The first thing that people ask me all the time is, you know, what are the different types of facelifts? When we talk about kind of a lower facelift, we have these many lives, we have these mid facelifts low, like there’s so many different words out there and people don’t understand the differences. So without getting too crazy, I think we want to kind of break down these types. So what are the differences?
 

Dr. David Blyweiss
Adjunct faculty at the University of Miami – Miller School of Medicine
Medical Director of the University of Miami School of Medicine, Osher Center for Integrative Medicine Conferences

(listen to the show or read the full transcript below)

Anti-Aging Unraveled: Cosmetic Surgery vs Injectables & Lasers

Announcer (00:11):
Welcome to anti-aging unraveled with Dr. Laurie Gerber? The body is one of the most complicated
systems in the universe, Dr. Groover and her guests explore integrative medicine and cosmetic
dermatology, combining traditional medicine, alternative health practices, new innovations and
technology, which work together to help you look and feel natural and age gracefully. Now here’s your
host, Dr. Lori Gerber. Hi everybody. And good evening. Um, welcome to another rainy day and, uh,
Philadelphia, I’m going to hope that there’s no technical difficulties tonight, but it is raining again. So
we’ll see how it goes, but I’m happy to bring you a new topic this evening. We are going to be discussing
cosmetic surgery versus injectables and lasers, and really which one’s right for you. There’s so many
questions and there’s so many things out there. So I brought in an expert in the field that is going to tell
us tons of things that I have no idea about.

Lori Gerber D.O. (01:07):
And that is Dr. Oren Friedman. Um, he is on with us and I’m going to try not to mess up his, uh, resume
here. He is the director of plastic facial plastic surgery at the department of [inaudible] child, Odo, rhino,
LRN geology. You guys say that three times fast. Cause I can’t. And I’ve been saying it for years at the
university of Pennsylvania, and he’s the co-director of the facial plastic fellowship program as well. And
ENT department of the university of Pennsylvania. Um, he has been doing that for almost a what like 10
or 11 years is the director and, um, several years as the co-director of the fellowship. So I want to
welcome him to the program and we’re going to dive in a little bit and just talk about him. Cause you
know, he tells me he can talk about himself a bit. So, um, I want to know how he got here. I like to know
where everyone’s coming from these days and how they ended up in medicine and it’s changed so much
over the last decade, at least even since I’ve announced. So I’m curious. So without further ado, Dr.
Freeman, I’m going to welcome you to the show.

Oren Friedman M.D. (02:07):
Well, thanks Lori. It’s great to be here. Thank you for having me. It’s a real privilege.

Lori Gerber D.O. (02:11):
Thank you. So let me ask you a couple of questions. So I was looking at your resume and wanted to know
how you got here. How did you get into medicine? What brought you to this field to begin with?

Oren Friedman M.D. (02:22):
Well, uh, the decision to go into medicine started way, way back. In fact, a friend of mine, uh, a friend of
my mother know a friend of mine from school’s mother made a comment about, um, my, uh, wish for,
uh, the future when I was in seventh grade, I think at the end of school yearbook. Um, and my comment
was I wish to be a successful doctor and she was really taken by the word successful, which I never really
gave any thought to. I just assumed all doctors are successful and that was fine. So, uh, but she, uh, uh,
specifically mentioned that, uh, 20 years later to me or something like that. So I thought that was, uh, a
funny, so for as long as I can remember, that’s kind of what I wanted to do was to be a doctor and over
time, uh, what I realized was that I really enjoyed, um, uh, the art and the imagination that’s required in
plastic surgery.

Oren Friedman M.D. (03:21):
Uh, I kind of realized that early my grandfather was an artist. Um, he, uh, was, um, in fact I was just in
New York city this week, walking down fifth Avenue and seeing some of the display windows, the few
that are there, um, currently because of the situation, they are not putting much into them, but typically
around Christmas, those beautiful storefront windows and that’s something, um, one of my grandfathers
did. And so like that artistry, I guess, is something that was passed along, uh, through the generations.
My mom is also quite artistic and, um, uh, that’s just kind of what I gravitated to ultimately was plastic
surgery because of the creativity that goes along with that.

Lori Gerber D.O. (04:03):
So that’s why we get along. I, it has to be connected with definitely there, so beautiful art hanging
behind you. So cool. Yeah. I can’t take credit for that. I’ll put some of mine up later in the, maybe the
next, um, so let me ask you about, so when you were younger, did you always know that you wanted to
do surgery? Were you always a hands on kind of kid? I mean, I know I, I didn’t know where I was going to
end up, so pediatric cardiac surgery was my, was what I wanted. So

Oren Friedman M.D. (04:33):
It’s pretty cool too. I mean, that’d be a different show, but I’d be to hear about that. Um, well, uh, when
also when I was a kid, I remember, um, hearing about, uh, plastic surgery of the nose, uh, through
someone that I knew and my dad happened to my dad was a professor and, um, he helped this person,
um, through that process, he was not a surgeon use a basic science professor, but he helped the person
through that process and got to meet the surgeon who was, um, doing that surgery and, um, hearing
from my dad, his thoughts about the surgeon and what he was doing. And he just sort of put them up on
a pedestal a bit. And, um, I guess that kind of stuck with me, uh, I think is what ended up happening. And
so, uh, I always had that as a vision of something that my dad respected, I guess.

Oren Friedman M.D. (05:31):
And I think maybe that’s what drew me to that. Um, it’s hard for me to really put a finger on, on that, but
definitely I was a tinker. I like to get into things. Uh, when I viewed myself as a physician, I kind of viewed
myself running around the hospital and, um, uh, with the offices and, um, just being able to help people,
uh, and, you know, as the training goes on medical school and residency and so forth, um, you kind of
see where you fit in based on personality. Each specialty seems to have a personality, orthopedics,
urology, brain surgery, plastic surgery, uh, and specifically facial plastic surgery is a little more delicate.
And, uh, I’ll say a little more refined. Uh, it’s more fine-tuned than whole body plastic surgery. And, um,
uh, that just felt right to me. Uh, so maybe that a combination of my dad putting this nose surgeon up on
a pedestal for me and my liking to tinker on a small scale, uh, really led me to this. And surgery was the
idea for surgery was just a no brainer. It was just natural when I, when I went through medical school,
um, that’s definitely what I was attracted to through the different rotations. I did spend a lot of time on
cardiac surgery. Actually, maybe I was a glutton for punishment, but, uh, yeah, I was meant to do six
weeks or eight weeks and I ended up doing 12 weeks of it, which was really cool. I love that.

