and it, it can, it can distort their ethics, and they may not even realize they're doing it. I'm not saying that there are physicians out there who are knowingly duping patients into having treatments, but I think it just becomes this unconscious drive because of the finances.

   20. SOSuzan Obagi52:22

       We were talking about that earlier.

   21. TNTanuj Nakra52:24

       Yes.

   22. SOSuzan Obagi52:24

       And I do think it's a challenge because, you know, here we go again. Medicare just got cut again in terms of reimbursements, and that's sad because w- we're talking about in our university practices, there's a huge push for doctors to see more patients because m- reimbursement is dropping. And so the only way that the medical centers can compensate is to increase the volume. There's only so many patients, though, in a day that we can see and offer really good care. So Tanuj and I have a very unique practice because most of our patients are self-pay. So we have the luxury of time. We can talk to our patients, get to know them, to the point that a lot of our patients come to us seeking medical advice and opinions on other advice that they've gotten from other physicians, and we can help them decipher the facts. Whereas their other physicians may be fabulous, but they have to see 30, 40 people in a day.

   23. PAPeter Attia53:17

       Yeah.

   24. SOSuzan Obagi53:17

       And that's a shame. That's do- that's the detriment now that the ph- uh, physicians' market is in because we're burning out a lot of really good physicians who want to give good care but find themselves having to see more and more patients so they can only spend 10 minutes a patient, and that's really unfair, and that's not why all of us go into medicine. And for both of us, we entered our fields before all of these devices and treatments existed. So I think we did come into it with a passion for what we love, but we both have an artistic bent to ours, to our personalities as well, so we kind of gravitated towards this.

8. 53:52 – 1:01:04

   Concerning trend of teenagers seeking cosmetic enhancements

   1. PAPeter Attia53:52

      I want to put a bow on the social media thing for a moment. Um, what is the most concerning trend, or what is the most concerning request you are getting from people that you believe is sort of unique to, to the social media phenomenon?

   2. SOSuzan Obagi54:07

      What I'm seeing a lot more are teenagers now coming in asking for fillers and neuromodulators in their li- in their forehead, fillers in their lips, and that's sad because-

   3. PAPeter Attia54:18

      But why would, I mean, would a neuromodulator do anything in, when you're at that age anyway?

   4. SOSuzan Obagi54:23

      No, but they're now being told that even 18, for example, it's okay to start preventative Botox. You don't need that until you're a lot further along in age.

   5. PAPeter Attia54:32

      So that's just an abject lie that they're being told.

   6. SOSuzan Obagi54:35

      Yes. And unfortunately, they're also being made to feel very poorly about their shape of their lips. They're being inundated with images, and like Tanuj was saying, these are highly filtered images. We know a lot of people who will take in their waist, take in their thighs, all of that, change the proportions, and then post that image. And, and what I try to tell patients Is that what you see in terms of images that are on social media, A, are filtered, B, are taken, um, with certain angles of the camera to enhance someone's appearance, and we will never, at least in my practice, take someone's photo that they took on their phone and then try to enhance them to look like their photo because what's happening is that you're going to make them look very different in life, in real life. So how you photograph, you're only going to photograph beautifully if you're the most symmetric person. And that's why even the most beautiful model on, in a photograph, if you look at them in person, they're very pretty, but you wouldn't think that they're supermodels sometimes. But when they photograph, they photograph beautifully because of their symmetry. But for us, with our forward-facing cameras, um, that we p- point at ourselves to take fa- uh, s- our selfies, they're going to distort our face. If you tilt one way, you elongate the face; tilt it a different way, you shorten the face. And patients get hung up on that, and, uh, that's really sad because in real life, they look fabulous.

   7. PAPeter Attia55:59

      Now, is this a i- ninety-five five female male problem that is, is arising from social media or are there, are there, are th- and is the m- I, I, I guess from the purpose of this discussion, I would guess it's mostly female. My guess is the male issue is probably much more on anabolic steroid abuse and things that, that m- young men are being influenced by. Is that safe to assume? So, so what is it that you see, Tanuj, that is most disconcerting? Is there a particular product or a pecif- particular procedure that is, that is showing up that is, would have been unheard of before social media?

   8. TNTanuj Nakra56:31

      I would say two areas. One is because fillers are non-surgical, relatively accessible price points, and, um, low risk, and are ubiquitous, you can find a clinic within one mile if you live in a major city. I think overfilling is a serious problem. Um, whether it's the lips or the cheeks, over, overvolumization has become an epidemic, and, and it's, and it's a serious problem not only because it, it looks exaggerated and distorted and strange, but even when a- as a facial surgeon I go in to perform surgeries, I will find that filler has disrupted normal anatomy. And so decades later, y- the companies will tell you that filler only lasts one year in the face, and then you have to refill it. That's definitely not true.

   9. PAPeter Attia57:21

      Really?

   10. TNTanuj Nakra57:21

       We see-- We-- I have patients coming in who don't mention that they've had fillers in the past, but then in surgery I will see filler in their cheek or in their face because they had it eight or ten years ago, and it's still there, and it's stretching the ligaments. It's changing the structure of the tissues. It actually makes routine surgical procedures later more challenging. So that's o- that's one area.

   11. PAPeter Attia57:43

       And by the way, are there biologic features of the individual that would make that more or less true? Are there some people in whom fillers go away after a year, or are you saying that for the most part they last longer?

   12. TNTanuj Nakra57:52

       Yeah, so that, that, that's also another whole complex topic is the metabolism-

   13. PAPeter Attia57:55

       Yeah

   14. TNTanuj Nakra57:55

       ... of hyaluronic acid, and some people are higher metabolizers, some are slower metabolizers, and we actually don't have a good sense of that. We, we have some general concepts just ba- based on experience, but there's very little science on that. We can't really predict who's going to be-

   15. PAPeter Attia58:10

       So one doesn't know.

   16. TNTanuj Nakra58:11

       One really doesn't know is the bottom line.

   17. PAPeter Attia58:12

       Okay. And I'm sorry. I, you, you were going to get to a second point.

   18. TNTanuj Nakra58:14

       Yeah. No. Uh, the second point is from a surgical standpoint, there is a trend right now where people are asking for this high arched brow effect where it's hyper exaggerated. The tail of the brow comes up very high. It's called a snatched look. A- about once every week or two, I've got someone who seriously wants to have their face distorted with a surgical procedure with me, and I have to say, "I'm sorry. We're, we're not gonna do that."

   19. PAPeter Attia58:38

       Is it safe to say that anyone who walks into a physician's office to do this needs to be able to be over eighteen to provide consent? But is it safe to say, or is it, is it, is it the case that people younger than eighteen can do this in less reputable, uh, places without parent consent? Do we know this?

   20. SOSuzan Obagi59:01

       So it should be eighteen.

   21. PAPeter Attia59:03

       Yep.

   22. TNTanuj Nakra59:03

       Yeah.

   23. SOSuzan Obagi59:03

       It's like any other medical procedure. You have to be eighteen years of age to consent. There are rare instances where, where I will treat someone who's sixteen or seventeen if the parent is there and if it's for something, for example, a patient has a h- hump on their nose that they don't like, but they're not e- ready to commit to a rhinoplasty.

   24. PAPeter Attia59:24

       Yep.

   25. SOSuzan Obagi59:24

       So I can use fillers in a creative way to help reduce the appearance of that.

   26. PAPeter Attia59:28

       Sure.

   27. SOSuzan Obagi59:28

       But that's very f- far and few in between. But-

   28. PAPeter Attia59:30

       Yes, but, but again, the point is the parent is there.

   29. SOSuzan Obagi59:32

       Yes.

