What Estrogen Does to Your Skin (And What Actually Works)

21:21Even if it has a slight brownish tint, that should be fine as well. Studies do show that if it's mildly oxidized, it still should work fine. But if it's brown, then it may have oxidized too much and it may not be effective. The other thing you want to consider with vitamin C is that there are studies that do show that if you combine vitamin C and vitamin E together, they can be synergistic together. There's a company called SkinCeuticals. I don't have any relationship with them, but they have a serum called CE Ferulic, which is legendary. I've seen it.

21:51Dr. Mary Claire Haver:I think I've tried it back in the past. It's like$180 for like a half ounce or one ounce. And so we kind of created my own version of CE anti-oxidant serum because I know, I mean, it's such a great idea because we know it's synergistic, it works best. And now you're getting actually the benefits of vitamin C and E. And we know that that can even work together to give you even a better result. In your professional opinion, since we're on the subject, why are, you can look at two bottles of vitamin C and one is$5 and one is$180. Like, what are you paying for? What is the difference? You're paying for the brand name.

22:20You're paying for the packaging. You may be paying for, you know, the company to get a bit of a higher return on their investment. But I think really one very important thing to realize with skincare is just because it's more expensive doesn't mean it's gonna work better. Now, if you like how the product smells and how it feels on your skin and you want to spend the extra money for that, that's fine. But there are a lot of, honestly, drugstore brand skincare products that work great. I really think it's important for people to realize that cost does not determine the value of a product. And if a big celebrity endorses it, that doesn't mean anything either.

22:54It just means that they got paid to endorse the product. So really, you want to look for the active ingredients. Make sure it actually has, you know, like L-ascorbic acid in it. Make sure that once again, that when you apply it, that it isn't brown. And then really it's just gonna be a personal preference in a lot of ways. Even when you look at percentages with a lot of skincare products, like let's say retinol, there's some that are 1%, some that are 0.5%. It's not an even playing field across. So you may find a quote unquote medical grade 1 % retinol that can be very aggressive on your skin.

23:25Yet another one you could buy at the drugstore that says 1 % retinol and it's not nearly as aggressive. And so unlike let's say prescription medications where we know that the amounts that they say are going to have to be very, very accurate with skincare, it's not the same.

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27:07Dr. Mary Claire Haver:So let's move on to the retinol products. So the Retin-A, you have to have a prescription, right? And there's several strengths. Which one would you recommend if you're going to your physician and getting a prescription for the skincare, you know, for your anti-aging? You know, I don't love that word, but, you know, to get some collagen back in your skin. Yeah, so the most scientifically proven ingredient is tretinoin. And that's prescription strength, retinoids, or retin-A is the other name for it. And it comes in three strengths. There's 0.1%, which is the strongest. Okay. 0.05%, which is the most commonly prescribed, and 0.025%, which is obviously the weakest.

27:47It's really important to keep in mind that not everybody can tolerate tretinoin. Okay. It's strong. What does it do? The easiest way to describe it, it creates an acute inflammation to eventually reduce chronic inflammation. Okay. So an acute inflammation to eventually reduce chronic. And there's a little bit of hormesis idea to it as well.

28:05Dr. Mary Claire Haver:Why does it work for acne? Like my kids have been prescribed it for their acne. So it will help to increase cellular turnover, and that can help with clearing out pores. It can help to regulate, let's say, oil content in the skin. It can help to reduce fine lines and wrinkles. It can help to support collagen production. There's an anti-inflammatory effect to it. There are some studies that show that, let's say, if you have a history of basal cell carcinomas on your face, that I recommend all my patients who have a history of skin cancer to apply then tritinoin afterwards. afterwards, you're not going to know what it prevents because it may take some cells that are maybe a little dysplastic and essentially slough them off before they become cancer.

28:43They just never show up that way. So really, it's a jack of all trades when you're talking about truly anti-aging. The problem with tretinoin, as I mentioned, is that it can be very strong. When I was in medical school, my wife and I were having issues with acne. And back then, I didn't think about what was the cause of it. Well, it was probably being up at night, Taking call, eating the fry bar at the hospital at night, the deep fried apple wedges and all that type of stuff. And God knows what my microbiome was doing at that time. There's so many factors. But I saw my family doctor and she said, oh, let me prescribe you tretinoin.

29:14It worked for me. So I was like, okay. So she prescribed me 0.1 % tretinoin. She said, apply it every night. And at the time, I'm like, okay, I'll have her prescribed for my wife too. So we both started taking it. And I didn't see her for about a week and a half. We had a bunch of call nights and stuff. And it was hilarious because we finally saw each other after about a week and a half, and we both broke out laughing because we both, our faces were bright red. They were on fire. They were peeling and flaking. It was hilarious. But in the end, when I think about it now, my family doc, she was female, but she had really thick, oily skin.

29:50And so for her, 0.1 % tretinoin was great. She tolerated just fine. For me and my wife, that's not our skin. and it was a very big lesson. So I actually don't tolerate tretinoin. I only tolerate retinol because it's too strong for me and I find that I get some too much skin irritation from it. That being said, we do know that the studies are very, very strong in its overall benefits and so many different things. So if you can tolerate tretinoin and if you have a dermatologist that's willing to prescribe it for you, even if you just buy it over the counter because technically you can only prescribe it for acne, that's a great anti-aging cream.

