Monique Ramsey (00:02):
Welcome everyone to the La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey, and I'm excited to welcome back to the podcast Dr. Johan Brahme. He recently celebrated his 20th anniversary at La Jolla Cosmetic, so congratulations, Dr. Brahme. Can you believe it?

Dr. Brahme (00:19):
Thank you. That's amazing. I can't believe it's gone so quickly.

Monique Ramsey (00:24):
It really has.

Dr. Brahme (00:25):
Yeah.

Monique Ramsey (00:26):
Time flies right? When you're having fun, and I think we do have fun.

Dr. Brahme (00:29):
Absolutely. Yeah. It's hard to believe that I'm the senior surgeon now after, after 20 years.

Monique Ramsey (00:39):
But your career actually spans 30 years and at this point, so in the 30 years that you've been practicing, what's the first big innovation during your career that sort of made a huge impact on your work or how you did things?

Dr. Brahme (00:56):
Well, I think that one of the biggest things in my career lifespan has been fat transfer. And it started very, very slowly. And there was a guy named Syd Coleman in New York who was a pioneer and doing very, very small injections of fat and taking a long, long time to do it. And then we branched out and we started doing fat transfer to when we started doing more liposuction. Liposuction when I first started, we didn't have tumescent techniques, so we couldn't get very much fat, and it was a much more, I would say, risky procedure. We used to do blood transfusions and all kinds of things, but when we could get more fat, then we could also do more fat transfer. And so that's been a big change in all our careers. And we do fat transfer to the butt. We do fat transfer to the breasts. We do fat transfer. I don't think I do a facelift without doing fat transfers anymore. So it's much safer. And with the instruments and technique and nano fat and micro fat, we're having a lot better results.

Monique Ramsey (02:15):
Interesting. And we'll have to actually do an episode about that just on nano fat, micro fat, what those mean, because that's all kind of new and fun. So that's kind of the biggest thing that's changed over the 30 years. But what's maybe the most recent innovation that you're excited about?

Dr. Brahme (02:31):
Well, we have something new called Ellacor, which is a skin extraction. It's sort of like microneedling except that it has a hollow core needle. So it actually removes skin, which is a technology that we had not had before. And we use that mostly in the lower part of the face. And we use it sometimes with a facelift and sometimes as a standalone procedure. And we're now trying it with nano fat for healing. So that's a very exciting thing. But there've been so many changes. When I first started, we were using all saline implants. My career started the same year that they took the silicone off the market. And so we were using saline for the first God, I don't know, 14 years of my career. And then we switched back to silicone and the incisions have changed, but most everybody gets silicone now. And all that fake science was sort of debunked.

Monique Ramsey (03:33):
Yeah. So let's talk about, since you're talking about breast implants, and I think the implants have changed quite a bit, the ones that were taken off the market aren't the same ones that are back on the market now, right?

Dr. Brahme (03:47):
No, no. The old ones were filled with sort of like a silicone oil. And the ones that we've been using since 2006 are cohesive gel. They're all cohesive, so they're sort of called the gummy bear implant. So if you were to take a pair of scissors and cut that implant in two nothing would leak out. So they're really good products and they feel natural. They're long living, and you don't need to change them out unless there's something wrong.

Monique Ramsey (04:21):
And that's a really nice thing that everything's more predictable about them, and the fact that they feel so natural is just a bonus.

Dr. Brahme (04:32):
And that's what people want now. They want longevity, predictability and something that's safe and well studied. And these are the most studied medical devices on the market.

Monique Ramsey (04:45):
And even, I remember I started 30 years ago also same time when everybody was panicking in 1991 or 92. But what was interesting then is two things. I think one is size preferences have changed. So back then maybe it was like everybody wanted something in the three hundreds. And then over time things got a little bigger and more exaggerated maybe. Baywatch came along.

Dr. Brahme (05:17):
Yeah, everybody watched Baywatch.

Monique Ramsey (05:19):
And now it's maybe a little dialing back to something more natural.

