The Best Cosmetic Procedures You’ve Never Heard Of

Announcer (00:02):
You're listening to Alabama the Beautiful.

Kirstin (00:05):
I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeons, Dr. James Koehler and Dr. Vincent Gardner. Do you want to know what we're talking about today?

Dr. Koehler (00:13):
Please let me know.

Kirstin (00:15):
All right. Everyone's debating Ozempic face and filler fatigue, but some of the highest satisfaction procedures in cosmetic surgery are ones that everybody's probably never Googled. Let's first talk about the bigger picture and why underrated matters. So first I'll ask Dr. Koehler, what are the procedures that you're genuinely excited to recommend? Where you know the patient is going to be thrilled, but nobody's really talking about it.

Dr. Koehler (00:46):
I don't know. I guess it really depends on the circumstance. Each treatment plan is individual, and it's really hard to predict what is going to thrill a patient. I've been surprised many times before from sometimes we can do a small thing and it makes a huge difference to the patient. And other times we do a major transformation and they're like, "Yeah, I like it. " But you think they should be doing cartwheels. So I don't know. It depends. Underrated procedures though, is that what you were wanting to talk about? I don't know. What do you have in mind?

Kirstin (01:23):
Well, I was kind of thinking procedures that stay under the radar. For example, everybody knows about a BBL, but we've learned from Dr. Gardner that a lot of patients would really benefit from an auto augmentation. Or there's certain procedures in the spa that we might do that aren't super talked about, like MiraDry.

Dr. Gardner (01:44):
Well, let's talk about MiraDry since you brought it up.

Kirstin (01:46):
Yeah. Okay. Let's talk about MiraDry.

Dr. Gardner (01:48):
I mean, if you're somebody that suffers with excessive sweating, underarm sweating, let's talk about the procedure. How many times does it take to ... And first off, what is the procedure? So MiraDry, explain the procedure.

Dr. Koehler (02:05):
Basically, we anesthetize the armpit area and then the device uses ... Basically, it's a radiation to kill the sweat glands and microwave energy to kill that. And an added benefit is you're going to have some hair loss there as well. So for those people who are wanting to do hair reduction in the underarm area, there also is going to be some certain degree of hair reduction. For guys, that may not be a big concern. And you'll lose some hair in the underarm area, but it's not going to be all gone. But the big thing is you're going to get a significant ... Even with just one treatment, most people can be treated with just one session where it doesn't mean you don't sweat. It's just that it is going to give you more benefit than, let's say, what you could get from prescription strength anteperspirant.

(02:59):
So a lot of people after one treatment don't even need to wear because you're not going to have the odor. And what little sweat you have is not going to be significant. And so I've personally had it done and some days I forget. Out of habit, I've put on deodorant, but I don't even need to do that. I go to the gym, I work out, my shirt will be soaking wet, but my underarms are dry. And it's great. Especially for people, I'd say from a man's perspective, if you have to wear a suit, a shirt and tie, and you're having to, maybe it's public speaking, maybe you're an attorney or in a court or something like that, but you are not going to sweat. And it's great to not have your dress shirts soak and wet. And I think it's a great ... That is definitely, as far as underrated procedures, it's not surgery, but it's definitely underrated.

(03:54):
It's not, again, the most popular thing because that's just not something that is at the top of people's heads to think about, "Oh, I really want to get my underarms treated." The people that seek it out are typically people that have really overactive underarmpit sweat. And that's what it was FDA approved for, which is hyperhidrosis for those people that abnormally sweat. But we get people saying, "Well, is it a bad thing if you don't sweat, your body's not going to be able to cool and all this kind of stuff." And it's just not true. Only less than 1% of your body cooling comes from underarm sweat and it's not significant.

Kirstin (04:31):
Yeah, you still sweat in other places.

Dr. Koehler (04:33):
Yeah. But the glands that produce that smelly underarm smell, those are eliminated. And so even though you may sweat, you don't have the odor. And so that's what's really nice about the MiraDry.

Dr. Gardner (04:48):
Well, I think that's interesting because I hadn't really thought about it in the sense that if you ... I thought it was obviously it's FDA approved for hyperhidrosis, but the average person, if you want to prevent pit stains and having underarm sweating when you're working out, that sort of thing, that's a big advantage that I think a lot more people would probably do it if they really thought about it and said, "Hey, this may be an option for me. " The other thing that when you compare it to the alternative, getting Botox shots in your armpit is quite expensive because of the amount of Botox you have to use and you're going to have to do it every three months. And like you said, the other alternative is using special deodorants and antiperspirants that may or may not be as effective.

