#11: Eight Most Frequently Asked Questions About Injectables

You are listening to The Natural Plastic Surgeon Podcast. I'm Dr. Daniel Barrett, Board-Certified Plastic and Reconstructive Surgeon located right here in Beverly Hills. I specialize in cosmetic surgery of the face, nose, breast and body. This podcast is dedicated to those deciding if plastic surgery is right for them and revealing all the latest beauty secrets. New episodes premiering every Monday at 10 am. Let’s get started.

On this episode of The Natural Plastic Surgeon…

Dr. Barrett: Well let's talk about those Med Spas, some of them are kind of scary. Like who's their doctor, is he even on site?

Jenna Guynn: Exactly.

Dr. Barrett: Like…

Jenna Guynn: Or it could be a nurse practitioner. It doesn't even have to be a doctor all the time.

Dr. Barrett: Right. Yeah. So you, you gotta really know like, who's, who's there if there's, like, a major problem? You know? And who's kind of running the show there, you know? Because if it's, if it's somebody that's coming to your house to do your Botox in your garage, it might not be legit.

Jenna Guynn: As you tell all the patients...like, Botox really isn't a dimmer switch. So it pretty much, the way that it works is it blocks the release of this neurotransmitter that's causing our muscles either to contract or not. So if we don't get enough of the Botox, we're essentially still going to have a little bit of that neurotransmitter being released in the muscle movement is still gonna be there.

Dr. Barrett: Yeah.

Jenna Guynn: So a lot of times what is seen is you're going to have, like, asymmetries and you just…

Dr. Barrett:...talk about that, that's the funniest look…

Dr. Barrett: They expect people to go through so much pain, they don't use any numbing, they don't use any ice, and they're just, like, you just gotta deal with it. And you know what? You don't have to deal with it. Like, a little bit of numbing cream costs pennies, and you're going to make the experience that much more enjoyable. If you do a little icing, you're going to help prevent bruising because it constricts the blood vessels right before you do the injection. So why not make it pain-free? Why not use the tiniest little Botox needle you possibly can? Why not do all these things that, kind of, make the experience much more comfortable?

Everyone it's Dr. Barrett here and we are here with The Natural Plastic Surgeon Podcast. And for my guest today, we have a great guest here. She actually works here in the office. Her name is Jenna Guynn, and she is one of our nurse injectors. Jenna, welcome.

Jenna Guynn: Thank you for having me.

Dr. Barrett: Excellent. I'm glad you're here, because you do...Tell us what you do, you basically, you do a lot of injections. You, you perform Botox injections in the practice. You do, you help consult with skincare. You also sometimes help with micro-needling, lasering. And we talked about Botox and also, you do recovery room work as well and circulating. You basically, you kind of do everything here at Barrett Plastic Surgery.

Jenna Guynn: A little bit of everything.

Dr. Barrett: So tell us, tell us about your day-to-day.

Jenna Guynn: Day-to-day? So it depends what day it is. If it's a clinic day, I'm usually assisting you with consultations. And then I have my circulating recovery days which I'd like to do once a week. But the other days where I'm not doing that, I love to see my own patients where I'm consulting with them, where they're coming in for Botox fillers, skincare, so every day is fun. So it mixes it up. So it's never the same. So…

Dr. Barrett: No, it’s been great. Now how long have you been working here?

Jenna Guynn: For a little over a year now.

Dr. Barrett: Yeah. And you guys, so when we first met Jenna, she came to us bruised and battered from a popular institution right here in town--UCLA.

Jenna Guynn: Mmm hmm. Yes.

Dr. Barrett: And prior to this, you actually weren't doing very many, you know, hands on treatments. You were doing some things. And I remember, you were a registered nurse at UCLA Medical Center for almost, actually little less than a year. But, but prior to that, you came to us from Santa Barbara. So, I mean, you were very well qualified in terms of credentials and everything else. And, and we brought you up to speed and sent you to some courses to get qualified and whatnot. But I want to, before we get into, kind of, what you do, and the amazing, natural-looking injections that you do, tell us about where you're from, and how you found your way all the way out to Los Angeles, right here in Beverly Hills.

03:55 WHERE JENNA IS FROM

Jenna Guynn: Sure. Yeah, honestly, I never really found myself living in LA. If you asked me ten years ago, it'd be a place that really wasn't interested in, to me whatsoever.

Dr. Barrett: Whatsoever.

Jenna Guynn: I grew up in a small town...Yeah, really. I'm not a really big city person, but I grew up in a small town in Mendocino County. I went to nursing school…

Dr. Barrett: Where is Mendocino County?

Jenna Guynn: It's about three hours north of San Francisco. So it's up there, up in the redwoods. It's beautiful. But I went to nursing school in Pensacola, Florida.

Dr. Barrett: I saw that you went to…I have it here. Let's see. Pensacola Christian College in Pensacola, Florida.

Jenna Guynn: Yes.

Dr. Barrett: And did you go all the way there just to get out of Mendocino or?

Jenna Guynn: Yeah, it was a great excuse to experience another state and it was a really good nursing program. And it was a very affordable nursing program also. I lucked out not having to take any student loans out to get all my education done. So I was able to start working as a nurse. I got my first job in Florida working in oncology and I did that for about a year. And...

