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Scot: Troy, I've got a question for you. I'm going to say a word, and I want you to tell me the first thing that comes to mind. Botox.

Troy: Crow's feet.

Scot: Okay. Mitch, Botox.

Mitch: Wrinkles.

Scot: All right. That's the same for me, crow's feet and wrinkles. Today, on "Who Cares About Men's Health," we're going to talk about Botox, not only for a more youthful appearance, but also some other things that it can treat that men might find useful. And also, we're going to answer the question "Is it safe?"

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. I'm curious if you might have a different opinion about Botox by the end of this episode. We're going to find that out. My name is Scot Singpiel. I bring the BS. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. I'm excited to learn about Botox for something besides my wrinkles.

Scot: All right. A guy who's working on his health and always has a unique perspective, Mitch Sears is on the show.

Mitch: I'm curious because TikTok keeps telling me in my 30s, I should start preventative Botox, and that worries me. Am I doing something wrong?

Scot: And Dr. Sarah Akkina, director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at University of Utah Health. Welcome to the show.

Dr. Akkina: Thanks so much for having me. I'm very excited to blow your minds about the other uses of Botox, botulinum toxin.

Troy: This is great.

Scot: I actually looked it up and it was really shocking some of the other things that Botox can do, because at the beginning of the show, as we all said, we tend to think about crow's feet or wrinkles, using it to get a more youthful appearance, right? And a lot of times, guys hear that word, too, and we have that misconception that maybe it's not for us, right?

Mitch, you had a similar experience. Tell us about how you reacted when you heard that you needed Botox for another reason.

Mitch: Oh, frustrating. So I had Bell's palsy, right? We've talked about it. It's another episode. We can direct you towards it. But one of the weird after effects was that I have a thing called crocodile tear syndrome, which means when I eat, my eye will sometimes tear up. Big tears sometimes, whatever, it depends on what I'm eating, etc. It just is a nerve that didn't quite match up right.

And so I went to the ophthalmologist and they looked at it, and the potential treatment was Botox in that area to see if we couldn't numb up the nerve that was misconnected.

And unfortunately, I immediately just said, "Nah, I don't do Botox." I don't even know where that comes from, this idea, "Yeah, I hear what you're saying, but no, that's not for me. I'm a man." How dumb is that?

But then afterwards, I thought about it and whatever, and there were some other things that I wasn't quite super excited about. But yeah, the second that word Botox came out, I shut down very quickly.

Troy: Oh, I think I would do the same thing, Mitch, if I had to tell people, "I'm going in for my Botox injections." Number one, I wouldn't tell people that, but if I had to admit it, I would be embarrassed.

Scot: Yeah. You would rather cry when you eat, huh?

Troy: I'd just rather tear up.

Mitch: Yeah, I would apparently.

Scot: Than tell somebody you were . . . Yeah. Dr. Akkina, is this how guys typically respond when they hear Botox, that word?

Dr. Akkina: Yeah, absolutely. And I think it's funny because in the zeitgeist in our society, it's become so synonymous with cosmetics and appearance, and then people think, "Oh, it's mostly for women." But there are so many different ways that we can use it.

So stepping back, Botox is a brand, first of all. So it's a type of botulinum toxin. If we want to be more cool, if you want, we can say the toxin.

Scot: Yeah, you're getting the toxin.

Dr. Akkina: So you can say you're going in for your toxin treatment.

Troy: I'm getting my toxin.

Mitch: Rad. I love that.

Dr. Akkina: That's right. So, heretofore, we'll say toxin. So your toxin treatments, the best way to think about it is it's this really cool drug that we can use that basically shuts off muscles right at the junction that the nerve is giving them input.

So when you think about it like that, this toxin can be used to basically shut down any muscle that we feel like is not working well. In Mitch's case, one of the kind of muscles that I think you're talking about treating for the crocodile tears, it's basically things around the lacrimal gland. So we can use it to stop that gland from secreting things because you're affecting that muscle function.

And another way that we can do that in a similar case, which probably a lot of people don't know, is you can actually use toxin to treat over sweating. So actually there are especially a lot of men who use it. Actually, we can use it in your armpits or other areas that you feel like you're sweating a ton and it's embarrassing or you're just not into it. We can treat that with Botox, or toxin, as we're saying.

But that does require a little bit of higher doses than we're typically talking about versus things like wrinkles. So that's one option that we can do.

Another really great use of toxin is in your masseter muscles to stop teeth grinding. Do any of you guys teeth grind?

Scot: Yeah.

Dr. Akkina: Fancy word, bruxism So that masseter muscle is often the culprit in what's really causing that grinding.

And fun side note, my husband was very much like you guys and was very anti all sorts of toxin treatment. But when I told him about this and he had been having a lot of struggle with teeth grinding and stress, things like that, he actually let me attempt to treat his masseters and his teeth grinding stopped. It was amazing. And to this day, this is actually two years later, he's still not grinding his teeth. I think because his body just learned to adapt without it a little bit.

Troy: After one injection, one treatment?

Dr. Akkina: Yeah, after one series of treatment.

Important things to just remember for toxin treatment, it does take about a week to bring into effect. And then it only lasts three to four months. So you do have to know that. So typically that effect wears off. Some people are able to use that for teeth grinding, for instance, just to kind of rewire their body a little bit. Other people certainly need treatment still every three to four months.

But it's a great way to, like I said, selectively stop these muscles from over-activating and to help you in whatever that means for you for that muscle.

Troy: And what about things like facial twitches? If someone notices their face gets kind of twitchy when they get anxious or something like that, have you used it for that?

Dr. Akkina: Yeah. So blepharospasm, or that twitching around the eyes that can happen when people are stressed, tired, things like that, super common indication, and actually one of the first indications for using Botox, or toxin.

So toxin initially was actually developed and promoted in the '80s by ophthalmologists who were treating something called strabismus or basically crossed eyes where your eyes are misaligning. And that was one of the first uses in humans. And then quickly after that, they realized they could use it for blepharospasm or the spasms around the eyes. And then that led to saying, "Hey, we don't have crow feet anymore. How exciting."

Scot: That was the side effect, huh?

Dr. Akkina: That's right. So that was a side effect of all the initial use of toxin. So that's how we started to develop in the market.

And all jokes aside, there are some very serious other medical conditions that we can treat with toxin. One of the other things in my field of otolaryngology is for people who have spasms in their larynx. So you can have these spasms that really prevent you from having normal speech and normal talking patterns. And our laryngologists, or throat specialists, are able to basically direct toxin to those specific muscles and help shut that down so people can talk normally.

Another really common indication, probably more than that, is things like migraines, or anything that you can think of that's a muscle chronically or misfiring where we can kind of gently turn that off.

Now, it's a little tough because the dosages are obviously all different for different areas. So, depending on what you want to treat and what the indication is, insurance can cover some.

So, Mitch, if you'd gone forward with your crocodile tears, it's likely that insurance would cover that because that's a medical disease and illness that you're treating with it. Certainly, for cosmetic things like the crow's feet and forehead wrinkles, things like that, that is out of pocket.

Troy: And where would you do an injection for a migraine?

Dr. Akkina: Yeah. So you can inject things like the temporalis muscles and sometimes even behind. Our neurology colleagues do treatments for that typically. But yeah, there are different things that we can work.

For me, I used to get a lot of tension headaches, and when I started getting toxin for my forehead wrinkles, actually my tension headaches went away because I think I wasn't contracting or squeezing my brow angrily all the time.

Troy: Wow.

Dr. Akkina: I don't actually do that, for the record, but . . .

Scot: You don't sound like an angry person, so I can't imagine that.

Dr. Akkina: Well, I can't contract my brow right now.

Scot: Because the toxin shut that muscle down.

Dr. Akkina: Because of the toxin, yes. Very smooth and content all the time now.

Scot: So what is the actual name of it, not the brand name?

Dr. Akkina: So botulinum toxin, that's the actual name.

Scot: I don't know. That doesn't sound too good to me. On one hand, it sounds cool because, "Oh, I'm tough, I'm taking my toxin," but on the other hand, is that safe?

Dr. Akkina: Yeah, there are very little side effects. So a few important things is that whenever that toxin is injected, it can diffuse to other things in the area. And this is a little dependent, of course, on where it's injected, what the concentration it's injected at, things like that.

So you do have to be careful, and that's why I always recommend going to someone who knows what they're doing and is very familiar in the anatomy and structures in whatever area that they're injecting.

But it's relatively safe. The nice thing, again, is that while it takes often five to seven days to act, it goes away in three to four months. So if you don't like whatever the action is, it will wash out eventually.

Very few people do have allergies to toxin. If you have egg allergies, actually the botulinum toxin A in Botox, for instance, is formulated with egg proteins, albumin, so you have to be a little bit careful to just think about that.

And if you have other things like neuromuscular diseases or disorders, yes, you definitely have to be very careful about the effects of it.

Also, certain antibiotics, like aminoglycosides, botulinum toxin can potentiate some of the effects of that.

But outside of those pretty specific circumstances, it's got a really safe profile for use in a lot of different ways.

Scot: I've heard of something else called botulism. Is it related to that?

Dr. Akkina: Yeah, the toxin is the same, believe it or not. So that is how they initially learned about it. And yes, that's a serious disease. That is more if you have canned food, like cans that are crushed or look funny or things like that, those can harbor botulinum toxin. Honey can actually technically have some relation to that too, but not in the ways . . . mostly just serious for babies and infants, things like that.

Scot: Sure. But the way you're using, it's . . .

Dr. Akkina: Yeah, very different.

Scot: It's safe. I'm not getting any of that illness.

Dr. Akkina: Correct. Yes, you're not getting any of that illness from an injection of the toxin.

Troy: My one piece of advice, Scot, would be to avoid botulism. Don't drink pruno. It's a prison wine. We had a big case series we published. A bunch of prisoners who unfortunately drank that, and they had a potato in it, which was the source of the botulism. But it was a big CDC report that we published with multiple prisoners. So yeah, if you want to avoid botulism . . . But this is not botulism. I think that's the point here. You're not putting yourself at risk of botulism.

Dr. Akkina: Yes, correct.

Scot: So it has a lot of really, really cool uses. The sweating thing, I bet you, for some guys could really be a game changer. We talk about the Core Fore, and emotional and mental health is one of them, and if it makes you self-conscious or anything like that . . . Lazy eyes, I think you mentioned that as well. Any sort of spasm disorder. To remove that from your life, I would imagine, can be a great thing.

Do you have any guys that have ever used it for those purposes and how did it change their lives?

Dr. Akkina: Yeah. I think the sweating thing in particular, I remember a patient a few years ago who came in, it was a gift from his mom for his 19th or maybe his 18th birthday, because he was going to be taking prom pictures soon and he didn't want to sweat through his shirt during prom, which is actually a really sweet gift I thought from his mom. So small things like that, I mean, they can make a big difference in people's lives.

Troy: Sweaty palms, people use it for that?

Dr. Akkina: I've not personally done that, but I think in theory you could. When you're treating large areas like that, again, you do have to be a little bit careful because it's probably just going to be a high dose. So it might just be a little bit dose-limited in terms of having to inject all these little areas there. The other tough part there is you wouldn't want to turn off the muscles in your hand.

Troy: Right. That could get awkward.

Dr. Akkina: It's always a balance. You can inject it in glands and things like that, but yeah, if you're injecting around muscles, you have to be prepared that it might diffuse a little bit.

Scot: So it can do a lot of really cool things. And since you're here, let's talk about using it to remove wrinkles. I'm just gathering information. I'm not saying it's for me.

Troy: Asking for a friend.

Dr. Akkina: For a friend, yeah.

Scot: I'm just asking for Troy.

Troy: I was curious. Yeah.

Scot: So, actually, I want to throw that out. Mitch, you had mentioned that it had been recommended that maybe . . . well, on the internet . . . that you start doing some preemptive Botox.

Mitch: Oh, no. I have a friend in my life who has also said it's not that big of a deal and if you start now, you'll never have wrinkles. I don't know if that's true or not, but . . .

Scot: Have you considered ever using Botox for a more youthful appearance?

Mitch: See, I have a pretty youthful appearance anyway, and the rule I've always told me is as long as I could play a high schooler on a CW original, I am okay. But there is a part of me that does wonder . . . I don't know. I don't particularly love the idea of becoming super duper wrinkly. Maybe. I'm open to it, but I'm not super excited about it.

Scot: What would your dad have to say about all this?

Mitch: I don't know. He's probably listening right now. I'm sure I'll get an email.

Scot: Troy, is this anything you've ever considered?

Troy: Botox? I haven't seriously considered it. No. It's probably crossed my mind because I'm at a point in life where I do see more wrinkles appearing, but I can't say I've ever really looked into it beyond thinking, "Huh, maybe."

