Anti-Aging Treatments of Tomorrow with Plastic Surgeon Dr. Richard Baxter

Airdate: 8/29/13

Esteemed Seattle-area plastic surgeon Dr. Richard Baxter joins Paula and Bryan to discuss the latest surgical and non-surgical treatments to look younger. From the vampire facial to advanced numbing agents that make recovery easier, Dr. Baxter shares his expert advice on what works now (and what’s on the horizon) for anti-aging treatments for face, body, and hands.

Paula Begoun: Hello! I’m Paula Begoun, part of the Cosmetics Cop Team, with Bryan Barron, my co-author and head of the team, who has been writing books about beauty and skincare and hair care with me for many years of which our best-selling book... – Well, actually, all of our books, and I humbly say this, all of our books have been best sellers. But, our best seller-best seller is “Don’t Go to the Cosmetics Counter Without Me” which is on its ninth edition.
00:00:29 But, of course, all of our reviews are also on our website at Thousands of reviews later, what we do is keep you beautifully informed. Now, on this radio show, we keep you beautifully informed so that you don’t waste money on looking good. Wasting money isn’t pretty. And today we’re going to be talking with our very special guest, Dr. Richard Baxter, who is a Seattle plastic surgeon.
00:01:00 Dr. Baxter does it all. He’s an incredible guy. Incredible physician. And board certified. All of the degrees. All of the educational background. Just stellar reputation. And researcher – has developed his techniques that are used worldwide in plastic surgery. We love Dr. Baxter. And he’s good-looking, too. It never hurts…
Bryan Barron: It never hurts.
Paula Begoun: Never hurts to have it all.
00:01:36 And so we’re going to just jump in here because I have so many questions for Dr. Baxter. Is that okay, Bryan? Can we just jump in?
Bryan Barron: It is absolutely fine. But just to let our listeners know, this show – we’ve done a lot of shows about anti-aging procedures and what a cosmetic dermatologist can do. The marriage between cosmetic corrective procedures or plastic surgery and a brilliant skincare routine is the best anti-aging pairing you can do, assuming you’re anti-aging routine includes a sunscreen, every day, rain or shine.
00:02:11 This show’s particular focus is going to be on anti-aging treatments of tomorrow. So, we’re of course going to touch on what’s being done today, what you can do right now, but one of the interesting facets of Dr. Baxter is that he really is one of the best for staying on the cutting edge of what is everyone going to be asking for one year, five years from now. What’s in development? What’s got him and his peers excited about the future of particularly non-invasive anti-aging because that is what most people want.
00:02:43 Going under the knife is a big deal. Not something that most people just jump into without asking, “What else can I do that has no downtime?” So, here we go.
Paula Begoun: So, Dr. Baxter, are you there?
Dr. Richard Baxter: I am here. Pleasure to be here, too.
Paula Begoun: Thank you.
00:02:58 And thank you for talking with us today because we have so many questions. And part of talking about what’s new, because in the world of plastic surgery and dermatologic procedures in general there is a lot of crazy stuff. A lot of people want to sell you stuff of which the one, and you’re one of the few people who actually has, I mean, just incredible information about one of these procedures that we wanted to ask you about – Vampire Facelift.
00:03:33 A vampire facelift, vampire facial. Kim Kardashian got this. And you go on the on the vampire facial/facelift Web page and it makes it sound like every other procedure.
Bryan Barron: Oops, bumped the mic.
Paula Begoun: Whoops! Bumped the mic. I’m throwing my hands around. That every other procedure, injections, whatever you’re going to get, it’s all going to pale in comparison to the vampire facelift/vampire facial.
00:04:02 Can you speak to that Dr. Baxter? Can you tell us if we should all be following, well, none of us should be following Kim Kardashian, but that’s a personal comment there. Should we follow what she’s doing or it says she’s doing to look beautiful?
Dr. Richard Baxter: The Vampire Facelift is actually a trademarked term, so we have to be careful in making comments about something that claims proprietary knowledge and so forth.
00:04:29 But the general idea behind it is to combine a component of your own blood called platelet rich plasma, so they take a blood sample from you and they spin it down and extract this. And then they inject it back in, usually in combination with something else like one of the established dermal fillers like Restylane or Juvederm. And they claim that in doing this they get better results, either longer lasting or more skin rejuvenation.
00:04:58 And the problem that I have with this is that I have never seen any presentation or any published data comparing it to doing the injections without the plasma. In other words, there’s just really no measurable data to demonstrate that it actually is any better than just having a syringe of Juvederm off the shelf.
Paula Begoun: So, is it possible – one of the claims, and we’ll be careful for this trademarked little whatever filler thing they’re doing.
Bryan Barron: Usually it’s called the Vampire Facial.
00:05:39 You know, we were doing some searching online and there were tremendously more results on a search for Vampire Facial versus Vampire Facelift. And it’s likely due to the trademarked issue.
Paula Begoun: Right. And when you see pictures of, you know, when they talk about , the woman has blood smeared all over her face. So, it looks like it’s superficial…
Bryan Barron: Well, and graphic.
Paula Begoun: …like painting blood on…oh my god. But, so in terms of one of the claims that the company is making for what this Vampire Facial/Vampire Facelift injections can do is that it stimulates your stem cells to do whatever to look younger, which Restylane and Juvederm by themselves, other injectables don’t do.
00:06:25 Any way that injecting some kind of special spun off blood into your skin can do something around your stem cells? And do you really want that stimulating your stem cells to do something, even if it could?
