Surgical & Non-Surgical Approaches to Facial Aesthetics

Dr. DeBusk (00:08):
Welcome back to Behind the Double Doors. This is Dr. Taylor DeBusk, board certified facial plastic surgeon with Basu Plastic Surgery. Today we've got Denae, our master injector, and we're going to talk about the relationship between the injectables, Botox, fillers and things like that, as well as facial rejuvenation surgery. So today, can you kind of tell us about yourself, your experience, your history, how long you've been in the industry?

Denae (00:32):
Yes, so I'm master nurse injector here. I started in nursing, in pediatrics, and after about five years in pediatrics, I changed to aesthetics. So I started injecting in 2007. So mostly I do neurotoxins, fillers, Sculptra like biostimulators and PRP into the face.

Dr. DeBusk (00:57):
When we look at the face as a surgeon, I focus on specific things and as an injector, I mean you focus on similar things, but you start kind of that process earlier. So for me, when we talk about facial rejuvenation, I'm seeing people a little bit further down the line when gravity has really taken hold of the face and we start to see those age related changes, whether it's due to laxity of skin, the separation and ptosis or dropping of the fat in the face. But for you, you see a lot of people at the beginning, kind of the preventative stages. Your clientele, what are you seeing most of? What are some of the trends you've kind of seen in your experience? Just things that you've seen over the years.

Denae (01:39):
Yeah, I mean, it's come a long way. When I started, a lot of people didn't really know what Botox and filler was for. So now when people come in, they have a very clear idea of what the differences are between them and that your Botox or toxins are really for preventative and your fillers are for correction. So I'm seeing people from all different ages. I mean even as low as 18 up until 80. It just depends on where they are, what their history is, how good they've taken care of their skin and what their goals are.

Dr. DeBusk (02:14):
Yeah, I mean it is for everyone, regardless of what stage you are in the aging process. One thing that our colleagues, patients have started to say or hear is that doing too much Botox will age you, make you look older. Have you had people ask you that and what are your thoughts on that?

Denae (02:33):
A little bit. I think we probably see that a little more in filler when filler overdone. It can make you look a little bit older. But with Botox, typically we want to do it to where you can't notice. So it's just preventing those lines from forming and the wrinkles from really becoming deep set. Because once they're set in stone, really when you're seeing it in between the eyes, that's typically where people find that it gets the strongest, then we really have trouble taking it away. So if you're preventing that muscle from crinkling up and causing that line, then you're going to see that you will look younger over time.

Dr. DeBusk (03:12):
What's interesting is that some of my friends in different states have had patients that have had previously been injected or seen specific providers that have told them that chronic use of Botox will cause atrophy or thinning of the facial muscles. And if you lose the volume of the facial muscles, they say that you lose volume in your face, it makes you look older. And in my experience, that is not the case. And it's kind of silly to think that atrophy of the facial muscles will cause any sort of visible volume change. Because when we talk about facial muscles, they're so thin, they're about one to two millimeters thick. They're not like a bicep. If you have atrophy of a large muscle, yes, it's visible, there's a visible change. But with atrophy, potential atrophy of the facial muscles, that's not anything that's any of any significance clinically. I mean, you can't tell. So I think it's funny that people are starting to hear this, starting to believe this, and I personally have not had patients ask me this, but I've had friends that have brought this up, which I thought was funny. We use Botox to prevent wrinkles, but they're being told that Botox makes them look older, cuz it makes your face too thin, which is not true.

Denae (04:23):
No,

Dr. DeBusk (04:25):
For us because us together provide the full spectrum of facial rejuvenation or preventative age-related changes to the face. When I see patients, I really kind of go from the top down, forehead, eyes, cheeks, lips, chin, neck, and talk to them about what we typically see with time, age, and genetics. For you, when you're looking at the forehead, I'm assuming that's one of the most common places that you treat with neurotoxin. Tell me, when you evaluate a forehead, what are you looking at? What do you recommend? What are the things that you have to watch out for when you're doing your initial evaluation?