Lori Gerber D.O. (06:57):
It’s very cool and very difficult, but yeah. Agreed. So, um, all right. So you spent time in Philadelphia, you
went to Minnesota, came back. So the brotherly love, um, love it here. Right? So let’s, let’s, let’s dive into
this a little bit. So I think, you know, what, I looked at this topic, um, because I get questions all the time,
you know, what should I do? They come in and they want all the time, and I know you guys can’t see the
camera, but all I’m doing is pulling up on my face a little bit on my cheek line or my jaw line. I just want
this, or I just want to pull up on my brows a little bit and, you know, for some people that make sense
and for some people, it doesn’t because you need to pull up a lot, right? So there’s, there’s two different
ways to look at this.

Lori Gerber D.O. (07:37):
And I feel like, you know, we have the surgical patients that are surgical candidates because really, I
might not be able to do enough for them as an injector. And then there’s the people that you can get
away with maybe lasers and injectables. So we’re going to tease apart the differences. And I think having
Dr. Friedman on here for a lot of the surgical information is key. So, um, you know, I think the first thing
that people ask me all the time is, you know, what are the different types of facelifts? When we talk
about kind of a lower facelift, we have these many lives, we have these mid facelifts low, like there’s so
many different words out there and people don’t understand the differences. So without getting too
crazy, I think we want to kind of break down these types. So what are the differences?

Oren Friedman M.D. (08:24):
Well, right. Well, something that sort of, uh, uh, covers all different areas of the world that we all know
about is marketing. And so some of these different names that people can understand, because, you
know, let’s say S lift or, um, max lift, or as you’re saying, mini facelift or rapid recovery, whatever it might
be, people are trying to bark at themselves in a specialized way and make something sound really sexy,
um, uh, regarding facelift. Uh, but you know, there’s some basic fundamentals to a good surgical
outcome. And we’ll talk about those as the hour progresses. Um, but just sort of in short, I would just
give it a brief synopsis, uh, to answer the question that you had. So, uh, when someone’s eyebrows
droop, one of the earliest areas of aging, uh, that affects us is, uh, where the eyes look older. And when
you’re looking in someone’s eyes, they don’t look as young as their stated age.

Oren Friedman M.D. (09:34):
And when they themselves are looking in the mirror, uh, they look more aged than, um, how they feel
inside. They feel really, really fresh and, uh, vibrant on the inside. Uh, but when they look at themselves
in the mirror, they’re seeing this old person looking back at them and they don’t recognize them. And so
one of the earliest signs of aging comes in the area surrounding the eyes, and we know that the
eyebrows, uh, play a significant role in this. So an upper facelift refers to elevation of the tissues of the
eyebrow, um, in order to create a nice opening of the eyes. Uh, we like to think of the eyes as the
doorway to the human soul. Um, I have these, um, images of, uh, various, uh, television characters. Um,
and, you know, you can see the sadness expressed emotionally, uh, through their eyes only.

Oren Friedman M.D. (10:27):
So you can really read people’s emotions when you look at them and look at their eye area. Uh, so
sadness, anger, you know, anger, sadness, frustration, and so forth, um, can be viewed through the
position of the eyebrows and the size of the aperture of the eyeballs of the eyes, where the eyelids lie.
And so an upper facelift implies that we’re doing something to get the eyebrows up out of the eyes so
that they’re not covering the eyes. And they’re allowing someone, uh, either the patient themselves
when they’re looking in the mirror or someone that the patient is communicating with to be able to see
that person in their eyes, um, and make eye contact. Uh, and that is amazing how rejuvenating that is for
a patient simply elevating the eyebrows and removing a small amount of skin from the eyelids is
tremendous at, um, creating better communication and a more youthful appearance to the person’s
face.

Lori Gerber D.O. (11:30):
Well, actually, we just got a question on that too, so, and it’s coming from Facebook, so they want to
know when you lift a brow and you do the lids, what kind of downtime is someone looking at and how
long does the actual surgery take? Like what’s the procedure like?

Oren Friedman M.D. (11:47):
Well, that’s a great question. And there are a number of different, uh, approaches to the brow lift, and
I’m a huge fan, minimally invasive surgery in general. And the reason for that is it’s more rapid recovery.
So for the eyebrows, um, eyebrow lifting, uh, can take place in a number of different ways. Uh, my
preference is called the endoscopic brow lift and the endoscopic brow lift allows all access incisions to be
behind the hairline. So two incisions behind the temporal hairline, two incisions behind for people who
have a good hairline, not like myself, uh, uh, the hairline, uh, lies, um, uh, or the incision lies in a place
within the hairline. So it’s totally invisible, uh, literally invisible. And so you can access the entire
forehead and brow region, and even the upper eyelids through that, I also do a brow lift through what’s
called, um, the, uh, uh, eyelid crease incision or a blepharoplasty incision.

Oren Friedman M.D. (12:51):
So it’s called a trans blepharoplasty brow lift. So literally through the same incision that’s made to do a
simple eyelid lift, uh, which has a really rapid recovery. So through that same incision, we can do a small
brow lift, uh, through that same incisions. That’s pretty incredible. Uh, and the recovery for both of those
is really rapid. I would say one to two weeks now. Um, it’ll be a few weeks, maybe even a few months
before the patient’s sensation comes back completely, uh, to the forehead and scalp area. Uh, but, uh,
from a standpoint of returning to work, uh, we’re talking about one week off of work, uh, and they’ll
have excellent healing after exercise, uh, exercise. I like my patients getting out of bed and walking
around immediately after surgery. I want them walking their dog one day after surgery. I think getting up
on their feet quickly helps to get the blood flowing, helps gravity to do the work of, uh, getting the, the
swelling, uh, resolved a bit quicker.