Dr. Barrett: Tell me a little bit about that, what, how was that?

Jenna Guynn: I actually really liked oncology, believe it or not. My, my dad, he had breast cancer so that was, kind of, the reason why I was interested in oncology to begin with.

Dr. Barrett: Yeah so folks, you heard that right. So men can get breast cancer as well. It's not as common as women, but it actually can happen, which is, it tends to be more advanced when we discover in men. And so that's, that's a really good thing, in case you guys don't know...men check, you know, if you're having unusual masses, you want to get that checked out, just like women.

Jenna Guynn: Yep. And it's treated the same way: mastectomy, chemo, radiation if needed. But yeah, I ended up on that oncology floor. I got my one year of experience. Then after being out there, I wanted to be, kind of, close back home to family again. So I was looking back towards California. But at that time, my family had moved down to Ventura County, so I wanted to be, kind of, close to them. And that's why I got a job at Cottage Hospital.

Dr. Barrett: Yeah.

05:55 JENNA DID TELEMETRY NURSING

Jenna Guynn: I would have stuck with oncology but they weren't hiring for positions at that time. So I ended up transitioning to doing telemetry nursing, which is a big change-up from oncology. It's a little bit faster paced. But ended up loving that. Did that for three years. And met my husband in Santa Barbara. And he came down here to pursue his career.

Dr. Barrett: Yeah.

Jenna Guynn: And we came down to LA, I thought I'd be working at UCLA, but just found out that it wasn't really the right fit for me. So aesthetics always really interested me. And I really didn't know how to get into this industry. And I just really lucked out when I stumbled across....I was applying to places and no offense, I didn't know about you at the time.

Dr. Barrett: How dare you?

Jenna Guynn:  I know, but...yeah. So as soon as I saw your practice...how beautiful it was, and I saw just how reputable you were, and I just absolutely loved how you just really steer patients to a very natural-looking result. Because I had the same stigma that just goes along with a lot of Botox and fillers, I thought that it just ends up looking very fake. I thought that that's something I would never be willing to be a part of. Much less do for other people.

Dr. Barrett: Yeah.

Jenna Guynn: But then after seeing your approach and seeing the results that you were able to accomplish with that, it's just totally changed my mindset. And I've since just fell in love with doing injectables.

07:20 NATURAL-LOOKING RESULTS

Dr. Barrett: I mean, that's, that's a really key thing because I feel like so many people are scared to get even Botox. They're scared to step in our door or any, any plastic surgeon’s door, or any skincare office or whatever. Because they're worried about looking fake. Because that's all you hear about the news, right? So-and-so...Kylie Jenner got her lips done, and they're really super big. And you know, people talk about that at length. And majority people, you know, I came, I came from the east coast, a state called Virginia, which is really into natural-looking...I mean, it's very, it's very government, educated state and you know, the stuff that goes on out here is, kind of, it’s crazy, and I still get flack for at home.

So it's, like, I, you know, there's a need here in Beverly Hills. There's a need here in Los Angeles to bring natural-looking results. Because the really good plastic surgery, the really good injections, you just don't notice. People just look great. They look refreshed, and, like, rejuvenated. And it feels really good to be able to do...That's, that's, that's a real measure of skill when you're able to…you…when you're able to take someone who's nothing really wrong with them, but make them look refreshed, rejuvenated, not in a fake way.

So it's awesome. I mean, you know, so you know, you came really highly recommended. We had dozens of interviews, hundreds of applicants for this. And I was like, we've got to get Jenna here and get you trained and get you right on board. Because, you know, I think you were a fantastic fit for our culture and for our philosophy. And so, and you, you definitely had the skill set and the background to kind of grow in that sense.

08:56 JENNA GOT TRAINING

Jenna Guynn: Yeah, thankfully lots of training from you, which I've learned so much. And continuing to learn a lot. And just all the education we continue to go to, doing conferences and things. We are always learning more about fillers and that's like the fascinating thing and there's new products that are coming out all the time. So it's just a very, kind of, cutting-edge industry and I really enjoy it.

Dr. Barrett: It is cutting edge. Because it's funny...people will balk about their $10 copay when they're going in for their cancer treatment. But when it comes to getting Botox and get rid of that wrinkle, people don't bat an eye at paying for Botox. And, and it's, it's kind of weird. It's just, like, youth and beauty is, is a premium in our society and it's important. I do think cancer treatment is very important too, by the way. But it does inspire a lot of research and development and new stuff, especially products--fillers, injectables, things that I am, and us both, are actively, we go to conferences to learn more about. We're not the first to bring on a new product. No, I like to try. I like to use things that are tried and tested. I don't like to experiment on my patients.

You will see people out there. And they'll talk about, oh, well, we have the nat...the latest lip filler, okay. But how, how many people have, how many years has this been on the market? Right? Oh, it's been out for six months. Okay, great. Do you really want to be the first people to try that new lip filler? I mean, no, why not use something that's like tried and tested until that other stuff has, kind of, proven its efficacy and safety. Although, to, to, to keep this in perspective, the FDA does do safety trials, and anything that's approved in the United States...so we do know it's safe, but I like to see a lot more data than that.