   30. PAPeter Attia59:32

       Yeah, yeah, yeah.
9. 1:01:04 – 1:12:57

   UV damage & sunscreen recommendations

   1. PAPeter Attia1:01:04

      care, right? So we can talk about preventive care and then move into sort of, you know, maybe where I am now, where I missed the boat on pure prevention and I now need to start being active. So for the person who's listening to this who's, um, you know, still in their prime, uh, from a, from a, from an aesthetic perspective, so I guess they're in their 20s, right, we would say. Uh, maybe even in their 30s, depending on their genes. Um, the only thing I know is wearing sunscreen is a net positive, right? So it clear- clear... I, I understand enough to say that UV damages skin. Um, is it damaging elastin? Is it damaging collagen, or is it purely just these sunspots that it creates? What is it that sun is doing that is damaging?

   2. SOSuzan Obagi1:01:50

      Quite a bit.

   3. PAPeter Attia1:01:51

      Okay.

   4. SOSuzan Obagi1:01:52

      So, um, I'm glad you mentioned sunscreen because if anyone's gonna come in and say, "What's the absolute minimum thing I should use on my skin every day?" It would be sunscreen. And in fact, there was a four-year study out of Australia that followed people for four years, and either they wore sunscreen or they didn't, and the ones that did aged better.

   5. PAPeter Attia1:02:11

      Was it randomized?

   6. SOSuzan Obagi1:02:12

      It was randomized.

   7. PAPeter Attia1:02:12

      Okay, good.

   8. SOSuzan Obagi1:02:13

      So it aged better. They aged better. Fewer lines, fewer wrinkles. And that's in a country that has a lot of sun.

   9. PAPeter Attia1:02:19

      Yep.

   10. SOSuzan Obagi1:02:20

       So that shows you the power of using sunscreen. Now, I'll take it a step further. I tell my patients they have to use mineral sunscreens as opposed to chemical sunscreens because I'm not convinced of the safety of avobenzone, oxybenzone as hormone disruptors. I do think there are some, uh, science, scientific studies that suggest maybe they play a role in infertility. You can measure them in the bloodstream.

   11. PAPeter Attia1:02:44

       Mm-hmm.

   12. SOSuzan Obagi1:02:44

       And especially if you're putting them over the entire body.

   13. PAPeter Attia1:02:47

       Yep.

   14. SOSuzan Obagi1:02:47

       The body... The skin is a great portal for chemicals to enter into the bloodstream if it's the right size chemical. So there have been already studies done that show a huge spike in the amount of these in your bloodstream after application. After saying this for 15 years, I think the FDA just a couple weeks ago finally told the companies they must do animal safety studies. It's about time. Some-

   15. PAPeter Attia1:03:09

       It's very late. Yeah, so late in the game.

   16. SOSuzan Obagi1:03:11

       Yeah. It's very late because-

   17. PAPeter Attia1:03:12

       And also the... I'm sorry to interrupt, but just the... I'm, I'm so on board with you about the problems with, uh, chemical sunscreens because the other problem it creates is that patients think they're covered.

   18. SOSuzan Obagi1:03:22

       Mm-hmm.

   19. PAPeter Attia1:03:22

       And then the chemicals that are actually protecting against the UV damage become inactivated over time, and you don't know-

   20. SOSuzan Obagi1:03:30

       Because you still have the film on you.

   21. PAPeter Attia1:03:32

       You have the film on you.

   22. SOSuzan Obagi1:03:33

       Yes.

   23. PAPeter Attia1:03:33

       And you don't know at what time of day you no longer have any solar protection.

   24. SOSuzan Obagi1:03:37

       It's within an hour.

   25. PAPeter Attia1:03:38

       What was the... Yeah.

   26. SOSuzan Obagi1:03:38

       It's within an hour. You put a sunscreen SPF 70 on, go outside, and it's gonna be... If it's strong sun-

   27. PAPeter Attia1:03:45

       Yep

   28. SOSuzan Obagi1:03:45

       ... it's gonna be deactivated within an hour. People will burn on SPF 70-

   29. PAPeter Attia1:03:49

       Mm-hmm

   30. SOSuzan Obagi1:03:49

       ... SPF 100. There should be nothing above a SPF 50 mineral because you can't get it into a formula that looks good.
10. 1:12:57 – 1:23:31

    Minimizing skin aging: retinoids, vitamin C, & evidence-based application methods

    1. PAPeter Attia1:12:57

       Okay. Uh, to your point, we could spend the rest of the podcast on it. We won't. We've established the fact that step one, the no regret move, protect your skin in the sun. Um, what's the next level thing that one can do for prevention?

    2. SOSuzan Obagi1:13:13

       So we may be on the same line. It might be a little bit different. I would say step two would be a retinoid of some sort. And it could be in your-

    3. PAPeter Attia1:13:22

       I was worried you were gonna say that.

    4. SOSuzan Obagi1:13:24

       I know. Everyone says that.

    5. PAPeter Attia1:13:25

       [laughs] It's just one more thing I have to apply.

    6. SOSuzan Obagi1:13:27

       Well, here's what I tell patients, 'cause you said you don't wash your face at night, right?

    7. PAPeter Attia1:13:31

       I know, don't, I, it's so gross.

    8. SOSuzan Obagi1:13:32

       Do you brush, do you brush your teeth at night?

    9. PAPeter Attia1:13:33

       I do.

    10. SOSuzan Obagi1:13:33

        Okay.

    11. PAPeter Attia1:13:34

        I'm a religious flosser and teeth brusher.

    12. SOSuzan Obagi1:13:36

        Right next to your toothbrush, put your little tube of retinoid. [laughs]

    13. PAPeter Attia1:13:41

        [laughs]

    14. SOSuzan Obagi1:13:41

        That's what I tell my patients. So retina- retinoids, we have different categories. There's retinol-

    15. PAPeter Attia1:13:47

        Mm-hmm

    16. SOSuzan Obagi1:13:47

        ... which is the weakest one, and your body will go put it through two enzymatic changes to become retinoic acid, which is what you get at the pharmacy. And that's great if you're in your 20s, late teens, early 20s, and you're just trying to be preventative with how your skin is aging, and at the same time, maybe addressing some acne.

    17. PAPeter Attia1:14:07

        Okay.

    18. SOSuzan Obagi1:14:07

        Once you hit late 20s into your 30s and early 40s, you need maybe something a little stronger, and that's where retinaldehyde is a little bit better. And that's the next conversion. So retinol becomes retinaldehyde, which then becomes retinoic acid. So retinaldehyde's that middle step, and there's more actual enzyme in your body that can convert retinaldehyde to retinoic acid, and that's less irritating for pa- people to use.

    19. PAPeter Attia1:14:32

        Mm-hmm.

    20. SOSuzan Obagi1:14:32

        So in your case, if you get irritated very easily and you're going to quit, it gives us an option to give patients something that's highly efficacious, that is going to irritate their skin less because it gets converted to the active form after it's been absorbed into the skin. And then the gold standard is retinoic acid, and that has multiple different strengths, but that's someone who's in their mid-40s and up. They're gonna need it continuously to keep boosting collagen because our peak collagen production -- You want to venture a guess as to what age we peaked in our collagen production?

    21. PAPeter Attia1:15:08

        Uh, I would say late teens, early 20s.

    22. SOSuzan Obagi1:15:10

        Yeah, 18.

    23. PAPeter Attia1:15:11

        Yeah.

    24. SOSuzan Obagi1:15:11

        That was the, when our fibroblasts were making the most of the matrix that Tanuj was talking about.

    25. PAPeter Attia1:15:16

        I guessed that because that's when in, in women, bone density peaks in, at about 18. For men, it's about 20, 21.