Oren Friedman M.D. (13:52):
So, um, I want them up and about walking around from day one and then starting to get to slightly more
vigorous exercise a week after surgery at that one week, Mark, uh, I tell them, you can start to ramp up
the vigorous nature of the exercise you’re doing. Um, but when you start to feel throbbing sensation or
pressure sensation in the area affected, then I want you to notice, slow it down at that point. And then
each day they can increase it as, um, as their body tolerates it. And that’s going to be judged by how they
sense it. And that works out really well because I want the patients to push themselves so that the
swelling can go down quicker, but I don’t want them to overdo it so that the swelling is increased
because of too much strain or stress. So that’s a good way for them to gauge it is on their own,

Lori Gerber D.O. (14:42):
All my workout girls that are worried. Cause that is that’s, I’m telling you, that’s the messages I’m getting
now that are worried that it’s going to take too long, get back to work out. So you’re really looking at
about a week to two weeks of maybe not as aggressive workouts, but then kind of being able to go back
as tolerated. Exactly. Right. Okay. Okay. So that’s, that’s the windows to the soul. That’s your eyelid lift
and your brow lift or your bluff and your brow lift. Um, what about kind of mid-face region? So, um, folds
around the mouth, um, guys that don’t know this is called nasal labial folds cheeks, um, the depressions
in the front of the cheek, maybe jowl area.

Oren Friedman M.D. (15:22):
Well, so that’s a great question. And it goes right along with endoscopic brow lift. So amazingly through
those same incisions that we’re using to raise the brows and the eyelids in that, uh, behind the hairline,
those, uh, four or five tiny incisions that are completely invisible. So, through those same incisions, we
can actually access the mid face to do a mid facelift. So doing a mid facelift, if you think about when, you
know, when we’re looking in the mirror, uh, we get to about age 30, we start to see a little bit of the, uh,
um, uh, dark circles under the eyes, let’s say. Um, and that occurs because of loss of some volume in the
lower eye to eyelid cheek junction, the junction between the lower eyelid and the cheek, um, loses out
on some fat. And there’s some dissent because of gravity, uh, there’s descent of the mid-face, um, fat
and volume tissue.

Oren Friedman M.D. (16:20):
And so our goal in all of the different rejuvenatiion procedures is to try to blend that a good way to look
at it is, think about a baby’s face and how full it is. Um, and there’s only one mound of tissue from the
eyelid margin all the way down the cheek. And that’s kind of what we’re going for when we want to
rejuvenate the face. We want to create one mound from the eyelids margin to the nasal labial folds
basically. And, um, so mid facelift through an endoscopic brow lift is a beautiful and very powerful
technique where through these totally invisible incisions, we can enter, get into a plane just over the
bone of the cheek and then raise that whole mound of tissue back up to where it belongs up higher on
the face, giving a more, um, baby like appearance. Um, now we can supplement that with various things.

Oren Friedman M.D. (17:11):
We talked about injectable fillers, and we’ll get into that more deeply later, but, um, we can fill in some
of those grooves that remain, uh, with either filler or with fat at the same time as doing one of these mid
facelifts. Um, another small incision that we make for that mid facelift to really access things in cases
where we want to get maximum efficiency is I might make a small incision inside the mouth, along the
upper, um, gum line, uh, where the cheek and the gum join. There’s that little sulcus, uh, um, a little
groove there. And so a tiny little incision allows an instrument to get in and elevate all the tissues more
widely. Once we elevate those tissues, they’re free to be positioned wherever we want them. And so
that’s a beautiful thing. The mid facelift goes very nicely with the endoscopic brow lift and with upper
eyelid blepharoplasty. And then of course, lower eyelid blepharoplasty, um, amount of time for healing.
Cause I’m anticipating that question. So again, because the incision lines are so small it’s, uh, and they’re
all hidden. Uh, you can get back to work after a week, you know, you’ll have some swelling, but guess
what swelling is beneficial in this area? Cause that’s what baby’s faces look like too. They’re filled with
volume. So swelling is actually working to our advantage. The thing that works against us is if there’s any
black and blue, because you know, you’re going to get funny looks on the elevator, uh, if you’re all black
and blue, so

Lori Gerber D.O. (18:46):
Needles do that too though. So, you know, that’s true. Okay. So you’re talking about last or the same
downtime. You’re talking about a couple of weeks

Oren Friedman M.D. (18:56):
Downtime, one to two weeks.

Lori Gerber D.O. (18:58):
Okay. And so just so you guys understand, cause there was some words, big words in there. I have to
learn to talk in smaller words that aren’t medical too. Um, is that really, these are, these are really just
ticking suture essentially underneath the skin through minimal incisions that are, that are not visible. So
they’re not outside the ear. We’re not talking about behind the ears. You’re talking about all the hidden
in the eye crays are hidden inside the mouth kind of by the gum line, um, where the mouth meets the
gums and really just hiding all of these. So nothing really visible to the naked eye except under your hair.
Right. Exactly. Okay. And do, do a lot of people do these endoscopic lifts, is this something that you’re
specialized in?

Oren Friedman M.D. (19:38):
Well, it’s definitely something you want to see us a highly specialized person for, um, the, uh, the
effectiveness of it is going to be dictated by the amount of tissue Ella elevation, lifting it up as you can do
now, as you get more aggressive with it, aggressive is a scary word, but for creating, uh, changes that are
visible aggressive is our friend from a standpoint of, um, of the, the maneuvers that we’re doing. So, uh,
I, and I think when you’re talking about trying to get an effective lift, you really have to understand the
anatomy, uh, because the facial nerve is the nerve that’s responsible for, uh, the muscle movement in
the face. And, um, the facial nerve branches are at risk in all of these facial procedures. So you certainly
want to go to someone who’s skilled, not only from a safety standpoint, to be able to avoid injuries to
those high-risk areas, but also someone who’s not afraid of those anatomical areas so that they can,
when aggressive, aggressive maneuvers are required to really free the tissues up so that you can
reposition them, uh, you’ll be able to do it because we all have heard about things.

