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Hormones and aging go hand in hand, so it makes sense that hormone replacement therapy may be able to help address common signs of aging.
In today’s episode, I sit down with Dr. Deb Durst and her nurse practitioner, Farideh Golembiewski at RevitalyzeMD to discuss how plastic surgery and hormone replacement therapy can work together, where these approaches overlap, and the best way to solve for common signs of aging.
Hello and welcome to The Trillium Show with Dr. Jason Hall!
This podcast is all about navigating the changes in our lives, whether they be through plastic surgery, adopting new habits, or making positive life improvements. Dr. Jason Hall, a renowned plastic surgeon and lifestyle expert, is here to guide us through the ups and downs of transformation.
Throughout this series, we'll explore topics such as body positivity, self-confidence, healthy living, and much more. Dr. Hall will share his expertise, as well as invite special guests to join us in the discussion.
So, whether you're considering plastic surgery or simply looking to make positive changes in your life, this podcast is for you. Get ready to be inspired, informed, and empowered on The Trillium Show with Dr. Jason Hall.
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.
Dr. Hall: So hey, everybody. We are here on location at RevitalyzeMD. You can tell we’ve got a different, very cool setting. I had the pleasure today of talking with Dr. Deb Durst and her nurse practitioner, Farideh Golembiewski about all things hormone replacement, vaginal rejuvenation, peptides, a bunch of stuff I really didn’t know about. I learned a ton; it was a great interview, so check it out, hit the little bell button, subscribe, like, share it with your friends, and get ready for a great show.
Dr. Durst: Hello everyone. It's Dr. Durst, and welcome to RMD, all things aesthetics and wellness podcast. And I have a special guest with me—I have Farideh, my co-host, and then we have a special guest with us today, Dr. Jason Hall. I’m going to let them both say a few words.
Dr. Hall: Sure. Well, I—Dr. Durst, I appreciate you having me here today. Really looking forward to getting into all things hormones and aesthetics, so this will be fun.
Dr. Durst: We’re so glad to have you.
Dr. Hall: Thank you.
Ms. Golembiewski: And I’m a regular on here, so you guys all know me. But we’re really excited to have Dr. Hall today and talk about all the things with plastic surgery, and hormones, and wherever else the topics may take us.
Dr. Durst: So, we’re going to start. Today’s podcast topic will really be, you know, surgery and hormones and how that might tie together and work in combination, you know, to get you lasting results and better outcomes, and all of the things. And so, as we have questions, we’ll just go back and forth. And—
Dr. Hall: Sure.
Dr. Durst: —you—
Dr. Hall: This’ll be fun.
Dr. Durst: Yeah, it’ll be fun. So, we’re going to start with, like, even, you know, I guess our patients being perimenopause and menopause age, are frequently looking for surgical corrections of things that are happening. We do aesthetics but obviously non-surgical options. But they’re of an age that they’re going to actually need a little bit more at times. And so, what do you think you see the most of a perimenopause, menopause age in the office?
Dr. Hall: That’s a great question. So, about two-thirds of my practice is women who are perimenopausal or menopausal. And in that age range, there really are all comers. We see a lot of breast and body surgery. So, breast lifts, breast lifts with implants, abdominoplasty, and then facial surgery from eyebrows and eyelids to face lifts, neck lifts. You know, with Covid and Zoom, the neck has become a real focus.
Dr. Durst: Mm-hm. Oh yeah, they don’t like seeing that.
Dr. Hall: Yeah.
Ms. Golembiewski: No, no.
Dr. Hall: Nobody likes the Zoom neck.
Dr. Durst: Well, Zoom can be kind of [crosstalk 00:02:59] without a filter of some sort.
Dr. Hall: Yes exactly.
Dr. Durst: A ring light.
Dr. Hall: A ring light plus.
Dr. Durst: Yeah.
Dr. Hall: So, that is the, in that age range, pretty much—
Dr. Durst: That’s everything.
Dr. Hall: Top of the head to the bottom of feet.
Dr. Durst: It’s everything. And so, that’s a significant proportion. That, like, not something that I knew, necessarily, but it sounds, like, two-thirds then are of an age, an older age. Because well, that gives us a lot of opportunity to talk about that age range and different things we can do to optimize them.
Because we don’t do a lot of younger patients. It’s mainly as they start to notice some symptoms, and when they hit the 40—and we always say 40 to 55 is that perimenopause and perimenopause is no-man’s land, you know?
Ms. Golembiewski: Yes.
Dr. Durst: You don’t really know what’s going on. Your estrogen tends to be a little high, not really high, but looks high in comparison with progesterone and testosterone which drop. And so, they tend to be, you know, a little more emotional; they’re starting to notice things that they might not have noticed before, they’re looking in the mirror, seeing things and not doing any composition—yeah—
Ms. Golembiewski: Not doing any composition changes.
Dr. Durst: Yeah.
Ms. Golembiewski: Sleep starts to not be so good, night sweats start to occur. So, some of those hormonal changes. Even as early as 30, in some of our patients, are starting to see those differences. And of the patients that you’re seeing for surgery about what percent do you see are on hormone therapy?
Dr. Durst: Mmm, good question.
Dr. Hall: Very, very few actually.
Ms. Golembiewski: Very few. Okay.
Dr. Hall: And this is really exciting for me to be here and learn from the two of you because I do see—and we were talking before we got started—I do see a significant number of those perimenopausal and menopausal patients are on some sort of antidepressant, anti-anxiety medication. And, you know, from your standpoint, we’re to those hormone deficiency symptoms start and what are, kind of, the most common things that you are seeing that you’re treating?
Dr. Durst: And so, that’s a great question because I didn’t realize so many weren’t on hormone replacement. But I think it is an underserved—like, women and hormones, they don’t know, really, where to go. And so, it brings up the—they’ve been to the gynecologist, they’ve been to the primary care physician, and basically it’s your aging, and so when you talk about medications, what’s the first thing that happens when they go to the gynecologist or primary? They’re not sleeping, so they get placed on sleep medicines.
Ms. Golembiewski: Sleep medications. Yeah.
Dr. Durst: They’re anxious; anti-anxiety. And they’re a little depressed, so antidepressants. So, we’re not deficient in antidepressants or anti-anxiety medicines. We’re deficient in progesterone.
