The 4 Pillars Of Facial Aging with Dr. Jay Burns

A new artificial intelligence tool can take a three dimensional image of a face and calculate how old that person is. But is AI smart enough to see through Botox, fillers, and laser treatments? Welcome to Skintuition. I'm Heather Furnas.

And I'm Josh Korman. From pimples to wrinkles, our skin affects how we feel about ourselves. As two plastic surgeons, we discuss what's new, what's safe, and what to look for when you're ready to hit refresh.

I'm delighted to introduce our special guest, Dr. Jay Burns. Dr. Burns is a world-renowned plastic surgeon and past president of the largest clinical laser society in the world. As a leader in the specialty, he is currently the medical director of Cosmetic Physician Partners, a national partnership of premier practices and med spas. All accomplishments pale in comparison to his 45 years of marriage he says, to his best friend Jenny, and being part of his greater family, especially those precious grandchildren. Welcome to Skintuition, Jay.

Um, it's great to be here. It's great to be here. You made me smile with that last line I gave you. That's great.

<laugh> So in all those 45 years, I'm sure you're an expert in how we age. So there are many ways to think about how we age Dr. Burns. So how do you think about how we age?

Yeah. I, I have, uh, developed, uh, a way to talk to my patients when they come into the office about aging. And I call it kind of the four pillars of aging. And, and so what I'm trying to do is just make sure I'm not trying to oversell them anything. I just wanna make sure they're educated. So, uh, even if they left my office and and didn't use my services, they would be better equipped to handle the world and ask the right question. So the way I break it down is most of the patients really know something about gravity. The gravity is, you know, would be like your face is melting. So the brows get heavy, the jowls develop the folds in your face, get a little deeper, and the neck starts getting a little more lax. That's just gravity. And then the second thing that I talk to them about are the dynamic lines that we cause by wrinkling.

(02:39)
Unfortunately, I'm a great model for that. But the wrinkles up here, when we raise our eye eyebrows, when we frown the frown lines, the crows feet, those are some of the examples of dynamic lines. And I talked to the patients about that. And then, you know, the skin is the canvas. It's the largest, people don't realize it's the largest organ in the body, but it is an organ. It protects us, it keeps our, we're 70% water, it keeps us in, but that canvas can wear out through environmental factors, sun, uh, wind, all those things. So that's one thing that's the canvas can wear out. And then finally, volume is, is an issue that can occur volume loss. And so I talked to him about all of those issues so that we can direct the right treatments, uh, toward that.

Now, Jay, in this podcast we emphasize non-surgical treatments. So can you discuss non-surgical treatments that can treat these four aging changes in the face?

Yes, I can. Let's take it one by one. You know, the gravitational changes, we're all surgeons here, so we know how to correct that. But if, but I, I love the non-surgical side of it because 90% of patients are non-surgical, uh patients. They're never gonna have surgery. So I've expanded my spa, uh, in med spa to do that. And so, um, one issue that I have is that I will tell them that if they can't do surgery, they can do things that tighten the skin, like radiofrequency microneedling. And uh, that would be one option to tighten the skin. You can do ultrasound. There's a thing called soft waves. That's another option that you can have something that will actually build collagen in the skin. Some people might call that volumization, but they could also call it skin tightening. Then when we get to the, the crow's feet, the dynamic lines, there are areas in the face, especially the crow's feet, the frown lines in the forehead, primarily you can do it in other areas, but those are probably the three main areas that we use neuromodulators, like neurotoxins and the like.

(04:39)
We've got several options. We can talk about that if you'd like. And then finally, the skin quality itself is what we try to address every day in our clinic is probably our number one issue. People don't like the reds, the browns, the textures of their skin. And there's various kinds of lasers that can address each one of those issues. And uh, a lot of people think that I'm just gonna go get a laser, but as you two obviously know, and there's all kinds of lasers out there, and when the, your patients are choosing that, you know, it's, it's hard to decipher that. But I think that that's, that's where you need to do your homework because there's some lasers that are better than others. There's some lasers that are for red, there's some that are for brown, there's some for those textures.

(05:17)
And so that's how we do that. And then the volume issue is one of the things we address, which would, uh, the primary thing a lot of people are aware of are the fillers. And there's various options for that. There's fillers that stimulate your own immune system to produce hyaluronic acid more. And then there's, uh, other fillers with varying links. And those are the things that you'd need to come in to a doctor's office and decipher. So that's, those are in from 30,000 feet. That's how you would address all those four pillars of aging. And I think the only thing I tell my patients are is that when each one of those tools are specifically used for a certain thing, and uh, the analogy I use a lot is, you know, they know a saw is what you use to cut a board into, and a hammer will do it, but it's not as elegant and it's a, there's a lot of side effects.