Dr. Akkina: Well, fair enough. I think a lot of patients, and especially men, are in that boat. But it is nice because from that . . . Mitch, you asked earlier I think about the preventative part. So Botox or toxin can't take away wrinkles that are already formed.

So when I think of wrinkles, there are both static wrinkles and dynamic wrinkles. So when we're young, if I raise my eyebrows, you can see typical areas where my muscle is causing contraction of the skin. That's causing temporary wrinkles. But when I relax, you can't see any of those wrinkles. Versus in another 20 years, unless I keep my toxin up, then those wrinkles are kind of permanently etched in the skin.

So important distinction. Toxin can't take the permanent wrinkles away because that's just part of your skin at that point. But it can always, as we said, inactivate the muscle under it.

So for forehead wrinkles, for instance, that's the frontalis muscle. We can make that muscle calm down, be much less active with the toxin, and then you're not actively working to keep forming those wrinkles. So that's why it can still help even if you have static wrinkles that are there.

Scot: What are other wrinkle locations it could help? So crow's feet, if I already have them, that's not going to help that, right?

Dr. Akkina: It still will make I think the appearance of the deep wrinkles less, right? If you have the crow's feet, yes, they're there, but if you're not activating the muscle all around it, it can still look a little bit softer, a little bit less aged overall.

For other areas . . . So we talked about the forehead. The between-the-eyes area, that brow, that's another super common one. And especially for men, right? It's that kind of furrowed, angry brow look. We call those the 11 lines because it leads to those two often horizontal lines in the very middle of your forehead. Those can respond really well to Botox.

And again, if you have permanent wrinkles there or static wrinkles, it's not going to take them away, but it does soften the overall appearance of your brow. It can help you look a little bit less angry or things like that.

Scot: How many men do you see in your office that actually come in and get treatment? And what are their reasons? Because I had read somewhere that Botox has just exploded among men. I think a 400% increase in treatment since 2000, so a lot more men are getting it nowadays. Why are they doing that?

Dr. Akkina: And most of it is for appearance. Yes, overall, for my patients coming in for toxin treatments, less than maybe . . . It's certainly a minority. I would say probably at this point, maybe 5% to 10%. But among those men, certainly things like the forehead wrinkles, but the masseters is also another really common indication for people who want to try to stop grinding their teeth.

That's another actually great thing that I'm getting more folks coming in for. I'm glad that it's getting out there that's something that we can use toxin for.

Scot: Yeah. I Googled a couple things because I was curious. I was like, "Gosh, is it vain that I want to get rid of my wrinkles?" For me, it's not actually wrinkles. I don't think Botox is the solution to my problem. I have these bags under my eyes. I look like I'm constantly fatigued. Botox isn't going to help that.

Dr. Akkina: No.

Scot: And I never thought I would think about getting any sort of cosmetic anything until we came into this world of Zoom. I'm looking at my face all the freaking time and I just look so run down and so tired, and I'm afraid people in the office are going to think, "Does he ever sleep? He looks sleepy."

So social media was one of the reasons why. And I thought, "Well, again, that's kind of vain." But then it said online dating. Well, okay. We're representing ourselves in a completely different way than we've ever had to, our dads or grandfathers have ever had to, in high resolution. So do you guys come in for those reasons and . . .

Dr. Akkina: Yes, absolutely. I had a patient the other day who was telling me that he's a little bit upper level in his company now, but he feels like some of the other people in the company are much younger than him and seem more youthful. And he gets embarrassed on these Zoom calls where he feels like he's the old person in the group, and he just wanted to feel more youthful.

So talked to him about things like facelifts, blepharoplasty. That's the under-eye or over-eye surgery where we try to help reduce that evidence of the extra skin and the bags, things like that. And he's really excited to get a little bit more of a youthful appearance just so he feels like he can stand up with the younger folks at his company.

Troy: I was going to say what about . . . The big thing I've heard with Botox is kind of the mask face where you get to where you always look like . . . Your expression doesn't change.

Mitch: You're a Barbie?

Troy: Yeah, exactly. Is that common, or are people just overdoing it when that sort of thing happens?

Dr. Akkina: Yeah, I call that a frozen face or freezing someone out. I don't like to do that. And when you have an injector that you're going to, I think talking about what your expectations and what your goals are is super important. And then having your injector listen to you and make sure they're not overdosing things to freeze things out is important.

So when folks come to see me, I talk through exactly what they're interested in getting. We talk through wrinkles often. And then I discuss my normal dosages.

And usually, I like to err on the lower side, right? I never want to free someone out. That's just my preference. So starting on lower ends of dosages, and then always coming to back for touchups, things like that. Super easy to do.

In general, when we go through the process of injecting Botox or Dysport or Xeomin, it's a very tiny needle. It's a couple little sticks. Yes, there is a risk of just a little pinpoint bleeding, things like that, or just a tiny bit of bruising. But overall, it's a pretty short and sweet procedure.

So we can start at low doses. I can have people come back and we can kind of keep augmenting until we find a regimen that they like in terms of its outcome.

Mitch: Now, I've heard about Botox parties. I've heard about going to a "spa." Is there a benefit? I mean, it sounds like this drug is pretty safe. Is there a reason that we should maybe err towards going to a medical person rather than some of these other things?

Dr. Akkina: Yes, absolutely. So we talked a little bit about some of the risks. I just mentioned injection risks certainly are something to always think about. But making sure that whoever is injecting your face is intimately familiar with those muscles and the other things in the area that could get affected by your injection is so important.

So one of the other common things that can happen if you're injecting around the eye, and especially if you're injecting in certain areas, is that toxin can diffuse and affect one of the upper muscles in your eyelid and basically give you a droopy eyelid. So that's something called ptosis.

And especially for cosmetic things, it's a little bit less common, but you want to make sure that your injector is injecting in places where that's a much lower risk. Certainly, we can treat that with eyedrops, and often it only acts for a few weeks even.

But yeah, that's a small example of you want to make sure you're going to someone who knows what they're doing and can provide the treatment in the places that you want it, giving you the effect that you want, and the dosage that you want.

So yeah, Botox injectors come in all sorts of varieties. I've even seen dentist office offering Botox. Have you guys seen that?

Mitch: What? No.

Scot: No.

Dr. Akkina: I mean, I think if you're well trained and have good results, okay, for sure. But yeah, you just never know and I think it's safer to make sure you're going to a place where the person knows the face, knows the muscles, knows what they're doing.

While it's safe in general, you can have unwanted consequences. You can freeze out a face. You can cause droopy eyelids. You can affect things like the smile overall. If you're doing masseter Botox, sometimes that can diffuse in different places. So you just want to make sure someone's really knowledgeable when they're doing it.

Scot: Those are some really good tips on how to look for a professional. And also, I love the fact that you said you should have a conversation and make sure that you feel comfortable with the person . . .

Dr. Akkina: Yes, absolutely.

Scot: . . . that's going to do it for you.

So I'm not going to pass judgment, I guess. I think the Scot of 10 years ago, and certainly the Scot that is the son of a South Dakota Rancher would. But we're in a different world, right? Botox is super useful for a lot of reasons beyond just appearance. If you want to get it for appearance too, and I've considered it, so I would completely understand.

So I want to find out where we are after our conversation. We started out with the association game. Troy, Botox.

Troy: Teeth grinding.

Scot: Okay. Wow. So we did change perception there.

Troy: That was my takeaway. And as we talked about it, I was grinding my teeth and I thought, "Maybe I need this."

Mitch: Oh, my. I've been struggling with this forever. I have a little mouth guard thing that I wear most nights, and I've still got sore muscles. It's like, "No duh, we have something out there that can turn those muscles off for a bit."

Scot: All right. Mitch, Botox.

Mitch: Toxin, my eyes. I don't know. What I'm thinking now is just, "Maybe I . . ." If it's for the most part relatively short term, maybe I could try it and see if it's worthwhile to have those muscles near my eye frozen. I didn't fully realize that it was kind of a temporary thing. So I don't know. I feel very different about it.

Scot: You're more open to it now?

Mitch: Oh, very much so.

Scot: All right. Very good.

Well, thank you very much, Dr. Akkina. We appreciate having you on the show.

And if you're listening, where are you about Botox after this episode? Have you ever used it for other procedures, for your appearance, or any of the conditions we talked about? And how did it work for you? Then finally, is it legit for a man to care about their appearance and want to use Botox?

If you have thoughts on any of those topics, you can email us at hello@thescoperadio.com.

Thank you for listening, and thank you for caring about men's health.
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Interviewer: As patients and loved ones of patients who have suffered from Bell's palsy know, the loss of one's ability to move one's face can be really serious and impact their lives. And if it's lasted for longer than six months or so, a surgical option may be available to give back a loved one's smile and ability to move their face.

We're joined by Dr. Sarah Akkina. She is the Assistant Professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology and Director of the Facial Nerve Center at University of Utah Health.

Now, Dr. Akkina, briefly, what is Bell's palsy and why is facial paralysis so potentially life impacting?
What is Bell's Palsy?

Dr. Akkina: Bell's palsy is a rapid, or less than 72 hours, one-sided facial nerve weakness of unknown cause, meaning we don't have an alternative reason for a patient to have it.

It's really important to know that recovery from Bell's palsy should start two to three weeks after. So that as an entire category really classifies Bell's palsy.

There are other conditions that can cause facial weakness, and that includes stroke, brain tumors, salivary gland tumors, cancers, and infectious diseases, including things like Lyme disease or a tick-borne disease.

Overall, we suspect that Bell's palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear, and taste to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth, a change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye, trouble keeping food and liquid in their mouth, nasal obstruction, and overall difficulty expressing emotions. So they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.
Treatment Options for Bell's Palsy

Interviewer: Wow. And so for patients who are maybe suffering from these different symptoms, whether it be facial paralysis, or inability to tear, or asymmetry, etc., what options are available for patients who are still experiencing those types of symptoms longer than is typically expected for healing, say, six months or so?

Dr. Akkina: For overall treatment of patients who have Bell's palsy with incomplete recovery, meaning they still have some muscle weakness, some asymmetry of their facial movements, or some major functional issues like being able to keep food or liquid in the mouth or nasal obstruction, we have a series of treatments that we can provide for those patients.

We provide treatments that are focused on both moving, or dynamic, and non-moving, or static, facial reanimation. Static procedures are focused on improving the overall symmetry of the face at rest, and that includes procedures focused on the brow, the eyes, the nose, the mouth, and the cheek.

Dynamic procedures can bring back facial movement itself, and that includes surgeries that connect working nerves to non-working nerves, as well as surgeries that transplant nerves or muscles from nearby or separate areas of the body.

For patients that have developed abnormal facial movement after facial paralysis called synkinesis, we offer procedures to reduce that abnormal movement, including chemodenervation, or using botulinum toxin injections, or Botox/Dysport/Xeomin, as well as selective neurectomy. And this is cutting nerves that lead to the abnormal movements. We can also cut selective muscles that are moving abnormally.

So there's a variety of ways that we can really delve into exactly what is abnormal for a patient and help them in these matters.

Interviewer: Wow. So you just described quite a few procedures. These are all under the umbrella of facial reanimation?

Dr. Akkina: Correct. Yeah.
What is Facial Reanimation for Bell's Palsy?

Interviewer: Wow. So what kinds of patients are, say, eligible for these types of procedures? Is there anyone that for one reason or another would not be eligible for something like this.

Dr. Akkina: So by group, I'll say, for things like nerve transfers, it's important to know . . . For Bell's palsy, we don't assume that there are other nerves that are affected. But for patients who may have the facial paralysis because of other skull-based tumors or other pathologies that may then affect other nerves, we have to make sure that the nerve we connect to the non-working nerve is going to work, if that makes sense.

Interviewer: Sure. Okay.

Dr. Akkina: For muscle therapies, a lot of patients will qualify for different work such as cutting muscles that are abnormally moving. But for moving muscles, so sometimes if a patient has permanent, abnormal movement of their smile, we can transplant a muscle from their leg into their face to basically recreate their smile muscle movement.

That, of course, does require that that patient's a good candidate to be able to undergo a long surgery where we transplant that muscle. They have good arteries and veins in their face that we can connect it to and are otherwise healthy from other standpoints too.

So, as you can tell, it is pretty individual-based, and that's why it's so important to be able to see a specialist who can talk you through all these different options.

Interviewer: And the specialist that they're looking for is a facial nerve specialist in surgery?

Dr. Akkina: Correct.

Interviewer: I guess this might be a strange question, but considering how tailored and kind of unique it is per patient, what kind of success rates do you see with your patients?

Dr. Akkina: We can get great success rates, especially with nerve transfers. One critical part is that timing is super important. So we talked about for things like Bell's palsy, if you have abnormal movement after three months, you should get immediately referred to a facial nerve specialist. Because overall, for some of these nerve transfers to work, we only have 12 to 18 months before that facial nerve itself may not work very well even if we connect it to a better nerve that can give it more input.