Dr. Richard Baxter: Well, boy, stem cells is a whole other big controversial category. You know, stem cell facelifts and all this stuff. You know, it’s an interesting idea. And the whole concept of injecting PRP, platelet rich plasma, for facial rejuvenation comes from other uses of it for say injecting it into inter-joints for faster healing after sports injuries and so forth.
00:07:07 And, you know, there’s science from a variety of sources that suggest it might have some benefit, but at the end of the day you really have to prove it. You have to actually prove it in a clinical trial to show that you’re getting an effect that you couldn’t get another way. And I’ve actually gone to the Web site for things like the Vampire Facelift and they’ve got this long list of publications that they say support the claims.
00:07:33 But if you actually go and look up each of those, none of them is a randomized prospective clinical trial.
Paula Begoun: And what do you mean by randomized clinical trial?
Dr. Richard Baxter: What that means is that if you want to say prove the case that adding PRP to Juvederm gives you a better result, then you need to do a prospective trial, meaning that you enroll people in it before they get the treatment. And then they’re randomized meaning that you sort of open an envelope to determine which treatment you’re going to get.
00:08:06 And then they get either one treatment or the other. And ideally they’d have what’s called a blinded observer, so the person evaluating the effect doesn’t know which treatment they got. And that’s the only way to really objectively prove whether something has made a difference or not.
Paula Begoun: And those studies don’t exist despite their long list of published research?
Dr. Richard Baxter: Not that I’ve seen.
Paula Begoun: Actually, you know, it’s interesting.
00:08:33 We often go to Web sites, when we’re doing our research that make claims about things, and I can’t tell you the number of times we’ve clicked through on the research and the research has nothing – first of all, it’s either not there or it has nothing. It’s like I think they just cut and pasted a journal and didn’t even look at what they were cutting and pasting. It has nothing to do with the topic at hand.
Dr. Richard Baxter: Exactly.
00:09:00 That’s a very good example.
Paula Begoun: So, in terms of injections, and of course now I am always talking about me, about this, sorry. So, one of the things that I’m hearing a lot about these days are new longer lasting injectables. I think it’s some of the new hyaluronic acid fillers…
Bryan Barron: Juvederm Ultra.
Paula Begoun: Right. Because, you know, they’re notorious for not lasting very long and almost as short a life as Botox in the six months to year range.
00:09:38 And, you know, you get injected, you get numbed up, and then you’ve got to go back in because it starts depleting almost from the moment it takes place. But they’re talking about there being longer lasting ones. Are three? Is that really happening where you see there’s better fillers out there?
Dr. Richard Baxter: Yes. I think there’s a pretty good variety right now. There is one that it’s more of a volumizer, not so much a wrinkle treatment, but to add volume.
00:10:06 And it’s called Sculptra. And that can give you a couple of years potentially. Another one called Radiesse….
Paula Begoun: Wait, Dr. Baxter. How come you can’t use Sculptra for wrinkles? And can you explain the difference between volumizing the face and what that would do to make you look younger versus plumping up wrinkles?
Dr. Richard Baxter: So, one of the signs of aging is loss of fat from the face, loss of subcutaneous fat and volume. You know, if you look at somebody who is old, what you notice immediately is that they have wrinkled skin, but if you look a little bit beyond that the face just looks sort of deflated.
00:10:48 So, adding volume back either with fillers or with fat grafting is a big component of what we do with anti-aging now. Things that are really intended to sort of create more of a mass effect are not going to work as well if you inject it into the skin as they do under the skin. So, those would be things that are more volumizers.
Paula Begoun: You don’t use Sculptra to just go into a wrinkle like the nasolabial folds?
Dr. Richard Baxter: Not typically, no.
Paula Begoun: So, Sculptra for filling out the face; it’s hard to think of a chubbier face as looking younger, but definitely chubbier women have a younger-looking face than a gaunt thin woman, so we know volumizing makes a difference.
00:11:39 What about the new longer lasting hyaluronic acid fillers and what that does in terms of do they really last longer. Do they go longer than six months to a year?
Dr. Richard Baxter: The thing with hyaluronic acid fillers is that how long they last depends a lot on where they’re put. So, none of them tend to last very long in lips, but many of them can last up to a year or more in the cheeks.
00:12:09 And somewhere in between for the nasolabial fold. I think, you know, the problem is the more they do this process called cross-linking, which is what makes them resistant to breaking down, it’s just a chemical term; but the thicker the material becomes then it’s less ideal to inject into wrinkles. It just makes it harder to use.
00:12:32 So, there are just some kind of tradeoffs there that I think are going to be hard to get around. There’s a different category, it’s a material called Radiesse, which does last longer than the hyaluronic acid fillers. And that’s, I think, a good option for people who are looking for something that’s going to maybe last nine to 12 months or so.
Bryan Barron: Yeah. Radiesse is the synthetic filler that’s made up of the calcium hydroxy appetite. Did I say that right, Dr. Baxter?
Dr. Richard Baxter: Exactly.
Bryan Barron: Okay.
00:13:05 And then that’s suspended in a gel.
Dr. Richard Baxter: Correct.
Paula Begoun: And so Radiesse doesn’t – personally I’ve had Artefill, Artecoll done. So, are the side effects of Radiesse, because they say once you – the pros and cons of a longer lasting filler is that when you have problems because there’s always a risk with all this stuff, is that if you have problems the problems last longer, meaning granulomas, little lumping or unevenness.
Dr. Richard Baxter: Yeah.
