The Eyes Have It: The Wide World of Periocular Rejuvenation w/ Dr. Jason Bloom

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Welcome to Park Avenue
Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your co-host Doreen Wu,

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a clinical assistant at Bass
Plastic Surgery in New York City.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator, and technology innovator.

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The title of today's episode
is "The Eyes Have It:

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The Wide World of Periocular
Rejuvenation." Joining
us for this episode is

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Dr. Jason Bloom, facial plastic
surgeon from Bryn Mawr, Pennsylvania.

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Dr. Bass, the eyes make up such a small
part of the face. Why is it important?

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You're right, Doreen,
the eye area is small,

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not much bigger than half of our thumb,

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but the eyes are where we look about
70% of the time when we're talking to

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people. It's how we
project our personality.

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It's probably the part of the
face we move the most to generate

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expressions along with our smile.

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Essentially, the eyes are
a focal point on our face.

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So this means that you get your
eyes fixed if you're aging,

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and then you're good, right?

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Not so fast. We'd all like life
to be simple, but the eyes,

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as small an area as they
are, have big issues.

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There are a lot of small changes,

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all of which show as we age and
each of which has a different

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treatment needed to correct it.
You can do a single treatment,

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you can do a bunch of treatments together,

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pick what bugs you the most.

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But what's really important is to pick
the treatment that addresses the feature

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you don't like.

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Picking the wrong treatment will end up
not addressing the feature of concern.

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And historically, how was
the eyelid surgery performed?

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Well, if we go back to the
1980s when there were just a

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handful of aesthetic
procedures as it had been for

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decades before that,

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the upper lid surgery was done
by taking a crescent of skin out

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centered over the lid fold and
taking out bulging or extra fat

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in the upper lid.

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And the lower lid surgery was done
by making a small incision under the

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eyelashes,

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lifting the skin or the skin and
the muscle up and taking out extra

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fat that, again, was bulging,
creating the bags under the eyes.

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And that was pretty much universally
what was done in eyelid surgery,

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along with an occasional chemical
peel on the lower eyelids.

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What's changed? How is it different now?

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Well,

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the upper lid surgery
typically has more limited fat

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removal. We either remove no fat,

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we add some fat, because if we
look at the lids in young people,

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upper eyelids, in fact,
they're rather full.

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So sometimes we take that fat
out in the, in the middle,

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just by the side of the nose,

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but we still take that crescent of skin
out through the upper lid incision.

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And so that's very common
in the lower eyelid.

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Probably more often than not,

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most surgeons are using what's
called a transconjunctival approach.

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So instead of making the incision
right under the eyelashes,

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the incision is made on the
inner surface of the eyelid

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to allow access to the fat that
creates the bags under the eyes.

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And so as a 50,000 foot view,

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those are probably the biggest
changes. But as I said,

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there's a lot of complexity in this area.

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So let me turn now to our guest
expert my friend and colleague,

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Dr. Jason Bloom. Dr. Bloom,

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what do you see as the main features
of modern lid surgery compared with the

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past?

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Well, first of all, thank you Dr.
Bess and Doreen for having me.

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it's always fun to talk to you
guys about these topics and I,

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I tend to agree with you
about what you were saying.

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I think what we've seen over
the past few years and is

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that hollowed eyelids,

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whether it's upper uppers or lowers,

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kind of look aged.

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So whereas in the upper
eyelid we were taking out

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me, you know, medial fat,

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and sometimes it can lead to
like an A-frame deformity,

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meaning hollowing of the upper eyelids.

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And certainly that is
done in a very, very,

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very limited manner now.

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But upper eyelid surgery,

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other than the preservation
of fat or the or addition of

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fat to make a more full upper eyelid with

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still the excision of skin is kind
of the one thing that's changed.

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In lower eyelids, I also
tend to agree with Dr. Bass.

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Really most people are
preserving eyelid function,

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so less going through the muscle
and more of a transconjunctival

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approach.

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And really what we've seen is that
it's more preservation at this

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point or restoration,

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so preservation of the eyelid fat,

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whereas we were in the past
taking out the fat of the lower

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eyelids.

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Now what we're doing is conservatively
taking out lower eyelid fat,

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but either transposing the fat,

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meaning sewing it underneath
the eyes to preserve some

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fullness or conservatively
removing and fat grafting to

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that area.

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So preserving the fat or trans or

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transposing it or grafting
it is going to lead to

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less periocular hollowing in the future.

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And now that we've discussed
some of the main features,

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what are other features
that are also chased?

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You know what,

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when we look at the whole eyelid
in general or the periocular

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area, you know,

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you have to start with the brow position.

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The eyelid position itself.

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Is it low on the pupil or the eyeball?

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What's the status of the skin
around the eyes, the crow's feet?

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Is there crepiness underneath the eyes?
Do you have crow's feet around them?

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Is there periocular or
infraorbital hollowing or volume

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loss? And then finally,
is the eye muscle? Is it,

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is the muscle bulging?

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Do you have excess you know
orbicularis or eye muscle

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that's causing some thickness in
the tissue underneath the eye?

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So we really look at that whole area.

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Yeah, that's really important because
each of these details, as I said,

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typically needs to get
chased in a different way.

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And just using a one size fits
all approach of taking down

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fat is not going to do it. Using an

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overblown or heavy handed
approach is not going to do it.

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And what Dr. Bloom just said,

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I agree completely in terms
of balancing the amount of

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fat removal or the positioning of the fat.

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And it's like Goldilocks and the three
bears not too much, not too little,

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just right, because if you do
too much, the lid is hollow.

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If you do too little, you
haven't really corrected it.

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So you need to get the balance just
right. And in a small area like this,

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that balance point is
a very narrow window.

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Like you both said, those are a lot of
little fine details in a very small area.

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Tell me what treatments
chase each of these features.

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So when we talk about
the brow, for example,

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I like to say that helps to
frame the periocular area.

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There are things you can do
everything from brow lifting surgery

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to some neuromodulators, for example,

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to raise the brows like a
Botox or a chemical brow lift.

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Same thing to treat the the crow's feet.

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There is everything from
neuromodulator or toxin products

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or topicals,

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peels to treat crepiness around the eyes.

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And then the lid position,

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if someone has ptosis or when the eyelid

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actually sits lower on the
pupil than, for example,

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on one side or the other or both.

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There are ptosis surgeries,

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oculoplastic surgeries that
we can do to open up the eye.

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And now there's even
drops, things like UPNEEQ,

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which is an oxymetazoline drop
to open the eye temporarily.

