 All right, we're going to go ahead and get started with today's webinar. It's titled, Waste to Achieve a Useful Glow, Discussing the Latest Anti-Aging Treatments and Techniques with Dr. Kalpesh Vakarya. He's an associate professor of odorinolaryngology, head and neck surgery, and he's also the chief of facial plastic and reconstructive surgery at the University of Maryland. We invite you to leave your questions for Dr. Vakarya using the questions or chat feature found in GoTo, and he will address them at the end of the presentation. You can also send us an email if you feel more comfortable that way, if you don't want to submit it publicly, and we'll be sure to include your question at the end. All right, Dr. Vakarya, go ahead and take it away. Well, thanks Meredith, and thanks everyone for coming for our webinar on Waste to Achieve a More Useful Glow. Some disclosures. I don't have any financial interest or arrangements or affiliations with any of the organizations that I'm going to be speaking about or any conflicts of interest related to this activity. I am a faculty member of the AO, which is a trauma organization outside of that, which is not related to what we're talking about today. I will discuss some non-FDA approved treatment options and we'll mention some commercial products, and photos from the literature were primarily used to demonstrate principles to avoid any kind of operation privacy issues here. I thank everyone for joining in today. So what we're going to talk about is I'm going to start talking about actually screen time, because that's actually changed a lot of plastic surgery, especially over this past year and a half. We'll then kind of dive into facial anatomy and kind of the anatomy of aging to put in context the treatment options that we have. We'll talk briefly about some surgical treatment options and more in depth about non-surgical treatment options, because it seems like in this day and age people are trying to look at more the non-surgical options if they're available. And then we'll end with hopefully some time with questions. So back well before I was a facial plastic surgeon, a majority of patients seem to seek out cosmetic procedures or facial plastic surgery, because one of their friends was having it and so or another friend or a colleague that they know was having it. And so that was one of the motivating factors that brought interest into patients getting cosmetic type procedures. However, definitely during the time that you know I've been a physician and surgeon, interest in plastic surgery has steadily gone up over the years, especially because a lot of the stigma has a significant decrease. And really the advent of social media, your Facebook, your Instagram, Snapchat, WhatsApp, has really kind of changed the game and increased interest in cosmetic surgical procedures. And so this is in part because a lot of the stigma has been kind of eliminated because you have a lot of support for cosmetic procedures in promotions, from celebrities, and also influencers that really started to affect public interest in cosmetic procedures, especially the non-invasive ones. And so I'm briefly going to talk about surgical options, but the non-invasive ones, it seems to be where the population in the field is really headed towards. Now as the internet, so that was initially, and I would say even more recently as the internet, social media, and smartphone technology has really become more widespread, and the exchange of photographs, especially selfies as a result in people looking at themselves and others more critically, there's been an increase of different types of apps that are readily available on our computer or smartphones. This is just one example called Facetune, where people can easily kind of do virtual plastic surgery in a sense and touch themselves up. And you can see here, you can remove blemishes, you can change kind of lighting, you can actually change your facial features, and in a sense kind of be somewhat of a completely different person to change your background. And I would say that, you know, over the, as this has become more common place and popular, patients are seeking out cosmetic procedures because they're realizing what the potential is out there. Now, I would say in the past year and a half, definitely since the COVID pandemic, there's been another kind of shift in how we see each other and see ourselves. And this is a big part of applications like what we're using right now or Zoom, Webex, where we're forced to look at other people much closer than we were in the past and look at ourselves for extended periods of times. And so this is really actually translated to a lot of patients the past year and a half requesting cosmetic procedures to improve their on-screen appearance, because they're noticing things that they wouldn't ordinarily notice before, where they're communicating with people, such as the way their lips are looking, the way their smile lines are, things around their eyes that may make them look more tighter and less youthful. And so I think the timing of this is very important because this is really a time where people are starting to really critically look at themselves and say, hey, you know, there's things about kind of my facial features, because I'm noticing them more that I'd be interested in potentially improving upon. So let's