So overall, for the nerve therapies, we really need to see patients, again, ideally within 12 months so we can start planning for whether they may be a candidate for the nerve surgeries.

That muscle transfer surgery can be done essentially at any time. That one we like to wait a little bit longer to know that they won't recover from the other standpoints and that they may not recover from things like the nerve transfers. But that is a really great option for patients who don't qualify for the nerve transfers themselves.

Interviewer: And for the static procedures, it's mostly for cosmetic, mostly for that kind of situation, or . . .?

Dr. Akkina: Both cosmetic and function. So the static procedures, they can really help with, for instance, for the eye work, again, closing the eye. So being able to maybe not necessarily use as many eye drops or have to tape the eye at night, things like that, our eye procedures can give that function back.

Another really great thing is . . . Outside of the symmetry, the nose can be droopy, so a lot of patients have nasal obstruction. And some of our static procedures, one called a static sling where I take fascia from the leg and reattach it to parts of the face, bring back basically support of the nasal valve and support of the mouth, so it's not drooping so much.

So it helps both the appearance of the face and the function in terms of that droopiness, which is why a lot of patients have difficulties with chewing food or keeping food and liquids in their mouth. So the static procedures can help both of those aspects.

Interviewer: We're just not necessarily replacing muscles or reconnecting nerves.

Dr. Akkina: Exactly.

Interviewer: We're doing structural things. Okay. Interesting. So what are some of the potential complications that come with these types of surgeries?

Dr. Akkina: Yeah, one of the main complications is sometimes for the nerve transfers, the nerves unfortunately don't connect as we like or don't eventually function as we like. But we do like to work with our physical therapists very intimately for those procedures as well, to teach patients how to use those new nerve connections.

One example is that we can connect a nerve that controls one of the muscles of mastication, or one of the muscles that's responsible for us closing the jaw, back to the facial nerve. But that does mean that a patient essentially has to clench their jaw to activate their smile. So there are different physical therapy things to learn about that, to teach a patient how to use their new nerves correctly.

Some of the complications that always exist for surgeries are things like bleeding, infection of the site, sometimes failure of the static sling procedures where we don't get as much of a lift of the face as we want, as well as ultimately relaxing of the face again.

Gravity wins always at the end, so even if we do these procedures when a patient is, say, in their 30s or 40s, over time the face will continue to droop and may need additional procedures in the future.
The Cost of Facial Reanimation for Bell's Palsy

Interviewer: Well, this is kind of really exciting to hear about all the potential ways that we can work on this, but what does this kind of procedure cost and is this something that is covered by insurance?

Dr. Akkina: Great question. So this procedure is typically covered by insurance. That's the number one thing, especially for things related to overall facial paralysis. Typically, insurance will cover any procedure related to that facial nerve motor dysfunction.

There are insurances that won't cover some smaller procedures. Sometimes things like the brow lift on that side of the face, because it is very focused on the symmetry and appearance of the face, has difficulty getting covered by insurance. But for the most part, a lot of these advanced procedures we've discussed will be covered.
How to Choose a Facial Nerve Specialist

Interviewer: So we've got a patient, and they're dealing with this kind of long-term facial paralysis. What should they be looking for in a doctor? If they want to explore some of these potential facial reanimation options, what kind of doctor are they looking for, and are there any particular trainings or certifications or something that they should be searching for?

Dr. Akkina: Absolutely. The first thing I'll note is that taking care of facial nerve disorders is a team sport. So we have, in our facial nerve center, multiple specialists from different aspects that all come together to collaborate and care for our facial nerve patients.

So our team includes experts in facial plastic surgery, neurotology, otolaryngology, head and neck surgery, oncology, ophthalmology, facial nerve rehabilitation. So you can get a sense that there are so many different aspects that we can come together to treat for patients.

And each specialist focuses on their area, but certainly in a facial nerve center setting, we can all basically collaborate on our individual aspects.

Initially, I think it is important to see a specialist who's at least aware of many of the procedures and treatments that we can offer. So, typically, facial plastic surgeons or even some neurosurgeons are focusing their practice on these areas.

This is an exciting field where we do have development of new techniques and new practices that are coming out each year. So being at an academic center can also really help because specialists in these centers are usually up to date on the latest knowledge, if not performing some of these trials and experiments ourselves. So going to folks who are most up to date on what's going on, I think, is also important.

For facial plastics, there are board-certified surgeons who have additional training and are, again, certified on a particular level with that training. So I would recommend always seeking a board-certified surgeon, especially moving forward with the surgical treatments.

Interviewer: So I guess look for a board-certified surgeon maybe at an academic center, or just look for that doctor that will be able to help you get the type of treatment that you need.

Now, as a patient who might be first starting out onto this, first looking into potential options, or a loved one of a patient, what is the message that you have for them in kind of starting this journey towards facial reanimation?

Dr. Akkina: Yeah, my main message is that, one, you're not alone, and two, there are ways that we can help. Even if that's mainly connecting a patient with a therapist to work on facial retraining or discussing some of these more advanced, both surgical and injection options, there is likely a way that we can help. And we want to work with you and evaluate all these aspects that you're going through.

Places like a facial nerve center will have multiple specialists who are all geared towards helping this very special patient population. So we want to help you. Please come find us.

Interviewer: After a person has experienced major weight loss, either through lifestyle changes or something like a bariatric surgery, you may be left with a bit of excess skin that just won't seem to go away. And there are a few surgical options available to help remove that skin. Dr. Brad Rockwell is a professor of plastic surgery at University of Utah Health.

Now, Dr. Rockwell, when it comes to the excess skin from weight loss, how common is it for someone to have excess skin that just won't seem to go away?

Dr. Rockwell: Oh, virtually 100%. Unfortunately, as we get older, our skin loses some of its collagen, loses some of its elasticity, and the skin will become loose. So, even at certain ages of maturity, even if someone is not overweight, they will still have some lax skin in their abdomen. For everyone that's lost weight, virtually 100% will have some extra skin that could be improved with abdominal surgery.

Interviewer: So the surgery is an abdominoplasty, correct?

Dr. Rockwell: Correct.

Interviewer: And it's my understanding that there's a gradation of how much skin, and that kind of relates to what kind of surgery that you as a plastic surgeon would perform. Why don't you walk me through some of these treatments and kind of walk me through how they work and what a patient could expect?

Dr. Rockwell: There's the standard abdominoplasty. The non-medical term for that is tummy tuck. That's also essentially one of the main components of a Mommy Makeover. But it's just loose skin in the abdomen. In addition to the loose skin, usually the muscles beneath. If it's in a female who's had a pregnancy, the muscles will be a little loose. The skin may have some redundancy.

And the standard abdominoplasty or tummy tuck will remove skin in the lower portion of the abdomen. The skin that is higher on the abdomen is stretched to close where the skin was removed. And in addition, the six-pack muscles or rectus muscles are tightened and that will narrow the waist.

Interviewer: Okay. So it's not just the skin that you're operating on. It's also the muscles underneath?

Dr. Rockwell: Right, by tightening the underlying muscles. No muscle is cut. No muscle is thrown away. The muscle is still fully functional. There's some experimental evidence that actually shows the tone in the muscle is increased and athletic performance may be boosted a little by tightening the muscles. But the muscle is tightened. That will narrow the waist and that actually allows more skin to be removed because the inside becomes a little smaller.

Interviewer: Ah, got you. So what's the next stage of treatment?

Dr. Rockwell: So the standard abdominoplasty that we just talked about will pull the skin from the upper portion of the abdomen down lower and remove skin in the lower abdomen. Some people who have lost more weight will have a vertical skin redundancy and also a transverse skin redundancy. So the skin can be tightened by pulling it down, and the skin could also be tightened by pulling each side towards the middle of the abdomen.

The standard abdominoplasty leaves a longer scar in the lower abdomen. It goes from one hipbone to the other hipbone. The second stage does everything that a standard abdominoplasty would do, but in addition tightens skin from side to side, and that leaves an additional scar along the vertical midline of the abdomen. It goes from the bottom of the breastbone down to the pubic bone.

Interviewer: Okay. And so that's for, say, someone who has additional excess skin on the sides, love handle area, or . . .

Dr. Rockwell: It would be someone who's probably lost 50 pounds or 100 pounds. Standard abdominoplasty, maybe the people haven't lost weight. Maybe they've actually gained a little bit of weight from their younger days.

So this second stage, which is also called a fleur-de-lis, which is a French term, that will tighten side to side. And most of those people have lost probably 50 to 100 pounds.

Interviewer: And so as we go onto the last stage, this is for people who have lost a lot of weight. Tell me a little bit about this Stage 3. And I hear that it was a procedure that was developed by someone from the University of Utah?

Dr. Rockwell: Yeah. So the third stage is called a corset abdominoplasty. Dr. Alex Moya, who was a plastic surgery resident at the University of Utah in the early 2000s, now practices in Pennsylvania, and he developed this surgery.

So it incorporates everything that a standard abdominoplasty would do and everything that a fleur-de-lis abdominoplasty would do. And in addition, he pulls skin from the upper portion of the abdomen up towards the chest. The downside of it is it adds a scar right under the chest, or in women right under the bottom of the breast. But it allows even more skin to be removed compared to the other two options.

Interviewer: When it comes to deciding which surgery to do . . . I've heard you kind of discuss it depends on how much weight has been lost, how much excess skin. How much does the scarring come into that decision-making?

Dr. Rockwell: For most of these people, scarring is a secondary concern. Removing the extra skin is more of a concern. Obviously, if someone is in clothing, the scars are not visible at all.

And the majority of people who have the fleur-de-lis abdominoplasty or the corset abdominoplasty may not be on a beach exposing their abdomen. They may have little more modest clothing to cover it up, and then the scars would not be visible at all. But even if they're in that clothing and had not had surgery, the redundant skin and the rolls of extra skin would show through their clothing.

So, for most of these people, the priority is removing as much skin as possible, and the secondary concern would be the scarring.

Interviewer: So, for patients that are choosing to have this procedure done, is it an outpatient procedure? Are they in the hospital for a few days? And how long does it take to get back to your day-to-day life?

Dr. Rockwell: So just about everyone that has any of the three versions of a tummy tuck that we have discussed, it would be performed as an outpatient. The reasons to stay overnight would usually not be specifically related to the involvement of the surgery, but would depend on pre-existing medical conditions.

So if someone had lung trouble or heart trouble and their lung doctor or heart doctor might say, "You need to be monitored overnight in the hospital after that surgery," that would be the reason to stay. But most of them, it's an outpatient operation.

Interviewer: After they get home, what is the recovery time, and what are the steps of recovery, and how long will they expect to be recovering for?

Dr. Rockwell: So if someone has a desk job, they would probably be able to return to a desk job after two weeks. If they have a job that's a little more physically demanding, maybe three weeks.

In tightening the muscle, there's a six-week recovery period to resume exercise. Where the muscle is tightened, it takes six weeks for the muscle to heal where someone could attempt to do a sit up. So the long point of recovery would be six weeks to resume exercise or six weeks to lift more than 10 to 15 pounds.

Interviewer: So, for patients that might be interested in a procedure like this, what should they be looking for when it comes to choosing a good surgeon who will be able to give them the best results possible?

Dr. Rockwell: So none of these options of an abdominoplasty are small operations. They usually require between three and maybe six or seven hours in the operating room. So you want to make sure you have a qualified surgeon.

The best level of qualification that the public could find out about a surgeon is to make sure the surgeon is board certified. And for this type of surgery, make sure they're board certified by the American Board of Plastic Surgery. There are non-plastic surgeons who offer this surgery, but their background training would not be as rigorous as a board-certified plastic surgeon.

Interviewer: And I guess the last question is what are some of the positive results that people see? Are most people happy with the procedure? What can a patient expect after they're all healed up and back to their lives?

Dr. Rockwell: Yes, I think universally the patients are happy. The extra skin is gone. The satisfaction is largely patient-derived where the abdomen is closed. There's not a lot of positive reinforcement from other people because other people aren't seeing it.

But the patient himself or herself just feels much better. Their confidence increases. They find clothing will fit differently. They can buy clothing more easily because they're more a standard size. And if exercise is an option, that extra skin, extra fat is not there, and just normal everyday moving around is easier and exercise is easier.

Interviewer: So maybe you're considering getting a cosmetic or a reconstructive procedure done. We've all seen the before and after photos, but it's there's sometimes a journey in between those two points, and to kind of talk us through this is Dr. Courtney Crombie. She's an Assistant Professor and plastic surgeon with University of Utah Health.

Now, Dr. Crombie, what are some of these, you know, you see in magazines, you see on advertisements, you know, the before and the after. But, you know, there's a lot more involved with the recovery, regardless of what your procedure is. Why don't you walk me through some of the things that you as a surgeon really want your patients to understand when they're first thinking about these kinds of procedures.

