The Most Underrated Cosmetic Procedures No One Knows About (But Should)

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey Dr. Koehler.

Dr. Koehler (00:10):
Hey Kirstin.

Kirstin (00:12):
We are talking about underrated but powerful cosmetic procedures.

Dr. Koehler (00:19):
Underrated but powerful.

Kirstin (00:22):
Yeah. Stuff people don't talk about all the time, but looks amazing.

Dr. Koehler (00:29):
Okay.

Kirstin (00:30):
Alright.

Dr. Koehler (00:31):
Alright.

Kirstin (00:32):
You down for it?

Dr. Koehler (00:33):
Sure. Fire away.

Kirstin (00:34):
Okay. Is there anything that you think should be more popular but it's not.

Dr. Koehler (00:42):
Well, I will tell you one thing. It's not surgery though, but I was talking with a friend of mine about, he was asking about some lasers and stuff like that. Anyhow, we got to talking about all the devices that we've bought over the years for various things and he said, well, of all the things in here in your office, what are you really, really glad you put money on? And what stuff wouldn't you wish was here? But anyhow, we were talking about it and I said, now this one machine right here in the corner is the MiraDry. And I'll tell you what, of all the machines that I have, this thing really works and it works pretty darn well. And yet it's not very popular. It is just not sexy, right? People are like, I don't worry about underarm sweat that much. I guess they're more concerned about other things, but man, I have to say some people do require a second or third treatment, but that's something that I think is completely just off the radar for people. But I've treated myself, I treated my son and my daughter. I'll probably end up treating my youngest son at some point. I mean, it just really works. And you don't have to use antiperspirant or if you want you can just use some deodorant, but it doesn't smell. You don't, when I work out, I have no sweat there. It's none. It's great.

Kirstin (02:07):
Most of the staff here has used it too. I mean, for the same reason. It's amazing.

Dr. Koehler (02:11):
Yeah, it ever, not surgery, but it's definitely underrated. I mean, people don't really know much about it. And yeah, I mean I think for the cost, it's completely worth it. So anyhow.

Kirstin (02:23):
Yeah. Well there's a million girls going on Instagram and TikTok saying, I got my Botox today, I got my filler today. But probably nobody wants to say, I got my underarms treated today.

Dr. Koehler (02:32):
Yeah, I got my sweaty pits treated today at Dr. Koehler's office.

Kirstin (02:36):
Yeah, but it is amazing.

Dr. Koehler (02:37):
Yeah. Alright, well, what do you got? What topics?

Kirstin (02:40):
Okay, well, what about surgery?

Dr. Koehler (02:42):
Underrated surgeries that are really powerful?

Kirstin (02:45):
Well, I'll tell you one thing that I didn't really know was a thing until I started working here was arm lifts.

Dr. Koehler (02:56):
Yeah. Well, the reason it's underrated is it's really not indicated for a lot of people because I mean, it's unlike a lot of things that we do where we can kind of hide the scar pretty well. I mean, we try to hide it, but it's to do an arm lift is a big incision on the inside of your arm. And typically we're talking about people who've lost significant amounts of weight that have loose skin. And for them, those people are very familiar with arm lifts, arm reductions.

Kirstin (03:28):
Well, let's talk about what an arm lift is. It is, I guess treatment for what we would call bat wings.

Dr. Koehler (03:37):
Yeah. I mean it's just, typically it's weight loss patients, that's your number one. And sometimes it's just old age heredity, whatever. But yeah, people have this sagging skin on the underarm and it's really getting rid of the skin and the fat. So liposuction doesn't tighten skin, so you can't liposuction the arm. Some of the nonsurgical skin tightening things like BodyTite or Renuvion they only, well in my practice and I have Renuvion it would be for a patient that is probably a borderline liposuction candidate for their arms. But if we can add something that maybe will help to tighten, tighten the skin a little bit to where we don't need to do an arm reduction, we'll use that. But it's very limited. You're not going to get, if you've got significant loose skin, you need an arm reduction or an arm lift. And that's excising the skin.

