Your plastic surgery questions are answered by Dr. Yune

Maedeh Samimi: Thank you so much for coming on to the podcast. Dr. Yune. How did you get into facial, cosmetic and reconstructive surgery?

Dr. Yune: Well, I just really enjoy art, and I feel like it's as much an art form as it is a science. I really like the creativity of it. And I have a nickname for it. I call it happy medicine. So we really get to enjoy fun visits with our patients. That's kind of a unique niche and medicine in general, right? Because most of the medicines take care of sick people. I actually take care of people that are well, that are just trying to accomplish something to help their self esteem. So we get to deal with happy patients typically, and it just makes our day so enjoyable. So I feel so privileged to be in this field.

Maedeh Samimi: That's wonderful. Why don't we start with injectables (neuromodulators)? A lot of my clients don't know too much about it. They're scared to try it. Let's talk a little bit about injectables. Who's the ideal candidate? Is it ever too early or too late to get into injectables?

Dr. Yune: Well, that's a great topic to start off with simply because injectables in general are the most common cosmetic treatment that's non-surgical. In fact, it's just the most common request across the board currently. So you brought up neuromodulators; there's sort of two main buckets as we talk about injectables, the first one being neuromodulators. Everybody knows the term Botox, they also have some competition, and other products called Dysport, Xeomin, jeuveau, and daxi; daxi is the newest kid on the block. There are different options. But what a neuromodulator does is it modulates or controls excessive movement. And where we apply that is to undesirable muscles. So what I mean by that, I just call them real basically the depressor of muscles of the face. So there are muscles that age you faster than gravity. And if you look how a person ages over time, you'll see certain consistencies. You'll see a grimace between the brow creating what my colleagues call the elevens furrows. You'll see lateral canthal lines called crow's feet. But those two muscles when they activate, they actually push your brow downward. Those depressors are on-label, FDA has approved cosmetic use for glabella and crow's feet.

The lower face actually has depressors too. There's a muscle of the pulse of the mouth in the angular fashion. The Depressor Angularis Oris called the DAO, and there's muscles that bend the neck that's called the platysma. These two lower face muscles age your face faster than gravity. So we're using neuromodulators for prevention. We're using them for maintenance. It's really the only preventative tool we have. So when you see people that get Botox regularly, especially to those for depressor muscles versus those who do not, it's dramatically different. The two lower face depressors are off label just so your audience understands that the FDA hasn't approved it for cosmetic use. I'm comfortable using it off-label, and I have since the beginning of my career using Botox nearly 30 years ago, because that's how we've kind of always used it. Anecdotally, it might be interesting for you to know that Botox was first released in the late 80s for essential blepharospasm which is the involuntary twitching of the eye. And early adopters recognized that it reduced the crow's feet, but it took several years to get FDA approval for cosmetic indication because that's just the way the FDA works. You know, cosmetic indications are not a priority to them. They have to worry about drugs and vaccines that are for medical indications. So I think we'll get FDA approval for lower face because the safety profile is just as good as upper face and I've been using what I call the Botox assisted facelift for 30 years it's just worked beautifully for me.

The other main category is fillers. Otherwise we call them volumizers, and biggest category in use today is hyaluronic acids. AHA is awesome. I love the AHA's because it gives us a safety profile. That's unbeatable, and what I mean by that is there's an enzyme to melt undesirable AHA's. So God forbid you get a result that you don't like, you can actually reverse it. And that enzymes applied one or two times, and it can pretty much reverse the undesirable effects in a day or two. So you don't have to live with a bad result. And a lot of patients don't know that. The AHA's lasts from nine months to two years. And we're using filler where there's need for volume.

As we age, we go through a process that we call a medicine atrophy, where things just shrink. Okay, so the most popular areas to apply fillers, that would be like the lips, I think girls start losing volume in their lips as soon as they graduate college. So it's not uncommon to do a little lip augmentation on girls in their 20s. Cheeks, a lot of the times we'll build up the cheek mound, and that can actually create a lifted look. So anytime you put volume in the upper face, it helps pull up the lower face.  Another common area, as people get really thin, they'll get a temporal holla, which really ages the face, we'll use it around the mouth and the folds, glabella folds, the chin, jawline, anywhere that needs volume, even off label, we're using it to augment noses. And that's high level, you need somebody with a lot of expertise and understanding of the vascular anatomy because you always have complications which are avoidable if you really use a safe technique. Even back of the hands, we'll even do scar tissue that's indented and even buttocks. The other category is poly lactic acid. That trade name is Sculptra. And we use that as a stimulator, so when you inject it, it has a delayed effect, usually takes place in six weeks. It requires repetition because you don't want to overdo it. Most patients will go through about three sessions separated by six weeks or more just depending on what the patient needs.

