#13 - Brett Kotlus, M.D.: How to look younger while you live longer
Dr. Brett Kotlis, a NYC oculofacial plastic surgeon, discusses maintaining a youthful look, covering surgical and non-surgical options. He shares practical advice on skincare, common cosmetic procedures like Botox and fillers, and how to choose a trustworthy provider.
Deep Dive Analysis
17 Topic Outline
Dr. Brett Kotlis's Unique Oculofacial Plastic Surgery Training
Intrinsic and Extrinsic Factors Causing Facial Aging
Genetic Influences on Skin Aging and Appearance
Avoiding the 'Unnatural Look' in Cosmetic Procedures
Trends in Facial Augmentation and Lip Fillers
Dr. Kotlis's Cannula Technique for Under-Eye Filler
How to Choose a Trustworthy Cosmetic Procedure Provider
Common Botox Mistakes and Correct Application
Psychological Aspects and Confidence in Cosmetic Procedures
Understanding Sunscreen: UVA, UVB, SPF, and Types
The Role of Retinoic Acid in Skin Rejuvenation
Benefits and Limitations of Topical Vitamin C for Skin
Modern Trends and Nuances in Botox Applications
Effectiveness of Cryolipolysis and Other Fat Reduction Devices
Chemical Peels vs. Laser Resurfacing for Skin
Skepticism and Efficacy of Platelet-Rich Plasma (PRP) Treatments
Future of Cosmetic Surgery: Biologics and 3D Bioprinting
8 Key Concepts
Solar Elastosis
This is a condition where the skin loses collagen and elastin due to prolonged sun exposure over many years, leading to decreased skin thickness and degradation of supporting structures.
Tear Trough
This refers to the groove or shadow that develops under the eyes, often making people look tired. It results from the combination of puffy under-eye fat pads and volume loss in the upper cheek area.
Cannula
A cannula is a blunt-tipped needle used for injections. It allows for a more accurate and less invasive approach, especially in sensitive areas like under the eyes, by creating a single entry point and then navigating the blunt tip.
Melasma
Also known as the 'mask of pregnancy,' melasma is a condition characterized by darkness or hyperpigmentation on areas like the cheeks, upper lip, and forehead. It can be worsened by heat, which is a factor in some chemical sunscreens.
Etched Lines
These are wrinkles that remain visible on the skin even when the underlying muscles are relaxed. Cosmetic treatments like Botox are most effective when applied before lines become 'etched' to prevent their formation.
Fractional Laser
A type of laser technology used for skin resurfacing that creates microscopic dots of treated skin, leaving areas of normal skin in between. This allows for faster healing compared to traditional lasers or chemical peels that treat the entire surface.
Cryolipolysis
A non-surgical fat reduction procedure that suctions and freezes subcutaneous fat cells at a specific temperature. This process causes apoptosis (programmed cell death) of the fat cells, leading to their gradual removal by the body.
Platelet-Rich Plasma (PRP)
PRP is derived from a patient's own blood, which is spun down to concentrate platelets. These platelets release growth factors that are thought to stimulate healing, angiogenesis (new blood vessel formation), and neocollagenesis (new collagen formation) when injected or applied to tissues.
7 Questions Answered
Facial skin ages due to intrinsic (genetics, bone and fat loss) and extrinsic (sun exposure causing solar elastosis, loss of collagen and elastin, increased blood vessels and brown spots) factors. These changes affect the skin, fat, muscle, bone, and supporting ligaments.
To avoid an unnatural look, one should aim for subtle changes that restore a more youthful appearance without distorting natural dimensions or expressions. This involves not trying to look too many years younger than one's actual age and selecting providers who prioritize balance and natural contours.
Look for providers certified by relevant organizations (e.g., oculoplastic, facial plastic surgery), seek referrals from trusted sources, meet with multiple providers to assess rapport and shared goals, and ask about their experience, complication rates, and willingness to refer out for procedures they don't specialize in.
The correct approach involves injecting the corrugator and procerus muscles (between the eyebrows) to treat frown lines, with only a light 'sprinkling' in the frontalis muscle (forehead) to weaken contraction without completely immobilizing the brows or causing them to drop.
People should use 'broad spectrum' physical sunscreens containing zinc or titanium, with an SPF of at least 30. Physical sunscreens reflect UV light and are generally preferred over chemical sunscreens, some of which can have hormonal disruptive effects or worsen melasma.
The three most important topical tools are sunscreen (in the morning), topical vitamin C (in the morning, after serum dries), and retinoic acid (at night). This trifecta provides protection, antioxidant benefits, and promotes collagen synthesis and skin cell turnover.
While PRP is widely available and aims to stimulate healing and collagen production, its effectiveness for facial rejuvenation (like 'vampire facials') or hair loss is often oversold and not strongly supported by robust scientific literature. Results can be subtle and inconsistent, and the biggest risk is often financial loss.