(04:40):
So you're making, there's a mini arm lift where the incision is just right in the armpit here, but it's only going to get you a little bit of skin tightening and maybe the upper third of the arm. And so for me, most people, that little mini arm lift really doesn't do a whole lot. And then the full arm lift is the incision that goes from the armpit and it goes all the way down to the elbow and the incisions on the inside of the arm. And we try to hide it kind of lower on the arm, but it's all the way across. And for people who have a lot of skin laxity, it makes a huge difference. And I enjoy doing it for patients. I mean, I had one patient, she was a school teacher, and when she came in for her consult, she goes, I know I want my arms done.

(05:31):
She goes, some people complain they want their arms done because they can't wear short sleeves. And she goes, I can't even wear long sleeves. This lady's arms were just so heavy and big that she couldn't even wear something comfortably that was long sleeves. So nevermind short sleeves. So anyhow, it can be a really rewarding procedure for the right patient. But all of the things that we talk about with surgery is like, okay, these are the potential downsides, the position of the scarring, the type of scarring. Because even a breast lift, right, there's significant scarring with a breast lift. But in the right patient, I mean, they'd take those incisions all day long to look perky and lifted and full. And so the hard part is with an arm, especially if you're in the south here, people do tend to want to wear sleeveless things. So it's, you know.

Kirstin (06:18):
Well also that batwing skin doesn't really respond well to strength training. So that's another,

Dr. Koehler (06:28):
It responds zero to strength training. It's skin, so you can work out all you want, but skin doesn't, skin will contract with weight loss to a certain extent. And we've talked maybe about this before, but as I've commented, I've watched that show the Biggest Loser when it was out and people losing all that weight. And I just found it very interesting because some people would lose significant amounts of weight and their skin would actually contract pretty nicely and then other people not. So that's a skin elasticity issue. It's a genetics issue, but it doesn't matter. It's not the working out that tightens the skin. The skin is the skin, and that is, it's its own entity. So working out can improve muscle tone, which may be indirectly can make the arm look better, but there's no exercise to tighten the skin.

Kirstin (07:22):
So who is the ideal candidate for an arm lift?

Dr. Koehler (07:27):
Ideal candidate is, well, somebody who's stable weight, who most, the best candidates are typically weight loss patients that have under arm laxity, that goes from the elbow to the armpit, and they're willing to accept that scar. Some people, they have laxity that extends down onto the forearm and you can extend the incision onto there, but then it becomes really visible. So typically we don't. So yeah, I mean that would be your ideal candidate. Healthy, non-smoker smoking for that, if you take your fingers and you pinch the skin in your inner arm, it is some of the thinnest skin on the body. It's very, very thin. And when we are closing that, there's just not a lot of deep layers of closure there. So typically with things like tummy tuck, we have deeper sutures that take tension off of the superficial skin, like off of just the skin.

(08:24):
So it's not just a skin closure, but depending on how you do your arm reduction, sometimes there are no deep sutures. And so anyhow, the point is is that the skin, you can tighten it and you have to be careful how much you tighten it. If you overtighten, it can break down and you can end up with a wound or a scar that's not very desirable. And so you have to find that nice balance. I know everybody wants perfectly tight arms, but as a surgeon you've got to kind of find, based off of their skin quality and stuff like that. What's the optimum amount of tightening that I can do for that patient?

Kirstin (09:04):
What is recovery like for an arm lift?

Dr. Koehler (09:09):
I don't think it's that bad. I mean, what we tell people is there is a sensory nerve that runs on the inside of the arm and it can commonly get injured and it can result in numbness to your forearm, but it's not painful. But you could have temporary or permanent numbness, but you can have that with tummy tuck and other things too. So we are in the area of sensory nerves, but the motor nerves, the nerves that move your hand, you move your arm, those are deeper and not involved. So the recovery, pain wise, I'd say we're looking at a week or less, but I just saw a patient of mine that I did an arm reduction on. She looked fantastic, but still a fair bit of swelling and some swelling in her forearms really, because she's wearing the ace wraps around her arms, and so that kind of pushes the swelling or you have that swelling on the distal part of the arm. So it takes four to six weeks for things to be looking really good. But yeah, no, she looked great at a week, no bruising, everything was looking great. So I mean, I think a week's time is probably typical, but it's going to be six weeks before you can start exercising, doing more significant things.