Jenna Guynn: Yeah, because they even found, like, even, like, some Juvederm products, they've done studies where they found...or on the labels, they say they only last six months to a year.

Dr. Barrett: Yeah.

Jenna Guynn: But they found that some fillers are lasting up to, like, nine years in some patients.

Dr. Barrett: That’s crazy.

Jenna Guynn: So…

Dr. Barrett: Which filler is that? Hyaluronic acid-based?

Jenna Guynn: Yeah, hyaluronic acid-based fillers.

10:50 UNDER-EYE FILLERS

Dr. Barrett: You know what, we see that sometimes. We see that in under eyes, we see that in areas that get low turnover of rejuvenation, like undereyes, where the skin is really thin. If you've seen some…I've seen some people that have had filler put in under their eyes, a heavy duty crosslink Juvederm or Voluma, or a really heavy product placed too close to the under eye skin. And it just lingers. And you can see it's like this gray tint or this, this translucent, like, bagginess underneath their eye.

So all right, so you're here, you're here at Barrett Plastic Surgery. You've done amazing. You've been here over a year and we've got so many...you've got so many happy patients and you do my Botox, and potentially my fillers, I haven't...

Jenna Guynn: One day.

Dr. Barrett: Yeah, I think soon I'll have my, I’ll have my Radiesse underneath my eyes. But tell us what should somebody be looking for? What, what do you advise potential new clients about what they should look for when they're considering getting you know, first time injections.

11:55 WHAT FACTORS SHOULD A POTENTIAL PATIENT CONSIDER?

Jenna Guynn: So honestly just...obviously going to, like, a board-certified plastic surgeon would be the best option in my opinion, just because of the amount of education and schooling... just the, their knowledge of, just, facial anatomy. Especially...even if they specialize in facial plastics, I feel like that would be someone that would be highly credentialed. But even, like, for instance myself, a nurse that's working directly underneath a plastic surgeon.

Dr. Barrett: And to do...yeah, so by the way, we, we actually consult on all the patients together to go over treatment plans for, for patients and then, and then you go and you provide the treatments.

Jenna Guynn: Mmm hmm. Yeah.

Dr. Barrett: So that's, that's something for people to, kind of, know. You've definitely developed a, a knack and an eye for it but we have to, you know, we always have to consult together and then, and then follow the plan accordingly.

12:43 NURSE CAN GIVE INJECTIONS

Jenna Guynn: Mmm hmm. Yeah, but like I was saying, as, like, a nurse working side by side with a plastic surgeon that would be someone that also, like myself, would be very qualified to do injectables just because I've had that in depth training. And I just have that knowledge that I've learned from you and the additional training that we've done. Now, with med spas and things you have to be really careful because you don't know how much training a lot of these nurses have. I'd recommend looking for a provider that has good reviews. Look on Yelp...review sites.

13:12 MED SPA TREATMENTS

Dr. Barrett: Well let's talk about those Med Spas, some of them are kind of scary. Like who's their doctor, is he even on site?

Jenna Guynn: Exactly.

Dr. Barrett: Like…

Jenna Guynn: Or it could be a nurse practitioner. It doesn't even have to be a doctor all the time.

Dr. Barrett: Right. Yeah. So you, you gotta really know like, who's, who's there if there's, like, a major problem? You know? And who's kind of running the show there, you know? Because if it's, if it's somebody that's coming to your house to do your Botox in your garage, it might not be legit.

Jenna Guynn: Yeah, and same thing with plastic surgery. You don't want to bargain shop for these kind of things. Like your, it's your face. You want to value what you're having done to your face. So you don't want to get the cheapest price that's out there. You’re not going to get the best results.

13:51 COMPLICATIONS OF CHEAP TREATMENTS

Dr. Barrett: True. And not only that, but you could get a complication, you can get something that looks fake or unnatural and becomes more difficult to fix. I…you know, we've gotten so busy with some great patients that when we get people that have gotten filler elsewhere that's really botched, sometimes we turn them away. Because it's become so difficult to rehabilitate some of these bad filler jobs mainly because we don't know what was done. We don't know what, where it was injected. It's one thing if it was our patient, but we don't know that and that's, that's a really difficult thing to treat. And so a lot of times we turn, we turn them away. And so if you make that mistake to try to save money on the front end, you know, the, the, you know, that saying “a penny wise but a pound foolish.” Because in the end, you're gonna end up, you're gonna end up paying and costing more to, to get things fixed and it may never look right. Unfortunately.

Jenna Guynn: Yeah.

14:55 WRINKLE REDUCERS

Dr. Barrett: All right, so, I have a list of the eight most frequently asked questions about injectable wrinkle reducers and fillers. Okay, so let's, let's go through them. Number one, will my wrinkle reducers make me look unnatural? And they're, they're probably talking about Botox or Venus. So just so you guys know, there's multiple versions of wrinkle reducers. These work by relaxing muscles that cause dynamic wrinkles. Dynamic wrinkles are the elevens that you get in your brow, the crow's feet that you get on the sides of your eyes, and typically the forehead lines. Will this make me look unnatural?