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And then finally, I would say for
kind of the infraorbital periocular,

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hollowing,

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everything from filler to fat transfer

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and those kind of are all very

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niche things in themselves.
So there's, you know,

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finer details about which
fillers we choose and,

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and how we take care of and process the
fat when we're doing these procedures.

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Yeah, so you see there's
a range of items there.

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And I agree that considering

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in process all of those areas and

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splitting that all out so that you get
to the root of what's really going on is

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critical also in the lower
lid lid support as people get

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older diminishes.

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And so that's another
functional consideration along

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with the eyelid posis that Dr.
Bloom was talking about in the upper

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eyelid. So all of that
needs to be looked at,

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evaluated and chased.

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If we want to get the most complete
correction in the periocular area.

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Dr. Bloom, what patterns or
combinations of treatments are typical?

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Are these generally true or do we
need to break it down by age group?

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So some of the,

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the patterns that we usually see kind of

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progress and get worse with more advanced

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age. So in younger patients, if we break
it up in some of the younger patients,

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we start to see some of, you know,

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some lateral hooding of the upper eyelids.

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We start to see some crow's feet
develop as well as some of the

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elevens or frown lines
in between the eyes.

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And even in our late twenties even,

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we begin to see some periocular
or infraorbital hollowing

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in some of those patients.

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Those kind of treatments are
usually done non-surgically.

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We can treat patients with
neuromodulators and fillers in those in

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the early age groups.

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But as patients get more
advanced upper eyelid skin

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hooding, lower brow position,

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more hollowing fat bags
starting to develop in the eyes.

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Now with more advanced age,

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we tend to move into more of a
surgical approach with those patients.

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And, and I think Dr. Bloom
really raised a critical point.

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The lid area is not an area that shows

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aging changes late in the game.

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It's an area that starts
to show aging changes,

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probably the earliest of any
place on the face. And, you know,

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this is our thinnest
skin on our entire body,

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the eyelid skin. So it's not
surprising that this is then,

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and it's out in the sun all the time.

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So it's not surprising that this
is the place that shows early

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changes, but fortunately,

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often we can chase those with
non-surgical options in the twenties,

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in the thirties, although
some individuals,

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and you can see a genetic component
because their sister and their mother and

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their aunt will all show a
lot of heavy bags in the lower

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lids or a lot of hooding
in the upper lid skin at

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a very early stage.

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So there's an occasional person who
needs surgery even in the twenties,

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certainly in the mid thirties and beyond.

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And very common in conjunction with lid

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surgery would be peeling of the
skin because again, that skin,

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and when I say peeling, that
could be a chemical peel,

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it could be a fractional laser
treatment, an RF microneedling treatment,

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something to to rejuvenate that skin along

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with the contouring that's
being done with fillers or with

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surgery to try to bring the lid back

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into balance.

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Let's talk about provider
selection for a moment.

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With these various combinations,

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do you need multiple providers or should
your plastic surgeon be able to handle

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it?

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So I, you know,

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I think it's important when you
do something not to be a one trick

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pony.

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Dr. Bloom has just very
clearly described all of

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the features that we
consider in the lid areas,

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and an experienced surgeon is going
to understand and have options for

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all of these features.

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They're not going to only
address one and not the other.

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That's really the essence of
modern aesthetic surgery is

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these global corrections considering
all the factors involved.

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So I think anyone who's working in
this area on a regular basis and is

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well trained and experienced can
bring what you need to get the best

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result.

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Yeah, I tend to agree with that. I mean,

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I definitely have been

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trained and performed all the procedures.

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The one thing is I know my
limitations and I work great with

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my oculoplastics colleagues,

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and if I feel that something is out
of my realm and I don't do a lot

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of ptosis surgery personally,

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and that's one of the
things that I tend to

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refer and those

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patients, I'm happy to send the
blepharoplasties to them too,

239
00:15:03,920 --> 00:15:07,430
if they're doing it in conjunction
with a ptosis procedure.

240
00:15:07,790 --> 00:15:10,310
So I know what I'm good at. And

241
00:15:14,290 --> 00:15:18,740
I'm happy to refer out if I think that
there is a colleague of mine who would

242
00:15:18,741 --> 00:15:22,610
perform a procedure better than I would.

243
00:15:23,210 --> 00:15:23,820
Yeah,

244
00:15:23,820 --> 00:15:28,610
I think the issue that I'm thinking
about when I hear this question is this

245
00:15:28,611 --> 00:15:33,350
process that I see frequently
in New York City where people

246
00:15:33,351 --> 00:15:38,000
have their Botox doctor and their
filler doctor and their facial plastic

247
00:15:38,001 --> 00:15:41,210
surgeon, and everyone's sticking
their finger in the pie.

248
00:15:41,540 --> 00:15:45,400
And that's different than taking someone
who has a functional consideration in

249
00:15:45,410 --> 00:15:50,270
their lids and getting involved
with the oculoplastic surgeon

250
00:15:50,720 --> 00:15:54,110
who's eminently qualified to
chase that particular feature.

251
00:15:55,580 --> 00:16:00,200
It also is a product of both
the training and the recent

252
00:16:00,210 --> 00:16:01,940
experience of the surgeon.

253
00:16:02,270 --> 00:16:07,070
I was fortunate enough to be
trained by a couple of plastic

254
00:16:07,080 --> 00:16:11,660
surgeons who were double boarded in
plastic surgery in ophthalmology.

255
00:16:12,440 --> 00:16:15,440
So we did a lot of complex lid surgery,

256
00:16:15,441 --> 00:16:17,600
including reconstructive things,

257
00:16:17,610 --> 00:16:22,370
support things as well as
advanced aesthetic procedures.

258
00:16:22,610 --> 00:16:26,420
And so that gives me a background in that.

259
00:16:27,050 --> 00:16:31,760
But doing that on a regular basis
and having just the right balance

260
00:16:31,770 --> 00:16:32,603
point,

261
00:16:32,950 --> 00:16:37,640
for ptosis surgery or lid support
surgery in the lower lid is

262
00:16:38,120 --> 00:16:40,430
critical to an excellent result.

263
00:16:41,480 --> 00:16:44,180
Let's shift gears for a moment
and talk about the brow.

264
00:16:44,600 --> 00:16:47,060
How is that part of the periocular area?

265
00:16:47,870 --> 00:16:52,670
Where do treatments for the brow fall
under? Is that more neuromodulator,

266
00:16:52,670 --> 00:16:53,810
surgery, muscle stimulation?