30:25Dr. Mary Claire Haver:So if someone was going to try to pick, like walk me through like you did for vitamin C, how do you pick a good retinol product? What do you look for in the bottle? So what you want to look for, ideally, a couple of things. Like if you have thick, oily skin and you want to be more aggressive, then I would go the tretinoin route. You know, no question. If you don't, if you have more sensitive skin or let's say you don't have access to a doctor, then there's a lot of different retinols out there. Pretty much every big skincare company has a retinol. And once again, percentages don't seem to matter, unfortunately.

30:54So you can't necessarily look for a percentage. There are certain things I do recommend that you look for overall with skincare products. The first thing is ideally you wanna avoid fragrance because that can be very irritating to the skin. So there are some companies where the fragrances are really strong and that's something I in general don't recommend. But there are good retinols that are from drugstore brands like Rock ROC, like that's just a drugstore brand. They've got a really nice retinol. There are brands that are gonna be more expensive, but what you really are paying for isn't necessarily a better quality of the retinol.

31:25You're just paying for the brand and the brand name.

31:27Dr. Mary Claire Haver:What did you put in yours and why? So ours is stabilized retinol liposomes because we know that by putting it in the liposome, it's a bit less irritating to the skin. Also, we have a bunch of moisturizers in it with antioxidants. We have a bunch of good fatty acids in it, so it's very moisturizing. What I like about ours is that virtually everybody can tolerate it unless you're super, super sensitive. But that being said, if you have really, really sun damaged skin, you've got a lot of spots and you want to change very quickly, then my Youn Beauty Retinol Moisturizer may not be the best option for you.

32:01That's where I would go more towards a tritinol if you want to be more aggressive. But if you're looking for something that's kind of long-term that you can tolerate, that's very stable, that feels good, it's moisturizing, then I think our, you know, then for me, it's a cornerstone. You know, I use it, my wife use it, my mom use it. We send it to them every month.

32:16Dr. Mary Claire Haver:Talk to me about sunscreen. How many people are actually using it the way they should. So about 15 % of the population in the U.S. wear sunscreen every day. I can't get my 22-year-old to wear it. She's still tanning. Still tanning? Yes. Oh, that's not even, yeah. So that's a whole other deal. Like in their bikinis, in the backyard. Yeah. I mean, my daughter, she likes getting color in her skin too. But it's tough because, you know, in general, yes, I'm not a dermatologist. If I was, I'd say you have to apply it every day and reapply every two hours. You apply it at lunchtime and all that. And even if you're in a dark room, you should have it on.

32:53Realistically, I'm going to be honest with you, I don't apply sunscreen every day. I'm in the OR two days a week. And if I'm in the OR where literally, I live in Michigan, where it's dark when you leave in the morning, it's dark when you come back sometimes. I don't necessarily put it on. It is very important if you're going to be out in the sun, you do want to wear it. No question. At least SPF 30. Make sure it's broad spectrum. If you have issues like, let's say, melasma, especially melasma that's hormone mediated, A lot of times an SPF 50 is going to be better for you. Okay. And that's where usually people stick with 30 or more.

33:2250 to 60 can be very helpful in certain issues like I said, like with melasma.

33:27Dr. Mary Claire Haver:Does it matter if it's chemical sunscreen versus mineral? I see a lot of debate on the internet. Okay. So there's no question that a mineral-based sunscreen is safe because essentially it sits on the surface of your skin and reflects the sun's rays. The problem with mineral-based sunscreens is they can be very thick and kind of tacky on your skin. Yeah, and very white. And especially if you're a person of color, then it can really change the color of your skin. Even if they micronize it, meaning that they make it much smaller particles, it can still change the color of your skin. And that can be an issue.

33:59The problem with chemical sunscreens is that there is a concern that some people have that certain ones, oxybenzone and octanoxate, could be potential hormone disruptors. and there are studies that show that the vast majority of americans it's like almost 100 literally have it in their urine when they have tested people it's like crazy how much people have it and then there's a concern with coral reefs if you're let's say right out on vacation of those disrupting the coral reefs so there are concerns with it i think number one is if you if all you have access to is a chemical based sunscreen then still use it okay because you do not want to get skin cancer that's you know i'm a plastic surgeon i can't tell you how many people that i've see in my office that get skin cancer on their face and it's disfiguring.

34:40You do not want skin cancer. I would be much more afraid of skin cancer than a hormone disruption from a use of a sunscreen on your face if you're on vacation. That being said, there are certain filters that I think have not been concerning. Avobenzone is one. Maxoral XL is another one. These are filters that nobody would argue are potentially harmful. The only two that I've seen any data for is oxybenzone and octanoxate. And a lot of sunscreen companies now are excluding those ingredients in their sunscreen products anyway. So I really wouldn't be all that worried at this point. You really want to protect your skin.

35:15If you are really fortunate though, the problem in the U.S. is the FDA has not approved a new filter since 1999, since the 1900s. Wow. 1900s was the last time they approved a new sunscreen filter. And there are other countries around the world that do have much more advanced filters than us. A couple of years ago, I went to Korea with my family and we bought a ton of sunscreens. And it's like you put a moisturizer on your skin in the morning and you'd forget that you have it on. It's just comfortable. You don't feel greasy. That's how these sunscreens feel on your skin. Just like you're putting your moisturizer on.

