IamA 29 year-old Doctor who practices Facial Cosmetic Medicine AMA!

Why is it when many people get facelifts, things look really artificial afterwards, instead of more or less removing wrinkles?

You only notice the poorly done procedures. The best procedures aren't noticed. However, sometimes patients ask for procedures that will have a noticeable effect (e.g. Renee Zellweger).

As an extension to this, what percentage (guessing) of procedures are done poorly so that the average person notices and says "oh god, they look awful/have had work done"? Is cosmetic surgery actually done way more often than the average person thinks?

I can't really speculate as any percentage is not based on any hard data, but I will say that it is far more common than you'd imagine, and many of my patients will not even disclose it to their partner.

Wow, that's crazy. I can't say I'd be happy if someone did that behind my back. Have you ever had a partner come in and try to blame you for their partner secretly getting work done?

No, no one has ever come to see me regarding work on their partner.

Nonetheless, I would never be able to discuss the matter with them, nor is it their business.

Have you ever felt like you may ruin a patient's life if you make a mistake? (Sorry if it sounds terrible.)

That potential always exists when you are dealing with someone's health care, and it is especially salient when performing elective procedures. It is important to have this thought with you as a physician as it will help keep you vigilant to avoid becoming laissez-fair in your assessments and techniques.

Prior to his death, what percentage of Michael Jackson's head do you think was in "factory condition"?

LOL

Interesting question. I'm not sure there's any good way to estimate that.

But for those interested, he suffered from vitiligo and had his skin bleached to match.

What do you think about the movie Predator?

Classic!

what are your top 5 foods ?

In no particular order: Salmon, Greek salad, Cinnamon Toast Crunch, D'Anjou pears, & Reese's Peanut Butter Cups

How would you describe your patients as? Are there any stereotypical real-houswives types?

My patient population spans all demographics, although, because of the price point of many procedures, they are typically of a certain minimum socioeconomic status to be able to have disposable income for my services.

The most surprising thing to most people is the fact that many younger and male patients utilize cosmetic services such as lip augmentation, neuromodulator for wrinkles (Botox/Xeomin/Dysport), and lesser-known services such as reducing "gummy" smiles and tightening the jawline.

How comfortable do you feel doing maxillofacial procedures, since you mentioned reducing gummy smiles and tightening jawlines. At what point would you leave it to a Perio, OMS specialist?

I don't perform maxillofacial procedures per se. Certain injectable products can help with very minor irregularities in the smile and jawline. Significant deviations requiring surgery are at another end of the spectrum and probably causing dysfunction and pain and are in the realm of a surgical subspecialist.

What would your best advice be for someone that wants to get into radiology but can barely do nightly high school homework? How do I learn how to do more work and study more?

I'd advise you to consider what is so compelling about radiology that you are convinced that is the career choice for you while still in high school. Perhaps have a more open mind and a broader realm of potential career paths.

Regarding the studying: if you find an area of interest that is very intrinsically rewarding to learn about then it becomes far easier to devote time and energy to it.

Do you have any fun stories? If so, please tell them. Also, what is your opinion on those who have heavy plastic surgery without really needing it?

My professional philosophy regarding expressing my personal opinion on a patient's looks is this: It is my job to understand your concerns and wishes related to your treatment, provide you with information to regarding what can be done, and providing my aesthetic eye to what I feel is the best treatment to help you achieve the desired outcome. In addition, any health care provider should go through the common and serious risks associated with any procedure. I would strongly caution against using the services of anyone that doesn't fully walk you through the potential adverse effects and their likelihoods. They should be open and welcoming to all of your questions and concerns.

I try to not impose my beauty ideals on the patient, but inform them of my expert opinion on how to achieve the improvement they seek. Personally, I believe the best work is subtle and leaves the patient with an improved, "refreshed" look that others can't easily identify as the outcome of a cosmetic procedure.

Fun stories? I have a lot of those, but nothing very lurid; every individual has an interesting back story that comes through once you've developed an open, calm, and professional environment.