switch gears before talking about some of these options available to make a youthful more youthful glow and really start talking about some anatomy, because this will be important to put the different procedures in context. So the face is definitely made up of different layers, starting with the skin layer, under the skin, you have the subcutaneous fat layer. Above that you have the facial muscles, as well as the ligaments that hold the skin tightly to the underlying bone. You have additional spaces, you have the facial nerve, which controls the muscles of the facial expression and muscles that are important and how we communicate with each other. And so, and then you have the deeper layers over the bone and the bone itself. And so aging happens on all these layers. And the different treatments that we have for facial aging really address one or more of these layers. Unfortunately, there isn't one pill kind of like in the matrix, which you can take. And then all of a sudden all the layers are fixed and you're kind of a completely different person that we haven't really achieved that as of yes. Now, the other appreciation I've gotten and I kind of try to embark and kind of give to my patients is impressed upon my patients is that kind of the face was made in a way to protect some of the critical structures around it. So you have some critical structures like your brain, your eye, your nose, your mouth, and all these structures are sensory organs. This is how we like communicate with our surroundings. And so the eyes are ability to see, our mouth is ability to speak with each other, swallow, breathe, our nose also similarly with breathing function and sense of sensation. So the facial structure is really made to house these special organs and the soft tissue is created in a way to protect these organs. So that's why you have all these muscles in and around the eye area. So that way you can help close your eye and open your eye to keep the eye protected. You have your kind of the appearance of your nose and the muscles around the nose and muscle around the mouth to help protect those sensory structures. Now these muscles which are really intended for kind of protection of these sensory structures also give us the ability to make these various facial expressions that you see here on the right. And it's through these repetitive actions that we see some of the wrinkling that we see on patients as we age and even kind of the in the younger age group, especially in the more expressively used patients. So before talking about aging, we need to kind of think about youth and what exactly is youth. And so babies are the epitome of use. And so babies have under, haven't undergone the years of wear and tear combined with the forces of gravity that has resulted in kind of aging science that we see in our own faces. So what are like the specifics of kind of this baby or babies in general that make them useful? So when you kind of look at the skin, you can see that the skin has a level of smoothness. There's, you know, when you kind of pinch their cheeks, you know, as you can see in this, this little baby just wants to wants to have your, have your cheeks pinched. There's a level of elasticity and kind of rebound and smoothness that exists within the facial soft tissue structure. Now most people don't want to look like our baby selves. I know I don't want to necessarily look like I was one years old again. However, we do want to recreate some of the features that are associated with our baby selves, especially when it comes to the volume. And so this kind of part of what makes this baby so attractive is the volume, the volume in the cheeks as well, the volume in the lips and the volume around the eyes. And so that has, that understanding has really changed how we take care of patients that are looking to kind of turn back the clock, whether it's one year, five years, or 10 years. So what do we see when we're aging? So as I mentioned, the facial structure is very layered. And so kind of the most deepest or the most internal layer is the bone layer. And so the bone layer, which is shown on the right, on the left side here, and with the arrows undergoes some changes as we age. So some of the things that we see is where you can see what happens with these arrows. So the eye sockets tend to enlarge a little bit. The cheekbone tends to sink in a little bit, especially if we start losing teeth, the upper jaw and lower jaw tend to thin as well. And so these are some of the kind of age associated changes that we see in the bony structure. And so additionally, as we go into the soft tissue, especially as you combine the forces of gravity, where you're just having gravity pushing down day in and day out, that also contributes to some of the age associated things that we see in the face. So the sagging that we see. So as you also age, you start losing some of that volume. So the volume is a combination of liquid volume, fat volume, some of that elasticity or rebound that we have in our faces and our skin, we start to lose. And so you can see in this picture where on the patient's left side, the age associated changes, you're going to see sagging of the eyebrows. You're going to see grooves developing in and around the eye area, especially between the junction of the eye and the cheek. That cheek volume is going to decrease because