I am thrilled today to connect with my friend and colleague, Dr. Elizabeth Chance, who is double board-certified as a facial plastic surgeon and a reconstructive surgeon.
Dr. Chance has dedicated her career to the art and science of esthetic surgery. In our conversation today, we dive into skin aging and reframe the aging process. We explain how we lose 30% of our collagen in the first five years of menopause and an added 2.1% in each following year. We explore the impact of supplements and collagen peptides, looking at the listener concerns, like scar revisions, under-eye wrinkles, neck laxity, and topical skincare, and the benefits of estrogen-specific interventions like neuromodulators, hyaluronic acid biostimulants, and resurfacing lasers.
You will love this enlightening conversation with Dr. Elizabeth Chance.
IN THIS EPISODE YOU WILL LEARN:
Skin changes that occur during menopause
Why early preventative measures are essential
How genetics and ethnicity impact skin aging
What are the benefits of collagen supplements?
Dr. Chance outlines her approach to treating old scars and discusses the complexities of treating under-eye wrinkles
How antioxidants, retinoids, and sunscreen help maintain skin quality
How minimally invasive treatments improve skin laxity
The importance of continuing skincare down to the neck and chest
The benefits of topical estrogen in postmenopausal and perimenopausal skincare
How to determine the depth and know which areas to avoid with CO2 laser treatments
The importance of setting realistic expectations for treatment outcomes
“I think of under-eye wrinkles as something we need to improve but probably will never eradicate.”
-Dr. Elizabeth Chance
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Connect with Dr. Elizabeth Chance
Transcript:
Cynthia Thurlow: [00:00:01] Welcome to Everyday Wellness podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:28] Today, I had the honor of connecting with friend and colleague Dr. Elizabeth Chance. She is a double board-certified facial plastic and reconstructive surgeon and has dedicated her career to the art and science of aesthetic surgery.
[00:00:43] Today, we spoke about the role of skin aging and how to reframe the aging process, how we lose 30% of collagen in the first five years of menopause, an additional 2.1% every year thereafter, the impact of supplements and collagen peptides, specific concerns expressed by listeners including [00:01:15] unitelligible GAR revisions, undereye wrinkles, neck laxity, the impact of topical skin care including estrogen, specific interventions like neuromodulators, hyaluronic acid, biostimulants, resurfacing lasers, and more. I know you will find this conversation invaluable.
[00:01:27] Welcome Dr. Chance, such a pleasure to reconnect with you. I feel like you are just a wealth of information and I know so many in the Everyday Wellness Community will really get quite a bit out of our conversation. I would love to think about how to explain to women anatomically, physiologically, what is changing in our skin in the perimenopause and in the menopause transition. What are the things that you both as a double board-certified ENT and also a facial plastic surgeon, what are the things that you're thinking about proactively, preventatively when you're meeting with patients and talking to them?
Dr. Elizabeth Chance: [00:02:05] So, obviously as a surgeon I'm a fixer, but so much of what I talk about is the prevention of facial aging. So, if you look at the actual histologic things that happen with menopause, if you look at your skin, the vast majority of the components of the skin are type I and type III collagen. So, those two types of collagens in the skin decrease significantly starting in menopause. So, if we look at menopausal data, we're looking at those early 50s as a classic, like you're heading into it in your 40s. I think average now is 51, but it could be coming down with time.
[00:02:45] And, and so what you're seeing is because of the reduced levels of estrogen derivatives in the skin, you've got a collagen reduction of about 30% in those first five years that then continues to decline over the next 15. So, it is really, really, really important that we talk about prevention and optimization strategies as early as the first time we're seeing patients. A lot of precocious 20-year-olds are talking about baby Botox and preventative things, but when those people come to our office, we do a lot of reframing with them of what are the most important things you can do for your skin now to see the best possible outcomes as you age into perimenopause, menopause and beyond. Because the decrease in collagen really underlies the dermal thinning, the fine lines and wrinkling.
[00:03:36] And we know that HRT may reverse or change some of these and improve dermal thickening. But we also know that a lot of our preventative measures, starting from excellent skin care, sunscreen, retinoids, judicious use of low downtime lasers, and really focusing on the more holistic aspect of what you're eating, what's going in your body, how you're sleeping, how you're treating yourself, oftentimes have these long stretching improvements that you can have that don't really require a whole lot of procedural medicine to happen. So, there's a pretty significant change around menopause that can be honestly, incredibly hard emotionally for women just to see this rapid onset aging. So, a lot of what we talk about is ahead of time, how we slow that trajectory down.
Cynthia Thurlow: [00:04:25] What do you think about the role of genetics and ethnicity? I'm sure that you probably see a wide range of women that come to you, and I know you work predominantly with women. I know that I have friends of like every ethnic group that I can think of, and we don't all age the same way. And I think some of it's beyond just the lifestyle piece.
Dr. Elizabeth Chance: [00:04:47] Oh, absolutely. I mean, I think we know from experience that different ethnicities often have different experiences with their skin texture, skin tone, and elasticity over time. I'll take, for example, the Asian ethnicity where you see their Fitzpatrick type IV-- like the Fitzpatrick type scale is one that tells you how much pigment you have and how skin responds to sun. So, it's a way within plastic surgery and dermatology that we categorize these patients to figure out what things we can do to their skin that will be successful. So that caramel beautiful skin is prone towards hyperpigmentation, prone towards inflammation.