00:13:35 So, a permanent filler would potentially have permanent problems, or it might look good for a number of years and then as everything ages around it then it starts to look kind of funny. So, I think something that lasts around a year or so like Radiesse is probably a good compromise. But it’s not as versatile a filler; for example, it’s not really suitable for lips. It just tends to get lumpy.
Paula Begoun: What about – so, that’s part of the problems with injectables is migration, right?
00:14:06 Because like I had fat injections under my eyes, and definitely one of the results I’ve had that I’m not so thrilled – I mean, it definitely looks better. But, I definitely have had, definitely one of the side effects I read about I’ve experienced which is bunching, where it’s congregated into areas so I have a couple of folds that weren’t there before the injections.
00:14:31 Is that – is your fat the only thing you can inject under your eye? Can you inject other things? Is there a risk of bunching for all the injectables you can put under the eye?
Dr. Richard Baxter: Well, I think, you know, fat has to sort of take. It has to become living tissue when you inject it that way. And it’s not an entirely controllable process. And so if it doesn’t take evenly it might tend to lump up like that.
00:14:58 I think the hyaluronic acid fillers can work really well under the eye, that area we call the tear trough, that just sort of groove that starts from the lower eyelid and goes down across the cheek. I think those can work really well there. And the advantage of the hyaluronic acid fillers, particularly for somebody who is having them done in an area they haven’t had treated before, or really just starting out, is that they can be reversed.
00:15:27 There’s an enzyme you can inject to dissolve it. So, you have that safety net with the AHA fillers that you don’t with the other products.
Paula Begoun: No kidding? Oh, I never heard of that before. So, you can actually resolve a granuloma or bunching or something like that?
Dr. Richard Baxter: If it’s from one of the AHA fillers, like Restylane or Juvederm.
Paula Begoun: Huh!
Bryan Barron: Isn’t it called Hyaloronase?
Dr. Richard Baxter: Hyaluronidase.
Bryan Barron: Ah, there you go.
00:15:51 Yeah, I had read about that.
Paula Begoun: So, what can I do about my fat bunching, because I haven’t been back in to see my plastic surgeon since I had my face lift? What can I do…?
Bryan Barron: You should go see Dr. Baxter.
Paula Begoun: I know! Ha! Of the Baxter Plastic Surgery Clinic.
Dr. Richard Baxter: It’s always a good idea to see the person that treated you, but they may consider injecting a little steroid cortisone type product or something like that.
Paula Begoun: What does that do?
Dr. Richard Baxter: Well, that would, for a fat nodule, that could dissolve it.
Paula Begoun: So, actually, thank you, Bryan.
00:16:27 Let me tell everyone that we’re talking to Dr. Richard Baxter who is a Board Certified plastic surgeon in the Seattle area. Actually, where are you located in the…?
Bryan Barron: It’s in Mountlake Terrace.
Paula Begoun: Mountlake Terrace.
Dr. Richard Baxter: Yeah, so just north of downtown.
Paula Begoun: Just north. But before the bridge that went down, right?
Dr. Richard Baxter: Oh, way before that.
Paula Begoun: It’s easier to get to you than it is to get to Canada.
Bryan Barron: His office is only accessible via helicopter.
Paula Begoun: Ha!
Dr. Richard Baxter: Yeah. I’m really just ten miles from downtown. So, this really is close to Seattle as Bellevue.
Paula Begoun: And Dr. Baxter is – the information on his Web site is spectacular. I just – it’s just so impressive.
00:17:09 And the work he does is, just the scope and the excellence is unparalleled. Dr. Baxter, it says on your Web site that you have created some techniques in plastic surgery that are being used that you’ve pioneered.
00:17:33 What are some of those techniques that you have led the charge on?
Dr. Richard Baxter: Well, one thing that I’m really pleased about is the use of materials called acellular dermal matrix, which are very useful for revision breast surgery and particular problems that can happen with implants. And now they’ve become pretty much the standard approach to breast reconstruction.
00:18:02 It’s just been an interesting arc. I was one of the people who did some very early work on it and published what you might consider a proof of concept paper.
Paula Begoun: And what is this that you do?
Dr. Richard Baxter: So, it’s called acellular dermal matrix. So, it’s a sheet of material that’s actually made from skin, but they remove all the living cells out of it, and so it’s just this matrix, you know, collagen structure of the skin is made from.
00:18:27 And the basic idea with breast reconstruction in these revision cases is to think of it as an internal bra. And it actually becomes living tissue that lasts a long time. We just published a 12-year follow up case on it. And it was just fully intact structural material after 12 years. So, it’s really useful. And now there is kind of a related topic, since we’re talking about celebrities and their surgeries recently, is Angelina Jolie and her prophylactic mastectomy.
Paula Begoun: Right.
Dr. Richard Baxter: Because she had the BRCA gene which puts her at very high risk for breast cancer.
00:19:06 And a lot of what we’re doing now for cases like that is called a skin-sparing mastectomy and immediate reconstruction using this acellular matrix material. The most popular brand of it is called AlloDerm. And so that makes this internal bra. And so we can go what’s called direct implant. So, she had hers done in two stages, but very often now we can do it all in one stage.
00:19:34 So, you are in and out of the hospital in less than 24 hours and sometimes you have perkier looking breasts than you went in with.
Paula Begoun: So, Angelina Jolie, just to be clear, and I’m very familiar with the BRCA gene test.
00:19:57 The BRCA gene is a genetic trait that if you have it, if you have this gene, the statistics I’ve seen says you have an 80 percent shot of getting breast cancer.
