Phenol Peel with Robert Kotler, MD, FACS

Trina Renea  0:07  

Hey everyone, welcome to Facially Conscious. I'm Trina Renea – a Medically Trained Master Esthetician here in Los Angeles, and I'm sitting with my rockstar co-hosts, Dr. Vicki Rapaport – a Board-Certified Dermatologist with practices in Beverly Hills and Culver City, Rebecca Gadberry – our Resident Skincare Scientists and Regulatory and Marketing Expert, and Julie Falls – our Educated Consumer who is here to represent you. We are here to help you navigate the sometimes confusing and competitive world of skincare. Our mission is to provide you with insider knowledge on everything from product ingredients to medical procedures, lasers, fillers, and ever-changing trends. With our expert interviews with chemists, doctors, laser reps and estheticians, you'll be equipped to make informative decisions before investing in potentially expensive treatments. It's the wild west out there, so let's make it easier for you one episode at a time. Are you ready to discover the latest and greatest skincare secrets? Tune in and let us be your go-to girls for all things facially conscious. Let's dive in.

Dr. Vicki Rapaport  1:26  

Good morning, everybody. We are so excited today because today we are talking to Dr. Robert Kotler. And he is an esteemed Beverly Hills Plastic Surgeon who does this incredible procedure that is truly unbelievable. I don't actually even think it's possible, but I know he's been doing it for years. So, we're going to talk to him about that. He trained at the Northwestern University and the University of Illinois and he is Double Board-Certified in head and neck surgery as well as cosmetic surgery. He has written numerous books on cosmetic surgery. He has 52 medical publications and presentations. And he has been practicing surgery for over 50 years. Welcome Dr. Kotler.

Trina Renea  2:12  

Hi, Dr. Kotler. Welcome.

Dr. Robert Kotler  2:15  

Hi, everybody. Good to be with you.

Dr. Vicki Rapaport  2:17  

Well, you know, we brought you on because I've seen you do this particular procedure called The Phenol Peel with really unbelievable results. So, I actually do send my brave patients to you.

Trina Renea  2:29  

By the way, that's Dr. Vicki speaking with that voice that you don't recognize, she's lost her voice a little bit. So, she's a little raspy today.

Dr. Vicki Rapaport  2:37  

A little raspy. But I send my patients Dr. Kotler to you for this phenol peel, can you tell us about this incredibly, but really unknown procedure called the Phenol Peel?

Dr. Robert Kotler  2:50  

Sure, I had an interesting history with it in my training, I was exposed to it as a resident under Dr. Ariano at Northwestern, and when I came out to California for my fellowship, I happened to meet another doctor and he was quite impressive. I wanted to spent some time with him and I did and he said if you want to come in as my assistant, whatever, and I saw him do the chemical peel and I said to myself, wow, it's just like Dr. Ariano did at Northwestern. And finally, we were talking about I said how did this all come about? And it turns out that he had taught it to Dr. Ariano, he was his student. And then I realized I fell into something good because I could see it was a marvelous procedure for the right patients of course and so then I dive deeply into it, and in 1992, I wrote a textbook on it, the single subject textbook, basically a how-to for our colleagues.

Trina Renea  3:52  

And so, what is a phenol peel and can anyone do it; dermatologists, plastic surgeons, estheticians?

Dr. Robert Kotler  4:03  

First, it is limited to positions because frankly there are medications that has to be given along with the application of chemicals. Well, a phenol is a commonly used chemical in industry and at a certain concentration it has ability to enter the skin and essentially destroy the outer layer; the epidermis and the upper dermis and encourage the growth thereby of new skins. Not a lot different conceptually, from a laser treatment. However, you can strengthen the phenol by the addition of other liquid ingredients. And a classic formula included, believe it or not water, which actually makes it stronger. That's a unique property and two other ingredients and the combination is quite potent. And for people that have very deep wrinkles, I have found it is the only solution.

Dr. Vicki Rapaport  5:03  

Well, you know, recently sent a patient to Dr. Kotler, who was 55-years-old, she had grown up in California. And she just aged with those crisscross deep wrinkles on her cheeks that truly, no filler, no Botox, and maybe even no CO2 Laser could fix her. And I really thought, okay, this is the perfect patient for Dr. Kotler. And I knew she was tough, because you have to be tough to get this done. There's a lot of downtime. And she ended up having a console and she ended up doing it. And when she came back to see me, my mouth dropped open. The results were unbelievable. And we're going to talk a little bit more about the details about the downtime, but for the right patient, it literally takes 30-years off of their face. 

Trina Renea  5:48  

Is this a patient who probably a facelift wouldn't even work for?

Dr. Vicki Rapaport  5:53  

Dr. Kotler, what do you think about that? Would a facelift work for these patients with those super deep crisscross wrinkles? Or is it phenol peel better?

Dr. Robert Kotler  6:00  

No, it is a great question. And it's always raised with the patient. What is the best treatment? Frankly, I've always thought of wrinkles as a skin only problem. Lack skin, hanging skin, loose skin. That's a surgical issue. And so, some of the examples that I've shown include both the chemical skin peel, and the face and neck lift. That's a combination that again, it's hard to beat because each address what it's best at. 