35:47Yeah. It feels like that. Yet the ones that we have here in the United States, they're old. Yeah, they're effective and they work, but they're not as comfortable. And that's where really the hope is that the FDA does start approving. They just made a recommendation to potentially approve a new one this past November. And like I said, it'd be the first one since the 1900s that one is potentially going to get approved.

36:09Dr. Mary Claire Haver:I see a lot of sunscreen being added to like makeup. Do those work? I mean, or should you really just have your sunscreen? So they work, but usually there's not enough in it to truly protect your skin. And what about my dermatologist friend gave me, because we hike a lot together, and she puts the powder one on, you know, and swears that it works. Yeah, I mean, however you like it, I think the powder is gonna be a mineral base that's gonna be zinc oxide or titanium dioxide. I do not. You know, dioxide, yeah. So, I mean, those work as well. I mean, even there are people using sticks now, roll-on sticks with it.

36:41Whatever works for you and it's comfortable and you will keep with, that's the important thing. Because really, like I said, you know, if you're gonna be out in the sun, it's so important to wear it. You know, I did a podcast interview, really nice guy. and he said, you know, Tony, I don't wear sunscreen. I just put lard on my face. He's like, what do you think about that? And I'm like, oh, okay. That's, you know, you know, and I think what I've seen, like I said, is too many people who you get premature aging from it in addition to the potential risk of skin cancer. And with the premature aging, and we're talking a lot about that here, all you have to do is compare the skin of your butt to the skin of your face and your neck and your hands.

37:19And you know that sun can really cause premature aging. And so really applying it is super important. And whatever it takes for you to be compliant, you know, if it's the powder, then by all means, then use it.

37:30Dr. Mary Claire Haver:Then use it. Let's talk about some other products. Lots of chatter on the internet about peptides. What is a peptide and why would you put it on your skin? Okay, so we got to look at peptides in two different manners. So peptides essentially are short chains of proteins, you know, of amino acids. So for our audience, if you don't know, like insulin is a peptide, GLP-1s are peptides, but that's not what we're talking about here. So essentially, there are small proteins that cause the body to react in a certain way. Now, when you put them in skincare, they do what we ideally want. Like we just talked about what happens with menopause, what happens with aging, you lose collagen in your skin.

38:04So peptides essentially are cellular messengers to message your skin cells to create more collagen. That's essentially what they do. The good thing about peptides is that they're in general relatively inexpensive. So if you go to, let's say, a drugstore and you look for an anti-aging cream and they claim to improve wrinkles and all that, oftentimes they'll have peptides in it. And they usually are well-tolerated, they're not that expensive, and they're a very good budget option. Studies when you compare, let's say, retinol to peptides, most of those studies will show and most dermatologists will tell you that they would prefer retinol over peptides in general for efficacy.

38:37The other group are growth factors. Growth factors, very prominent, you know, we can get them through PRP, but there are growth factor serums out there that are being sold and some that are being sold for a lot of money. That too, there's science behind those. The same thing. They promote the skin cells to create more collagen. Those are going to be more expensive.

38:54Dr. Mary Claire Haver:Is this the salmon sperm stuff that I've been seeing? Salmon DNA is polyribonucleotides. That's PDRN, polydeoxyribonucleotides, technically. Let's go there. So that's a whole other thing too. So right now, what's really one of the newest topics in anti-aging medicine and plastic surgery are biostimulators. These are substances that you can inject underneath the skin. So they're injectable. To help in general, to help cause your skin to rejuvenate. Now, once again, we look at increased production of collagen, but it may also help reduce inflammation. There are other potential effects that they may create.

39:30And they're, once again, biostimulators is the name of it. PDRN is really popular in Korea. And it's basically salmon DNA, or people call it salmon sperm, but salmon DNA, whatever. I don't know how you actually get it out of the salmon, but people have made funny memes about it. But you take the DNA from the salmon, and it's actually very similar to human DNA, believe it or not. And they create then these biostimulating products. One of them is called Rigeron. And in Korea, they will actually inject it underneath the skin, literally like dozens of injections throughout the face. And they say it's one of the most painful non-surgical treatments because you're having like dozens of injections.

40:06Dr. Mary Claire Haver:I've seen the videos from Korea. Yeah. Here in the U.S., it's not FDA approved for that. It is illegal to do it that way, but it's not illegal to use the product as a topical. And so there are places who are doing, let's say, microneedling, where you're making tiny little pokes on the skin, and then they're applying the PDRN, the salmon DNA, like Rogeron, on top of it. And then the idea of it there is that it seeps into those tiny little holes made by the microneedling, and it rejuvenates the skin from the inside out. So that is legal to do. Wow. I would expect that the salmon DNA, the PDRN, is probably going to get FDA approved sometime the next year or two, hopefully.

40:42I mean, we don't have a lot of studies on it, but what you hear is a lot of anecdotal reports that are pretty impressive.

40:47Dr. Mary Claire Haver:Have you ever gone to Korea for any of this or checked out stuff? I have not. I mean, you see these women flying over there and they're getting eight, nine, 10 procedures all in the same week. Yeah. Is that safe? I mean. It depends on what it is. So they do a lot of stacking treatments and that is popular here in the US as well. But when you see who's going over there, I see influencers going there where they're getting the treatments comped for them because they're gonna post on it. I think it's really important for people to realize that this is a small, tiny group of people who are going there.