Dr. Koehler (05:41):
Yeah. So I did, before this device came out, what was really kind of popular as around weddings, we would have the bride or maybe the mother of the bride would come in to get their underarms injected with Botox. And it works because like, oh, nobody wants to have these women. They don't want to be in their dress at their wedding and have sweaty arms, armpits. So it works great. But like you said, I mean, you have to use about 50 units of Botox, 50, 5-0 per side, some people more, but that's about average, is about 50 units per side to treat it. And it does work and it does probably last long. It lasts longer than three months for the purposes of sweating, but it's not something that ... I never have seen a person that continues to do it. Typically, the people that do it is like, "I've got a big event, I want to not have sweaty underarms." And when you look at the cost, it's really not that much more expensive to do mirror dry, which gives you a permanent result compared to doing Botox, which is a temporary result.

Kirstin (06:44):
MiraDry is one and a half treatments of underarm Botox cost-wise.

Dr. Koehler (06:50):
There you go. There you go.

Kirstin (06:51):
So if you've got a wedding and Mardi Gras, that already paid for your MiraDy.

Dr. Gardner (06:58):
Okay. So quick question about the MiraDry. People that have hyperhidrosis

Kirstin (07:03):
No.

Dr. Gardner (07:03):
of the hands. Okay.

Dr. Koehler (07:04):
Not yet.

Kirstin (07:05):
Only FDA approved for the underarms.

Dr. Koehler (07:08):
Yeah, only in other arms currently. Yeah. But I've been hearing talk about that it may be other areas in the future, but for right now, that's all that it is FDA approved for. And that's all that we use it for.

Dr. Gardner (07:19):
All right. Last thing I'm going to say, there's a movie where, and I can't remember who the actress is, but she talks about this family that lives in their crawlspace because they were born without sweat glands.

Kirstin (07:34):
What?

Dr. Koehler (07:34):
Okay.

Dr. Gardner (07:35):
Yeah. I'll figure it out. I'll let you know next time.

Kirstin (07:37):
Oh, so they can't sweat?

Dr. Gardner (07:40):
Yeah. So they sleep in the crawlspace because it's cooler.

Kirstin (07:43):
Oh, man. Okay. Well, the only thing I was going to mention about Mary Dry is the recovery's super easy. It's non-invasive treatment. Your armpits are swollen for just a couple of days and that's because of the anesthetic and that's it. It's not bad at all. So anyways. Okay. Next thing we're going to talk about is the lip lift. The tagline is your lips have a waistline.

Dr. Koehler (08:09):
Okay.

Kirstin (08:10):
Okay. So for a lip augmentation, lip filler is everyone's first thought, obviously. How do you bring up a lip lift when the patient came in asking for filler?

Dr. Koehler (08:21):
Well, it depends on the circumstance because sometimes lip filler is a fine option, but there's a difference between what ... I mean, there has to be a discussion of what the goal is. Okay? So let's start with a younger patient. If it's a younger patient and they're just wanting more fullness to their lips, then filler is a fine option. But if we've got, let's say an older patient, let's say somebody 65 years of age or older. The interesting thing for me, when I see a patient in their 60s and they come in asking for filler, if you really dig deep into why they want filler, it's usually one of two reasons that they want filler. One is they think it will help with the fine lines around the vertical lines around their mouth, which it may help a little bit, but they don't like the vertical lines around their mouth.

(09:08):
And the second thing is that they just want to have more display of the pink portion of their lip. Okay? They're not necessarily wanting bigger lips. It's just that when they put lipstick on, it doesn't really show because they don't really have much of an upper lip anymore. So filler doesn't really address those two things really well. It can help, but a lot of times in these older patients that have really no upper lip, when you put that filler in, you've all seen these people where instead of it giving them more display to the pink portion of the lip, it just pushes the lip outward. And so then it just looks like a duct bill and it doesn't look good. So when you get into that discussion with those patients, that's where the advantage of a lip lift comes in is that what it does, it doesn't make your lips any bigger and it also doesn't really affect those vertical lines.

