Small Treatments, Big Results w/ Dr. Munique Maia

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "Small Treatments, Big Results." Dr. Bass, tell me about the idea behind this episode.

Dr. Lawrence Bass (00:30):
Really, I was thinking of two things here. First, most treatments are either small treatments, small results, or big treatment or big surgery with a big result. But there are some exceptions. These are treatments that don't involve a big investment in recovery time or money, but have a significant impact on appearance. Second, treatments that address small features that are often overlooked, but provide obvious tell tales of age or other unwanted features. I'm going to discuss some examples of these things with our guest today. Dr. Munique Maia was a plastic surgery resident at the Northwell Health Program with me, and then completed the aesthetic surgery fellowship at Harvard and is now a plastic surgeon in the Washington, DC, metro area with a very busy and popular practice. Dr. Maia, welcome.

Doreen Wu (01:42):
Thank you. I'm so excited to be here. Okay, let's get started. So, Dr. Bass, let's revisit the first point. You brought up small treatments that have big results. Can you detail some examples for me?

Dr. Lawrence Bass (01:55):
So probably the best example is Botox and other neuromodulators things like Dysport, Xeomin, Jeuveau, and now Daxxify. Often the area that's being treated as something small, like the elevens, the little vertical lines in between our eyebrows, it seems like such a trivial, small thing, but it has such a big impact on our appearance. The impact is so big that it's the most popular aesthetic treatment of all time, even though it's just a few little lines. That's how it started. Now, of course, we use it for many other things as well. IPL or BBL intense pulse light, broadband light. This is in a light-based energy treatment that will knock back redness on our face and clear off a lot of the irregular pigment, the brown age spots, and give us a fresher appearance. And that treatment that typically has no recovery and is done in two or three treatments can really, really change how old and worn out you look if your skin has a lot of those features and then becomes clearer fresher skin.

(03:17):
So that's another great example in my view. Things like microdermabrasion, you know, non-invasive treatment, no recovery, but it really freshens the skin. I think of it like the dental cleaning of the skin. Everyone's skin is better off with a little microdermabrasion. And things we do around the eyes that periocular area, the area around our eyes is a small area on the face, but it's the area where everyone is looking most of the time. So doing appeal in that area, or a little filler in that area, or even having a blepharoplasty, which is a surgery, has a big impact on your appearance, even though it's a small area, because if you fresh in that area, that's where everyone looks when they talk to you. And of course there are a lot of filler options. And Dr. Maia and I can talk about this a bit you know, where we hit small features on the face that have a big impact.

Dr. Munique Maia (04:25):
Dr. Maia, what are some examples that you see in your practice of this? Yes, so Dr. Bass mentioned a few popular procedures that the plastic surgeons performed with minimal, no downtime and a huge impact on the patient's appearance. So one of the things that he mentioned was fillers. We can do a lot to volumize the face, to reshape the nose, or even make the jawline more defined. It's a very popular procedure to use fillers to rejuvenate the face and also to reshape the face. So liquid rhinoplasty, so we call nonsurgical rhinoplasty, can make a huge impact on patients that are not ready for, for surgical rhinoplasty. It's also small procedures like Dr. Bass mentioned, is you can do fat grafting to the face. So even a upper blepharoplasty that can make a huge impact on someone's appearance with very minimal downtime.

Dr. Lawrence Bass (05:32):
Yeah, and I think that's important. I mean, everyone's got a busy schedule and everyone has to budget a little bit, both their time and their money. And so being practical about what things can get you a a really improved appearance quickly is, is something to spend a little time thinking about. That's, that's something to include in your planning.

Doreen Wu (05:59):
Let's talk about the small features that shouldn't be overlooked. What are you referring to here, Dr. Bass?

Dr. Lawrence Bass (06:06):
So I'll give you a couple of examples. You know, we do filler, you know, with build cheeks and straighten the jawline and you know, big changes. But putting a little filler in an aging empty earlobe and making it look like a plump youthful earlobe really improves aging appearance and creates an attractive feature instead of a worn out looking feature. And the same kind of thing when you're doing laser for wrinkles. You know, a lot of people will laser their upper lip or laser the face, but they leave out the ear lobes and you have a wrinkly ear lobe with a smooth face, and that doesn't look right and you can have a nice smooth ear lobe. And if you're already having the recovery time of lasering the face, why wouldn't you include the earlobe? The same is true with the nose. You know, the nose always has large pores. We can't get rid of pores because they're a normal part of the skin, but we'd like to make the pores smaller, smooth out that skin a little bit. And so if you're lasering a large part of the face, always a good idea to include the nose.