Jenna Guynn: A lot of factors into that. Botox can make you look unnatural if you get way too much Botox injected. Also the placement of the Botox is probably the most important thing. Just because of the...you have to know the muscle anatomy so well. You have to know the effect it's going to have once that muscle gets paralyzed, what kind of expression it's gonna, you're gonna be left with if that muscle does get paralyzed. So again, it's just so important going to someone who knows what they're doing. We pride ourselves in doing our Botox in a very natural-looking way. So a lot of people can't even tell that we have anything done.

Dr. Barrett: Yeah. So it's interesting. There's, like, the, you know, there's a textbook about Botox injections, and there's these cookie cutter patterns. And you can see the people that have had bad Botox because they'll have what's called the Spock effect, right? So in a, in a two dimensional paper structure of doing the forehead lines, you will see somebody get Botox and almost all of the forehead movement is stopped in the middle, but then they get these little bit of sidewinders right in the corners of their brow. And it looks like, what was it, I don't know, was it captain Spock, I can't remember. Spock on Star Trek, where he's a Vulcan, and he has these natural pointed…Did you ever watch Star Trek?

Jenna Guynn: Oh, yes.

Dr. Barrett: Okay. All right. So he had pointy ears too and he was really logical, but anyway. So he had these little pointy eyebrows that just stuck up on the sides. And you see that sometimes when people don't even know that that's a problem. Another one that's more subtle, is the accessory movement at the widow peak, widow’s peak area. So everyone, their whole forehead will be nice and smooth, but then they'll get this little wrinkle at the top of their hairline and they think everything’s fine, but they're not seeing that. And that starts to look unnatural, right? Like, why is your whole forehead smooth as a slate and then you have these tiny little wrinkles right, right up your hairline and your widow’s peak. Have you ever seen that?

17:09 BALD PEOPLE AND BOTOX

Jenna Guynn: Yeah, I have. I've even, even encountered, like, some patients that come in where they’re, like, completely bald. And I think you mentioned to me before it's, like, at what point do you stop the Botox? Because they came in, had Botox, just treated their forehead, but then you still have a little bit of accessory movement with your scalp too. So...

Dr. Barrett: You’ve gotta follow the movement, if you don't…

Jenna Guynn: Yeah.

Dr. Barrett: That's why, that's why, like, cookie cutter textbooks don't work for Botox. You have to follow, you have to understand the muscle anatomy and then you have to follow the movement. What else was I going to say? You know, what I, we get sometimes is people that want to do half the recommended Botox. What happens if people don't get the right amount of Botox?

17:45 WHAT’S THE RIGHT AMOUNT OF BOTOX?

Jenna Guynn: As you tell all the patients...like, Botox really isn't a dimmer switch. So it pretty much, the way that it works is it blocks the release of this neurotransmitter that's causing our muscles either to contract or not. So if we don't get enough of the Botox, we're essentially still going to have a little bit of that neurotransmitter being released in the muscle movement is still gonna be there.

Dr. Barrett: Yeah.

Jenna Guynn: So a lot of times what is seen is you're going to have, like, asymmetries and you just…

Dr. Barrett:...talk about that, that's the funniest look...it’s like…

Jenna Guynn: Not a good look.

Dr. Barrett: Like, I remember when I first started I had patients that were, like, do I really need 20 units of Botox on my forehead? I'm, like, yes, you do. And they're, like, oh, I only want to do 10. Let's try 10. I'm, like, okay, we'll try it and I was stupid. Because it would, like, it would take on one side and then it wouldn't take on the other side. And then they’d look like Popeye for a week until it got fixed.

And it's, like, I didn't do that person a favor by saving them that 10 units. I should have stuck to my guns and now we do. We do the right amount and, and we recommend that amount based on the amount of movement typically, the age of the patient, male or female. Typically, we can get away with a little less if people have a little less movement, but for the most part, we have some pretty standard dosages.

Jenna Guynn: Yeah, yeah, I see that a lot.

18:54 DO INJECTABLES HURT?

Dr. Barrett: Yeah. All right. So, it may look unnatural if you go to the wrong person.

Jenna Guynn: Mmm hmm. Yes

Dr. Barrett: Okay, so next one, will injectables hurt?

Jenna Guynn: So they can. There's a lot of places here that don't numb prior to doing any injectables. We try to make it as comfortable as possible. We numb beforehand, we apply ice. The ice adds a little bit more numbing effect. And for the people that really can't tolerate pain in the slightest bit, we do even offer laughing gas. So we cover all our bases...

Dr. Barrett: I, it’s like...

Jenna Guynn:...to make it comfortable.

Dr. Barrett: Yeah, when we decided to do a lot…I mean, when I decided to do a lot of injectables, I was like I want to make this as pain-free as possible, because people's subconscious will stop them from coming getting injections. And it's amazing what people put themselves through in various places. Manhattan is, whenever I get a patient from Manhattan, they come here they're, like, oh my gosh, this is such a nice way. First of all, it's cheaper than Manhattan. Everything is super expensive there. And second of all they expect people to go through so much pain, they don't use any numbing, they don't use any ice, and they're just, like, you just gotta deal with it. And you know what? You don't have to deal with it. Like, a little bit of numbing cream costs pennies, and you're going to make the experience that much more enjoyable. If you do a little icing, you're going to help prevent bruising because it constricts the blood vessels right before you do the injection. So why not make it pain-free? Why not use the tiniest little Botox needle you possibly can? Why not do all these things that, kind of, make the experience much more comfortable? That's my philosophy.