[00:05:26] And we see a different aging trajectory than say Irish skin and African-American skin have darker pigmentation because it is deep with melanocytes and has such a sun protective factor to itself that it tends to have a thicker dermis, a thicker epidermis, and much, much more resilient skin, more sebum. There's just a whole component of different aspects of skin that confer different aging trajectories and oftentimes confer a different rate of you being in my operating room. Also, I will tell you there is a component across all those different ethnic backgrounds of hypermobility or hyper-elasticity to skin. I see it a lot in my Italian population, some in my Asian, some in my Caucasian. But those listening to this podcast who have this type of skin will know like it's almost hyper-distensible.
[00:06:18] And I think that's a whole thing in of itself where people find their way to my operating room early just because they're seeing an accelerated path of aging that's very different than their peers that are in their same ethnic background. So, there's a whole subset of that, that's different than everything else. But we definitely see across ethnicities, many different patterns of aging, particularly those around thickness of skin, resilience to sun damage, resilience to wrinkles that changes across all the different colors and all the different ethnic backgrounds that we have.
Cynthia Thurlow: [00:06:53] I remember during my training, I had the most amazing woman that I worked with, and she was African-American and she was probably the best tech I ever worked with in the ER. And she looked at me one day, I'd been a nurse for probably six months. And she said, “Today's my last day.” And I looked at her, “I said, are you working at another hospital?” And she said, “No, I'm 70 years old.” And I said, “You've got to be kidding me.” And she said, “Cynthia, one thing you will realize over time is that African Americans do not age the same way that you all do. I'm sorry to tell you that if you haven't already realized this. And this is me in my 20s.” And she was the most amazing, dynamic, vivacious, wonderful woman.
[00:07:30] And that was really like my first exposure because in my 20s I wasn't even thinking about aging. Whereas I think for most women, maybe they get into their mid-30s, early-40s, and they start noticing these changes. But I never forgot Mary. Mary was wonderful. And hopefully Mary is still living a vibrant, happy, healthy life. But when we're talking about the aging process, you mentioned this 30% reduction in collagen in the first five years of menopause, which is quite significant. And I think the other statistic I read was it decreases by an additional 2.1% every year after that.
Dr. Elizabeth Chance: [00:08:04] Every year after that.
Cynthia Thurlow: [00:08:04] You're really at this collagen disadvantage. Do you find that taking oral collagen, collagen peptides are such a popular supplement at this point in time. Do you feel like they really make a difference or do you feel like—[crosstalk]
Dr. Elizabeth Chance: [00:08:21] So, I did a deep dive into this about four or five years ago because I had a patient who was just a researcher and she kept asking me about different types of supplements and different collagen supplements and how the gastric contents break them down and what the pH stability of these different pills were. And so, I did probably in 2000, I would say 17 to 18, a pretty deep dive into this. I read 75 different studies and actually there's some pretty good evidence that taking collagen, even though if you think about it, you take a pill, it gets down to your stomach, I don't care what it's packaged in, it's going to be kind of cooked to pH of 3.5 to 4.
[00:09:02] But it's somehow the components of that because you're giving your body some level of amino acid, you're giving it the building blocks to help the collagen in your skin. And honestly, I'm at the age where at 44, almost 45, I am willing to throw the kitchen sink at it. And if it's just a supplement that I put in my coffee every morning, I use vital proteins, the marine based collagen. I put it in my coffee every morning, I don't taste it. I'm willing to do something that has basically only a positive and no negative if it's going to help any.
[00:09:34] But I was amazed by the number of biopsy studies, like studies where they had someone taking collagen, waited a commitment certain amount of time and did biopsy studies on people that were and weren't taking it that showed an improvement in the collagen content of the skin. So, there's got to be some special sauce in oral collagen. And I do think it matters which one you take and what brand you take because as you know, in the supplement world there's a variety pack and you can get high quality-stuff and low-quality stuff and have different outcomes. We talk to our patients about it and I personally do also take it. I think there's some special sauce to it.
Cynthia Thurlow: [00:10:11] Yeah, I think it's an easy way, provided it's interesting. Certainly, some of the women that end up in our programs are very oxalate sensitive. And so, for some individuals, whether it's a histamine sensitivity or oxalate sensitivity, helping them understand, maybe it's something you take a couple days a week. Maybe it's something that, if you can remember to take it, I do think that benefits from supplemental collagen. And I found anecdotally, a lot of my female patients feel like it helps with joints, that they have less joint discomfort. And let's be fair, women in that perimenopause to menopause transition, that loss of estrogen, fluctuations in estrogen can definitely impact how our joints feel. Thankfully, that's not my issue, but I do take collagen every day myself.
[00:10:58] Now, one of the things I asked my community was what are some of their specific concerns, biggest pain points? I think before we started recording, we were talking about, when we had our first children and I had two C-sections and so, scars came up. People were talking about whether it's been surgeries, you wanted to have or surgeries, you didn't want to have, what are your thoughts and what is your approach to scars that are not fresh, scars that maybe are a few years old, maybe something that bothers someone. What is your general prevailing philosophy around scar treatment?