Dr. Crombie: So most of the time, you know, our patients come and meet with us. They'll have at least one, and sometimes multiple meetings with us prior to a given procedure. And then on the day of the procedure, once again, we meet in the morning. They'll meet their anesthesiologists, and then they'll meet with us, and usually, depending on what the procedure is, we'll do our markings and our consent forms and then off to surgery.

After the procedure, we usually see them within the first week for their first follow-up appointment, and it'll either be with the surgeon, or someone on our team to check in and make sure that they're doing okay with their pain medicines and that our surgical sites are doing okay, if there is drains involved, you know, a drain check and just to see overall how they're doing.

On my service, I usually end up seeing patients probably every one to two weeks after their procedure until the kind of the final product of our procedure is done, which may be anywhere up to six weeks later. All our checkups were following drain outputs and removing drains, checking on wounds, removing Steri-Strips, and when it is time to start doing massages on massaging of scars, we will talk you through that portion, talk about sun exposure to scar, and get you through everything to the end product.

Interviewer: So beyond say scar care, wound care, pain management, what are some other things that they also should be keeping in mind? I would assume that, you know, they're going to be out for a while, they're not going to be able to, you know, lift anything, run around with the kids. What are some of those other kind of, you know, social and psychosocial aspects of all this?

Dr. Crombie: We discuss with you your daily activities of what we start allowing you to do, from walking the dog to, you know, carrying your children, playing with your kids, riding a bike. Whatever the activities are, we're usually discussing what those things are that we think is okay to do based on what wounds you have, what muscles are lying under those wounds. So we're very involved with everything because we want you to have the very best outcome for the things that we're helping you through.

Interviewer: So a patient who, you know, they hear that it's going to be a process, right? They hear maybe they're going to hurt for a while, they might have to, you know, work through one thing or another, what is something you tell them to kind of reassure them, if this is something they really want to do?

Dr. Crombie: I remind them that there are going to be good days and bad days, and on your good days, you really need to sort of tone it down so that your bad day, you don't totally crash. And I ask them about their support system, and I encourage their significant others to help them through on, you know, to be their cheerleader, and to help them through on their bad days, and hopefully they have a good support system. We want our patients to do well. It's a reflection of us, of course, and, you know, we want the best for our patients. We want good outcomes for them. And that's why we're here.

Interviewer: If you are struggling with that last little bit of body fat, that one kind of struggle area or something along those lines, you might be looking at a surgical option. But a tummy tuck, a liposuction, these are terms we might understand, but what do they really mean? We're here with Dr. Courtney Crombie. She's an assistant professor and plastic surgeon with University of Utah Health now. Dr. Crombie, liposuction, tummy tuck, what are the differences in these procedures?

Dr. Crombie: So, first of all, a tummy tuck or abdominoplasty is a surgical procedure that is meant to remove excess skin and fat in the abdominal area, and can also be used to tighten muscles underneath that skin and fat. For liposuction, this is also a surgical procedure, but it's meant to sculpt or reduce small pockets of fat that are resistant to change from diet and exercise. This can also be done on the abdominal area, but can be done in other areas of the body as well.

So liposuction is a much easier recovery because there aren't as many limitations put on you. Basically, you're wearing compression, either abdominal binder, if it's around your belly, or some compression like a girdle or something if it's other places like on your hips for probably four to six weeks. And so fairly easy to conceal because it's just under your clothes. And you're going to have pain in those areas where we liposuction, but you're getting around okay.

Now, for an abdominoplasty, if you're having a full-out abdominoplasty with the muscle placation, that's a much greater recovery. Six weeks where we don't have you lift anything heavier than let's say, a gallon of milk, you are wearing an abdominal binder, you have drains in place that you have to carry around with you for two, maybe upwards of three weeks, you may not be able to stand up straight for the first two weeks. And so it's a much harder recovery and it may be the full six weeks before you feel like nothing happened to you.

Interviewer: If I'm a patient who is looking to get one of these procedures done, what is one of the kind of first steps I should take on my journey trying to decide which of these procedures is best for me?

Dr. Crombie: If there's an area where you have loose skin, then liposuction probably isn't the thing for you because if we remove the fat under that loose skin, that loose skin is probably going to just get looser and wigglier and it's probably not the thing that you're going to want to see when you look in the mirror. You're probably looking at more at having to remove that skin along with the fat underneath. So then we're thinking more of the procedures that are removing the skin along with the fat.

Interviewer: Okay. So like the tummy tuck?

Dr. Crombie: Yeah.

Interviewer: If it's in that region?

Dr. Crombie: Exactly.

Interviewer: Okay.

Dr. Crombie: So liposuction really is to just take away areas where there's just stubborn fat that you can't get rid of, but your skin tone is really quite good there. And one thing also that I want to remind people of is that it's not a good way to lose weight.

Interviewer: What do you mean by that?

Dr. Crombie: Well, sometimes I have people coming in that want to use that as a way to take lots of pounds off, but I don't recommend that. If you're on your way to losing weight, I would recommend that you get to a point of weight loss that you want to be where you're at your comfortable weight. And it's a healthy way that you can maintain and that you're not struggling to stay there, and you're not starving yourself to stay there. But it's something that you can easily stay at comfortably, then that's the time to come see us so that whatever procedure we do is worth your while, worth your time, and worth your money. Does that make sense?

Interviewer: That? Yeah. I like that because that's just it is if you guys remove the fat and I'm just going to put it back on. Is that what you're saying or is it just . . . We want to make sure.

Dr. Crombie: Yeah. Exactly. If you're only partway there and then we do say the tummy tuck and then you go ahead and lose another 20 pounds and then your skin loosens up again, I'd hate to have to redo that procedure after you've just spent all this time and effort because with a tummy tuck when we tighten the muscles, that's a long time where we're not letting you do any heavy weight lifting, you're very immobile, you may have drains in place, and you may have a lot of time off work. And so there's a big investment of pain and suffering to get through your recovery and a lot of people don't want to go through all that again. And then plus it is costly too. So you want to be one and done.

Interviewer: That's some great advice coming from a professional because someone from the outside is like, "Oh, well, it'll just help me get thin. It'll make me look the way I want." No. That's not what we're looking for here. This is that last step. Right?

Dr. Crombie: Right.

Interviewer: So if I am looking for a procedure like this, what is my first step when it comes to finding the right surgeon, finding the right facility, etc., like right procedure? This is some stuff that I didn't know. As a layperson, I record these types of interviews all the time. If I'm just someone coming in for the first time thinking about this, what is the first step when figuring out a surgeon?

Dr. Crombie: Well, certainly you can come and see any one of us at the university. Our Consultations are free and so if you're not sure, then let us take a look, let's talk about what your goals are, and we can even help you if you're not sure, if you're at a point where you're ready to take that next step or if you're still on your journey of weight loss or toning or whatever. And we can figure out where your endpoint is and come up with a plan.

Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: So you look in the mirror and you're starting to see the signs of aging on your face. What options are available to you at any point in life? I'm here with Dr. Cori Agarwal. She is an Associate Professor of Plastic Surgery at the University of Utah Health. So Dr. Agarwal, what are the kinds of people that are coming in for facelifts or rejuvenations? Is there a particular age, or is it all across the board?

Dr. Agarwal: It's definitely all across the board. I think when people start to see their face change at all, there is a little bit of panic that age is coming and they want to come in and see what their options are to slow things down or maintain their youth as long as possible. So we get people even in their 20s or 30s who may be seeing new wrinkles show up and asking what could be done and is it time for a surgery or what other options we can offer them.

Interviewer: At 20 or 30, what kind of things are we seeing? Are we, you know, just a little wrinkles and stuff and what options are available for, say, that age group?

Dr. Agarwal: So in that age group, it would be rare to have a full face lift recommended, but it's very common that you would benefit from things like Botox, which relax the wrinkle lines and maybe fillers that would soften some of the early wrinkles that you would get at those early ages. Other options at those ages would be products that can rejuvenate the skin, like Retin-A, some light chemical peels, things short of surgery.

Interviewer: So we're not looking at a full face change, you know, pull everything back up. It's these small rejuvenation type changes for that age group.

Dr. Agarwal: Yeah. And one thing to point out though is that everyone does age differently. I think a lot of it comes down to your genetics, your exposure to the outdoors and the sun and wind. People can age earlier. So sometimes in the 30s, that decade, people will benefit from a small surgery of some kind, and it's worth coming in and talking to your surgeon at that point if you have certain areas that are starting to sag or droop.

Interviewer: So when you get into the you said a small surgery, I've heard mini facelift or what kind of small surgeries are available?

Dr. Agarwal: Smaller surgeries could be something like eyelid lift, blepharoplasty where there's just a little bit of extra skin. If there is such a thing as a mini facelift, that really focuses on the middle portion of the face, less so on the neck. And another option is facial fat grafting where you're just plumping up some areas, like the cheeks, possibly to add some a youthfulness.

Interviewer: So besides these fillers and, you know, smaller surgeries and other options available, what is the age that most people are getting, say, the full facelift?

Dr. Agarwal: There isn't an absolute age, but I think we start to see people coming in who would benefit from a lift somewhere in the late 40s, 50s. I think those decades, the neck becomes more lax, and I think it's when the jowls form and the neck becomes lax that you're really looking at needing something more rather than just use more minimal techniques to correct that. If you have extra skin hanging in the jowls and neck, you're probably going to do best with a facelift.

Interviewer: So say a patient is looking in the mirror and they're seeing some of the signs of aging, what's the first step that they should do to find out what procedures are even available to them?

Dr. Agarwal: So I think the best advice for that individual is to go in and have a consultation and talk to your surgeon and learn what's out there, learn about what may be best for you, what you're looking for, for your skin type, for your age and I think you can come up with a plan. And you may combine surgery with some of these resurfacing or noninvasive techniques out there to really optimize your result.

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Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: So you've decided to get some cosmetic surgery done. How do you know that your surgeon is really the right surgeon for you? We're here with Dr. Cori Agarwal. She is an associate professor of plastic surgery at University of Utah Health.

Dr. Agarwal, say I'm looking to find myself a cosmetic surgeon. What should I be looking for as a patient?

Dr. Agarwal: I think there are a number of factors. I think you want to make sure someone has good experience and that they have good results, and it's hard to do that as a consumer when you're looking at multiple websites and comparing them. I think it's very hard to tell who's actually qualified. And so we look towards board certification as something that you need to look towards and ask your doctor about.

Interviewer: I mean, the results must be kind of important in making a decision, but the actual board certification, what kinds of things should people be looking for? Is there like a certain gold stamp of approval for "These are the best surgeons"?

Dr. Agarwal: Well, it doesn't guarantee you're going to have an excellent result or an excellent surgeon, but it definitely . . . by being board certified in a recognized board, you know that these surgeons have had a basic training, a certain number of years of surgery, and graduated from an accredited medical school, and gone through safety training, and taken oral boards and written boards. It's very rigorous to be board certified in plastic surgery and board certified in facial plastic surgery.

And so you know that at least they've gone through the correct amount of training and I think you should feel much more safe. I think if you don't see that kind of board certification, it's just more of a question mark as to where they did their training and how much training they actually did.

Interviewer: We were talking a little bit before. You said that there are certain certifications that don't really mean anything. They're just kind of buzz terms. What kind of things should people be looking out for?

Dr. Agarwal: There's a board of cosmetic surgery, and that's a board that is out there and people will put it on their website and advertise it, but it's not a recognized board by the American Board of Medical Specialties, which has been certifying all the medical specialties for a hundred years and it's the one that we look for.

So the cosmetic surgery board certification doesn't hold the same weight. It doesn't have the same requirements for medical school training, for surgery training and residency, and then the testing and maintenance of sort of the safety certification afterwards.

Interviewer: That seems a little . . . I mean, as a consumer, I would see cosmetic surgery board and just assume that, you know, it's solid, that that's a real, legitimate board. Are there any particular names of organizations or something that we should be looking for, that if you see that for a surgeon, you know they're going to have that experience, that certification?

Dr. Agarwal: Yeah, I think the easiest one is the American Board of Plastic Surgery. If you are certified by the American Board of Plastic Surgery, nearly all of them will have the ASPS stamp on their website, American Society of Plastic Surgeons. So once you see that, you know for sure that they're certified.

There's also a facial plastic surgery certification that's equally good through training in otolaryngology. And so, if you see those as certifications, then you know that your surgeon has gone through appropriate training.

Interviewer: But it's not just that board certification. I mean, when you're talking about these types of results, they're something a little different than just a heart surgeon. What is it about plastic surgery, facial plastic surgery especially? What kind of relationship do you need to . . . as a consumer, how do you know that you have found the right surgeon?