Oren Friedman M.D. (20:53):
I’m going to ask the question. Well, what about, um, the, uh, the thread lift, I’ve heard about a thread lift
that doesn’t even require any incision. Um, so the thread lift is something that does allow you to lift
again, it’s a suture, uh, that or the silhouette. Now that is one of the brand names. Um, that’s out there.
Uh, Laurie, I don’t know if you have other names that you wanted to mention about that

Lori Gerber D.O. (21:17):
You’re talking about PDs or, yeah. Yeah. So, I mean, you know, there’s, there’s actually so many right now
that are new on the market. I mean, um, I I’ve been, you know, in the past I’ve used Euro threads, I’ve
used Nova threads. Um, we used to live on Cray. That’s a new one. Um, but yeah, all, all simultaneous or
I guess the word is whatever with S lift, um, right. They’re just different versions of the same dissolvable
suture.

Oren Friedman M.D. (21:42):
Exactly. Yeah. Which highlights, I mean, so the first word dissolvable, that’s something we have to be
cognizant of because what that means is that that’s a temporary effect. Right? So now, so we can argue
that that’s the most invasive of the lifting methods would be just with a tiny little needle poke, uh, and
then sliding the suture in a position and lifting it up with maximum force to lift these tissues up. And that
is, uh, very, seems to be very attractive on the surface. Uh, but the problem with it is, um, in is that
you’re not number one, not getting a maximum lift. I mean, just logically, if you think about it, uh, you’re
tying a string, pulling tissues up gravity and the forces of those tissues being held to the bone on the
undersurface and the skin on the super surface, just above that soft tissue, um, is going to continue to
want to pull that tissue back to its original position.

Oren Friedman M.D. (22:37):
So when I’m talking about being aggressive, I’m talking about just freeing the tissues up so that you can
reposition them in a new location on the face higher up, and then allow, take advantage of the scarring
process so that the scar tissue heals and heals your face in a way that holds that tissue in the newly
positioned space. So it’s a really beautiful thing. One of the other things that I’ve encountered with, um,
patients who have undergone, um, thread lifting or just suture type techniques without manipulation of
the tissue by freeing it, which would be the surgical method to do it, um, is that imagine if one of those
sutures tears on one side, but not on the other side, I actually have a colleague, uh, in Canada who told
me he he’s one of the earliest users of this had done 300 patients, so had vast experience with it. Um,
but, uh, and then, and he had operated on his own wife in that fashion and he stopped doing this
procedure when one side of his wife’s face fell. And the other side

Lori Gerber D.O. (23:38):
As why you don’t operate on your own way. Um, yeah, I, I joke, I say that’s an, a crochet hook. Um, and
some numbing come in really handy to go fish out. Um, knock on some wood. I have any around here,
but okay. So we’ve gotten some really good information. So we’ve talked about I’s, we’ve talked about
mid-face, um, we’ve talked about kind of the endoscopic method and endoscopic you, do you do that
awake? Do you do it under anesthesia? How are you performing those?

Oren Friedman M.D. (24:10):
Well, that can be done either under general anesthesia for patients who want to be completely asleep or
it can be done under Twilight anesthesia, which is similar to what a patient might get when they get their
wisdom teeth removed in the office, or when they get a colonoscopy, um, that happy juice, um, could be
all that’s required to, uh, to numb a person up and get them comfortable for the procedure. Minimally
invasive goes with rapid recovery, minimal swelling, uh, and therefore minimal pain.

Lori Gerber D.O. (24:44):
Okay. Um, so, all right, we’ve gotten the, the top of the face done and let’s talk about, and I know you
guys can’t see, but, um, my, my problem area, which is like right around my jaw line, I have no chin, um,
you know, that Eastern European lack of chin that I have. So what do we do about the jowly jaw line
around the mouth kind of hanging and, well, I know you can tag neck into this cause it probably ties in
very well. Um, can that be done endoscopically?

Oren Friedman M.D. (25:17):
Well, that’s a really good question. And first of all, it’s rewind a little bit. You look fantastic. So I don’t
accept what you’re saying.

Lori Gerber D.O. (25:26):
I’m going to keep filling it up until I have to do it. We can talk about that last.

Oren Friedman M.D. (25:31):
There you go. We’ll get to that. Um, yeah, so you could definitely do parts of the lower face through
minimally invasive methods as well. But again, if you think about, so one of the major concerns when
patients come in for, Hey, I want a mini facelift, or I want just a neck lift. I don’t want the full facelift.
There’s definitely a stigma attached to facelift surgery, uh, on a number of levels. The first level is people
think of it as, um, perhaps a vanity that they never anticipated, they would experience. But when you’re
looking at yourself in the mirror and you’re feeling like you’re 30 years old, uh, but you’re looking at your
butt as the person that’s looking back at you is looking 70 with a Turkey waddled, neck and jowls along
the jawline and things like that. Um, you know, that is something that can be done still with rapid
recovery, but it requires more manipulation of tissue than, uh, than what I think, um, is, uh, fair to put
onto an endoscopic procedure.

Oren Friedman M.D. (26:37):
And it’s for the same reason that we’ve already sort of highlighted, and that is in order to get those
tissues to stay the position you want them, uh, mobilized to or repositioned to, which means basically,
Hey, I want my tissues repositioned to what they looked like 20 years ago. Uh, and that’s, um, so to do
that, you’ve got to mobilize the tissue and allow it to heal in that new location. I think back to the
eighties when I was a kid and, um, you know, the hot, uh, way to do people’s hair was a perm. And the
reason that people love the perm is because it was just, I remember those commercials for perms on
television. Uh, it was just get up and go, you know, you twist your hair, your head around. I don’t know.
Maybe you could describe that maneuver better

Lori Gerber D.O. (27:24):
Thinking of ahead, you know, hair’s all ready to go when you hop out of bed. Gotcha.

Oren Friedman M.D. (27:28):
Exactly. So, um, you know, you get up and you shake it a little bit and, uh, the hair is in an, all the position
that it needs to be in order to look great. So, you know, people think about minimally invasive, but the
thing to think about is what’s the least, um, maintenance therapy that’s needed over time. And so a
facelift that’s done well, which will get your neck back to it was 20 or more years ago and it’ll get the
jowls back to what they were 20 years ago. The jowls are the, the lines, the bulldog, uh, lines along the
jawline. Um, getting that back to that point 20 years ago and allowing it to heal in that new position, uh,
allows you to just get up and go and look beautifully refreshed every single day without the need to, um,
uh, you know, place all the makeup and the camouflage and things like that. And you feel great about
yourself. You wake up, you look in the mirror when you’re brushing your teeth or washing your face, and
you’re happy with what you see back at ya.

