355 – Skincare strategies, the science of facial aging, and cosmetic-intervention guidance

Susan explains that peak collagen production occurs at age 18, after which fibroblasts produce less collagen, elastin, and glycosaminoglycans. Retinoids work at the DNA level to upregulate these structural proteins. She notes that early studies showing increased photosensitivity led people to stop retinoids in summer, but after the initial exfoliation phase, the stratum corneum rebuilds and photosensitivity decreases. Retinoids also have DNA repair properties even with sun exposure. Tanish adds that for sensitive patients, mixing with OTC hydrocortisone 1% can reduce initial inflammation. Both agree that consistency is key, and the tube should last about 3 months—if longer, the patient isn't using enough.

Susan emphasizes that acne scarring traumatizes patients for life—she sees 70-year-olds still crying about scars from their teens. She distinguishes comedonal acne (whiteheads/blackheads, don't scar unless picked), inflammatory acne (red pustules, may scar if picked), and cystic acne (deep, rupturing nodules that scar even without picking). She considers cystic acne a 'medical emergency' due to psychological impact. She avoids long-term antibiotics to preserve the gut microbiome. Photodynamic therapy uses ALA to selectively damage overactive sebaceous glands, offering an alternative for those who cannot take isotretinoin. She notes that 85% of patients are cured after one 5-month course; a small subset needs a second course. For adults with oily skin but not active acne, she sometimes prescribes one month per year to reduce oiliness and improve texture.

Susan explains that fat from the abdomen has the highest concentration of preadipocytes (stem cells), but she prefers flank fat because it contains more stromal/septal tissue, providing a scaffolding that improves graft take. She harvests about 120cc, centrifuges to remove anesthetic fluid, and adds albumin for oncotic pressure. She also spins the patient's blood to obtain PRP and processes additional fat into nanofat (by passing through meshes to break down adipocytes, enriching stem cells). This 'triple cocktail' (fat + PRP + nanofat) increases graft survival. Tanish uses a similar technique learned from Dr. Obaji but typically harvests less volume because he often combines fat grafting with surgical lifts. Both note that fat retains its donor-site metabolic behavior: if a patient gains weight, the grafted facial fat will enlarge like abdominal fat. Susan tells patients not to gain more than a few pounds post-procedure. Fat grafting is preferred over fillers when multiple areas need treatment because the cost of many syringes of filler would exceed the one-time fat grafting cost over time.

Susan explains that for someone like Peter (male, thicker skin), a single non-ablative treatment like Clear + Brilliant alone may be insufficient. By adding a light chemical peel immediately after the laser, the combined injury triggers a stronger healing response while still keeping downtime to 3-4 days of peeling. This approach can be repeated quarterly. Tanish notes that the field is confusing because of the proliferation of devices, many with aggressive marketing but limited efficacy. He cautions against ultrasound and radiofrequency-based tightening in patients under 40-45 due to risk of fat atrophy. Both experts emphasize that the choice of resurfacing modality should be customized based on skin type, concern, and downtime tolerance, not driven by brand names or trends.

Susan describes her customized approach: she uses a medium-depth TCA peel on the majority of the face because it can be feathered into the hairline, ears, and neck, leaving no untreated borders. TCA percolates into pores, causing them to contract during healing. For deep perioral lines, she uses a fractionated ablative CO2 laser for its precision and depth. For redundant lower eyelid skin (often in patients who decline or have already had blepharoplasty), she applies phenol, which provides a 'mini eye lift' effect that can delay surgery by 2-3 years. Tanish adds that full ablative CO2 laser is the gold standard but can be dialed down in intensity; lighter erbium lasers have faster recovery because they produce less thermal injury. Both note that chemical peels are generally safer for darker skin types because the depth can be controlled differently than lasers, which can permanently damage deeper melanocytes.

Susan explains that chemical sunscreens like avobenzone and oxybenzone absorb UV rays but generate reactive oxygen species that damage DNA, potentially increasing skin cancer risk. She notes that despite rising sunscreen use since the 1990s, skin cancer rates continue to climb, which she attributes to rapid degradation of chemical filters (within an hour) and the oxidative damage they cause. Tanish adds that the film remains on skin even after protection is lost, giving a false sense of security. Both experts have formulated their own skincare lines and acknowledge that companies intentionally make it confusing, marketing both mineral and chemical options because customer satisfaction is higher with chemical products. Susan mentions that the FDA recently mandated animal safety studies for these chemicals, a move she advocated for 15 years. They recommend SPF 50 mineral as the maximum achievable in a mineral formula.