Dr. Brahme (05:24):
I mean, everybody, and that's the thing about plastic surgery. You can go into the supermarket line and see botched plastic surgery, overdone plastic surgery, plastic surgery, terrible plastic surgery on the stars and so on and so forth. My patients, they want to look natural, whether it's a breast, whether it's a face, whether it's a tummy tuck, they want to look like nobody's operated on them. Did they have surgery? Did they not have surgery? And so that's sort of the hallmark of my plastic surgery practice.

Monique Ramsey (06:04):
And I think that we talk about that a lot on the podcast is nobody really wants that 0.1% that we see on TV or in the magazines. It's really, most people just want to look better and feel better and feel more confident by changing something little. And one other thing I think on the breasts is over time for a while, everything was on top of the muscle where you'd put the implant on top of the muscle, and that was maybe thought to help with capsular contracture rates. And so now you really don't do that very often. They go behind the muscle.

Dr. Brahme (06:40):
They go behind the muscle. And we've been doing that for probably the last 20, well, 30 years probably. In my early career, we did a few on top of the muscle, and that's how things really started. But for the past 30 years, I don't think I've done an implant on top of the muscle for the last five years for sure. And it's interesting also, the incision preference has changed. It used to be. It used to be that everybody wanted it under the breast, and then for a while, everybody wanted it around the areola. And now it's back to under the breast again, which is absolutely the safest and easiest and fastest way to do it.

Monique Ramsey (07:24):
Yeah, and it's really not noticeable either.

Dr. Brahme (07:27):
It's not noticeable wherever you put it.

Monique Ramsey (07:29):
Well, that's probably true. Yeah. Yeah. Okay. So let's move on to faces. And how have facelifts or the techniques, I guess of facelifts evolved since you started practicing?

Dr. Brahme (07:41):
Well, there are a lot of trends and fads that come and go. And when I first started doing the facelift, we were doing basically skin just tightening the skin. And that looked great for a while, but the longevity was not really there at all. And so then people started doing deeper layers and deeper layers. And even for a while, people were doing facelifts that were close to the bone, but the so-called Subperiosteal facelift, but the complication rate was very high and the swelling lasted a long time. So that's sort of gone by the wayside. And now you hear a lot about the deep plane facelift, and is it better, is it not? I think that prospective patients should go and meet with a plastic surgeon and see what the results are like because we're all doing deeper planes. The question is just how deep is it and where is it deep and where is it superficial? And I think that you should look at the results and the experience of the plastic surgeon and see, do you like that result? Do they have good natural results? And I think that that's, whether they do a SMAS or a deep SMAS or a deep plane, I don't think it matters very much.

Monique Ramsey (09:06):
Okay. And let me ask you about something that I remember. You used to do a lot with facelifts or for around the mouth, was dermabrasion and that was to sort of help with the wrinkles. And is that something you still do and when if you do, or what do you do instead now?

Dr. Brahme (09:30):
Well, I still do dermabrasion. There was just a meeting in New York with all the aesthetic plastic surgeons a couple of years ago, and some of the senior plastic surgeons, well-known facelift plastic surgeons talked and they all agreed that dermabrasion is probably the most effective way to get rid of the wrinkles around the mouth. You could do a laser or you could do a peel, but everybody agreed that dermabrasion, which has been around since I was a medical student, is probably the best way to go. But we're also doing things to alter the lip, because as we get older, the lip grows longer and thinner, and it sort of makes people lose their smile a little bit. And a lot of people go and have dermal fillers, but that sort of, in some patients just sort of complicates the problem. And they have big lips that are long and skinny and puffy. It looks sort of abnormal.

Monique Ramsey (10:36):
Yeah, it does.

Dr. Brahme (10:38):
You can pick it out in a heartbeat. So a procedure that I do that's very easy to do with a facelift, and I do it probably in about 30% of my facelifts now, is to shorten the upper lip. And that sort of rolls out the red part, what we call the vermilion, and gives a very nice sort of restores a smile, and people are good candidates for it. It's the first thing they see when we take off the bandages and they say, "oh God, this looks great." And it heals beautifully. And I think we have some pictures on the website.