you have some loss of some of the fat layers of the face. There's also going to be some descent as some of the tissue becomes a little bit more relaxed, which will create additional grooves. So the kind of the smile lines around the upper portion of the mouth and then lines around the or the marionette lines allow next to the lower corner of the mouth. Also, as you start having some sagging that tends to go on, you're going to start noticing them jowling or some relaxation of the skin and muscles of the neck. You're also going to see as we continue to use our muscles of facial expression with repetitive use, such as puckering, for those that smoke really puckering around the kind of a cigarette, you're going to start seeing more and more lines develop, especially around kind of the mouth in those in those patients that smoke with that repetitive puckering, resulting in these kind of radial lines around the mouth. And so these are some of the age associated things that we see, which is important to understand because there's different options for the different areas of the face that may bother one person. So when it comes to aging, we don't all age the same way. So these are two Caucasian females in somewhat different age ranges. Yes, but the person on the left has aged differently than the person on the right. And so the person on the right really demonstrates what happens when you have a lot of volume loss in terms of the age associated changes as we age. You're going to have some of the bony structure become more prominent. Kind of the full cheeks that were present on that baby are not present in this person. And so because of the volume loss associated with aging, compared to the person on the left, yes, she does have some volume loss, but you can see the develop more of the fine lines and some deeper wrinkles and grooves, kind of the smile lines, the marionette lines, some volume loss in the cheeks and some descent in the cheeks rather than just primarily volume loss in the person on the other side here. You're going to have some grooves develop around the eyes, some excess skin around the upper eyelid, lower eyelid, some droopiness of the eyebrows can happen in some asymmetry. Now, we all have asymmetry, whether we're young or old, but as we age, sometimes some of this asymmetry between our right side and their left side can become a little bit more exacerbated. And so patients that present to our office, we don't treat them all the same way. So really, our goal is to figure out what areas of the face are troublesome to any particular person. And we direct our treatment options toward that. So now the topmost layer is your skin layer. And so there's a lot of aging that tends to go on when it comes to the skin layer. And so you can kind of break it up as extrinsic aging versus intrinsic aging. So extrinsic aging are things like exposure to your, that happens in your environment. So chronic light exposure, sun exposure, UV light exposure, exposure to radiation or chemicals or toxins, tanning beds, if you will. So these are extrinsic factors that can affect or help age the skin in a more rapid manner. And so we spend a lot of time with patients in our, in our, in our spot, talking to them about how important it is to kind of treat the skin and minimize exposure to the factors that we can, we can minimize such as minimizing UV exposure, good sun, sunblock application, avoiding those tanning beds versus intrinsic changes or aging that happens in the skin or things that are out of our control. And these things really, you can kind of highlight them in the non sun exposed areas. So areas you're not really getting direct contact to the environmental factors. And so these intrinsic aging things are really kind of genetic or hormonal or some combination of the two. And so this is where it's not uncommon. When patients come in, they'll say, Oh, you know, my mom or my dad had really deep set eyes or they had really droopy eyebrows, or they had really deep smile lines. And so those are things that happen, you know, because of our genes. And so we can't really escape that or modify that, but there's a lot in general, when it comes to extrinsic aging of the skin that we can modify. And so for that reason, I encourage my patients to adopt healthier lifestyles when it comes to, you know, smoking cessation, healthy skincare regimens, combination of sunblock and moisturizers and limiting excess of sun exposure are crucial in treating some of the aging process. So I'm going to demonstrate some of the skin, especially skin related or slightly deeper in the skin related changes that we tend to see in our, in our offices related to aging. And so one of the most common things that we see is pigment. And so as we age, especially in the setting of sun exposure, whether it's through tanning beds, or just spending multiple hours with full exposure on the beach, we tend to form pigment in those exposed areas of our body. And so pigments around the face, as you can see here, kind of melanocytes getting together and producing this kind of dark brownish type of pigment, pigment on our upper chest areas, pigments on our cheek. And so these are very common areas that we see, and that contributes that to that less youthful glow, I would say, and contributes to the kind of aged look of the skin. Other things that we see as we age