Lori Gerber D.O. (28:29):
So where, so where are those incisions? I know there’s so many, um, and I guess the stigma, at least in
my brain revolves around where maybe the downtime, but also where the, the incisions are placed,
right? Where, where your skin’s pulled to. And I guess back, you know, let’s just say maybe 10, 15 years
ago. Um, some of the ways that we did these closures and incisions were a little bit different than they
are now. So can you just, you know, maybe clarify or make people feel better, one about how long a
facelift lasts compared to some other procedures, um, and maybe not having to go back in more than
one time in a certain number of years, um, and see where these incisions are placed.

Oren Friedman M.D. (29:09):
Well, those are really great questions. And, um, I agree with you looking back even 10 years ago and 20
years ago, certainly, um, a facelift often looked really unnatural. And I think, um, this is a point that, um,
uh, I’ve learned over my 20 years in practice, I started practicing at the Mayo clinic in Rochester,
Minnesota. I was the director of facial plastic and reconstructive surgery there. And that was an amazing
opportunity for me to go around the world. Literally, uh, that’s part of their, um, part of their culture is
that they, um, encourage, uh, physicians to go around the world and visit with all the top experts in the
world. So as a young surgeon coming out and having been outstandingly trained, uh, at one of the top
fellowship training programs in the world in facial plastic and reconstructive surgery, I felt really
well-trained.

Oren Friedman M.D. (30:04):
But what really trained me was, you know, once I was on the job and I saw what it was like, and then I
had the opportunity to go visit these world experts, literally around the world and all the corners of the
world. Um, and, uh, and see what is a natural result look like? What does a good result look like? And to
me, natural is synonymous with good result. It’s got to be something that does not look polled. It doesn’t
look a stretch. It doesn’t look like you’ve walked in to a wind storm and the wind is plastering your skin
against your, your face and neck. It’s got to be something that no one can tell that you had anything
done, and it looks like you. Uh, and, uh, and that’s my goal. So good plastic surgery, especially good
plastic surgery of the face means it looks natural.

Oren Friedman M.D. (30:56):
It looks on operated on. So that goes to your question, where do you place the incisions? So the incisions
need to be placed in aware in a place where they’re not going to alter the hairline, because one of the
telltale signs of the, um, traditional facelifts is that the hairline is altered. And that’s something that I
learned, uh, while traveling, uh, to see top, uh, uh, facelift surgeons when I was a youngster. Um, so that
means in the front of the hair, uh, in the temporal Tuft, we call it and also in the back of the ear, uh,
where the hairline, um, extends. So we want to hide the incisions, uh, and match up the hair lines so that
it looks natural. And you can’t see any of the scars. So the scars run within the borders between the ear
and the cheek, and then they go in a woman in a female patient that goes behind the, uh, tragus of the
ear, which is the part of the year where the earbud is hidden in part.

Oren Friedman M.D. (31:54):
Um, uh, so it kind of goes into the ear canal in that area. And then it goes around the ear lobe, and then
everything else is hidden behind the, behind the ear. So the incisions in that region happened to hide
extremely well. Uh, even the ones that are on the cheek at the junction between the ear and the cheek.
So they had very, very well. The second important thing is what is the right vector of pole for a facelift? If
you think about it, gravity is working to pull us downward straight down toward the center of the earth.
It does not pull out, pull our faces backward. So the wind swept look that was a sign of maybe, uh,
prominence wealth and, uh, and a person who’s taking care of themselves, uh, 20 years ago, uh, was,
um, uh, was this pullback look of the facelift that really stretched things out.

Oren Friedman M.D. (32:49):
We talked about the nasal labial folds a bit earlier. That’s the fold that goes from the corner of the nose
and sort of, uh, towards the corner of the mouth. Um, so it used to be that you needed to pull the face in
a direction that was perpendicular upward and perpendicular to that, that, uh, uh, direction of that nasal
labial fold. Um, but really, uh, for the deeper tissues, we want to pull those straight up vertically to
reposition the tissues where nature placed them and where gravity pulled them down. And that’s what
makes things look natural is to pull the volume straight up, uh, and to pull the skin back along the lines
that the skin should run. So along the lines of the wrinkles, this way, the wrinkles are going in the right
direction and the soft tissue and volume is going in the right direction.

Oren Friedman M.D. (33:39):
And that’s what we’ll give a full face. So what does facelift treat? What does a full face of, it’s not that
you should not be stigmatized by the word. It’s not a bigger operation than a neck lift truly. Um, I mean,
there are ways to do many neck lifts, and we can talk about that in greater detail. Uh, another time, um,
there are ways to do minimalize minimize, uh, uh, neck lifts, exclusively neck lifts, and there are, and
there are certain patients who are candidates for that. We, um, again, we can discuss that later, but a
facelift that, um, creates a blended appearance between the neck and the cheeks, and then the upper
face as well, um, can be done very conservatively. It’s not a huge operation. It doesn’t mean that, um,
uh, you know, you’re a frivolous or superficial person, all it’s doing is restoring tissues to where they
belong, if gravity was not, um, working against us in the aging process.

Lori Gerber D.O. (34:41):
And, and so, um, to circle back and, um, what’s the downtime when something like a facelift. I know we
talked about a couple of weeks with some of the endoscopic lifts. What about a facelift?

Oren Friedman M.D. (34:52):
So, uh, facelift would take, um, I tell patients the first week, you’re with a head wrap on your face 24
seven, pretty much. That’s making sure that the tissues that we reposition are held in their new place, by
the wrap that we put in the operating room, um, and a similar wrap afterwards, uh, after that first week,
I want you to remove the wrap and, um, allow gravity to drain the fluid that’s causing the swelling. And
it’s at that point that I want you to starting to mobilize a little bit more aggressively that’s during week
two. Um, if you think about Hollywood celebrities who are walking out with their baseball caps, pulled
down their big sunglasses, uh, and, um, things like that, that’s somewhere between week two and three.
So in other words, the incisions are hidden by the hair. That’s covering the incision lines in front of the
ear.