Denae (04:59):
So the forehead is probably one of the most tricky areas to treat in between the eyes isn't too bad, so we see a little bit of a lift in between the eyes whenever we do Botox there, but whenever we go into the forehead, it's pushing down on the eyebrows. So if you have very lax skin or maybe you're already genetically predisposed to a little bit of eyelid hooding, then you might see an increase in that once we treat the forehead. So have to be really careful with people that have a lot of movement in their forehead. They want to reduce the wrinkles, but then they also have a lot of hooding and heaviness in the eyebrows. So as people age, we see that this becomes more of an issue. We really have to back off of the amount of Botox that they use because they want their eyes nice and open, but they want to take care of the wrinkles too. So that's where you come in, because I can only do so much with Botox. It will push down on the eyebrows and then close the eyelids a little bit.

Dr. DeBusk (05:57):
Yeah, no, I mean that's a good point because every time I see a patient for facial rejuvenation, I always ask if they get Botox on their forehead. And most often people experience the heaviness of the brows, just like you're saying. They used to get a lot of Botox on the forehead, but as of recent or the last couple of years, I feel like the brows got really, really heavy. So I've actually backed off. And for me, that's a really telltale sign that people are ready for a brow lift. There are many different types of brow lifts depending on the patient, the gender, the hairline, the amount of we call ptosis or heaviness of the brows. So when we look at that, when we look at the patient, we have to tailor our approach. So I would say the most common type of brow lift I do is the temporal brow lift or really just elevating the outside of the brow.

(06:47):
And that's what people notice first, like you said, the hooding. And that's where people usually are most symptomatic in the beginning. And by doing a temporal brow lift, it's a small incision in the hairline in the temple, and we release the attachments from the bone to the underlying soft tissue and just subtly elevate the outside of the brow. At most, you can only get about five millimeters of elevation. Patients are always weary in the beginning when I say brow lift, because when people say brow lift or when I say brow lift, people think Kenny Rogers or that over surprised look. But when we talk about the approaches, we talk about the conservative ways to give them a really natural appearance. I also tell patients that just because we surgically manage the brow doesn't mean that you should stop your neurotoxin treatment. What the brow list will do is they put your brow back in a more youthful position so that when you dose up the forehead, the brows will no longer drop.

(07:44):
So you reposition the brow, rejuvenate the brow, continue to the Botox to prevent the further deepening of the wrinkles that they have. So I think you can see that you start with the non-invasive or the injectables. Once everybody gets to that point, they need surgery. Just because you have surgery doesn't mean that you no longer need the neurotoxins or injectables. They compliment each other. So then when we're looking at the eyes, one of the things that we see as we age specifically of cheeks and the lower eyes is that the superficial and deep fat pads over the most prominent part of the cheekbone, the fat starts to involute or resorb. They separate and then they drop. And when I talk to people, the most common thing you see in the midface is you start to see the deep nasal labial folds and people start to see the tear trough, which both can be managed with injectables. And then there's obviously with just like everything else, there's a point with which you have to treat surgically. So for you, how do you approach the lower eyes, the cheeks, kind of that midface nasal labial fold area when you're evaluating a patient?

Denae (08:53):
So temples are something that we do too, which is just a little bit on the outside of the eyebrows. That's where you see the little hollowing right there. People will call that a peanut head, which is not nice, but that's typically what it's called. But we can fill in that space and then as we get a little bit lower into the tear troughs and the cheeks, we can fill in the cheeks with our hyaluronic acid fillers as well as the tear troughs. Some people can get away with just having filler in the tear troughs, but most do need that support in the cheeks because it will get that support for the tear troughs so that we'll get the best results. I will have people come to me and say, well, I had it in the tear troughs and I didn't see good enough results. Well, they have flat cheeks, we need to also treat the cheeks so that they get that full support. And then for the nasal labial folds, we typically see that improve when we do the cheeks because it gives a little bit of a lift. It is a subtle lift, so when people do come in and they say, oh, I want to pull my face back where it was 20 years ago, we're not going to achieve that with filler. We'll get a subtle lift with filler, but not that that is more of a surgical candidate for sure.