41:16And to afford that is so unusual. Yes, if you have the ability to do it and you wanna do it, by all means, go ahead. But I also think it's important for real people to realize that you don't need to do that. And that it's, yes, they will stack treatments. I'll do microneedling. They'll do, let's say, IPL with it. Lasers. Yeah, high-frequency ultrasound. They'll inject some Botox. They may do a little bit of filler. And they're doing these stacking treatments that you can do in the US, but it does get very, very expensive. And you don't have to do all that stuff. Start with the base stuff that we'll talk about with diet supplements, with skincare.

41:52And then there's even at-home treatments that work really great. And for the vast majority of people who can't spend 20 grand going to Korea, I don't want to spend that myself. Yeah, yeah, yeah. There's so much you can do. Okay.

42:02Dr. Mary Claire Haver:Niacinamide. Like, talk to me more about topicals. So a couple of things to consider. Niacinamide is nice. So if you do look at drugstore brand products, and especially if you're looking for a sunspot reducing product like a brightening, niacinamide is very common in brightening products. It is a form of vitamin B3, very well tolerated. It's kind of like a jack of all trades for anti-aging skincare. So it does have some antioxidant effects. It definitely can be very moisturizing for the skin. It has some anti-inflammatory effects, can help with fine lines and wrinkles, but mostly what people use that for are spots.

42:34And that's one thing we haven't mentioned yet too, is with actual menopause, there is an increase in people who do get hyperpigmentation of their skin. It could be melasma or it just could be the sunspots and age spots. That does seem to become more of an issue as women go through menopause. Niacinamide, very nice ingredient in over-the-counter brightening cream. So if you're on a budget and you're going to your local drugstore, that could be one of the products that you see. Very safe, moderately effective. Not the most, but moderately effective and good for somebody who's on a budget.

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46:52say it doesn't matter because you wash it off. Now, you don't want to use bar soap because bar soap can leave a film on your skin. You do want to use a facial cleanser. And ideally, you want to use a cleanser appropriate for your skin type. So for example, if you have oily skin, then a foaming cleanser will help with controlling that oil a little bit better. If you have more sensitive or drier skin, which is often the case in women who've got menopause, then you're going to want more of a milky or hydrating or gentle type of cleanser. But that's where you can really save money. Get something that's a large amount because once again, it shouldn't be that expensive.

47:21and as long as you're tolerating it, what you want after you cleanse your skin and you gently dry it off is you don't want your skin to feel tight. If it feels tight, then it's probably too dry into your skin. If you give it a minute or two and it feels comfortable, then that's when you know it's doing fine. So save money there. Another place you can save money is toners.

47:39Dr. Mary Claire Haver:What is a toner? I never understood what a toner was. Okay, so back - I mean, I felt like sea breeze when I was a kid. Back when we grew up, the belief was that you would cleanse your skin, then you would apply an astringent or a toner that had alcohol in it. And then you would apply it with a cotton ball and your skin would feel nice and cold and like it felt great. And then your skin would dry. And what we've determined now is that those astringents filled with alcohol actually would disrupt the skin's microbiome. And so that's the first thing is we have a microbiome on the surface of our skin, kind of like the microbiome inside our gut, trillions of bacteria that live there that help with skin homeostasis and it helps with keeping your skin healthy.

48:18And when you're using an astringent, like sea breeze that people used to use, you basically kill off all of that bacteria. So that's the first problem with the toners back then. The other thing is people would use them because they were having, let's say, oil problems. And so people would say, hey, I've got a lot of acne. I'm going to use these toners and I'm going to get rid of that oil. But what would happen is you would get rid of it initially, but then the skin cells would say, hey, what happened to the oil? And it would cause the skin cells to actually create this cycle of creating even more oil.

48:44So it would backfire because you would get rid of it that then your skin would be so oil-free that your body would create even more oil to compensate for it. So eventually people realize, hey, this isn't working. And so then they switch toners over to balance the pH of the skin. That was how it was marketed. And yes, there is some truth to that. If you have a real harsh cleanser, then applying a good toner that's closer to the pH of your skin may help with it. But a lot of cleansers nowadays, especially gentle cleansers, aren't really all that harsh on your skin anyway. So it's not all that necessary.

49:14But that's where you can save money. And then the final thing I I would say saving money, and maybe you don't need to, is there are moisturizers out there that smell nice, they feel nice on your skin, but they don't do squat, okay? Because they don't have those active ingredients. They don't have peptides. They don't have growth factors. They don't have retinol. They don't have bakuchiol or any of that stuff. The old cold creams, okay? Same thing.

49:33Dr. Mary Claire Haver:My grandmother swore by cold cream. Cold creams are fine. Also, she gave me my first jar of St. Ives. Oh, there you go. We'll talk about exfoliants. Yes, exfoliants. Ground up apricot. Yeah, exactly. So really careful. I mean, you can apply cold cream if you want. If you love it, by all means, do it, you know. But if you want to save money, combine a moisturizer that has active ingredients into one step. You don't have to if you don't want to, but that's where you can definitely save if you want. There are fancy moisturizers out there that cost a ton of money by big names, and they have absolutely nothing in there that's going to actually fight the aging process or make your skin healthier other than just moisturizing.

50:12And if you want to spend the money, you can. But if you want to save it, then buy those moisturizers that have actual active ingredients like we've talked about.