(07:26):
Another area to think about is the neck. And you know, if there's hanging skin, sort of that Turkey gobbler neck, we al always see that as a bad feature. but there are a lot of other aging changes in the neck that show up even earlier that make it very clear that you're no longer a young adult. So crepiness in that skin, which is much thinner than our face skin and some of the, the wrinkles that go across the neck sort of creases in the skin in the lower part of the neck are things that we can chase with a variety of treatments and give a much fresher look. Same idea with the decollete, you know, taking that area below the neck at the top of the chest, that often shows even when we're dressed, you're wearing an evening gown or you're wearing a blouse at work.

(08:25):
And that area shows blending the pigment and texture in that area avoids a mismatch with the rest of your appearance. And in the same thought process, having all the areas match up, chasing the appearance of veins and tendons and age spots and just crepey thinning skin in hands as we age, again, is a small area that a lot of people overlook or don't with, but that is often a giveaway of how much aging has really taken place even though you've kept your face up. Another area that I do not very often, but on occasion that that can be very pleasing, is to boost the outer part of the brow, get a nice arching in the brow using a little bit of filler, which is placed right over the bony orbital rim. So it's placed fairly deep, but it just creates a little more of a shelf or support to hold that brow up.

(09:34):
And especially for patients who aren't getting the brow lift that they would like to with Botox, this can sometimes be a way just to enhance that feature in a quick non-invasive way. We talked about the eyes and the tear trough area in the eyes is sort of a big deal. You know, it doesn't have to be zero, people in their twenties have some shape there, but when you start to get a really deep trough that demarcates, you know, the eyelid skin above from the cheek skin below, filling that in with a little bit of filler just has a dramatic effect on making you look rested natural but much younger than than when you have a deep trough there. another occasional filler area for me is at the nasal base down by the side of the nostrils. Bone sinks in as we age and occasionally separate from just filling the nasal labial fold. Projecting that area can help with the width of the nose in the area, the length of the lip in the area bringing back a little more of the anatomy at the deep level that you had when you were younger.

(11:03):
A filler area that I do frequently is temples. When temples look very hollow, that's an aged look. If you look at people at, at the far extreme of age, temples become very deep. And so that's not a healthy look. We don't want to be convex, but if the temple is to concave, it needs a little filler to level it. And Dr. Maia already mentioned the nose, and I think she is 100% correct. There's precision with fillers that were never able to achieve with rhinoplasty surgery. And so if the feature is very tiny, we can more predictably create the shape change with filler very often than we can with surgery. If it's more of a support issue or a big shape change in the nose, that's more appropriate for rhinoplasty surgery. But there are many, many things we can do to change how the dorsum or the bridge of the nose looks or the tip of the nose using fillers.

Doreen Wu (12:18):
Dr. Maia, you probably have a list of small features you see as important as well. Can you share those with us please?

Dr. Munique Maia (12:24):
Yeah, so Dr. Bass mentioned a few areas of common concern for a lot of patients. One thing that is huge also in plastic surgery office is skin care. So very important for patients to start using medical grade, skin care, all the things that we do in plastic surgery. We want the skin to stay healthy. So skin sun protection and, and good skincare will go a long way to maintain the results of office procedures, lasers energy, energy devices. Also we have microneedling radio frequency devices like Morpheus that can improve the texture of the skin, can help with acne scars and also a little bit of skin tightening for patients that are young and not ready for a facelift, for example. So I offer this to my patients when I've seen amazing results. One thing we always focus on the face, but there are new technology that helps also with body shaping. Like Emsculpt is it's a new technology that has high intensity electromagnetic therapy that can help form the muscles and that prevention do work well for a lot of patients. So these are things that are being in a lot of plastic surgery offices that can help patients improve their appearance and feel their best.

Doreen Wu (13:59):
Dr. Bass, you mentioned new superficial fillers a number of times. Can you and Dr. Maia each share your approach to addressing fine lines in the skin?