Ms. Golembiewski: And progesterone is our feel-good hormone, and that’s usually one of the first hormones that drop as we start going through perimenopause. So, a lot of times, we can just replace progesterone if we’re low and balance it with estrogen, and we can see sleep improve, mood improve. Bouncing the estrogen can make a huge difference in these women’s lives.
Dr. Durst: Yeah. And again, it’s really that 40 to 55. So, estrogen doesn’t drop, it looks high in comparison to progesterone and testosterone. And, like Farideh said, progesterone is your feel good hormone, so you can’t sleep. Now, all of a sudden, you’re pissed off that everything, you know? Just like—
Dr. Hall: [laugh].
Dr. Durst: —that. And so, like—
Ms. Golembiewski: Little things set you off that never set you off before.
Dr. Durst: And we used to—
Ms. Golembiewski: Anyone think that meme the other day was hilarious? You’re, like, “Why is the floor on the damn floor?” Like, all the little things make you mad.
Dr. Durst: Anything makes you mad. And so, we frequently hear, you know, “I was laid back, and now all of a sudden, I’m not laid back.” So, those are the most frequent things we see in perimenopause is, “I can’t sleep. I’m anxious. You know, my mood is not the same.”
And that can be testosterone or progesterone, but test drops too, and so that lifeforce for men and for women is testosterone, but it’s really, like, almost a gender bias for women because women and testosterone is unheard of. There’s no FDA-approved treatments for women and testosterone. But you can still do that. You’re using bioidentical, you know, which it’s different. So, we’re using, maybe, pellets or injectables to do testosterone. But, again, it brings us to improve healing with surgery. And then again, moods better, they’re sleeping better, you know, the inflammation is going to be fast—
Ms. Golembiewski: Energy is better.
Dr. Durst: Or energy. All that. So.
Ms. Golembiewski: Which is huge when you’re looking at body composition changes, right? If I have the energy after work to go to the gym and workout and I’m able to build muscle because my testosterone is optimized, I’m going to have better composition overall, I’m going to have a better workout, I’m going to have better recovery, less inflammation, and I’m just going to feel better overall.
Dr. Durst: You know, as in medicine, in general, bleeding, like uterine bleeding, is a big thing—fibroids. And so, I worked the ER for decades. And so, people would come in that perimenopause age and they have excessive bleeding, uterine bleeding, so they have ablations and hysterectomies and all of that. Endometriosis is more common.
And really what they needed is progesterone optimization. You know, not necessarily a guarantee, but most of the time, if you have long enough period of time to oppose estrogen with progesterone, you might stop their bleeding. So, we might have less surgical hysterectomies, fibroids, all of that. So, it’s interesting because we don’t learn that in traditional medicine.
Dr. Hall: No.
Dr. Durst: You don’t learn anything about hormones in traditional medicine. At all.
Dr. Hall: No. Very, very—you learn the pathways, how they’re made, and—
Dr. Durst: Correct.
Dr. Hall: —how they help support pregnancy, and then that’s pretty much it.
Dr. Durst: Correct. Yeah. No, we don’t learn anything. So, you really have to branch off and learn just hormone replacement to be able to do it, right. So, I would prefer that people send them to somebody that has hormone replacement as a specialty in it because otherwise they get the wrong answers or the wrong approaches or they put them on estrogen—
Ms. Golembiewski: Or they get half treatments.
Dr. Durst: Yeah.
Ms. Golembiewski: We see that a lot. Half treatment.
Dr. Durst: Well, and again, hot flashes and night sweats don’t equal estrogen loss, but you don’t actually see them, at least on estrogen first. And they’re already looking estrogen-dominant, and so it makes it worse. So, when you get the very emotional patients in that age range, it could be that, too. So, it’s just interesting that we never learned a thing about it.
Dr. Hall: It really is. And one of the things, you know, I came from a general surgery background first. So, before plastic surgery, went through the whole five-year torture that is general surgery residency. And so, one of the things we start hearing about hormone replacement, one of the things that I immediately start thinking, and I know some of our colleagues in medicine start thinking about it.
Dr. Durst: [crosstalk 00:09:26] probably.
Dr. Hall: You probably—
Dr. Durst: Oh yeah.
Dr. Hall: —already guessed is the breast cancer correlation. And you know, what does hormone replacement in a perimenopausal woman do to their breast cancer risk? So, what—help me with that one.
Dr. Durst: All right. Well, and that’s interesting—
Ms. Golembiewski: And this is very common. It gets brought up often.
Dr. Durst: Well, and I think it goes back to, like, so the initial, like, big scare with that was, like, the World Health Initiative study, which was, like, 1993 to 2002, and it had, like, 16,000 women in it. And so, with that, it was actually ended early when they did two—a combination therapy of estrogen and progestin. So, to be clear, neither of those in the study were bioidentical, which is what we do now. But, you know, even doctors don’t understand bioidentical versus some synthetic—
Ms. Golembiewski: Synthetic.
Dr. Durst: Even to this day. And so, I’ve been doing this for 12 years and it has not changed in traditional medicine. But so that study, everyone was on Premarin and Provera. You remember that?
Dr. Hall: Oh, absolutely. Yeah.
Dr. Durst: Everyone was. So, Provera is a synthetic progestin that is not bioidentical. And Premarin is an equine horse urine estrogen. So again, neither one of those are bioidentical.
They’re synthetic. So, when they actually—they stopped it early for breast cancer, cardiovascular risk, and stroke. And in the study, people on hormone replacement actually had less in the way of colon cancer and osteoporosis, but it was the other concerns. So, when they actually looked at that later on, it wasn’t actually even the Premarin arm; it was the Premarin and Provera. So, the progestin was actually the one that caused more issues.
But again, now we’re using bioidentical, and so you’re using a different form, and so it’s not—it doesn’t cause breast cancer, but it can cause a breast cancer—like, an estrogen receptor-positive breast cancer to grow if it’s there. So, screening mammograms are necessary once we reach menopause and are replacing estrogen. We’re not to a point where we’re actually using estrogen in breast cancer or even breast cancer treatment survivor patients. So, we’re not doing that at all. But just like estrogen, you would think that if estrogen caused it, everyone when they’re pregnant and younger, would get breast cancer.
But it’s the same thing; if they get it, it’s genetic predisposition, so if they get it, they block estrogen production. And so, we won’t place somebody on estrogen if they have it. So, we do require screening mammograms, but it doesn’t cause. And it’s kind of similar to men. Like, everyone made it seem, like, testosterone caused prostate cancer.