Dr. Agarwal: Yeah, I think that's a really good point. I think there's something about a patient/doctor relationship, and I think you need to go in and meet your surgeon, talk to them about your goals, see if they listen to you, see if they see what you're looking for, and you seem to have a good eye to eye.

And I think one thing you can do is ask to see results. You can see before-and-after pictures that your surgeon may put on the website, or if not, then perhaps in the consultation they can show you some of their results from previous patients.

But I think it's making sure that this surgeon understands what you're looking for. They're not trying to push something on you. They're really listening to what your goals are for your desired surgery.

Interviewer: So other than asking for, say, before-and-after results and making sure that they're listening, what kinds of questions should you ask on that first consult to kind of get a feeling if they're the right doctor for you?

Dr. Agarwal: You know, I think it depends a lot on what you're looking for. So if you're looking for rejuvenation versus rhinoplasty versus eyelids, there are going to be specific questions.

I think you should do some homework and do some reading about the type of surgery. You never want to Google too much about your surgery, but I think it does give you a little insight into the terminology and, you know, make sure that the surgeon seems to understand what you're looking for.

It's important for them to talk to you about risks of the surgery. I think you have to go into any surgery knowing that there are always some risks involved. And if the surgeon doesn't bring any of those up, you may want to ask them about that.

Interviewer: So do your homework. Do your homework and go to that consult with eyes wide open.

Dr. Agarwal: You know, one other thing that can be helpful is looking at reviews online. They're not always going to be great as resources because some people just want to vent or complain, and so it's hard to know if that's all legitimate, but I think it gives you a trend.

I think if you see a lot of positive reviews, or a lot of negative reviews alternatively, that does give you some insight. You have to be careful where these sources are coming from, but it's something that I think goes along with doing your homework about a surgeon.

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Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: It's a pretty common question. How do you fix droopy eyelids? Dr. Eric Cerrati is the Director of Facial Plastic Surgery at University of Utah Health. Dr. Cerrati, first of all, what usually brings patients to you looking for an eyelid procedure? What are some of the common themes?

Dr. Cerrati: I would say the most common thing across the board is that patients say that they feel or look tired, especially when they look at themselves in the mirror.

Interviewer: Got you. And you have a procedure that can do that. Now, is it something that you can do without surgery, or is surgery always involved?

Dr. Cerrati: So there are actually a lot of different options. There are nonsurgical options, in which case you put filler underneath the eye, you can do laser procedures to tighten the skin under the lid, and then there's a whole arsenal of surgical procedures, where we tighten the muscle underneath, we remove some of the skin, and we lift the brows, all giving a more rejuvenated or rested appearance.

Interviewer: How would you decide what is best for a particular patient?

Dr. Cerrati: It starts with the patient's concerns and what their question is. This is actually more common in males than you would think. It's very common that patients come in and just say they look tired and their colleagues are commenting, both male and female.

Another common complaint that patients will say is that it's affecting their vision, in which case the droopy eyelids can actually block some of their peripheral vision. If that's the case, we could actually send them for an objective visual field test is what we call it. They have the test. Depending on how they perform, there are certain insurance criteria and if they meet that criteria, insurance will actually cover the procedure.

Interviewer: So you can get rid of the tired look and also improve your vision, which is fantastic. It's a safety thing, really.

Dr. Cerrati: Exactly.

Interviewer: You know? And just a quality of life thing as well. So you have a conversation with them. You try to find out what their needs are as far as then determining which one of these procedures you're going to go with. How often is it possible that somebody could do nonsurgical?

Dr. Cerrati: It's difficult to say. I would say people that have more on the mild side of findings we can treat it nonsurgically. Botox Botox, which is actually common medication that we use, that you think of smoothing wrinkles on the face, but you can actually use the push/pull of muscles on the face to actually create a brow lift to give a more rested appearance to the brow. Some other nonsurgical options include, for the brow, using Botox to elevate the brow. Fillers Really not much you can do for the upper eyelid skin, but the lower eyelid you can place filler in the tear trough to help provide some volume to the under eye, which gives them more of a rested appearance, and also doing a laser procedure to tighten the skin underneath the eyelid.

As far as topical creams and those sorts of things, they do help slightly. I wouldn't say it would give the patients a long-lasting result that they're really looking for when they come to my office.

Interviewer: And when you talk about long-lasting results, how long could somebody expect this to continue to be what they want it to be?

Dr. Cerrati: So obviously, we can't stop the aging process, so it continues. But I would say for eyelid and brow revisions, usually you're talking several, several years down the road, 10-plus years.

Interviewer: And then where, if it is a surgical option . . . I'd imagine the nonsurgical happens in your clinic. What about the surgical options? Tell me more about that.

Dr. Cerrati: So the surgical options are performed either up at the main hospital, the University Hospital, or out at one of the satellite offices. When I consider eyelid rejuvenation, you have to consider the brow and the eyelids kind of as one unit. And so, if the brows are ptotic or have fallen down some, addressing the brow can create a very significant improvement in the appearance.

So if the brow is being done, usually I perform that under general anesthesia, and then the upper lids, if we're coupling that with the brow, again under general anesthesia. If it's just the upper eyelids, we can actually do that in the clinic setting just under local anesthesia. It takes maybe 45 minutes to an hour. And then the lower lids are a little bit more involved. I tend to do those back in the operating room.

Interviewer: Got you. And what kind of recovery time are we talking about? I'd imagine it varies because it sounds like the approaches vary.

Dr. Cerrati: So I tell everyone it's about a one-week recovery. At one week, all the stitches come out. Most of the bruising has resolved. Still taking it easy as far as activity-wise, but one week you're pretty much recovered and back to your normal day-to-day activities.

Interviewer: Do people generally choose not to go to work for that one-week period while they're healing?

Dr. Cerrati: Depending on what their job is, yes.

Interviewer: See if they can work remotely and maybe do that?

Dr. Cerrati: Exactly.

Interviewer: Got you. And you mentioned insurance covered it if it was a sight thing, so that's pretty good.

Dr. Cerrati: If insurance feels that the findings affect your peripheral vision, they will actually cover both the brow lift and the upper blepharoplasty or upper eye lift.

Interviewer: Tell me about how the skill and experience of the surgeon can make a difference in the outcome when it comes to this type of procedure. I mean, you do it. You also have some very talented colleagues that do it. How would somebody choose the person that they want?

Dr. Cerrati: So there's a team of surgeons, and with every surgeon, there's a team that works around them to help provide the best care here at the University. For brows, I tend to use an endoscopic approach, which is incisions hidden way back in the hairline, so that way, really minimizing the amount of scarring or any incisions on the face.

The eyelid incisions are hidden right in the natural creases of the eye. And again, all of this is tailored to the specific patient's needs and the skill the patient takes, in both aesthetics and shorten the recovery time.

Interviewer: And how could a patient make sure they're picking the surgeon that's right for them?

Dr. Cerrati: So the most important thing is the in-person consultation. It's important to come meet your surgeon, discuss with them kind of what you're hoping to achieve. You can look at some before and after pictures. And if you feel comfortable with the surgeon, that's the most important thing.

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Interviewer: What is the difference between a mini facelift versus a normal facelift? Dr. Eric Cerrati is the director of facial plastic surgery at University of Utah Health. And Dr. Cerrati, I'm just going to guess here, I think the difference probably is, like, a mini is just a smaller version of a facelift. Am I right? Do we need to go further?

Dr. Cerrati: Kind of true, but there are some, you know, details we should talk about.

Interviewer: Okay. It's a little more complicated than what I just made it.

Dr. Cerrati: Exactly.

Interviewer: All right. So what is the difference between a mini facelift and a normal facelift?

Dr. Cerrati: So, first off, they recently did a study surveying facial plastic surgeons all across the country trying to define that exact question. And what they found with it is that there is no consensus about what the difference is except that a mini facelift has a shorter scar. As far as the techniques and recovery and those sorts of things, they all differ from surgeon to surgeon.

Interviewer: Okay. So, really, it's interesting that you've got a lot of different people, they all have different definitions. So, for the customer or the person who's coming in, it's important that maybe they ask a few additional questions to find out how that particular person defines it.

Dr. Cerrati: Exactly. So every surgeon has, you know, their own techniques that they do for facelift surgery. It used to be, back in the day, was just tightening skin. And now we've learned that, you know, a more natural, more rejuvenated look is to tighten the muscles underneath the skin. And so that layer is either, you know, pulled tighter, it's resected, and then, you know, sewn in a more suspended fashion, the ligaments of the face are at least. You know, I personally do a deep plane facelift, where I release the ligaments of the face and re-suspend it in a more natural position. So my mini facelift is essentially the same thing, just with a shorter scar.

Interviewer: Okay. And that also sounds like it could differ from surgeon to surgeon.

Dr. Cerrati: Exactly.

Interviewer: Yeah, yeah, okay. So let's back up a second here. A patient comes in. They're interested in a facelift. They come into your office. They think maybe they want a mini facelift. They don't know for sure. Where do you start this conversation?

Dr. Cerrati: So, really, patients who are going to be, you know, good candidates for a mini facelift are ones that don't have a lot of excess skin or neck skin laxity. And that's really what the extended incision allows you to do, is to remove that excess skin. You know, it tends to be underneath the neck. So for younger patients, say 40s, 50s, you know, usually you can just keep the scar kind of right around the ear and not really extend it back into the hairline, which would qualify for a mini facelift.

Interviewer: Gotcha. And what about somebody that maybe had a lot of weight and then lost a lot of weight? It sounds like maybe a mini facelift would not be the best option because you've got more skin to take care of.

Dr. Cerrati: Yeah. So that differs patient to patient. But usually, those patients have more skin laxity that needs to be addressed.

Interviewer: Okay. So, to summarize, I mean, am I getting the summary right, a full facelift is when perhaps you've got more skin that needs to be tightened versus the mini facelift where it's somebody younger, maybe somebody who hasn't gained a lot of weight, lost a lot of weight, that doesn't have as much skin to move, they could get the mini?

Dr. Cerrati: Exactly, earlier signs of aging.

Interviewer: All right. So what's the difference then in recovery time, cost? I would think a mini might be less recovery and cheaper?

Dr. Cerrati: For faces that qualify for a mini facelift, it is a little bit cheaper, and the recovery time is a little bit shorter because it's less of a recovery for the neck portion. But, you know, I usually tell all my patients it's similar recovery, in that, you know, they have a face wrap that's on for 24 hours that's taken off. I don't use any drains, whether it's a mini or a full facelift. And again, there are variations from surgeon to surgeon. If someone really has very minor signs of aging and, you know, qualifies for a mini facelift, then a slightly less aggressive technique can be used, and that would significantly reduce the recovery time.

Interviewer: And do mini facelifts tend to look a little bit more natural then too?

Dr. Cerrati: I find that the technique actually affects how natural a result looks. I find that the deep plane facelift gives the most natural look, you know, and that can be done in a very aggressive fashion or a less invasive, tailored fashion for the patient. But every procedure is customized to the patient and what their needs are.

Interviewer: All right. And you have that conversation with the patient when you come in. How long does that normally take?

Dr. Cerrati: Oh, our consults usually last anywhere from 30 to 45 minutes, and we kind of go through everything.

Interviewer: Yeah, gotcha. Okay. Let's talk about the procedure itself. Where is it generally performed?

Dr. Cerrati: I do it in the hospital setting, so here at the University of Utah, but the main hospital. And I also have an office and an operating room at South Jordan, both university facilities.

Interviewer: Is there an advantage to being able to have access to a hospital as opposed to maybe just being in a standalone clinic?

Dr. Cerrati: I think the advantages of coming to a university facility, whether it's out at South Jordan or one of our satellites locations versus the main hospital is that all the physicians within the university, you know, are board certified, very highly qualified, and you really receive topnotch care. In some private offices, you don't have board-certified anesthesiologists watching throughout the entire case. And so, you know, we really focusing on the details so that every patient gets the best possible care throughout their procedure.

Interviewer: Gotcha. And when you do a procedure with a patient, how do you and the patient then define success? So, when the procedure is done, you know, the patient is fair . . . because I would imagine this is kind of a scary thing. It could be a scary thing going in. Like, "Am I going to get the results I want?" This is, you know . . . how do you kind of work with the patient to make sure they get exactly what it is that they hoped for?

Dr. Cerrati: So I would say, across the board, facelift surgery is probably one of the highest satisfaction rates out of all facial plastic surgery procedures. But we mimic what we do by pulling on the skin and trying to give the patient idea what the jawline and what the cheeks would look like afterwards. We show them before and after pictures and try to have as detailed of a conversation as we can.

Interviewer: And then, what about the risks, because that would be something else that perhaps would be a concern? I think we kind of touched on this a little bit. Here in the university setting, you're going to have, you know, like you said, the anesthesiologist is here to make sure that that goes okay. What are some of the other risks that you look out for that you really try to mitigate?