Kirstin (10:23):
Okay. What about a brow lift?

Dr. Koehler (10:27):
What about it?

Kirstin (10:29):
Well, I feel like it's underrated. People come in saying, I want a facelift. I want a facelift. But really,

Dr. Koehler (10:36):
Well, the problem is what people think a facelift means a brow lift. That's the problem. That's the thing that we're always trying to educate people is that I think a lot of the general public just associates the term facelift, meaning you're going to do everything on my face and fix it, and that's just not true. A facelift is incisions that sort of go around the ear and under the chin and it will address primarily jawline, neckline. And if you're doing a deep plane facelift, well, you'll probably also get a little improvement in the cheek as well. But it doesn't do anything for your brow. It doesn't do anything for your eyelids. And so those are additional procedures, but a brow lift is very commonly paired with a facelift because as the face descends, a lot of times the brow descends. So we've talked about it before when you want the carpet and the curtains to match. So you got to sometimes do both.

Kirstin (11:37):
Well, what if somebody is nervous about looking overdone? Is that a thing?

Dr. Koehler (11:43):
It is a thing, but it's not based off of the number of procedures. So I remember I gave an interview for a magazine one time, and I was talking about this subject, and it was, I think sometimes if I told you that I was going to do surgery tomorrow and I'm going to do a brow lift, upper and lower eyelids with CO2 laser skin resurfacing, fat grafting, a lip lift and a lower face and neck lift, you might go, oh my gosh, that's just too much. That person's going to look over done. It's not the number of procedures that you do. It's like the extent that you carry those procedures, and in fact, you could actually look more natural by doing more procedures than trying to do too much with one procedure. So as I was joking about the carpet and the curtains, but if you get the neck and jawline looking really good, but they've got bags under their eyes and they've got a droopy brow and everything else, now all of a sudden the lower face looks a lot more youthful and it really doesn't match the upper face.

(12:54):
And so where people look unnatural is when, okay, I've had patients say this to me too, it's like they want a face lift, get it as tight as you can do it. And I'm like, no, that's not what we want to do. I mean, we want to get it repositioned as naturally as we can to give the maximum improvement without making you look pulled and overdone. And so those brow lifts and other things, adding that does not necessarily make you look unnatural. It's we're not trying to pull your brows to the ceiling. We're just trying to give, and so sometimes if we're only going, okay, we're moving the brow two millimeters, well, you might go, well, that's not very much. But sometimes it doesn't take much. We're only trying to give a person a refreshed or youthful look. We're not trying to make it go, oh yeah, she had a brow lift. Unless that's the goal, but I don't want that.

Kirstin (13:49):
Yeah. Okay. Well, what about, this is one that I don't really see too often, but chin augmentations.

Dr. Koehler (14:02):
Well, that's one that I think chin augmentations are great, typically.

Kirstin (14:10):
I have a chin right here.

Dr. Koehler (14:11):
Yeah, there you go. Is that yours? Are we doing it next week?

Kirstin (14:15):
No, that's not mine. That's for an upcoming case.

Dr. Koehler (14:19):
Okay, alright. No, I mean I think chins are great. So a lot of times when people come in for a rhinoplasty consult, a chin is often talked about. And the reason is, is when people are disliking their profile with their nose. So this is typically someone that comes in and let's say they've got a large hump on their nose and they feel like their nose looks too big for their face. The surgeon will often check and at the proportions of the chin, because sometimes the nose, yes, they may have a hump and all that stuff, but the nose may in and of itself not look too big for the face. It's just that if the chin is not proportion enough and giving enough projection, the weak chin makes the nose even look that much bigger.