There’s a good book out called Testosterone for Life, and Morgentaler is a neurologist from Harvard that wrote the book, and basically has, you know, critically—
Ms. Golembiewski: Multiple studies. Yep. [laugh].
Dr. Durst: Critically looked at all the studies that suggested it, and it doesn’t cause prostate cancer either, but it can cause it to grow if it’s there. And so because, again, I think common sense would tell us it’s not the case, you know, because if estrogen causes breast cancer or if testosterone cause prostate cancer, men and women would have it at a very young age, but it always happens at an older age. So logically, it made sense, but I think that huge study scared everyone. And at the time, you were probably I don’t know where you were in your—
Dr. Hall: At the time that came out, I was in—finishing medical school when all that came out.
Dr. Durst: And everyone was being taken off of hormones. And so, 50% of people were taken hormones with that. But then after they evaluated later on, it really was the progestin part, and now anything related to bioidentical has no correlation with breast cancer.
Dr. Hall: That’s another question that I have is in doing some preparatory work for this is, that the bioidentical designation is tossed around a lot, and it’s not something that I, until I started reading about it, understood. And I think a lot of patients, certainly, if I start recommending—if and when I start recommending patients seeing somebody for hormone replacement, what does that bioidentical designation actually mean?
Dr. Durst: So, it’s actually very interesting. Because it is, like, it’s a term that I think even—
Ms. Golembiewski: It’s interchanged so much in medicine inappropriately.
Dr. Durst: Yeah.
Ms. Golembiewski: And I think it is a key word that has become a little pop—you know, like, it’s a fad, this bioidentical, but really, when we look at bioidentical hormones, the body is recognizing it as its own and utilizing as its own. And so, it’s seeing that synthetic arm. So, it is a big difference between pharmaceutical companies making a chemical comment to try to mimic the body versus taking something natural, like from yams, and having the same components the body can actually see it and utilize it as if it is our own production.
Dr. Durst: And again, so they’re synthetic, in that they’re made and not obtained from someone, so I think that’s one of the big confusing points. Because it’s still made, but it’s identical to the body’s own hormone. So, estradiol is the one we’re replacing. So, there’s three estrogens. You know, estriol, estradiol, and estrones. Oh, estrone is a very weak one nobody uses, that it’s postmenopausal and weak. Estradiol is the one that’s premenopausal and strong and preventative. So, preventative for bone, brain, heart stuff, but it’s E2, estradiol. It’s identical to the estradiol that we produce in our body. So, for simplicity terms, no matter what term is used, I think there’s other things, like, bioacti—bioidentical, bioorganic, like, there’s all kinds of different terms, but we’re measuring hormones before we’re replacing and we’re measuring after. So, a drug or Premarin, for instance, which was a synthetic, we could not test in the blood. And so, we can do an E2 level, a baseline, treat, and then do an E2 level and see where we’re at. So, it’s identical to the E2 of the body. And progesterone, bioidentical micronized, is also identical to progesterone. So, they don’t add, like, a small chemical component that’s close and mimics, but it’s identical.
Dr. Hall: So, the testing that you’re doing is very similar to say, testing vitamin levels. If you like, Vitamin D has been all over the news in the last couple of years. You’ve replaced vitamin D3 with vitamin D3, and then you check vitamin D3 later, and see where you are?
Dr. Durst: Correct. Like, that’s a perfect way to—
Ms. Golembiewski: Exactly.
Dr. Durst: Make it simple for people to understand. Because there’s lots of terms used, and I think the synthetic component, the fact that it is synthetic—so there are, like, stem cells or exosomes and things that are obtained from live births and used. This is not, and so I think the fact that it’s made from something confuses people, but it’s identical.
And you’re right. It’s just like vitamins. If they get vitamins at the vitamin store, they’re identical.
Dr. Hall: Yeah.
Dr. Durst: You know? And they’re made, but you can test them and get levels, yes.
Dr. Hall: And I think I heard you, I think you tried to slip something in there: made from yam?
Dr. Durst: [laugh].
Dr. Hall: So, these are all plant-based?
Ms. Golembiewski: A lot of times yeah.
Dr. Hall: For the most part?
Ms. Golembiewski: Yeah.
Dr. Hall: Okay.
Dr. Durst: Mm-hm.
Ms. Golembiewski: Absolutely.
Dr. Hall: That’s totally cool.
Dr. Durst: Yeah. Yeah. And I think that—
Ms. Golembiewski: Versus taking from horses.
Dr. Hall: Horse urine.
Ms. Golembiewski: Yes.
Dr. Durst: [crosstalk 00:16:48] should not be doing, right?
Ms. Golembiewski: Correct.
Dr. Durst: And then I think that for patients, they very much understand, we’re testing, we’re replacing, we’re testing, you know? So, we’re going to know what your level is. There’s lots of things thrown around and we won’t get much into it, but, like, you can do salivary testing versus blood. But blood is very easily recognized by physicians, you can communicate with other physicians. And so, salivary tends to be more of, like, either an academic term used or people that can’t actually order, like, providers that can’t order blood testing, so they’ll do salivary testing. So.
Ms. Golembiewski: And like Dr. Durst said, it’s harder when you’re working in a community with multiple physicians, right? We want a good relationship with primary, you want a good relationship with endocrine, with the urologist. So, blood serum is universal. Everybody understands it.
The test in front of me, you’re going to understand that test in front of you. The salivary testing is very complex sometimes, and you look at it and you’re, like, okay, the measurement is way different. The ranges are way different, so they’re not as universally understood. So, it makes a little bit harder when we’re partnering [crosstalk 00:17:55].
Dr. Durst: Very, very hard.
Dr. Hall: Interesting.
Dr. Durst: Like, even after 12 years of doing this, I don’t understand it. But yeah.
Dr. Hall: Still—[laugh].
Dr. Durst: I’m still thinking about—I’m still [crosstalk 00:18:02].
Ms. Golembiewski: [crosstalk 00:18:04].
Dr. Hall: —still learning the salivary testing part of that?
Dr. Durst: Yeah.
Dr. Hall: Yeah, that’s not a part of the practice that we do at all. So.