Dr. Lawrence Bass (14:09):
Sure.There are several approaches. I mean, historically, fine lines and wrinkles have mostly been treated with peeling, whether that's a chemical peel, a laser peel, or some of the fractional lasers and energy-based devices like Dr. Maia mentioned, RF microneedling. So these are, these are ways to resurface the skin, get a rebuilding of the superficial layers of the connective tissue of the skin, the dermis, and diminish the appearance or ideally eliminate the appearance of the wrinkle. And that's the classic way, but it's typically multiple treatments or recovery-based treatments. And so some of the new superficial fillers, and the first example in the US was Redensity or RHA 1. But some of these fillers, and there are a couple of others coming online now, have the ability in no recovery treatment to fill in some of the wrinkling superficially and structure that superficial portion of the skin. But you have the difference between a more durable correction of the skin and a plumping of the skin with the filler, which will absorb and need to be repeated in a few months. How do you approach it and how do you decide Dr. Maia, which patient should go where?

Dr. Munique Maia (15:50):
That's an interesting question. It's always the art of consultation that we go, what the patient wants how quick they want to achieve that goal and how much downtime. So I usually take a comprehensive analysis when I look at an aging phase and just like you, I like to combine multiple treatments that surgery is not answered for everything. That's why we offer all these non-invasive treatments and minimally invasive treatments to help to either prevent or reverse the signs of aging. So usually the treatment plan involves multiple modality treatments with skincare, filler, lasers and sometimes surgery.

Dr. Lawrence Bass (16:43):
Yeah, and I think that's a great point because when you push a little bit with multiple modalities, you stay at the low end of any risk profile, but you get a more complete correction because each one is contributing something that the other one can't do quite as well. When you try to take one modality and push it really hard, I think more likely to have some unpredictable result, and it will only, it becomes diminishing returns after a while.

Dr. Munique Maia (17:18):
Yeah, I think that's the synergy of all these treatments, to help the patient achieve the goals. And as you said, in a safe way to minimize risks and optimize results.

Doreen Wu (17:32):
Those are all great points that you each brought up. So it sounds like there are a lot of workable approaches. How do each of you approach skin quality changes in the neck? Not necessarily laxity, but all the rest?

Dr. Lawrence Bass (17:44):
Yeah, this is an important point and I mentioned some of the small features in the neck earlier, but the neck skin, as I said, is thinner. A lot of the source of healing cells when you do an energy treatment or a peel in the neck, even though it's only a few inches away from the face, those healing cells are a thousand fold less plentiful in the neck than they are in the face. So we have to approach the neck skin differently. We can do things to the face very safely and predictably that we could never do on the neck without getting into terrible trouble. So it means doing energy-based treatments sequentially to stimulate new collagen addition to the skin. And sometimes that's energy from above with a light-based application or radiofrequency microneedling, sometimes it's placing energy under the skin to stimulate the skin from underneath with minimally invasive treatments. And sometimes it's putting collagen stimulating fillers, things like radis and sculptra, which are being used in a hyper dilute fashion under the skin to stimulate firming and plumping of the skin from underneath at the same time as you're either peeling or applying energy above. So that multi-modality approach but adjusted to be safe and productive with the delicate neck skin.

Dr. Munique Maia (19:31):
Yes, I follow the same approach as ave very individualized approach for each patient to see where the main concerns that, as Dr. Bass mentioned, the next skin is very thin. I like to use all the treatments that he mentioned. I usually like the heavy lasers like CO2 laser, more aggressive treatments, but also better results. So that's, that's usually my go-to. And in combination with radiofrequency microneedling together with I usually leave fillers as less resource for my patients because I think their the risk profile is a little bit higher compared to the other equipments. But I still do lasers and I also do Botox. So I do a lot of what we call Botox necklace or even microdosing Botox to help with the lines and a little bit with the muscle as well that I've seen good results.

Dr. Lawrence Bass (20:40):
Yeah, it's, it's interesting. I agree with you. I do hyper dilute fillers, but it's not my first step probably much lower down on my list. And I don't do a lot of Botox neck lifts, but I love Botox for the vertical banding where the vertical banding is muscle and not hanging skin. It really can be a home run and, you know, keep things looking much better controlled in the neck much, much longer. So everyone approaches a little different, but I wanted to ask you this, Dr. Maia, you said CO2 in the neck, but do you mean a full field ablative treatment or a fractional CO2?

Dr. Munique Maia (21:29):
Fractional CO2,

Dr. Lawrence Bass (21:31):
Yeah, that's an important distinction.