50:20Dr. Mary Claire Haver:So go back. Do we need to exfoliate? Is that a thing? Yes. So exfoliation is a thing. So our skin, when we're young, exfoliate turns over every about six to eight weeks. Okay. So I think of it for our listeners who don't understand skin, it's like a conveyor belt. Yeah. So it's like our skin, essentially it's made at the base of the skin where the skin actually meets with the fat. And then as the skin cells age, they go towards the top and eventually they're at the top and then they slough off. And that whole process takes about six to eight weeks. That's one reason why, too, if let's say you're using certain types of creams, sometimes it takes a couple of months, six to eight weeks for you to start seeing the benefits of it because you are waiting for that skin to turn over.

51:01And those older, you know, let's say more aged skin cells, more damaged skin cells to eventually slough off. As we get older, like everything, that process, that sloughing exfoliation process slows down. It starts taking 10 weeks, 12 weeks, maybe even longer for those skin cells to slough off. And that's one reason why our skin feels rougher in texture as we get older. When you exfoliate your skin, you can do it in one of two ways. You can do it with mechanical exfoliation, like with a gentle scrub, or you can do it with a harsh scrub, like you mentioned, or you can do it chemically with acids like glycolic acids and hydroxy acids, that type of thing.

51:37What that does actually is that that will then get rid of that upper layer of dead skin cells, but that will actually send a cellular signal to deeper layers of skin cells to start turning over more quickly. And so you can start revving that process up. So I usually recommend to exfoliate your skin if you have quote unquote normal skin, maybe two to three times a week. If you're sensitive, maybe once a week. You'll know you're over exfoliating if you find that your skin is irritated, if it's kind of red and inflamed, then you're overdoing it. And if it's not, then it may be a reasonable amount.

52:07Dr. Mary Claire Haver:Let's move on to procedures. Everybody wants to know. We're getting closer and closer to surgery. So we're gonna get there. But so walk me through the case for starting a neurotoxin like Botox, Dysport. And what's the difference between those two? There's Botox, there's Dysport. There's Xeomin, there's Javot, and there's Daxify. So there's five that are FDA approved in the U.S. Botox obviously is a gold standard. It's been used for the longest time. And all the other ones are essentially competitors. Essentially, it's their neurotoxins. And what they do is they prevent the transmission of nerve impulses to muscles.

52:42And there are certain muscles that create wrinkles. They're called dynamic wrinkles. When the muscle contracts, it causes the skin to wrinkle in a certain way. And so, yeah, just like you're doing. So in the upper face -

52:53Dr. Mary Claire Haver:My forehead is Botox. Three main areas. So the first area is right between the eyebrows. Actually, my Botox is worn off, so I don't have any. It's right between the eyebrows, most common. Second are the crow's feet. This is from the orbicularis muscle. And then the third is the forehead or the frontalis muscle that creates the vertical lines. These are the three most common areas that you Botox. Obviously, they're injections. Results last about three to four months, and then it wears off. Dysport is a brand that's been around the longest as a competitor. There is a belief that in some people, it's a little bit of a softer result.

53:24So if you Botox somebody, if you inject it, you know exactly what you're gonna get, it's pretty strong, like things don't move. The idea behind Dysport is that spreads just a touch more and for some people, it gets a little bit of a softer result. So some people like that. Xeomin, it has like peptides in it that the idea is it's a little more pure, but I don't see any true benefit from it. They've tried to advertise that, oh, it's got peptides to improve the skin quality, but I don't use it. Jivo actually is from a company that I was one of the founding investors in. called Avalis. And I'll be honest with you.

53:57Dr. Mary Claire Haver:And thank you for your transparency. I'll be honest with you. They had the studies actually looked really good for it and comparable to Botox. So I was really excited when it came out. And when we started injecting patients, didn't seem to last as long and patients weren't as happy with it. So I stopped using it. And I don't think the people in the company are that happy with me because as an investor, I'm like, yeah, I don't use it anymore because I don't, for me, I don't find, but there are some people who love it. It's just, I haven't found great results. And then Daxify is the newest one that came out as a longer lasting compared to Botox claiming a six month duration.

54:29We do see that in some patients, but not everybody. And so that has been walked back a bit. I do think that one works really well. I've used that myself.

54:37Dr. Mary Claire Haver:So comparable to Botox. Yeah. And like I said, I think in some people it may last a little bit longer, but it doesn't appear to be in everybody. So I think Daxify, so my office, we use Botox, Dysport, and Daxify. I think I love all three of them. I think they're great. I don't have anything much to say about Xeomin. And then my experience with Javoh wasn't great, but there are some people who love it. So I see a lot of, you know, it's so funny what our algorithms show us. And I see a lot of injectors injecting all over, platysmal bands, the Nefertiti lift. What are those? Because people are wondering.

55:09So the three traditional areas to inject are the three I mentioned earlier. In general, when you inject below the crow's feet area or the cheeks on down, you are going to create potentially more of an effect. You have to be more careful, I guess, because these are areas where the dynamic wrinkles are caused by muscles that also move your mouth, okay? And so we will inject a tiny bit of Botox, let's say under the corners of the mouth in the depressor anguli orus muscles. DAO, this is kind of the permafrown muscle. And I've had that injected in myself. And it's a muscle that does this. And if you inject right here and here a tiny amount, it will weaken that muscle and it lifts the corners of the mouth.

55:46So it kind of turns the permafrown upside down. You can inject it in the platysmal bands. Those are the platysma is the sheet-like muscle that comes up the neck. And when it gets droopy, yep, you can get little bands here. So if you inject it, it basically weakens those bands. And in some people, if they don't have a bunch of loose skin, that can smooth that area out a bit. The nefertiti lift is injections of Botox right underneath the jawline. And the idea is that it weakens the muscles that may pull down and that can create a mild upward lifting effect, which you don't see that a whole lot in people.