Bryan Barron: And I think a 50 percent of getting ovarian cancer.
Dr. Richard Baxter: Right.
Paula Begoun: Oh, wow. I didn’t realize that.
Bryan Barron: In fact, I believe I just read something that Angelina Jolie is going to have a full hysterectomy as well.
Paula Begoun: No kidding?
00:20:25 So, I’m particularly familiar with the BRCA gene because my family has a high incidence of breast cancer. My sister had breast cancer. Lots of aunts had breast cancer. And as an Eastern European/Semitic background, that puts me in a high category. Now, we chose not to get tested for the BRCA gene as a family because why get the test if none of would be – because what Angelina Jolie did is incredibly brave.
00:21:02 My sisters and I sat down and talked about it and we didn’t feel that if we knew we had a BRCA gene that we would jump in and get a hysterectomy and a double mastectomy. Because if you know you have it, unless you’re willing to do something about it, why know and have that hanging over your head.
Bryan Barron: Over your head.
Paula Begoun: But she did choose to get tested and it’s really rather incredible what she chose to do.
00:21:28 So, she had this technique to reconstruct her breasts, even though she didn’t do it immediately after the double mastectomy, removing both breasts. She did part of the technique that you pioneered to make the results better?
Dr. Richard Baxter: Yes. So, one of the things is that for people facing this decision, if getting the test has been recommended to them, and not everybody should do it. But they have options now that they didn’t have ten years ago. So, she had, you know, a variation on what’s called immediate reconstruction using tissue expanders.
00:22:10 So, the expanders were put in at the time of her surgery. But, you know, then you go back later and exchange those for permanent implants. But, for a lot of women now they can even do what’s called nipple sparing, and so it can all be done in one stage. And that’s not as daunting of a procedure as mastectomy and reconstruction ten years ago was.
00:22:34 It’s a whole different set of options to consider now.
Paula Begoun: Wow. And so in your practice in Seattle, Dr. Baxter, do you do all kinds of breast reconstruction, breast implants? What would you say is the major cosmetic corrective procedure or plastic surgery procedures you do?
Dr. Richard Baxter: Well, most of my practice is cosmetic surgery and that’s equally divided between face and body.
00:23:04 But I have this small component where I do some breast reconstruction, partly because I just want to and partly because I have this long history of developing these materials and these techniques. And I just find it interesting still and kind of want to stay involved.
Paula Begoun: So, one of the things I noticed on your website and the pictures are striking, and tempting I should say, is something you do that isn’t cosmetic surgery but sure as heck looks like cosmetic surgery without the scar is this Liposonix treatment that is fat reduction.
00:23:46 You sit on a table, you get hooked up, and two months later you don’t have as much fat. Is that really what happens?
Dr. Richard Baxter: Sort of. It’s sort of like that. So, Liposonix uses what’s called intense focused ultrasound. And ultrasound in general, I think, is one of the big new categories for aesthetic medicine in particular. There’s another version of it called Ulthera which is more for skin tightening and lifting.
00:24:16 And the way it works is you can focus ultrasound energy just the way you can focus light with a lens. So, if you essentially put the lens or it’s called an ultrasound transducer on the skin then that focal point is going to be at some layer underneath. So, with Liposonix it’s placed at about three-fourths of an inch beneath the surface of the skin, and you can actually destroy the fat cells in a single treatment. And then it just takes the body some time to reabsorb that.
Bryan Barron: So, Dr. Baxter, I had – at the beginning of the year – I had the Coolsculpting procedure done on my love handles, which I hate that term because I’ve never loved them.
00:24:57 And I can’t think of anyone else who has either. And I’ve actually been really impressed with the results. I have some lingering numbness and the loss of sensation in the areas that were treated. It’s gotten better over time. But we’ve written about Coolsculpting. I’ve looked into the research behind it. How would you say, other than one is using very cold temperatures, Liposonix uses ultrasound, was there a reason you went with Liposonix versus Coolsculpting?
Dr. Richard Baxter: Well, yeah, there is a reason which I guess I can get to in a minute.
00:25:34 But they both work. They’re both FDA-approved technologies. They both treat focal areas of excess fat. And with the Coolsculpting it’s a little less precise. It’s sort of kind of bulk reduction of fat tissue in whatever area you can kind of pinch up to that suction head that delivers the treatment. But it seems to be very well tolerated.
Bryan Barron: Very uncomfortable for the first couple of minutes?
Dr. Richard Baxter: Is it?
Bryan Barron: Yeah.
Dr. Richard Baxter: The interesting thing is that the nerve tissue is more sensitive to cold than fat tissue.
00:26:11 So, that probably explains why it’s uncomfortable at the beginning and then why you have that kind of lingering numbness afterwards. But that seems to get better with time. I ended up going with Liposonix because I was involved very early on with the company that developed the technology, which the company was founded in Bothell which is near Seattle here.
Paula Begoun: Ooh!
Bryan Barron: Bothell, Washington, yeah.
Dr. Richard Baxter: Yeah.
00:26:36 It’s really one of the sort of world centers of medical ultrasound.
Bryan Barron: Bothell?
Dr. Richard Baxter: Bothell.
Paula Begoun: In Seattle? Bothell, up north by you?
Dr. Richard Baxter: Yeah. There’s historical reason for that. There was a spinoff from some engineers at the University of Washington called Advanced Technology Labs. And they ended up in Bothell. And then all these kind of medical ultrasound companies like Philips and SonoSite.