Dr. Munique Maia (21:33):
Yeah, I usually do a few months after I do a neck left. I like to, to go to that skin and treat that skin 69 months after neck lift. And I've seen very good results especially patients that are massive weight loss patients that they don't have good skin to begin with. and it's very difficult to get a good result or long-lasting result in, in this, in patients that lost a lot of weight. So I've seen good results of that. And Morpheus8 radiofrequency microneedling devices are wonderful treatment that can help maintain surgical results.

Dr. Lawrence Bass (22:15):
Yeah, I mean that's a really critical point and I think there's much better understanding of this in the aesthetic community than there was a few years back. But you said it, you said this, this super important point that, you know, the lift does a major job on resetting the skin position, but it's still your aging skin. It doesn't change the skin biology or the skin surface appearance. And so something is needed to take that now aged skin and make it look younger and so that second modality focused on making the skin look and act youthful is really important to get a more complete correction with your facial rejuvenation.

Dr. Munique Maia (23:01):
Yeah, I explain to the patients in a simple way, that the neck lift will reshape the neck, it will lift the skin, it will remove the excessive skin. So it it's about the quantity of the skin or the quality of the skin. So even though we are addressing that problem, we still have to address the quality of the skin, which comes with all these treatments that Dr. Bass mentioned.

Dr. Lawrence Bass (23:34):
Yeah, that's the buzzword nowadays that we've always worked on different features of skin that didn't look ideal or youthful, but we're now making much more global assessment and global treatment for skin quality separate from what we do with laxity and skin redraping.

Doreen Wu (23:56):
Lastly, before we wrap up our discussion today, Dr. Bass, what takeaways should our listeners leave with from today's episode?

Dr. Lawrence Bass (24:04):
What I'd like everyone to remember is that small features can really be a telltale of age. You may have chased the major issues or you may not yet need the big items, but keeping the small details in place will really help you look your best when you're smoothing facial wrinkles. It's really important not to leave out small areas because those areas will stick out like a sore of thumb. You're already having the treatment and important to hit all the little corners and edges that show that feature. A wrinkly neck, chest, or hands or the earlobes are going to be giveaways. If the rest of your face looks smooth, they're going to let people know you're not really as young as your face is trying to represent. As I said earlier, features around the eyes really have a big impact. It's a small area, but it's where people look most of the time when they're interacting with you. And Botox and other neuromodulators are still the king of small feature improvements, creating an overall better and more pleasing appearance that, you know, there's reason that most people who start doing Botox never want to stop because they look like themselves, but they just look so good that they love it.

Doreen Wu (25:36):
Dr. Maia, what you like to add? Any parting words?

Dr. Munique Maia (25:40):
Yes, I totally agree with Dr. Bass. I think it's a, you know, good discussion and an important for patients to know. One thing I want to mention, it's also the small surgeries that can be performed on the local anesthesia. A lot of patients are worried about big surgeries and then they're not ready to do a full facelift, but a brow lift can be performed in the office under a local anesthesia, downtime about a week. And as Dr. Bass mentioned, the features around the eyes, super important. So an eyelid lift, which is the upper blepharoplasty, it's also very quick procedure and very satisfying and rewarding for both patients and surgeons to to see how quick, you know, changes can be made in such a quick procedure in the office. So I think most important for people, they're listening to this conversation, let's keep an open mind.

(26:39):
talk to your local plastic surgeon and what's available to you. and you'll be surprised what can be done with small procedures. And the other thing I like to always say, plastic surgery is not about vanity. It's about quality of life. So there's a lot of bad rap sometimes for leadership plastic surgery because people only advertise the bad results. Nobody sees the good results because everybody's somewhat hiding that they have plastic surgery procedures done. So I think, you know, visit your local plastic surgeon, discuss your options, and you'll be surprised what can be done for small treatments.

Doreen Wu (27:23):
Very well said. After this lively discussion, I see that sometimes good things do come in small packages. Thank you Dr. Bass and Dr. Maia for your insights into this fascinating topic.

Dr. Munique Maia (27:34):
Thank you, Doreen.

Dr. Lawrence Bass (27:36):
And I'd like to thank Dr. Maia for joining us today and sharing her expert perspective. That was tremendous. And I agree a hundred percent with everything you just said. I think that's beautifully expressed. Thank you. Mm-hmm.

Dr. Munique Maia (27:50):
<affirmative>. Thank you Dr. Bass.

Doreen Wu (27:52):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram, @drbassnyc.