(10:03):
That's microneedling, laser resurfacing, something else. But to increase the vermilion display and whatnot, we have to just remove a section of the skin up underneath the nose and lift the lip upward. And so yeah, it gives more display to the upper lip. And of course, this has been studied, but as we age, it's known that our upper lip lengthens with age. And so if your lip is too long, you just are basically shortening that vertical height with a lip lift.

Kirstin (10:36):
Okay. What about scarring? If a patient is nervous about having scars on their face from surgery?

Dr. Koehler (10:43):
Well, I mean, it's a discussion. Unfortunately, we can't predict how scars are going to heal. Typically in older patients, these scars tend to heal actually pretty well. I'd be more concerned about doing this procedure on a younger patient. I think scarring sometimes on younger people, it can sometimes look more obvious, but age is not really the relevant thing. It has to be closed nicely. There's lots of things that we do at the procedure to try to minimize scarring, but it is in a visible area, like it's right in the center of your face. But when that scar heals, I mean, I have patients that you can't even see those scars. So nobody has the crystal ball, but a well done procedure in a patient that typically heals well, usually the scar is insignificant. And or worst case scenario, a minimal amount of makeup can cover that up.

Kirstin (11:37):
I'm never scared of scars because we got all kinds of stuff for that. All kinds. All kinds of people. The next thing that we're going to talk about is otoplasty. Underrated.

Dr. Koehler (11:52):
Well, maybe.

Kirstin (11:53):
Unless you've had one.

Dr. Koehler (11:56):
No, I haven't had one of those, but I mean, we've talked about otoplasty before on one of our shows here, but definitely one of my ... I love doing that operation. It's the only cosmetic surgery that we do on young kids. And this is an operation that if we do it, like a lot of times we're trying to do it between kindergarten and first grade, or at least in those early formative years before kids start teasing them and then they start to have the stigma and feeling self-conscious about their ears. So it's a nice operation. It's a pretty straightforward, quick operation. And this is where we're not ... I sometimes have to, I don't want to say correct people. I've been in group discussions where people are like, "Oh, that just seems like you shouldn't do that to your child and this and that. " And I'm like, look, these are not parents that are looking for a perfect child.

(12:50):
The reason they're doing it for their children is because their ears are outside of what we would consider normal. And all they want is a normal ... They don't want their kid to be teased. And I tell them, actually, quite frankly, a lot of the parents that had their kids get it done, they were teased as a child and wished they would have had the operation done. So that's why they're bringing their child in. And then of course, I do it on adults that even out there like, "I've wanted to do this my whole entire life. It's driven me crazy, but now I'm an adult. I can afford to pay for this and I want it done." So yeah, I wouldn't say it's an underrated procedure. It's an excellent operation. It's just not common. Most people's ears are sort of within normal realm, but yeah, if your ears stick out too much or they're too prominent or you don't have the proper creases in your ears to make them look normal, we can fix that.

(13:38):
The other thing I'll say is that a lot of the surgery for ears is kind of slowly disappearing because now they have these ear molding devices that they can do on these young kids. And so if you catch these ears at a really young age, like when they're infants, they just put these little ear molds on and it just reshapes the ear as it grows and you can avoid surgery altogether. And so I think you're going to see with the pediatricians being much more aware and understanding that this is a cosmetic concern and there is something that can be done. And again, people, it's not like seeking the perfect child, it's just keeping the ears within what we consider a normal range.

Kirstin (14:24):
All right. How about cheek augmentation?

Dr. Koehler (14:28):
What about it?

Kirstin (14:29):
Well, people are realizing that filler isn't always the answer for the mid-face. So when is the time when people need structure versus just volume?

Dr. Koehler (14:39):
This also really hits upon what the goal is. Okay. So I just had a patient in today that said they wanted filler in their cheek because they know they didn't say this part, but I know this is where it comes from. It comes from TikTok or Instagram or whatever. And I've heard these injectors say this that, "Oh, you put filler in your cheek and it's just going to lift." It's going to lift your face and lift your jowls. And I'm like, "It does not, not do that. " It might give the illusion that your face is more lifted because when we're youthful and in our younger ages, when we're young, the cheek is fuller and this volume is higher. And then as we age, the Malar fat pad descends and then it becomes a little flatter in the cheek area and the fold becomes more prominent because the cheek is settled or the fat pad has descended.