    26. SOSuzan Obagi1:15:23

        Yes, exactly. So 18, we start to make less collagen, elastin, and glycosaminoglycan. So if we can add a retinoid in there, we're telling the fibroblasts to boost more of those production of those k- uh, ingredients, those peptides in those collagen matrix. If we are looking at the melanocytes, those retinoids also f- normalize the function of melanocytes so that they're less aggregated, less overactive, and they also help to normalize the turnover of the keratinocytes. So they're working at the major str- cellular structure of the skin at the level of the DNA.

    27. PAPeter Attia1:15:59

        Now, my recollection is there were two concentrations of this stuff that you could get. Does that ring a bell?

    28. SOSuzan Obagi1:16:04

        Of the prescription?

    29. PAPeter Attia1:16:05

        Yes.

    30. SOSuzan Obagi1:16:05

        There's three.
11. 1:23:31 – 1:37:07

    Daily skincare routine: cleansing, antioxidants, retinoids, moisturization

    1. PAPeter Attia1:23:31

       Let's talk then about how you wash your face before you begin this procedure. So I've just come in from whatever I've done. I've... You know, I'm brushing my teeth 'cause that's the only time I'll do this, and, uh, I'm gonna wash my face now. What should I do? I g- I'm guessing that the hand sanitizer next to my sink-

    2. TNTanuj Nakra1:23:48

       [laughs]

    3. SOSuzan Obagi1:23:48

       Oh. [laughs]

    4. PAPeter Attia1:23:48

       ... is not the thing to use.

    5. TNTanuj Nakra1:23:50

       So there, there has been a huge shift in so many areas of skincare that is now syncing more with what science is telling us. And so historically, there was a belief that you would need to strip all the oil off your face, and debris, and dirt before you apply products. We're talking about, you know, skincare routines from 10 or 20 years ago, and th- we now know that that is harmful. It creates inflammation. It disrupts the microbiome of the skin. It does all sorts of negative things. And so a, a modern, uh, cleanser that we suggest is usually something that is glycerin-based. Usually. There's also other, other versions, but it's a, it's a way of cleansing the skin without overly stripping the oils out of the skin. Um, and, uh, glycerin-based cleansers don't s- don't foam. Um, and so that's certainly my bias. I'm sure you might have some, some other thoughts, Suzan, but that, that's the first step, uh, to, to get the debris and superficial oils off the face, and y- you know, previously applied product. And then as Suzan said, you go from, um, thin to thick. And so usually on top of that will be serums, like vitamin C serum, um, or, uh, retinols and, and then finally you'll put a moisturizer on to kind of seal it all down.

    6. PAPeter Attia1:25:09

       Okay, so hang on. Serum, um-

    7. SOSuzan Obagi1:25:11

       And the antioxidant serum.

    8. PAPeter Attia1:25:13

       Okay.

    9. TNTanuj Nakra1:25:14

       Yeah.

    10. PAPeter Attia1:25:14

        So an-

    11. SOSuzan Obagi1:25:14

        So we, we mentioned vitamin C, but there are so many other great-

    12. PAPeter Attia1:25:16

        What are the others?

    13. TNTanuj Nakra1:25:17

        Yeah.

    14. SOSuzan Obagi1:25:17

        There are great antioxidant serums that contain silymarin, phloretin, glutathione-

    15. PAPeter Attia1:25:22

        So how, how, how does one pick? How do you... What?

    16. SOSuzan Obagi1:25:24

        That's where you have to look and see who's invested in doing the clinical research based behind the products that they're promoting.

    17. PAPeter Attia1:25:31

        So you tell me, what are you guys using?

    18. TNTanuj Nakra1:25:34

        I mean, I, I would say that generically speaking, um, if you can find a vitamin C serum that has a higher quality vehicle to make sure the bioavailability of the vitamin C gets to your skin-

    19. PAPeter Attia1:25:47

        Yep

    20. TNTanuj Nakra1:25:47

        ... that product is going to have additional, you know, associated antioxidants that are gonna be very useful and helpful. And you know, again, to avoid naming brand names here, you can find that quite easily and especially with the advice of physician-

    21. PAPeter Attia1:26:01

        Can we go ahead and name brands? Because honestly, people just wanna know, so let's just-

    22. TNTanuj Nakra1:26:06

        Sure

    23. PAPeter Attia1:26:06

        ... give some brands that you guys trust, uh, maybe across a range of price points.

    24. TNTanuj Nakra1:26:12

        Sure, I mean, I'll, I'll give you some names. So I'll give you m- my brand name, but then also brands that I suggest to other people as well. Uh, my brand name is called Avia Skincare, and it is designed to-

    25. PAPeter Attia1:26:22

        A-V-I-A?

    26. TNTanuj Nakra1:26:23

        A-V-I-A, yes.

    27. PAPeter Attia1:26:24

        A-V-I-A.

    28. TNTanuj Nakra1:26:25

        And we, um, formulate these products to have medical grade efficacy. We also incorporate some Ayurvedic wisdom, which is anti-inflammatory, so it has turmeric and other kind of Eastern botanicals for anti-inflammatory care. And we have a vitamin C serum that is mi- microencapsulated that also has a retinol in it and also has various other antioxidants that are niacinamide that are all useful to apply to the skin right after you've washed it. Now, there are other brands as well. Um, you know, I mean, we can name 100 of them probably. Um, you know, I think, uh-

    29. PAPeter Attia1:26:59

        But if you couldn't use yours, what are two others you would recommend?

    30. TNTanuj Nakra1:27:02

        You know, SkinCeuticals is probably one of the most available-
12. 1:37:07 – 1:46:08

    Managing acne

    1. PAPeter Attia1:37:07

       Before we leave this, I guess one thing I just want to chat about is acne. Again, it's mostly something I, that adolescents are experiencing, but a- a- adults get acne as well. Um, is that something you guys spend much time on?

    2. SOSuzan Obagi1:37:21

       I do.

    3. PAPeter Attia1:37:22

       What, so give me, give me the, the, the sort of playbook you have on, on acne. I assume it involves spironolactone if it looks to be, you know, endocrine in nature. Um, I'd be very curious to hear about, you know, Accutane. I hear horror stories about it, but obviously it probably works very well. What do people need to be aware of? How-

    4. SOSuzan Obagi1:37:42

       Yeah

    5. PAPeter Attia1:37:42

       ... what's your playbook for addressing acne?

    6. SOSuzan Obagi1:37:44

       So my number one thing I tell people is w- for themselves or their children-

    7. PAPeter Attia1:37:48

       Yep

    8. SOSuzan Obagi1:37:48

       ... try to treat the acne before it scars, because I cannot tell you how many times I see patients for consults for acne scars. They're in their 70s, and they're still crying about it as if it was yesterday. They've been traumatized all their life with these acne scars.

    9. PAPeter Attia1:38:03

       And what causes acne to scar?

    10. SOSuzan Obagi1:38:05

        So it depends on how inflammatory your acne is. There are different types of acne. There's comedonal acne, which are just your run-of-the-mill small pimples, whiteheads, blackheads. Those don't typically scar unless someone picks at them. So number one rule for patients, don't pick at your skin. Second thing, they can have a little bit more inflammatory acne, and those tend to be the red ones that come up and they're maybe pustur-

    11. PAPeter Attia1:38:29

        Yep

    12. SOSuzan Obagi1:38:29

        ... pustular on the skin. And if you don't pick at them, those also might heal without scarring. And then there's cystic acne, and those are a completely different type of acne where you're getting inflammation in that sebaceous, pilosebaceous unit-

    13. PAPeter Attia1:38:44

        Yep

    14. SOSuzan Obagi1:38:44

        ... which is the hair follicle and the oil gland feeding in there. And you get swelling deep in the dermis, and then you might get enough inflammation and rupture of that cyst that you leave a divot at that point, and that causes what we call a valley scar. Or you might have enough damage of the-

    15. PAPeter Attia1:39:01

        Even if not picked?