Dr. DeBusk (10:03):
Yeah, no, I agree. I think that's the biggest facade in regards to filler and the aging face is that you see out there the liquid facelift. And I think that is really misleading to most, if not all patients, because reading that or seeing that, you just assume that you get the facelift results with injectable treatments. And I agree with you. I think that you can get an improvement, but once you get to the point where aging has really crossed that threshold, there's no getting that surgical result with non-surgical treatments. When people ask you about filler in the tear troughs, it was very popular for a while, I think it started to fade. Obviously you have a very heavy injectable practice. Are you seeing that trend away from filler in the tear troughs or what are you seeing in that area?

Denae (10:58):
A little bit. It does seem that the trends will follow what the FDA approval is. So when we saw FDA approval for cheeks, that increased quite a bit. When we saw it for chin, that increased quite a bit. And then now for tear troughs, well tear troughs has been a little while, but there's been some products that came back out remarketed for tear troughs. So then we see the popularity come out. Again, I think people are understanding that you do need to have cheeks as well as tear troughs. And then some people are wanting to go a little bit more natural with things like PRP, but I still do see quite a bit of tear trough filler and there's a lot of benefit to it. I mean, you're seeing it right away, but there is a downside to it as well. It can cause some puffiness there, especially if you're prone to getting puffiness.

(11:45):
If you wake up and your eyes are already a little bit swollen or you have allergies, then you're going to see that increase whenever we put filler there. So you might be a better candidate for PRP. The other thing is it's not the fix for everything. It's not the fix for crepey skin. And I think a lot of people come in thinking that filler is going to fix everything under the eyes, but sometimes you need something else. Lasers, chemical peels, maybe even Botox for around the crow's feet. So people are definitely asking for it, but we're trying to educate on what it's actually used for.

Dr. DeBusk (12:21):
So filler, there's all kinds of variations, and it's overwhelming even for me because I feel like it's constantly changing. When you're looking at the types of fillers that you want use, say in the cheeks or in the fine lines, wrinkles of mouth around the mouth or the under eyes, what are you looking at? Are you looking at the thickness of the types of filler? What kind of pushes you to use a specific type of filler in one part of the face versus the other?

Denae (12:46):
Well, so most of the fillers that we use are hyaluronic acid, and there are a lot of different brands of hyaluronic acids. In the US we use Juvederm and Restylane, and under those brands, they each have about six or seven different types of filler. So they have different consistencies, different flexibility. So if I'm going into the cheeks, then I don't need all that flexibility. I want something that's going to be very robust and kind of mimic the bone or the fat that's there. If I'm going in the nasal labial folds or in the lips, then I want a different consistency. Nasal labial folds, you want something that's more flexible so that when you smile, it moves with you. So it really depends on where we're going and what their goals are with what we're going to choose. But typically it's going to be a hyaluronic acid filler.

Dr. DeBusk (13:38):
Yeah, I think that because you've had a lot of experience, have you seen different types of fillers that have been used in the past that maybe aren't as easily treated or dissolvable specifically in the midface, the jaw, the nose, different areas?

Denae (13:53):
Yeah, so hyaluronic acid has just become so much more popular because we can reverse it. So it gives us that peace of mind. So if something goes wrong, we can go in with an enzyme called hyaluronidase and dissolve, but there are other fillers that are a little bit more permanent. So people really like the idea of something that isn't quite as temporary as a hyaluronic acid, but we don't have a reversal agent to it. So Hydroxyapatite is one of those also called Radiesse. I really like it, but it isn't reversible, so it's good in certain situations. And then there's also things like Bellafill a little more permanent, but again, we can't reverse it. So it's good if you're looking for something, but if something goes wrong, then you just have to wait and see it out.

Dr. DeBusk (14:44):
Yeah, I think that when you approach patients that are maybe interested in something that's a little bit more permanent, how do you approach that? Do you say, all right, well, initially we'll start with kind of an HA filler. If you're liking the results once it dissolves or we dissolve it, then that kind of maps out our plan. For your hydroxyapatite or calcium hydroxyapatite, long-term filler, how do you approach patients that are really interested in radius but may be a little bit apprehensive?

