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Welcome to Listen to your Skin by Moon and Skin, the podcast where science meets nature to celebrate the story of your skin.
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Your skin is a living canvas, ever evolving, deeply personal and uniquely yours.
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Each week, we'll dive into the science of healthy skin, share empowering stories and uncover transformative self-care rituals.
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We're here to help you embrace every phase of your journey with confidence and care.
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Hi everyone, welcome to this week's episode of Listen to your Skin podcast by Moon and Skin.
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I'm your host, dr Jen Haley, and this week I have one of my dear friends, dr Brenda Lutowski, on the episode.
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She is my go-to person for all of my dermatology needs and especially my aesthetic needs.
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So, dr Lutowski, she is another board-certified dermatologist.
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She practices here in Scottsdale, arizona, and she is the founder of Clear Dermatology and Aesthetic Center, which has grown since I have arrived here.
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She has places all over the valley and she's been providing patients comprehensive, expert dermatological care for over 12 years.
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She's also founded InvestigateMD, which is a clinical research company that has conducted over 75 dermatological clinical trials and has helped with the FDA approval and clearance of many dermatology drugs, technologies and devices that have improved care for millions of patients, and she's always on the cutting edge of everything that have improved care for millions of patients, and she's always on the cutting edge of everything.
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And also she has formed Clear Vanity, a mobile dermatology service providing luxury skincare anywhere.
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And not only is she board certified in dermatology, but she also completed a laser and cosmetic fellowship with skincare physicians in Boston, massachusetts.
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So, based on this, she should be like 100 years old, but she's not.
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Hi.
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Brenda, welcome, you are too kind.
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Thank you so much.
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Thank you for having me Jen yeah, I love having you.
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So you've been on my other podcast and we've talked about so many things, things that we've seen come and go over the years, and we often talk about cutting edge procedures and I want to break it down today on simple things Botox, other neuromodulators, because these things are.
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We use the term Botox like we would use the word Kleenex or a Band-Aid or Q-tip, but there's other neuromodulators out there.
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What does Botox do?
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What do fillers do?
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Neuromodulators out there Like, what does Botox do?
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What do fillers do and when are each indicated to help someone with, like, the building of the house, of the rejuvenation of their face?
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If you can just start with, like how you approach someone who comes into you for a cosmetic consultation, like if I'm a person that comes into you today and I don't know anything about what I can do for my skin and I want to look refreshed and younger, like where do I even start?
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That is a great question and I think it's very important to ask, because there are so many things out there that we can do and the rate limiting step tends to be patient's time, patient's budget, and so to your point, I think it's good to have a starting place.
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I usually ask patients when they're coming into the office where do you want to start?
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What are your priorities?
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And I have them show me their priorities and then we go from there and I can add in simple suggestions as they request.
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But really starting with what's bugging them will get us started.
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In terms of neuromodulators, you're right.
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There used to only be Botox for decades and now we have several more.
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I think it's up to five FDA-approved neuromodulators, with many more in the pipeline, by the way.
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So you're right, and it's a common question what's the difference between Botox and all the other menu out there?
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We use Botox.
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Botox, in fact, prohibits nerve signaling, so we use Botox to temporarily weaken the muscles that are creasing the skin.
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So, for instance, 11s, forehead lines, crow's feet those are the areas that we use Botox more commonly.
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However, we can also use it on the lower face, and right now platysma is really big because Botox did just get an FDA indication for treating the platysma.
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So those are the areas we tend to use Botox and neuromodulators.
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Fillers, however, can be used to support the skin and the face, to build the house back up instead of letting it crumble down.
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So we tend to use fillers to support the cheeks, to lift the cheeks, to support the jawline and to pull the jawline tight, and nowadays the sky's the limit.
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We can go on and treat the neck off the face off the neck and so on, but usually we're starting with the face and going from there.
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Right.
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So with Botox, I always think of it as your weakening muscles that form lines.
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So today is day one.
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So what's the why?
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Why is someone coming into the office?
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And if they have something in two days from now, that's really just enough time to form a bruise and not really get results.
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You're right for now, although there is in the works a very short acting neuromodulator that will probably be FDA approved here in another few years, but you're right.
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So usually with neuromodulators they are kicking in in three to seven days, and some of them can kick in a day or two faster.
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So, any events, someone has that is a decision maker when it comes to choosing a neuromodulator, right.
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Yeah, I think it's important for people to realize that we're weakening muscles, we're not freezing them.