are kind of broken capillaries or more prominent veins that are mostly found on the face and often on the legs. They can be caused by numerous things. They can be genetic to sun exposure to rosacea, which I'll talk a little bit briefly about, to alcohol exposure, liver problems, weather changes, pregnancy, all these things that can contribute to some of these more exposed blood vessels. In the past, fortunately, we didn't really have too many options for them, but I'll talk to you about some of the more novel, innovative options available to treat some of these pesky blemishes that have started to pop up. So excess hair. So this isn't per se completely related to aging, but there are areas that people will have hair that usually people don't have or don't care to have. So in female patients, they may not like the area of the upper lip having hair, the lower lip. And male patients just excessive on their face and neck. And so these are obviously related to genetics as well as hormonal changes that occur related to our aging, but contribute to a decreased kind of quality of life or decrease impressions of how one likes their face. And then there's rosacea, kind of reddening of the skin. And so this happens to some people. It's a condition that is not well understood, but it results in kind of facial redness or flushing. It's thought to be related to more visible blood vessels just right under the skin. The reason of it is unknown, but there are some treatments available, which I will talk briefly about. So let's switch gears here. We've talked about some of the age related changes that we see, some of the blemishes, if you will, that you could use the Facetune app or your various filters on Snapchat or on your computer to get rid of. Or you can kind of come in and see a facial plastic surgeon. We can talk about what options there are available. In general, the way I think of treatment for facial aging is with the treatment triangle. It's a nice easy way to kind of organize it. It's a combination of injectables, laser and surgery. And you'll kind of notice that injectables kind of really is on top, laser to the left and surgery to the right. I would say when I began my practice many years ago, and even kind of during my training, surgery was really the go-to answer for the majority of problems presenting to our offices. And so I would say over the past two decades, surgery has become an important but less utilized option because of the arrival of really innovative and novel injectable agents to turn back the clock of aging, as well as laser and light treatments that really make a significant impact on patients' facial appearance as well as function. Let's talk about location. So location, location, location. Location is really everything to understanding how we treat the different parts of the face in terms of what options people may have. So one of the areas in blue is what's shown is tend to be areas where people as we age lose volume. What's highlighted in pink are areas that it has some volume loss effect, but it's really related to the loss of elasticity or the relaxation of the soft tissues or sagging that can happen. And so the areas in pink, so which is really the lower third and the neck, are often treated with surgery versus the rest of the face. While there may be some surgical options, we've really kind of navigated or pushed ourselves to really innovative and creating techniques that are more non-surgical that have less downtime, get patients back to their activities and work in a more expeditious fashion. So I'm going to talk about a couple surgeries just to be complete because there are situations where the other two arms on the treatment triangle, the injectables and lasers just won't do the trick. So especially as the aging associate changes become more moderate to severe. So we're going to talk about some of the brows. And so as we age, we tend to form four horizontal wrinkles along our forehead. And as we age, our eyebrows start to droop with time. Now some people because of genes, I've seen patients in their 20s or 30s where they have very droopy eyebrows. Now, but this tends to be an issue as we head into our late 40s, 50s and thereafter. You know, before surgery would be much more involved with much larger incisions. Now, depending on various patient factors, we're able to downscale the extent of surgery and still get a very good result just through much smaller incisions, about two, three centimeter incisions hidden well in the hairline and a larger incision on the side along the temple. And through this, combined with little telescopes and cameras, we're able to perform a surgery that would require much bigger incisions to do, therefore minimizing the recovery time as well as some of the potential side effects related to numbness and so on and so forth. Next is blepharoplasty. I would say about two decades ago, this was the gold standard, the way to go when it came to issues around the eye. So also as we have talked about the upper eyelid, you tend to either form some wrinkling or excess skin. You started forming some hollows or grooves around your lower eyelid and some wrinkling and fine lines around the eyes, especially laterally here on the side or underneath. And our usual go to a couple of decades ago, this person would definitely get surgery coming in and there wasn't really