267
00:16:54,440 --> 00:16:58,070
So, Dr. Bloom talked about
this a little bit earlier,

268
00:16:58,970 --> 00:17:01,940
and it is the frame,

269
00:17:01,941 --> 00:17:06,500
it's the upper limit of that
periocular or around the

270
00:17:06,501 --> 00:17:08,030
eye area.

271
00:17:09,920 --> 00:17:14,780
The brow position is
something that changes as we

272
00:17:14,781 --> 00:17:19,220
age and sometimes even in
youth is not in an ideal

273
00:17:19,820 --> 00:17:21,440
position or can be enhanced.

274
00:17:22,250 --> 00:17:27,080
So that's importantly part of what

275
00:17:27,081 --> 00:17:31,520
you assess and plan for in performing any

276
00:17:31,850 --> 00:17:33,830
rejuvenation around the eye.

277
00:17:34,280 --> 00:17:39,020
Now the interesting
question is that nowadays

278
00:17:39,021 --> 00:17:41,900
mostly Botox and other

279
00:17:41,960 --> 00:17:46,190
neuromodulators? Is it surgery like brow

280
00:17:46,191 --> 00:17:49,590
lifting? Or more recently,

281
00:17:49,591 --> 00:17:54,510
one of the manufacturers has
just revisited an old concept,

282
00:17:54,511 --> 00:17:59,220
which is muscle stimulation in the face

283
00:17:59,221 --> 00:18:04,140
with the thought of rejuvenating
the face by training and

284
00:18:04,150 --> 00:18:07,740
stimulating muscles to
increase muscle tone,

285
00:18:08,010 --> 00:18:12,750
which seems paradoxical because
it's sort of the opposite of what

286
00:18:13,410 --> 00:18:14,460
Botox does,

287
00:18:14,461 --> 00:18:19,170
which is to block nerve
signals and relax muscles.

288
00:18:19,590 --> 00:18:24,330
So Dr. Bloom , let me drop
this in your lap and let you,

289
00:18:24,540 --> 00:18:26,160
you say what you think about it.

290
00:18:26,760 --> 00:18:31,650
You know, I'll give my views
and also add one other thing,

291
00:18:31,651 --> 00:18:33,000
but you know,

292
00:18:33,630 --> 00:18:37,380
I've kind of gone back and
forth with brow lifting surgery.

293
00:18:37,830 --> 00:18:42,570
I've really struggled with something
to give me a very long lasting

294
00:18:42,580 --> 00:18:43,413
result.

295
00:18:44,130 --> 00:18:49,050
I tend to do some endo brows
occasionally endoscopic brow

296
00:18:49,290 --> 00:18:51,450
lift surgery. But you know,

297
00:18:51,451 --> 00:18:55,980
I think that neuromodulators
work great. And I've,

298
00:18:56,130 --> 00:19:00,810
that is the majority of what
I do for brows at this point.

299
00:19:01,230 --> 00:19:02,160
We have,

300
00:19:02,161 --> 00:19:06,930
I have no experience with the muscle
stimulation and I know you have

301
00:19:06,931 --> 00:19:09,900
kind of gotten into that. I'd be
interested to hear your thoughts.

302
00:19:10,590 --> 00:19:14,550
One of the other things that we've
been using a little bit more with good

303
00:19:14,560 --> 00:19:17,760
results is something called Sofwave,

304
00:19:17,761 --> 00:19:21,390
which Sofwave is an ultrasound non-focused

305
00:19:21,391 --> 00:19:24,120
ultrasound approach,

306
00:19:24,121 --> 00:19:29,100
which basically targets the
dermis about 1.5 millimeters

307
00:19:29,110 --> 00:19:29,943
under the skin.

308
00:19:30,030 --> 00:19:34,170
And by contracting that
layer over the brows,

309
00:19:34,500 --> 00:19:39,420
they did some clinical trials that
actually showed on average a four to

310
00:19:39,421 --> 00:19:41,340
five millimeter brow lift,

311
00:19:41,341 --> 00:19:45,930
which is quite impressive
for a nonsurgical approach.

312
00:19:46,200 --> 00:19:50,010
And we've been using it with
my practice with some really,

313
00:19:50,020 --> 00:19:51,390
really nice results.

314
00:19:51,870 --> 00:19:56,550
Yeah, that's an interesting
point because I feel in my

315
00:19:56,551 --> 00:20:01,410
hands most of the time
I'm trying to encourage

316
00:20:01,411 --> 00:20:03,570
patients to work with neuromodulators.

317
00:20:03,600 --> 00:20:08,070
I think you have tremendous
shape control that is

318
00:20:08,071 --> 00:20:11,220
sometimes hard to obtain
with surgical approaches.

319
00:20:12,480 --> 00:20:17,070
You have more ability probably
than surgery to deal with

320
00:20:17,071 --> 00:20:21,900
asymmetric brows. Many people have
one brow higher than the other,

321
00:20:22,200 --> 00:20:27,180
and brow lift surgery is notorious
for, not making it worse,

322
00:20:27,190 --> 00:20:30,060
but not correcting it as
much as one might hope.

323
00:20:31,140 --> 00:20:34,920
So that's probably the
mainstay. I agree completely.

324
00:20:35,340 --> 00:20:39,930
But there is a role in a certain
number of patients for brow lift

325
00:20:39,940 --> 00:20:43,260
surgery. It's, I think,

326
00:20:43,261 --> 00:20:47,980
not in its heyday like it
was in the 1990s when we

327
00:20:47,981 --> 00:20:50,980
got endo brow lifts or
endoscopic brow lifts,

328
00:20:50,981 --> 00:20:55,090
and the ability to do a brow
lift without a big long incision

329
00:20:55,930 --> 00:20:58,870
made it much more
appealing to go ahead with.

330
00:20:59,290 --> 00:21:04,150
But I think we've identified
a narrower range of patients

331
00:21:04,360 --> 00:21:08,980
who really aesthetically have a major

332
00:21:08,981 --> 00:21:11,770
brow issue that needs a surgical approach.

333
00:21:13,330 --> 00:21:18,250
The muscle stimulation I think
was examined in the 1990s and

334
00:21:18,550 --> 00:21:22,120
it's more for other parts
of the face than the brow.

335
00:21:22,180 --> 00:21:27,010
But we'll see as this
new product that's just

336
00:21:27,011 --> 00:21:31,030
come out develops a little
more clinical experience.

337
00:21:31,930 --> 00:21:36,400
But the energy lifting approach,

338
00:21:36,640 --> 00:21:41,140
every device that's been a
non-surgical skin lifter or a

339
00:21:41,800 --> 00:21:46,360
tightener has had a brow lift
approval that started with Thermage in

340
00:21:46,361 --> 00:21:50,740
2004 and their first FDA approval or

341
00:21:50,741 --> 00:21:55,270
clearance, actually, because
it's a device, was for brow lift.