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We're weakening muscles that form lines.
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So there's no solutions, there's just trade-offs, right?
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So are we willing to compromise the movement of the muscle to make the line go away?
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I think in the frown area, most people are willing to lose you know that fierce, heavy pulling down of the eyebrow in order to get rid of the 11 lines.
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Now, when we're talking around the mouth and other areas of the face, even the platysmal bands, I mean, like Pilates, can be hard if you do too much, right?
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So we're trading off, there's trade-offs in all of this.
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So a lot of times, people will have forehead lines that they don't like.
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Well, if you weaken the muscle that pulls up the brow, especially as we get older and we lose bone and we lose fat from the face, now we're getting a heavier brow, so we might not have any lines, but we iron out the area and now the look of a heavy, angry baboon look isn't really what we want at the end of the day.
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So that's the conversations I think that we want to have about the pros and the cons of all of these.
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Absolutely, and that's why Botox is really such an art.
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It's really not a cookie cutter approach, and these are conversations we have to have in the office.
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In addition, a lot of people don't like that really frozen look anymore.
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That was something that was done way back in the days, as you recall, when we were first doing Botox.
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Nowadays it's more of an art.
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So we're, just as you said, weakening the muscles and we're preserving a lot of the expression.
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A lot of patients want to be able to raise their eyebrows.
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Some patients actually do want to be able to frown Judges, psychiatrists, counselors, et counselors, etc.
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They want to be able to frown a little bit to show some empathy for for those and they're dealing with in their careers.
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So really, it starts with the consultation and education and finding out the patient's preferences right and what their goals are, because if you even just weaken the muscles a little bit, you can still have a frown, but not enough to have a deep crease.
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Exactly, exactly.
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That's the beauty of it.
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So I know it was so different in the 90s, before it was even FDA approved, we would put 40 units here and that's what caused the spock, because everything was so imbalanced in the face and to your point.
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When you lose the micro expressions, the reason I always ask what's the why behind why we do these things?
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Ultimately, at the end of the day, the reason why we want to look better and show up better and be more successful is so we can connect better with people.
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And if we're doing anything to inhibit connection with other people, we're not doing a good job.
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As a dermatologist, and if we get rid of our micro-expressions and I say I'm happy to see you, like you don't feel that I have to be able to raise my brow, so you know I'm happy to see you right, because we do communicate through microexpressions.
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And I think that's where people have gotten so polarized with Botox and other neuromodulators is that we've seen so much bad Botox out there that it can be done very nicely as an art form.
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Yes, exactly, and that is.
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It's funny.
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You said that that is a conversation I sometimes have to sit down and have with patients, because sometimes they come in and they say, well, I can still raise my eyebrows, the Botox didn't work.
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And I have to explain to them no, we actually want you to be able to raise your eyebrows.
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The goal is not to be frozen.
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The goal is not to make deep wrinkles your eyebrows.
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The goal is not to be frozen.
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The goal is not to make deep wrinkles.
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And same thing with the smile lines, like you mentioned.
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The goal is to have lines when you're smiling, but not have them be deep and not have them form permanent creases that are there even when you're not smiling.
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So, 100% agree, it's really an art and sometimes it takes a little extra education to let the patients know what our goals are.
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Right Do?
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you think that?
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How old do you think people can start doing these procedures?
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You are going to.
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Some people in your audience are going to think I'm crazy, but I would say early to mid-20s is completely acceptable, again in contrast to what we saw when we were doing Botox decades ago Decades ago, I probably would have said 40s, 50s whenever someone's forming the creases.
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But Botox is actually preventative.
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So when we're doing Botox, we're preventing the creases from forming, and when we prevent the creases from forming, the skin also looks better.
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There's less wear and tear on the skin.
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So you have two improvements.
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Number one the wrinkles aren't forming.
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Number two, less wear and tear on the skin.
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And so, even if someone's just doing like a little baby dose of Botox or they're not doing it as frequently, it's nice to start that prevention early on.
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Just like anything in medicine, the earlier the better.
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I kind of agree.
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How old were you when you started?
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I was in residency.
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It's all a blur, but I do remember getting Botox before my wedding in residency.
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But nowadays I wish I would have started early.
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So were you in your twenties?
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I was in my late twenties yes, yeah, I was 29 on stage with Dr Neil Sadick and he's like, wow, you have the strongest muscles.
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And I said, oh, I went to Catholic school.
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You have always had such a great wit.
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I just love that.