00:27:00 And they all ended up going there. So, if you ever feel like using focused ultrasound to destroy fat tissue and you’re looking to expertise to start the company, you go to Bothell.
Paula Begoun: Go figure!
Dr. Richard Baxter: So, I ended up getting involved with them very early on and learned a lot about ultrasound over the past eight years or so.
Paula Begoun: So, in terms of – I’m sorry, I’m not exactly getting clear the benefit of the ultrasound versus the cold, you know, freezing the fat versus ultra sounding the fat and why one is better than the other.
Dr. Richard Baxter: So, with ultrasound you can map it could just like you would do a liposuction procedure.
00:27:45 You can pinch the thickness and you know exactly where it’s thicker. And you map it out and you deliver the treatment into a specific layer over a specific area. So, you have that deal of precision and control that you don’t get with the Coolsculpting. In fact, we had one patient who had had a Coolsculpting procedure on her abdomen and she said it worked really nicely and she was happy with that.
00:28:12 But they couldn’t get the paddles on that kind of low back area; it just didn’t work. And so we gave her a Liposonix treatment back there and she lost an additional, I think, two inches of circumference.
Paula Begoun: Oh, I am so seeing Dr. Baxter. I am so…! And he’s ten miles away. Where have I been?! Oh my gosh.
00:28:29 Okay, I’m sorry, Dr. Baxter. Go on.
Dr. Richard Baxter: Well, so that’s just an example of how you can kind of map it out with a little more precision, so that’s what I like about it.
Paula Begoun: I’m sorry, Bryan, did you want to ask something? The underarms?
Bryan Barron: Can it be used on that? Because I know Coolsculpting can’t…
Paula Begoun: What do you call this area? The flaps under the arm?
Bryan Barron: The bat wings.
Paula Begoun: The bat wings under the arms. You know, when the underarm area gets saggy and heavy.
00:28:57 You wouldn’t want to deplete the fat because then you just have sagging skin. What do you do for those flapping underarms?
Dr. Richard Baxter: Yeah. That’s an area that doesn’t have a really great solution yet. But I think there is some potential with focused ultrasound because the actual mechanism of action, what happens when all those ultrasound waves converge at that focal point is heat. And so it’s not just rupturing the fat cells; it’s actually getting that tightening effect on the collagen as well.
00:29:28 The trick to doing areas like the arms is going to be a shallow or focal depth so that you get some of that tightening closer to the surface of the skin. And we don’t have that available in the US right now, so that’s one of those things maybe for the future file and hopefully not too far out.
Paula Begoun: So, I have to go someplace else to get rid of my bat wings so that when I wave my whole arm isn’t waving? Is that what you’re saying?
Dr. Richard Baxter: Well, I think we need to do some clinical research and see whether this idea is really going to be as cool as I think it will. But, like I was saying earlier, we need a prospective trial.
Paula Begoun: So, in terms – you always need studies.
00:30:05 So in terms, oh, I’m sorry, Bryan.
Bryan Barron: I love that Dr. Baxter keeps mentioning that because there are a lot of doctors and surgeons out there who tend to get very excited about something they read about and they don’t necessarily look beyond the surface of that.
Paula Begoun: Right. A lot of physicians – a lot of physicians as I’m sure you well know, Dr. Baxter, get very pressured by their patients and they want to earn a living, too.
00:30:35 And they need customers. And if their patients are calling, prospective patients are calling and saying, “Do you do this?” it’s very tempting, you know, you don’t want to keep saying no, no, no. And then they go to someplace else that’s doing the latest thing they read. So, a lot of physicians jump on, dermatologists and plastic surgeons jump on a bandwagon because it’s the latest greatest and women and men are calling saying, “I want that done, too.”
00:31:03 And then they often jump on and do something that doesn’t have any proof that it’s better or worth it. And often those new procedures are more expensive.
Dr. Richard Baxter: Mm-hmm.
Paula Begoun: And you don’t do that? Say you don’t do that?
Dr. Richard Baxter: I try not to.
Paula Begoun: Ha! We know you don’t. So, one of the things that is actually not new, has actually been around for a long time, but took a back seat for a long time is the endoscopic brow lift.
00:31:31 It used to be something everybody talked about about 10, 15, maybe even 20 years ago, and then it kind of, I think because of Botox, it kind of took a backseat. And an endoscopic brow lift, versus a brow lift, versus Botox – can you explain the difference? Explain which one you do and why and what should I do? No, I’m teasing. So, can you explain what you can do about the deep wrinkles on the forehead?
Dr. Richard Baxter: Yeah.
00:32:01 That’s actually a really good question and one that’s a little more complicated than it seems. The wrinkles on the forehead, the horizontal wrinkles tend to form due to hyper activity of the frontalis muscle. That’s the one that you use to raise your eyebrows.
Paula Begoun: So, when you say hyper activity you mean frowning and raising your brows?
Dr. Richard Baxter: Just raising your brow a lot. And the reason that people tend to do that is if the brow starts to sag then you compensate for it by using that muscle a lot. And that’s why doing a brow lift, whether you do it endoscopically or some other technique tends to have an improvement on those wrinkles because then the muscle can relax and the brow is still in the right position.
00:32:44 The tricky part gets when you’re trying to use Botox for that, because Botox will relax the muscle. And if the reason that the muscle is so active is because of sagging brow then Botox will actually make it worse. So, it takes a lot of, I think, experience and good judgment when you’re trying to get brow shaping with Botox, and particularly when you’re trying to get the brow to go up. So, you need to really see somebody who can kind of analyze that and see whether a brow lift or something else is going to work for you.