Dr. Elizabeth Chance: [00:11:33] So, I obviously see a lot of older scars from patients that are getting revision facelifts with me. I'm going to be removing them during surgery. But I have that discussion with a lot of patients who are then showing me a C-section scar or showing me a scar from a carpal tunnel surgery or something that doesn't quite look how they want it to look. So, there's a dropdown menu based on what the scar looks like, how far out from surgery it is, and also does it have any component of, say, a hypertrophic scar. Does it have any component of a keloid that could be making it look untoward? So that what that means is it raised? Is it red? Is it extending beyond the border of the given area where the incision was made?
[00:12:17] Is it a scar that has healed abnormally due to inflammation? So that is a whole different category of itself. If it's just a scar that was sutured under tension, it's wide, it's white, and it looks just, it's in a bad place and doesn't look great. Oftentimes really there's very little to do topically or with silicone that can help. And we're looking at revising that, making an incision, cutting that entire widened area out and remaking it in a very aesthetically pleasing way. Because scars are a combination of multiple different variables. You've got how does your skin scar like, what is your type of scar that you're going to make with your skin?
[00:13:01] For example, my favorite scars are the collagen depleted, 80-year-old female or male that I used to do all the skin cancer reconstructions on because they literally have almost no inflammatory response. And so, you can't find the scars, they literally don't exist versus, you have a 15-year-old that has a scar on their face from a fall and it's pink for years, oftentimes inversely happens. The more collagen you can make, the worse the scar looks. You're old and collagen depleted and mature female, your scar looks so much better. But closing a scar under tension where the edges are pulled apart is probably the thing that most of your readers have experienced. And so, they've just got a wide, unhappy looking scar. And that's usually a scar revision and just making that line cleaner.
[00:13:48] We do have a pretty rigorous program for patients who have facelift scars about how we deal with them that can apply to other people's scarring. So, what I would say is 100% medical silicone cream that you apply twice a day during that 12-to-16-week period where the scar is a little bit pink during that vascular phase. You can microneedle it at the time, you can treat it with a broad-based light or an intense pulse light to take the pink out. And then as you get past that phase, you start using topical Retin-A on the scar. And that will induce your body to make collagen within the scar and to get it to fade because it's pushing down the pigment-containing components of your skin.
[00:14:29] And then the final thing that we do is CO2 laser, which is an ablative laser which disrupts the scars appearance so that it basically washes it away. So, there's a multistep thing to get the best out of a scar. The older the scar, the harder it is to modulate with any of these treatments. And oftentimes, we may be looking at an additional surgery to get it to look good.
Cynthia Thurlow: [00:14:53] Yeah, I love that you have this multifaceted approach. And I think for many people, I think about my younger son, fell and fractured both his arms, had an open reduction internal fixation of both of his arm bones about six years ago. And to this day, probably because he's still growing, he's 17. He scars are not particularly faded. Even though it's been such a long period of time, it doesn't bother him at all. Thankfully, he's a boy and to him he looks at it as has battle wounds. But it makes a good point that his are much more noticeable given the age and stage that he's in versus if that, God forbid, were to happen to an older family member, it would be completely different on every level. [crosstalk]
Dr. Elizabeth Chance: [00:15:33] Oh for sure.
Cynthia Thurlow: [00:15:34] They would not recover nearly as well and probably would have less of a scar. What is your philosophy around. These were the biggest pain points. Number one were scars. Number two were undereye wrinkles. And I would say the average woman listening to this podcast is North of 35, but could be in the upwards of 60s and 70s, so pretty wide range universally irrespective of age. Those undereye wrinkles, which can be related to a myriad of different reasons are a huge pain point. And I think that the one thing that I have learned, and I know we'll get to talking about more formal interventions, is that you have to use, even using products and Botox or neuromodulators, you have to use very carefully and judiciously in this area of the face. So, what are your thoughts on undereye wrinkles? It wasn't specified whether they were significant or just fine lines. What is your philosophy? Yeah.
Dr. Elizabeth Chance: [00:16:29] All right, so are you ready for my opus? Because this is how I talk to every patient about it.
[laughter]
Cynthia Thurlow: [00:16:35] I love that.
Dr. Elizabeth Chance: [00:16:36] Sit back, sit back and take it in. Okay, so undereye wrinkles are a pain in the behind to almost every person. This is not exclusive to women. This is everything. And what we found is the reason for that is cheek elevation. So, every time you smile, you're tensing this muscle upwards, causing a wrinkling effect to happen under the eyes. What that means is because you've got a dynamic area here, surgery, which oftentimes fix static areas but doesn't always treat dynamic areas, isn't always the fix for it. And so there is a multivariate approach to how we treat or improve undereye wrinkles, knowing that you are never going to be completely smooth unless you have so much Botox piled in there that when you go to smile, you look like a sinister character from a movie.
[laughter]
[00:17:31] And I will tell you, I am a surgeon, surgeon, right? I love operating. I love the effects that I can get and the transformations I can get. But the older I get, the more I appreciate some of the signs of age, some of the signs of wisdom, and some of the signs of the years that you've earned and the lessons you've learned. And so, I think of undereye wrinkles as something that we need to improve but probably will never eradicate. So, let's go from that point and go back to the beginning. When you're in your 20s and 30s, probably one of the best things you can invest in is a high-quality eye cream. Whether it has tretinoin, caffeine, some of the collagen stimulating things. The lower eyelid skin is the thinnest skin in your body, upper and lower eyelid. I mean, it is gossamer thin.