Dr. Cerrati: So the surgical risk in the procedure, there's bleeding and infection. Obviously, we do everything we can to try to minimize those. Anytime you make an incision to the skin, there's a risk of scarring. Facelift scars, you know, we hide them as best we can behind all the little crevices in the ears. So it's all hidden in shadows. And, you know, the main risk is really that you're close to the facial nerve, you know, the nerves that innervate all the muscles of the face. You know, we are a couple, you know, layers above it, but it is within a few millimeters. So careful surgical technique and training really allow you to get the exact result that you're going for.

Interviewer: Yeah. So you really want somebody who knows what they're doing.

Dr. Cerrati: Exactly.

Interviewer: That's got the skill and does a lot of the procedures and that sort of thing. So, hopefully, this is just probably a small part of the conversation you might have if somebody actually came in for a consultation. If somebody has any more questions, where would they go at that point?

Dr. Cerrati: So I always welcome patients, you know, when we're first having this conversation, obviously, ask everything. I kind of give them my spiel kind of start to finish. And I tell them if they ever have questions, write them down, call the office, come back in, we can do another conversation. And so that way, they're fully informed, fully comfortable with proceeding. I mean, the most important thing is the patient needs to be very comfortable with the surgeon, you know, the facility, and the plan that they're undertaking.

Interviewer: You mentioned that the patient should be really comfortable with the surgeon performing the procedure. And I know there's a lot of surgeons here that perform mini facelifts and normal facelifts. Give us some just general advice on how you might be able to figure out, you know, who might be best for you because, you know, it might be you, it might be one of your talented colleagues.

Dr. Cerrati: Exactly. So there are a handful of surgeons here at the university, all very talented, come from slightly different training, but offer very good work. And that's why it's very important for the patient to have an in-person consultation. In that way, they feel comfortable with the surgeon that they're choosing.

Interviewer: And regardless of whether it's you or one of your other colleagues, are there some things that you all have in common?

Dr. Cerrati: As being part of the university, we keep abreast on all the cutting-edge technologies here, offer the most advanced facial plastic surgery procedures. And again, we all come from slightly different training, which, you know, plays to the advantage of the different care that we can offer here at the university.

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Interviewer: What to know if you're considering a facelift. That's coming up next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Dr. Eric Cerrati is a plastic surgeon at University of Utah Health, and he specializes in cosmetic and reconstructive surgery of the face and neck. And if you're thinking about having a face lift, hopefully we'll answer some of the questions that you might have.

So why do patients consider a facelift? What kind of leads them to making the decision that that's something that they want to pursue?

Dr. Cerrati: So a lot of times it's a patient, middle aged and they're starting to notice the jowling or the extra skin that's kind of hanging down over the chin. That's really kind of the first signs that people are looking at.

Interviewer: And when one says facelift, is it generally the jowling that we're talking about that we're fixing, or does facelift encompass other things?

Dr. Cerrati: The most common thing is facelift will redefine the jawline. That's really the main target area, under the chin and along the jaw.

Interviewer: All right. And when somebody comes in and you do an evaluation, which is what you recommend, that you see a specialist, how do you help determine if they're a candidate for it or not?

Dr. Cerrati: So first and foremost, it is an elective surgery, so the patient needs to be medically fit for the procedure. Then as you look at body habitus to make sure the patient's not having weight shifts or that sort of thing, to make sure you can get him a lasting result and something that they're happy with. And a lot of it does have to do with patient selection. You want to make sure that their hopes and wishes is something that you can accomplish.

Interviewer: Sure that what they're asking for is something that can actually be done.

Dr. Cerrati: Exactly.

Interviewer: So what can't facelifts do? Do you get patients coming to you that say, "I want a facelift," and they're trying to accomplish something that just can't be done?

Dr. Cerrati: Absolutely. There's the anatomy of the neck and the way that the neck is structured that some patients are more, say, ideal candidates for a facelift and some that are not, in which case you can't get a very defined jawline.

Interviewer: So there are a lot of different types of facelifts and ways to do a facelift. When a patient comes in and starts asking you about those different things, how do you walk them through that process?

Dr. Cerrati: So you can go through all the different types of facelifts, skin only and addressing the underlying tissues and that sort of thing. But really, all these things are not necessarily important for the patient. The patient needs to be familiar with their surgeon and make sure the surgeon has the proper credentials. And if the surgeon has the same aesthetic and can achieve the goal that the patient wants, the approach that they use isn't necessarily the most important thing.

Interviewer: Got you. So a lot of times you're kind of explaining that, I'd imagine.

Dr. Cerrati: Exactly.

Interviewer: So somebody wants to get a facelift. What does that kind of look like? I would imagine there's not a lot of preparation if they are already healthy and whatnot. They would come in, have the procedure. How long does it normally take?

Dr. Cerrati: So the procedure can last anywhere between, I don't know, say two and a half to four and a half hours. All the incisions are really hidden behind the hairline and then around the ear. After a couple weeks, those incisions are very hard to see. And for me, I do do some planning pre-operatively to try to minimize any type of bruising and to help the patient throughout the whole process. At the end of the day, it is an elective procedure and these patients do not want to feel sick and have a long, drawn-out post-operative course.

So I do a lot of things before surgery to kind of help the patient get through that and minimize. I also don't like to use drains and prolonged dressings and those type of things, so patients can really get back to their daily lives as fast as possible.

Interviewer: Is there kind of a range in there? Does it really vary depending on what procedure's been done?

Dr. Cerrati: It really varies, but usually I tell people after two to three weeks they're really back to their pre-operative status.

Interviewer: And if you go back to work, are people going to be able to see visible signs at that point that you've had something done?

Dr. Cerrati: So after about two weeks, a lot of the swelling and bruising has pretty much subsided. The incisions may be slightly red, but patients can really get back to their normal routines after two weeks. At that time they can also. . . After the first week you can really apply makeup, so a lot of it can be hidden.

Interviewer: Got you. And the results, do they last? For how long?

Dr. Cerrati: So depending on the approach, if you address the underlying deeper tissues, usually the results last about 10 years, is kind of the ballpark range. It's because the aging processing and with gravity, it's still going on. So even though you've had the procedure, the aging process continues.

Interviewer: And picking the right doctor to do a facelift is really important, because it is your face. So how does somebody know that they have somebody that is going to really do a good job for them?

Dr. Cerrati: So the number one thing I would say is the patient should do their homework. They should look to see who the surgeons are, where they've done their training and what pathway they've taken in order to get to become a plastic surgeon who's operating on someone's face.

Interviewer: Are there some certifications in general that you should kind of make sure that the surgeon has?

Dr. Cerrati: Absolutely. So is there a residency in plastic surgery that's monitored by the American Board of Plastic Surgery. A fellowship by the American Academy of Facial Plastic and Reconstructive Surgery, and that's also a board certification as well. And those are really the two main ones.

Interviewer: And it's your opinion that you should look for somebody who has both of those?

Dr. Cerrati: Either one of those.

Interviewer: Oh, either one of those?

Dr. Cerrati: Those are two separate pathways.

Interviewer: They're two separate things. Got you.

Dr. Cerrati: So for myself, I did a fellowship by the American Academy of Facial Plastic and Reconstructive Surgery.

Interviewer: And if they don't have one of those pathways, then maybe be a little cautious?

Dr. Cerrati: I would raise a red flag.

Interviewer: All right. And ask some more questions at that point?

Dr. Cerrati: Absolutely. In addition to qualifications, you should really feel comfortable with your surgeon. Even after the initial consultation you don't have a great feeling, go back and visit the office again. And just make sure before you sign up for anything that it's something that you're happy with and that you're confident that the surgeon can give you the results that you want.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

Interviewer: What to know if you're considering a cosmetic rhinoplasty. We'll talk about that next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Dr. Eric Cerrati is a plastic surgeon at University of Utah Health that specializes in cosmetic and reconstructive surgery of the face and neck. Dr. Cerrati, when a patient comes to you for a cosmetic rhinoplasty, what are some of the common things that they're trying to address or take care of?

Dr. Cerrati: So usually that's kind of grouped in two to three different categories. The first one is your patient who's never had a rhinoplasty before and is really trying to address maybe some family features of theirs that they want to alter, say like a bump on the nose or a wide nasal base or that sort of thing. The next group is probably someone who has had rhinoplasty in the past and as a result has had some scar contracture leading to some asymmetry, whether it's in the kind of the distal part of the nose or the nasal tip. And then the last group I would say that has . . . after rhinoplasty, you have nasal obstruction that kind of results from that, from the first surgery.

Interviewer: Got you. What about somebody who's just had a nose that's may have been dislocated through, I don't know what could happen, they got hit or something of that nature and now as a result the nose is crooked?

Dr. Cerrati: Oh no, definitely yeah. Traumatic injuries are definitely a common cause for having rhinoplasty surgery.

Interviewer: Got you. So what can you do with this type of surgery when it comes to when a patient comes in? Most of the time are you able to help address their issues, or are there some times you just really can't?

Dr. Cerrati: So a lot of times yes, we can get the symmetry back, get the nose back in the midline, and fortunately form and function kind of go hand in hand. So when we improve their breathing, we also improve the appearance of their nose. But then if it's a purely cosmetic case, where we're really just trying to alter the external appearance, I would say that patients need to be careful, that there are risks involved, and that you're trying to chase the perfect physical feature, it gets very difficult.

There are definitely patients that we tell them that we don't think it's the best idea to undergo surgery. One, if a patient's had a lot of nasal surgery and say that they're missing a lot of cartilage in their nose and would require big reconstructive case, if their nose is functioning fine and they can breathe out of both sides and that's really just a small physical feature that they're chasing, I personally don't think that's a great idea and I would not recommend surgery to that patient.

Another situation where I wouldn't recommend surgery is if a patient has unrealistic expectations or if there's something that I just won't be able to achieve a surgery.

Interviewer: So what are some of the common questions that you get when it comes to this type of a procedure that we haven't discussed so far?

Dr. Cerrati: So commonly, a lot of patients ask about a closed rhinoplasty or an endonasal rhinoplasty versus the open or external rhinoplasty. Usually patients, by the time that they're considering the surgery, have kind of googled and come across a lot of these terms. Endonasal rhinoplasty, you can address a lot of these features, external appearance, and even function with that approach. Usually when you start altering say the tip or really going for correcting fine asymmetrical issues with the nose, really an external approach gives you better visibility and allows you to really address the problem better.

Interviewer: And the internal one is more useful for . . .

Dr. Cerrati: You can still accomplish a lot of things. It's just harder to get to, say, the tip of the nose.

Interviewer: Got you. And what's the preferred method? Is it the internal version because you have less scarring, or what's the advantage of that over the external?

Dr. Cerrati: So for the patient, really they're pretty equal. It's really surgeon's preference in which way a surgeon's been trained in. Endonasal rhinoplasty was very popular say 10, 15 years ago, and most surgeons were trained that way back then. Now, kind of the external approach, the pendulum has kind of swung the other way and most surgeons now are doing the external approach. For the patient really, if your surgeon is comfortable with either approach, they can get you the same result either way. With the external approach, you do have a very small incision. However, I would tell patients that after two or three months that incision essentially heals and becomes invisible.

Interviewer: After a procedure, how long does it take to kind of get back to your normal everyday life, go back to work, that sort of thing?

Dr. Cerrati: So I tell all my patients that for the first week really to take it easy. You'll have a cast on your nose. A lot of times you'll have bruising and swelling around the eyes. At the end of that first week, the cast comes off, the bruising and swelling starts to resolve, and probably midway through the second week or the end of the second week you're really back to all your normal activities and feel pretty fine.

Interviewer: And after a procedure, a cosmetic procedure, how long do those results last? You had mentioned that sometimes things can change a little bit after you've had one and you might have to get another one. So explain that a little bit.

Dr. Cerrati: So hopefully the results last a lifetime, especially in the nose when you're addressing the underlying structures. What I see with the revision rhinoplasty is a lot of times if, say the first surgeon takes way too much of the structure of the nose, too much of the cartilage, then over time the nose will start to warp and you'll get scar contracture. And that can lead to asymmetry in the nose and also lead to breathing problems.

Interviewer: And if somebody comes in and they need additional support in the nose, how do you do that exactly?

Dr. Cerrati: So there's a couple different places where you can get extra cartilage in order to rebuild the different areas of the nose. A lot of times the most common is the nasal septum, the cartilage there itself. It's right there in the nose, and there's really no other extra incisions for the patient. Another common one is the ear, which you make a small incision in the back of the ear and really take out the cup portion of the ear. All the external structure of the ear is maintained, so there's no change in the form or the function of the ear. And then lastly there's the option of using rib cartilage. So where your rib comes around and connect your sternum, there's actually a section of cartilage there that can be used to rebuild the nose as well.