any other alternative. Now I would say that's really shifted and I'm going to kind of show you some of the techniques that we have, well shorter surgery, but you can see surgery still has a role in the treatment of kind of the aging eye lids and the aging eye area that can still rejuvenate the upper and lower eyelids. Furthermore, as however, as things get more severe, you get a lot of excess skin, a lot of droopy eyebrow, a lot of excess skin or deep grooves or a kind of really poochy fat sticking out of the lower eyelid area. That's really where surgery, you know, there really isn't an alternative option. Next, when it comes to the lower third of the face, the face and neck area, the face and neck lift initially has always been the go to. I'm going to show you some kind of more innovative options as in the mild to moderate severity categories to treat the areas of the lower third of the face. You can do this. It's an outpatient procedure. It's about a week-long recovery. You'll have incisions as kind of marked out here that are fairly well hidden around the ear, behind the ear, along the hairline. So well hidden incisions and then underneath the neck to get the types of results as shown here from this paper in 2018. And so as we age, we start forming jowls or relaxation of our neck skin if you have some excess fat in this area, just relaxed muscles. A face and neck lift is a great option for patients to take them from what's on the left side over to what's on the right side here. And you can see improvement in the jaw line, improvement in the neck contour and removal of the excess skin. And then depending on the type of face, neck lift, you can get kind of a more pulled result, less pulled result. There's some variation that exists. And that's important to understand because different patients and different people are looking or wanting different types of results. And we can achieve that. Fat grafting. And so this is a surgical approach, but this is kind of headed toward almost the non-surgical, if you will. But patients, as we lose volume as we age, but we do have some excess fat in non-ideal areas, such as around the thighs or around the belly. Taking fat from this area and transparently in the face is definitely a nice option. As what you can kind of see here in this patient who's in her 30s, who's developed some smile lines and some volume loss. And so this is kind of before you can see less volume in the cheek area. And this is after a couple of sessions. And so the traditional, you do about two to three sessions, three, four months apart, depending on any particular patient's needs to get a one, two year type of result. And so patients who grab it toward this procedure are those that want to use their own tissue and use their own material to help rejuvenate their face. Now there's some other kind of novel adjuncts to this, such as platelet-rich plasma, which has been kind of popularized as the vampire facelift, for example, which we can add on to help with achieving a little bit more youthful glow either independently or in combination with this type of procedure. So let's switch gears and let's talk about injectables, which is one of the treatment triangle options. So neuromodulators, this is one of the most common injectable used throughout the country. There's multiple, initially it was just called Botox or the Botulinum toxin. So Botox was the initial option. There's more options out there, Disport and Javau. What this is, is injection of protein into the area. And what these neuromodulators do is they paralyze muscles. And so you're not actually treating the wrinkle, you're just paralyzing the muscles so you can get the side effect of the wrinkle reduction. And so this is an example of injecting into the muscles around the eyes. You can see the wrinkling that is there before versus the smoothing effect that happens afterward that is associated with the paralysis of those muscles. Similarly, injection into the forehead or the area between the eyebrows, your 11s, if you will, you can see what's on the left is before and then on the right is after the softening and wrinkle reduction that you get with that. Now with the wrinkle reduction is the lack of movement that you're going to get, which is something that is preferred in some situations and not preferred in others. So now these are areas that are FDA approved. Now if you start using these neuromodulators in other areas such as around the mouth, around the neck, you may get some of these wrinkle reductions associated with paralysis if used thoughtfully and appropriately in other areas of the face. So this is another example of neuromodulators. So kind of as you have deeper forehead lines, you can see the softening and effect that can happen, deep 11s between the eyebrows, the softening that occurs between the eyebrows. And so with this procedure, you come into the office, the injections take about 30 seconds in each site up to a minute. So one appointment takes about five to 10 minutes to complete the injections. They're well tolerated the way the neuromodulators work. It takes a couple of days to take effect. And so you don't expect the wrinkle reduction to happen right away, especially if the wrinkles are deeper. The paralysis takes about two, three days to kick in, after which you will start seeing the smoothing effect over the next