    16. SOSuzan Obagi1:39:02

        Even if not picked. So cystic acne is a true, in my standpoint, a medical emergency because you want to treat it before-

    17. PAPeter Attia1:39:09

        Maybe not on the level of anaphylaxis, but-

    18. SOSuzan Obagi1:39:11

        Correct. Correct

    19. PAPeter Attia1:39:12

        [laughs]

    20. SOSuzan Obagi1:39:12

        Yes, but for parents, yeah, you-

    21. PAPeter Attia1:39:14

        It, it's a dermatologic medical emergency.

    22. SOSuzan Obagi1:39:16

        Yes.

    23. PAPeter Attia1:39:16

        Yes, very well.

    24. SOSuzan Obagi1:39:16

        Because it can cause so much psychological trauma to the child. People with cystic acne, even bad inflammatory acne, they're shy to go out in public. They wanna hide their face. They hide their face with their hair.

    25. PAPeter Attia1:39:27

        What percentage of adolescents will develop cystic acne?

    26. SOSuzan Obagi1:39:31

        I don't know that I can quote the exact per- percentages.

    27. PAPeter Attia1:39:34

        Minority?

    28. SOSuzan Obagi1:39:34

        But about 20%.

    29. PAPeter Attia1:39:35

        Oh, wow, so pretty high.

    30. SOSuzan Obagi1:39:36

        Yes.
13. 1:46:08 – 1:58:22

    The 4 changes of aging & the complexities of aesthetic consultations—anatomical, psychological, & ethical factors

    1. PAPeter Attia1:46:08

       move now into the really confusing realm of I show up in your office. I can't tell you what's wrong, but I show you a picture of me ten years ago, and I say, "I wanna look like that." And I should have brought a picture in of me so you could actually see it. But, like, I-- you've already described it without having seen the picture, right? I don't have bags under my eyes. My skin just looks better. Everything just looks better. Part of it is color. I, I will admit, ten years ago, there was no gray anywhere in my beard. We're not gonna fix that problem. That's fine. But, but aside from that, um, like-- Oh, and the wrinkles in my forehead. Like, I notice in pictures of me in the past, I had some wrinkles. Now, it looks like I have a wrinkle farm, right? So, so w- go-- again, go over the changes, assuming I had that photo. How would you describe them pathologically? Or maybe that's too strong a word, but you know what I mean.

    2. TNTanuj Nakra1:47:12

       So I think, um, there are three basic changes that happen to every single person with aging, and we've touched on this a little bit, and, and we'll dive deeper now. So there are skin changes. Uh, there are volume changes. There are gravitational changes. Um, and, and maybe we should throw in the fourth, which is, you know, bone structural foundational changes. And so those happen to everybody. Um, when we see patients in our clinics who are presenting the way you've just suggested, we will spend extra time analyzing the individual nuances of skin volume, bony ligamentous anatomy, gravitational changes that are specific to your face. Um, and then also we'll just rely on just general knowledge that we have about what types of aging changes we see at this point. And, um, it's a very, um, complex process. I, I tried to analyze this a little bit before walking into this podcast today. Like, what am I actually thinking about when I'm starting to comm- communicate with the patient? As soon as I see the patient, y- while I'm, you know, making some niceties and saying hello and get to know them, I'm already analyzing. I'm already looking at their skin. I'm looking at the bone structure. I'm analyzing the facial proportion. I'm looking at areas where there's volume loss that's obvious. I'm looking at the dynamic movement of the forehead and the face. I'm analyzing how much, um, heaviness is on the eyes that might be driving frontalis muscle tone that's causing forehead wrinkles. I'll b- I'll be looking for facial asymmetries. So a lot of the, lot of the physical exam that we do in our offices happens in the first fifteen seconds because we're just-- this is what we do, and it just happens quickly in our, in our mind.

    3. SOSuzan Obagi1:48:55

       It's that blink moment.

    4. PAPeter Attia1:48:55

       Big, big difference.

    5. SOSuzan Obagi1:48:56

       It's that blink moment.

    6. TNTanuj Nakra1:48:56

       Yes, it is.

    7. SOSuzan Obagi1:48:57

       You look at someone, and you're like, "I know what I'm gonna do on them."

    8. TNTanuj Nakra1:48:59

       Yes, yes.

    9. PAPeter Attia1:49:00

       The urologist doesn't have this advantage.

    10. SOSuzan Obagi1:49:03

        No.

    11. TNTanuj Nakra1:49:03

        Right. [laughs]

    12. PAPeter Attia1:49:03

        He has to-- He can't, you know, examine the prostate and the scrotal tissue during that first fifteen seconds.

    13. TNTanuj Nakra1:49:09

        Very good point, yes. So, so we do that, um, when we walk into the room. That analysis already happens. And then because I've already got that sort of snapshot anatomic analysis already in my mind, then the next step that I'm doing is, uh-- and I'd love to hear what your process is, Suzan. But the next step is I'm now going into their mind and trying to understand their psychology and what their motivation is. And the problem that we have is that the patient doesn't know what words to say-

    14. PAPeter Attia1:49:42

        Yeah, they're like me

    15. TNTanuj Nakra1:49:42

        ... for them to communicate-

    16. PAPeter Attia1:49:44

        Yep

    17. TNTanuj Nakra1:49:44

        ... what's actually driving them.

    18. PAPeter Attia1:49:46

        Yep.

    19. TNTanuj Nakra1:49:46

        And so I have to pull that out of them. This is a little bit of detective work. Um, a little bit of background, um, my parents are both psychiatrists. I actually went to medical school thinking I was gonna go into psychiatry, and then I rapidly pivoted into surgery and ended up where I am. But that initial love and appreciation for what's happening inside the neuronal processing and the subconscious is something that we actually work with every single day in our offices. And so, um, so the next step that happens in a consultation is-

    20. PAPeter Attia1:50:20

        I would say hopefully. I, I, I mean-

    21. SOSuzan Obagi1:50:21

        Yes

    22. PAPeter Attia1:50:21

        ... to me, that's a, that's a great thing. But I, I don't know. I-- not to be a downer, I, I don't know that that's true of every you know, person who is, who is dealing with, with aesthetics. I, I would guess there are a lot of people who are just kind of doing this in a coin-operated way-

    23. SOSuzan Obagi1:50:36

        Cookie cutter

    24. PAPeter Attia1:50:36

        ... yeah, and are not really thinking it through.

    25. TNTanuj Nakra1:50:38

        Yeah. I think you're right. Unfortunately, there is a, a, there, there can be a tendency to take a cookie cutter approach, where you recognize this, and here's the... It's a knee-jerk reaction.

    26. PAPeter Attia1:50:46

        Yep.

    27. TNTanuj Nakra1:50:47

        There's wrinkles on the forehead, inject Botox. You know, there's jowls, do a facelift. That's not the way that we should be practicing aesthetics. Every single individual has a totally customized situation anatomically, physiologically, and psychologically. And so our job is to try and figure that out when the patient doesn't have the ability to express. So sometimes this almost overlaps into pediatrics, which is something that I know you've got some history with in, in, in surgery. But, you know, you're trying to do a physical exam and get history from someone who's unable to communicate what they're actually-

    28. PAPeter Attia1:51:23

        Mm

    29. TNTanuj Nakra1:51:23

        ... able, what they, what they want you to figure out. And so we'll all start asking questions. You know, "Did you like the way you looked when you were 20?" If they say yes, that means that they actually like their natural facial proportions, and they're probably looking more for rejuvenation. But if they say, "You know, I always had a heavy eyelid, and I never could put makeup on my eye," then I know that they may be looking for something that's a more substantial result in that particular area. That's just one example. And then, um, I'll try to get to know them from a, just l- what are they, what kind of, what's their occupation? What's their situation at home? Do they have kids? Tell me a little bit about your life. I'm trying to understand their social history to, to f- see if there's any red flags that would stop the process and say, "Okay, this is not the right time to be considering aesthetics. You gotta get your mental health in order before we proceed," which is something that I would, you know, very openly tell a patient, you know, at the right time in the consultation.