[00:18:12] And so, doing things that help your body stimulate collagen from a topical standpoint are very important. One of the probably least expensive but highest quality for over the counter is Roche-Posay actually makes a topical cream for the lower eyelids. That's one I send a lot of people to and then medical grade lower eyelid creams and upper eyelid creams. The eyelids are both this area and this area are really helpful and are a twice-a-day thing. When you are looking at this skin, there's a lot of other components that you can see, bluishness, pigmentation, hollowness under the eyes. All those things oftentimes have a component of blood vessels seeing the muscle layer underneath.
[00:18:56] Nasal inflammation, you can have a puff that goes up and down throughout the day depending on your venous congestion there. The under eye is very, very, very reflective of your overall health. So, it is also where, when we see 20- and 30-year-olds, we talk about. If you're somebody who's seeing some gluten sensitivity, if you're somebody who's seeing some dairy sensitivity, the lower eyelids are literally like an indicator strip for how healthy you are. And so, I can tell you if I showed you a picture from 10 years ago versus today at almost 45, my lower eyelids look better than they ever have, not because of intervention. I've never put a filler in it, I've never lasered it. I very sparingly Botox it. I use eye cream twice a day. It's because I came off of dairy seven years ago.
[00:19:41] So, there's a component of your overall general health and what you're taking into your body that makes a difference specifically in your lower eyelids. All right, so my 20- and 30-year-olds, we're talking a cream for the lower eyelids twice a day, plus or minus, using some kind of a topical retinoid to thicken. And if you start to see static, fixed wrinkles, meaning that slight line in the skin, you want to sparingly use a little bit of botox or neurotox in those lines. Two to four units, four to six units, never more than something that's going to inhibit your normal movement. This is a very, very small muscle group. It is going to cook through those doses. So, you're going to start seeing movement back at like 8 to 10 weeks. So, it's not going to be that Botox treatment that lasts for four months. That's a figment of people's imaginations. So, for about 8 to 10 weeks, you'll have a little bit of relief from those and then it will come back. So that's one that will require coming back into your injector's office three to four times a year to keep those at bay.
[00:20:40] As you're moving into your 30s and 40s and you are not in a surgical territory, things that really, really help the lower eyelid are laser resurfacing. What is laser resurfacing? Laser is like the word Xerox or Kleenex. It's just a big word for a lot of different things. The specific laser I'm talking about for the lower eyelids that in my hands I find most beneficial is the fractionated CO2 laser. So, what it's doing is it's poking lots of little holes in the skin using thermal, using heat, and then the body is contracting and putting collagen back into the skin through resurfacing heat. What you'll do is you'll see over four to six months, an improvement in the collagen content, an improvement in the thickness and an improvement in the resilience of that lower eyelid skin, super-duper-duper important.
[00:21:32] It is a low downtime procedure. Once you have it done, you're pink and swollen for a couple days. You have to stay out of the sun for two to three months. But in my hands, I think that's probably one of the best things we could do for women for that lower eyelid skin and typically, we're CO2 lasering a patient once a year, maybe once every other year. So, it's not something you're going to be doing all of the time. You will continue to do the cream twice a day, episodically put Botox in if those fine lines are bothering you. But that's kind of your 30s to 40s into your 50s playbook. If those wrinkles then turn into excess skin, then we're looking at a different surgery. So, as the female face ages, the lower eyelid is the canary in the coal mine. Oftentimes, you'll start to see the upper and the lower eyelid age as your first thing that you're seeing your face aging in its late 30s, early 40s.
[00:22:25] And the reason why we know that is women will report a lot of times how people say, you look angrier, you look tired. And that's oftentimes because we're seeing that lower eyelid aging, which gives off an appearance of being tired or being sad because of the hollowing and the aging changes that happen. So, at that point, we're deciding, are you someone who is a surgical candidate to help with excess skin under the lower eyelids, or are you someone who needs volume under the lower eyelids in order to support their function? I'm going to draw back here for just one second and say that the concepts around how we treat the lower eyelid in 2024 have dramatically changed from how we even treated them in 2022. So, this is new information. So, if your injector is not telling you this, just know that the information is percolating out there. I think more and more that we're moving away from some treatments that we were previously recommending. So, this is best practice for 2024, in my opinion.
[00:23:28] And that is, I do not believe that hyaluronic acid fillers should be placed under the eye. Typically, when someone was aging even two or three years ago, if a patient came into my office and they had hollows and hyperdynamic folds around their eyes, I would be offering them a Restylane product under their eyes and a little Botox to the corner of their eyes, and it would be a beautiful improvement. Their lower eyelids would look healthy and supple and full or fuller or flush, and they would improve the appearance. But now what we know is the function of the muscle under your eye is way more important than the look of what's under your eye.
[00:24:10] The function is compromised as filler is attracted to the muscle layer, and it gets in the muscle layer, causing it not to work as well, causing you to have weird swelling under your eyes as that pump that it helps, the lymphatic pump that muscle helps under your eye is compromised because filler's in there. And so, we have now seen after 10 years of using filler under the eye, lots and lots of functional consequences of that. So, if you came to my practice today, and again, everybody has different opinions, but in my practice, I would not offer you hyaluronic filler under the eyes. I would steer you towards a regenerative product, one of the platelet derived products, like we have easy gel here in the practice, which is a fibrin gel that's made from your own blood.