subsequent week or two. And so when it comes timing, if you have a big event plan, you don't want to get this right before you want to kind of think about this, you know, one, two weeks prior to your event just to maximize the wrinkle reduction. Now other areas that you can utilize this that we utilize quite frequently is around the mouth, as well as along the corners of the jaw. And so around the mouth, some people, and I'm going to use the more approved term, the resting frowny phrase, if you will, come in to see me because they'll say, look, people, especially when I'm on Zoom, they think I'm displeased. I'm looking kind of upset or I'm not happy related to what's being talked about when I feel perfectly fine. And so in these types of situations, often it's because the way any particular patient's facial muscles are kind of wired, the muscles that pull the corner of the mouth down are a little bit more active than the muscles that are pulling the corner of the mouth up. And so in this situation, if you paralyze the muscles that are pulling the corner of the mouth down, you're going to get a nice softening effect on the corner of the mouth. And so, and an inability to frown, which most people are completely fine by. And so you can take this kind of frown and really turn it upside down, if you will, and make people look happier, look, you know, more, more smiley, if you will. Now other patients may be bothered by their kind of contour of their jaws. And so, and that's related to overactivity or enlarged master muscles. And so a very minimally invasive way to help this is with a neuromodular injection. And through injection of the master muscles on both sides and waiting a few weeks, because it will take some time for the slimming of the muscle to really kick in, you see the nice contouring and appearance of the jaw more streamlined appearance of the jaw that can that can occur. So another very common noninvasive tool that is in our toolbox is the use of dermal fillers. This has become even more common as the pandemic has pushed us into really a virtual existence as we're looking at ourselves on zoom and and such similar platforms. And so people have noticed that they have thinning of their lips or their smile lines or areas around the eyes are becoming the grooves are becoming more prominent and they're looking more tired, which is not surprising because the level of fatigue being on being on the computer is in itself pretty extreme. And so very common procedures that we do here in our medical spa is injection of dermal fillers. I use cannula to minimize any complications and help minimize any bruising. And so patients have thinning of the lips. You can give them more volume with a kind of short procedure that takes about 30 45 minutes to achieve this type of effect. You can go back to work the same day and then kind of continue to live your life. So there really isn't downtime that you have related to any of the surgical options I've talked about. That being said, if you have an event coming up, let's say your wedding or a landmark birthday, if you will, this is something you want to think about at least a week or two prior just because there is some swelling associated with this. So you want to let some of the swelling kind of evolve and to kind of get you to that perfect kind of lip volume in preparation for your event. Other, now these are more common FDA approved uses of dermal fillers is around the smile area. You can see in this patient her left side is much deeper than the right side. So you can see the improvement that you can get with the injection of these fillers. And once again, this is a procedure we do in the office. It takes about 30 minutes and then go back to work thereafter. Now more novel areas that we've been using a filler on to kind of turn back the clock and also as an alternative to surgery is that in that lower third of the face is in jowl areas you can see here. And so this is something that you I would say about 20 years ago, the only option for this person would be a facelift. But however, in the patient that has the mild at most moderate level of relaxation, jawline disturbance or jowling, injection of a filler can really help smooth that out in addition to the other areas of the face. The other area that's also become more common because we're looking at ourselves much closely as we're sitting here on zoom is around the eyes. And so this groove, the naso juggle groove and the hollowing that we tend to see around the eyes and the associated dark circles around the eyes. And so we're just application of a half syringe to syringe. You can kind of see the results that you get and that smoothing effect around the eyes. Also a fairly new in innovative treatment is Kybella. This is another injectable agent that this material destroys fat cells. Now it's FDA approved to be used primarily around the chin area. There is further research going on about the idea of using this other areas to dissolve fat. But this has been well described. And it's something that we offer as well in patients that come in with kind of a mild to moderate amount of fat, primarily fat in this area underneath the chin. So the double chin patient, they're bothered by the appearance either in the front view or the side view. And so this is a very common treatment that patients are or area that people are trying