    30. PAPeter Attia1:52:22

        But, but if a woman came in and said, "My husband is leaving me," right, which is unfortunately probably not an uncommon thing, um... And, and let's make it more extreme, right? A 50-year-old woman comes in and says, "My husband of 25 years is leaving me for a 20-year-old." Understandably, she's in duress.
14. 1:58:22 – 2:01:22

    The 5 R’s of rejuvenation

    1. TNTanuj Nakra1:58:22

       How about you, Suzan?

    2. SOSuzan Obagi1:58:23

       Yeah. Oh, pretty much everything that Tanuj said.

    3. TNTanuj Nakra1:58:26

       [laughs]

    4. SOSuzan Obagi1:58:26

       And I was so glad to hear that you would talk to the patient about their mental state at that time too because we do a lot of almost like psycho- psychology and therapy with our patients.

    5. TNTanuj Nakra1:58:37

       Yeah.

    6. SOSuzan Obagi1:58:37

       If they open up to you, then that's an honor to you, and you have to take that, and you have to help them through that issue. And my... I have a psychology background as well, so I was biology and psychology double major in school. So, and I find that I use it a lot. It's so important. But, um, I approach patients very similarly, but I try to put things in terms that they can understand. So I tell them there are the five Rs of rejuvenation, and it doesn't mean they need all of it at that point in time, but at some point in their life they're going to need one of them, uh, and they'll make it through all, all five. And that is we need to relax overactive muscles, and I'm showing them on their face the movements. I will say we need to refill lost volume, whether it's through fat grafting, which is still one of my favorite procedures to do, or refilling with fillers. And I tell them we need to resurface the skin because to me, the, how the skin looks is absolutely much more important than how tight they are.

    7. TNTanuj Nakra1:59:38

       Mm.

    8. SOSuzan Obagi1:59:38

       So patients sometimes come in, they're like, "I just want a lift here," and they want a lift their lower face, and their skin is terribly wrinkled, and, uh, h- they have hyperpigmentation and sunspots. And I'll tell them, "If I lift you now, no one's gonna notice that you look better. But if I make your skin look better, people are gonna notice you look better before I even do the surgery."

    9. TNTanuj Nakra1:59:57

       Hmm.

    10. SOSuzan Obagi1:59:58

        So we have relax, refill, resurface. We need to do redraping. So there are going to be times that you can't lift in... uh, I'm sorry, fill enough. You have to lift. So they either will lift with devices, such as microneedling, radiof- uh, radiofrequency devices or ultrasound devices to tighten the skin or a facelift of some sort. So those you need to do. And then what people don't realize, my fifth R, is that you have to keep renewing because the aging process continues, and the minute they leave your office, everything you just did on them looks great, and then it starts to diminish.

    11. TNTanuj Nakra2:00:34

        And that's what we talked about a mo- that's what we were just talking about.

    12. SOSuzan Obagi2:00:36

        Yes.

    13. TNTanuj Nakra2:00:36

        The renewal was the maintenance.

    14. SOSuzan Obagi2:00:38

        Absolutely. So you have to keep renewing because otherwise you're going to lose that benefit. And h- what do I mean by renewing? You definitely maintain your neuromodulators and your fillers, but they have to be strategically placed. You don't need a lot of fillers. You need to keep the skin priming itself and turning over, and so you can achieve a lot of that at home. And I think people underestimate how much they can do at home with their skincare regimens and then have to do less in the office, and that's my big emphasis. Do more at home, and then let us do in the office a little boost here and there afterwards. And so those five Rs make it very easy for these patients to comprehend. And they might not need all that yet-

    15. TNTanuj Nakra2:01:18

        Yep

    16. SOSuzan Obagi2:01:18

        ... but at some point in their life they're going to have all those f- five Rs.

    17. TNTanuj Nakra2:01:21

        All right. So what I want to

15. 2:01:22 – 2:05:07

    Facial aging analysis & cosmetic strategy using Peter’s face as a case study

    1. TNTanuj Nakra2:01:22

       do then is I want you to go through the five Rs looking at me. And Tanuj, I want you to go through your four changes looking at me. So the... just feel free to brutalize me.

    2. SOSuzan Obagi2:01:34

       [laughs]

    3. TNTanuj Nakra2:01:35

       Y- you're not going to humiliate me.

    4. SOSuzan Obagi2:01:37

       All right.

    5. TNTanuj Nakra2:01:37

       Um, so, so let's start... So, so Suzan, you look at me, and let's start with relax. What needs to be relaxed in my face?

    6. SOSuzan Obagi2:01:45

       Yeah. So here's the thing. You do move your eyebrows a lot, and your forehead, so you've got a lot of forehead wrinkles. I do notice the glabellar 11s in here.

    7. TNTanuj Nakra2:01:54

       Where are the... Oh, these are those little-

    8. SOSuzan Obagi2:01:55

       Yes

    9. TNTanuj Nakra2:01:55

       ... sharp lines there. Yep.

    10. SOSuzan Obagi2:01:56

        Yep. So knit your brows for me. Yeah. And so raise your eyebrows up. Now, part of the reason you're raising your eyebrows maybe now more than you did 10 years ago is you have a little more hooding on your upper eyelids, and your eyelids are almost touching your eyelashes. And when that happens, you're sending a signal to the forehead to lift so you can see better.

    11. TNTanuj Nakra2:02:16

        And is that because I've lost elasticity in the eyelid, and it's just drooping more?

    12. SOSuzan Obagi2:02:21

        Well, no, more, more so going back to what we were talking about, the bony structure.

    13. TNTanuj Nakra2:02:25

        Ah, that's right, the bone.

    14. SOSuzan Obagi2:02:26

        We're losing bony support, fat atrophy, including the brow fat pad. And so now you've got a descent, a little bit, of your brow but a little more, uh, of the extra s- redundant skin there.

    15. TNTanuj Nakra2:02:36

        I got it.

    16. SOSuzan Obagi2:02:37

        So part-

    17. TNTanuj Nakra2:02:38

        So I'm, I'm actually using this muscle more to try to keep these guys up.

    18. SOSuzan Obagi2:02:43

        Exactly. Now, if you go to someone who doesn't evaluate you like we do, they might look at your forehead like target practice and say, "I'm going to use a neuromodulator across that entire forehead and make it so you can't move, and then you're gonna walk around very hooded and very heavy

    19. PAPeter Attia2:02:57

        I would feel silly. I wouldn't want to look that way.

    20. SOSuzan Obagi2:02:59

        You would hate the feeling.

    21. PAPeter Attia2:03:00

        Yeah.

    22. SOSuzan Obagi2:03:00

        It would feel very hooded and very heavy. And I've done that on purpose to myself just to see what patients experience, so... And it's not a nice feeling. Secondly, you are very fit, so you have not a lot of fat in your face. And like I said, doesn't matter what you think your weight is on your body now or how much fat percentage you have on your body, you've atrophied some of the facial fat pads. So you- you've exposed the entire orbital rim. I can see that.

    23. PAPeter Attia2:03:27

        And you may also notice I have a scar here, and it has created an asymmetry in the drooping. So, uh-

    24. SOSuzan Obagi2:03:34

        Yeah

    25. PAPeter Attia2:03:34

        ... from back in the, when my teenage years when I was boxing, I actually had -- I was split to my cheek-

    26. SOSuzan Obagi2:03:40

        Wow

    27. PAPeter Attia2:03:40

        ... there. So that is a very deep scar, um, that I, I'm -- I suspect the connective tissue there is actually tethered-

    28. SOSuzan Obagi2:03:47

        Yes

    29. PAPeter Attia2:03:47

        ... near the bone.