00:33:18 Now, the endoscopic technique is still a good one. That is based on the idea of just making little tiny incisions behind the hair line and using an endoscope for the dissection to move the brow up. I think a lot of people have found that it’s not as reliable long term as they would like, and what I’m seeing is more of a trend toward doing a technique, it’s called a subcutaneous brow lift.
00:33:46 And you actually make the incision right at the hair line. And it seems like that scar would be more noticeable but there are ways of doing it that really can make it almost disappear. And those give you more control over the brow shape and position in some cases.
Paula Begoun: So, you’re talking about – so the difference between – so Botox obviously, you know, you get injected and for a period of months the muscles start moving and you literally get a smooth baby butt forehead.
Dr. Richard Baxter: Right.
00:34:18 But the price may be that your eyebrows actually drop.
Paula Begoun: Actually, one of my eyebrows actually pops. And the dermatologist I see who does my Botox injections actually does a technique actually to make my brow drop because one will actually raise up.
Dr. Richard Baxter: Yeah. So, it depends on where you’re putting it. If it’s horizontal winkles in the forehead that you’re treating then you’re more likely to get brow drop. If it’s the sort of 11, the vertical creases between the eyebrows – that muscle actually is what’s called a brow depressor.
00:34:58 So, that can result in the brow coming up a little bit. And the same thing when you’re doing the crow’s feet, because that muscle is also a brow depressor. And that’s the one where you can really get that sort of Spock brow if it’s overdone.
Paula Begoun: Yeah. Bryan, can you see how this pops a little bit?
Bryan Barron: Yeah.
Paula Begoun: I’m so due.
Bryan Barron: But it’s also, though, I mean, very few people have exactly symmetrical brows.
Dr. Richard Baxter: Right.
Paula Begoun: Right.
00:35:27 it’s only because I really…
Bryan Barron: And you have this weird obsession with your magnifying mirror.
Paula Begoun: I do have. I am so high maintenance. Oh my god.
Bryan Barron: There was one of those, I stayed at a W Hotel in Austin, and they have more of what I call a high tech hotel room bathroom which is actually quite nice in that you actually have counter space. But they had a magnifying mirror attached and it was one of those lighted makeup mirrors. And I thought, what the hell, I’ll take a look. Oh my!
Paula Begoun: Ha! Now you know what I go through!
Bryan Barron: Oh my gosh.
00:35:59 I’ve had bigger apartments than some of my pores.
Dr. Richard Baxter: They should have a little ad in there that appears in the mirror for skincare products.
Paula Begoun: Or you could say “things appear larger” like they have on a car mirror. Things appear larger than they are, or whatever they say.
Bryan Barron: Botox versus Dysport?
Paula Begoun: Oh right. Yeah, I know we want to ask about Botox versus Dysport. But just to be clear, an endoscopic brow lift you do little tiny incisions and reposition muscles.
Dr. Richard Baxter: Well, you’re really raising the whole forehead.
00:36:37 Both of them are ways of raising pretty much the whole forehead including the eyebrows.
Paula Begoun: And then when you do a traditional brow lift where you do cutting and pasting, because an endoscopic brow lift you don’t cut and paste, right? You just…you don’t touch the skin? You’re touching under the…?
Dr. Richard Baxter: Exactly. Yeah.
Paula Begoun: And then a traditional brow lift at the hair line you’re actually going in and lifting the skin up, too?
00:37:04 Is that how that works?
Dr. Richard Baxter: Yeah.
Bryan Barron: Probably the muscles.
Dr. Richard Baxter: You know, it’s not so much a traditional brow lift that people are going to now. It’s called a subcutaneous brow lift. So, it really is just that skin layer, but you can reshape the eyebrow area really nicely that way. You can give it some muscle manipulation if you need to to try to soften wrinkles. But there’s this traditional version which made a big cut all the way across the top of the head, behind the hair line, that I don’t think is done very much anymore.
Paula Begoun: And you don’t want –
00:37:38 Actually, I’ve seen it. Yeah, I’m sure there are still people who might, depending on their aging get it. But, it’s rarely done now, right?
Dr. Richard Baxter: Yeah. It’s not common.
Paula Begoun: So, if a guy – if a physician, male or female, says they want to go in and cut up your forehead like Frankenstein you want to say no?
Dr. Richard Baxter: I think you should maybe just get another opinion.
Bryan Barron: Get a second opinion. Yeah.
Paula Begoun: Ha!
Bryan Barron: So, Dr. Baxter, I noticed on your Web site that you are offering Botox and Dysport.
00:38:09 And they’re competing products if I’m not mistaken, correct? Botox being Allergan…
Dr. Richard Baxter: Yeah.
Bryan Barron: Okay. Paula has a long history with Botox.
Paula Begoun: Way too long!
Bryan Barron: And I asked her before the show if she had ever tried Dysport and she said no. So, we saw that you do both and thought, well, that’s perfect then.
Dr. Richard Baxter: Yeah.
00:38:30 And there’s actually a third one that’s FDA-approved now called Xeomin.
Paula Begoun: I’m sorry, Dr. Baxter. Spell that again?
Dr. Richard Baxter: Xeomin.
Paula Begoun: X..oh, who came up with that name? Xeomin? Okay.
Dr. Richard Baxter: Yes. Xeomin.