What's the incidence of serious complications like for a healthy 20-30 something undergoing

a: a nose job?
b: a cosmetic procedure that alters facial bone structure?

Are most of your patients doing elective cosmetic procedures or reconstructive surgery? Which pays more for the surgeon?

These are very broad questions that have cannot be answered without knowing a lot of additional information to set them in the appropriate context.

I'd advise you to chat with a local surgeon face to face.

First off, shout out to Ontario!! I'm assuming you're a Schulich Alumnus?

My actual question: after spending so long in school, how did you find the money to open your own practice with so much student debt?

Without disclosing too much personal information, there are many avenues available in helping you start your own small business, especially if you are hard-working and ambitious.

Medical school prepares physicians extremely poorly for the business world. As such, there are multiple opportunities available outside the typical medical bubble.

Sorry to pry, but how helpful were government grants and the like? I live in Ontario and I plan on opening a business after I get my masters (biochemistry), but it seems like there's very little guidance available for starting a business in the science or medical field. I guess that owes to the uniqueness of the situation.

I did not use any government grants.

What did you find surprising about the business side of things?

The amount of paperwork!

There is so much work to do legally with setting up a business, never mind a medical business. Like I mentioned elsewhere, most physicians are very poorly educated regarding the "real world" of medical business, if at all.

There is a lot to learn, and quickly. That being said, if you are intelligent and motivated, it is very doable and rewarding to be your own boss.

Ah, I see.

How hard was it getting your first clients and building momentum?

I had a leg up because I had worked with other medical professionals in the industry prior to heading out on my own.

The cosmetic medicine industry is very competitive, especially in large markets such as Toronto. Marketing and advertising are very important. I have a marketing company working for me to help with that aspect of the business, although I'm very hands-on with it as well.

The best way to build your business - regardless of the industry - is to provide what you claim to provide, do it well, be available for your clientele. If you are professional and do good work you will grow organically through word of mouth and as your reputation improves you will see more and more referrals.

Cool. I appreciate all this feedback.

What are your goals? Are you trying to build mutlipul business's and start a chain or are you just happy with what you have going on right now?

The current goal is to continue to grow and develop not only my business, but my areas of expertise and experience.

Who knows what lies ahead!

There are a lot of rumor about dealing with acne problem. What do you think is the best way to treat it. How about the scar after the acne is gone? Edited

I assume you are referring to "acne?"

What rumors did you have questions about, specifically?

In general, acne is condition with a wide range of clinical presentations from minor, occasional pimples on the face, back, chest to significant inflammatory nodules that have a large impact on patients' quality of life and self-image. There are many different topical as well as oral medications that can be used to treat acne depending on the severity of the condition for a particular individual.

The most important facial skin care tip is to prevent skin damage by having a healthy lifestyle (balanced diet, exercise, avoiding all smoking, and limiting excessive alcohol intake) combined with barrier protection from UV radiation (i.e., sunscreen daily) and gentle daily facial cleanser use.

I hope that helps.

Hi Dr.,

Thanks for the oportunity to ask you questions.

1) What's the most common procedure? (maybe splitting the answer by gender could make more sense)

2) Do you have experience with hair implants and that sort of thing? If so, what would you recommend for a patient with a high hairline but good hair quality and quantity that want's to make it a little lower?

1) Neuromodulator (Botox/Dysport/Xeomin) for wrinkle reduction is the most common for both sexes and all ages, most definitely.

2) I do not practice hair transplantation. My advice would be to consider a consultation with a local hair transplant provider. Sorry that I can't elucidate further.

What's your favorite procedure?

What's the most common one you do?

Favourite procedure is facial filler (Juvederm/Belotero/Radiesse): The results are immediate, well-tolerated, and last a year or more. Because the patients see the immediate result they are extremely happy.

Most common procedure is neuromodulator (Botox/Xeomin/Dysport). This is most common for most of us in the field, I suspect, as the price point is lower, effects are significant with no downtime, and the effects are of "removing" or reducing the pronouncement of wrinkles already there, so there is less change in the facial aesthetics away from their natural look as compared with fillers.