    30. SOSuzan Obagi2:03:48

        And we can free that up with subcision. So that is kind of similar to the microneedling Tanuj did on your other scar, but this is going under the scar-
16. 2:05:07 – 2:11:08

    Fat grafting vs dermal fillers for facial rejuvenation

    1. PAPeter Attia2:05:07

       about this, of course, but, but when do you guys make the decision of an, an, an autograft of fat versus Restylane you mentioned earlier?

    2. SOSuzan Obagi2:05:17

       I love fat if we can do it. Now, with the advent of fillers, the volume of fat grafting we do goes down, but I just did a lady yesterday, and I'll tell you why.

    3. PAPeter Attia2:05:26

       Yeah.

    4. SOSuzan Obagi2:05:26

       Uh, on her, she came in. She had never had anything before. And she was hollow everywhere. So yes, we could use-

    5. PAPeter Attia2:05:34

       How old?

    6. SOSuzan Obagi2:05:34

       Seven -- uh, 69.

    7. PAPeter Attia2:05:36

       Okay.

    8. SOSuzan Obagi2:05:37

       So yes, we could use lots of fillers, but she'll spend a small fortune putting a lot of fillers in her face over time. And I personally don't like to inject more than two or three syringes of filler in one visit, so it's going to take a process to build up different areas on her because I just don't want to have a reaction, and I also want to see where I'm placing everything. But in her case, we went straight for the fat because she has a thin face, but she has a normal body mass index. So her fat-

    9. PAPeter Attia2:06:04

       H- how much-

    10. SOSuzan Obagi2:06:05

        ... is going to do well

    11. PAPeter Attia2:06:05

        ... how much, uh, filler would I require for... Just ba- what would your guess be?

    12. SOSuzan Obagi2:06:10

        Probably about -- I'd start with a syringe split between both under eyelids, and then I would do another syringe probably in about three or four months if I need to.

    13. PAPeter Attia2:06:18

        And that, what's the cost of each syringe? Yeah, not the-

    14. SOSuzan Obagi2:06:21

        De- depending-

    15. PAPeter Attia2:06:21

        Not your cost, the patient's cost

    16. SOSuzan Obagi2:06:22

        ... de- yeah, about 800 to $1,000, depending on the filler.

    17. PAPeter Attia2:06:26

        Again, what is the cost of the procedure, the fat graft procedure? That's obviously much more, but it's a lifetime, presumably.

    18. SOSuzan Obagi2:06:32

        It's about 5,000.

    19. PAPeter Attia2:06:34

        Okay, so five years' worth of treatment, basically. So it's cheaper in the long run to do a fat graft, presumably.

    20. SOSuzan Obagi2:06:40

        Yes, but also remember that we're just talking about your under eyes. But let's say you're my typical patient. They need their temples filled. They need their cheeks filled. They need their chin filled, jawline enhancement. So yesterday, I did about 35, 40 mLs of fat on my patient. So that, if you were to multiply that by-

    21. PAPeter Attia2:06:59

        Yeah, it gets-

    22. SOSuzan Obagi2:07:00

        It gets very expensive.

    23. PAPeter Attia2:07:01

        Um, are my temples too sunken?

    24. SOSuzan Obagi2:07:04

        Yours are still good. So, uh, and your cheekbones are still good. Your jawline is still good. I would put a little neuromodulator or Botox in your platysma muscle 'cause I am starting to see some platysma banding there.

    25. PAPeter Attia2:07:17

        Wow.

    26. SOSuzan Obagi2:07:17

        Mine's worn off, so you don't want to look at mine. Um, but that helps to relax that muscle that does nothing but pull lower, uh, to the lower face down.

    27. PAPeter Attia2:07:26

        Okay.

    28. SOSuzan Obagi2:07:28

        And I would possibly add a little volume right in your malar. In your case, I would love a biostimulatory filler, something like poly-L-lactic acid, or Sculptra is the other name for it, to start building collagen and thicken your dermis thickness in here 'cause I'm starting to see some of your buccal fat pad atrophy as well, and that just goes along with how fit you are. So using this to build your own collagen is a great way because -- and if you were a female, very thin, we would have an issue because those patients tend to burn through their fillers very quickly. So if we can get a biostimulatory filler on board where they're building their own collagen, sometimes it works a little better.

    29. PAPeter Attia2:08:06

        Now, do you ever look at a patient like me and say, "You're, you're most fat depleted here and here, but you're not yet fat depleted here and here. I d- I only want to do one fat graft on you, so let's -- cost aside, let's use fillers until I have to do this procedure once and for all, and then I'll literally just take a bunch of fat off you and do it"?

    30. SOSuzan Obagi2:08:30

        Absolutely.
17. 2:11:08 – 2:15:18

    How self-image, eye aesthetics, & fleeting photos drive the desire for cosmetic enhancement

    1. TNTanuj Nakra2:11:08

       w- again, kind of going back to the way that I do a, a, a cosmetic exam, b-because I just heard you say the thing that bothers me-

    2. PAPeter Attia2:11:14

       Yep

    3. TNTanuj Nakra2:11:15

       ... most is this area, and we could list off another 10 things that are, quote-unquote, "aesthetically problematic"-

    4. PAPeter Attia2:11:20

       Like, I didn't even notice this.

    5. TNTanuj Nakra2:11:22

       Yeah.

    6. PAPeter Attia2:11:22

       So now you've given me something to be self-conscious about.

    7. SOSuzan Obagi2:11:24

       [laughs]

    8. TNTanuj Nakra2:11:25

       [laughs]

    9. SOSuzan Obagi2:11:26

       I should have prefaced it saying, "I'm just gonna point out something."

    10. PAPeter Attia2:11:28

        I wanted you to. I-

    11. SOSuzan Obagi2:11:29

        Yeah. [laughs]

    12. PAPeter Attia2:11:29

        I'm totally teasing. I'm totally teasing.

    13. TNTanuj Nakra2:11:32

        So I would laser focus on the area that the patient is now presenting to me as their major reason for even calling up my office and making an appointment is probably because they wanted to address this area.

    14. PAPeter Attia2:11:44

        Yep.

    15. TNTanuj Nakra2:11:45

        And yes, they're curiously interested in all the other things that I had to say, but because this patient, you know, in this case you, is, um, never had surgery on their face, is probably not looking for massive shifts in their face, I would probably laser focus on this one area, not just because it's what you pointed out, but also in the, um, realm of, uh, rejuvenation procedures that we, we perform surgically or non-surgically, the eye region is probably the sweet spot. You know, just again, going back to psychology evolution, we focus on people's eyes in conversation. We pub-

    16. PAPeter Attia2:12:23

        Yep

    17. TNTanuj Nakra2:12:23

        ... you know, when we talk about beauty, we're looking at the eyes. So when, when people's eyes are now starting to become further and further away from the way they remember it when they were younger, it creates this discomfort. It's, it's the self-discrepancy theory from psychology, where you've got this self-image of yourself, and then you look at yourself, and you're like, "Wait a second."

    18. PAPeter Attia2:12:44

        That's not what I-

    19. TNTanuj Nakra2:12:45

        "That's, that's not me." Right?

    20. PAPeter Attia2:12:45

        Yeah, yeah.

    21. TNTanuj Nakra2:12:46

        And then it creates this discomfort of like, "Is that what I really look like?" And then it creates, you know, the psychological effect of, like, maybe a little less confidence or dissatisfaction with your appearance. That's the big motivator for why people actually end up coming to see someone like, like us is because they're, that self-discrepancy theory is kicking in, and they're... the, the, the d- the delta between their self-view and their actual appearance is getting greater and greater.