Paula Begoun: Xeomin, yeah. Why do they do that – come up with names that you can’t? Okay, sorry. All right…
Dr. Richard Baxter: The differences between the different products are not dramatic.
00:39:00 They’re basically all the same thing with some differences in processing. What a Botox molecule is, Botulinum Toxin Type A, it’s this cluster of proteins and in the middle is the actual toxin molecule that gets released after it is injected. And with Dysport they’ve removed some of those outer proteins so it’s thought that it might potentially release the active molecule a little bit earlier for sooner onset.
00:39:33 It might enable it to sort of spread a little bit more for a softer effect. But I think those are real subtle things that it’s hard to give a huge importance to. And Xeomin is just the actual pure toxin molecule. It has all the other parts removed. But that active molecule is the same in all of them. So, they’re all going to last about the same amount of time. They’re all going to work the same way and have the same sort of list of potential side effects.
Bryan Barron: So, if someone had say a bad reaction to Botox, it’s not like Dysport or Xeomin would be the next attempt, right?
00:40:13 Because it sounds like they’d be too similar that the likelihood of a bad reaction, assuming it was injected properly, would be the same?
Dr. Richard Baxter: I think it’s pretty much the same, although it depends on the nature of the reaction. You know, there’s this thought that maybe people start to get antibodies to some of these proteins and that might affect the results of it a little bit.
Bryan Barron: Paula says not for her.
Paula Begoun: Ha!
Dr. Richard Baxter: There’s a lot of data to support that.
00:40:42 You know, ultimately it comes down to what you’re familiar with and what your practitioner recommends. Most people who have been doing Botox for a long time just find that it’s familiar and predictable and don’t see a big reason to change unless one of these competitors drops the price on it really dramatically.
Paula Begoun: So, we’re talking to Dr. Richard Baxter from the plastic surgery clinic here in the Seattle area. Board Certified. Long list of credentials and all the educational background you can imagine.
00:41:16 He’s an expert in all kinds of cosmetic corrective procedures and cosmetic surgery. So, before we let you go, Dr. Baxter, what’s new and exciting that has research behind it as opposed to just being new and exciting without any research and nobody wants to be, or nobody should be a guinea pig without knowing they’re being a guinea pig for a procedure.
00:41:44 What are you excited about that you’re either doing or waiting to see for more research to be done. What’s on the horizon, if anything?
Dr. Richard Baxter: Well, I’ll give you a couple things that are just sort of at the top of my list. And one of them is not a procedure, but it’s something that makes surgery a lot better. It’s called Exparel. And what it is is a very long-acting numbing agent.
00:42:12 It lasts up to three days. So, for people having a surgical procedure, if they can get their surgeon to put this into the surgical area at the time of surgery, it can dramatically cut down on the amount of discomfort that they have afterwards. They don’t need to take the pain pills with all the side effects as much. And that’s making a big difference and that’s something that’s out there already.
00:42:36 And there’s another one. This is maybe a little bit of a commercial plug because I’m a consultant to the company, but it’s called Jenu. And this is a home use device which is an ultrasound wand that is coupled with specific skincare products that are designed to penetrate more deeply with the ultrasound. So, for example, we have a cream containing retinol for the eyes. And we get 12 times deeper penetration using the ultrasound.
00:43:08 And it just takes a minute to do. And you do it at home. But you have to make the product in a specific way. It has these little micro spheres that oscillate in response to the ultrasound. And that’s how we get them to push through that outer layer of – the outer layer of dead cells, the stratum corneum, and kind of get down into the tissue where they can have a greater effect.
Paula Begoun: And what work did you do for the company, Dr. Baxter?
Dr. Richard Baxter: I consulted with them on the development of it and am still involved with them, so.
Paula Begoun: Is this ultrasound device, is this like – this wouldn’t be like the ultrasound device like…
Bryan Barron: Like Liposonix?
Dr. Richard Baxter: It’s a completely different thing, because Liposonix is focused ultrasound for a very intense effect.
00:43:55 This is non-focused. You’ll feel just a little bit of warming, but the whole purpose of the ultrasound is different. It’s just to enhance the product penetration.
Paula Begoun: Oh, got it. So, other than that, just one last question, sorry. A procedure I’ve been thinking about. I’m very good about sun protection. I have almost no brown discolorations on the back of my hands.
00:44:24 But as a result of having very severe eczema for most of my life, and particularly on my hands, and used corticosteroids, you know, heavy strength corticosteroids for years. And I have unusually thin skin on the back of my hands. My hands are very prematurely aged in comparison to anything, anywhere else on my body. And I’ve been thinking about getting injections of some kind that I’ve seen recommended and I’ve seen videos of and articles on for fat injections or some other kind of injectables in the back of my hands.
00:45:06 Again, I am like I said, high maintenance. Any thoughts about that? Have you been doing any of that? Any success with it?
Dr. Richard Baxter: I’ve done a little bit of it. And I think it works. Fat transfer works if it’s done really well. Radiesse can actually be very, very good there. I haven’t used Sculptra in that area, but I am told that’s another very good option for that area.
00:45:33 I would not do one of the hyaluronic acid fillers like Restylane or Juvederm there.
Paula Begoun: Because it’s too much movement? Is that the problem with it?
Dr. Richard Baxter: Yeah. It’s just not going to look and feel right.
Paula Begoun: I am so curious to give that a try. It’s really striking the difference between my hands from all those years of using cortisone, and particularly my palms. They’re just deeply wrinkled. And my fingers just – I always look like I just got out of a bathtub.