[00:24:58] Is it as effective and long lasting as semi-permanent hyaluronic acid filler? No, it is not. But it is not going to compromise your lymphatics, it is not going to get stuck in your muscle around your eye and it's not going to have any downstream negative consequences. So, if you're in that 40s to 50s range and you're looking at your lower eyelids and you're thinking, “Gosh, this is not what I want them to look like,” lasering a little bit of Botox and adding a little bit of component of volume here with a non-hyaluronic acid product, I think is your gain. And then should you at some point move to having a lot of excess skin under the eyes, you can do all sorts of procedures to the lower eyelids that can improve that.
[00:25:41] None of which will keep you from being able to wrinkle your lower eyelids because you're still moving your cheek. And so, I circle back full circle to the end of this to say those lines are something that not one surgeon on this planet would tell you they'd be able to wipe away. But a lot of what we're discussing here and that I've quickly gone through can help improve the skin quality, improve the skin thickness, improve the structure of the lower eyelids so that you can get the best appearance from it that you can.
Cynthia Thurlow: [00:26:10] I think it's very helpful to understand there's a trajectory with which we can proactively look at these things and to understand that if anyone is promising you that they will get rid of all of your undereye wrinkles, that's actually not a good thing. Now I want to emphasize one point that you made about those hyaluronic acid fillers under the eye. They can disrupt the normal lymphatic flow. So, let's just briefly talk about why that's so important. And for listeners that are health care providers, they understand the role of lymphatic system, but other listeners may not. And I think that's very important. I would imagine it could exacerbate further swelling if it's disruptive of that lymphatic system.
Dr. Elizabeth Chance: [00:26:57] Oh, yeah. So, the lymphatics of the face, I think, are actually fascinating. Most of the time, if you look in the body, the lymphatics are going to run along the venous system. And, as you go about your day, fluid is coming out of your blood vessels and into your tissue. That's just the way that our body works. Our arteries beat with our heart, so they have a little bit of a distension. Fluid makes its way out of those and into your tissues and then the lymphatics pick up parts of it, the veins pick up parts of it, gets dumped back into your heart and rinse and repeat that's kind of what happens every day. In the face, the lymphatics are super, super, super important just for the cleanliness of the tissue of your face.
[00:27:38] So, you've got lymphatics running over the cheek and down the face and down the neck. Interestingly, we don't have a lot here. We have it more from the lower eyelid, comes across the malar cheek in front of the ear, and then across the jawline towards the ear and then back down the neck. And it's the reason why we have really figured out the impact of HA filler, particularly in the last four or five years, is that there was such a boom in cosmetic surgery around the time of COVID that lower eyelid surgeries were being done on repeat. And if you've had hyaluronic acid under your eye and you have a lower eyelid lift, even if you didn't remember you had it, that hyaluronic acid filler shows up in the form of prolonged swelling after surgery.
[00:28:28] Because hyaluronic acid is a sugar molecule and its target, what it does is hold water. Some fillers love water more than others. It's hydrophilic or hydrophobic are kind of the words we use. Most fillers are hydrophilic, meaning they love water, they take it in. Some are more than others. But the thing that we thought for so long, because it's what we're being told by the companies making these fillers, was that they went away. So, for example, most studies would show, when these filler companies would educate us on how to use the product, oftentimes they were looking at studies that would say they would last 6 to 12 months before your body would pick them up and bring them back and basically your macrophages would eat them up and they would go away.
[00:29:13] But what we're actually finding now that we're putting ultrasound on the tissue, we're getting MRIs, we're operating deep into the face like I do with a deep plane facelift, is we're finding filler that's 10, 15 years old, that's in its same form, that's still in the tissues. And so, because hyaluronic acid is broken down in the lymphatics, it preferentially goes to those and the molecules are so large that they're blocking lymphatic drainage. I see it every day with my facelift patients. We try to dissolve as much of the lower eyelid as possible. But when you have these discussions with some of the busiest oculoplastic surgeons in Beverly Hills or New York who all they do all day long is eyelids, they will tell you squarely and purely that even with the most effort to dissolving these with the enzymes that dissolve hyaluronic acid filler, they're still finding trace amounts in the lower eyelid, even after comprehensive dissolving.
[00:30:09] And that's the same thing I'm finding. But it's one of those things, when we look back, it's a probably a failure on multiple fronts. But I think now in 2024, most of us are trying to guide patients not by fear mongering, but just by education of this is what we're seeing, this is what's happening. Here's how I would treat your face now versus a few years ago. Because I think it's important not to point, blame anybody. I mean, I don't even think the companies really understood what was happening. But what we know now is these gels are lasting far longer than we thought.
Cynthia Thurlow: [00:30:44] Well, and I think this is also why it's so important if you choose to use filler, going to someone that's going to be judicious and conservative, knowing that these products last far longer than even the physicians or probably researchers even realized initially. And I think, one thing I've been very transparent with my community. I've had fillers. Initially, there's an acclaimed facial plastic surgeon in Northern Virginia, and I had under eye filler probably 15 years ago and I had a Tyndall effect, which I know you know what that is, but I literally look like I had blue coloring underneath my eyes. And I have a whole series of Christmas photos where I look back and I can laugh now. Yes. And said, thankfully, you can reverse that.