Jenna Guynn: Yeah.

Dr. Barrett: And I know it's your philosophy too. You've had, you've had Botox yourself.

Jenna Guynn: Mmm hmm.

Dr. Barrett: Okay. And you've had the numbing medicine with it.

Jenna Guynn: Yeah.

Dr. Barrett: What were your thoughts?

Jenna Guynn: It’s great. It works so quick, literally, like, three, five minutes. It's working. And then, like I said, the icing just finishes it off.

Dr. Barrett: Yeah.

Jenna Guynn: So you really don't feel much of anything at all.

Dr. Barrett: Amazing.

20:42 WHEN TO TRY WRINKLE REDUCERS?

Dr. Barrett: Is it too soon for me to start trying wrinkled reducers? So when’s, what's too young for someone...what's the youngest patient you've ever done?

Jenna Guynn: So the youngest has probably been about 20...

Dr. Barrett: Yeah.

Jenna Guynn: 21 years old? People are starting to get Botox younger and younger now because they're realizing that it is preventative. So instead of waiting for those static wrinkles to already be formed, and letting those wrinkles really get deep inset before you’re starting to do, like, backtracking...

Dr. Barrett: Exactly.

Jenna Guynn:...and try to make up for all this lost time, you can, kind of, stay ahead of the game. So by, kind of, limiting that muscle movement, we're gonna, kind of, give our skin a little bit more of a break. And without all that extra wear and tear, we're going to be developing wrinkles at a, kind of, later ages in our life, if we're consistent with Botox.

Dr. Barrett: You know, they did a, a couple twin studies on identical twins. You know, these are people that have the exact, exact same genetic DNA, right? There's some epigenetics that are slightly different probably due to environmental...but for most part, you can't get a more identical person. And they had one twin who got Botox her whole life and they had another twin who didn't. And the results were dramatically different. One looked ten year...I should, I should show you. Have you seen this thing?

Jenna Guynn: No, I haven't. I want to see it.

21:52 BOTOX STIMULATES COLLAGEN PRODUCTION AND DECREASES DEPRESSION

Dr. Barrett: Yeah, one looked about ten years older than her other twin. So there is that relief of that dynamic movement of Bot, of Botox relaxation or wrinkle reducer relaxation. But there's something else that happens with Botox that we don't fully understand yet. There's, there's an increase production of collagen and elastin whenever you get a Botox injection and it's beyond…they've tested it against getting saline injections. So you're stimulating, still, a little, like, a little traumatic response. There's still a difference. We don't really know what that is yet, but it's almost like a miracle drug. You know, the other thing about Botox that's really cool is that it reduces the risk of depression for people to get it in the frown area your body is able to not frown as much and these people have... when you get Botox there, you're less likely to get depressed. Kind of crazy.

Jenna Guynn: Yeah, and it helps prevent sweating too. So people who have excessive sweating...I mean, there's so many different things that Botox is used for.

Dr. Barrett: I know...Raynaud Syndrome in the hands...so people get ulcers in their fingertips, or you get really cold hands, you can get it injected in your hands. You get all kinds of, you know, problems with cerebral palsy, things like muscle treatments that you can inject...these are, these are more medical applications. It's really, it's, and it's not even fully understood yet.

That being said, it’s completely safe though. Millions of people get lots of Botox injections in qualified hands. Obviously if you get too much Botox injected you could have problems...or injected in the wrong place. But in qualified hands, there's been no real complications for Botox. Some people can get a headache, but people don't.

Jenna Guynn: That’s about it.

23:23 BOTOX AND MIGRAINES

Dr. Barrett: Yeah, that's about it because it, if you're, if you...it's actually treats migraines, by the way. So if you have migraines, you may want to talk to your doctor about getting Botox...if medication is not working for you. Because it, we don't really know why that works, but it actually, kind of, relaxes some of the smooth muscle within the endovascular endothelium which we don't understand. But those people that get migraines, it might trigger the migraine at the time of the injection, but then migraines go away for three months. So just be aware of that--that you could get a headache at the, at the day of, day or two of your Botox injection. Okay. Am I too old for Botox or am I too old for wrinkle reducers or fillers?

24:00 AM I TOO OLD FOR INJECTABLES?

Jenna Guynn: That's a good question, sometimes a tricky question. So it really depends on how deep your musc, your wrinkles are. And then there's specific areas that are, kind of, as you would say, like a homerun to hit. So, like, treating the brow, the crow's feet, are pretty, like, complication-free because those are the areas where they'll open up the eyes more. Now treating the forehead can be a little bit more tricky in more elderly patients just because they typically have increased skin laxity. So what happens when we inject the forehead muscle, it tends to sometimes want to drop the brow ever so slightly, and if you have more skin laxity, you're going to have even a more, more, like, pronounced brow drop also.

Dr. Barrett: Yeah.