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I'm not sure if I would have been able to do it for the first time on stage, but I did.
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Well, yes, okay.
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In that case, the answer is yes, you know, when you're a starving resident, you'll do anything for free.
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You'll do anything.
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Yes, looking back, I did do it for the first time before my wedding, so that was pretty brave, I think.
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Right, you don't have to do a lot when you're younger.
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It's not the way I look at it.
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I look at daily cost average.
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If you're coming in three times, maybe four times, a year, how often actually do you recommend people do these procedures?
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Because there's different products out there Feel free to name different products.
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How often do most people need to?
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Have it done.
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I generally give a blanket statement of three to four times a year initially, but that's just to set a patient's expectations.
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Everyone is different and people have different preferences and so, for instance, those who are doing Botox as more preventative they don't have lines yet.
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They may be on limited budgets because they're very young.
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They may have limited time because they're very busy with their early careers have limited time because they're very busy with their early careers we may decide twice a year and twice a year is certainly better than not doing it, because that's half the year you're actually not forming those lines.
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And then you also have that other time where the skin is still soft and supple, it's recovered from that wear and tear, and so at an early stage that's an acceptable time frame.
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As we go on in life, the skin loses elasticity, it loses collagen, it becomes a little less forgiving when the Botox wears off.
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So I do find after a certain point maybe somewhere in the early 40s I'm sorry, early 50s or 60s patients are feeling like they really have to come back every three or four months.
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We can alter the dose a little bit to make the Botox last longer.
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So I have some patients who are very time conscious.
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Or, for instance, there was a woman who unfortunately had to go through six months of chemotherapy and she said I am not going to be able to come back, but I don't want to have wrinkles during this chemotherapy, I just need to do something for myself.
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And so we did an increased dose and she was thrilled and in fact she got beyond the chemotherapy.
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But she came back and said do that exact same dose because I love the way it lasted.
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So three to four months is a good starting point.
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But again, this is an art and that's what makes it so fun it's art combined with science, exactly.
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I know.
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That's why I haven't gotten bored of it after 20 plus years, because it's different for everyone and it's different throughout their lifetime, and I'm always constantly trying to figure out how to do things.
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So at what point?
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Okay, let's take a step back, because we'll talk about off-label areas of use, if you're comfortable with that.
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So where can?
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If you could just point to your face, or you can come over and point to my face, if you want?
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What areas can people use Botox?
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And when we use the word Botox, we're talking about all of the neuromodulators, because I don't know how you feel, but I feel that it's more about who's doing the procedure than the product you're using.
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You can change the properties of the product based off of how you inject it into someone.
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If you're going to someone who's experienced, who knows what they're doing.
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I agree a hundred percent.
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The technique can vary a little bit between products and so you can adjust to each patient's needs based on the product that we have on hand to work with.
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So what we can treat on label would be the 11s or the frown lines, and that's the glabella area.
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We can also treat the frontalis or the forehead area, and those are the horizontal lines that we see.
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And we can treat the crow's feet and those are the smile lines, which, again, we talked about having smile lines when we're smiling, but maybe not so many of them when we're at rest and not smiling.
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Also, as I mentioned earlier, Botox just did get an indication to treat platysmal bands or to treat the neck, which will help with bands and also will help, in my opinion, define the jawline and let the neck drape smoother and have a more youthful effect.
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Now some areas off-label, and sometimes I feel like the sky is the limit when it comes to Botox, but some areas off-label that I typically do in the clinic would be the chin area to prevent the orange peel.
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Look, there's some muscles here called DAOs and that turns down the corners of the mouth so it gives us a frowny appearance.
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So doing the opposite.
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Applying the Botox so those muscles aren't as strong, will sometimes have an uplift in the corners.
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Treating here on the upper cutaneous lip will actually prevent lip lines and actually turn the lip outward a little bit or evert the lip, and so there will be a little bit of what people call lip flip.
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And then also we use a micro dilution of Botox, so very, very dilute Botox, and we can use that in the cheeks and that can help with excess sweating in that area and it can also help with rosacea.
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So really, really fun stuff that we can do.
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I love that.
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I love that.
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So, as we pivot into fillers, when do you recommend someone do?
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Besides the price point, when do you recommend someone do a lip flip versus filler or both?
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a lip flip versus filler or both?
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I love that question because it comes up several times a day in clinic.
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So if you throw the price out, here is my advice For patients who are new to aesthetics and or very nervous about how it's going to look.