[00:31:29] But I think if you choose to do or proceed with fillers, just understanding that they hang around a whole lot longer than we anticipate. The kind of last area of concern that a lot of women expressed was neck laxity, which I'm sure is not unique. I mean, I think it probably happens for a lot of women, 40s, 50s, and beyond, neck laxity. So that skin laxity on the neck, what can we do about it again from a low conservative perspective all the way up to surgical intervention.
Dr. Elizabeth Chance: [00:32:03] So, for the patients or the people that follow me on my Instagram page, I use my main page for before and after primarily but on stories I post almost every day, just in my daily life, much like you do, just in the gym, out and about with my children, when I think of salient topics, that will help. And about three weeks ago, I was working out in the gym looking at this strong Platysmal band that was driving me crazy at 44, almost 45, that first bit of laxity that you start seeing. And I just hopped on stories and talked about this exact thing. And it was amazing that two to three minutes of my life that I shared was so impactful to hundreds of women that I got messages from because they were like, “Thank you.”
[00:32:50] We're too early for a facelift, but we're not too early. This tells you kind of a road map of how to do it. So, Nora Ephron wrote an autobiographical book called I Hate My Neck. And it really makes me laugh because she was spot on for when you start to see it for most Caucasian women. So, 42, 43, 44 is when the laxity first starts to show up under your chin. And I think if there's one takeaway point from all of this information that you guys have received is please don't jump the gun and think of normal things before you think of surgical intervention.
[00:33:31] Because I really will say, whether you're going through a mini-lift or a platysmaplasty or smaller procedures, or you're going for the big kit and caboodle, and you're going to have a long-lasting deep plane facelift and deep structural neck lift. Surgery is surgery, and it needs to be respected and not taken on lightly. And if anyone tries to undervalue that to you, they are not your person. So, make sure that every step of the way, you're thinking about the little things to do first before the big things. So, as you start to notice aging changes in the neck, sometimes as early as our 20s and 30s, because we're all looking down at our phones, you start to see these exaggerated necklace lines in the neck.
[00:34:14] Continuing your skin care down onto your neck is probably one of the first and most important things we can do. So that includes your antioxidant like a vitamin C, that includes your tretinoin or retinoic acid or Retin-A that comes onto your neck. And most, most, most importantly, that includes your sunscreen. So, make sure that your sun protecting the neck and the chest, they're not nearly as resilient as your facial skin because of different architecture. So, make sure you're doing a good job of covering this and staying out of that super, super strong sun if you live in very sunny parts of the world where we tend to see exaggerated photoaging at an early age. So that's number one. Number two is I'm not a super significant fan of separate neck creams.
[00:35:02] Unlike the eyelid skin, which is very, very different, the neck skin is akin enough to the facial skin that I think you can just continue your normal skin care down onto your neck. That being said, I do have a fair number of patients in their 50s to 60s that want a separate one. I actually oftentimes send them to one we don't carry at the office. I'll tell you guys, it's called revision skin care. They have something called Nectifirm that we don't carry. But I will oftentimes send to that because I think it's probably one of the better studied neck creams, but that is again a twice a day. But keeping that tretinoin going on your neck when it's going on your face at night is probably the biggest bang for your buck that you have topically for neck skin.
[00:35:43] Is that going to change the laxity? No, it is going to improve the quality of the skin but the laxity is a slow course that's going to take effect as you head towards perimenopause and menopause that it's going to be very, very, very hard to slow down. So, let's talk about the minimally invasive things that happen that you can use to improve the quality of your neck skin. So, we've got Ultherapy, Thermage, and Sofwave are all in kind of a group. They're not exactly the same mechanism, but they're called basically noninvasive tightening mechanisms. Like, for example, Ultherapy uses micro-focused ultrasound to target deeper tissues in order to stimulate collagen. All of them use slightly different things. Sofwave is just a little bit more superficial than Ultherapy.
[00:36:31] While they are helpful in stimulating collagen, they will likely only improve laxity by a very small margin while also potentially impacting the subcutaneous fat of your neck. No great study has been created on that, but that is anecdotal thing that a lot of patients tell me. We don't have any of these machines, so I can't speak to them myself. But that is if you research Ultherapy, Sofwave, Thermage as well as radio frequency microneedling are the kind of minimally invasive options for tissue tightening to help put that laxity at bay. I think the key thing for all of those is you want the most superficial expression of whether it's Morpheus, Virtue RF and, all the different types of RF microneedling that are going to put a needle in and give you a pulse of energy in order to stimulate collagen.
[00:37:20] None of these things are massively impactful in terms of the overall result, but they can be impactful if you're going to have future surgery to creating scar tissue. So, what I would advise you to do is do the least depth in all of these because you're not going to get that much of a big of a or a smaller difference than the maximal depth, but you're not going to inhibit future surgery. Also once you start seeing laxity, Botox actually can be massively helpful in the neck in order to lift the platysma. So, most of you are probably thinking that Botox is a relaxant, so how would it lift anything?
[00:37:58] When we Botox the platysma, this muscle here, in certain places, by Botoxing along the jawline and specific parts of the neck, by inhibiting this muscle and keeping the elevating muscles working, you will actually get better definition to your neck and better definition to your jawline if you have the anatomy that works for that improvement. And so that's where you find a really amazing, minimally invasive provider who can let you know if you're a candidate for Botox to help the laxity in your lower face and neck. But I myself get Botox every six months to my neck and particularly for the first three months it's like my favorite my profile looks and my favorite my jawline looks primarily because it does get rid of those mild amounts of laxity. Things that I would not do Radiesse and Sculptra in the neck.