342
00:21:55,271 --> 00:21:59,920
And then they got a more general facial
lifting clearance and then Ultherapy

343
00:22:00,850 --> 00:22:04,870
did the same thing. And
Sofwave is the newest,

344
00:22:04,871 --> 00:22:09,130
most modern iteration
with certain advantages in

345
00:22:09,131 --> 00:22:12,310
application compared to
the older technologies.

346
00:22:13,060 --> 00:22:16,630
But brow lift, I agree completely,

347
00:22:16,631 --> 00:22:19,990
four millimeters, it may sound small,

348
00:22:19,991 --> 00:22:24,160
but that's actually big when it
comes to the brow and probably

349
00:22:24,161 --> 00:22:28,870
rivals what you can do
surgically with a whole lot

350
00:22:28,871 --> 00:22:33,220
less in terms of time recovery

351
00:22:33,880 --> 00:22:38,020
cost and so forth. So that, that's
an interesting development for sure.

352
00:22:39,130 --> 00:22:42,730
If we turn to the lower lid, what are
some of the new approaches in this area?

353
00:22:43,510 --> 00:22:48,040
A lot of the lower lid
advancement revolves

354
00:22:48,041 --> 00:22:52,930
around chasing the
deepening of the tear trough

355
00:22:52,960 --> 00:22:54,850
and the lid junction.

356
00:22:55,330 --> 00:23:00,310
So you heard Dr. Bloom
mention a lot of the options

357
00:23:00,320 --> 00:23:03,220
here. One is just fat
grafting into the area.

358
00:23:04,610 --> 00:23:06,100
Another is using filler

359
00:23:07,870 --> 00:23:11,380
nonsurgically to augment the area.

360
00:23:11,710 --> 00:23:16,540
And then there are techniques
that actually release the
ligamentous attachments

361
00:23:16,870 --> 00:23:19,540
at the orbital rim, at the bone,

362
00:23:20,020 --> 00:23:24,760
at the bottom of the lower lid
and take some of that fat that

363
00:23:24,770 --> 00:23:29,290
in days past we might
have removed and instead

364
00:23:29,770 --> 00:23:33,730
it across that, that dividing line,

365
00:23:33,731 --> 00:23:38,260
that lid junction in order to have an even

366
00:23:38,261 --> 00:23:40,540
curtain of fat. Because as I said,

367
00:23:40,541 --> 00:23:44,740
young people typically are not hollow
or empty, they're actually full,

368
00:23:45,170 --> 00:23:48,170
but their fat is very smooth and even,

369
00:23:48,171 --> 00:23:52,670
and that's a typically youthful
appearance. So Dr. Bloom, what,

370
00:23:52,760 --> 00:23:53,780
what do you think?

371
00:23:54,470 --> 00:23:57,770
So I totally agree if we're talking

372
00:23:57,771 --> 00:24:00,890
in let's say a younger

373
00:24:00,900 --> 00:24:05,300
patient the depth of

374
00:24:05,360 --> 00:24:06,193
the,

375
00:24:07,010 --> 00:24:10,550
the tear trough for the hollowing around
the eye of the infraorbital area really

376
00:24:10,551 --> 00:24:14,420
determines a lot if
we're treating a patient

377
00:24:14,480 --> 00:24:19,340
with with filler and let's say

378
00:24:19,341 --> 00:24:22,340
we're not choosing a
surgery for that patient,

379
00:24:22,520 --> 00:24:25,610
and I'm going to use some
like filler names here,

380
00:24:25,611 --> 00:24:30,170
but if it's a deeper
kind of hollowing in that

381
00:24:30,171 --> 00:24:31,004
area,

382
00:24:31,190 --> 00:24:35,660
I tend to camouflage the lower
eyelid fat or infraorbital area

383
00:24:35,900 --> 00:24:38,030
with a product like Restylane.

384
00:24:39,080 --> 00:24:43,820
And that has been my go-to for
a long time. More recently,

385
00:24:43,821 --> 00:24:48,530
and this is in clinical trials so
Restylane is not approved for the

386
00:24:48,531 --> 00:24:52,790
periocular area. It has undergone
clinical trials and most likely would be,

387
00:24:53,000 --> 00:24:55,670
will be approved next year
for the Infraorbital area.

388
00:24:56,630 --> 00:24:59,570
Most recently for a more
shallow infraorbital

389
00:24:59,571 --> 00:25:02,900
area, infraorbital hollowing,

390
00:25:03,230 --> 00:25:06,410
I tend to use a new product
called RHA redensity,

391
00:25:06,500 --> 00:25:11,210
which I think is really nice for that
area also in clinical trials currently for

392
00:25:11,211 --> 00:25:12,470
the periocular area.

393
00:25:13,220 --> 00:25:16,820
Now if we're switching gears
to a more surgical approach,

394
00:25:17,600 --> 00:25:21,410
everything I've done in my practice has
kind of been trial and error over the

395
00:25:21,411 --> 00:25:25,190
last 13 years. And it's,

396
00:25:25,220 --> 00:25:28,880
it's usually because the pendulum
in periocular rejuvenation

397
00:25:30,520 --> 00:25:32,510
surgically has kind of switched.

398
00:25:32,840 --> 00:25:36,710
And what I used to do was
excise some of the fat.

399
00:25:37,220 --> 00:25:41,960
And what we saw is when you see those
patients back five to 10 years later,

400
00:25:42,170 --> 00:25:44,360
then they're looking a
little bit more hollow.

401
00:25:44,810 --> 00:25:49,760
So then I switched to releasing
all the ligamentous attachments

402
00:25:49,761 --> 00:25:54,650
in the lower lid all through the
transconj approach in all these cases

403
00:25:54,651 --> 00:25:59,540
and then transposing the fat
underneath the periosteum.

404
00:25:59,930 --> 00:26:04,760
And I did that for a few
years and kind of saw it

405
00:26:04,770 --> 00:26:08,080
wasn't as I would say,

406
00:26:08,081 --> 00:26:12,230
I was seeing some lumpiness occasionally
patients would feel like kind of

407
00:26:12,231 --> 00:26:16,670
tethered occasionally. I just didn't
love it as as much as I should.