    22. PAPeter Attia2:13:12

        It, it's one of the reasons I c- ... It sounds ridiculous that I'm saying this on video and that I have a podcast. I freaking hate being on video. I don't mind the sound of my voice. The seeing me on a video, and as you know, in this type of a situation, you're always overhead lit. It is an unbearable appearance because when you have these bags under your eyes, overhead lighting just makes it look 10 times worse.

    23. TNTanuj Nakra2:13:36

        Mm-hmm.

    24. PAPeter Attia2:13:36

        So if I, if I pass myself in the mirror, I'm like, "Eh, I notice it." If, if someone ever sends me a clip of me on video, like on YouTube or on... I'm like, "How in the hell are we allowing this to be in the public domain?"

    25. TNTanuj Nakra2:13:51

        [laughs]

    26. PAPeter Attia2:13:51

        I mean, seriously.

    27. TNTanuj Nakra2:13:52

        And, and part of it may be what we were mentioning earlier, that subconscious posing, because when you're looking in the mirror, you know you're looking in the mirror, and your subconscious makes you lift your cheek a little bit.

    28. PAPeter Attia2:14:01

        Maybe I angle my head different or something.

    29. TNTanuj Nakra2:14:02

        You angle your head or you smile a little bit, and it pulls the cheek up and minimizes that hollow between your under-eye and your cheek, and everybody does this, and that's why people tend to be shocked by photographs that are taken of them when they weren't prepared for it 'cause they, they're not prepared to pose for the picture, and their, um, flat, undynamic face in a photograph that's taken like that is shocking to them and i- is often a big motivator for them to come to see us.

    30. PAPeter Attia2:14:28

        I also made the mistake of once reading some comments on social media where people were just ripping me apart for how horrible-
18. 2:15:18 – 2:21:12

    Advice for wrinkles, causes of dark circles under the eyes, & the importance of facial symmetry

    1. TNTanuj Nakra2:15:18

       um-

    2. PAPeter Attia2:15:18

       And then what about the wrinkle situation?

    3. TNTanuj Nakra2:15:20

       Yeah. So, um, you know, I would kind-- what I would do is I would kind of go through all of the areas, the four areas that we're talking about, and then I would laser focus on the eyes. So to go through the four areas, we're talking about skin.

    4. PAPeter Attia2:15:32

       Yes.

    5. TNTanuj Nakra2:15:32

       Um, we, we've done a lot of discussion already on skincare. I think that you should start a skincare regimen. I think you'll appreciate it as time goes by. You will find-

    6. PAPeter Attia2:15:40

       I'm gonna, I'm gonna commit to three months for sure

    7. TNTanuj Nakra2:15:42

       You, you have, uh, d-- you have uneven pigmentation in your face.

    8. PAPeter Attia2:15:46

       Yep.

    9. TNTanuj Nakra2:15:46

       Um, you have some fine lines that are more concentrated in the eye region because that's-- the eyelid skin is the thinnest on the entire body. And there's-- it's the one area of the body, um, and you're, you're a surgeon by training. You know that when you cut into the body, there's always a fat layer.

    10. PAPeter Attia2:16:00

        Yep.

    11. TNTanuj Nakra2:16:01

        Not in the eyelids. So the eyelid does not have a subcutaneous fat layer. It's the only place in the body. And so-

    12. PAPeter Attia2:16:06

        So what's underneath the skin? The muscle directly?

    13. TNTanuj Nakra2:16:08

        The orbicularis muscle. Mm-hmm.

    14. PAPeter Attia2:16:10

        Wow.

    15. TNTanuj Nakra2:16:10

        And so there are four causes of dark circles under the eyes. There's visibility of the orbicularis muscle, there's shadowing, which is why you probably don't like your appearance in this kind of situation 'cause the shadowing is visible down here. Um, there's hemosiderin deposition, and then there's hyperpigmentation. So those are the four reasons why people get dark circles under the eyes. And, and, and you actually have all four of them. [laughs]

    16. PAPeter Attia2:16:32

        Wonderful.

    17. TNTanuj Nakra2:16:32

        Um, and then so, so we would definitely want you to get onto a good quality skincare regimen because it, it, it's one of the four areas that needs to be addressed, not only to reverse some changes, but for prevention purposes.

    18. PAPeter Attia2:16:45

        Yep.

    19. TNTanuj Nakra2:16:45

        And when it comes to volume loss, I think Suzan sort of already picked you apart there. You've got, you know, volume loss in the midface. I think your temporal volume loss is enough where if you were going to have some kind of volume treatment, putting a little bit in would be nice. Your left temple sinks in a little more than the right.

    20. SOSuzan Obagi2:17:03

        I can only see his-- oh, okay.

    21. TNTanuj Nakra2:17:04

        Yeah.

    22. SOSuzan Obagi2:17:05

        Yeah, I'm mostly looking at this side of his face.

    23. TNTanuj Nakra2:17:07

        Yeah, yeah. The right temple is less, less hollow.

    24. PAPeter Attia2:17:08

        Is that common?

    25. SOSuzan Obagi2:17:10

        Yes.

    26. TNTanuj Nakra2:17:10

        Extremely common. So, um, when I put that mirror up in front of patients to start pointing out their asymmetries, I'm, I'm not kidding, ninety-five to ninety-nine percent of the time, people are unaware of their own asymmetries until I point them out to them. And the reason why it's important to point it out to them, because if I'm going to be employed to manipulate their face, they need to know where the starting point was. And so-

    27. PAPeter Attia2:17:31

        Now, do we want to fix asymmetries all the time? Like, does it matter?

    28. TNTanuj Nakra2:17:35

        Sometimes. Sometimes. Um, um, so we don't wanna make it worse. The first-- certainly. You know, that, that's probably a big, big factor. Um, and then if there's a way to make it better when we're doing maneuvers, we'll dial that in because again, going back to the three, you know, biological reasons of why people perceive beauty, it'll make that person look more, more handsome or beautiful.

    29. PAPeter Attia2:17:56

        Interesting. Okay. So-

    30. SOSuzan Obagi2:17:56

        And some people do have significant asymmetries.
19. 2:21:12 – 2:32:39

    Considerations that shape clinical decision making around fat grafting & other procedures to address the eye area

    1. TNTanuj Nakra2:21:12

       Yeah.

    2. PAPeter Attia2:21:12

       Is fat always a superior filler?

    3. SOSuzan Obagi2:21:15

       Not n- not necessarily. I do like fat because it's your own living tissue, and of course it has those stem cells in it that can become multiple different types of tissue. So if you place it at the periosteal level, it can build bone.

    4. PAPeter Attia2:21:29

       Hmm.

    5. SOSuzan Obagi2:21:29

       If you put it in fat, it becomes fat, and if you put it along muscle, it can turn into muscle, and if you put it, um, under the skin, it enhances how the skin ages. So something anecdotally that there are many of us that do a lot of fat grafting, and we were on a panel one day talking about it. Before we knew about the stem cells being in the fat, we're talking 15, 20 years ago, and we were talking about the fat grafting patients and how they all uniformly look like they just age better, and their skin ages better. And now s-

    6. PAPeter Attia2:21:59

       Starting to think it's the, yeah

    7. SOSuzan Obagi2:22:00

       ... we've started to realize it's e- all of that

    8. PAPeter Attia2:22:01

       ... the stem cells. Yeah. Um, where do you harvest from?

    9. SOSuzan Obagi2:22:05

       The, the most po- uh, like, numerous areas of, uh, pre-adipocytes, I should say, the tissue that has the most pre-adipocytes is the abdomen.