14 Actionable Insights
1. Embrace Small, Consistent Changes
Adopt a philosophy of making small but consistent changes over time, as these seemingly minor improvements accumulate to produce significant long-term results in areas like health, longevity, and appearance.
2. Adopt a Daily Skincare Trifecta
Implement a core daily skincare routine by applying broad-spectrum physical sunscreen (SPF 30+) and topical Vitamin C serum in the morning, and using a retinol or tretinoin product at night. This powerful regimen is highly effective for anti-aging and overall skin health.
3. Prioritize Daily Sun Protection
Protect your skin from UV radiation by applying broad-spectrum physical sunscreen with at least SPF 30 every morning, reapplying every two hours when exposed. Focus on the face, hands, and chest, and wear a wide-brimmed hat for additional protection, as sun avoidance is crucial for preventing skin damage and cancer.
4. Incorporate Retinoids into Night Routine
Use a retinol (over-the-counter) or prescription tretinoin product nightly to promote collagen synthesis, increase skin cell turnover, and reduce wrinkles and pigment. Start with lower potency or less frequent application if new to retinoids, and apply to the entire face, including eyelids, for comprehensive results.
5. Apply Topical Vitamin C Serum
Integrate topical Vitamin C serum into your morning routine, ideally after cleansing and before sunscreen, to act as a powerful antioxidant, scavenge free radicals, and protect against UV damage. It works synergistically with Vitamin E, and you should allow it to dry for a couple of minutes before applying sunscreen.
6. Select Cosmetic Providers Carefully
When choosing a provider for any cosmetic procedure, seek referrals from trusted sources, interview multiple doctors to ensure good rapport and shared goals, and prioritize their experience, knowledge of anatomy, and patient selection over specific labels or training types.
7. Ask Critical Questions to Providers
During consultations, ask providers about the number of procedures they’ve performed, request to speak with previous patients, inquire about potential complications and their management, and ask if they offer alternative solutions or refer out for procedures they don’t specialize in.
8. Aim for Natural-Looking Botox
If considering Botox, seek a provider who understands facial anatomy and aims for subtle, natural results by primarily treating the corrugator and procerus muscles (furrow lines) with only a light sprinkling in the forehead to preserve natural brow elevation and expression.
9. Consider Under-Eye Filler with Cannula
For under-eye bags or tear troughs, explore hyaluronic gel filler injected with a blunt-tipped cannula from the cheek, as this technique minimizes needles under the eye and can effectively brighten the face by replacing lost fat or disguising bulging fat pads.
10. Set Realistic Cosmetic Goals
Approach cosmetic procedures with a healthy mindset, aiming to look refreshed or about 7-10 years younger, rather than trying to revert to a much younger age, as chasing an unrealistic ideal can lead to unnatural or distorted results.
11. Evaluate Procedure Efficacy Critically
When considering new procedures or devices (e.g., energy devices, PRP), be skeptical of cure-all claims and critically examine before-and-after photos for genuine improvement, being wary of results that might be due to lighting differences or overselling.
12. Verify Device Authenticity & Approval
For non-surgical fat reduction (e.g., CoolSculpting), ensure the clinic uses genuine, FDA-approved devices, as knock-off machines may not be safe or effective, and prioritize the provider’s reputation over the specific device itself.
13. Understand Chemical Peel Risks
If considering chemical peels, recognize that they are highly operator-dependent and carry risks like burns or scars; thoroughly discuss the type of peel, its strength, and safety for your specific skin type with an experienced provider.
14. Take an Anti-Gravity Selfie
To see how your face looks without the effects of gravity, take a selfie while lying down, as this can reveal contours and volume status that are obscured when standing.
5 Key Quotes
Think about all the people that are walking by you on the street that have had work done and you haven't, you don't notice it because it's done well.
Dr. Brett Kotlis
The goal of a natural looking face is not to be totally smooth and to have no curves and no shadows and no lines.
Dr. Brett Kotlis
Your reputation as a surgeon is going to be much more about the patients you choose not to operate on than the patients you choose to operate on.
Peter Attia (quoting an attending)
If you look for a device or a treatment, it's probably better to look for a provider that you trust than to look for the device.
Dr. Brett Kotlis
To the hammer, the world's a nail. And so how that applies to this field is when you go into someone's office, are they, are they willing to refer you to somebody for something that they don't do or that they don't think that they're the best person to do?
Dr. Brett Kotlis
1 Protocols
Daily Skincare Regimen for Anti-Aging
Dr. Brett Kotlis- Apply topical Vitamin C serum in the morning, allowing it to dry for a few minutes.
- Apply a broad-spectrum physical sunscreen (SPF 30 or higher) on top of the vitamin C in the morning, reapplying every two hours if exposed to sun.
- Apply a retinoic acid product (retinol or prescription tretinoin) to the entire face, including eyelids, at night.