(15:11):
And so we're trying to get things in balance. So a lot of times in rhinoplasty consults, that's when a surgeon might go, oh, have you ever thought about a chin? And one thing I want to comment is that, well, at least for me personally, if a patient comes in and they come and they ask me about their nose, unless I feel like the chin is really weak and they're going to really benefit from it, I really don't bring that up. I mean, we're not in the business of picking people apart and going, oh hey, your chin's not in the ideal position and you should go here.

(15:45):
I think a lot of surgeons are really that way. But when your surgeon brings up another procedure, sometimes it's not just because trying to pad their wallet, they're like, oh, in order for me to get the kind of result I need to get you, we need to combine some procedures here. So anyhow, that's when getting other opinions is important and you make sure you're doing the right thing. But a lot of times when they explain it to you and show you it makes total sense. But yeah, chin implant's nice, little incision under the chin, you can, they come in different sizes and different styles. And the great part about it is it's like, okay, well let's say you got it done and you're just like, you know what? I just can't get used to this new look. I really don't like it. I mean, it's not a big deal to take it out. It's reversible for the most part. It's a lot bigger discussion there. But yeah, chin implants, they're made of solid silicone, they're safe. They've been around for a long time, and it's a pretty easy recovery really.

Kirstin (16:53):
I think it's really funny that you said something about facial balancing because that's a huge buzzword right now. And I know you don't watch TikTok or Instagram reels or whatever, but all the nurse injectors are talking about facial balancing with filler, and you do real facial balancing with surgery. I love it.

Dr. Koehler (17:14):
Well, don't get me on the topic of facial balancing with filler, but I will say that,

Kirstin (17:23):
But chins.

Dr. Koehler (17:24):
Yeah, chins. But okay. Well, so let me give you an example. I've had people come and ask me, can you put filler in my chin and augment my chin with filler? I'm like, well, I can. But that implant that you've got in that box is probably, if I was to weigh it, it's probably about five grams or something. Like it's probably about five milliliters worth of chin implant in there. Which means each one of those syringes of filler is one milliliter, which means it would take me five syringes of filler to augment the chin in the same way that that chin implant is. And when you figure out the cost of five syringes of filler, and by the way, it's temporary, that's where, to me it doesn't make much sense. But anyhow, I'm not anti filler. I just feel like sometimes, I mean, if somebody's really not sure, okay, if that's what they want to try, it's their money. But I just don't feel like we should be squirting syringe after syringe of filler throughout people's faces. But anyhow, another topic.

Kirstin (18:30):
Especially if you're talking about cost, because you're right, I knew that's what you were going to say. The cost of a chin augmentation compared to filler is kind of amazing. So anyways.

Dr. Koehler (18:41):
Yeah. So I mean, you pretty much could get a chin implant for the cost of doing all that filler.

Kirstin (18:45):
Yeah, for real. Okay. Well, how about lip lifts?

Dr. Koehler (18:52):
Yeah, lip lifts. It's an old technique. It's the old staghorn lip lift. Now it's termed other things like it's the cupid lift and other things that changed the name. But the lift has been around for a long time. But there's definitely been some changes to the way that procedure's done. The incision's the same, but some of the technical things are a little different, which has made it a better operation, I think. Basically the incision is right under the nose, and as we age, our lip gets longer and the amount of vermilion, the pink part of the lip that we show is less. And sometimes people come in and go, well, can you make my lips more full with filler? And what they don't like is after they had the filler, the other lips are bigger, but it's just like their lip just got pushed forward and they didn't get any more pink part of the lip showing, which is really what they were wanting to have.

(19:54):
And part of that has to do with how the lip expands when you put the filler in. And it's just hard to increase that vertical length of the lip or the pink part of the lip. But when you remove skin and roll this up, it actually gives more of the pink part to be displayed. And so like I said, as we age, the upper lip lengthens. And so in somebody who doesn't show maybe any tooth at rest and they've got no upper lip, you can do this little procedure and it can be very powerful and give somebody a much more youthful look. Scar placement and incision placement and all that surgical technique is really important to get a good result because that scar is in a potentially visible place right up under your nose. But aside from that, I think it's a good technique.