Oren Friedman M.D. (35:41):
The glasses are covering the swelling of the eyes and the hat is so that they’re more anonymous, but
that’s how you can go out during week two to the grocery store, uh, and remain, um, anonymous. And
then I like to tell patients that by the end of your third week after surgery, you can feel totally
comfortable going to your favorite restaurant and being seen by people who, you know, and them not
necessarily knowing that you had a facelift done now, you and I, the patient and the surgeon are going to
know that the face is still swollen, but the average onlooker is just going to look at you as though you
look refreshed. So certainly there’s still swelling, but, um, it looks good enough to present to people who
know you well.

Lori Gerber D.O. (36:23):
Okay. And just so you guys understand when he was talking about vectors and pulling, we, we actually
met at a, um, an Allegan conference, um, training that was going over contour, contour, and shadows. So,
you know, in injectables, we have a very similar, I guess, dichotomy of what was done 10 years ago by
physicians versus what’s done now. And they were treating things in a way that probably, again, it made
people look just morphic, right? They look like a little alien, like maybe the cheeks were too high. You
know, the chin looked too sharp. Things were too stiff, um, treating and planes that maybe weren’t
appropriate. And, uh, we also, you know, we met over cutting steaks with a butter knife, but also talking
about, you know, the, the shadows and how to fix shadows. And that’s really what he’s talking about is
pulling up in it.

Lori Gerber D.O. (37:09):
I mean, in a perpendicular straight up and down lane, which is counteracting gravity, right. Instead of
pulling in a verdict or a horizontal fashion where you’re really looking like you’re, you’re just, you’re just
disrupted, you know, you’re kind of punching your face against the glass if you will, or that windswept
look. Um, so I, on that note, I think that, that brings me to my next question. Um, and I did have a
question. So someone did ask me about the thread lift versus permanent versus, um, non-permanent
and what happens when the threads dissolve? Um, do you go back to square one or is there, is it, is
there any benefit to doing the thread, the dissolvable thread lift first before you go and have a
permanent or permanent mid facelift? Um, so that was a question I just got as well. I don’t know if you
want to answer that. I can answer a little bit as well. You can,

Oren Friedman M.D. (38:02):
I’ll let you, I’ll let you, uh, uh, let me know your thoughts on that. Yeah.

Lori Gerber D.O. (38:06):
So, you know, thread lifts for me are rather new. I, you know, I’ve been doing them probably about a year
and a half to two years at this point, and I feel like they have gotten better. Um, the, but we’re talking
about textured, um, materials that don’t have a lot of tensile strength, so you’re not getting a ton of pull
out of them. I say, it’s a really nice way to get an idea if that’s something that you’d like the look of, or to
get an idea, if you know, the slimming of the jaw is what you want, but for S and if someone has what I
would call medium grade skin where they’re not too heavy and they’re not too thin, it’s really got to be a
very perfect patient. Um, otherwise you can see, again, we’re talking, when we talk about vectors, you
can see the vector line, you know, you’re, you can only pull in one direction.

Lori Gerber D.O. (38:47):
Yes, you can curve as many little pokey things around the face, as you want to try to get it, to connect to
the connective tissue. But at some point on very thin skin, you’re going to see the line and on heavy skin,
it’s not going to hold it. Um, I think it’s a temporizing measure for most people. I think maybe it’ll buy
you a year or two. Um, but for the most part, by the second year, I’m telling you not to waste your
money anymore, and I’m sending you for a facelift. Um, I don’t know what your thoughts are. And I
actually, um, I would say that’s more common than not. I would say, you know, I actually talked people
out of it unless they are the perfect, maybe younger than middle-aged, maybe they’ve aged a little bit
more quickly and their jawline and Joel, maybe even underneath their neck, they’re not necessarily
ready to go get a facelift because they’re in their thirties or maybe even early forties. And it’s something
to temporize them for a little while.

Oren Friedman M.D. (39:39):
I mean, I would totally agree with everything you just said. I think that there’s some patients who just are
so, um, opposed to surgery, afraid of surgery, um, and we’ll do anything, uh, but do surgery. And so those
patients are great candidates for this. And many of them would be happy to repeat the process. Uh,
whenever the suture lets go or becomes visible, things like that, uh, cause with relaxation, you can also
see an unnatural tension on one of the strings or something like that. Um, you know, but, um, and then,
you know, it’s hard because, uh, while you try to give the best advice and what you feel is in the patient’s
best interest, which is how you say something really that’s at the core of my existence as a, as a surgeon,
um, truly, uh, my job is to make patients happy. And my job is to, um, uh, do what I believe is the right
thing for patients and serve the needs of the patient.

Oren Friedman M.D. (40:42):
So that’s something I learned early on in my career is that the needs of the patient come first. That’s
what the Mayo clinic brothers, the brothers who started Mayo clinic, that’s one of the aphorisms that
they put out. And again, that’s part of the culture and, um, you know, I feel it a real privilege and I know
Laurie United spoken about this at length previously. I know you feel the same way. It’s just such an
honor that patients and trust us with their care and we take it seriously, um, to the point where we’re
making the recommendations of what is in the patient’s best interest. And so as much as in some cases, I
try to explain, you know, what your best interest is because of the prominence, because of sutures
breaking because of, uh, it looking most natural to reposition whole blocks of tissue.

Oren Friedman M.D. (41:31):
Um, some patients are not comfortable doing surgery and just want no downtime at all, or minimal
downtime, even less than the one week that we’re talking about. And so in those circumstances, uh,
doing the thread lift, um, is the right thing for that patient at the time. Uh, and, um, while we can guide,
uh, our patients as best as we, as best as we believe, um, they are, uh, the primary D they’re going to be
the dictators of how it goes, and that’s what we want. We want a hundred percent buy-in from our
patients. I think they’re happier that way. So, um, I think there’s a role for it. There are some permanent
sutures that can be used. Uh, Gore-Tex sutures can be used with some of the devices. Uh, uh, some of
the threads can be permanent. Um, and sometimes we can combine those, uh, threads, um, with even
open surgical procedures, but also with thread lifts. And so sort of do some hybrid surgeries that are also
really even more minimally invasive and they can work nicely. And so then they can hold for longer, as
long as the suture holds up, even if it’s a permanent suture may not hold truly permanently, but, but
often they can. Um, uh, and the tissues relax slowly. So I I’m for it. Um, for the, for that patient who is
really averse to having a surgical intervention.