Monique Ramsey (11:19):
We'll put those in the show notes. And we talked about the lip lift, I think last year, and we can put the link to that podcast as well, because yeah, we talked about, and for people in the audience trying to picture it, really the incision is going right around the base of the nose because you're taking away some skin in between the top of your lip and the bottom of your nose, and that's where you're trying to shorten that distance. And it's amazing to me to see how much younger that one procedure.

Dr. Brahme (11:51):
That little 15 minute procedure takes. And you can do it either as a standalone or you can do it with a facelift. I've done both. You can do it under local anesthesia if you're not doing a facelift. So it's a very nice little procedure.

Monique Ramsey (12:06):
And you were talking with facelifts also at the beginning we were talking about what changed the most and fat transfer procedures. And so you mentioned with your facelifts, you do the fat transfer in almost all of them, which sounds to me like an awesome sort of little extra bonus that you can take. You got to get the fat from somewhere, so the patient gets to choose where, "Hey, I don't like my love handles. Let's move it."

Dr. Brahme (12:33):
Let's just use it somewhere else. Yeah. Yeah. It's not really so much liposuction as it is just harvesting a little fat, because for most patients, you don't need very much fat. And in some patients who are slender and trim, it's hard to find that fat. But as we age, we lose fat in the face. And replacing that is really a nice bonus. And the fat, not all of it survives, but I would say about 60 to 70% survives, and that's your fat, and it stays there forever and it doesn't move around or anything like that. So it's really a great tool to have.

Monique Ramsey (13:20):
Now, talking about body procedures, you're so well known for your mommy makeovers and have tummy tuck techniques evolved at all throughout your career?

Dr. Brahme (13:30):
Well, in my practice, it's changed a bit. I think that the procedures were, maybe they were there but not used very much because they're big procedures now. But with better anesthesia and better monitoring, we can do more and more aggressive procedures. So for example, with tummy tucks, I used to do a standard tummy tuck or a mini tummy tuck most of the time. And now we do what's called extended tummy tuck, because that really gives you an incredible waistline when you're doing body recontouring surgery and the extended time it tucks, the scar goes around a little bit to the back, and you've already got a big scar. So most people, when I show them the pictures of the difference between the extended and standard tummy tuck, they go, "oh, I want that." Because it takes away those love handles on the side of the, people find hanging over their jeans and aren't so happy with. So I've gone from doing maybe 5% extended tummy tuck to probably doing at least 50% extended tummy tuck in my most recent practice.

Monique Ramsey (14:44):
Interesting. And going into that with the tummy tuck a of times liposuction, or not a lot of times, but sometimes liposuction may be involved at the same time. The patient is looking to flatten their tummy and their hips maybe, but also take some fat away from somewhere else. And so over the years, has liposuction improved safety wise and results wise?

Dr. Brahme (15:12):
The tools for the liposuction now are really great. They are aggressive but gentle on the fat. And so you can get very good quality fat. And with the system that we use, the fat never leaves the system. It stays sterile the whole time. So you suck it out, you drain off the fluid, you turn the knob, and you can put it right back in. So a very, because fat is very sensitive, and so you want to have something that doesn't injure the fat and you want to put it back in really quickly. You don't want the fat to be outside the body for very long.

Monique Ramsey (15:54):
And the reason is because the fat can die off if it's not getting the blood supply.

Dr. Brahme (16:01):
Exactly. Yeah.

Monique Ramsey (16:02):
It can make a happy home in its new spot.

Dr. Brahme (16:07):
Yeah. Doesn't want to be away from home for very long.

Monique Ramsey (16:10):
Right. Well, why not move it from one place to another? I mean, it's like liquid gold. So I think it's wonderful.

Dr. Brahme (16:19):
Yeah, fat has a lot of stem cells. It's probably the biggest source of stem cells in the body, so it's really healthy tissue that we're putting back in.