to rejuvenate. And so in this particular patient, this is before this is after four treatments in general, the company will say six treatments to get this type of benefit. But it depends on the patient depends on the amount of fat that they have and depends on the response. So it's rarely after one treatment, although I've had one patient that had a significant improvement just after one treatment. But usually after about two to three treatments of this area underneath the chin, you'll see you'll start seeing some improvement and you can tailor it. So you don't have to do six treatments if you're getting if you're happy with the level improvement after treatment two or three or even as a matter of fact one, you know, that's kind of where you stop and keep the keep the injectable in your back pocket if there's any recurrence of that that can occur. So how does this work? So coming in the office, you mark out the area which is the central area underneath the chin where the majority of the fat is really is really present. You numb up the area with topical as well as injection medication. And then with some markings you do a calculation of how much kibela either one bile or two bile you're going to inject depending on how much how large of an area you need to treat. And so this is a patient that got just three treatments. You can see the significant improvement in that area underneath the chin that she was able to achieve just after three treatments. And one of the side effects if used inappropriately and if you start injecting in areas you shouldn't be injecting is some facial asymmetry in terms of this smile. And that's really only happens in patients that if you start injecting really outside of the white lines in this side of the neck where you have one of the important nerves that controls the lower lip when it comes to smiling. And so there has been some temporary weakness that's happened that's been reported but the majority of that is in patients that you know we really that was treated in areas in their initial trials outside of the central area. Okay I'm going to end with the the last treatment option of the triangle is these laser and light options. And this I would say has really been a game changer in my practice over the past 10 years. Things that patients coming in that ordinarily they themselves would be expecting surgery because either their friends have had or they've seen other physicians and surgeons who really encouraged them to have surgery for ex-quasi reason. Sometimes there's a laser light option that actually works way better and the results are better and the the results are it can be even more immediate. And so let's talk about some of this. And so more often than not I'm going to show you a little bit of video of what one of these treatments would be like. So we had the cytone system which is a broadband light is the system it's an intense pulse light. And so what this is is applying light on certain wavelengths to the skin. And so this is a skin level treatment that works with the skin and just right below the skin. And depending on how you set the computer system you're you can treat various areas or various blemishes that patients have. And so this is really a quick this is kind of like that Facetune app if you will kind of quick easy after a few treatments anywhere from two to six you can show some significant improvement. And so let me show you what a treatment looks like. And so you can see the the bright lights so it's important to protect the the eyes when you're doing this. You can see I'm going to show you some of the the treatments responses and you can't be this works pretty nicely at kind of befores and afters. And so the procedure takes depending on what we're treating if we're treating a full face it takes about 15-20 minutes. Patients some patients will require some topical numbing prior to the procedure some don't it just depends on the patient's sensitivity and their skin sensitivity. After the procedure you're going to look like you're just out in the sun and you have kind of the feeling of a very mild sunburn. Maybe some patients do get more red depending on how their response to light is that tends to last for a day or two at most. But this is something that you can just come in you know on your lunchtime your lunch break get the procedure go straight back to work and go from there you can cover up back on there afterward. And so this is the types of rich cells you're getting and it depends on the patients and depends on what we're using it for but in general it's anywhere from one to six treatments. This patient got a really good response just after two treatments broadband light use you can see the significant improvement in the pigment reduction that that came into play. Additionally for patients with rosacea or very fine capillaries broken capillaries on the skin this has become a nice tool in our toolbox. This is after two treatments you can see the significant reduction in the rosacea or the redness that's apparent in this general skin. Combined doing combination treatments with laser and light we have an indiag laser as well so that's using both or one either one independently can really be beneficial to treat some of the fine as well as larger bed blood vessels right underneath the skin. So you can see the significant improvement in blemishes