Maedeh Samimi: Is Sculptura form of a filler?

Dr. Yune: So it's not really a filler per se. That's why I was telling you the word is stimulators. It's quite an ingenious product, frankly, because it's a similar product to the dissolvable sutures I use for instance, in the face. When somebody realizes is when that stitch was reopened, there was a ball of scar tissue around there. So it made sense to take that same product, powderiz then suspend it in saline and local anesthetic and inject it creating that same collagen replacement of it. And that's what takes six weeks. So it's not really a filler but it gives you volume by stimulating your own collagen.

Maedeh Samimi: You mentioned fillers are reversible (they're dissolvable) but That is not the case with Botox, Correct? If someone let's say, receives Botox, and they feel that heavy feeling on the eyebrows, do they have to wait until it wears off? Or is it correctable?

Dr. Yune: Well, the good thing about Botox is if you don't like it, it does go away. It lasts about three to six months. For most people it's three months. You brought up droopy brows. Well, that's the most common complication, if you will, cause by Botox and it's basically always avoidable.  We just talked about the depressors, where you get the droopy brows when you start using it in the mid forehead and up! The forehead muscle that causes  horizontal lines, is a lifting muscle. So if you Botox that, the brows will be coming down every time. Once you've established the brow lift, then you can treat the forehead, know that you're going to actually offset some of that lift. So the patient has to really understand the dynamics. And then you can always avoid droopy brow. But that's really common in this era of Botox being so popular. A lot of people are just doing it with all due respect, with a weekend courses. And in my practice, we have what's called Dr. Yun boot camp where I put my injectors through years worth of training.

Maedeh Samimi: I always tell my clients just as you mentioned, it's an art. Go to someone who you know, like and trust and they have credentials. Alright, the next question is who is an ideal candidate for a facelift and is a facelift permanent?

Dr. Yune: Okay, good question, right up my alley. One of my most popular procedures is the facelift. So when we talk about faces, we're usually talking about like, Temple, cheek, jawline, neck, extended collarbones. And then some people will call the upper face brow lift, we'll get to that in a little bit. But I think with any surgical procedure, or even non surgical, you have to consider safety first. And by that, I mean making sure you're operating on somebody that can tolerate general anesthesia. Some people will do this under IV sedation, my preference is general, but either way, I think you should, depending on their age, get a medical clearance from their primary care doctor, cardiologists, whatever is applicable. So you want to take a thorough medical history too, even though we're practicing aesthetic medicine, it's still real medicine. In fact you almost have to have your guard up more so because like I said earlier, we're dealing with healthy patients, right, so let your guard down. Can't do that, because it's just as serious as a heart transplant. So we have to have safety first.

Facelifting really needs to be on somebody with realistic expectations. So consider a facelift probably the most rejuvenating to the lower face. But we already talked about two other buckets, bad muscle movement, well, that's treated with Botox, and volume loss that's treated with filler. But I would tell my patients, typically a facelift is going to be three fourths of the equation, it's the majority of rejuvenation. And it's not that hard to imagine. Because really what a proper facelift surgeon does is they don't really make you look different, they make you look younger, and my patients over the course of three decades have told me the average rejuvenation is 10 to 15 years in appearance. It's literally what you do in the bathroom mirror (pulling your skin back) and if that's what you like, that's what you're gonna get, within reason. The facelifts hold up based off of your skin's elasticity. And so fortunately, in this era, we have devices. I call them the energy based devices, that will be radiofrequency and ultrasound and plasma. And these kinds of things that heat the soft tissues creating better elasticity, that thermal injury creates basically a shrink wrap effect. So when a patient gets a facelift, you're going to experience some sagging as it's healing, that's just the elasticity dictating where it ends up, you find that out at three to six months when the swelling is gone. And then you decide if you want to implement energy based devices. They're subtle. So you have to do multiple treatments. We usually say three or more is the sweet spot. My two favorite devices of my clinic are Ultherapy and secret RF. And then again, when the swelling is gone, you decide if you want to add filler, and Botox to maintain. It's really an educational process to make sure the patient knows what to expect many years down the road. So permanency, is always an interesting question. Because if you do a proper facelift, we're going to set your clock back 10 to 15 years, that's always going to be with you. The problem is the aging process starts day one after the facelift. So you will always look relatively younger. So in that regard, that portion is permanent.

Maedeh Samimi: What do women need to know before considering plastic surgery?