Denae (15:11):
Yeah, what I prefer to do is pair hyaluronic acid with other injectables too. So there is s Sculptra, that's a bio stimulator, so we're actually getting some stimulation of collagen and elastin, whereas your hyaluronic acids, they're just adding volume to the area. So those two together work really well. Also, I recommend getting some laser treatments, maybe radio frequency, something else to help stimulate collagen.

Dr. DeBusk (15:42):
So for you, when you start to see people that are not really responding or start to have significant age-related changes or the tear trough, if it gets to a point that you don't feel like they're going to respond well to filler, how do you approach that with patients?

Denae (15:59):
We talk about surgery, and that's just based on people's preference too. I mean, some people are okay with having some lines and folds and a little bit of sagging here and there, and some people are absolutely not okay with that even at a young age. So it just kind of depends on that person. But I do discuss that there are other options outside of filler, and sometimes even they'll get surgery and then we'll still end up doing filler, but they'll get a lot more out of it after maybe having some surgical intervention.

Dr. DeBusk (16:32):
Yeah, intervention. No, I totally agree. When we look at the eyes, specifically the lower eyes and people once they're ready for a blepharoplasty or a lower eyelid lift, blepharoplasty is not the same thing across the board. So all surgeons may have different approaches. Blepharoplasty is just a generic term for eyelid surgery. So for me, I see people with tear troughs that have had filler in the past or maybe don't want filler or haven't responded well to it, and they're ready to have a more permanent surgical change. And I see people with really big eye bags, and when I see those are the two most common reasons people want lower eyelid surgery and I treat them or have to treat them differently. So when we're talking about the aging process of the midface is the fat separates resorbs and drops, we start to see the fat in the orbit or in the eye socket.

(17:26):
It's not that we have, we're getting fatter in the eye. We're just starting to see what's there because of the lack of volume elsewhere. So with big, fat, eye bags or really puffy, lower eyes, we can do a scarless approach or we make an incision underneath the eyelid and we remove fat to try and create a more soft or smooth contour from the lash line down to the cheeks. And then people with deep tear troughs instead of taking out fat because they have a hollow actually reposition the fat. So we take two of the three fat bags and we mobilize them, and then we actually bury them underneath the soft tissue of the cheek, right onto the cheek bone itself. So what that does is it elevates that hollowness in the lower eye, eliminates that tissue void, creates again, that soft transition from the lash line down to the cheeks.

(18:20):
It's a permanent change because the fat has blood supply, so it doesn't go anywhere. So a lot of times it's good for patients that have had filler consistently in the past, they've had good results, but they're ready for a permanent change. But that being said, again, with age-related changes to the face, we see that volume loss. So just because you have the lower eyelid blepharoplasty doesn't mean that you're done with filler. There's still a good role, a very important role for filler to volumize the cheek because there is such an intimate relationship between the cheek and the eyelid. So anyways, that's something that people aren't always aware of after having eyelid surgery because the first question is, is this permanent? Am I going to have to do this again, nothing's permanent because you can't get rid of gravity, but it is a much longer lasting treatment option than kind of your noninvasive options. So then we've kind of talked about the forehead, the cheeks, the midface, now lips. Lip filler I think is probably one of the most common types of filler that people get, but most people are afraid of the duck lip. What is the role in lip filler? How do you approach it? Do you use neurotoxins around the mouth, around the lip chin? How do you manage the lower face?

Denae (19:39):
Yeah, sometimes some people want to show a little bit more lip when they're smiling and if that's the case, and typically that's muscular, so I can add a little bit of toxin to the upper lip. They call that a lip flip. It also helps the vertical lip lines from forming. We can also help with gummy smile with toxin. That also takes a small amount, and it just keeps the lip from pulling up so high so that you see the gums. So this way the lip just stays down a little bit. If they're looking for volume, then of course filler is the way to go, but there are multiple types of filler there, too, different consistencies. And so I'll ask them, well, do you want a really full lip? Do you want just hydration? So we'll go off of that and then we'll decide which type of filler is best for them all hyaluronic acid, it's just which consistency filler do we want to use.