Dr. Vicki Rapaport  6:34  

Yes, that's true. And you can't do phenol peel on the neck. Is that correct? 

Dr. Robert Kotler  6:39  

You know, you can. I did some work on many years ago, but frankly, the neck skin being different, it was too problematic. Even color issues came up. So, I decided we just wouldn't do it anymore because we couldn't get the consistency we wanted. 

Dr. Vicki Rapaport  6:54  

Are you like the Phenol Peel expert in LA?

Dr. Robert Kotler  7:02  

I suppose no one's done them longer than I have. But I'll put that feature in. It's hardly ever a subject in formal training these days. And I think that, frankly, the laser treatments are easier to master; both in your residency, and if you're out of residency, this particular process takes a long time to understand and master. And actually, I think they doing it in a residency is a good start. But you really have to have a lot of cases over the years and learn from your patients. It's an art form to some extent, some areas have to be treated more aggressively than others, you have a lot of issues. And I know we'll talk about a bit in terms of color of the skin, many things that come into the picture that experience, guides you.

Dr. Vicki Rapaport  8:03  

I think that's also why it is not something that well known just exactly what you said it's so hard to master and you know, lasers are “easier to master”. And this makes so much sense to me, finally, I never really understood with such incredible results. why more practitioners and physicians didn’t do it. So, this makes sense.

Trina Renea  8:25  

But then where do the residents these days learn? Do they have to go and learn from someone like you? Do you teach it to people or other? Is there a doctor who's teaching it? 

Dr. Vicki Rapaport  8:37  

They can get his book that he wrote?  

Trina Renea  8:38  

But then he didn’t get the hands on.

Dr. Vicki Rapaport  8:40  

Yeah, that's true. Right?

Dr. Robert Kotler  8:41  

The book is essentially an evergreen book, the lessons and techniques they're in are eternal, and nothing's changed. I still perform the procedure the exact same way that I did in 1992, when I wrote the book, by I would tell you that, first of all, you have to have a large volume of cases. And frankly, because of the advent of laser technology, and the continual improvement in laser technology and other modalities, there's very little taste for anyone for any practitioner to take on the burden of learning that chemical skin peel. I understand that. And I would have trouble basically taking someone on because we don't do many of them anymore. That's just the reality because there's not much demand, mainly because patients don't know about it. And interestingly, I can tell you of all the cosmetic procedures that we do, that has the smallest referral rate. I know it sounds somewhat contrary to common sense, because it is successful. But a lot of the patients don't talk about it, and aren’t apt to admit that they had it and you can't count referrals, despite the quality the result. So, all these things add into whether it should be a part of your practice or not. 

Dr. Vicki Rapaport  10:09  

I see. And can you talk a little bit about like, who's a good candidate? Because I know, darker skinned patients really are not good candidates. Who is the perfect patient for a phenol peel?

Dr. Robert Kotler  10:18  

That is the great question. patient selection here is everything indeed. And if you stray from performing it on the ideal patients, there's more challenge, the ideal patient would be a fair skin, literally white skin, thin skin woman of Northern or Central European ancestry, where they have basically much less potential for pigmentary issues. Blonde or red hair, green or blue eyes, that's the best candidate, and you can predict that their result will be good without the pigmentary changes. At the other end of the spectrum, those with dark skin and that would include Asian people, Hispanic people, black people, the issues with pigment will be significant. And so, that has to be considered.

Trina Renea  11:11  

Well, so I think that the demographic that you're describing does wrinkle a lot more than those other darker skinned pigments. So, you know, they're the ones who get the deepest wrinkles and have issues with pulling it back tightly. 

Dr. Robert Kotler  11:28  

Yeah, great, great point. That's exactly right. But if you limit your work to those who are the ideal candidates, your success rate will be high and your complication rate low. 

Dr. Vicki Rapaport  11:40  

Can you talk a little bit about downtime and does it actually hurt during the downtime?

Dr. Robert Kotler  11:48  

I'll tell you, we'll take a step back because the point of maximum discomfort is within the first 10 to 12 hours of the application of the chemicals and by the way, we do it under general anesthesia. In a certified outpatient surgery center with a board-certified physician anesthesiologist. In other words, we introduced the same level of safety and comfort to the patient as if it were surgery. And so, after the procedure is done, the patients also go to a professional recovery facility where they can be managed because pain is a burning type pain. It can be severe and must be managed with our products. Hence the reason they have a professional environment with nurses there. Interestingly, after the first 10 to 12 hours, the phenol seeping deeper into the skin, and that anesthetizes the nerve endings. And I explained that to patients by reminding them that they're familiar with Chloraseptic gargle for a sore throat. If you look at the ingredients, one of them is phenol. 10 to 12 hours the pain actually goes away by the next morning the patients are in much there's very little discomfort and at that point, even extra strength Tylenol work. However, the itching comes about the second week but the timeline is pretty consistent.