What would you say your motivations were in pursuing a career in cosmetic medicine? Is it just the money? Also, how do you feel your skill-set compares to that of a plastic surgeon or ent facial plastic surgeon? I have often heard the criticism that non-surgical doctors (family, dentists, general practitioners) have a higher rate of complications compared to physicians with surgical training.

I'm very interested in aesthetics, art, fashion, personal health and fitness. Cosmetic medicine is a natural extension of my personal interests and was a good fit.

The cosmetic medicine field is very competitive and you will often hear criticisms of those with different training backgrounds. The most important thing I would say in my experience working in the field is to ensure you have a medical doctor who has had appropriate training, performs the procedures regularly, as well as continues with training through courses or other events.

What facial cleaner do you recommend as a daily face wash? I have regular / somewhat oily skin.

Avoid harsh cleansers and look for a hypoallergenic, non-comedogenic product. I personally like Cetaphil.

I got elbowed in my nose when i was younger and my septum healed crooked, and now my nose has a dimple on one side. I can use one finger to pop it straight, but then it un pops. Is there a way to straighten it without paying thousands of dollars?

Minor dimpling and nasal deformations may be amenable to filler treatment in lieu of surgical intervention. Consider discussing this with a doctor that performs cosmetic procedures in your particular case.

So this morning I went a little hard with a washcloth in the shower and now I have a pink spot on my face where I presume I peeled the upper level of skin off. What is the best way to make sure I don't get a noticeable scar?

Best way to avoid scarring of injured tissue is to prevent infection with keeping the area clean and dry, and staying out of the sun as tanning the injured area can discolor the skin.

What is the biggest complaint about your industry?

What is the most common, most expensive procedure?

I'm not quite sure how to answer the complaint question as it is quite broad and non-specific.

Most common procedure I perform is wrinkle reduction.

Most expensive depends on many variables. I don't have a quick and easy answer to that.

Dr. Alves, what is the best way to get rid of "racoon eyes"?

Raccoon eyes can have multiple causes. For one, poor sleep will exacerbate any lower eye darkness. As does dehydration. Additionally, as assessment by a physician will be able to determine whether there are any medical conditions leading to skin changes that are beyond the scope of just cosmetic considerations. However, as we age, areas of thinner skin such as under the eyes, neck, and hands will allow for greater visualization of the underlying structures such as fat and blood vessels which can create the darkened look.

A medical consultation would be a good start to ensure proper evaluation of your "raccoon eyes."

Thank you for your answer. By medical consultation would my regular physician be able to do that for me?

I would begin with that.

Your surname "Alves" tells me you are of portuguese descent. Is it true?

I'm Portuguese by blood and Canadian by good fortune ;)

Hi. I've wanted a rhinoplasty ever since I broke my nose when I was 15. I'm 26 and got it last week, spent $7000. I told the doctor I wanted the bump on my nose shaved down. My swelling has completely gone down, I still have the bump, and the doctor changed the tip and it looks really cutesy. I'm very unhappy. I told the doctor I didn't want the tip changed, just the hump.

I want to talk to him about getting it changed, but I don't have the money for a revision. Should he not charge me because he did exactly what I didn't ask him to do? I'm devastated. I only wanted the hump changed because that's what was broken. He changed the tip and it makes me look different.

I'm female if that makes a difference.

This is far to specific for me to comment on, nor is it medical advice. I'd consider getting a second opinion from another surgeon.

She's asking if doctors ever revise the nose for free if they feel like their requests were not listened to

I imagine most would, but I can't comment on what she and her physician had agreed upon previously. Although, to maintain a good professional reputation I would believe it wise to ensure patient satisfaction.

Can you still look at people without immediately seeing 'what to change'? Has your clinical 'eye' affected your personal relationships?

Yes, definitely. I don't look at people with an eye as to what to change by any means.

I don't think it has effected any of my personal relationships. It is something that I can decide to consider if someone is a patient of mine, but by no means do I use it as a frame through which I look at people, especially when first meeting them. There is so much more to individuals than just their outward appearance.