Kirstin (20:52):
Okay. What's recovery like?

Dr. Koehler (20:57):
It looks really good in a week. It may still have some swelling to the upper lip, but it looks pretty good in a week. Stitches are coming out, I dunno, I'd say after a couple of weeks, people wouldn't even really know you had anything done.

Kirstin (21:12):
So, two weeks back on Instagram.

Dr. Koehler (21:14):
Oh yeah.

Kirstin (21:15):
Back in front of the camera.

Dr. Koehler (21:16):
Yeah. I mean, you have to cover the incision up with makeup. It takes time, right? For scars to mature and heal. But if it's been closed really well and everything else, I mean, it's not terribly noticeable after a couple of weeks.

Kirstin (21:27):
Okay. Well the next thing we're going to talk about is otoplasty or ear pinning.

Dr. Koehler (21:33):
Yeah. Love that operation. I mean, it's fun. I mean, for people who have very prominent ears, they have their ears instead of being back, they're sticking out to the side like this. And I think we may have talked about it before, but that's the only cosmetic surgery we really do on kids. And we do typically try to do 'em when they go to kindergarten or before they go to first grade. So we're looking around five, six years old because kids are terrible. And we'd really try to prefer that they not get teased about their ears. And usually the parents are the ones that are bringing these kids in because they themselves or a parent or somebody they know. It's typically the parent maybe didn't even get it fixed, but they dealt with it their whole life and they're like, I'm not having my kid go through this. So it's a very straightforward operation. The children take Tylenol afterwards. They don't take narcotic medicine. My adult patients all take narcotics, but, they're wimpier, but the kids are strong. The kids seem to do well with it. But yeah, the ears typically are looking pretty good in a week, maybe a couple weeks.

(22:55):
Yeah, it's a nice little reshaping procedure for the ear.

Kirstin (22:58):
It's the best surgery I feel like as far as people being so surprised and happy with their results at first.

Dr. Koehler (23:04):
The reason I feel like that operation carries more excitement than other things. So if it's your breasts, if it's your tummy, whatever, you might've had a good tummy, you might've had good breasts at one point in your life, but then you had kids and now, but you can cover it up. So it's like, yeah, you're aware of it, of it, but nobody else may really kind of know to the extent of what you're concerned about. Same thing with your face. At one point your face was young and then it got older, and yeah, you don't like how you've got sagging skin under your neck, but you have pictures of yourself and you remember yourself looking like, oh, it was gorgeous back then, or whatever, but now you want it fixed. But the thing about ears is they've dealt with it their whole lives. And so cosmetic surgery, I gave a talk at the high school for my son's high school one time, and I was saying how, in a way, there's some negative stigma with cosmetic surgery because people think, oh, well, you're just not happy with yourself and you should be happy with yourself and you shouldn't have to change anything and all this kind of stuff.

(24:17):
And I said, well, that can be, obviously there are people that carry this to an extreme, they've got bigger issues. But I said, a lot of my patients like, okay, if I said you had a cleft lip and you were born with a cleft lip, there's plenty of people that live their whole lives with a cleft lip in other third world countries. Like you can still eat and you can survive and it doesn't look good. Your speech is impaired, but you can live. And so looking more normal with a cleft lip or a cleft palate is a big deal. And I say to people, if somebody's ears are sticking out like this, and we took 50 other kids from that class, I mean, probably nobody else is going to have ears that stick out like that. And so these people are just trying to look normal. Not perfect, but normal. So anyhow, I think that's why the ear patients are so excited because they've dealt with it their whole lives. They've never felt normal. Whereas all the other cosmetic surgeries now with breasts, like I said, they can hide it. So it's not, even if you didn't have breasts your whole life, you can wear a padded bra and kind of make it look like that anyhow. I know you didn't want to hear all that, but that's what you get.

Kirstin (25:30):
I always get more than I bargain for with you.

Dr. Koehler (25:31):
Yeah, whatever.