Dr. Durst: No. Yeah. So, it’s good, like, blood and communication. And again, you know, finding surgeons, urologists, GYN docs that are, like, not going to scare patients, too, you know? Because some of them don’t understand, but it’s better to not understand and refer on than to scare. So, we have some primary care doctors that’ll—like, again, I thought maybe you were going to say clots because that’s the second thing, and I’m sure that comes up all the time with you.
Dr. Hall: That was—with surgery, that was going to be my next question.
Dr. Durst: That was it. I knew we were going there.
Dr. Hall: [laugh].
Ms. Golembiewski: Right? Always.
Dr. Durst: I knew it was, like, breast cancer or clot; I wasn’t sure which one was coming first. We knew they were both coming.
Dr. Hall: Yeah, yeah. You were expecting them both.
Dr. Durst: Well, and with you—like, with breast surgeries, this is actually a good question for us to know is, is screening mammograms and, like, breast surgery or if they’re on hormones—because not many of your patients are on hormones, but do you—is screening mammogram required for, like, a breast surgery?
Dr. Hall: It is if you are over 40 or are high risk. I tend to use the current Breast Society guidelines to drive that. So, and we’ve had women—I had a lady, very nice lady was coming in for breast surgery about six months ago and hadn’t been screened. She was in her mid-40s, and we ended up finding a breast tumor on a screening—asymptomatic on a screening mammogram, and had to delay her surgery so that she could have her breast cancer treated.
Dr. Durst: Okay.
Dr. Hall: And so, it’s with specializing in surgery nobody really needs but they want, it’s those kind of safety measures are really important. That, you know, we can talk about clots and risk assessment for them and anticoagulation, but all of that stuff is really important. So long, long answer to what’s a short question is, yeah, the screening mammogram for the over 40, or high risk population is—
Dr. Durst: So, based on—like, pretty standardized based on guidelines?
Ms. Golembiewski: Then what about your patients that are on hormones? Do you have them hold their hormones or stop their hormones pre surgery?
Dr. Hall: That really—that’s a great question and I don’t have a good answer for you because the number of patients who are on bioidentical hormones before surgery is so low, I have to actually go look up recommendations every time I see one. So, it’s a very—and I would love to get y’all’s input on how to make that process more data-driven and safe for this patient. What should we do?
Dr. Durst: It’s actually interesting because we did a lot of looking into that even prior to this podcast, kind of to see if there’s, like, any good science, studies that have solid recommendations, and there’s not a lot out there, I will say. And, like, one said, like, I think 42% of bioidentical companies would recommend stopping about four weeks to three months before. And I think that’s probably a common timeframe that you’ve heard.
Ms. Golembiewski: Or four to six weeks. We saw that kind of a lot.
Dr. Durst: Yes. And there was, like, a 24% percent of synthetic or OCPs, like, birth control, that same timeframe, but only, like, 3% of surgeons doing it. And that was about the most solid study we found. But having said that, like, estrogen is the hormone you’re concerned with when it comes to clots.
Progesterone and testosterone have nothing to do with it. You probably won’t have many patients on testosterone because it’s not commonly used with women and I’m assuming that the practice is mainly women. Probably a small about of men—
Ms. Golembiewski: Mostly.
Dr. Hall: About 98% women.
Dr. Durst: Yeah, I was going to say.
Dr. Hall: Yeah.
Dr. Durst: [crosstalk 00:21:55] I was to guess that it was mainly—and so testosterone isn’t used a ton with women—and we’ll talk about that because it should be; it’s awesome for healing purposes—but estrogen is the only one. So, if anything is given orally—I’ll just make it simple from my standpoint, and I couldn’t find anything to back it up or not—is oral estrogen goes to the liver, increases clotting factors, and increases your risk. And so, birth control, oral estrogen, Estradiol, which is a manufactured brand that the primary doctors are more likely to us—
Ms. Golembiewski: And GYN.
Dr. Durst: And we never use oral. Ever. Because—oral estrogen—because it increases clotting and clotting factors. So, ours is all either transdermal or pellets.
Dr. Hall: Okay.
Dr. Durst: And so, I think if you’re looking at bioidentical, transdermal, or pellets, you don’t need to stop it. And if you’re looking at oral estrogens, then it sounds like there’s some guidelines out there, and it’s like four weeks to three months. But no one’s really—
Ms. Golembiewski: And you—
Dr. Durst: Routinely following it.
Ms. Golembiewski: And we were seeing a lot online where it was saying, when we were looking trying to find solid studies, but if it’s transdermal estrogen, you don’t have to stop it. So gel, spray, patch, no need; just oral. So, it’s… like Dr. Durst said, it’s very swayed, you know?
It’s kind of for every three studies, we could find one way, we could find three on the other hand as well. But there was, across the board, micronized progesterone, no need to stop, no worry about any clotting. And then with testosterone, as long as we’re watching hemoglobin hematocrit and blood levels are normalized, there’s no reason—
Dr. Durst: Good point.
Ms. Golembiewski: To come off.
Dr. Hall: Yeah, and with us, you know, for anybody who’s actually having surgery, we use a clotting risk assessment before that’s a standardized—
Dr. Durst: Got you. Okay.
Dr. Hall: —you know, a standardized protocol that assigns point values to every single one of those things. And, you know, oral contraception, oral hormone replacement is one of the line items on there. And once you get to a certain point, it kind of tips you over into a risk category that you need IV for subcutaneous anticoagulation before surgery to prevent those clots. Because those clots are going to form essentially on induction of anesthesia is when you’re going to get that clot started.
And then other things, the way we provide anesthesia, the level of relaxation that the patient has, and then them laying around after surgery, all of those things kind of affect that clotting pathway.
Dr. Durst: I love scoring systems for that reason.
Ms. Golembiewski: [laugh]. Yeah.
Dr. Durst: You know—
Dr. Hall: Yeah, they’re awesome.
Dr. Durst: —kind of lays it out and it makes it—
Ms. Golembiewski: More objective.
Dr. Durst: —more standard. Yeah. Yeah.
Dr. Hall: Everybody can do it. Everybody can score it. Yeah, you just got to go down. But yeah. And I think that that makes sense that if oral, you know, estrogens or birth control are on there, that would make sense completely.
Ms. Golembiewski: Especially with clotting factor history, family history, if you’ve had a previous clot, things like that, make you a high risk, of course it makes sense to hold.
Dr. Durst: And again, for us even treating patients with clotting history, you know, it comes down to—because they come into us the same way where I have clotting history, I can’t be on it. Which isn’t necessarily true, but it depends. If it’s a DVT post-flight, you know, you’re on an airplane, then there’s a risk factor. And if we didn’t use oral, you could, so it just depends. So, the same thing.