[00:38:51] Radiesse is a calcium hydroxyapatite injectable. Sculptra is a bio-stimulant. The two of them can produce some types of collagen in the neck, but they're not going to lift anything and they are going to really get in the way of future surgery. So, if you are considering surgery as part of your journey, I would suggest sticking away from those just to make your future surgeon have a whole lot less of a high heart rate when they're operating in your neck. Other than that, those are the minimally invasive strategies that are going to help laxity. But we are not, in 2024, at a point where we have any really great solution for it, particularly if it's significant other than surgery.
[00:39:38] And I know there are millions and millions of dollars of research going into how to non-surgically or non-operatively help with neck laxity because it is a diffuse problem. Surgery is wildly effective for this. And I think that's why so many women make their way to my operating room and so many facelifts and neck lifts are done in the country at large because it is a fell swoop to really help laxity and help it for years to come.
Cynthia Thurlow: [00:40:06] I think that's so helpful. It's interesting to me. I feel like Morpheus has had a moment, meaning it seemed like for many years a lot of people were going that direction. And I've just been hearing from more and more plastic surgery friends that that is starting to fall out of favor for concerns about loss of subcutaneous tissue. So, for anyone that's listening, subcutaneous tissue although we may not enjoy it in other parts of our body and our face, it's very, very important for not looking-- [crosstalk]
Dr. Elizabeth Chance: [00:40:34] In our neck, it's as important as in the face.
Cynthia Thurlow: [00:40:37] Yeah.
Dr. Elizabeth Chance: [00:40:38] Super important in the neck.
Cynthia Thurlow: [00:40:39] Yeah.
Dr. Elizabeth Chance: [00:40:39] It's what makes your neck look youthful.
Cynthia Thurlow: [00:40:41] Yes. So important. So, we touched a little bit on skin care. I had a couple questions. What are your thoughts on topical estrogen?
Dr. Elizabeth Chance: [00:40:48] So, one of my absolute, absolute, absolute favorite beauty researchers, Jolene Edgar, just wrote a piece on this that I was lucky enough to read. And I think the data is really good. I mean, you have to think if you look at the studies of topical estrogen, that is helping for any level of postmenopausal aging. It's actually been studied for a fairly long amount of time. So, I'm surprised it's taken this long for it to somewhat become mainstream. But it looks like the data is actually pretty sound on placing topical estrogen on the skin. In fact, I think we're going to start carrying one in the office in the current throes of research about which one is the not only the best but in the most stable concoction. So, that it will be something that can be absorbed by the skin, which I think is really important.
[00:41:41] Skin care is one of those things that the vehicle of how it gets to your skin is almost important as what's in it so that it can be absorbed past the barrier of the skin. But I think the research is very, very good on increasing epidermal and dermal thickness, increasing skin collagen content. And I think a year from now it'll be a mainstay in most people's regimens for postmenopausal and perimenopausal women.
Cynthia Thurlow: [00:42:06] Now, I just started using it earlier this year and I've been noticing, I've been doing an experiment of N-of-1. I've been using topical estrogen on one hand versus the other so that I can kind of be able to demonstrate for myself because I feel like for many things like where I see aging for me personally, not just in my face but also like the skin on my hands is a very like telling area because you start losing-- like I look at my hands sometimes and I think it looks like my mom's hands. My mom's obviously 25 years older than me. But noticing that subcutaneous loss of tissue really makes a big difference. Let's briefly-- I know we touched on some of these neuromodulators, hyaluronic acid, bio-stimulants, resurfacing. I know that you talk about the use of CO2 lasers in the hands of someone that is well trained, judicious, conservative, etc., how do you determine when you're working with your patients who to use it just sparingly like under the eyes or if they need full surface resurfacing. How do you make that determination? Because that's another question we got.
Dr. Elizabeth Chance: [00:43:16] So, there are some no fly zones for CO2 laser that are very important. So, patients that aren't able to get it. It has actually a fairly small window of the color of your skin because of its mechanism, it uses heat. And so, anyone who has a caramel-colored skin all the way through a deeply pigmented skin, those colors of skin cannot have the CO2 laser because they will develop something called post-inflammatory hyperpigmentation. For anybody who's seen dark patches on the skin or melasma, it's in that same family where your body responds to the heat of the laser by really, we only use this for very white skin that would burn with sun exposure or those that would burn and then tan. So those are the two groups that typically get laser.
[00:44:10] You can do it in slightly more like that very first bit of caramel skin, both treating them with a pigment. But it's a very narrow window in terms of that about whose skin you can do it in. If the patient suffers from rosacea, 40% of Caucasian women do. It's an inflammatory condition of the skin where your skin is hyper like red and blotchy and it's very, very sensitive. You cannot have a CO2 laser until the rosacea is under good control. If patients have had Accutane within a year of treatment, they can't have CO2 laser. So, there's some definite, like, who can't have it. But if you range in who can have it, when you decide how they have it and what depth they have it, is so individualized to the provider that almost it's just like anything.