(06:04)
And so if you'd use filler early on when you have some deepening areas in the fold, for example, that will mask it for a while. But as that gets deeper, you've gotta realize that's really the wrong tool. I mean, you can use it, but the point is, when it gets so much, that's really a gravitational issue. And some people say, I don't want to use filler cuz it looks unnatural. And I believe that's when we use the filler too much because it's the wrong tool for aggressive advanced gravitational issues. So it's, that's why I think it's important for the patients to know the pillars and what's used to do it. And you want to use the right tool in a surgeon or a aesthetic expert to, uh, address all of those issues in the right way.

So that's super interesting to, and obviously correct that you want to know to use the right things. What do you think about combining non-surgical treatments that potentially can have a synergistic effect? Obviously if you use a heat generating device along with fillers, it can melt the fillers and, but what about, do you find that energy devices, the radio frequencies seems to be the energy of the decade and lots of different microneedling things.Do, do you find that, that using different devices on the same patient either at the same time or at different times, do you find that they can have a synergistic effect?

I really do, Josh, uh, it's a great question and I, I rarely, if ever use one laser. I mean we will, we will do it, but I I, I rarely, I rarely do. For example, what you just said is that if you are gonna go radiofrequency, the needles go down in the skin and at the tip of that needle, ideally there's a little difference with radiofrequency microneedling devices. But in general, the theory is that we're trying to heat collagen at the deeper level in the dermis to 55 to 62 degrees. And if we can do that, we stimulate the immune system collagen down there. Well, uh, we've got devices now that can stay right up at the epidermal level and actually polish the skin. So we always combine our radiofrequency microneedling with, it's a 1927 wavelength. Those are different. They could be called Moxi, Ultra, Fraxel Dual.

(08:20)
It doesn't really matter on that point. But the point is, is that, is that we polish that skin so the patients can see an immediate improvement within a week where the skin is just much better looking from the surface while the radiofrequency may take three to six months to see the final result. And so the combination is that we have really done more to the skin, we've treated the superficial and the deep and we've done it safely cuz we've used techniques. We also use a ton of combination therapies where we go after reds and browns and we add that polishing laser in there. But we, we combine a lot of lasers. I've been doing this since the late eighties and, uh, we tried this combination back around the turn of the century back in, I remember 1998 to 2005, we were combining technologies, but they weren't nearly as good as they were, are now. And so basically when we combined back then, zero plus zero was, was zero. And so it, it didn't work very well, but now we've got, we've got the best technology we've ever had since I've been doing this. And if you know how to combine therapies, the patient can get much more bang for their buck and much more value. They can get a couple of treatments at the same time and get to where their goals are achieved in a much more rapid way. It's a great question and I hope that helps, uh, the listeners here.

So Jay, you said that, you know, we've got the best technology we've ever had. We, we can get different levels of the skin. Do you think non-surgical treatments can take the place of surgery?

I don't, I I'm pretty adamant about that. I, I think there's, there's no way I've, I've never seen a non-surgical treatment. I've heard it said in the meetings that, oh, this is like facelift in a bottle or this is the new facelift. And you know, as a plastic surgeon, I have to, to laugh at that. It's from people who really don't do facelifts because, you know, the only facelifts that people, uh, remember are the ones they, they notice and those are the ones as plastic surgeons, we don't want them to notice. We want it to be natural and good. And there's tons and tons of people out there that have great facelifts in my opinion. On the other hand, as I stated, 90% of the people are never gonna have a, a facelift. And that is okay as a plastic surgeon, I've, I've been very fortunate to, you know, it's by God's grace that I came to that conclusion because I've been, I, I have a hat where I can do surgery, but if the patient doesn't want that, I can give them as much as we can get up to a certain point. But we can clearly make advances we've never been able to make before. But I don't believe Heather, they're ever going to, at least for the foreseeable future we can get there to achieve surgical results.

Do you think that surgery can actually offer permanent results? Obviously permanent is death and taxes and that's about it. But do you think surgery can provide for those that are interested in it, do you think that can provide permanent results?

