#13 – Brett Kotlus, M.D.: How to look younger while we live longer

KEYPOINTS

• 01

  Facial aging combines sun damage, thinning skin and shifting volume

  Kotlus, an oculoplastic and cosmetic surgeon, says years of sun exposure cause solar elastosis. Collagen and elastin fall, the skin gets thinner, and small blood vessels (telangiectasias) and brown spots appear. Meanwhile the face loses volume, sometimes in the wrong places. In his practice, darker skin types and many Asian patients tend to age better. He attributes this to denser connective tissue and the UV protection pigment provides, while stressing that they still need sunscreen.

• 02

  Kotlus suspects UV exposure slowly destroys facial fat, but calls it a hypothesis

  His reasoning is by analogy. Focused heat and laser devices are known to destroy fat cells, so he believes decades of UV may do something similar to facial fat. As supporting observation, he points to lifelong sun-avoiders with 'porcelain skin' who have fewer wrinkles and younger-looking faces. He frames it as his own belief, not established science.

• 03

  Looking 'done' comes from over-enlarging or over-pulling natural shapes

  A natural face needs shadows and movement. He gives the analogy that you can't have light without dark. Overfilled lips lose the Cupid's bow and the 'two pillows' of the lower lip and turn into a 'sausage'. Over-tight facelifts create the windswept look. His rough guideline is to aim for looking about seven to ten years younger, because 'there's no amount of money' that makes someone look naturally 30 years younger.

• 04

  Social drift and 'provider shopping' push people too far

  Kotlus describes an 'Instagram effect': filtered and augmented faces start to look normal, peer groups escalate together, and some patients find a new injector when one says stop. Peter adds that he only sees the badly done cases, the numerator, and not the denominator of people whose work goes unnoticed.

• 05

  Hyaluronic acid fillers are biocompatible and reversible, but lips swell at first

  Hyaluronic acid already exists in skin, allergic reactions are generally absent, and an enzyme can dissolve it if something looks wrong. The gels attract water, so lips look oversized for about two to three days. He says almost every first-timer then admits they 'sort of missed' the swelling and wants more next time. Lip filler lasts about six to eight months; under-eye filler lasts one to two years and sometimes four to five.

• 06

  Bad Botox is usually too much in the forehead

  The frontalis is the only muscle that raises the eyebrows. Heavily injecting it to erase horizontal lines leaves a shiny, frozen forehead and brows that actually drop, which he calls a giveaway at the Oscars. He says a better approach often targets the corrugator and procerus muscles between the brows that cause frowning. Modern technique uses smaller amounts spread more widely, and can lift mouth corners, reduce a gummy smile or open the eyes slightly.

• 07

  Start prevention before lines become etched

  Kotlus emphasizes that nobody has to do any of this. For those who care, prevention comes first: sun avoidance from youth, and possibly neurotoxin before expression lines become permanent creases, for example if you see those lines on your parents.

• 08

  His three core skincare tools are sunscreen, a retinoid and topical vitamin C

  Retinoids act at the gene-transcription level, boosting collagen and cell turnover. He calls them one of the few proven anti-aging treatments. Vitamin C is an antioxidant and a collagen cofactor, and it works better with vitamin E. Its caveat: if blood vitamin C is already high, skin may absorb topical C poorly. Evidence supports it for reversing existing sun damage more than for preventing it. He says some patients improve dramatically from this regimen alone, 'without touching them with a needle'.

• 09

  Some devices are operator-independent, but lasers and peels are not

  For cryolipolysis such as CoolSculpting, or heat-based alternatives, the main point is to use an FDA-approved device rather than a knockoff. He says these typically reduce about 20% of subcutaneous fat over a course of treatment. Peels and resurfacing lasers depend heavily on the operator.