Jenna Guynn: So, sometimes just doing very light doses of Botox in the forehead can help, kind of, smooth out those wrinkles. But sometimes we do get to a point where Botox is not going to take those wrinkles away completely. And you're gonna have to do other treatments as well such as microneedling or CO2 laser. Just kind of to resurface the, the top layer of the skin to work out those wrinkles a little bit better.

Dr. Barrett: And sometimes surgery, you know, it's, like, we…what I love about our practice here is that we offer full spectrum, right? We get somebody in that is trying to, kind of, dip their toes in. And I have a perfect example. You know, I had one patient who was 65, dealt cards in Las Vegas for her whole life, never had a touch of Botox, lots of sun damage, and coming in trying to get Botox and fillers. Maybe 20 units of Botox and maybe a little bit of fillers. And I was like, look, let's just save your money and let's just talk about surgical options. Because you reach a point where the amount of money it would cost to do non-surgical interventions, minimally invasive, like injection, injections or fillers is going to add up so much to the point that the person would be better served by just undergoing surgery...and fat grafting or something like that.

So that's, that's why we kind of...what you see is what you get here. We're really transparent with people, like, you know what, we can do this but you're going to be better served by getting a more comprehensive treatment. And obviously, you know how those surgeries go and some of the transformative capabilities of facial surgery. But you are right, the forehead is the most challenging area. Hopefully you've learned this by now.

Jenna Guynn: Oh yeah.

Dr. Barrett: Yeah, it is the most tricky or challenging area to do Botox. And starting an older person on that forehead area is, is tough and people have to, people have to understand what's going to happen, you know? Forehead’s going to drop, it's going to take a while to adjust. You might need several treatments. If you're walking around and you're raising your eyebrows up like a, like a surprised person all the time just so you can see…Botox in your forehead, not a good idea.

Jenna Guynn: Not a good idea.

Dr. Barrett: Yeah. Does your skin eventually adjust? Yes, it does. But it's a, it's a difficult transition if you ever had it...and that's why it's important to, kind of, start earlier if you want Botox to, to work well without having that forehead drop. Now that forehead drop on a, on a middle aged person is bad the first time, the second time is not as bad, third time eventually goes away. And that whole area tightens up so that you don't get that forehead drop anymore. But it's tough to get people through that transition. They're like, oh my god, I can't, like, I have droopy brow...you don't have droopy brow, you have, actually, a good effect of the Botox. And so that's, that's another reason why it's good to go to some place that can, kind of, identify that from happening before it actually happens.

Jenna Guynn: Yeah, and it's good for patients to be consistent with their Botox too, because if they get it one time, they experience that brow, brow drop. And then they wait several years and have done again, they’re gonna go right through the same effect.

Dr. Barrett: Right, which we don't want.

Jenna Guynn: Yeah.

Dr. Barrett: Now that's a different complication from eyelid ptosis. Tell us about eyelid ptosis.

27:39 EYELID PTOSIS

Jenna Guynn: So eyelid ptosis...So a lot of times that occurs when injecting the brow muscles where the injection sometimes this placed too deeply into the muscle, where it kind of just leaks behind everything...comes, comes down to the eye area and then that's where you get that…eyelid ptosis is a drooping eyelid.

Dr. Barrett: Have you ever had that?

Jenna Guynn: I, no. I haven’t had that done.

Dr. Barrett: Ok. I had it, I think I had it one time and it was a patient...this is why I don't do Botox during surgery anymore. It was a, a, a patient who had surgery, wanted Botox done while she was out. And I just don't, I don't do it anymore because you can't…the muscle is so relaxed during surgery that you can't, you can't control your depth. And so I think I got a little bit too deep and it...What happens is if you get down to the periosteum, it'll actually leak along the muscle plane behind the muscle and get down to the little eyelid elevator and it takes a lo...half a unit of Botox to relax your eyelid and then boom, you've got eyelid ptosis.

Now the good news is it’s treatable. It typically lasts, doesn't long, doesn't last longer than two weeks. You get a lazy eye, but there's treatable with eye drops that open it up. Thankfully I haven't, since then, I, I haven't had that ever happen. I, I just don't do Botox while patients are asleep, I, I make sure that they're awake so that I can, I have a better sense for their muscle tone and their muscle placement.

Jenna Guynn: Yeah, I couldn't imagine doing it when they're asleep. Every time I do an injection I like to see people animate their face, see that muscle movement so I really know exactly where we're injecting.

29:00 ARE WRINKLE REDUCERS PERMANENT?

Dr. Barrett: All right, next question, are wrinkle reducers permanent?

Jenna Guynn: No, they're not. Which can be a good thing and a bad thing. It's great for those first-time patients that are really curious about Botox, they’re really hesitant. But that's the beautiful thing about Botox. You try it, if you decide it's not something that you really like or want to continue with, give it three to five months, that's pretty much the lifespan of the Botox. Everything goes back to normal. There's no long-lasting side effects from it. But yeah, three to five months is kind of what you'd expect for you to get your treatments redone with Botox.

Dr. Barrett: Wonderful.

29:32 ARE FILLERS PERMANENT?

Dr. Barrett: What about fillers?