408
00:26:17,150 --> 00:26:22,040
And I would say for the past about six
or seven years I've been doing some

409
00:26:22,041 --> 00:26:26,630
conservative fat removal
with fat grafting in that

410
00:26:26,631 --> 00:26:31,160
area. And now I've really found
that to be the best result in my

411
00:26:31,161 --> 00:26:34,940
hand seeing these patients
back six or seven years later.

412
00:26:34,941 --> 00:26:39,470
So that's kind of been my
approach for this entire time.

413
00:26:39,890 --> 00:26:40,491
Yeah, it's,

414
00:26:40,491 --> 00:26:45,480
it's interesting because I've
gone through a similar kind

415
00:26:45,481 --> 00:26:49,680
of evolution in my
approach. The, you know,

416
00:26:49,681 --> 00:26:52,200
the issues with transposing, the fat,

417
00:26:52,201 --> 00:26:56,670
the beauty of that is it
sounds very anatomically

418
00:26:56,671 --> 00:27:00,090
appealing. You are, you are
releasing the tether point,

419
00:27:00,960 --> 00:27:03,930
you are taking vascularized fat,

420
00:27:04,410 --> 00:27:09,120
fat that has a blood supply
that's still attached and

421
00:27:09,180 --> 00:27:10,800
draping it across.

422
00:27:10,950 --> 00:27:15,300
So you'd expect that to give you a
degree of control and predictability.

423
00:27:15,690 --> 00:27:17,070
But in fact,

424
00:27:17,310 --> 00:27:22,110
releasing the ligamentous attachments
means a lot more bruising and

425
00:27:22,111 --> 00:27:23,700
swelling in the recovery.

426
00:27:24,480 --> 00:27:28,860
And while I was able to get very good

427
00:27:28,861 --> 00:27:32,400
correction in the fold up to a point,

428
00:27:33,210 --> 00:27:37,770
if it was deeper than a certain
amount or that fold extended

429
00:27:37,860 --> 00:27:40,500
towards the side too far,

430
00:27:41,760 --> 00:27:46,440
that I would be limited in the
ability to fully correct those areas.

431
00:27:46,680 --> 00:27:51,480
So doing that with some fat
removal and some fat grafting is a

432
00:27:51,481 --> 00:27:52,890
much simpler approach.

433
00:27:52,900 --> 00:27:57,870
And the other limitation of the
release approaches is they didn't

434
00:27:57,871 --> 00:28:02,730
help me for older patients
because you need good lid support.

435
00:28:02,970 --> 00:28:07,500
You either need to have good lid support
or you need to build good lid support

436
00:28:07,950 --> 00:28:12,750
once you release all of of
those bony attachments or you're

437
00:28:12,751 --> 00:28:15,420
going to have lid retraction problems.

438
00:28:15,540 --> 00:28:20,520
And some of the surgeons who were big
proponents of this had rather staggering

439
00:28:20,521 --> 00:28:25,380
rates of lid support problems
after some of the orbicularis

440
00:28:25,381 --> 00:28:29,430
reset surgeries based
on their published data.

441
00:28:30,370 --> 00:28:33,900
I'm not speaking out of school, it's
what they reported themselves in,

442
00:28:33,930 --> 00:28:38,790
in their own articles. And
that's concerning because we,

443
00:28:38,820 --> 00:28:40,680
we want to get people out of trouble,

444
00:28:40,690 --> 00:28:45,600
not into trouble when we do
these treatments. So you know,

445
00:28:45,601 --> 00:28:50,310
I started to mention functional
issues even in aesthetic lid

446
00:28:50,610 --> 00:28:54,510
surgery. We talked about
it earlier in this podcast,

447
00:28:55,050 --> 00:28:59,610
but you know, the important thing
to understand is that lid support

448
00:28:59,700 --> 00:29:04,410
loosens as we age and our

449
00:29:04,411 --> 00:29:09,300
eyes reduce tear production and tear

450
00:29:09,301 --> 00:29:13,140
quality also diminishes the
lubricating aspects of the tears

451
00:29:15,780 --> 00:29:18,450
become less good at doing that.

452
00:29:18,930 --> 00:29:23,790
And so that's something we have to
consider as we look at people from their

453
00:29:24,000 --> 00:29:27,810
thirties to their eighties in
terms of doing eyelid surgery.

454
00:29:29,040 --> 00:29:31,080
How would I know if these are a problem?

455
00:29:31,200 --> 00:29:33,660
At what point should I
start becoming concerned?

456
00:29:34,950 --> 00:29:39,210
I, I think one of the, the most
important things is, you know,

457
00:29:39,211 --> 00:29:42,760
in starting anything when you,

458
00:29:43,000 --> 00:29:45,820
it goes back to like
very early medicine is,

459
00:29:46,150 --> 00:29:48,670
is really getting a good history. I,

460
00:29:48,730 --> 00:29:52,780
when I'm when I'm going through and
talking to patients about periocular

461
00:29:52,781 --> 00:29:55,870
surgery, I'm asking them about have,

462
00:29:56,020 --> 00:29:59,620
have they had any history of
dry eye? Do they wear contacts?

463
00:29:59,621 --> 00:30:03,550
Do they wear glasses? Have they had
any orbital or ocular surgery, LASIKS,

464
00:30:05,320 --> 00:30:10,300
cataracts, things like that. Do they
have any diabetes, thyroid issues,

465
00:30:10,301 --> 00:30:14,770
autoimmune issues? So picking some of
these things up from the history, right,

466
00:30:14,771 --> 00:30:17,500
it's is like, as we learn
this in medical school,

467
00:30:17,501 --> 00:30:21,820
is getting a good history
will give you a lot of

468
00:30:21,850 --> 00:30:25,000
information prior to, you know, you,

469
00:30:25,001 --> 00:30:29,620
you don't want to like take a patient
to surgery and learn they have

470
00:30:30,000 --> 00:30:32,830
Sjogren's syndrome after,
after the fact, right?

471
00:30:32,831 --> 00:30:35,020
And that's dry eye and things like that.

472
00:30:35,021 --> 00:30:39,730
So do they see a an ophthalmologist or an

473
00:30:39,731 --> 00:30:44,710
optometrist regularly for issues dealing
with dry eye and things like that?

474
00:30:44,711 --> 00:30:49,660
So picking a lot of these things up
from a really good history will save

475
00:30:49,661 --> 00:30:52,750
you on the back end in dealing
with these problems later.

476
00:30:53,680 --> 00:30:57,160
Absolutely. I mean we want
everyone to look beautiful,

477
00:30:57,161 --> 00:31:01,540
but it's critically important to
remember this is medical care.