    10. PAPeter Attia2:22:14

        So subcutaneous abdomen.

    11. SOSuzan Obagi2:22:16

        But I really like the flanks because it turns out you don't just want the fat and the fat stem cells, you need all the connective tissue stem cells as well. And when you go to the flanks, the reason the flanks feel so firm, even though they may have fat in them, is they have a lot of s- septae and stromal tissue there. And when you aspirate the fat, you're also aspirating along with it some of that stromal tissue. So you're getting the matrix and the scaffolding cells that will help that fat also repopulate.

    12. PAPeter Attia2:22:46

        And just to give me a sense of volume, so if you, if you decided to go full bore on somebody and do temporal, and eye, and, you know, outside of the lip and jaw, you, you're... How much fat are you putting in, and how much fat and tissue do you need to harvest to acquire the necessary, uh, volume?

    13. SOSuzan Obagi2:23:02

        So we may differ in our techniques. I'll let Tanuj speak to his. Um, I will typically harvest about 120 cc's of fat. So we're talking about an area about the size of a small cantaloupe.

    14. PAPeter Attia2:23:13

        And just, uh, just to put that in perspective, w- if, if a person undergoes liposuction, how much is being harvested?

    15. SOSuzan Obagi2:23:19

        Probably, um, so usually we're filling canisters of fat.

    16. PAPeter Attia2:23:24

        So liters?

    17. SOSuzan Obagi2:23:24

        Litres.

    18. PAPeter Attia2:23:25

        Okay, so this is not-

    19. SOSuzan Obagi2:23:26

        So about two, three, four liters of fat

    20. PAPeter Attia2:23:27

        ... okay, so this is not gonna make a material difference in your s- subcutaneous fat depot in your body?

    21. SOSuzan Obagi2:23:32

        Correct. And if we artistically do it, we can take it from both sides so that you don't have any divots or asymmetries. But people always have an asymmetry even on their body. So I tell them, "You know, the benefit of this is I'm taking also the fat and evening you out-

    22. PAPeter Attia2:23:45

        Evening you out

    23. SOSuzan Obagi2:23:45

        ... with your other hip." And they're like, "Oh, I never even knew I was asymmetric." So I typically harvest about 120 cc's, and then we centrifuge it.

    24. PAPeter Attia2:23:54

        Yep.

    25. SOSuzan Obagi2:23:55

        And it condenses it down, so it takes off all the anesthetic fluid you put in. We have albumin in there to r- to restore some of the oncotic pressure as well. And we are taking people's own PRP, spinning that, spinning their blood down to get the PRP, the platelet-rich plasma, and adding that in, along with something that we call m- nano fat. So it turns out if you take fat and you graft it into tissue, a certain percentage will take. But if you take fat and then you add in extra stem cells, more of that tissue will take. So what we do is we harvest extra fat and extract the n- nano fat from that, meaning all the pre-adipocytes-

    26. PAPeter Attia2:24:35

        Hmm

    27. SOSuzan Obagi2:24:35

        ... by running it through some meshes and adding that back in to supplement the fat to try to get-

    28. PAPeter Attia2:24:40

        It's the patient's own.

    29. SOSuzan Obagi2:24:40

        It's all the patient.

    30. PAPeter Attia2:24:40

        It's autologous.
20. 2:32:39 – 2:38:59

    Evolution of facial cosmetic surgery techniques, the serious risks, & how physician skill & procedure selection impact outcomes

    1. TNTanuj Nakra2:32:39

       one of the big changes that's happened in aesthetic surgery from nineteen ninety-five to now is back in the old days of cosmetic surgery, there was a lot of cutting fat out, cutting skin out to make eyelids look tighter, cutting skin in front of the ears to tighten the face, doing surgeries that mostly remove tissue. And now we're becoming much more sophisticated where we're actually manipulating the ligamentous attachments to the bone. And so because we're recognizing the ligaments are-

    2. PAPeter Attia2:33:10

       You don't have to remove the skin necessarily.

    3. TNTanuj Nakra2:33:12

       We don't have to remove as much, yes.

    4. PAPeter Attia2:33:13

       Yeah.

    5. TNTanuj Nakra2:33:13

       And so, so we're, we're-

    6. SOSuzan Obagi2:33:14

       And if you do, you can tighten it with lasers and peels-

    7. TNTanuj Nakra2:33:17

       Yes, exactly

    8. SOSuzan Obagi2:33:17

       ... rather than cutting it out.

    9. TNTanuj Nakra2:33:19

       So, so, so, you know, just to kind of, um, conclude what the suggestion would be for some of, with your kind of anatomy, we would transpose the fat, which would two birds, one stone, reduce bulk here, add volume here. Three birds, actually, because it would, uh, uh, basically eliminate the visibility of the ligament 'cause there's fat under it now, which is pushing it forward. Um, and then, um, we would do something to improve the skin, as Suzan said, either a laser resurfacing or s- a chemical peel. And then there's a new technique that we're using where we're injecting tetracycline into areas of swelling of the face. So this is pretty cutting edge. You know, it's been around for several years now, and we've got pretty good experience with this technique. But tetracycline is an old drug that was repurposed by the pulmonologists to address pulmonary issues where they want the, the, the pleura to stick to the lining better. And because it has that property of, um, you know, basically creating fibrous attachments, it can be used to shrink that sponge down by injecting delicately into the malar mound to kind of flatten it. And so that would be the constellation of procedures probably to-

    10. PAPeter Attia2:34:25

        And, and what can go wrong here? Because, you know, I think for many people that would be contemplating something like this, you know, it's one thing if you are, are having a procedure where y- you know-- Well, first off, this is a cosmetic procedure, so, so out of the gate, A, it's not essential. B, if you don't look better when it's done, it's, it's the worst possible outcome. And then, C, it's the most visible part of your body. You know, I've heard stories of women who have breast augmentations where they have complications, and at, you know, at least the breasts aren't always visible, m- meaning the actual skin itself. Um, so even if you have to reoperate, and it creates another scar, um, you know, it's only visible to her partner, right? Um, but, but here, it's just the highest stakes game. So how do you navigate complications, risks, and mitigation strategies?

    11. SOSuzan Obagi2:35:24

        And that's what we were talking about before. You have to make sure that whoever's doing your treatments, A, is well-trained, qualified to do the injections, and can manage the complications, because everyone's gonna have complications. You-- We've had complications, and speaking for me, I'm sure you, you've seen cases.

    12. PAPeter Attia2:35:40

        Of course, yes.

    13. SOSuzan Obagi2:35:41

        You can't treat patients and then not do enough cases to not have a complication. But there are some really notable complications that are vision-threatening or tissue-threatening. So when you're treating around the eyes, for example, or even into the temples, there are reported instances of stroke and death and vision loss, and in treat- including treating around the nose. Because all of these vessels interconnect with the internal carotid system, so anywhere you inject a filler and you get into a vessel on the outside of the skin-

    14. PAPeter Attia2:36:16

        You could create an embolism

    15. SOSuzan Obagi2:36:17

        ... you can create an embolism, and it's going to go follow the path of least resistance. Once you bolus it into the tissue, it's gonna backflow, but then it's gonna be pushed forward again. It's gonna go to the ophthalmic artery. It may go into your central nervous system-- I'm sorry, into your brain, I should say, and the vasculature there and create a stroke. Now, some of the more serious strokes were caused by people injecting fat with needles, but all of these other complications really come from injecting fillers in this kind of central face area. So there is a technique. There's knowledge of the anatomy. There's knowledge of, um, how to do, to do very little pressure, w- um, aspirate where you need to aspirate, depending on the filler you're using, and watching the tissue, looking for signs of any kind of embolus that's forming.

Episode duration: 3:10:33