Jenna Guynn: Fillers, not permanent either. I mean, there are some more permanent type fillers that we don't use. We don't really recommend permanent fillers because the aging process is always changing your face. So when you’re…

Dr. Barrett: What’s an example of, like, a permanent filler?

Jenna Guynn: Like, like all these collagen fillers that we...

Dr. Barrett: You know people used to use silicone actually.

Jenna Guynn: Yeah.

Dr. Barrett: There's some that still do. There's a Dr. Kotler who does, who actually is probably one of the only certified people that I would actually recommend someone to go get silicone fillers. And, the, it's, it could be very damaging if not done properly. And I, I would just, hands down, just not recommend it personally. I've seen some people…I've had...early on in my practice had a lot of patients come from where they had filler done in, like, Mexico or overseas. Not necessarily...there's some good doctors in Mexico, don't get me wrong. But these are clearly not...the ones that these patients came from were not well established doctor’s offices, and so they had all kinds of…one, one patient had what looked like sand in her lips, like a sand filler? It was really bizarre...the stuff that I've taken out of people's lips, I'm just like, what are you doing? You know, but yeah, generally, I like to stay away from the, the permanent filler options. So the collagen ones, and, which are kind of highly reacted to, you gotta get skin testing for that...

Jenna Guynn: Exactly.

Dr. Barrett:...and then raw silicone, which is just very dicey.

31:00 CADAVER STUDIES AND THE AGING PROCESS

Dr. Barrett: Now, I always get this. I have…so if you understand, if you understand facial aging, if you understand volume loss, we know that pre, it predictably occurs in various parts of the face. Some areas are more than others depending on the person. But one of the places is the mid cheek, mid cheek compartment. We have some anatomical studies out of UT Southwestern where they did cadaver studies, Dr. Rod Rohrich did, where he actually looked at where he did cross section analysis of enough cadavers to see where the fat loss occurred. Certain places stayed the same, like jowls, right? Great. Exactly where we don't want that.

Other areas decreased in volume. One was the middle cheek fat compartment of the face. So when we, when we talk about placing revolumization...if you really understand how to do inject, injectables, you go for the areas that are going to rejuvenate the face. Not change the face, not give you a lion face.

31:56 WILL FILLERS STRETCH OUT MY FACE?

Dr. Barrett: So the next question is will filler stretch out my face? So let's talk about that.

Jenna Guynn: No because as we're aging our skin is getting more lax. We're losing collagen, we're losing elasticity of our face. So our skin is already stretching out on its own, whether we like it or not. So what fillers do is they help achieve us replacing that volume where we naturally have it, so, again, it just gives us more of that youthful appearance that we once had.

Dr. Barrett: Yeah, I get a lot of people that show me that picture of that lion face woman. Horrible, like, way over done. And I'm just, like, if you had any concept of what one cc is. It's literally, like, a few drops and it's not even, doesn't even fill a teaspoon. It is such a small amount of filler. And we are so conservative with what we do. We’re always just, like, let's inject a little bit, let's see how you like it. Come back in two weeks, we can add more. And so that, that was...actually leads into the last question. Will my fill, will fillers make my face look fat?

32:50 WILL FILLERS MAKE MY FACE LOOK FAT?

Jenna Guynn: It depends if you go to a place where they're trying to pump you full of, like, five, six syringes at one time.

Dr. Barrett: Have you ever seen that happen? Have you ever had anybody come in that…

Jenna Guynn: Yeah, we've had some patients come in where they've obviously had a lot of filler done already. And I'm, I’m not sure if they just get used to it. Or if they just think that that's, like, normal. But they come into us. And they're pointing out certain areas that they want to achieve more volume. And we take a look at them, and we're just, like, you need to take a break from everything. So we just really, really value keeping our patients looking as natural as possible. We don't want people to look at you and be like, oh, wow, they've had this done.

Dr. Barrett: Right.

Jenna Guynn: So…

Dr. Barrett: I mean, if you look at babies, they have nasolabial lines...

Jenna Guynn: Mmm hmm and tear troughs.

Dr. Barrett: And tear troughs, right. So it's like, when you get so obsessed that every little wrinkle has to be completely gone, your face is going to look like the Michelin Man. You know, it's just, like...and your skin's not going to tolerate that, you're gonna have problems. So it, it can be a very addicting thing, and, and I forget the name...is it Oliver Sacks who wrote The Man in the Purple Hat...I forget what it is.

But anyways it’s about this body dysmorphia that some people can have, where they look in a mirror and what they see is not what the rest of the world sees. And I think that happens sometimes. And if you go to a place that all they care about is money, they're gonna tell you exactly what you want to hear to generate the biggest amount of profit.

And you just can't have that in healthcare. I think I wish we had more control over, in terms of our industry. We certainly don't do that here. I'm the last person that's going to upsell somebody on anything and I'm straight up honest with people, I'll tell them, look, your lips are way too big. We need to dissolve them, or we need to do something else. And, and I try to get them on a path, or I’ll at least try to, I'll try to focus on other areas that we can do, like temporal hollowing, or the, the mid face cheek filling, or maybe even just focusing on Botox or skincare.