Monique Ramsey (16:31):
Now everybody always talks about brow lifts and they're worried about a brow lift or how does the brow lift change? Or who's the right candidate? So let's talk about a little bit, how has the brow lift kind of gone through your practice, and how often do you use it, and where are the incisions?

Dr. Brahme (16:50):
Okay. So brow lifts have gone through sort of phases, and it used to be that a brow lift was an incision that went just straight across the scalp.

Monique Ramsey (17:03):
From ear to ear, right?

Dr. Brahme (17:04):
From ear to ear. And it was basically the continuation of the facelift incision. And then you peeled down the forehead and you stretched it. But it's not so good for somebody who has a high hairline to begin with. So now I do mostly what's called the anterior, which it goes up to about this portion. And then it skirts around the forehead and around the hairline here. And the scar heals beautifully. We flirted briefly with endoscopic brow lifts, but that was a big thing in the 90s and 2000s, but they didn't seem to be so permanent, and they sort of relied scar tissue to hold them in place rather than removal of tissue. So the recurrence rate of the brow falling down was pretty high.

Monique Ramsey (18:00):
I think that's one of those medicine, trying to make the patient happy with less scarring. And it doesn't really work.

Dr. Brahme (18:11):
And that was true with a lot of procedures that, especially facelift procedures, the no scar facelifts and no touch facelift. And we don't like scars any more than anybody does, and we always try to limit them, but sometimes no pain, no gain.

Monique Ramsey (18:31):
So one other thing, getting back to the body is that you're very known for is vaginal rejuvenation and feminine rejuvenation, maybe because we're talking about labiaplasty and also vaginoplasty. And can you touch on how that, when did that come into your practice and how much of your practice is those procedures?

Dr. Brahme (18:57):
Yeah, I mean, it is funny. That is actually the fastest growing segment of plastic surgery. When I first started doing this. And you would go to the big meetings and maybe there would be one talk on it or two talks on it. Now, there are whole days devoted to feminine rejuvenation. So it's one of the fastest growing areas. I've been doing it since about 2008, and I've done 500 vaginoplasties since then. And it's basically for tightening the vagina after childbirth because everything gets stretched out with childbirth breasts, tummies, vaginas too. And so it's really to make the sexual experience better for both the man and both partners after childbirth. And then some people have problems with large labia. And what's interesting is that people don't talk about this, and so they think that they're abnormal. And one thing I tell them, "yeah, what you have is normal, but it doesn't mean that we can't change it so it looks more pleasing to you." And these are nice procedures to do. Patients are very happy and recovery is easy, and I've never had a major complication ever, so it heals so well because of blood supply down there is so good.

Monique Ramsey (20:28):
And I think you're right, that is something that people don't know that there's even it's possible to, the vaginal canal gets stretched out with childbirth. And so how do we make it a little bit tighter in there? And so that you were talking about having more sensation for both partners. And I know we did a podcast about this recently, so we'll put that in the show notes because that really goes into more of the details about what is a vaginoplasty, what is the healing like, what's the difference with a labiaplasty? How does that work? And so we'll put that in the show notes.

Dr. Brahme (21:07):
And it's a very personal thing. And patients, when they come in to talk about it, they're a little shy and so on. But we treat it, it's just another body part, and it's just something else that we can improve and change and make their life better.

Monique Ramsey (21:27):
And that's something that I think at any age, women, especially with a labiaplasty, if you're born with a little extra skin more than you would like, and maybe it gets in the way, that's something that you could do and change and fix when you're 18 years old or 19 years old and you finished growing. And that could be a life changing procedure for you. And so, especially I think about athletes and when they're having to wear bathing suits or they're wearing tight uniforms and there's just too much skin there, too much tissue, and it's nobody's fault.

Dr. Brahme (22:00):
No, and it's uncomfortable and people get self-conscious about it, and it's an easy thing to take care of. So you're very right about that.

Monique Ramsey (22:12):
And let's get into sort of, is there any trends in the non-surgical realm over your 30 years? I mean, there's so many probably, but what things really stand out to you? I know that the things have come and gone, but.