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I think a lip flip is really great for kind of dipping your toe into slightly eversion of the lip or making the lip look a little poutier, a little bit more full, especially the upper lip.
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If they're looking for a little bit more volume, something a little bit more noticeable or a little bit longer lasting, then I recommend doing lip filler.
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And lip filler is a gel.
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It goes into the lips, it makes them plumper, and I usually tell patients the way we start is we try to make the lips look like they did three or four years ago, so we just sort of re-inflate them a little bit and it's a really, really beautiful natural look.
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So I usually start there with the patient and then we have a conversation and see where they want to go, and you can do both, by the way.
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Right, because if you can't push the muscles, the filler actually lasts longer.
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Exactly, yeah.
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So when people bring in photos, you know like there's so much out there on social media and you see the photos of bad lip filler or too much filler I think it's important for people to understand that one syringe is one-fifth of a teaspoon and one syringe usually doesn't do that.
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That's multiple, multiple sessions.
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And when someone is doing lip filler, it's very important for them to understand that you want to keep the proportions of the lip, like in a Caucasian lip it has different proportions than an African-American lip, so you always want to keep somebody's proportions correct so that we don't get those duck lips correct.
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That's absolutely correct.
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Lip filler is again an instance where this is such an art, but it's art and science, so we don't want to go and just treat willy-nilly.
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We want to be thinking about what we're doing and be intentional with what we're doing.
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So, yes, the dreaded photo that patients bring in with them.
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I actually stopped writing the photo because I do think it's a way of communication and for so.
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Sometimes patient doesn't know how to communicate their wants with me, so I can often draw out what they're looking for with a photo.
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But some of the challenges of photos are that we don't really change the shape of the lip with lip filler, and so I always have to tell a patient you might love the way her lip shape is, but we're actually going to keep your lip shape and we're just going to enhance it so you like it better as well.
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So that's one thing.
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The second thing is when you do see an overfilled lip.
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A lot of times in clinic I will sit down with a patient and tell them that my style is actually conservative and my goal is to keep them looking as conservative as possible, and unfortunately it's sometimes easy to go too far.
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So there are often times where I have to tell the patients this is enough filler, you don't need it today.
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Maybe we can talk about another area on your face that we can put some filler in.
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Yeah, it's interesting.
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Over the years, like when Restylane was the first product that came out, we would see all of the marketing of the nose and down and we would just see the nasolabial folds or the marionettes filled.
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And now we look at the face so much more differently.
00:20:47.740 --> 00:20:51.731
We look at it as like the global effect, sort of like what we did with Botox.
00:20:51.731 --> 00:21:00.116
We addressed those 11s, really heavy, but then the muscles around it would give the Spock look and we weren't looking at balance and proportion in the face.
00:21:00.116 --> 00:21:05.907
And now it's all about balance, proportion, bringing out your best asset and not throwing off that balance, right.
00:21:06.048 --> 00:21:11.442
So when should someone start looking at filler versus Botox?
00:21:11.442 --> 00:21:17.702
When is Botox going to stop being the tool for, you know, building as part of the house?
00:21:17.702 --> 00:21:20.479
And when should they look at filler?
00:21:20.479 --> 00:21:25.159
Because one of the areas I see is when they have the forehead.
00:21:25.159 --> 00:21:30.099
You know, like the forehead lines, and more Botox is just going to lower the brow.
00:21:30.099 --> 00:21:34.461
But we also don't really have filler in the forehead that we want to use safely.
00:21:34.461 --> 00:21:37.859
So how do you do a little bit of this and a little bit of that?
00:21:39.152 --> 00:21:39.996
I love that question.
00:21:39.996 --> 00:22:03.442
It is so important to look at the overall face and right now I really believe it's a great time to be in aesthetics because there are so many things we can do and we actually are making people look the best they actually can, in contrast to the early days where we were just effacing these nasolabial folds and it didn't necessarily look super natural in every single case.
00:22:03.442 --> 00:22:12.243
The beauty of someone who is consistent with their neuromodulator meaning they're coming in every three to four months.
00:22:12.243 --> 00:22:43.894
We have these frequent conversations in that maybe a patient has started noticing the apples of their cheeks have flattened out and they will mention it to me during our Botox visit and because of that I can address options with them that may not include neuromodulator, it may include some filler, and then we can talk about what filler can do and what Botox can do and the contrast between them.
00:22:44.634 --> 00:22:49.022
Also, it's very common for someone to really focus on an area.