Dr. DeBusk (20:33):
With lips, do you feel like there's a specific type of filler that may swell more or brings in more water versus a different type of filler? Or for the most part, is it pretty consistent across brands?

Denae (20:46):
Yeah, there's some that swell more than others, but what I do tell patients is that you are going to swell. I mean, no matter what you're going to swell, you'll probably bruise. You might just bruise a little bit. You might bruise a lot, but I tell them, give it two weeks to really calm down. So don't plan on taking pictures the next day because you're likely not going to how you look the day after you get lip filler, it's going to be swollen and it's probably going to be bruised. So no matter which type of filler you use, it's going to do that.

Dr. DeBusk (21:15):
Yeah. Do you feel like specifically with your aging patient population, there's a point where filler just is not doing what they want it to do?

Denae (21:26):
Yes. I mean, we see as people age, we get a bigger space between the nose and the upper lip. So sometimes they really want to decrease that space, and sometimes we can do that with filler, but sometimes we get to the point where they go, okay, I don't want my lips any bigger. I just want my youthfulness back. Which really they're saying they want that space to be decreased. So that's where you come in again?

Dr. DeBusk (21:51):
Yeah, no, I think so you have the lip flip, which is the neurotoxin, and you have the lip lift, which is the surgical procedure, and that in itself is confusing. And the lip lift is just like you said, you remove a small amount of tissue just below the nose and embryologically, there is actually, there's a really natural crease that creates a shadow, which is perfect for incisions right under the nose, kind of the sub nasal lip lift. And what that does is with time, just like you said, the skin of the lip elongates, and a lot of people, they'll start to notice that when they smile to get this crease of this pleat underneath the nose. And what that is, is, again, the muscle underneath the skin hasn't actually elongated or been as affected by gravity, but the skin has, so the muscle will contract because there's extra skin.

(22:46):
They get that pleat, that natural pleat in the lip under the nose. So for me, that's what I always look for when people are interested in a lip lift, because it's the body's way of telling me, Hey, this is how much I need removed. But also when you're looking at lips, lips are very, very, can be challenging to treat because they're a very dynamic circular muscle to face, and they have a very unique shape to them. So in order to rejuvenate the lips, you have to recreate a very natural number one shape to the overall lip, but then an appropriate amount of volumization because you can get a very unnatural lip very easily, and specifically with a sub nasal lip lift. When we look at the lips, the central part, if you just elevate the central part of the lip, well then it can be very unnatural, especially if you make the lip too short.

(23:36):
So you have to look not only the central part, but as well as the outside or towards the corners of the mouth because you want a good relationship between all of that. You see a lot of people that just do the lip lift under the nose, and then these patients kind of look like chipmunks where there's too much dental show and it's a very unnatural overall shape. So those are the things I talk to patients about. I think initially during the discussion, most people are really afraid of the scar because it's a scar under the nose. But when we show them post-ops, they're very surprised at how well the scars heal as long as they're put in an appropriate spot. Then when it comes to volumizing the lip, there's actually, because you can use the filler. Again, filler's, not necessarily permanent, but you can use fat and you can actually use subcutaneous tissue to fill or volumize the lips. And it's kind of the same as a filler approach when it comes to fat. So you take fat from the leg, the abdomen, and you can inject fat directly into the lip, and the majority of that fat should be viable or live long-term. Usually it is a permanent option. Then oftentimes when we do facelifts, you can use some of the extra skin and remove the top of that skin off and put that in the lip. Again, that's another option to volumize the lip with a more permanent result.

Denae (25:00):
I used to see lip implants quite a bit. Do you see that anymore?