478
00:31:01,550 --> 00:31:06,430
And medical care needs to
follow the correct process

479
00:31:06,490 --> 00:31:09,490
of history examination,

480
00:31:09,491 --> 00:31:12,700
not just of what your aesthetic
concerns are, but of your,

481
00:31:12,820 --> 00:31:14,770
your general health and wellbeing,

482
00:31:15,160 --> 00:31:19,930
which will alert a knowledgeable surgeon

483
00:31:20,560 --> 00:31:25,510
that there's more risk or that
something needs to be evaluated in

484
00:31:25,520 --> 00:31:26,650
more detail.

485
00:31:27,040 --> 00:31:31,810
And we can still almost
always perform lid surgery,

486
00:31:31,840 --> 00:31:36,760
but we may need to adjust the
techniques to compensate for

487
00:31:36,761 --> 00:31:41,020
some of the trouble with lid
support or with dry eyes.

488
00:31:41,270 --> 00:31:43,840
And if we know that ahead of time,

489
00:31:43,850 --> 00:31:47,950
it's easy to do and if we don't know
about it, then there can be trouble.

490
00:31:48,640 --> 00:31:52,990
So some of those support procedures
are things like canthopexy

491
00:31:54,080 --> 00:31:55,970
and canthoplasty,

492
00:31:56,350 --> 00:32:00,850
which are commonly used
again as protection or

493
00:32:00,851 --> 00:32:05,050
support or even
reconstruction at the time of

494
00:32:05,470 --> 00:32:07,930
aesthetic lid surgery. So Dr. Bloom,

495
00:32:07,931 --> 00:32:12,220
what's the difference between the two
and what's your view about when they

496
00:32:12,221 --> 00:32:13,330
should be used?

497
00:32:13,331 --> 00:32:17,080
Because there are surgeons who feel who
will always want to do it or always in

498
00:32:17,081 --> 00:32:20,770
certain age groups. so
what's your approach to this?

499
00:32:21,020 --> 00:32:25,960
So the difference really between
a canthopexy is something

500
00:32:25,961 --> 00:32:29,080
to support. So the canthus is where the,

501
00:32:29,110 --> 00:32:34,000
the eye kind of upper and
eyelid come together laterally

502
00:32:34,001 --> 00:32:37,600
by the ears or by the nose,

503
00:32:37,610 --> 00:32:39,950
so either medial or laterally,

504
00:32:40,460 --> 00:32:45,230
and a canthopexy is something
that's done to support the

505
00:32:45,231 --> 00:32:49,580
underlying campus without truly cutting

506
00:32:49,581 --> 00:32:51,350
through that area.

507
00:32:52,400 --> 00:32:56,780
And then a canthoplasty
would be a reconstruction of

508
00:32:57,080 --> 00:33:00,590
that campus where we can
actually cut through it,

509
00:33:01,040 --> 00:33:06,020
tighten the tendon in the
lower eyelid and really give it

510
00:33:06,021 --> 00:33:07,640
a lot of extra support.

511
00:33:09,980 --> 00:33:12,080
What I can tell you is

512
00:33:14,370 --> 00:33:19,040
I tend to avoid doing canthoplasty

513
00:33:20,780 --> 00:33:23,480
unless a patient has true,

514
00:33:23,630 --> 00:33:28,340
that means cutting the canthus
itself unless a patient has true

515
00:33:28,341 --> 00:33:32,870
lower eyelid rounding or
what we call ectropion,

516
00:33:32,900 --> 00:33:36,860
which is pulling down the lid where,

517
00:33:36,861 --> 00:33:40,730
where you can see some of
the white underneath the eye,

518
00:33:41,150 --> 00:33:42,770
underneath the iris of the eye.

519
00:33:43,160 --> 00:33:46,700
So in more of a reconstructive procedure,

520
00:33:46,880 --> 00:33:51,500
that's when I would consider a
canthoplasty or a lid shortening

521
00:33:51,501 --> 00:33:56,390
tightening procedure of the lower
eyelid. I tend to do a canthopexy

522
00:33:58,670 --> 00:34:03,530
when I'm doing something to support
the muscle of the lower eyelid.

523
00:34:03,531 --> 00:34:08,270
So for example I am about,

524
00:34:08,290 --> 00:34:10,430
I do about 90%

525
00:34:11,590 --> 00:34:14,930
transconjunctival lower eyelid surgery,

526
00:34:15,350 --> 00:34:18,740
but if a patient has true muscle swag,

527
00:34:18,770 --> 00:34:21,290
looseness of the muscle of the eye,

528
00:34:22,250 --> 00:34:26,450
I tend to do a transcutaneous,

529
00:34:26,451 --> 00:34:29,150
meaning an incision underneath the eyelid,

530
00:34:31,250 --> 00:34:32,780
through the muscle.

531
00:34:33,080 --> 00:34:37,880
And then I do an orbicularis
or a muscle suspension where

532
00:34:37,881 --> 00:34:42,800
I'm actually sewing a tag
of the muscle up to the

533
00:34:42,801 --> 00:34:44,060
orbital tubercle.

534
00:34:44,210 --> 00:34:48,920
And what that will do is that
will support some of the lower

535
00:34:48,930 --> 00:34:53,390
eyelid muscle and help prevent
that from pulling down.

536
00:34:54,320 --> 00:34:55,520
Additionally,

537
00:34:55,820 --> 00:34:59,570
I can sew that muscle and some of the lid,

538
00:35:00,470 --> 00:35:04,940
the tendon to that same
position to help that pull down.

539
00:35:05,540 --> 00:35:10,520
That would be the main reason
why I would do a canthoopexy in

540
00:35:10,521 --> 00:35:13,250
those cases. but again,

541
00:35:13,310 --> 00:35:17,840
it's a rare situation
where a patient truly has

542
00:35:17,841 --> 00:35:21,860
muscle laxity in the lower
eyelid that I need to correct.

543
00:35:22,730 --> 00:35:25,880
Yeah, I, the way I think
about it is similar.

544
00:35:26,450 --> 00:35:31,400
I think there are people who
have an existing support problem

545
00:35:31,401 --> 00:35:33,590
and you can usually see that the,

546
00:35:33,680 --> 00:35:38,280
just about the instant you walk in the
exam room because the lid is not in its

547
00:35:38,281 --> 00:35:39,560
proper position.

548
00:35:40,020 --> 00:35:44,580
And importantly the idea is
that the lid not only has to be

549
00:35:44,581 --> 00:35:48,750
up, but it also has to be
back against the eyeball.

550
00:35:48,810 --> 00:35:51,270
And if it's not up and back,

551
00:35:51,540 --> 00:35:55,710
it is not going to be able to do its
job properly of spreading the tear film

552
00:35:55,711 --> 00:35:56,544
over the eye.