Lori Gerber D.O. (42:52):
Okay. I mean, cost to benefit ratio too. I mean, if you had look at it and that’s, I, I try to do that for all my
patients. You know, this is none of our, our stuff is necessarily cheap. So, you know, with the cost of a
non-permanent thread, versus how many years are you going to do that before you’re equaling what we
would call a facelift in mini left, mid left, whatever, whatever lift you’re talking about that surgical, you
know, it might not be worth it to do that for multiple years on end, unless you’re really opposed to
surgery. So I tell my patients that a lot too, and you’re always fighting gravity. So at some point we’re not
going to get you the result that you want. And when you talked about being happy with what you see in
the mirror inside matching the outside, um, there’s going to come a point, and that probably brings me
to our last 15 minutes, but there’s going to come a point where I can’t help you with all of the injectables
and fillers and threads that we have.

Lori Gerber D.O. (43:40):
Um, so cost to benefit ratio is a big deal to, you know, you can only do so much every year before. You’re
really looking at some kind of surgical intervention. So with that, um, I want to talk a little bit about
non-surgical and not to really necessarily swayed someone in one direction or the other, but I want to
just explain, cause I do get this question a lot and actually I just got one, um, on email too, that said, if I
do a surgical intervention, let’s just say I do a brow lift. Do I still need Botox? Do I still need Botox around
the eyes with a blast? Um, so that was the question. I think, um, what my question is and how I want to
go forward is really, at what point do you still use lasers and Botox and fillers for your surgical patients or
at what point do you switch them over from one to the other? Um, so I think the first question is, do you
use Botox still after someone gets a brow lift? Let’s answer the email question first.

Oren Friedman M.D. (44:43):
So, um, the answer is yes, at some point after brow lift, most patients will be, uh, using Botox. Uh, when I
do a brow lift, uh, I like to get rid of the muscles, uh, truly get rid of the muscles that, that create the
Eleven’s or the ones, uh, in the glabellar area. So I actually remove those muscles, um, which helps to,
uh, eliminate the need for Botox for pretty long period of time in that central region, uh, on the side, on
the areas of the side where the crow’s feet are, um, there’s really no way to get rid of those, uh, those
lines. So you’re going to need to continue Botox certainly in that region. Uh, once the muscle activity
comes back, which could be, you know, even six months, let’s say before. So it may be an extended
period of time, uh, before you, you have to do that.

Oren Friedman M.D. (45:43):
And in the front talus area, the forehead creases that go horizontally across the whole forehead, um,
some patients have more of those. Some patients have less of those. Uh, the, um, those will need to be
restarted as well in order to keep it, keep things looking smooth and to preserve what we’ve achieved.
The other thing is, um, a lot of surgeons and there’ve been studies on this, recognize that the muscle
activity of the brow muscles in particular, um, will play a role in where the brow heals after surgery. So,
uh, we, we intentionally, may, uh, paralyzed that’s what Botox does or other similar Xeomin and Dysport
Botox all the different brands. That’s what they do is they will, um, paralyze those muscles so that, uh,
the tissues are not being pulled down. And, uh, they’re being a tug of war between the Bralyn that raises
the brow and the muscles that otherwise pull the browse downward. So we might do Botox before
surgery and then three or four months after surgery to preserve what we’ve done and make sure it’s
healed in the right location, basically upward.

Lori Gerber D.O. (46:56):
And at what point, I mean, do you, and I know you do a lot of, um, neurotoxins as well. At what point do
you say to somebody, you know what, we’re not getting you the brow lifts you need, because you know,
these things kind of give you a slight brow lift. And I say slight, because some people are more than
others. Um, at what point do you say, you know, what this isn’t really working for you or the muscle is
just you’re, your depressors are winning essentially. Yeah,

Oren Friedman M.D. (47:19):
Yeah. Waiting that tug of war, just the, up the, up of the muscles that pull it up versus the tug of war
muscles, pulling it down the depressors. Yeah. The, um, uh, I would say the point where you switch over
is, uh, the right, the correct position for the brow should be once in a female, should be one centimeter
above the, uh, bony or bill rim. So for the listeners out there, if you put your finger on the bony orbital
rim, and then feel, where is the hair of your eyebrow, or look in the mirror, if they’re, um, tattooed or
painted on makeup on and pay attention to where those eyebrows are, if they’re less than a centimeter,
especially towards the sides of the eye, the eyebrow, the parts closest to the ear, not closest to the nose.
Um, that’s the part that we want to see a nice, smooth, upward, um, uh, uh, elevation or flow of the
brow upward in that lateral aspect. So if that’s not a centimeter above the, um, above the bone of the
brow of the upper eye and brow, then, um, and after the Botox has effectively raised it as high as it’ll go,
that’s where you start thinking that you want to get that, um, surgically treated, I would say.

Lori Gerber D.O. (48:40):
Okay. And w let’s um, I know I didn’t bring up smiles, but I think I’ll save that for a different talk. Let’s.
Um, talk about lasers. Are you, do you combo lasers with your surgical interventions? Are you a fan of
just doing them before to get the college in boosted? There’s so many lasers out there guys, and I think
kind of like facelifts, it’s all marketing, right? There’s only a certain amount of technology out there
available to us. Um, and they think as, as a surgeon or as an interventionalist, if you will, that you’re
probably more prone to use some CO2 lasers. Um, maybe some intense radio-frequency totally correct
me if I’m wrong, maybe some IPL for color. Um, so let’s, let’s talk about CO2 and radio-frequency and
tightening. Do you combo that before and after your surgical procedures?