Dr. DeBusk (25:05):
So silicone lip implants, I have seen them. I have personally have not placed them. I've removed some. There's acellular dermis that people have used, which is kind of like a cadaveric skin, which sounds crazy, but you can get decent results. The one thing is though the body can create a foreign body reaction to it, so there's more complications with those types of things that are not dissolvable and are not made up of your own body that are foreign materials. Now, when we are looking at the lower face with age, we see that the chin will recess or kind of drops back as the bone resorbs. We also start to get to the jowls. Now, a lot of people are always complaining of jowls, but what are jowls? So that's where we start to get on the outside of the chin, the skin will start to thin, which creates a shadow, and then the soft tissue of the face starts to drop, which further emphasizes that shadow for you. Do you get a lot of people complaining of jowls and want filler to manage those jowls, and do you feel that neurotoxins can help with that? What has been your experience?

Denae (26:13):
I don't see that neurotoxin helps with it a whole lot, but I do have a lot of people complaining of jowls. So most of the time I will put filler into the prejowl sulcus, so in between the chin and the jowl to kind of bridge that gap also in the marionette area to kind of fill in this hollow as well. And then sometimes we can put it in the chin to also just trick the eye a little bit. I think some people think that treating the masseters or the muscles in the jaw with toxin can help with that, but I find that people that are typically over 40 tend to see the jowling get a little bit worse whenever we treat the masseters. So I would say that filler is definitely my best option when treating the jowls.

Dr. DeBusk (27:01):
Now, for me, that is the most common reason people want a facelift is the jowl, because the jowl really ages the face and you can't hide it. There's no makeup that really can cover up the jowl. So the way that we manage that is through the deep plane facelift technique, by elevating the soft tissue, actually releasing a really strong attachment from the jowl skin to the bone. And when you release that as well as the deeper muscle layer, and you can reposition it and it completely eliminate the jowl as well as those marionette lines. And then chin implants are fantastic. I think that just like chin filler, you have to know how far out the chin needs to be width, all those types of things. And that's what I have to evaluate when we want to put in a chin implant, because you don't want to give everybody a Jay Leno chin, even though it's attractive chin to some, maybe not to all. When you're looking at somebody's chin, male or female, what are you looking at? What are you evaluating to tell you where to put your filler, how much filler to put in, or what kind of shape you're trying to create?

Denae (28:08):
So normally I look at their profile first to see if it is retracted a little bit. Also, if they want to add lip filler, then sometimes that'll make it look even more off balance, so then we definitely need to bring the chin out and give it a little bit more projection. Some people just want that projection, and then some people do want a little bit more narrowing of the face from the front, so we look at that as well. But not everyone needs that. It just depends. Typically, I am using a thicker filler there, and some people after using filler there for a while, they do end up getting a chin implant because they do want something a little bit more permanent.

Dr. DeBusk (28:45):
Yeah, again, I think you stated it perfectly that you have to look at the balance of the rest of the face. I see people all the time that come in and will really dislike the projection of their chin, but it's not the chin. It is actually maybe the relationship between the nose and the chin. So by fixing the nose, it gives you a better relationship between the two or vice versa. Sometimes they focus on the nose, but it's actually, if you project the chin a little bit more, makes the nose look smaller, kind of works better with the face. With men, men want a little bit more of a broad square chin. Women want a little bit of a sharper contour to kind of help create that heart shaped face. So when I do chin implants, I do a small incision underneath the chin where we all have a natural crease, and it does two things.

(29:32):
It minimizes risk for infection as opposed to go into the mouth. And then two, it gives us me better control of where I place the implant. I think chin implants, again, like the rest of the face, if done appropriately and conservatively, it really can improve your overall facial balance or the relationships with the different parts of the face, especially the chin and the neck. For you, with the neck, a lot of times I feel like the platysmal banding or those cords that we start to get as we age can be treated obviously surgically, but have you found good options to treat it with neurotoxin, fillers? How do you approach those bands in the neck?

Denae (30:15):
Yeah, the vertical bands tend to react really well to toxin treatment, and we can do the medial vertical bands or the lateral or both, because some people you definitely see it more than others, the medial ones, it could look like your chin or your neck is coming down a little bit more, but if we relax that band, then it kind of pops back up a little bit. There used to be an indication for a toxin for the horizontal bands, but I don't really see a great improvement with that. We have tried filler there as well, but not as good. We see a little bit better results with microneedling, lasers, things like that for the horizontal bands. But vertical bands, yeah, they react very well with toxin.