[00:45:01] I'm sure it's the same thing with functional medicine, but it's the same thing with surgery. It is so much to the experience of the provider and their own individual algorithm for what makes sense for patients that it's your treatment with me could be completely different than your treatment with someone else versus people who have tons of experience versus not. I've used the same CO2 laser for 12 years and so I'm able to really run the machine to the limits of its abilities. But it is amazing how it is just like anything. It is very, very customized in the mind of the surgeon or the provider and in their abilities to deliver a result to a patient. For me, when I look at a patient to determine whether they have their candidate for CO2 laser, I very infrequently will preemptively do a CO2 laser. I'm not a big believer in doing things to people until they need it.
[00:45:52] So, if you have baby beautiful skin and it's clear and it's gorgeous and you don't have a line on your face, someone could CO2 laser you, but that is not me. I need the risk reward ratio to match right up. So, you have to have fine lines, wrinkles, some brown pigmentation, freckling, age spots that I want to treat. Kind of a sallowness or a loss of luster to the skin. Those are my patients that fit in the criteria of who I would like to laser. And if someone is most bothered by their lower eyelids, face, their brows, their lips, but their lower eyelids are their priority, I don't feel like I need to force them into lasering their whole face.
[00:46:30] I think it's so important what bothers you rather than what bothers me. That's part of the conversation that we have with patients about what your desired outcome is. But usually, it has to be a patient that is going to get an excellent outcome, who has the downtime, which can be as long as 10 days and as short as five days, and who has reasonable expectations for the outcome. I'll give you an example. So, for say you or me, like a late 40s or mid-40s female who's taken good care of her skin, when I laser you, the improvements are minimal, but they're durable. There's an improvement in texture and tone, an improvement in thickness, decreasing in pore size, and an overall just a luminescence to the skin that you could see where you wouldn't repeat the laser for three or four years.
[00:47:21] On the other extreme of that, when I have patients come in from very sunny areas who have loved the sun and who have that cross-hatched wrinkles, very thick kind of tanned, leathered skin. When I talk to them about laser resurfacing, here's the conversation I have. Say they're 65. I'm going to laser your skin at the extreme of what this instrument can do, it'll still take you 7 to 10 days to heal, but at best we're looking at a 4% to 5% improvement in your skin. So, because of the preexisting quality of their skin, even with maximal treatment, I'm not going to get this amazing change in their skin. I'm going to get a very small incremental improvement. And I think that's really important in setting patient expectation because not everybody's going to get the same outcome.
[00:48:12] And it's the provider's experience and their knowledge of the machine and how many patients they've treated which will help them prognosticate with each patient what to expect for their outcome. Also, if you're having CO2 laser with a provider and they're not talking to you about topical skin treatments for your face and skin care, that's like going to the dentist but not brushing your teeth every day. There are parts of being patient is being treated on a whole. And so, if you're going to the limit of doing a procedure that has a weak downtime, but you're not washing your face every night and you don't know what to put on it, even if it's drugstore brand, knowing those little everyday improvements can be as impactful as a costly and high downtime laser treatment. And so having that conversation and taking the time to love a patient enough to have that conversation, I think is super important.
Cynthia Thurlow: [00:49:03] Well, I think that, on so many different levels, it's so evident that you are so conscientious, so research based, but also have a love and a passion for the work that you do. Please let listeners know how to connect with you on social media. Please go follow Dr. Chance on Instagram. I learn something every day. There's always some nugget of wisdom-- [crosstalk]
Dr. Elizabeth Chance: [00:49:25] Aw. Thank you.
Cynthia Thurlow: [00:49:26] I learned so much. Please let listeners know how to connect with you, how to learn more about your work.
Dr. Elizabeth Chance: [00:49:32] Sure. So, I am @drchanceplasticsurgery. I'll see if I can bring it up on my, let's see here, so this is me. I don't know if you can even see that. Can you see that?
Cynthia Thurlow: [00:49:44] Yeah, we can see that.
Dr. Elizabeth Chance: [00:49:45] And I actually do respond to messages. I'm the only one that does this. It's just me. I don't have a social media manager, so when you're getting a message, it's for me. We have a website, www.drchance.com which allows you to also communicate with our staff and me. I will tell you, one of the gifts of being in solo practice is I have been able to collect a group of women together that all has this set the similar vision of patient centric care for each person. So, one of the things that I love is that I think every patient feels focused on and unrushed.
[00:50:24] And I think in a world where particularly in aesthetics, it's just a churn and burn, we've slowed it down to where even if we treat less people per year, it's so much more a relationship-based practice that it makes, I think every patient's experience be that much more meaningful and that much more impactful. And so that's really the focus of our practice. But no, I really will say part of my focus of Instagram that I've personally grown from one follower to what I am now is that every week I try to educate you on something and whether or not it's salient to your journey or maybe what be more for your mother or your cousin.
[00:51:04] Every day, I'm trying to in my head think of what's something that I haven't taught my either patients or friends or colleagues or complete strangers on the Internet and I really enjoy it. I've found that it takes so little out of me to just be a sharer of information because I am a curious person and I love this field and I really enjoy it. It's just been such an element of my practice that I never really thought was going to be such a huge part and now I deeply enjoy it. But much as you do Cynthia with your immense amount of education for your patients and your followers, I think it's just a really cool platform to be able to share a piece of you.
Cynthia Thurlow: [00:51:42] Absolutely. Thank you again for your time.
Dr. Elizabeth Chance: [00:51:44] Oh yeah, my pleasure.
Cynthia Thurlow: [00:51:47] If you love this podcast episode, please leave a rating in review. subscribe and tell a friend.
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