00:46:03 It’s just, it’s so…and I remember when I first started noticing my hands aging in comparison, and I remember it dawned on me that it was all those years of the cortisone use that can send skin. So, Dr. Baxter, Board Certified Seattle plastic surgeon, give me your last bit of advice about cosmetic surgery, cosmetic corrective procedures. What do I need to know?
00:46:39 You know, I might not be in the Seattle area; I can’t go see you. What do I need to know besides, by the way, Dr. Baxter’s Web site is filled with incredibly great information – his article about the Vampire Facial/Facelift is particularly interesting, among many articles he’s written. What do I need to know?
Dr. Richard Baxter: Well, I think if it’s a technology-based procedure, look for published data that is from a randomized prospective trial.
00:47:11 And it’s really easy to do. You can just Google Medline, it will take you to a Web site and you can just put in the keywords and it will come up with a list of publications. And it just takes a minute to do and it will show you whether there is actually published data from good studies to back it up or not. And if it’s a surgical procedure, just do your homework. It’s always a good idea to get more than one opinion.
00:47:42 And particularly if it’s a corrective procedure, if it’s a revision of something that didn’t quite turn out right, that’s something to really take your time with and make sure you find the right person, because if the revision isn’t right then it’s an even more difficult problem the third time around. So, that’s where you really need to be careful.
Paula Begoun: Okay.
00:48:04 All right, Dr. Baxter. You’re wonderful! We love talking to you. We will probably talk to you soon. I will probably talk to you sooner in person than on the radio. Thank you so much for taking the time today and good luck to you sir.
Dr. Richard Baxter: It’s been my pleasure. Thank you.
Paula Begoun: Thank you.
Bryan Barron: Thank you, Dr. Baxter.
Paula Begoun: So, what do you think on the back of my hands, Bryan? What do you think? Yeah?
Bryan Barron: Yeah.
Paula Begoun: Look at that. Unbelievable.
00:48:33 Those years of cortisone.
Bryan Barron: The rest of you just keeps getting younger.
Paula Begoun: Ha! Then why shouldn’t my hands? You know, I always tell people that you can absolutely tell that sun damage – one of the ways you can tell that sun damage is taking a toll is compare – if you’re driving in a country where you sit on the left side of the car, where your arm is on the left side of the car that’s getting most of the sun exposure, your left side of your face and your arm will look older than your right side because it’s less exposed.
00:49:10 I’m a classic example of having more sun damage on my left side than not. So, definitely we know sun damage plays a role, but also for people who have to chronically use cortisone and it’s not the once and awhile that you use cortisone, but I used it twice, three, four times a day for years, and years, and years. You do get thinning of the skin. So, my hands, which otherwise, because I don’t have brown discolorations, and where I didn’t use cortisone I’m nice and plumpy.
00:49:42 But, you know, the depletion on my hand is really, really striking. So, I’ve been thinking about that for awhile. Okay. So, Dr. Baxter helped us out. We now know that the Vampire Facial, think twice about that. It’s not so much a facial; it’s injectables. And according to Dr. Baxter, and we’ve actually done research on this, there really aren’t randomized independent studies showing that it’s beneficial.
Bryan Barron: Well, or that it’s better than just getting a dermal filler, which is a much more straightforward procedure.
Paula Begoun: And cheaper. By far.
Bryan Barron: Oh yes.
Paula Begoun: Cheaper.
00:50:18 You’re not getting any more bang for your buck. Talked about the new longer-lasting injectables. Talked about Radiesse. Talked about the new ones with Juvederm. Dr. Baxter was great. Incredible information. Anything else, Bryan, we should sum up about other than you, well, actually, let me sum up. I know where I’m going with this. Sorry.
Bryan Barron: I figured you would.
Paula Begoun: Yeah, I know. I can’t help myself.
00:50:45 So, what the Paula’s Choice Team wants you to know is that we know that great skincare can do incredible things for the skin. There is no question that you can have night and day differences in terms of the health of your skin, the appearance of your skin. But in terms of what cosmetic corrective procedures can do, and what plastic surgery can do, there isn’t a skincare product in the world – I know you’re all looking for it and I’m here to tell you unequivocally it doesn’t exist.
00:51:20 I don’t care what a celebrity is telling you that you can’t get to over the age of 45 and have a smooth looking skin that’s lifted and tight and no wrinkles, and you’ve either been Photoshopped heavily in the picture or you’ve had cosmetic corrective procedures or cosmetic surgery. It is the combination – not that you need, nobody needs to get cosmetic corrective procedures. Nobody needs to get plastic surgery.
00:51:46 But if you want to know what really works and what really doesn’t, and that’s all we’re ever interested in is what is the facts, what is the truth about what things can and can’t do, what is good or bad, what works or doesn’t work, then in truth there isn’t a skincare product or skincare routine that replaces what cosmetic corrective procedures can do or replaces what cosmetic surgery can do. So, while I love that people use Paula’s Choice and give me all kinds of wonderful feedback and the products we recommend that are well formulated can do remarkable things for skin, it’s not going to put a plastic surgeon or a dermatologist who is doing cosmetic corrective procedures out of business. It’s not going to happen.
Bryan Barron: Yeah.
Paula Begoun: So, I’m Paula Begoun with Bryan Barron – god, I was almost going to pronounce your name wrong!
00:52:35 We are co-authors of “Don’t Go to the Cosmetics Counter Without Me.” We are part of the Paula’s Choice Team. Come visit us and see everything we’ve written and our product reviews on
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