this is not touched up you know with snapchat or anything this is this is a real result to significant improvement in this. Now these are long-term improvements so people will ask oh how long is this last so if you're eliminating you know a lot of these capillaries may come back depending on what your exposure is. So if you're still going back down the sun and getting a lot of sun exposure tanning beds you may have some of this return depending on your genetics or your any other related medical issues but short of that you know the treatment is fairly long lasting. Now as part of this there's a treatment protocol called Forever Young which I encourage patients to think about doing and so this is application of intense pulse light so the same as I kind of showed you frequently over the course of years so three or four times a year they've done some studies which show that by applying this it changes some of the genetic makeup in terms of it activates the some of the younger associated genes to keep the tone and texture of the skin a little bit more youthful and so you can see here in the person that this is him at age 43 and this is him at age 55 after 12 years of continued intense pulse light treatment throughout the area and so not only can we help to treat the problem when a person presents with the wrinkle or the groove or the skin blemishes but there's some preventative that we have now in our toolbox and we're out of the air where we have to wait till things become so severe where we need to just you know offer surgery the next laser option is the is laser resurfacing and this has also been really I would say a game changer in our practice because it offers the ability to chain really treat the skin and sometimes that's all you really need you don't need an aggressive surgery you can just treat the skin and get some this the results that a more aggressive surgery would give you and so this is just demonstrating an example of what's called a micro laser appeals or laser resurfacing so we want to protect the eyes and with our handheld piece where we're resurfacing the upper layers of skin and so what's nice about this is we can adjust this depending on how much time the patient has to heal how much time they have available and how aggressive they want to be and so we just tune the laser to that and so these are some before and exam after examples of the improvement in the skin layer that can happen in terms of the contour the tone the texture and the appearance of four sizes the smoothing effect and so I do recommend this to patients quite often as we get more severe wrinkling as what's kind of shown here doing this is after just one treatment 10 months after one treatment but you know multiple treatments of this over time could help keep the skin a little bit tighter a little bit more toned and so you're going to kind of turn back the clock as well as erase some of the blemishes and the fine lines and wrinkles that you can see here one common area people come see me about is the lip lines and lines around the lips this is before neuromodulators would be one of the options or just cover up frankly but really with the advent of the laser this has changed the game when it comes to treating the lips and so this is four months after just one treatment albeit an aggressive treatment to the upper and lower lip area you can see the significant improvement in terms the lines in the lips that were present before and we really are just just erasing them away as if as if we're doing our photoshop now this compared to some of the micro laser peels which are much lighter peels there is more downtime related to this downtime meaning in terms of care and so it's similar to a micro laser peel it's just applying ointments but in terms of recovery this area will take about two weeks to really recover and versus the micro laser peel takes about depending on the depth like one to two to three days so the eyelids so this has been once again a game changer for the eyelid especially the low eyelid area using a laser just to resurface that so really just softening some of these wrinkles and so this is a patient that traditionally about 20 years ago the only option would have been a lower eyelid blepharoplasty or a surgery but here this is about about a 45 minute hour procedure you just come and go home and you apply ointment on until the area heals and you're going to get a tightening and smoothing effect and this is a final example of a more deep resurfacing so more more involved there is going to be more downtime but you can see significant improvement in the level of wrinkling kind of around the cheek around the eyes and you'll notice she still has these as she's smiling around the eyes and so these are related to the one of the eye muscles and so this is where neuromodulators such as Botox would still be important and her management for aging face changes but you can see still how much younger this person looks compared to here given just just the treatment of the skin without any surgery so these are my references and conclusion aging occurs to all of us we get to determine what we can do about it fortunately now there are multiple options available to us and a personalized approach is essential in achieving our goals and this is our contact information and I will open the floor to questions thank you for your attention