You know that risk stratification with it. But we could go on forever about hormones and surgery and effects. So, I think what’s interesting to me is to see if you have a difference—or have noticed; observed a difference—in women of different ages—and again because most of the patients are women, not that I was, you know, just pointing out women—but in healing times after surgery. Like, younger do better; do older tend to have more complications?
Ms. Golembiewski: Or just comorbidities?
Dr. Hall: So, it’s an interesting question. I actually was just talking about this the other day that in cosmetic plastic surgery, age really isn’t a factor as much as—chronological age; so how many years, you know, for those of you-how many years old you are is less of a factor than physically how old you are. And when, with what I do, most of that is soft tissue, is just for example, when talking about breast surgery, is the breast tissue dense and firm like a youthful breast or has it atrophied and gotten replaced with fatty tissue, which is, you know, less pliability to it—
Ms. Golembiewski: Supple?
Dr. Durst: Less firm, less elasticity.
Dr. Hall: Yeah, the ligaments that support the breast stretch out with pregnancy and different—can those still support a breast? Is a skin thin with stretch marks or is it nice and thick and elastic? And that’s where I’m interested to hear from you is how hormone replacement can help that. Because certainly, with thin tissue, atrophic breast tissue, with stretched out suspensory ligaments, that breast lift with implants isn’t going to be as durable as it is if that tissue is really healthy.
Ms. Golembiewski: Supple.
Dr. Durst: [crosstalk 00:27:03]. Yeah. Well, I think when it comes down to, like, hormone optimization and cell health and so even what you’re talking about is just how healthy is that cell. And so, you know, collagen elastin, there’s, like, a huge component in a lot of skin aging, or—
Ms. Golembiewski: [crosstalk 00:27:17].
Dr. Durst: Soft tissue aging because we’re talking about both. Biologic age, skin aging, so if they’re down, I always say, like, if they’re going to lose 1% of collagen a year, so if so—like, that’s a gross, you know, estimate. So, if somebody comes in at 50 and they’ve done nothing to stimulate collagen, they’re 50% down. And so, it’s easy to talk to them about ways to stimulate collagen elastin, in addition to just, like, I want Botox, I want fillers because we can control movement, right?
We can fill a little bit, but you’re not going to get everything that you want in just filling and Botox. You can get 20, you know, 30, but not once we’re older, right?
Dr. Hall: Yeah.
Dr. Durst: And so, I think that when we talk about effects of hormones on collagen production, there’s lots of stuff there. Testosterone is got a huge, you know, amount of literature on healing and even collagen production and tensile strength of collagen once it’s there. Estrogen, there’s—
Ms. Golembiewski: Estrogen’s a huge amount.
Dr. Durst: Yeah.
Ms. Golembiewski: There was just an article in Dermatology Times talking about as estrogen starts to deplete, we start losing that collagen, we start having those still us histological changes in the skin, we see IGF1 go down. I mean, it’s pretty interesting that we can see that how much of a big effect estrogen can have an overall skin health and starting estrogen in women when they need versus waiting until they’re ten years postmenopausal, starting when they’re losing that estrogen, helping that skin stay supple, preventing those changes.
Dr. Durst: And not just skin, right? Soft tissue is what you’re talking about.
Ms. Golembiewski: Exactly.
Dr. Durst: So, everybody thinks of skin, and so that’s just a very superficial aspect of it, but that perfusion is, like, a huge thing with estrogen. So, just getting healthier fat, if there is such a thing, which there is.
Dr. Hall: Oh yeah, absolutely.
Dr. Durst: Like, there’s a level of subcutaneous fat that is needed and again, beyond that, it becomes less of just a storage unit and more of an endocrine, so you get negative effects if you get too much. So, obesity and body contouring and liposuction has great endocrine effects on the body, too, because now you don’t have fat producing bad things because you’ve taken some of the fat out. And then I think their mood also improves so they’re also motivated. But again, fat effects of estrogen matter, too, because you’re going to have healthier fat. So, in the breast tissue, that’s one thing, and then test is another one. Progesterone has a little bit, but less in the way of skin and soft tissue and muscle in healing and anti-inflammatory effects as estrogen and testosterone do.
Dr. Hall: Help me out because I, you know, I do a lot of—you know, about half of my practice is facial surgery, and in that a lot of patients come in and want to know how to improve their skin, lines and wrinkles, texture, and I end up recommending for a lot of those patients, some form of laser resurfacing?
Dr. Durst: Absolutely. That’s great.
Dr. Hall: And there are kind of old reports about estrogen replacement and skin healing. How can I help those patients? And have you seen patients who have gotten better results from resurfacing procedures that are on testosterone replacement versus patients who are not?
Dr. Durst: Absolutely.
Ms. Golembiewski: [laugh].
Dr. Durst: I mean, to me, it’s all about, like, behind the scenes, too. So like, we’re doing a lot of stuff to treat something we’re seeing. So, as we age, we all notice things in the mirror that we don’t want to see or we didn’t see before. And I think one thing leads to another. So, you correct one; you see something different. I mean, women are.
Ms. Golembiewski: We don’t want to chase lines. We tell them that all the time. Do not chase the lines.
Dr. Hall: Yeah.
Dr. Durst: Yeah. With filler, with—so you know, that doesn’t make any sense, right? So, we’re just filling a line, but you’re not getting at underlying cause, so I think laser resurfacing, number one, is an awesome addition to everything else.
So, you can—that’s a finishing, right? You’re finishing. Like, you’re making everything thicker, the entire skin surface thicker depending on what laser you’re using. But then behind the scenes is the cell health. So, like, I think if you’re perimenopause and you’re menopausal, you’re not going to get sustained results unless your cell is completely healthy. So, your nutrition is good, your sleep is good, you know—
Ms. Golembiewski: You’re not dehydrated.
Dr. Durst: —you’re exercising, your biological skin health is younger, you know, so already you’re going to get better results. But estrogen, like, again, that glow of pregnancy, the vascular, you know, supply to the skin is huge. And so, that’s why we start to lose elasticity in collagen as we get older because the estrogen, you know, and the blood flow to the skin is less, but testosterone has a huge effect on that, too. Your supporting bone growth—because facial aging, you know, more than us, and we would love to hear more about it, the fat pads and bone, you know, they give us support, which is one of the reasons why you get all the sagging with gravity.