Kirstin (25:34):
Okay. What about buccal fat?

Dr. Koehler (25:37):
Buccal fat? So I'm kind of so-so on buckle fat. I mean, yes, it's okay. I do recommend it for some patients, but it's not something that I think is an underrated, we should be doing more buccal fat pad removal.

Kirstin (25:57):
It's got to be the right candidate.

Dr. Koehler (25:59):
Yeah. Your buccal fat's there for a reason, and it really has to be the right candidate. And so people, they want to have that more slender look to their face, and in some cases taking it out can be helpful. Or some older patients, they have jowling, but some of the jowl is actually contributed by buccal fat. That's kind of herniated out a little bit too. So we have to sometimes remove that. But there's no question that as we get older, we lose fat volume in our face. And so taking out buccal fat pad on a younger patient might look good at that point in time, but years down the road, they may really look sunken in and not good. So it's not just the immediate that we're looking at maybe the long term. And so, I dunno, a lot of my surgical friends, I mean all of us do buccal fat pad removal. It's not like it's a procedure we don't like. It's just you got to do it on the right person. And so it's not like it's an underrated procedure we should be doing more. I think it's a good procedure, but just patient selection is important.

Kirstin (26:57):
All right. Next thing that's underrated that we're going to talk about is the skinny BBL.

Dr. Koehler (27:03):
Sure.

Kirstin (27:04):
Not a full blown BBL. Just a little subtle fat transfer to the butt. Yeah. Have people asking for that these days?

Dr. Koehler (27:14):
Yeah, we get some of that. I mean, I don't see tons of BBL patients. I mean, yeah, we do them regularly. I don't want to make it sound like we don't do them, but it's not our most common procedure. Yeah. The skinny BBL is, I actually prefer that the goal is just to improve shape, not necessarily to give a large buttocks. If you want to just improve the shape, yeah, that's actually really nice. Sometimes people don't have ideal shape, and so placing strategic fat in certain areas and removing fat in others can really improve the shape. And that looks really good. And so, yeah, to me, that's a better goal for surgery than I want it as big as you can get it or whatever. I don't see much of that anymore. Most people are wanting improvement in shape, and some people are wanting more fullness, but they're not necessarily looking for huge.

Kirstin (28:17):
Can I talk about mine?

Dr. Koehler (28:19):
Sure. Go ahead.

Kirstin (28:21):
Whenever anybody asks me if my butt's real, I always say, yeah, my butt was given to me by my mother, but Dr. Koehler just made it a little bit better. That's true.

Dr. Koehler (28:32):
Yeah. Well.

Kirstin (28:33):
I mean, it was good butt. You just made it a little better.

Dr. Koehler (28:36):
Yeah. Well, again, that's the goal, right? It's shape. And sometimes it's extremely subtle things. Extremely subtle.

Kirstin (28:47):
Okay. Well, can you pair a skinny BBL with lipo somewhere else to get that cinched effect that we keep seeing all over Instagram?

Dr. Koehler (28:56):
Yes. We pair wine with cheese. We do that all the time.

Kirstin (29:00):
We like snatched around here.

Dr. Koehler (29:02):
Well, I mean, you have to get the fat from somewhere. So you're going to be doing liposuction in addition to BBL.

Kirstin (29:10):
Yep. Okay. Is that all?

Dr. Koehler (29:14):
That's all I got. Unless you have more questions?

Kirstin (29:18):
I don't have anymore. I don't have any more procedures to talk about.

Dr. Koehler (29:21):
Okay. Nothing else that's underrated that we overlooked?

Kirstin (29:25):
Everything is highly rated.

Dr. Koehler (29:30):
Good. As long as it's G rated. We're good. Good.

Kirstin (29:34):
All right. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks for doc. Ah.

Dr. Koehler (29:47):
Thanks for what?

Kirstin (29:49):
Go back to Making Alabama beautiful.

Dr. Koehler (29:51):
Alright. Bye.

Announcer (29:54):
Got a question for Dr. Koehler? Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and 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 Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.