Dr. DeBusk (31:02):
Yeah, I mean, the vertical bands are usually strong areas of the platysma muscle that become more prominent with age. We see it actually, you see it in facial paralysis patients where they get hyperactive platysma muscles and it creates this really, really thick band, and it responds extremely well to neurotoxin. The horizontal bands are usually the creases that are perpendicular to the muscle contraction. So yeah, I think that you got to treat the skin with the fillers or the microneedling and things like that. And then with surgery, the way that we treat the bands, it gets to a point where there's so much laxity in the muscle and there's such a separation of the ligament from the muscle to that bone above the voice box that you have to just completely sew those muscles together and recreate the ligament to put it back in a more youthful position.

(31:53):
Or people with those hereditary neck, that kind of really full, lower neck because it's just a genetic thing. Their parents had it, their mom had it, their dad had it. You can recreate or create a more defined neckline by removing some fat, sewing those muscles up to that bone and pulling it actually tight laterally from underneath the jaw just to give improved contour. So I think the face is a very interesting thing. There's a lot of different ways to manage the same concern. Well we talked about a lot. This is how I approach every patient, we talk about the face as a whole, but really the role for filler or injectables as well as surgery. And I think that oftentimes surgical patients think once they heal from their facelifts or their surgeries that they're done with injectables. And I think that I need to do a better job of preemptively letting them know that surgery is just one part of the rejuvenation process.

(32:53):
It helps to combat some of those age-related and gravity related changes, but not all of them. You need to keep up with the Botox to minimize the deepening of the wrinkles, keep up with the fillers, because again, we lose volume in our face soft tissue as well as bone. So there is a significant need or indication to continue doing those things in the appropriate way. And I think that you probably have patients that aren't as aware also that fighting the aging process or maintaining that face rejuvenation is a multi-prong approach. It's not just one thing or the other. You kind of have to hit it from every angle. So Denae, when you're seeing people for Botox, is there a point where you tell patients you're too far gone or Botox is not the only thing you need? Do you recommend other treatments, other options? How do you approach that?

Denae (33:45):
Yeah, I mean, it's a difficult thing to approach, but I don't want people just wasting money just to waste money. Also, there can be some side effects with it, like we talked about doing a forehead and getting heavy eyelids, and nobody wants that either. So I will talk to them about surgical intervention, and normally I'll refer them to you or Dr. Basu and tell them it's, it is not nearly as scary as it used to be, and people don't look as pulled and tight as they used to either after getting facelifts. I'm surprised by that. Same as upper blephs, lower blephs, we do see a lot of that now too. I'm shocked at how natural people are coming out. Yeah, they're going to have some downtime, but it does seem to be a lot less than what it used to as well.

Dr. DeBusk (34:34):
I agree with you a hundred percent. I think most of my patients initially are concerned about looking overdone or looking fake, and we've come a long way with facial rejuvenation surgery even within the past decade in creating a very natural appearance. And not only the natural appearance, but again, I think I always stress that as a patient, you need to have a great relationship with your injector as well as your surgeon because again, we work hand in hand to optimize their result, to obtain their goals, and to continue to rejuvenate and maintain that more youthful appearance.

Denae (35:12):
And this business is unique where we have our medical background, but then we also put art into it. So I think because of that, we take a whole lot of pride in our work. So we want people to be happy, we want them to look good, we want them to feel good, so we want the best for them. So we don't want to just put things in them that they don't need or have some unnecessary costs or side effects that they don't anticipate. So we're looking for the best for our patients.

Dr. DeBusk (35:43):
Yeah, no, I agree. And I think what we do, the way patients look quite literally reflects on us. So I think that we want to give them the best because we want to create the best product or best results.

Announcer (36:01):
Basu Aesthetics and Plastic Surgery is located in Northwest Houston in the Towne Lake area of Cypress. If you'd like to be a guest or ask a question for Dr. Basu to answer on the podcast, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery, that's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, T-H-E-A-X-I-S.io.