Ms. Golembiewski: When you lose estrogen and testosterone, you lose bone.
Dr. Hall: Yeah.
Dr. Durst: So, what do you notice with that? Like, and I think that our ladies would love to hear more of the change in the facial structure as they age related to, you know, bonded fat pads.
Dr. Hall: Sure, yeah. There have been—I talk about this almost every consultation—that the face ages in a relatively predictable way. You know, we all experience the same changes over time. The interesting thing is that I’ve never really thought to link that to hormone fluctuations versus just time. But the two probably go hand in hand.
Most notably in women, you’d kind of mentioned bone aging, we all lose volume in our facial skeleton over time, which contributes to the hollow eyes, the undereye bags, jowling, both jowling in the front loss of the kind of the angle of your mandible. Because the bony skeleton actually recedes around the eye sockets, recedes around the jaw. And people talk about their nose getting bigger over time, that’s actually from the skeleton getting smaller is the nose doesn’t actually change; the skeleton gets smaller. And so, a lot of, you know, we can’t really do a whole lot about bone replacement, so we end up camouflaging that with either deep soft tissue fillers which can offer modest improvement in that early patient with those early signs of aging, and then your own body fat, actually taking fat—doing fat grafting, taking fat with syringe liposuction, processing that out very similar to, you know, we had talked about stem cells earlier, very similar to some of the processing that’s done for that, and then reinjecting those into those areas.
An interesting thing about that is that there were some work that just came out of San Diego earlier this year that showed that there’s a cut off at about 55 years old. And if you’re younger than 5500, and these are patients that are primarily women—if you’re younger than 55, you have about an 80 to 90% take, so 80 to 90% of what we inject stays at a year-and-a-half. If you’re over 55 that number drops to 50% or less.
Ms. Golembiewski: That’s interesting.
Dr. Durst: Have you ever lost PRP addition to, like, some of the fat? Because I know that’s a new kind of area that is intriguing. I’ve just touched on, like, a couple—and a times it’s our patients bringing something to us, like, because we do PRP but don’t do fat transfer. So, they’ll come to us and ask, and so just briefly looked at it.
Dr. Hall: Yeah, it’s something that has started to kind of catch on in plastic surgery world, but right now, looking at the data, the take is not astronomically different. You get a little bit more, but it’s not the difference between 30% take and 90% take.
Dr. Durst: We’re not taking your 55-year-olds and now they’re all responding.
Dr. Hall: Yeah.
Ms. Golembiewski: And now they’re 80, 90%.
Dr. Durst: It’s not [crosstalk 00:35:15]. [laugh].
Dr. Hall: Unfortunately not yet. Not yet.
Dr. Durst: You’re not improving it to—yeah—95 with that group. But anyhow, I think that it’s interesting that you say—so when I’m hearing again, obviously, the bone decreases, you can’t do anything about that. So, you have skeleton shrinkage with time, and so everything starts to sag. And the gravity is, you know, is pulling it down. You can’t do anything about that, but fat you can, so you can take it from somewhere else because that’s something that’s also getting heavier with time, moves to the lower face away from the upper face, and—
Ms. Golembiewski: Are you usually pairing that at the same time you’re doing deep dermal? Are they two separate? Just out of curiosity because we have patients that are—we’re realistic with our patients. We have women sometimes that come in and they’re like, “I want this.” And I’m like, “Well, that’s a facelift.”
Dr. Hall: Yeah.
Dr. Durst: Yes. Yeah.
Ms. Golembiewski: You’re not going to get that from filler—
Dr. Durst: Anything we do.
Ms. Golembiewski: You’re not going to get that from threads, you’re not going to get that from laser resurfacing or micro-needling; it’s just not realistic. So, they’ll ask, you know, “Well, what does that look like?” So, out of curiosity, do you do—at the same time, are you doing dermal fillers and also fat transfers, that grafting?
Dr. Hall: With that, I’m doing pretty much either-or. And the conversation in my office is, you know, we talk about—and I’ve talked about this on a podcast episode in the past is that there really three different areas of facial aging that you have to address to get a comprehensive treatment. You’ve got to address the skin, you’ve got to address the volume loss—and I got kind of carried away with the bony part and forgot about the fat pads—your facial, you’ve got a bunch of little facial fat compartments that most of them lose volume over time. Some of them kind of the ones right around your nasal [crosstalk 00:36:57] crease—
Dr. Durst: The lower ones.
Dr. Hall: —crease tend to grow which we don’t want. But trying to refill some of those areas with either filler or fat is one of the pillars of facial aging that we try and reverse. You can do some of that with fillers, but the cost lines tend to cross fairly soon. You know, when you’re talking about eight, nine, ten syringes of filler to hit all of these different areas versus a single session of fat grafting, with the possibility of coming back at a year and adding a little bit more to select areas.
And that’s the third part of kind of the facial aging triad is the structural part, kind of, the part that gravity takes over the bone, all of the muscles supporting your face, and that, you know, facelift surgery, neck lift surgery is really muscle tightening. There’s no—the skin kind of comes along for the ride. And so, that part of it is where—and once you start seeing jowling, once you start seeing neck laxity, those are things that you may get a very, very slight improvement with revolumising but without looking alien, it’s tough to fix that.
Dr. Durst: [laugh].
Ms. Golembiewski: Yes. And then we have those conversations a lot in this office, too, about that. You know, we don’t do overdone. [laugh].
Dr. Durst: Well, and I think that, again, filler gets a bad rap for that reason because—
Dr. Hall: Absolutely.
Dr. Durst: —you’re trying to do it beyond the point where you need to and so they’re not very realistic. And so, we have that because people don’t want filler at all, but you’re, like, “What do you need?” Like your point, because I almost look at it as, like, a firm, fill, and finish. Like, that firming is what you’re talking about, like, where they need lift.
And so, you need more. You can fill and do some volume replacement, and then you can finish with all the, you know, Botox and laser resurfacing and all that. But again, it looks abnormal and gets a bad rap because people are overdoing it trying to fix everything, and that’s impossible. And then you’re going to distort movement, you’re going to look abnormal. Alien is a good term. [laugh].
Ms. Golembiewski: Alien is a really good term. I like that.
Dr. Durst: That’s a really good term. So yeah.