Thank you for answering! I remember feeling really self-conscious during my plastic surgery rotation. The surgeon had this picture book filled with 'before' and 'after' pictures, and most 'before' pictures looked totally 'normal' to me, but he could point out all kinds of features that were 'wrong'...

Follow-up question, just out of curiousity: do you have any experience using autologous or allogeneic cell-based products? Do you see a role for them in cosmetic medicine, or do the available pharmacologic sustances fulfill most of the clinical need?

I imagine you are alluding to PRP treatments?

There is a lot of buzz right now over PRP, but the literature has found it wanting (at least for OA knee pain where it is no better than steroid injections). I suspect much of it is the same for cosmetics. However, I have not seen any clinical trial data such as an RCT or non-inferiority study to compare PRP with filler, although anecdotally many of my colleagues have mentioned that the PRP will be resorbed much faster (which makes sense theoretically).

I have been wanting to get lip injections and have an upcoming appt. with a PA at a medical spa. Originally my procedure was scheduled to be done by the spa's MD, but she cancelled on me last minute, and now they've rescheduled me with her new PA-C (the MD says she is no longer accepting new clients). Looking around, I've read similar stories online of this happening to others and feeling like it's a sort of "bait and switch" type scenario. Should I be worried or is this somewhat normal behavior for plastic surgery centers / medical spas?

It is very common. It is common to have nurses inject as well.

I perform all of my procedures myself. If you are uncomfortable with the situation I would give the situation reconsideration.

Why should a patient go see a family practice doctor instead of a plastic surgeon or dermatologist for these issues?

You should see a doctor with experience, regardless of their designation, who you feel comfortable with and will walk you through the entirety of the procedures they propose and answer any and all questions you have.

What is the oddest request that you have received?

Occasionally a patient will attempt to cross the patient-doctor professional boundary. I'm sure you can use your imagination...

What's the area of the face or type of surgery that has the most return patients other than non permanent procedures?

I can only speak in anecdotal generalities, but surgical procedures are generally only performed once or once every several years, whereas non-permanent procedures by their nature require the patient to follow up for additional treatments. Generally, neuromodulators must be performed every 3-4 months and fillers every 9-18 months.

What's a neuromodulator? I googled it and still don't understand it. That's a surgery?

Directly from Google: "A neuromodulator is a messenger released from a neuron in the central nervous system, or in the periphery, that affects groups of neurons, or effector cells that have the appropriate receptors."

In the context of cosmetic medicine, it is a drug (main example being Botox) that "freezes" muscles, stopping them from contracting. This doesn't allow the muscles to create lines and wrinkles. They are commonly used in the face to treat forehead wrinkles, frown lines, crows' feet, etc.

What's a good small gift to get a surgeon who worked on you?

Most jurisdictions strongly oppose any gifting. A sincere appreciation for their work is often more than enough.

Can you fix my face?

Perhaps...

Do you wish you'd done your residency in plastic surgery instead of family medicine?

No, because I never intended to perform surgeries. I prefer to provide outpatient services with limited downtime and immediate results.

The benefits of being a family physician are far and many, and extended beyond the scope of this discussion. If you are interested in more info, PM me.

Seeing as how you just finished your residency and have no real experience, how do patients trust your abilities?

I am young and have limited experience relative to some older physicians, but I have considerable experience with the actual procedures themselves. Additionally, as a physician, I have much more thorough and expansive training than other allied health professionals who perform these procedures, as well as the knowledge and expertise to deal with potential adverse events.

As mentioned elsewhere in the thread, I undertake a thorough medical history and spend considerable time and energy overviewing the procedures with my patients. I show them results of my previous work, and if we both feel comfortable, we move ahead with treatment.

What's something you think your patients should think before considering getting a cosmetic surgery?

A few that I like to know my patient has considered:

• What do I want?
• Why do I want it?
• What is my expected result?
• How does this fit with my past and current medical history and issues?
• Do I understand the potential limitations and risks associated with the procedure?