56:19And then there are other areas you can do, like you can do it for the gummy smile. Some people do a lip flip where you put a tiny bit right here, which just cause the lip to avert just a touch. So there's a lot of these little types of things that you can do with Botox. But you have to be careful because it really, these doses in the lower face and the neck are on, in general, smaller doses. Because if you do too much, now you can't. Yeah, your mouth doesn't move right and stuff like that.

56:44Dr. Mary Claire Haver:What is baby Botox? So there is, it's this idea of prejuvenation. So baby Botox basically are small injections of Botox. You can look at it two different ways. So some people refer to baby Botox as, hey, I'm just doing little bits of Botox. And you could be 40, 50, 60 years old, but you just are doing little bits to make tiny changes. And that's fine. There's no issue with that. Other people refer to baby Botox as doing Botox for prejuvenation, where you inject areas to prevent wrinkles from happening. That I'm not a big fan of. You know, there are people in their 20s getting Botox injected, and they have smooth faces before Botox, and they have smooth faces after.

57:22You know, I mean, Botox in general is a very safe treatment unless you have it done, God forbid, in a black market Botox or something like that. But in general, it's very, very safe. But we also know that there are people who eventually develop antibodies to Botox and that don't tolerate it after a while. Like they get injected and it just doesn't work. And for me, I think two things. Number one, it still is a medical procedure and I'm not a fan doing medical procedures that are not necessary, period. Okay, if you don't need it, then why inject it? Because there are potential risks of complications.

57:53They're pretty rare, but there still is a potential. And then the second thing is, are you using Botox now? And then when you actually need it in the future, it doesn't work anymore. There's a lot of people who are in their 20s that think, I can't imagine what it's going to be like when I'm 50. I thought that. I'm like, I'm not even going to make it there, for God's sakes. And when I do, it's funny because you'll hear people say, oh, I'm 40 now. When I'm 50, I'm not going to care how I look. Or when I'm 60, I'm not going to care how I look. My patients tell me this all the time. Every decade, they always will say that.

58:21you will care. Like we do, you know, and it's okay. But don't assume that you're not going to because you probably will. And that's where I'm not a fan of that. I think that some people are doing it just to make money. And I just feel like you're not really doing the right thing for these patients.

58:34Dr. Mary Claire Haver:So what would be a good age or time or what, you know, who should start Botox or consider it? Like when is the right time? When you start seeing those wrinkles and they're starting to bother you. Okay. Yeah. That's, you don't want to wait too long because there are wrinkles that can get inset and they can get deep. And no matter what you do with them, you Botox them, you fill them, and they're just not going to go away. And the way I describe it to my patients, it's like the wrinkles of my hand. Okay. I can Botox all the muscles on my forearm. I can inject filler into the wrinkles of my hand. They're never going to go away.

59:01They've been there way too long. And the same thing can happen with wrinkles of the face. You know, if you wait too, too long, then you Botox them and it's not going to work. So the best time to do it is when you start seeing those wrinkles come by and they start bothering you. Then that's a good time to start.

59:18Dr. Mary Claire Haver:Welcome back to another MidiPause. I'm Dr. Mary Claire Haver, host of Unpaused. As we move through midlife, our healthcare needs change, and often women are left without the right support. That's where MidiHealth comes in. From your first virtual visit, their clinicians deliver convenient, compassionate care that is covered by insurance and tailored to meet your unique needs. Midlife is a journey, and Midi is your map. Wherever you are in your journey, it's not too early or too late to start finding real solutions. When you address the root cause of your symptoms, not just the symptoms themselves, you can start to feel better with more energy, more clarity, and more confidence.

1:00:00Dr. Mary Claire Haver:One of the biggest challenges for so many women is knowing how to prepare ahead of time to get the most out of an upcoming appointment. So here's three simple ways to make sure you're ready for your virtual visit. First, write down your family health history. What conditions run in your family, who had them, and at what age? This can help your clinician determine whether certain treatments, like hormone therapy, may be right for you. Second, keep a symptom journal. Track any changes to your health since your last visit. Symptoms like fatigue, sleep issues, hair loss, weight changes, brain fog, or mood shifts.

1:00:38Dr. Mary Claire Haver:The more specific you are, the more helpful it is. And third, consider your treatment preferences. Whether you're interested in hormone therapy, a more natural approach, or lifestyle changes, it's important to go in knowing what feels right for you. And to ask your clinician for guidance based on your personal health history. If you want a little extra support, you can check out my menopause empowerment guide in the show notes to help you feel even more prepared for your next visit. Progress starts with a personal plan, because there's no one-size-fits-all approach to midlife care. That's why the Midi approach centers around a holistic combination of solutions, from medications like weight loss medications and hormone therapy, to lifestyle changes with a care plan that works for your body and your needs.

1:01:29Dr. Mary Claire Haver:MidiHealth is setting a new standard for health care. As the nation's fastest-growing women's telehealth company, Midi provides accessible, insurance-covered services. MIDI fills the critical health gaps women face, building on its leadership in perimenopause and menopause. If you want a clinician in your corner who truly understands what your body and brain need, MIDI is there for you. Go to joinmidi.com, join midi.com, and connect with one of their clinicians today.