Interviewer: And when looking for the right doctor to do a rhinoplasty procedure, that would be really important. I'd imagine there's a certain level of trust that a patient wants because after all it is your face. It's the first thing everybody sees. How do you recommend finding the right doctor for that procedure?

Dr. Cerrati: So I'd recommend looking at your surgeon's training. Being board-certified by the American Board of Facial Plastic and Reconstructive Surgery or the American Board of Plastic Surgery is very important. There's a lot of different paths that people can get to in order to get that board certification. For myself, I did a five-year residency in head and neck surgery, just really concentrating on operating above the shoulders. And then I did an additional year fellowship sponsored by the American Academy of Facial Plastic and Reconstructive Surgery, just operating on the face specifically.

Interviewer: So it sounds like just have a conversation with the doctor you're talking about and just ask them, "What path did you take? What preparation did you use to get here?"

Dr. Cerrati: Absolutely, and ask him how many procedures they do and you'll get an idea of how comfortable they are and kind of what their background is.

Interviewer: Yeah, and then what about the personal relationship? Like if you feel a connection or you don't, is there anything you recommend on that? I know some doctors, if you don't feel the connection with the surgeon, you should maybe look elsewhere.

Dr. Cerrati: Absolutely. I mean, you have to be comfortable. If this person's going to be operating on your face and external appearances, it's very important that you feel comfortable. So no matter how good they are or how good their credentials are, the number one thing is you need to feel comfortable with that person.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: July 17, 2019
originally published: November 7, 2017

Announcer: Health tips, medical news, research and more for happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Sometimes it just doesn't seem right. You exercise. You're leading a healthy, active life. Maybe in another life, you have a little too much fat, but you fixed that, right? You're trying to lose it, yet some of those stubborn areas just won't go away. Well, I want to talk about two non-invasive fat reduction techniques. One is called the CoolSculpting; the other is Kybella. Dr. David Smart is a dermatologist with the University of Utah Health Care.

First of all, I always get little bit skeptical when I hear about non-invasive fat removal. I mean, I kind of hear the ads on the radio. I'm told there's no such thing as a quick fix. So your job . . .

Dr. Smart: Yet, here I am with quick fixes.

Interviewer: So your job is to convince me.

Dr. Smart: Got you. Let's take CoolSculpting. That's a great example. Cool Sculpting is a machine that was invented and developed by dermatologists. It's all based on this principle: fat cells are more sensitive to cold than skin cells, and muscle cells, and all the cells around it.

Interviewer: So they freeze easier?

Dr. Smart: They freeze easier and then they die from being frozen more easily. This has been well known in dermatology for some time. With frostbite, even sometimes, equestrians, it's called equestrians. It's equestrian fat loss. When they're riding horses in the very cold, those inner thighs that are really cold on that saddle, they'll actually start to lose fat on the inner thighs.

Interviewer: Because their fat's freezing?

Dr. Smart: Because their fat's freezing. Also, little children with popsicles, those popsicles sometimes will cause . . . if the popsicles been in the mouth too long, it will cause a fat loss in certain areas. So it's just this cold is killing off the fat. CoolSculpting has been around now for a long enough time, several years.

There have been hundreds of thousands of cases of CoolSculpting done and the results are very reliable. It's not a brand new fad, although there are a lot of machines in the same sector of non-invasive fat loss that I personally do not believe in and have used and thought, "Hey, this doesn't do anything." CoolSculpting is not one of those. CoolSculpting does show results.

Interviewer: So as a doctor, I would think that you would be more to encourage somebody to exercise to get rid of that fat. You know? That last five pounds or those little stubborn areas, "Just keep going and you'll get there."

Dr. Smart: It's important to remember or at least recognize that you can't spot treat fat when you're working out. No matter what exercise video says, you can't do more sit ups, necessarily. "If I really do crunches just very hard, I'm going to get rid of that fat right around the belly button or I'll do these side bends and that would get rid of my love handles." That's just not how the body works. You don't spot treat fat when you exercise.

The ideal candidate for one of these procedures, whether it's Kybella, CoolSculpting, is a person that is in relatively good shape, you haven't just started your weight loss journey, you're not necessarily more than 30 pounds outside of your weight goal, but you have a few stubborn pockets of fat that just don't seem to go away.

Interviewer: Because each one of us has our own little . . .

Dr. Smart: We've all got.

Interviewer: No matter how lean you are, like for example mine is right here on the backside, right?

Dr. Smart: Exactly. So are mine.

Interviewer: I could have a six-pack and I'd still have this roll a little bit.

Dr. Smart: On the back. This little love handle, it just wouldn't do away.

Interviewer: Is that what the CoolSculpting would treat?

Dr. Smart: Precisely, that is what is why it's developed to treat. It was rigorously studied by the scientists that made it in Harvard. It was not created by some company looking to make a quick dollar.

Interviewer: So there's actual evidence-based support?

Dr. Smart: Significant evidence to support this. It is a really great treatment for those areas. For men, right around the love handles, that's a very common area for men to have little pockets of stubborn fat. Women, outer and inner thighs and around the belly button. All these places are potential areas of opportunity to get rid of.

Interviewer: So can I use multiple treatments to treat multiple areas?

Dr. Smart: You sure can. Now CoolSculpting, that treatment was not designed to be a treatment course in the sense that very reliably with one treatment of the area that's treated, about 20% of the fat will leave. But depending on how much fat you have, you might need to do more than one.

Interviewer: So CoolSculpting works different areas of the body. Kybella works primarily for fat under the chin?

Dr. Smart: True. Now that's because it's FDA approved for that area. Kybella is actually a very, sort of groundbreaking, very exciting product. It's less than a year old now, as far as the FDA is concerned. It was FDA approved less than a year ago for the treatment of the submental fat pocket, which is just the double-chin area. That doesn't mean that fat in other areas doesn't respond to it, it just means that the studies were done to get FDA approval were done just there.

Interviewer: Is it the same technique? Is it freezing the fat or is it different than CoolSculpting?

Dr. Smart: It's different. So Kybella is a liquid. It's a chemical that's naturally found in the body. It's produced by the liver and helps to absorb fats in your diet, but if you inject it directly into the fat, it dissolves fat cells. So it's been done for many years in different countries, but it's not just been regulated. Finally, a company here developed a formulation and went through the very rigorous testing to get it safety and efficacy approved by the FDA.

You inject it in a series of injections, so similar to Botox, in very small needles under the chin and it dissolves fat. Most people need to do that injection anywhere from two to four times and it really sharpens the jaw and gets rid of the fat under the chin.

Interviewer: Side effects for either one of these two treatments?

Dr. Smart: With CoolSculpting, there's no cutting, there's no downtime, there's no nothing. As you can imagine, it's destroying some of the fat there. You do get some bruising and a little bit of tenderness that would come from feeling like, "I got a good bruise in this area." Those are the most common side effects. They happen pretty regularly.

Interviewer: What about Kybella?

Dr. Smart: Kybella, those are injections. You do have to be okay with some very small needle pokes. And then I would say that the most common side effect with Kybella is swelling. Most of the time, it's pretty mild. But about one in 10 get a good amount of swelling under the chin, to the size of almost like a golf ball or an Easter egg. So you definitely don't want to do Kybella right before you have some sort of event or some pictures to be taken. You'll most likely be okay, but pretty normally, like I say, about 10%, one out of 10 people, I feel like, get pretty appreciable swelling under the chin.

Interviewer: If somebody is interested in the Kybella treatment, that's physician only.

Dr. Smart: That is available only to physicians and specifically only to physicians that have been trained in Kybella. Allergan, the company that owns Kybella, was very particular about this when they released the medicine. A lot of things in cosmetic medicine get taken up by people that don't know how to use them and it gives the product a bad name because they're using it incorrectly, getting side effects and that's bad for the product, it's bad for the company. So the company was very sure to only release it to physicians that they have specifically trained to do this that have the pathology knowledge to handle any potential side effect that may come up and that aren't going to use it irresponsibly.

Interviewer: So with the case of CoolSculpting and Kybella, what else would a listener need to know to make an informed decision about using one of these procedures? What do they need to know?

Dr. Smart: The amount of people that could benefit from these procedures is enormous. We all have these areas of fat that really tend to bother us. What they should know is that it really does work. It is not a substitute for weight loss and that's probably what I would say to someone who's interested in CoolSculpting.

Whenever anyone comes in and they're interested in body shaping, whether that's liposuction, CoolSculpting, Kybella, we have a discussion about what your outcomes are and where you're starting from, as long as your expectations are realistic. It is not going to change your weight. If you're looking to lose weight, these aren't the treatments for you. If you're looking to simply sculpt some areas of the body, you're the perfect candidate.

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Interviewer: The picosecond laser is the first advancement in laser tattoo removal in the last 20 years. Faster recovery and fewer treatments. Coming up on The Scope, more about the laser capable of bursts as short as one-trillionth of a second to better remove your ink.

Announcer: Health tips, medical views, research and more for a happier and healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: The picosecond laser is one of the most advanced pieces of dermatological equipment in decades. There's only a handful of these lasers in the state, and we have one. We're here with Dr. David Smart, dermatologist at the University of Utah. Dr. Smart, how common is tattoo removal in this day and age?

Dr. Smart: Tattoo is extremely common. Just go ahead and look around at how many people you know or see that have tattoos. Just as many of those people end up thinking, "Maybe I should've done something differently with this tattoo" and they like it altered, changed, or removed somehow.

Interviewer: So how exactly does laser tattoo removal work? When we're talking about, you know, it's in the skin. How do you just make it disappear?

Dr. Smart: So, we'll talk a little bit first about how tattoos stay in the skin because I think that's probably the most important part. So what happens, there are certain cells in the skin that don't go anywhere. They stay there, they're always there. They don't go, they don't change, and they eat up the tattoo pigment that's placed deep in the skin with needles. The tattoo artist puts the pigment deep in the skin. It gets eaten up by these permanent cells and then it stays there for years and years and theoretically forever. The lasers are designed to attack the pigment particle within those cells, to get them to break up into small enough pieces that the cells will then clear them rather than just keep them around.

Interviewer: And you said lasers there, so there's multiple lasers? It's not just like you have one?

Dr. Smart: Oh you bet, yeah. And sort of what we mentioned in the first, the newest technology, which is actually very exciting, is the picosecond lasers, of which there are a few different companies making them. The picosecond lasers are very, very short. The way lasers work for laser tattoo removal, they target these very small pigments. To make that target more specific, you try to make the laser pulse, meaning the length of which the laser is on, as small as possible. The same size or smaller than the particle you're going after. So picoseconds are a trillionth of a second. If you think about that, a trillionth of a second, a picosecond is to a second what a second is to 32,000 years. It is incredibly, incredibly small. And the picosecond lasers do a much, much better job than their previous counterparts.

Interviewer: In what ways? Like what are we talking about here? What can someone expect if they're getting a picosecond Ferrari laser versus a . . .

Dr. Smart: Very much the Ferrari of tattoo removal. So laser tattoo removal in general, imagine if you were at a shooting range. You've got this laser, and you've got a target 20 feet down. And you're trying to hit just the bullseye, but your laser is in fact bigger than the entire target so you're shooting this bazooka down and hitting the target. You hit your target, you hit the middle, you hit the bullseye, but you also took out the entire target, everything surrounding it as well. That's similar to what older, longer pulse lasers used to do. They would take out the target, not as effectively, but also you'd get quite a bit of other damage: blistering, redness, and burn. Picosecond lasers are able to be much more precise and hit their targets with less surrounding damage.

Interviewer: And what does that mean in the end for a patient? Is that quicker recovery, less damage, you know what are we talking about?

Dr. Smart: Definitely. So you're dealing with a quicker recovery and a speedier time to resolution of your tattoo. Laser tattoo removal is not a once and done tattoo treatment. In fact, the average black tattoo probably takes, with older technology, around 6 to 10 different treatments. The picosecond laser is able to remove those black tattoos in less than half of that in most cases. So rather than 10 treatments, you're doing more like 4. It's really quite impressive.

Interviewer: The patient's going in to get their tattoo removed, what kind of side effects or risks are they going under by wanting to get their tattoo removed?

Dr. Smart: The biggest risk in laser tattoo removal is it not working. There are some patients, especially with the older lasers, where they will come in 20 times or even more, and we'll treat it again to try and get it to lighten further and further. And some are just resistant. That hasn't happened quite with the picosecond laser because when they become resistant to those older technologies, well, the picosecond laser will get better improvement than what you've gotten before. So the biggest risk is it's not going to work. Second biggest risk is that you are shining, you're firing this powerful laser on the skin, trying to hit the color, the pigment. And like I said before, you also get some surrounding skin burn-type injuries, so blistering and like a really good sunburn - not just a light one, but a good sunburn appearance is not that unusual of a side effect from laser tattoo removal, especially with the older technologies, less so with the pico.