Dr. Hall: You know, and you don’t want to don’t hit the injectable companies too hard, but they’ve developed some of these stronger fillers, your Voluma, some of these fillers that are really stiff, and they say, “Well, this will give you a lot of lift. If you just put it all up in here you can get rid of that jowl.” And so, you start seeing people whose faces are either totally square or they’ve got these very exaggerated cheekbones.
Dr. Durst: Their cheeks are quite impressive.
Ms. Golembiewski: Yes.
Dr. Hall: Their jowls have gotten a little better, though.
Dr. Durst: Well yeah, because you’ve lifted—
Dr. Hall: The jowls are a little better.
Dr. Durst: —you’ve lifted everything.
Dr. Hall: Yeah.
Ms. Golembiewski: You’ve lifted everything.
Dr. Durst: Well, but if you look at—so I’ve seen a couple and I should have brought a filler on, but if you squeeze it out, like, so, for the G Prime, you know, all of that, if I squeeze it onto my finger and press down, it’s going to move, you know? So, it’s not, like, it’s as firm as they try to make it seem. You’re going to still make it move. It’s not a correction.
Dr. Hall: Yeah.
Dr. Durst: Yeah.
Dr. Hall: Yeah. And I, like, using those, not to throw those guys under the bus, those, I think those stiffer fillers have a good—have a role in facial rejuvenation.
Dr. Durst: Absolutely.
Dr. Hall: I, like, using them to contour the areas of bone loss, and then use some of those softer fillers to go in and fill fat pads and try and, like your—I liked your firm, fill, and finish. Is there—
Dr. Durst: If they start talking about, you know, lifting in some way, then it’s different, but you can volume loss and, you know, and fill, and you can—finishing, everyone needs.
Dr. Hall: Yeah.
Dr. Durst: So, we have those conversations—
Ms. Golembiewski: The fat laser—.
Dr. Durst: Yeah.
Ms. Golembiewski: —resurfacing you were talking about. Everybody benefits from that, young and old.
Dr. Durst: Yeah. And laser resurfacing is the key to that, completely, one hundred percent. And again, it depends on which one and it depends on downtime and what they want. But still, you got to have laser resurfacing as well.
Dr. Hall: I couldn’t agree with—it has become—over time has become one of my favorite facial rejuvenation modalities is just finding the person that is—the patient—you’re matching the patient to the result to the downtime.
Dr. Durst: Yeah, oh, yeah.
Ms. Golembiewski: Absolutely.
Dr. Durst: And we have that. Again, we don’t, we just don’t talk about resurfacing enough. And I love lasers for that reason because you can do so much with them. And you still need that because that’s your finishing. Like, your finishing touches, you still don’t want wrinkles and you want thick skin and you want it to look healthy and vibrant. And so—
Ms. Golembiewski: We tell our patients, you should be doing something every month.
Dr. Durst: Every month.
Ms. Golembiewski: Every month. So, we do memberships for laser resurfacing for our patients, and that they love. They get to come in once a month, and they’ve got a variety of things I can choose from and it makes a huge difference overall.
Dr. Hall: What do you like? What’s your favorite?
Dr. Durst: For laser resurfacing?
Dr. Hall: Mm-hm. Yeah.
Ms. Golembiewski: Right now mine is the Triple Glow, which is where we’ll dermaplane, do hydrafacial, and then we use the Lutronic ULTRA Glow just over. So, it does a little bit of everything, cleans out the pores, it makes me not fuzzy. And then just that light few top layers of skin off I just huge, huge, huge difference in my skin since I’ve been doing that.
Dr. Durst: So, I think that’s a good, like, maintenance.
Ms. Golembiewski: Yeah. Pores—
Dr. Durst: So, it’s a good maintenance on, but you’re not going to really treat. And I look at them as different. So, you’re treating, or you’re just maintaining, or preventing. And so, that’s a prevention one.
So, on a monthly basis, it’s almost this prevention. Like, you need to do something once a month. But so when it comes to, like, treatment, in here, we do one of two mainly, and we don’t do—we don’t have a CO2 but we have an Erbium that can go superficial or deep, so depending on their downtime. It also does, like, a 4D—what we call a 4D—non-surgical facelift because we go into the mouth with it. It’s a different type of laser.
Dr. Hall: Oh wow.
Dr. Durst: And Fatona is the name of the laser which is, like, one of my favorites.
Ms. Golembiewski: It’s a beast of a machine.
Dr. Durst: It’s a beast. But you can go in the mouth and do deep dermal where—you know, all therapy before [crosstalk 00:43:07] is deep. So, at least you can thicken everything. So, you can go in the mouth, you know, so you’re getting the nasal labial folds around the mouth.
Dr. Hall: Wow.
Dr. Durst: Then you come to the outside for two other steps for a mid and upper dermis, and then resurfacing. And that resurfacing is an Erbium. That usually is ablative, but you can actually do it in non-ablative mode or you can take it really deep with downtime, not probably quite the results that you would get with CO2, but we could. But none of our patients want it.
They’re not coming to us because they are looking for downtime, really. So, I think if they’re looking for surgery or they’re looking for, you know, something more aggressive, like a one-time, maybe a two-time but usually one-time. Because CO2, is that one of your favorites?
Dr. Hall: So, I have an Erbium YAG. So, it is interesting because we have an attachment that does the combination fractional ablative and deeper nonablative, but then most of the device is ablative, either fraction or full field.
Dr. Durst: Okay.
Dr. Hall: I want to get back to what you said about the Fatona. That was—in-the-mouth is kind of cool. So, that’s a non-ablative—
Dr. Durst: So, it’s very interesting—
Dr. Hall: Laser?
Dr. Durst: So, what you’re saying, too, even with this final step, so Fatona has two wavelengths. So, it’s a 2940 Erbium, and then it’s a 1064 NDI. And so, the first one is for BM, but it’s an Erbium with a long pulse wave. So, like, with—or with a long wavelength.
And so, with that you can get deep but not ablative. So, you can heat, so you can go in the mouth and obviously Erbium’s attracted to water so you can basically laser inside the mouth and get deeper to thicken the deep dermal. The outside next few steps are actually NDI, and so you get a little deeper a little more superficial with almost something similar to your frag, but NDI targets pigments, and so you really don’t want to do that with men. But then you come to the last step and it’s Erbium again, so you can do, you know, your deeper nonablative. You can do fractional, full, full field if you wanted to.
