What's the first sign of aging in the face that people tend to notice? [Ricardo Rodriguez, MD, Baltimore]

Welcome to the podcast Where Before Meets After. Submit your questions for our experts at wherebeforemeetsafter.com. I'm your host, Eva Sheie. My guest today is Ricardo Rodriguez, and when we start to reach the age of needing facial rejuvenation, let's use 47 for example. We can't, either for financial reasons or schedule reasons or even just the way we feel about it, maybe don't want to do everything all at once. And so I think one of the things I heard you say was if you're going to have to choose, at least this is my interpretation, if you're going to have to choose between several things, start with your eyes because of the way that we look at faces.

Yes, eyes and lips are a great first step, or the area around the eyes, I should say, the area around the eyes.

I think you're giving me permission not to worry about what my neck looks like as much as I actually do.

The funny thing is people care a lot about it, but other people don't.

Don't care.

Right. The person looking at you doesn't care even though you care.

I like that a lot.

And so a lot of times it comes to that, I'll ask the patient, okay, we can do the surgery for one or two people. We can do the surgery for you or for the rest of the world. And some people say, well, I don't care what the rest of the world thinks. I want those neck lines gone. And a lot of other people will say, well, I want to look younger to other people, of course. So thankfully the eyes and the lips are things that can be pretty cheaply because a lip lift is done under local anesthesia. It's not a big procedure. And the other one around the eyes, there's several things you can do. You can do injection of fat underneath the eyes. The one thing I don't recommend that a lot of people do is the upper blepharoplasty or they're taking the skin out of the upper eyelids because

You don't recommend that?

No, and there's a physiological reason for it. First of all, let me start out from the muscles of the face, that's another subject we haven't broached that's really important. We approach it indirectly in the mouth, how the mouth ages by pulling away from the nose and all of that. But the eyes sort of works the same way every time you close your eyes and you start focusing, and in your thirties you start losing visual acuity. So like a camera lens, when you narrow a camera lens, it actually allows you to see further and see more definition. You pay a price in light, but it's okay, you turn up the lights, you do it in sunlight. So people start focusing, they start narrowing and squinching their eyes, and that starts pulling all the tissues of the brows down. So what do people do in response to that?

(02:51)
They start raising their brows to get their eyelids out of the way, and then they get the creases in the forehead. So the first thing those people come asking for in their mid thirties is they start wanting Botox to the forehead. Then I have to start explaining to them, look, the better approach to Botox is not to paralyze everything, because then your brows will fall because of gravity. You want to neutralize those muscles that bring your brows down and not worry so much about the forehead. We will hit the forehead, but not heavy. And so the muscles that bring your brows down are those elevens right in between your nose and then the crows feet. Those are muscles that constrict the brows and bring 'em down. So the minute you knock those two out, what happens is the brows open up because now they're unopposed. They're being elevated by the forehead muscle without even being conscious of it or trying. It's just the muscle is working unopposed against without resistance. So now it's much more efficient because it's pulling a lighter weight and then it opens up your eyes more, which is another marker of youthful appearance is a wider distance between the brow and the eye. It's a bright eyed and bushy tailed.

There's that engineering again, it's in everything that you've talked about today. You've pulled the engineering in there.

So then you open up your brows and now there's hardly any excess skin. So I'll rely on neurotoxins until they get sick of it. And then they say, do I have to do this every three months? And then I say, well, you can't get an endoscopic brow lift. And the endoscopic brow lift, it's not like the old fashioned brow lift where you cut skin and you pull because that creates a permanent surprised look. It has to because you just pulled it up physically by cutting out skin and putting it together. So the endoscopic brow lift works by neutralizing the same muscles that you injected with Botox. It neutralizes those muscles so that now the brow comes at are higher resting place because of the unopposed action of the muscles. And that gets rid of the excess skin on the upper eyelid without even trying.

(05:18)
Now, when you do, when you say, let's say you don't do that, and you just go ahead for it easy, which is the taking out the skin or the upper eyelids, what happens is since you don't have that thing bothering your eyes anymore and your eyelashes anymore, your brow is going to drop more. And then when your brow drops more, now there's excess skin again. So what usually happens is there's actually, there's an old surgical saying for the upper eyelids, you never take out enough skin. So they recognized right away, an old wisdom of plastic surgeons was that whatever much you took out is probably not going to be enough. They're going to have some leftover and you're going to have to take it out later. But that left people with too little skin. And then people get symptoms like dry eye and a lot of that.

(06:13)
And then if that person comes saying, none of this solved my problem and now my brows are low, you can't raise the brow then because then they won't be able to close their eyes at night. So my approach is very conservative in the beginning, neurotoxins like the Botox or the Xeomin, to essentially open up the brows, bring 'em out open, make 'em look younger that way, and then when they're ready for it, I'll do the endoscopic brow again, very little scars in the hairline. It's an interruption of muscles, so it's not even cutting across the scalp, a very minimally invasive thing. And when you combine that with fat grafting underneath the eyes, it makes a dramatic improvement in the person's appearance with two very minimally invasive procedures rather than the old facelift and all of that. So the approaches that I take in my practice, I guess, come from that central inverted triangle. It's where people are looking at. That's where the money is, and it's an inverted triangle from the eyes to the lips. And so that's as far as the geolocation of your problem. And then the under girders of your problem are the structural supports and the quality of the skin. My work tends to focus on that muscle balance.

If we're listening today and want to find out more about you, your website is cosmeticsurg.net. Is there an Instagram? Is there somewhere else you can point us?

Yeah, there's an Instagram cosmeticsurg. I'm not that active on it, I used to be. I'm not that active now. It's the website.

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