Dr. Brahme (22:30):
There are many, many more lasers, and I don't even do lasers anymore. We have a med spa that does all the lasers, but in terms of, there's a radiofrequency modality for tightening skin called Morpheus8, which is very good. There's even a treatment for that came out for people who need minimum vaginal tightening called ThermiVa, and that uses radiofrequency technology. Basically, it heats up the interior of the vagina and makes it a little bit more tight. And the nice thing about that is that it also treats incontinence and the operations for stress incontinence. When women lose a little urine, when they laugh or cough or sneeze, the surgical solutions for that are big time operations. And with this technique, we can treat that very effectively with just three noninvasive treatments that don't require any recovery at all.

Monique Ramsey (23:43):
I actually had ThermiVa treatments years ago, and it's a really cool technology because it sort of helps rejuvenate those tissues down there. And the side benefit is that you're getting help with that stress incontinence, which I think almost all of us ladies deal with.

Dr. Brahme (24:03):
Yeah, I mean, most people who've had children have, to some degree, maybe minor or maybe major, but I haven't had any patient who didn't have improvement with the ThermiVa.

Monique Ramsey (24:15):
Yeah. Now, let's talk about you personally in your own personal evolution as a surgeon, and how have all these changes around you helped you as a surgeon?

Dr. Brahme (24:28):
Oh, it's like opening a book. It's like all these new things are available, and also you learn what works and what, what's a fad and what's a real improvement. And you learn what patient is right for the right procedure. And so that's where the experience comes in. And so it's fun to learn new things, but it's also fun to perfect the things that you know.

Monique Ramsey (25:02):
Ooh, I love that. And that's so true because I think I love it that people have this sort of entrepreneurial spirit to let's make this one topic better. Let's try to solve this problem. And it is exciting, but at the same time, the discerning eye like, well, let's just see. And it doesn't mean we won't try it, but I think a lot of times the hype can be more than the result.

Dr. Brahme (25:32):
Oh, many, many times, especially when there's medical equipment surrounding it and there's incentive to get things sold and this new machine and there's new stuff that comes out all the time. And fortunately because we're a big office and have a high volume, we get approached a lot. So we see all the latest technology and see what sounds good. And the most recent thing has been the Ellacor, which has been very, very satisfying for us.

Monique Ramsey (26:02):
And that's something I think I remember that we were one of the first 50 practices to be able to do it. Right. You're the one who helped bring that technology into the practice.

Dr. Brahme (26:13):
I was very excited about it, and I continue to remain excited. I mean, it's not the panacea, nothing is, but it has increased our armamentarium where we were lacking in technology.

Monique Ramsey (26:30):
And I think you described it well in our podcast when we talked about it. It's sort of like that area right around the mouth and the lower face. If somebody's had a facelift and they want that area fixed, or even if they haven't, how do you get all around close to the lips and those little wrinkles, whether the person's a smoker or not, or that the jowls, it's like pulling from the back by the ears is fine, but you'd have to pull so tight that the person would look deformed.

Dr. Brahme (27:03):
Would look very strange. And everything relaxes after time. So when you do a facelift, the initial way it looks at one month, it relaxes over a year, and you wish you could have done it a little bit tighter, but you know that that's not the right thing. So we have now something that can help us come back after a year and maybe do a little touch up.

Monique Ramsey (27:31):
I love that. And I love the whole, I don't know who thought of it, but the whole theory behind Ellacor, helping to extract a little bit of that tissue and tighten everything up. And what would you say for the average patient is healing the healing time for that?

Dr. Brahme (27:49):
A couple of weeks.

Monique Ramsey (27:50):
Okay.

Dr. Brahme (27:51):
Couple of weeks. And you can put makeup on after usually about four days.

Monique Ramsey (27:58):
Now what about the future? Let's talk about...

Dr. Brahme (28:01):
Ah, who knows what the future holds.