Dr. Yune: That's a pretty broad question. And maybe we can kind of break it down into key points. The first thing to do is understand how to find a good provider. That's not easy for the consumer because there's a huge onslaught of marketing and cosmetic surgery. And so what consumer needs to do is understand how to vet a provider. So understand that plastic surgery is so wide and broad now. It's specialized into certain areas. There are those who just do reconstructive surgery, that would be like repair for breast cancer for instance, there are those who specialize in just burns. Those who specialize in pediatric cranial facial cases. Cosmetic surgery is a whole different animal. And when you have the privilege like I did to do a fellowship, you really can gain a lot of experience. So there are these things called fellowships, which is training specifically in cosmetic surgery that gives the trainee a hundreds to thousands of cases in a year or two. And this is obtained after residency. So when you hear the marketing term frequently only trust a board certified plastic surgeon by such and such boards, that really is the tip of the iceberg. You've got to realize board certification's an indicator of general knowledge, it does not indicate what you specifically trained in. So don't be ashamed. And don't be concerned about asking your prospective surgeon, what did you train in, and what what was involved. So I'm getting on this because there's a lot of work being done that's not ideal, and I think that's because of lack of training. You can actually with the proper board certification, get carte blanche hospital privileges to do whatever you want including cosmetic surgery, even if you haven't done a single one in your residency. That's a problem. And I've had this because at any given time, sometimes over 50% of my surgical work is correcting bad jobs, which we refer to as botched jobs. Now there's a TV show about it. And it always breaks my heart when I see these people struggling who've had bad work done. Fortunately, there's ways to fix some of it, but some of it you can't fix. So make sure your surgeon is experienced and trained in the area of interest. You can vet that through pictures, and reviews, you know, with pictures, I think it's really important to show a huge cross section of your work. I went to my website designers and said I'm gonna put 1000 pictures on my website. And they said, Well, that's ridiculous, nobody does that. Don't you want to put out your three best examples? I said no, that's not really honest, we have to be fair, and show them all my work. And so they obliged. And I think that's one of the favorite things about our website is that patients can really browse numerous cases and get a real good feel. Because I think we really need to emphasize improvements that look natural. I want all my patients to look like they just look rested. They look 10 to 15 years younger.

In this business, we have a saying that, if it looks like they've had a facelift or too much filler. That's just bad work. So that's always avoidable. But that's the part that you need a lot of training to understand the aesthetics, because it is artistry. It's not just cut and sew and fix a hernia, we've got to make it look good, especially facial surgery, because you're not covering that up with a garment. So you know, understand there's a level beyond board certification and most come to reputable practices, they typically are built by indirect referral, you come because your mother and sister look great, and normal. So vetting through other people and patients. I think it's always good to get a couple of opinions, I'll encourage my own patients when they're consulting with me, it's not a bad idea for you to talk to other folks.

Maedeh Samimi: I agree with you 100% on that. What is the best procedure for under eye bags, hooded eyes, and what's the recovery time like?

Dr. Yune: So the most popular rejuvenation surgery, if you will, is eyelid surgery, otherwise medically called "blepharoplasty". So let's just call it eyelid surgery. And so under eye bags, let's start with that. That's usually an inherited condition, or the orbital fat. So you have fat around your eyeball in your eyes socket, some patients will have a bulge. And that's because the very thin membrane that holds the fat back is weakened or there's just an excessive amount of fat, creating an undesirable appearance where people feel like they're too bulgy or baggy are called verticals, if you will, you really have to understand how to diagnose the anatomy to treat it properly. So as a surgeon, what I'm doing is I'm evaluating that patient because if you have a fat bulge, let's call that a hill. We want to take it down to sea level, and that's done surgically. What most people would have with a bag is they'll have a little trough below it called the teartrough. Now, if you go to a clinic that's just offering injectables, you might get that tear trough filled. That's not going to be a better aesthetic most times it's just gonna look like a taller fat pad. So what you really want to do is to take that fat pad down to sea level. See where you end up with three to six months, that's when swelling is gone. And then decide if you even want filler, which more times than not my patients don't care to do because it requires maintenance. See an overhead lighting casts a shadow below the fat pad making it look like a dark circle. When it's not pigmentation at all. It's just the shadow. That is often done in conjunction with the lower eyelid lifts because if you reduce fat pads, you're going to create some more wrinkling. So it usually requires some suspension. And in fair skinned people, we can do a laser type resurfacing to the lower eyelid skin to create tightening. And that has to be done very judiciously because you can't do laser surfacing on dark brunettes or darker pigments. So sometimes you have to leave a wrinkle or two behind. But I'm not doing a lot of skin removal below the lower eyelid because that can create a real problem where the patient is getting lower eyelid rounding or what's called ectropion. And it can give them dry eye syndrome as well as a very negative aesthetic appearance. So really got to be cautious with how you handle the lower eyelid. The lower eyelid fat pad, if it's just fat we're removing that's an incision on the inside of the lower eyelid. So it's a hidden scar.