Well, as I tell my patients, I tell them a facelift will last. If we're trying to address, let's say it's jowls, it's the skin component, the jowls and the neck and, and the brow. I say, you know, your best result, if I was gonna take a picture to win a contest, I would do that at six months, the swelling's gone, gravity hasn't set in, but from that point forward you reset the clock and we live on a planet with gravity, so every year you're gonna get a year older. So no, I don't believe that the, the gravitational improvement we can get from surgery is permanent. I, I don't, and some people think that's the case. Now, on the other hand, if we take some fat out of the eyes, if we were to do some surgical procedures, some of the things that we do can be very long lasting. But I don't believe anything is totally permanent.

So as we age, we will like to stave things off. What would you recommend for maintenance and um, prevention focus on maintenance?

Yeah, I think that, I really believe that we have the best data we've ever had to answer that question. And um, there are some technologies out, and I don't know if you want me to mention those precisely, but there are technologies out where studies were done that showed that three of these particular procedures that were done, uh, which are very low downtime, you know, maybe an hour of redness, no numbing required. And if you do that three times a year for three years, it actually activates the youthful genetic makeup of your skin and you turn on the youthful genes. Or if you're young, we treat a ton of people now in their thirties and forties that say, when should I come in? And I used to say, I don't know, maybe you know, when you look like your mother or your dad or whatever. And the point was is that we didn't really have anything. But now we have data that shows if they'll do that simple procedure, tremendous value three times a year, that they will change the actual genetic structure. We see great results with doing that kind of maintenance treatment and hopefully, you know, we have been doing this, but

This laser, I'm on the edge of my seat. Just tell, go ahead and tell us what the treatment is, <laugh>.

Yeah, well it's the BBL treatment. Now it's what the study was done. There may be other lasers, there's theories that if you treat the skin long, you know long enough and steady enough that maybe many lasers can do this. We've had this debate forever, but the only study that I've ever seen where that's been proven was with the BBL and it's an I P L device. It's called a broadband light. And it's very powerful. It's the fastest I P L in the world. It's very strong. I have two of them, it's going all the time in my clinic. And so I show the patients the actual, there's 1500 genes that they test for the, the skin and, and you're, you know, I, you can actually see the difference when you do these studies. Uh, they came outta Stanford in your neck of the woods.

(14:18)
You guys are both out there close and by reputable people. So we do that. And then, then there was a study done by Dr. Bitter and Dr. Pozner, who we all know as experts in the field. And they did a study where if you went on and on and on in their practice over 10 years, he shows many, many patients that their skin actually looks better 10 years later than they did when they started. I know that sounds crazy, people want a magic wand. But I really believe that after I do some aggressive treatments on, you know, you know, I'm, I'm, I'm known for doing aggressive laser resurfacing, which has much more downtime. It's actually in between non-surgical and surgical. But that's not the point of my discussion. My discussion is after they get a tremendous improvement in those deep, deep wrinkles, how do I maintain it? BBL hero is, is one of, is the way I would do it across the board and then if I have young patients who wanna prevent it so they may never have to have those aggressive treatments. I just think that's the biggest pearl and probably the one of the biggest advances I've seen in this space in the last, uh, 10 years or even the last 30 years. It's been a fabulous treatment.

So do you think that's true on different kinds of skin? Do you think that's true on Caucasian skin, on Asian skin, on African American skin, native American skin? Do you think it, it doesn't matter which genetics or do you think it depends?

Well I think that it's a little complicated question. The problem with the BBL laser and know, I don't wanna get too technical with the viewers, but from certain wavelengths 400 to 700, usually that's visible light. The colors of the rainbow when you're in that spectrum, it absorbs the browns very heavily. And so we have to be very careful in ethnic skin. So there's six skin types, the three, 1, 2 and 3 are very light Caucasian skins, various shades, but it's all Caucasian. When you get into ethnicity and when you get up, uh, into you know, pacific rim descent and uh, up into even, you know, Haitian black, you gotta be very careful to even treat with B B L cuz there's some other complications. So Josh, I'm not really sure, it's a great question, but I would, I would think that on one perspective, if you, we have to turn the energy down, but if you did it, I bet it would actually enhance the youthfulness of the skin. The problem is if you're not careful, you can call some darkening of the skin, it can be splotchy. So we have to be really careful when we get and treat darker skin types with that device.

So that's a good point. Really good point. The question then is, okay, so what preventive measures can we take to delay aging changes? Can we use products, injectables, energy devices like the BBL you're mentioning? Yeah. What is the consumer who's like, okay, there's a big buffet, how do I know what to do when?