553
00:35:58,290 --> 00:36:02,520
so those are the
canthoplasty people who need

554
00:36:02,940 --> 00:36:07,140
support rebuilt because
the support is gone.

555
00:36:07,650 --> 00:36:11,190
And then there are people who are loose,

556
00:36:11,550 --> 00:36:16,140
they don't have a major problem now,
but they're right on the cusp of it.

557
00:36:16,470 --> 00:36:17,790
And those are the ones,

558
00:36:17,791 --> 00:36:21,420
if they're having extensive lid surgery
that I'll think about canthopexy,

559
00:36:23,910 --> 00:36:25,890
or a support procedure.

560
00:36:25,890 --> 00:36:29,580
And I don't believe that people who

561
00:36:29,581 --> 00:36:33,960
are not symptomatic and
have good lid support

562
00:36:34,290 --> 00:36:38,460
with modern aesthetic
techniques need a canthopexy

563
00:36:39,900 --> 00:36:44,100
on a prophylactic basis. And there
are surgeons who are doing that,

564
00:36:44,460 --> 00:36:49,240
but every intervention has
risks and has downsides.

565
00:36:49,680 --> 00:36:54,660
And so I've avoided doing that in

566
00:36:55,110 --> 00:36:59,550
patients who don't have a clear
indication on exam in terms of dryness,

567
00:36:59,551 --> 00:37:01,410
in terms of lid snap or lid,

568
00:37:01,411 --> 00:37:06,240
some other attribute of of lid
support deficit like rounding in the

569
00:37:06,270 --> 00:37:08,520
corner or something else as you described.

570
00:37:09,690 --> 00:37:14,610
So by being more selective, I
feel like I use it when I need it.

571
00:37:15,210 --> 00:37:20,130
I could always come if one of the
patients who looks like they have good

572
00:37:20,131 --> 00:37:23,280
support gets in trouble after a procedure,

573
00:37:24,000 --> 00:37:27,810
I always have the option to come
back and pex them at that point.

574
00:37:27,811 --> 00:37:32,100
I don't want to do an extra procedure
and I haven't had to do that

575
00:37:32,460 --> 00:37:37,410
in really pretty much the
last 20 years, even once.

576
00:37:37,710 --> 00:37:39,330
But if I got in trouble,

577
00:37:39,331 --> 00:37:43,920
I always have that escape hatch
rather than giving everybody the

578
00:37:44,800 --> 00:37:47,610
fix that 99% of them don't need.

579
00:37:48,690 --> 00:37:52,830
So just as a curiosity I'm

580
00:37:53,550 --> 00:37:57,030
interested to hear what
you think Dr. Bloom about,

581
00:37:58,110 --> 00:38:02,430
we talked about brow elevation
using neuromodulators

582
00:38:03,120 --> 00:38:08,010
and we talked about brow lifting and
energy-based treatments that tighten up

583
00:38:08,760 --> 00:38:12,630
the deep layers of the
skin, pulling the brow up.

584
00:38:14,160 --> 00:38:18,870
what are, what are your thoughts about
using fat or fillers as an option for

585
00:38:18,871 --> 00:38:21,720
mild lateral brow elevation?

586
00:38:22,650 --> 00:38:24,120
You know, I, I think,

587
00:38:24,330 --> 00:38:28,830
so my my feeling is I don't
use fat or filler to try to

588
00:38:28,831 --> 00:38:33,660
elevate the brow, but I think
what happens is with age,

589
00:38:33,870 --> 00:38:36,970
we lose volume in our brow.

590
00:38:37,000 --> 00:38:41,640
And so from both the
temple from the muscular

591
00:38:41,650 --> 00:38:44,350
standpoint, from some
of the subcutaneous fat,

592
00:38:44,440 --> 00:38:49,330
and then also we start to lose
some of the bony aspects of

593
00:38:49,331 --> 00:38:51,640
the skeleton in that super brow area.

594
00:38:51,650 --> 00:38:56,560
And it begins to hollow
and all happens with age or

595
00:38:56,561 --> 00:38:58,750
muscle atrophy in the temple area.

596
00:38:58,900 --> 00:39:03,610
And I think I actually enjoy doing fat or

597
00:39:03,611 --> 00:39:08,140
filler there to kind of
give you back some of that

598
00:39:08,141 --> 00:39:10,030
brow height. So I,

599
00:39:10,630 --> 00:39:14,530
and not that I'm trying to like
crank out up a brow with that,

600
00:39:14,531 --> 00:39:19,450
but today actually I use
two different fillers to

601
00:39:19,480 --> 00:39:20,740
really address,

602
00:39:20,890 --> 00:39:25,300
it's mainly the super brow
area in that area of the most

603
00:39:25,301 --> 00:39:27,250
anterior part of the temple.

604
00:39:27,460 --> 00:39:31,660
By injecting in some of those
that area either filler or fat,

605
00:39:31,900 --> 00:39:36,070
you're beginning to
replace some of the really,

606
00:39:36,071 --> 00:39:39,040
the skeleton, the brow,

607
00:39:39,220 --> 00:39:43,870
the bony brow skeleton that's
beginning to atrophy as well as the

608
00:39:43,871 --> 00:39:47,170
muscular and soft tissue
support in that area,

609
00:39:47,350 --> 00:39:52,240
which will kind of bring out that tail
of the brow and give you a little bit

610
00:39:52,241 --> 00:39:55,480
of support and return of the brow height.

611
00:39:56,080 --> 00:39:58,510
Yeah, I think that's a
critical point. You know,

612
00:39:58,520 --> 00:40:01,720
we're losing fat in our
face from our twenties,

613
00:40:01,721 --> 00:40:04,060
but as we get into our fifties and beyond,

614
00:40:04,300 --> 00:40:08,980
we're losing muscle volume and
bone volume and rejuvenation

615
00:40:08,981 --> 00:40:11,890
is, is not just about tightening up skin,

616
00:40:11,891 --> 00:40:16,510
it's as much about
restoring youthful shape as

617
00:40:17,000 --> 00:40:21,490
anything else. And so that's
critically important. That being said,

618
00:40:21,491 --> 00:40:26,410
I will put filler or fat
if I'm working in that

619
00:40:26,411 --> 00:40:31,270
area sometimes right
along the bony rim in that

620
00:40:31,271 --> 00:40:36,100
lateral third just to help
with a little bit of arching,

621
00:40:36,100 --> 00:40:38,980
projection and elevation of that brow.