Interviewer: So what you're saying is that some of these older lasers have a bigger chance of causing this type of damage?

Dr. Smart: They're less specific. They're hitting everything in their path, so you're getting more blistering.

Interviewer: And considering those types of dangers and . . . what would you say to a patient. You know, do you hop in a laser center at the mall? Like why is it important with dealing with this type of stuff to go to a real dermatologist rather than just a laser center?

Dr. Smart: Going somewhere that's inexperienced . . . so laser technology is fascinating. Clearly, I love it. I'm biased. I'm a skin doctor. But there are a lot of intricacies, a lot of nuances with what you're trying to hit and why. For example, the picosecond lasers they're pigmented in general. We use them to treat birthmarks of all kinds, scars, moles, and just aging - age spots, sunspots - they work phenomenal for just rejuvenation of the skin, evening out tone and pigment, not just tattoos. But you have to know what you're treating. You have to know what's in there - what pigments, what birthmark. And you tailor your laser settings and your laser choice, what laser you'll actually use, based very much on that. The laser companies do a very good job to give you a rote cookbook. Say, if person A comes in, here are settings. Use these settings. It's in their best interest to make it so that anyone can use these lasers. But be careful.

Interviewer: That's actually one of the bizarre things I came across while I was researching for this segment, was there are places online that are selling these lasers and like anyone can do it with a quick 19-hour course. How do you respond to that as a dermatologist?

Dr. Smart: Well, I think the biggest issue is that you get into it. There's a lot of people that are doing these lasers and we could get into a discussion about state laws and who can actually operate these Class 4 lasers and you can't. But I think most importantly, you will be able to tell if you're going to someone who has the knowledge and the science underlying what they're trying to do because they will be able to tailor the treatment very much to you and your situation. The better chance for a good outcome and less chance of negative side effects.

Interviewer: How would a patient know? How would a patient know that they are getting a good laser and they are going to a person who knows how to use this laser?

Dr. Smart: So honestly I would say talk to your dermatologist because while not all dermatologists do these things, all dermatologists know about these things because they're trained in it. It's on their board exams. They know about skin. They are the experts on skin, so they will be able to recommend and say, "Hey, what laser is this medi-spa using? Well, we don't have one, but if you're wanting to get this laser done at a medi-spa of some kind, tell me what they're doing. What settings are they using? I can help you out that way." As far as it relates to the picosecond laser, there are only a handful of those. I'd be very surprised if there were more than literally three or four in the entire state of Utah. They're very expensive. The downside of the new technology is you're paying for it. Not very many places can afford that kind of investment. So with the new toys, you want to have the new knowledge to handle them.

Interviewer: All right, so have a patient want to get their tattoo removed, what should they be doing?

Dr. Smart: The picosecond technology, that will get you the best results fastest, no question. There's a lot of great scientific evidence behind that. There's not a lot of picosecond lasers available so do your research and talk to your dermatologist.

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Interviewer: What types of skin conditions can laser skin therapy treat? How does it work, and why you should have a dermatologist do the procedure? That's next on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Your skin protects you, and just like any other protective cover it takes damage from the sun, the wind, even pollution. The result a lot of times is fine lines, wrinkles, pigment problems on the face, acne scars, sun damage, the stuff you look in the mirror, you see, and you're like, "I wish that could go away." Well, you don't have to live with all those things. Dermatologists can use lasers to take up to five years off the skin by treating surface issues.

We're with Dr. David Smart. He's a dermatologist with University of Utah Health Care. I want to learn more about your lasers and this skin therapy. So what are some of the common conditions that lasers can treat?

Dr. Smart: Well, that's a great question. I think people don't quite realize, there are many different types of lasers, and different types of lasers treat many different skin conditions. I like to describe lasers as being a modality or a treatment to help normalize the skin. Meaning, when you have too much hair, lasers can remove it. When you have too little hair, lasers can help grow it back. If you have too many brown spots, lasers can help get rid of those brown spots. If you don't have enough, if you have some light spots, lasers can help bring back that color.

So there are a variety of lasers that go after many different targets, and in the end they really help normalize or bring that skin back to health.

Interviewer: That's pretty amazing. How long has this technology been around?

Dr. Smart: It is quite recent in the grand scheme of medicine. In the last 20 or 30 years, there have been many really impressive, remarkable breakthroughs in laser medicine.

Interviewer: So is it fair to say that if you have some sort of a skin issue that bothers you and you're thinking to yourself, "Oh, I wish I could do something about that," lasers might be able to offer a solution?

Dr. Smart: There's a solution for that. It's certainly a possibility.

Interviewer: All right. Get a little geeky for me here. Tell me how does a laser . . . What's going on? Like when the laser hits my skin, how is it fixing problems?

Dr. Smart: Light. When we're dealing with the spectrum of light, not all light is the same. You've got a wide spectrum of light, and that light comes in different sizes. The sunlight is a specific size, and then you get into visible light, blue light, all the colors that you see, that's a different size. You get into ultraviolet, infrared. So there is a spectrum of light.

On that spectrum of light, there are certain things that absorb different wavelengths of light with different sort of affinities, meaning, this brown spot, that's going to absorb this wavelength of light. But really, that other one is not going to even touch it. Fat cells absorb different wavelengths of light, color-making cells. Tattoo pigment absorbs different wavelengths of light.

So what's happening is, depending on the medical condition that you have, someone who knows about laser medicine is choosing a specific wavelength of light, a specific type of laser to treat your condition, because your condition responds to a specific band of light.

When that band of light hits that target, the light is absorbed preferentially by that target and not by the surrounding tissue so that that target can be effectively heat-damaged without damaging everything around it.

Interviewer: When you say "that target," this is a cellular level?

Dr. Smart: Yeah. We're talking real small. We're talking particles. Like the molecule that makes brown in your skin, that's a possible target. The molecule that makes red in your blood vessels, that's a target.

Interviewer: So let's just take the molecule that makes brown. The laser hits it, then what happens to that?

Dr. Smart: The laser hits it, and depending on what setting you've chosen on the laser, you're either warming it up or you're shaking it to the point of disruption or explosion, essentially.

Interviewer: If you want to get rid of it, I would imagine you explode it.

Dr. Smart: Explode it, exactly.

Interviewer: If you want to make it more pronounced, you would warm it up.

Dr. Smart: Yeah, precisely. You would warm it up slowly, and that decreases the inflammatory pathway around it. That can result in improvement in conditions like psoriasis, vitiligo which is a color problem, and even that's why hair loss seems to be helped with certain types of lasers.

Interviewer: What about wrinkles? How are you getting rid of those wrinkles?

Dr. Smart: That's a great question, and while we're geeking out about this the target that you use to get rid of wrinkles is actually water. So you deliver the laser energy at a very specific depth. So you're telling the laser how deep you want to go, and you're essentially exploding, or removing, or damaging all cells that have water, which is all cells, in them in a specific pattern at a specific depth. So when you've calculated that out, you are effectively controlling which skin you're removing and which skin you're leaving.

Like aerating a lawn, the tool that you use is you really just cut it out. With the laser, the laser uses a wavelength that targets water and removes everything with water in that area so that the skin underneath can say, "Yeah. We are looking a little bit old. We are starting to get a little bit thin. We should rejuvenate this area," and the skin really does the rest. It's pretty remarkable that you cause the damage, the skin is what heals and cures itself.

Interviewer: Oh, so you're intentionally damaging skin in order to motivate it.

Dr. Smart: Force it to say, "Hey, step up to the plate here. Start working," and it does.

Interviewer: Very cool. Tell me a little bit about using these lasers, because I think I've heard ads for a lot of organizations that might use lasers for skin treatment. You're a doctor, a physician, a dermatologist, this is your area of expertise. Do you receive some special training, or is there an advantage to coming to you to use this technology?

Dr. Smart: Oh, you bet. So lasers were invented by dermatologists. Back on the East Coast, sort of the grandfathers of laser medicine are dermatologists out of Harvard, and they in fact own many of the companies back there that have created these layers to treat a variety of skin conditions. So there is specialty training both in residency, and there is specialty training in post-residency.

For me, myself, I completed a laser and cosmetic fellowship, extra training after residency for over a year in Manhattan, and those kinds of things do exist. But they're just getting started, and mostly just in dermatology.

Some very important issues, lasers are fairly powerful. Every now and again, more regularly than I'd like to see, a lot of people come in with complications that they've received at medi-spas, or somebody that decided they wanted to stop being whatever their profession was and start treating skin problems and call themselves a laser center.

So you do have to watch out for that, because there is specialty training and not every laser is created the same. Some lasers are Ferraris and some lasers are the Kia Souls, the very cheap type of lasers.

There are more side effects for the lasers that claim to do absolutely everything. And for people who are running them that really don't know the difference in how the chest skin is different from the face, and how the face skin is different from the scalp, what laser settings need to be used to treat those areas, and sometimes to the patient's detriment.

Interviewer: I think the important thing to remember is you've got the technology, and then you need to have the skilled technician that understands how the technology works, how the skin works, how the body is different.

Dr. Smart: Yeah, definitely.

Interviewer: Are the treatments for the various skin conditions relatively the same, in so far as how many treatments you're going to need, how often you need to go in, how long it's going to take? Or does it vary quite a bit?

Dr. Smart: It varies quite a bit. I'll use one specific example, and that's laser resurfacing. Laser resurfacing does a great job at, those lasers that you mentioned before, taking five years off the skin, those are resurfacing lasers.

Interviewer: How do you take five years off the skin? What exactly is going on there?

Dr. Smart: So like you said, skin takes a lot of the brunt of the damage, pollution, time, weather, sun, all of that, and it starts to get blotchy overtime. The pores start to get larger. The texture is not as smooth. It's more cobblestone-y, "crepe-y" we like to call it, a sort of fine paper type of appearance with a lot of wrinkles. Removing those things, normalizing the color, taking away the brown spots and the red spots, making it a smooth tone, and also smoothening out the texture, that's taking at least five years in many cases off the skin.

Interviewer: It sounds like to do something like that, you're probably using a lot of different lasers. Like you've kind of got to mix and match for each patient that comes in, "What are the issues we're trying to solve?"

Dr. Smart: Certainly.

Interviewer: And put together a treatment regimen.

Dr. Smart: Yeah. It's very, very personalized, which brings me back to that point before that not one laser is going to do all of these things. Some of the lasers actually do take quite a bit of time, a course of them. You are going to want to repeat some of these lasers four to six times. Some of the other lasers that have a little bit more bang right up front as far as their efficacy, they also have more downtime. So there are some lasers that are going to get you five years off the skin with just one treatment, but you're probably going to not want to leave the house for a week.

You're going to be a little bit red. It's going to be apparent that you had something done for several weeks after that treatment. Whereas, some of the other lasers that do the same thing in a more conservative, more elegant fashion, they get you the same result, but it might take six months, nine months of repeating this laser treatment on a regular basis. But your downtime, much better.

Interviewer: There again, that's where having somebody that really understands the skin and how these lasers work, and the best laser for the job. Are there side effects to these treatments? Twenty, 25 years down the road, am I going to have less skin now and I'm going to be more vulnerable to the elements?

Dr. Smart: That's a great question. Surprisingly, no. To be totally fair, we haven't been doing these treatments on a very large scale for more than a few decades. So we don't have quite that much evidence. But going back to what I said, normalizing the skin, so the skin actually becomes healthier, stronger, and thicker with repeated laser treatments, rather than thinner and less skin.

Interviewer: This is such a crude analogy. It's not like sandblasting?

Dr. Smart: No, it's not like sandblasting.

Interviewer: It actually makes the skin healthier. That's fascinating.

Dr. Smart: Yeah. It's more like aerating a lawn, actually. You're removing certain places, but leaving healthy patches to grow in, fill in that area.

Interviewer: Then, overtime it becomes a healthier lawn.

Dr. Smart: It's even healthier, yeah.

Interviewer: The skin becomes healthier with laser treatment as well.

Dr. Smart: Precisely.

Interviewer: Are there any side effects? You had mentioned that some treatments you might need to take a few days off, because somebody would be able to tell that something happened.

Dr. Smart: Oh, yeah. Most definitely, and of course depending on the laser entirely. But laser energy is essentially, when it all boils down to it, heat. So burns are the most common side effect, burning, blistering, and most of the time you're trying to get a mild burn. You're going for a light sunburn appearance, because that's what the result is to show efficacy.

You really do want to have some appearance that something's been done. Generally speaking, that can go away in anywhere from 30 minutes to a day, a few days, and that just depends on the laser you choose and what you're going after.

Interviewer: What should a listener know to make an informed decision about this? I think we've covered a lot of the bases. Is there anything that I forgot?

Dr. Smart: There are many different lasers, and there are many different problems, tattoos, scars, and a variety of medical treatments that can effectively be treated by laser. So you really just have to go somewhere that has some experience.

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