Yeah, well I think that's a great take home point. And so I'll always tell people I don't wanna oversell you, but I'm, I'm gonna tell you all of your options. So if you were in my office, I'd say here are the options you can do. And I have people in my office that, that are gonna use one product and one product only. Some people use five products, some will use 19 products because they've got the time and they're, it's very important to 'em. So I do believe that good skincare, good skincare products are fantastic. Sunscreen is the, the most basic thing you can do. It prevents that sun damage and that can absolutely prevent the aging look of a skin and so much more avid about putting sunscreen on as I was, I'm in that age group where most people get most of their sun between the ages of 18 and 25.

(17:58)
And so by the time we get old enough and wise enough to go, okay, maybe I am gonna get old, it's a little late for the sun damage. So get your kids on sunscreen, do that. Then you can actually use antioxidants like vitamin C, vitamin E, there's all kinds of products that are antioxidants and if the sun does get through and starts creating some damage that vitamin C and those antioxidants can clean up and prevent the effects of the sun and it's damage. And then finally we have great skincare products now that can stimulate collagen and elastin and can restore the skin. And I really can say honestly that I put on regimens in the morning and the evening and use my sunscreen, I'm a golfer when I go outside I wear the sleeves that are SPF protected SPF hat with a wide brim. So that's for the product. Injectables, no question.

(18:46)
You know, my daughter's a dermatologist and for the viewers you can see my forehead, which is not a pretty sight and my daughter's beautiful and she's a dermatologist and she got some Botox when she was about 32 or three. And I said, what are you doing? And she said, dad, go look in the mirror I I've inherited your forehead. So she has been getting neurotoxins, whether that's Dysport, Botox, daxi, whatever it is to try to prevent that. It's kind of like, you know, if your pants are wrinkled, just hanging them up and letting the wrinkles fall out of that. If your muscles are not moving, those wrinkles will soften quite a bit and it's really good around the crow's feet, uh, the frown lines in the forehead. So that's an injectable that you can use. And then finally the, the energy devices is what I mentioned. The BBL is our probably number one device, but it has, the study's never been done but I believe that other lasers would probably do similar effects. We use Pico lasers for toning and so I don't wanna get into all the specifics but I believe you can really do a lot early on with those great categories. You mentioned products, injectables and energy devices.

Are you seeing more men taking an interest in prevention and looking younger?

I absolutely am. I think that, you know, I'm sure I'll get a laugh, people think I'm joking, but men are definitely not as tough as women for sure. And so we have devices now that don't hurt as much, so they we're getting 'em in the office. Now the BBL is, it doesn't require a numbing. And so we've got great devices that can, they can really see a difference and uh, we have to be careful with beards and things like that and so that they don't lose any hair temporarily. But yes, I see more and more men and their wives are driving them in and so we we're targeting them because I mean I see my pictures and I keep my before and after pictures and all you have to do is see my before and after pictures with three BBL and I threw in a moxie there as well, which is the 1927 laser I told you about.

(20:48)
And my pictures before and afters are amazing. So I think everybody would benefit from this cuz we've got some, we've just got some easy ways that really work. You know, you guys both have been around long enough to know that we'd go to meetings 20 years ago and people would throw up before and after pictures and I'd be struggling to see a difference and that's just not true anymore. I think that if you do it well and you get the right technology and great people doing it, we just see the best results we've ever seen before doesn't approach surgical gravitational improvement. But in terms of skin quality, we didn't script this, but I'd be interested in talk asking two plastic surgeons if they think I'm crazy. But if a patient asks me of those four pillars of aging, what's the one thing you could do to make the most difference? I would tell you if you could make your skin look younger and healthier and homogeneous, I think that's the best thing we can do. And I'm a surgeon, I think if you can do all of it, it's great and do it well. But I, I'd I'd love your opinion on that. I mean what do you think?

Well I saw a patient today who's 67 years old who came to me for a facelift and I really tried to convince her that the most important thing was the quality of her skin because the quality of her skin was by far, she still signed up for her facelift cuz she didn't, that's what she came for. But I tried hard, I tried hard because I think she would actually, yes she has the, the gravitational pulls of the neck, but really the number one thing was the quality of the skin.

Yeah, I agree. Cuz oftentimes people come in for facelift and their jowls aren't bad, you know, under the chin isn't bad, but the quality of their skin is what makes them feel old. They've had a lot of sun damage, some may have a history of smoking and or there'll be sailors or something like that. And if you can avoid the, the direct sunlight, use sunscreen, use some Retin A use some of those products, that that really goes a long way.