Monique Ramsey (28:04):
And what about the future for you? How long do we get to enjoy your talent? Because I got, yesterday, I got a letter from my dentist that I was not expecting, and he's retiring, and I was like, whoa, hold on. I've been going there since 1996. So we need to prepare for these things, Dr. Promi. Absolutely. So how long do we get to enjoy?

Dr. Brahme (28:30):
The same thing happened to me with my dentist. I was very disappointed.

Monique Ramsey (28:33):
How dare they? How dare they.

Dr. Brahme (28:35):
How dare they? That's right. Well, I have no plans right now. I enjoy what I do. I feel like I'm sort of at the peak of my powers, and I really truly enjoy my patients. And it gets easier as you get a little older because you know what your limitations are. You know what you can and can't do, but yet the field is so constantly changing that learning new things and having younger partners is wonderful as well. So we all learn from each other. And yeah, I'm going to be around for a while.

Monique Ramsey (29:14):
Oh, good. Oh good. Well, this was so interesting to have you on today, Dr. Brome, and celebrating the last 20 years of your time at LJCSC, but also the last 30 years in your career. And we're just so happy to have you, and you have to make sure that Cristina doesn't retire before you do either.

Dr. Brahme (29:33):
I know. I don't know what to do without her. She's been my nurse for 20 years, so.

Monique Ramsey (29:37):
Every time we post about her on social media, it's like the most popular post because everybody loves Cristina.

Dr. Brahme (29:43):
Everybody loves Cristina.

Monique Ramsey (29:44):
Yeah, you've got to time it together. So if you're listening today and you have questions for Dr. Brahme or you need information about consultations or scheduling or financing, reviews, all of it, we'll have in the show notes. And I encourage you, I think Dr. Brahme, you touched on something right at the beginning, which is sit down and take an hour and have a consultation. If you're thinking about something just to wrap your head around, what are we talking about in terms of healing and what the, am I a candidate?

Dr. Brahme (30:16):
Right. Talking is always the first step and not to be afraid and to see if you can connect with the person that you're talking to. I mean, does it make sense? Is it something that sounds good to you and it doesn't cost anything to come in and talk to us?

Monique Ramsey (30:39):
And I think that's really the key, because then you can plan around the healing journey that you're going to have to have and childcare if that's part of what you're dealing with. But it helps you be able to solidify instead of having a bunch of stuff bouncing around in your head, you have something on paper, you've had the conversation, and you can start to sort of visualize that dream coming to reality.

Dr. Brahme (31:05):
Yeah. And everybody here is so supportive and so sort of low key about it that we're all willing, we know that this is not something that you do every day, but we do. And we try to give you the comfort of knowing that we do it all the time and still respect the fact that this is a unique situation for you.

Monique Ramsey (31:29):
Right, right. Yeah. We've all done it many times, but each patient hasn't done it necessarily very many times or at all. Yeah. And I think that's true that our team is very special and very supportive and helps handhold during that journey.

Dr. Brahme (31:47):
It's very supportive.

Monique Ramsey (31:48):
And not just before and during, but after. And that's, I think the key is that we stick with you and we're about to celebrate 36 years being in San Diego. Yeah, since 1988. So there you go. There's a bigger number than the one we're talking about, but.

Dr. Brahme (32:06):
Well that shows stability too.

Monique Ramsey (32:08):
Right? And I think that's the key is who's going to be there with you through it and maybe 10 years later for whatever other procedures you might want? So thanks again, Dr. Brahme. It was very nice.

Dr. Brahme (32:20):
My pleasure. Thank you, Monique.

Monique Ramsey (32:22):
Nice to be able to catch up with you and hopefully we'll see you again and we can talk about nano fat and micro fat.

Dr. Brahme (32:27):
Okay, sounds great.

Monique Ramsey (32:29):
All right. Thanks everybody. Thanks all of you for joining today. And check the show notes for all the links we were talking about.

Announcer (32:38):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code podcast to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed Building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @LJCSC. The La Jolla Cosmetic Podcast is a production of the Axis T-H-E-A-X-I-S.io.