1:02:04Dr. Mary Claire Haver:Moving on to more injectables. What is a filler? What are we filling? The majority of fillers are made with hyaluronic acid. And as I mentioned earlier, that's a naturally occurring moisturizer of our skin. The original filler was collagen. And you may remember, you and I remember the show Beaches, the movie where Barbara Hershey got a lot of flack for saying that, oh, she had filler injected in her lips before. The problem with collagen is it only lasted a couple months. And so hyaluronic acid fillers came around after that. And that's still what we use primarily. Now there are so many different types of hyaluronic acids.

1:02:34Some of them are really thin and they're used for areas, let's say like in the lips, where you don't want something that's real thick. And then other ones that are thicker, let's say that you can use like in the cheeks or in the chin to even simulate bone essentially. The way I describe fillers to my patients is it's like liquid skin. You inject it and it provides structure. It could be soft structure, like I said, in the lips, or it could be something firmer. Usually they last anywhere from six months at the absolute least to a couple of years. And there are some reports now that we know of where it can last even longer than that.

1:03:04And some fillers, because hyaluronic acid is a moisturizer. It actually is a humectant, so it actually will draw moisture to it. There are some reports that it can actually increase in size to a mild extent. I think fillers are great for the right people, but they're also much more risky than Botox. The reason why I'm talking about hyaluronic acid fillers, there are other fillers out there that I don't recommend. Such as? There's ones made of calcium hydroxyl apatite. Others are ones made of just plain silicone. There's another one. There's permanent fillers out there.

1:03:35Dr. Mary Claire Haver:Well, we've all seen some people in Hollywood who've had the permanent fillers done. The problem with permanent fillers is that they're permanent problems. And the worst thing that can happen with a filler, you know, we can talk about people get overdone, but even worse than that is what's called intravascular injection or intravascular occlusion, where you inject a filler and it goes into a blood vessel. And if it clogs that blood vessel up, then the tissue that's supplied blood from that can actually necrose or die. People have even gone blind from filler injections. And so you do want to be careful.

1:04:07The reason why I recommend an HA filler like Restylane or Juvederm are the two big brands is because there is an antidote to them. We can inject hyaluronidase that can actually melt it away in worst case scenarios. Whereas some of the other fillers that are not HA fillers, you get intravascular injection and - That's it. Yeah, there's not much you can do. You go to hyperbaric oxygen, you put warm compresses, and you pray to God that somehow it's going to be okay. So I don't recommend the other ones.

1:04:32Dr. Mary Claire Haver:Who should be doing these injections? Obviously, the top of the line is going to be placidurins and dermatologists. But I do believe in general it's safe for physician extenders, nurse practitioners, RNs, PAs to be doing it as well. I actually have four injectors in my practice because I can't treat everybody myself. But they're all trained by me. Yeah, like how do you check their training? So if you're going to a physician extender, how would you know how they were trained? You probably don't. But what you want to make sure is that they are working with either a plastic surgeon or a dermatologist.

1:05:07That is the key, okay? Because anybody can get you potentially a good result. And we know that as surgeons, that the true mark of how good a surgeon is is not how many good results they get, but what happens when somebody has a complication or a bad result. can they take care of that patient? That's number one. And so if you're gonna get any type of injection or any type of cosmetic treatment, period, you wanna make sure if that's not the actual doctor doing it, which once again can be acceptable if it's not surgery, that they have either a dermatologist or a plastic surgeon that they work underneath.

1:05:36Because right now it's legal for injectors to inject patients and have a doctor who has an MD by their name or a DO, but maybe they're a family doc, or maybe they're an ER doctor, or who knows what they are, who don't know anything about the treatment.

1:05:51Dr. Mary Claire Haver:Complications, right. I've had patients come to me with complications from injections and I tell them, who injected you? They say, oh, this nurse at this center. And I said, well, who's our medical director? And the patient's like, I don't know. It's some doctor that I've never seen before. I think he is a family doc. And it's like, well, they don't have training in anatomy and how to treat these complications. That's why these patients end up at our door like - Help. Concerned, yeah, because like nobody's here to help me. So that's why I would make sure, if you're gonna get these injections, once again, I do think it's safe to have an extender do it like a PA or a nurse or a nurse practitioner, but just make sure that they're under the care of a dermatologist or a plastic surgeon.

1:06:25Dr. Mary Claire Haver:So I see a lot of before and afters on social media as well. And I think that's how a lot of patients out there are picking their injectors. But I also see things that I would consider to be overfilling that are so obvious and not a natural result. What would you go in to say to your injector? So a very simple rule, if you're thinking about filler, okay? is not to inject more than about two to three syringes if you wanna get it done. Give me the numbers. So if you see somebody in Hollywood, like on a Real Housewife type of show, and they look overly filled, you're not talking two or three syringes.

1:07:00You're talking six, eight syringes, maybe even more, okay? Because the volume is the key. We are in, unfortunately, an era right now where there's a lot of filler fear because people think, oh, I'm gonna go get filler and I'm gonna look like this person on TV. And what I try to explain to patients is that there is a lot between where you are and what that person is. And to get to that point, number one, you have to sign on on getting a crap ton of syringes. And number two, you're going to be spending a crap ton of money to get there. It's not like you're going to have it done in like one minute, you're going to look like yourself.

1:07:33And then 10 minutes later, you're going to look like a real housewife. It's not that quick. And if you're not sure, then start maybe with a maximum of two to three syringes max.