(15:36):
So it doesn't lift anything, but if you add that fullness and that volume there, then it can look more youthful provided you don't overdo it. Now, a cheek implant does not really lift anything either. It just provides some volume, but it's predictable and you don't have to repeat it. And so that's the nice part about a cheek implant. So if the issue is the patient needs volume, then if it's a little bit of volume, filler is nice. And also if you're not really sure if you're going to like it or not, do filler because it's temporary. But if you've done filler and you're like, "I really do like more volume in my cheeks and I don't really want to ... I'm getting injection fatigue and I don't want to keep getting injected." Cheek implant might be an option. Now, there's pros and cons to the cheek implants, just like breast implants and everything else.

(16:28):
These are solid silicone implants. Typically, there's other materials that are used as well, but they're typically made of solid silicone. They're usually, they're put in typically through the mouth. The mouth is not a clean place. So they are, of all the implants that we do, they probably carry one of the higher rates of infection compared to chin implants, which also can be put in through the mouth, but a lot of times are put in through an incision underneath. They are held in place with a little titanium screw, and it's important that they're secured because of the location and you don't want them to rotate or move. So it's a little bit more involved than let's say a chin implant, but it is a nice long-term procedure if you need volume, and especially if you need a lot of volume. So a syringe of filler is only one milliliter, and to put that into perspective, that means five syringes, five syringes of filler would be one teaspoon.

(17:21):
So if you're thinking about augmenting your cheek, even if I said, "Hey, we're going to put one teaspoon of filler here and one teaspoon of filler here," that's 10 syringes of filler, okay? I mean, go home and look at a teaspoon. It's not very much. So if you need a lot of volume, a cheek implant is the better choice, or fat grafting, and then fat is also not as predictable. So depends on, there's options for everybody. I like cheek implants in the right circumstance. I think fat is nice in a lot of circumstances just because it's not going to be rejected typically, but it's not as predictable and you may have to do more sessions.

Kirstin (18:01):
You've led me to my next segment. Okay, because you mentioned fat transfer, and we're going to start doing a segment called Get Off My Lawn, which was introduced last year. Dr. Koehler did a whole episode on things like keep it or get off my lawn, like the grumpy old man he is. So today, both of y'all are grumpy old men and going to tell me when it comes to fat transfer to the lips, is it a keep it we love it or get off my lawn.

Dr. Koehler (18:33):
Get off my lawn.

Dr. Gardner (18:34):
Get off my lawn.

Kirstin (18:35):
You both agree.

Dr. Koehler (18:36):
Well, I did a study on this in 2002 at the University of Alabama in Birmingham and I looked at fat grafting in the lips and we really weren't doing fat grafting hardly any differently back in 2002 than what is being done now. I mean, Sydney Coleman and that whole micro droplet fat technique, that was all out even then. Probably the only difference now with fat grafting is maybe now people are trying to enhance the fat take by adding things like platelet-rich plasma or other things to help get the fat to take better. But bottom line is, is you'd put fat in the lips. The nice thing about fat is that it felt natural, it didn't feel firm like filler, but the lips typically swelled up a lot after you put the fat in, the whole procedure, their lips would get particularly swollen. Usually by about three weeks or four weeks, people absolutely love them, but then by six months, most people felt like their fat was completely gone.

(19:37):
And so we'd like to say that it's a more permanent solution, but in my experience with doing it, certainly with one session of fat grafting, most people visually, the fat looked like it was all gone by six months in almost every single person that had it done. So you're looking at multiple sessions of fat grafting. A lot of people don't want to go through that whole surgical type ... You can be done under sedation or even local, but it's a lot more involved than just coming in and getting some filler injected and leaving. So yeah, get off my lawn.

Kirstin (20:11):
You agree, Dr. Gardner?

Dr. Gardner (20:12):
I agree. I mean, I've done it a few times and the same result. People are unhappy. Long term it doesn't stay and they feel like they wasted the effort.

Kirstin (20:23):
All right. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you.

Dr. Gardner (20:35):
And before we finish, it was Doc Hollywood where the family was born with no sweat glands and they all slept under the house.

Kirstin (20:44):
Doc Hollywood. Is that your movie recommendation for the week?

Dr. Gardner (20:48):
That's a great movie, actually. It's Michael J. Fox. It's a great movie. Old, but good movie.

Kirstin (20:55):
All right. Thanks, Dr. Koehler and Dr. Gardner.

Dr. Gardner (20:58):
Thank you.

Kirstin (21:00):
Go back to making Alabama beautiful.

Dr. Koehler (21:01):
All right. We're going to do that.

Announcer (21:06):
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.