Now, upper eyelid surgery is as popular if not more popular. Eventually we all get the curtain coming down (the skin), but also in conjunction with excess skin, there's oftentimes a fat pad toward the nose and called the nasal pocket. So see eyelid surgery is not just skin removal, it's muscle contouring, ligament tightening, skin resurfacing, fat pad reduction, and then you really have to understand a patient's anatomy and how do you approach it. So we do video imaging, we take pictures, we give them realistic expectations, we take those pictures to the OR, so we can target our surgeries very precisely. Everybody's different. When you do this surgery, you'll realize each case is different. That's the artistry. So eyelids are the most popular because it has a high aesthetic value. We studied this years ago, we noted where people looked when you asked about youth and beauty? Turns out we spend 80% of the time looking at the eyes and mouth area. That's heavy hitters, eyes and mouth. Plus the skin is thin, doesn't have many oil glands. So your eyes are going to age much faster than your cheeks, and your lower face. We're doing eyelid surgery sometimes some people in their 30s.

Maedeh Samimi: What is the biggest misconception when it comes to cosmetic plastic surgery?

Dr. Yune: I would tell you there's a couple. And as I mentioned earlier that board certification equates to expertise, I would tell you that, again, shopping wisely, because you really don't want to find your surgeon just because he's in a fancy magazine ad. So dig a level deeper, and understand that there are specialists who've had additional training. And when you're doing something over and over again, you tend to give better outcomes and have a better safety profile. So biggest misconception is all plastic surgeons are created equal. And it's not that way. The misconception is that plastic surgery always looks plastic that looks done. And also, as we mentioned in the past, if it's done properly, you really don't leave any footprints behind, even with facelifting with scars hidden around the ear and into the hair. In eyelid surgery with incisions hidden in the crease, and on the lower surface on the inside, you can do upper and lower eyelid surgery, facelift and even rhinoplasty and not see any visible scarring no matter how you wear your hairstyle. So that's just understanding where to place incisions, how much tension you can place on it. The facelifts that you see have too much tension on the skin, pulling the ear lobe down the bump in front of the ear canal called the trigger is being pulled forward or just wide scars that are unsightly. So understanding how to do a layered approach when we talk about the Smas (SMAS) lift, whether you do a smas or a deep plain face, if that's really your tissue that holds well. That's what gives you longevity. I know there's a big trend toward many facelifts which are local anesthesia, small incisional pattern, small skin flap. But what we've noticed with those types of cases, even though it's convenient, easy, less painful and less downtime, the results are less too. So my theory is I'm going to make that incisional pattern, I'm going to give them the maximum result. So I'm not a big fan of the mini facelifts even though they become so widely popular. You really have to understand facial anatomy, where the nerve that allows your face to move lives to do a proper facelift.

Maedeh Samimi: What is the typical downtime after a full facelift?

Dr. Yune: Okay, so I always call these the milestones because downtime is translated differently depending on the person asking and I think what patients are most concerned about is, when am I going to look normal? That's going to be about 10 to 14 days, I call it "restaurant ready". And what matters to us as healthcare providers is when are things going to be sturdy? That's six to eight weeks. That is when you have maximum wound healing strength or what we call tensile strength. So the scar can't be disrupted if you go do heavy exercise or sleep with your face on the pillow. So six weeks, I call that graduation day, do whatever you want. But it actually takes three to six months for soft tissue swelling to subside completely. And noses take a year. We actually manage noses with quarter cortisone shots for pockets of swelling up to a year. millimeters manner! So that's why we're managing our noses. It takes nine months for nerves to wake back up. So you feel with my patients call it the new normal, because there's a lot of sensory nerves that get disrupted. While you're healing from surgery, some parts will be a little sensitive, some parts will be numb, nine months before you feel no physical signs or symptoms of having had this surgery, and then it's a full year, for scars look their best. So you have to follow your patients throughout the whole year and more if necessary, very rarely will you deal with some thicker scars that happened more typically in darker skin types. You might see that in some Asians and American Indians, African Americans. And those can be managed quite successfully with cortisone shots, lasers, steroid injections we've talked about and then maybe micro needling. So you really have to know how to manage your patient to the finish line. But those are your key milestones.

Maedeh Samimi: Thank you so much for answering all of our questions. Is there anything else I am not asking that you think would be valuable to our listeners?

Dr. Yune: Well, we certainly covered a lot of territory there. So I think I would just want to emphasize natural appearances, vetting your provider and having realistic expectations and safety first, always. I hope we gave your listeners some good material there. And I really appreciate you having us do this for you.

Maedeh Samimi: You can check out Dr. Yune on his website www.asc-psd.com