1:07:41Dr. Mary Claire Haver:Okay, so lips are very popular. I've had my lips done and very happy with the result. I kind of look like my lips at 30 instead of 57. So, you know. Honestly, I look at you and I didn't realize that. Yeah. If you were going in like, I'm curious about this. I want to learn more. How, like for lips, what would you say would be a reasonable amount to start with? One syringe. One syringe. Okay. Yeah. Yeah. One syringe is usually enough to get a nice, modest change. Now, initially, keep in mind that the lips swell a lot and they'll swell for the first couple hours and then they really come down if you're icing them.

1:08:15So if you initially go in, you have a syringe done, and you're like, oh my gosh, my lips are huge, and you're nervous, don't worry, it's going to settle down. And usually you get a mild to moderate change with one syringe. Okay.

1:08:24Dr. Mary Claire Haver:If you were doing other parts of the face. So cheeks are popular? Yeah. So cheeks, I would say I would max out. If you really want a significant change in one and a half to two syringes on each side at the most to start out with, even one is typically sufficient to see a modest, nice improvement for most people. So I will max out with my patients at maybe four at the most in somebody who really knows what they're looking for and we're studying it together. That's probably the most that I've done in a patient is four syringes at one time. Most commonly, I'll do two and occasionally three. And that's for the cheeks.

1:08:59And the lips typically will do one syringe for most patients with lips. It's rare that they'll do more than one syringe at a time. And then you let it wear off and then you know when things are getting thin. Now, you can do half syringes occasionally. There's not a lot of brands that sell them in half, but there's a couple. So that's another option, let's say, with the lips.

1:09:15Dr. Mary Claire Haver:And what about under the eyes? That's also another really popular area. Under the eyes, you have to be really cautious. And really what you're looking at is about half a syringe on each side. Okay. So one syringe for a total of both is typically sufficient for most people. If you're doing more, if you're doing a syringe on each side, that's typically considered a lot. It migrates a lot, right? I think the migration is overstated. It depends on where you inject it. So the idea is that, you know, There are people who online will say, oh, if you, and I've seen this video once, a guy said, oh, if you inject it in your forehead, it could end up in your chin.

1:09:46And like, there's absolutely no chance that that happens. But we do know that if you're injecting a filler in and around, let's say muscles, and those muscles are constantly contracting, can it move that filler a millimeter or two potentially? I think that's definitely possible. But is it gonna move all around your face? No, there definitely is some migration of filler. But once again, I don't think that's gonna be more than a millimeter or two because there's tissue planes. Your stuff just doesn't move around in your face that easily. Botox can also migrate, but that's not something that happens later on.

1:10:16It happens within a week or two. And the worst thing that happens with that is you can get a droopy eyelid for a couple of months. And if that happens, there's actually an eye drop that can help counteract that.

1:10:23Dr. Mary Claire Haver:What about the fat transfers? What is that? Fat's great. I actually trained with one of the top fat transfer surgeons back when I did my fellowship in Beverly Hills many years ago. And really what it is is it's the original filler. So we use like a small liposuction type cannula. We remove fat from the abdomen or the hips, purify the fat by spinning it down and then literally just inject it. So I do a little incision, each corner of the mouth, inject it under the eyes, in the cheekbones, put some in the lips. And the good thing with fat is it's your own tissue and some of it will last a really long time.

1:10:54You know, I've had patients 15 years later that still have some of that fat there. The bad thing about fat is it's unpredictable. Anywhere from 30 to 50 % of that fat will stay and sometimes even a little bit less. you can't really predict it. In the lips, like 10 % will stay, very little. And so what I usually tell my patients is that I will overcorrect them by maybe 20%, knowing that at least 50 % is going to go away. And I tell them, look, you're going to be underdone in the end. Okay. But I don't want to risk overdoing you and now having to try to liposuck some of the fat back out. And so a lot of times I'll, you know, like I said, people will say, hey, look, what I tell them is at one week, you're going to get buyer's remorse.

1:11:28You're going to be like, oh my gosh, you put too much fat in my face. It's too puffy. At three weeks, you're going to say, it looks really good. Is more of it going to go away? And then at eight weeks, you'll say, you know what? It looks better than it started, but I wish you would have put more fat in my face.

1:11:39Dr. Mary Claire Haver:And aging process, not so much menopause, but aging in general, we lose fat in our face, right? We do. Yeah. Yeah. We lose volume and the volume is fat. It's also bone. There are all studies showing that you actually, the bony structure changes as we get older and that contributes to it as well. To find out more about Dr. Yoon and his products, go to his website, YoonBeauty.com. You can also follow him on Instagram at Tony Yoon MD or on YouTube at Dr. Tony. His newest book, Younger for Life, is available wherever you buy your books. I would love to hear from you about this topic and anything else that's on your mind.

1:12:17Dr. Mary Claire Haver:You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawslife.com. My new book, The New Perimenopause, is available now everywhere you buy books and through our website. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and share the show with women you love. We would be so grateful. You can also find full episodes on YouTube. Unpaused is presented by Odyssey in collaboration with Pod People. I'm your host, Dr. Mary Claire Haver.

1:12:56Dr. Mary Claire Haver:The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. This episode was sponsored by MidiHealth, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. MIDI can help. Visit JoinMIDI.com to learn more. This episode is brought to you by Progressive Insurance.

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