Kind of a random question but I'll ask anyways. Do you ever use Ketamine locally on an area before you make an incision? I've read that this decreases post-operative pain scores, and helps prevent the "wind up" phenomenon of pain generated weeks/months post-operatively. Just interested!

I don't perform surgery or use ketamine in my practice. If you know of any anesthesiologists, they would have more to say!

What do you think is the best procedure for excessive sweating? botox? Miradry? something else?

Many of my patients have tried multiple topical anti-perspirants with minimal or less than ideal outcomes. I prefer to use neuromodulators (e.g. Botox) for excessive underarm sweating.

If you are a generally sweaty person, there are multiple oral medications that can help. Again, it is important to see your doctor because there can be significant medical conditions causing excessive sweating that need to be ruled out prior to treating the symptoms of excessive sweating.

How long does botox generally work? I've heard 4-6 months, which is why im leaning toward miradry

Results can be expected to last between 3-4 months typically.

Has anyone ever asked for chipmunk cheeks? And if someone did, were you then permitted to take a selfie and call it "Alves and the Chipmunk?" Anyway, what's the weirdest thing a patient's ever asked for? If nothing comes to mind for that, what are some of the most memorable requests? (Has anyone ever asked to look like Lord Nicolas Cage or Lord Gaben?)

Cute joke lol.

I haven't received any far out requests. 99.9% of people are looking to regain a more youthful look. They want to look like themselves, but a little more rested, or with a little more volume in their lips, or with less wrinkles.

I feel that the popular media has made salient weird and odd requests for drastic changes that are not common in day to day practice. Sorry to disappoint.

what is your favorite Wham! song?

Wham!

Careless Whisper

Have you heard of early acceptance programs (BS/MD) which guarantees admission to medical school assuming you reach certain requirement? Do you think those programs are worth participating in?

My undergrad degree was in experimental psychology and I intended to pursue a research career initially. Before that, my first semester of university was in finance.

I think it is worthwhile keeping an open mind and following whatever field draws you in. People change their interests multiple times in college, and indeed during medical school. Keeping your options open is never a bad idea, but if you are certain medicine is for you then when you make that decision you must pursue it single-mindedly to be successful.

I am 62 yr old lady in USA, and my eyelids are starting to droop. Perhaps it is different in Canada, but I have heard that it's best to wait till they droop enough to affect vision. Then insurance will pay for a medically needed surgery. Is there a % of vision that needs to be affected? Who determines if it is medically needed - you, an eye doctor, etc? Thank you.

What is covered by your insurer will be very specific to your policy so that's outside of my area to comment.

I am assuming that they will consider covering the procedure when the skin has begun to affect your daily functioning. It is always important to weigh the potential benefits and potential consequences of any medical procedure in light of your own personal medical history.

What is your worst experience with a dissatisfied customer?

Thankfully, most - if not all - patients have been very pleased with their results. I haven't had any serious adverse events knocks on wood

I believe the key to having satisfied patients is to be very thorough in assessing their wants and concerns, being forthright and explicit in what you can do to help them achieve them, and follow up to ensure things have gone as intended. If they have not, then it is important to have an open communicative discourse to rectify the issue(s) at hand.

have you considered being a politician?

It is a career somewhat afield of medicine, but never say never. Any reason you ask in particular, or has the House of Cards Season 4 hyper extended to all sub-reddits?

You just seemed to answer a different question than was asked, is all :D

I'm not trying to deflect, but I have had very good experiences overall.

It does remind me to mention that many complaints and dissatisfaction can be avoided with proper documentation and pre/post photos.

Greetings Dr. Alves,

Fellow Portagee here. As you know, we are sweaty people... With your experience in Botox, would you recommend applying Botox to the armpits to relieve excessive sweating? Thanks.

Neuromodulators works very very well for hyperhidrosis. I perform neuromodulator for hyperhidrosis of the underarms very regularly and patients are commonly very satisfied with the results.

You should consider discussing it with your physician.