I've written some stuff and I've championed an idea where you can do facelifts and lasers at the same time and, but I, um, if I had one quick story I was, it was 20 years ago and I, I learned a valuable lesson about this as I was dancing at a wedding. We had a couple that I love, but she always wants to know who's had plastic surgery. And so she danced over with me and she said, go dance over that lady. She's had a terrible facelift. And I go, what are you talking about? She said, I, I don't wanna do that. She said, no, no, go dance over there and confirm she's had a terrible facelift. So I mean we, we love them. So I went over there and it hit me. She had a perfect facelift but they had totally neglected her skin so her skin looked 70 and her contour looked 50 and it didn't set. And it was almost great for me because I think the plastic surgeon sometimes and sometimes the patients just don't want to do it, but boy, matching the skin to the contours of the face and not neglecting that. I think plastic surgeons are getting better and better about making sure we all these four pillars. But that was a real educational moment for me and I, and maybe it led me to the, to making sure that I took care of the skin when I did their faces, but it served me well in my career.

Yeah, it sure makes the facelift look a lot better. So do you think that, you know, in my introduction I mentioned an artificial intelligence tool. Do you think by doing these various, uh, things, fillers and Botox and neuromodulators and lasers and products, could we fool artificial intelligence into thinking that we are younger than our chronological age?

I don't know, you're, you're a little bit out of my pay grade on that one, but I'm just trying to understand this artificial intelligence. It's blowing me away at everything that it can do. And I don't know if we can fool it or not. You know, our iPhones can recognize me sometimes when I have my sunglasses on or when I've gained weight or lost weight or whatever, or when, even when I've grown, I grow a little, uh, a beard, you know, in the winter sometimes. So I bet it probably could. I mean, AI is blowing me away. I, I've talked with you and your husband about this just recently and I was actually playing with it last night, the AI feature where you can look and see the AI tells you what you need and I'll, I will have to tell you, it was fascinating.

(25:08)
It, it was really quite a trip cuz it changed my face and I didn't notice it. It was really an interesting concept. I looked at my face and I said, where's the before picture? And it said, tap on the screen to see your before. And I didn't even see it change to do that. We always think we look better than we do. And I tapped on that screen and it went back to the before and I went, oh my god, I'm walking around looking like that. That's crazy. And so you guys actually introduced me to that and I've been, I played with it yesterday and it is very intriguing. Uh, and it's amazing what AI's gonna do. I know that we're gonna use AI and robotics. I'm doing research on that and we're gonna do that for lasers to make that even better in the future and safer. And anytime we can do that and we're humans and we're, we get tired and we, you know, we lose focus on, in the best of hands, I don't care how good a surgeon you are. So I do believe that AI and robotics are gonna be the next step in safety and, and uh, efficiency and speed and um, and results, I think. That's what we're working on.

Well I think that's why we got that, you know, there's three ages in life, youth, middle age and you're looking great. So I think we can have <laugh>, I think AI will help us look great. So Dr. Burns, what, what is one big thing everyone should be using or be doing to stave off aging changes, besides getting ChatGPT?

There you go. There you go. Well, I mean the simplest, cheapest thing, we've already mentioned it. Heather mentioned it, it, you know, we beat it to death, but I just think that preventing sun reaching your skin is the best thing we can do. I'm an outdoors person but you know, putting on sunscreen, wearing protective clothing, hats, those kind of things is the very simplest thing you can do. And uh, if you could only do one thing and doesn't cost very much compared to the others, that'd be a great place to start Josh.

Yeah, I only add to that, that you should put it on at least 30 minutes before you go out in the sun cuz to just go the second before you go on. Especially if you're gonna go swimming, it's good to put it on early.

Yeah, yeah. And I also would say that people don't realize this, but the two things I tell my patients, the studies have shown that when they give those SPF numbers, they did a study and they, they had patients put on sunscreen, just gave them the tube and put it on. They measured how much they used and they found that they put on six times less sunscreen than in the studies that were used to produce those things. So we need more than we think. And the other thing is that sun begins to start degrading that sunscreen the minute it hits it. So the longest lasting sunscreen that I know of is zinc oxide and it lasts about 80 minutes under the sun. So we just, we have to reapply it and we have to put on more than we think.

That's great.

That is great place. Jay, thank you so much for joining Josh and me on Skintuition. We really appreciate your time.

My pleasure. I respect you both and it's a, it's a great honor to be here. I hope we've helped the, the listeners.

Great. Thank you.