622
00:40:39,670 --> 00:40:42,520
and I picture that as sort
of a subgaleal placement,

623
00:40:42,521 --> 00:40:47,110
if you will right at that level along

624
00:40:47,111 --> 00:40:49,960
with above the brow in that,

625
00:40:50,080 --> 00:40:53,170
in that medial or lower temple area.

626
00:40:54,550 --> 00:40:54,701
Well,

627
00:40:54,701 --> 00:40:58,360
this has certainly been an interesting
episode with lots of riveting discussion.

628
00:40:58,810 --> 00:41:00,340
Before you wrap up Dr. Bass,

629
00:41:00,341 --> 00:41:02,770
can you share some important
takeaways for our listeners?

630
00:41:03,580 --> 00:41:08,410
Treating the periocular
or around the eye area

631
00:41:08,560 --> 00:41:13,150
is a multi-modality approach

632
00:41:13,450 --> 00:41:16,600
with specific treatments
for specific features.

633
00:41:17,800 --> 00:41:21,880
Currently, as we record
this at the end of 2022,

634
00:41:21,910 --> 00:41:26,290
there's no meaningful
substitute for eyelid

635
00:41:26,291 --> 00:41:27,160
surgery,

636
00:41:27,860 --> 00:41:32,110
blepharoplasty in either the upper
or lower lid to do what those

637
00:41:32,111 --> 00:41:33,410
procedures do.

638
00:41:35,900 --> 00:41:40,250
and this is one of the areas where
we see aging changes early on,

639
00:41:41,060 --> 00:41:44,630
we didn't talk a lot about the
appearance after lid surgery,

640
00:41:44,631 --> 00:41:49,520
but the goal is always to
create a natural look and it

641
00:41:49,521 --> 00:41:53,840
is possible to have eyelid surgery and
it should not change the way your lids

642
00:41:53,841 --> 00:41:58,280
look again, except for those
reconstructive circumstances where,

643
00:41:58,610 --> 00:42:02,020
where the lid is not working properly.

644
00:42:04,040 --> 00:42:08,840
And as we discussed a capable plastic
surgeon is going to be able to

645
00:42:08,841 --> 00:42:13,340
bring you the necessary
scope of multimodality

646
00:42:13,341 --> 00:42:18,050
treatments that are currently
state-of-the-art care in this

647
00:42:18,051 --> 00:42:18,884
area.

648
00:42:19,580 --> 00:42:21,560
And Dr. Bloom, would you
like to add anything?

649
00:42:22,040 --> 00:42:25,010
I will just say in this in this age,

650
00:42:25,011 --> 00:42:28,580
we're in where there are, you know,

651
00:42:28,581 --> 00:42:31,660
there are so many different
practitioners out there doing

652
00:42:32,570 --> 00:42:35,990
injectables and lasers
and things like that.

653
00:42:38,210 --> 00:42:42,980
Dr. Bass and I are lucky to be
doing what we do as surgeons because

654
00:42:44,740 --> 00:42:46,670
you, you have to, there,

655
00:42:47,260 --> 00:42:49,820
there always is,

656
00:42:49,821 --> 00:42:54,380
you have to be reasonable when
you're talking to patients and

657
00:42:54,381 --> 00:42:59,060
explain that sometimes,
you know, I like to,

658
00:42:59,720 --> 00:43:00,553
you know,

659
00:43:00,680 --> 00:43:04,790
keep it simple and do some
injectables when it's the right case,

660
00:43:05,120 --> 00:43:10,040
but really nothing does take the place
for surgery when it's indicated. And,

661
00:43:10,050 --> 00:43:14,240
you know I'm sure Dr.
Bass feels the same way,

662
00:43:14,241 --> 00:43:19,010
but we see patients with all sorts of
things injected in and around their eyes

663
00:43:19,310 --> 00:43:22,070
and sometimes, you know,
it's like all those,

664
00:43:22,460 --> 00:43:25,250
those situations when all you have is
a hammer, everything looks like a nail.

665
00:43:25,520 --> 00:43:29,780
And we see patients that have seen
multiple different people and sometimes I

666
00:43:29,781 --> 00:43:33,020
just want to say, you know
what, your best option here,

667
00:43:33,260 --> 00:43:36,260
even if it's a young patient,
your best option here is surgery.

668
00:43:36,590 --> 00:43:40,730
And so we're lucky to be
doing what we do and to,

669
00:43:41,360 --> 00:43:45,980
you know, give patients that option
if it's indicated in these cases.

670
00:43:46,790 --> 00:43:51,200
You know, the other thing which we didn't
mention that's important is the lid

671
00:43:51,201 --> 00:43:56,090
surgeries are probably the
most durable thing we do

672
00:43:56,091 --> 00:44:00,650
in facial rejuvenation. So 10,

673
00:44:00,651 --> 00:44:05,360
20 years or sometimes
never for redoing a lid

674
00:44:05,361 --> 00:44:09,290
surgery is the norm
rather than the exception.

675
00:44:09,291 --> 00:44:12,260
And among everything that's available,

676
00:44:12,650 --> 00:44:15,200
it is definitively the most durable.

677
00:44:15,830 --> 00:44:17,750
On that note, thank you Dr. Bloom,

678
00:44:17,751 --> 00:44:21,620
Dr. Bass for helping me and our
listeners understand this complex area.

679
00:44:22,100 --> 00:44:24,770
The eyes may not take up a lot
of real estate on our face,

680
00:44:24,771 --> 00:44:26,660
but they certainly have a major impact.

681
00:44:27,290 --> 00:44:31,710
And I'd like to thank Dr. Bloom for
joining us yet again on the podcast in

682
00:44:31,711 --> 00:44:35,850
sharing his extensive experience
and his wise perspective.

683
00:44:36,330 --> 00:44:40,230
Thank you guys again. It's always a
pleasure to be a guest on the podcast.

684
00:44:41,850 --> 00:44:45,510
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.

685
00:44:45,930 --> 00:44:48,180
Follow us on Apple
Podcasts, write a review,

686
00:44:48,181 --> 00:44:49,560
and share the show with your friends.

687
00:44:49,950 --> 00:44:53,070
Be sure to join us next time to avoid
missing all the great content that's

688
00:44:53,071 --> 00:44:56,580
coming your way. If you want to
contact us with comments or questions,

689
00:44:56,581 --> 00:44:57,510
we'd love to hear from you,

690
00:44:57,990 --> 00:45:02,280
send us an email at podcast@drbass.net
or dm us on Instagram,

691
00:45:03,320 --> 00:45:03,720
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