So, it depends on their downtime. So, you can go deep but the nice thing about this one is, like, you can dial it deeper or more superficial on any of the modes. But it does, like, 170 other treatments. So, we can do vaginal rejuvenation, we do, like, a 4V vaginal facelift, like, with the laser, so similar to the face, but on that vagina, on the outside for—so with some pretty amazing results. For somebody—
Ms. Golembiewski: Oh, absolutely. You would be—[laugh].
Dr. Durst: For somebody that isn’t like a surgical candidate, you know, but didn’t even think about making it prettier, but they can make it prettier.
Dr. Hall: Yeah. So, that’s an actually—you jumped me there on that one because I was going to ask you about that because when we were walking through earlier, you talked about the vaginal rejuvenation laser. And that’s not something that I do. And we’ve—I think we’ve all seen an uptick in cosmetic genital—
Ms. Golembiewski: Absolutely.
Dr. Hall: Procedures in the last couple of years. You know, labiaplasty has become a really popular surgical procedure, but the non-surgical vaginal rejuvenation is not something that I have a whole lot of familiarity with, other than the devices are out there. So, educate me on what that is.
Ms. Golembiewski: It is unbelievable. When these ladies came back last year from Texas and were like, “We can do 4D on the vagina,” I was like, “What?” I’m like, “No way.” [laugh]. And our first patient that jumped on the table, we were blown away. In just one treatment, that tightening, external, that we saw was just remarkable.
She came back seven, eight months later and there was no change. No laxity. She was just as firm as she was when she left after that first treatment. And usually we’re doing about three of them because we want to maintain, but it is unbelievable the changes that we’re seeing. We had a patient recently that came in that has done, labiaplasty before and is still seeing some changes now a few years later, and we’re trying to target some of those areas. And we’re being able to correct that laxity. And just, it’s blown me away.
Dr. Durst: So, most of them are, like, non-surgical candidates for the outside. So, they’re not even really thinking about it necessarily until—and we didn’t even think about it. Like, honestly, I did ER for decades—I tell this story all the time—pelvic exams non-stop, right? Never looked at a vagina and thought, “That needs to be prettier.” I just thought—
Dr. Durst: —that needs to be—like, they’re all different. They’re all different.
Dr. Hall: Yeah.
Dr. Durst: You know, that’s it. And so, the first one we did last year, I was shocked at the results.
Ms. Golembiewski: She was pacing in front of my door, waiting for me to come out just to show me the picture.
Dr. Durst: Yeah. So, it was pretty amazing. We’ll show you that at—but then the inside though—so those are all non-surgical and I think we’re bringing that to light just because people are more aware.
So, if we’re talking internal vaginal rejuvenation, then we’re naturally just talking to them about external. But they’re not anyone that’s ever been told they needed a labiaplasty. I mean, those patients that come to you for labiaplasty are probably kind of told and directed to come in because the gynecologist or someone else—it’s not usually the patients, is it, that has noticed a big change?
Ms. Golembiewski: Or they have, like, pinching, right? Just excessive skin. So, we’re not seeing those patients.
Dr. Hall: Yeah, it’s the yoga pants, tight swimsuits—
Dr. Durst: Oh, yeah. Yeah.
Dr. Hall: And that Instagram and the internet, not a lot—surprisingly, not a lot of physician referrals for that.
Ms. Golembiewski: Okay.
Dr. Hall: It’s a lot of self-referral—
Dr. Durst: Well, I wonder—
Dr. Hall: —for the labiaplasty [crosstalk 00:48:33].
Ms. Golembiewski: I just love that article about the yoga pants, and one physician had, like, a crazy increase in labiaplasty thanks to—
Dr. Durst: Well, he doubled.
Ms. Golembiewski: Yeah doubled. Because of yoga pants.
Dr. Durst: —la—surgical labiaplasty in 2022. They [crosstalk 00:48:43] so, yeah, that’s interesting. And I figured, maybe if anything, like, somebody had told them, like, I knew, gynecology-wise, you know, this is surgical if they were bothered by it. But yeah. I think that with Instagram and social media, clearly, women are more aware of what they look, like, versus what others and again, if pornography is become more—
Ms. Golembiewski: Pronounced.
Dr. Durst: —or pronounced in a younger generation, then it’s going to only increase, right?
Dr. Hall: Yeah. For sure.
Ms. Golembiewski: But I think women are sitting around and talking a lot more about this kind of stuff, too. Like, my mom wasn’t talking to her girlfriends about what her vagina looked like or if she’s ever done any treatment or thought about it, you know? That I think it’s changing as we are all sitting around, we’re talking about it. There’s more just openness about it. It’s not as taboo to talk about—
Dr. Durst: It’s a sexual revolution, girl.
Ms. Golembiewski: These different things.
Dr. Durst: Like, it’s [crosstalk 00:49:32]. But it’s one without borders this time, right?
Dr. Hall: Yeah. [laugh].
Ms. Golembiewski: [laugh].
Dr. Durst: It has no borders. It’s open. So, I think that’s the big issue is I think that they’re noticing others. And then under 18, I think it was like a 5% of labiaplasties done.
Dr. Hall: Mm-hm.
Ms. Golembiewski: Which is crazy.
Dr. Durst: Are under 18. Is that—
Dr. Hall: Yeah. It’s—
Dr. Durst: —seem reasonable?
Dr. Hall: I’m seeing older teenagers. I can’t say that I’ve seen somebody under 18 yet, but certainly early college-age, 19, 20, 21. I’m learning a ton about genital cosmetics surgery today.
Dr. Durst: [laugh].
Ms. Golembiewski: [laugh].
Dr. Hall: Yeah, this is awesome.
Dr. Durst: Vaginal esthetic. Like, [crosstalk 00:50:12]—
Ms. Golembiewski: We call it vaginal rejuvenation.
Dr. Durst: —designer vaginer. [laugh].
Ms. Golembiewski: [laugh].
Dr. Hall: [laugh]. I love it.
Dr. Hall: Wow. So, that was a really awesome episode. I feel like I learned a ton. I’m going to have to go back and listen to that just to get all of the details out of that episode. Our conversation went well longer than this, so we’re going to cut it short here. Stay tuned for our next episode, which will be part two of this show, where we will get into some really interesting topics. So, thanks for listening and we’ll see you soon.
Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at@jhallmd on Instagram and Twitter and@DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.