34:40 4Rs OF FACIAL REJUVENATION

Dr. Barrett: The, you know the, there's the four R's when it comes to minimally-invasive facial rejuvenation. There is Relax--that's our Botox or our wrinkle reduction. So we're relaxing dynamic wrinkles. Those are, the, tend to be the big wrinkles on our faces.

There's Refilling, that's the filler solution, right? So we're revolumizing areas that are getting depleted over time.

We are Resurfacing. So the very superficial wrinkles on people's faces are best served with co2 laser, microneedling, skincare...

And then the last one is Relifting. And that's where we're actually using deeper technologies--either ultrasound with ultherapy, or radiofrequency skin tightening like Venus Legacy that can actually tighten the underlying muscle, fascia, skin and get some fat reduction as well.

So that's what I tell people, the four R's, it's not just all about filler. It's not just all about Botox, you need to have a comprehensive plan. We've actually got some newer emerging technologies--LED light therapy--that are, that's coming out, that's helping boost collagen and, kind of, boost our, our facial results as well, which we offer here in the practice. But I think it's, wherever you decide to go, you need to find a place that can give you a comprehensive strategy. If you're, if you want to be the minimally invasive route, but we’ll tell you too, straight, what the best plan is. And then you can dial it in based off of either your budget, or your downtime preferences.

36:05 JENNA SHARES ADVICE

Dr. Barrett: So what el, would you want to tell, what advice do you have for, let's say, the 30 year old something who maybe just had two children, is done breastfeeding, and is thinking about doing something for her face. Never stepped foot in a plastic surgery office before.

Jenna Guynn: I think the best place to start, ultimately, is just always getting on good skincare. Because our skin just speaks volumes of just, like, our health and it's what people notice first when they take a look at us. But good skincare, probably you're looking at starting on some Botox if they're getting some of those dynam, dynamic wrinkles, which they typically do start after pregnancy, especially. And then there's probably some, a little bit of, just, facial volume loss, and we would just address those areas if they need them.

Dr. Barrett: Yeah. Great. No I think those, I think that's great first advice and you know, I think for someone, they should, you know, where do they start? I think doing your research, finding out, you know, is there a real person there? Is there a real doctor there? Or, you know, what's, how long, what's this business’ credentials whatnot?

Check out the reviews. If they don't have any reviews, maybe they haven't been in business long enough. You might want to find a place that has a more established…I, you know, LA is very popular for Yelp. You can't make these reviews up, on Yelp. There's other ones--Healthgrades, things like that, that typically are more geared towards mainstream medical doctors like orthopedic surgeons and so forth. So I always tell people to look at Yelp reviews, look at their website, look at their before and afters. Like, is this an aesthetic that you're looking for? You can also check out people's social media. A lot of times Instagram profiles have great before and afters on there and great informational graphics and things like that. So yeah, I mean, that's, that's, kind of, you know, facial fillers, like, a nut she...I feel like we could talk about this for, like, a week on end.

37:55 DR. BARRETT’S FAVORITE AREA TO DO FILLERS

Jenna Guynn: What's your favorite area to do filler? Do you have a favorite?

Dr. Barrett: Yes I do. One of them, the sneakiest areas that some people that have it, they don't even realize they have it, it's called a a-frame deformity. It’s when they get this hollowing out, it’s typically around 40 or 50 years old, that patients get this. And they get this hollowing out around their eyes, especially the upper eye. And, and you see it because it looks like a little cavern right above their eyeball.

And if you really study, like, a youthful eye, you see fullness between the eyelashes and the eyebrow, you don't see a hollowed out appearance there. So there's this little revolumization can do with a very light, low molecular weight, hyaluronic acid base filler in the upper eyelid area. This is a very tricky, very dangerous area because there's a lot of blood vessels around there and if you inject into a blood vessel, you can cause problems. So if done properly, though, is like a Grand Slam. I mean these people look five, seven years younger, you know, from, from getting this right. And you know, it's, it's one of my favorite areas mainly just because it's so challenging to do and the payoff is, is pretty awesome.

But, and then again, the, the other ones I like are with my, our, our long-term patients that come in. They start from Botox and we've, we've, kind of, developed their trust, developed a good relationship with them. And this is, this is the thing, you don't want to go to a place based off a Groupon. You really want to go to a place that you can establish a long-term relationship with, that you can have your regular treatments, that's very safe. And my favorite patients are the ones that have started from very little Botox treatments, and we've gotten it done, their, their basic filler work, we've done some resurfacing, maybe even done, you know, moved on and done a couple of surgical things. And these people have had some of the biggest dramatic changes. So...great.

Well, Jenna, thank you so much for being on the podcast. So if you guys are interested in getting injections by Jenna, just give us a call: 310-598-2648. Check out our website, DrDanielBarrett.com. And we have a whole section on injectables, and the medical spa. Where you can learn more about Jenna on the Meet the Staff page. And if you want her or myself to do your injectables, just let us know. Give us a call. Jenna, thanks so much.

Jenna Guynn: Thank you.

Thank you for tuning into our podcast. If you liked today's podcast, don't forget to share rate, review and subscribe. Join us every Monday at 10 am for upcoming episodes. Also find out if plastic surgery is right for you by using our virtual consultation at DrDanielBarrett.com/virtual-consultation. See you soon.

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