00:22:49.022 --> 00:23:08.459
So, for instance, if someone comes in and they have deep glabellar lines or deep frown lines and they don't want to treat their forehead because maybe they have bangs at the time or maybe they don't bother them, I will eventually, once I have their trust, talk to them about sort of blending our results.
00:23:08.459 --> 00:23:39.301
So again, not focusing on one area but thinking of the face as being a global area, because it will look funny if someone has a completely smooth crease but they have deep forehead lines or smooth forehead but very deep crow's feet, and so that's an area where an expert can kind of gently guide someone and respect their wishes but also keep them looking as beautiful and as naturally striking as possible.
00:23:40.083 --> 00:23:47.760
Okay, so what's the difference between filler and biostimulatory or collagen stimulating products?
00:23:48.903 --> 00:24:01.093
Filler is a gel and most fillers are made out of hyaluronic acid gel, so that's something that's found naturally in our own skin and it as you know, and it will go in and look so smooth and so beautiful.
00:24:01.093 --> 00:24:25.270
Biostimulators are things that stimulate collagen and there is some overlap between the two, because doing filler will stimulate a little bit of collagen and there's a biostimulator called Radiesse that has some filler properties to it, so there's some overlap and, again, a lot of this is really nice to talk about in a specific consultation with patient.
00:24:25.270 --> 00:24:41.386
But what's great about the biostimulators are they stimulate collagen and therefore they last longer, and oftentimes because of that, we're thinking of it in a more global sense of the face, versus just spot treating an area.
00:24:48.471 --> 00:24:56.498
Many times I'm using filler to spot, treat, biostimulator to treat the whole face and the filler you get more of an immediate response and the biostimulatory a little bit, and then over three to six months you form more collagen.
00:24:56.979 --> 00:24:58.502
Exactly, that's exactly it.
00:24:58.502 --> 00:25:09.978
So that could also be a decision maker um instant gratification versus waiting a little bit for the gratification but having that to last longer.
00:25:10.219 --> 00:25:18.714
I feel like it's so nice to do both at the same time, because you're getting a little bit of result, but not enough for everyone around you to say what happened to you.
00:25:18.714 --> 00:25:21.823
And then, over three to six months, you slowly look a little bit better.
00:25:22.671 --> 00:25:25.179
I think that's the ideal scenario.
00:25:25.179 --> 00:25:31.705
The instant gratification really helps patients say, hey, I made this investment, I'm so happy I did.
00:25:31.705 --> 00:25:33.432
I immediately feel refreshed.
00:25:33.432 --> 00:25:41.958
But I personally love the feeling of every day I'm waking up a little bit better and looking a little bit younger than I did yesterday.
00:25:41.958 --> 00:25:44.412
That's a great thing about the biosimulators.
00:25:44.412 --> 00:25:51.814
They will not only peak at six months, but I believe that you get a little bit of benefit even beyond that, right.
00:25:52.615 --> 00:26:03.991
Okay, so let's talk about well, let's first talk about locations of where people can look at doing fillers and biostimulators, because I don't think that people are even aware of all of the locations.
00:26:03.991 --> 00:26:08.972
Can you just kind of talk about some of the places you've done it, whether it's on-label or off-label?
00:26:09.353 --> 00:26:12.419
Sure, let's start from the top and go down.
00:26:12.419 --> 00:26:21.829
So, um, the temples are a really common area for us to treat because what happens is, over time they get hollow.
00:26:21.829 --> 00:26:33.201
We may not notice they're getting hollow, but as they're getting hollow it's letting the eyelid skin sag down because it's not providing as much support as we used to have.
00:26:33.201 --> 00:26:44.500
And that's really the key, both with biostimulators and with fillers, really trying to put support back to where it used to be so the skin can drape as beautifully as it used to.
00:26:44.500 --> 00:26:58.326
So when we put filler or a biostimulator into the temple it will round out the upper face, which preserves the youthful proportions of the face, and then it will lift the eyes a little bit.
00:26:58.326 --> 00:26:59.990
So it's one of my favorite places.
00:26:59.990 --> 00:27:08.790
Moving down, we can absolutely put filler in the cheekbones, the outer cheekbones, and what that will do.
00:27:08.790 --> 00:27:16.776
It will pull from whatever volume loss the patient has had on the side of their cheek or around their jawline.
00:27:16.776 --> 00:27:25.438
So it will pull and put everything up and we can continue the filler in towards the middle of the cheek.