Oren Friedman M.D. (49:26):
Yeah, the answer is yes, definitely. I mean, there’s, pre-treatment, uh, again, most patients are not
coming in and ready to go with everything. Uh, some have had friends who’ve had it done, and so
they’re ready to jump aboard. They know what a beautiful outcome surgery can give, but most patients
want to, you know, uh, jump in the pool with their toe first dipping into a feel the temperature of the
water. And so, um, that’s where the injectable fillers, uh, the neurotoxins, the Botox and Dysport, and
CMNS come in, that’s where lasers and radiofrequency come in, all kinds of things that we can do to
tighten the skin and, uh, help reduce some wrinkles. Um, lasers are great at reducing some of the very
fine lines, some of the discolorations, all of which, um, uh, play a role in giving someone a more aged
look. So as you well know, um, from your own experience, it’s just incredible, the power of some of those
tools, uh, to refresh and rejuvenate and refresh has just the right, uh, the right word for it.

Oren Friedman M.D. (50:33):
Um, it can be made to the patient can be made to look so natural and naturally refreshed that no one
knows that something was out with a laser. So it’s a beautiful, um, uh, thing to do prior to, and then once
the patient is comfortable, uh, that they’ve dipped their big toe in and the waters are pretty comfortable
there. And they’re getting confident with your recommendations and seeing that you’re able to deliver,
uh, just as you’re, um, uh, counseling them before the treatment starts, uh, then they’ll be comfortable
taking the next step and the next step. And that’s really what a good relationship between doctor and
patient is in my mind is, um, you know, we want to do what’s least risky, what’s least invasive, uh, and
what, um, what works well for the patient and, uh, uh, that’s what the patient wants. And so we can
gradually transition them into that, uh, easily.

Lori Gerber D.O. (51:26):
So I’m told that we have four minutes, so here’s what I’m going to do instead of us trying to rush through
all of these interventions. I want to ask and pick your brain for a minute, what laser, and this is going to
be a kind of an impromptu. What laser is your favorite laser for tightening? Um, that’s, that’s not fully
ablative. Let’s start there, not a fully ablative kind of meaning, like, you look like a burn victim for you
guys that don’t know, um, it has minimal downtime, you know, maybe takes three sessions or so,

Oren Friedman M.D. (51:55):
I mean, my favorite laser for that is fractionated CO2 laser. Um, yeah, what fractionated means is that,
um, uh, the entire laser beam is not contacting the skin at one time, so that there’s normal unmanaged
untreated skin in between those very, very fine laser beams that are treating, uh, certain spots. And that
allows the skin to very rapidly heal. And that’s a beautiful laser. And I do it in conjunction with facelifts,
all the different facelifts or eyelid lifts that I might do. Uh, many patients will choose to get it done at
that time. And, uh, uh, we love that as a, as a, um, a contemporaneous treatment for those patients.

Lori Gerber D.O. (52:38):
Perfect. And that would be my same, my same answer. Um, I also actually love, um, radio-frequency with
micro-needling. I find for people that don’t want it, the downtime to get some really, really nice results
on that fine micro fine lines that man, Oh man, I just can’t fail if I try all day, um, I call them roadmaps. So
that is one of my favorites as well. Um, so I think what we’ll do is we’ll bring Dr. Freeman back another
time and we’ll discuss, um, some of the other non-surgical interventions. I think one of the biggest
questions that I’ve had on that I haven’t addressed in them and give you like two minutes so that people
don’t pick your brain apart cost, how much cost are we talking about? Are we talking about $20,000? Are
we talking about $5,000, $4,000 for some of these procedures would say it’s variable.

Oren Friedman M.D. (53:26):
Um, and, uh, yeah, so the, uh, brow lift each of these different procedures that we’ve spoken about,
brow lifts, laser eyelid, lift facelift of different varieties, um, are each separate procedures, uh, depending
on the needs of the patient. Some will come in just for the bleph, some for the eyelid lift some just for
the facelift and the neck lift, some just for the laser. And then you’ve got patients who come in for what
we call the blue plate special, which means getting it all done at once. Um, if they’re going to take the
time to, to do it. And, uh, uh, then, uh, so when you’re talking,

Lori Gerber D.O. (54:00):
The rich and famous anymore is really what I’m getting at.

Oren Friedman M.D. (54:03):
Thank you for clarifying. Exactly. It’s totally for the average patient. In fact, there’s statistics, 70% of the
patients who wanted to go cosmetic procedures like this, uh, may earn $60,000, uh, or so, so under
$70,000, uh, 70% of agents, it’s not for the rich and famous it’s for everyone. And, um, we love all our
patients.

Lori Gerber D.O. (54:29):
No that’s for everyone. So everyone that’s listening today, um, Dr. Freeman does do consults at, um,
refresh my office there. Um, we can set you up there. You can also reach out and find him online at
university of Pennsylvania. Um, he also has an office in what’s the town, is it that you can see them, so
you don’t have to go to the city. You can also stay tuned for some more shows with him. We will be doing
some more shows and break this down further, but we’ll see you next week. This is Dr. Lori Gerber. Um,
and next week I believe we’re going to be doing, um, some talking about, um, my post COVID and my
wellness patients, and bring on a bunch of patients to, um, discuss their issues. So if you want to tune in
again at 6:00 PM Eastern standard time with Dr.

Lori Gerber D.O. (55:12):
Laurie Gerber on anti-aging unraveled, and you can meet someone else like Dr. Freeman, or maybe he’ll
join us again really, really soon. Um, if I’m really stuck, um, he is, um, one of the best people I’ve ever
met by the way. So just, I’m going to make him turn red for these last couple seconds, but he is a great
person in general, as a surgeon, he is phenomenal, but as a human being, he is just wonderful. So, um, I
want to encourage everyone, if you want a really great consultation and just someone to give you an
honest opinion. Um, it is absolutely Dr. Friedman. So on that note, we can just talk freely, cause we’re
almost done and we’re going to be heading out soon, but, um, so what is your favorite procedure that
you’ve done internationally? I’m going to end with that?

Oren Friedman M.D. (55:55):
Well, I love cleft lip. It’s life-changing for, uh, for kids who otherwise may be shunned in fact left for dead
at the end of their, uh, family farm, because they don’t want to care for those children that they feel
have the devil in them. Um, so bringing them back to their families or to an adoptive family is amazing.

Lori Gerber D.O. (56:17):
Well, thank you. I’m going to say over and out for now and, uh, see you next time. Thanks.

Oren Friedman M.D. (56:22):
Thank you all