Trina Renea  13:10  

I ask a question. Can you in that first 12 hours where the pain is severe, can you just knock them out into a nice deep sleep with drugs?

Dr. Robert Kotler  13:21  

They are, that's exactly what we do. they are knocked out, given we actually use methadone which is not commonly used, but it's a great drug for that, it has a long duration of action, is very strong and a sedative like Phenergan or Valium. And so, they are indeed knocked out. We don't want them to suffer. That works. It just works. But obviously that implies you must have professional supervision. In the recovery facilities, they check pulse, blood pressure, pulse oximetry.

Trina Renea  13:57  

How many days are they in there?

Dr. Robert Kotler  13:59  

Two days. We have a very rigid schedule. We do, for procedure on Tuesday, patient is brought into the office on Wednesday, back to the surgery center on Thursday to remove the dressing, the dressings are an important integral part of the procedure. And again, for patient comfort, the anesthesiologist gives them a short blast of propofol and we remove the mask, wash the face. It's a little bit of a debrief moment, if you will, coat it with antibiotic ointment and at home they go. Yeah, again it looks a little unusual. But they are prepped because we show patients what other patients look like. You have to prepare the patient very well for this procedure. They must know how they'll feel, what they will look like so that they look in the mirror they won't say ‘oh my god, what's going on here?’ There's a lot that goes into it. I think that's one of the points I want to make. And Vicki and I have talked about, it's not a simple procedure, it has many steps in it. We like to execute them in a consistent classic manner so that we can have confidence that the result will be good without complications. 

Trina Renea  15:18  

How long are they at home before they can actually see the light of day?

Dr. Robert Kotler  15:28  

It's actually kind of go by the day of the week, if they go home on Thursday, Friday, Saturday and Sunday, and we washing off the basically dead skin. And by Monday, much of it will be off maybe 80-90%. We see them that day to check out how they're doing, and was another two days it's off. So typically, it's a week for all dead skin to come off. And then it's this process of having a fire engine red face for a few days. So, by the end of that second week, three, four days later, the skin has calmed down, it is fully epithelialized, and thereby can now be concealed with cosmetics. And on our little slide presentation that you'll have available to your listeners, the camouflage is very important. Because if we just camouflage the red color, they're fine. It's not like surgery, where they're swelling, where there's stitches that are in for a while, where you can see the incisions. It’s strictly a skin surface issue. The skin is read and after another month or six weeks, it's pretty well clear. But that's not a short recovery time, but the patient isn't disabled. 

Trina Renea  16:45  

And so, can the patient with that darker pink skin that you can cover with cosmetics, can they go outside like during the day if they have sunscreen on, are they protected? Or could they potentially hyper pigment? And is the epidermis completely renewed? Is it super sensitive to the sun? Or are they like hypo-pigmented or what happens at that point?

Dr. Robert Kotler  17:15  

Well, you're right, those are the questions by the end of that second week they are fully resurfaced, fully up. It's just red skin, it looks like a sunburn looks like a bad sunburn, it will fade of course on the other hand, we also speed up that process by using prescription level cortisone ointments. And if they're going to be out in the world, they can wash it off and put on the camouflage makeup, it's not a good idea to go out to the beach and spend some time because the skin is sensitive. Pigmentation is the concern, of course, as you mentioned, so all these caveats are part of the instructions. And we rigorously enforce them as much as we can. And we do see the patient often. That's the other important feature. The doctor has to make a commitment to the patient, and be certain the patient keeps the appointments etc. Because it's in the first six weeks that if they're going to be some issues, such as pigmentary issues we need to know and if pigment starts to develop, we can reverse it using basically the hydrocodone formulation, it works.

Trina Renea  18:29  

You can put a hydrocodone on that raw skin? 

Dr. Robert Kotler  18:34  

Yeah, it’s not raw, it’s red. But if there has to be a pigmentary reaction. Typically, it's going to occur in those first four to six weeks.

Trina Renea  18:44  

Uh-huh. Okay. Dr. Dunn has joined us. Hi, Dr. Dunn.

Dr. Vicki Rapaport  18:56  

Dr. Kotler, we want to know how much it costs. And then we want to also tell you that Dr. Dunn has joined us who is, the younger colleague, who knows about phenol peels but doesn't perform them. So, you know, when we're old and wrinkled, and we need it Dr. Kotler if you're not around, we need somebody like Dr. Dunn to do it, hopefully. So, how much does this phenol peel cost? And then Dr. Dunn, do you want to weigh in on, I know you haven't been listening, but you know, Dr. Kotler loves the phenol peel but he just says it's just not that well known, and, you know, it's not that common, not a lot of people refer their friends to do it versus facelift. So, we're going to find out kind of what your opinion is on that too. 

Trina Renea  19:42  

Before you give us a price. Dr. Kolter. Dr. Vicki had a patient who did this with you, she was 55 and she did not do the facelift. Is that correct, Dr. Vicki? 

Dr. Vicki Rapaport  19:56  

No, she just did the phenol peel. 

Trina Renea  19:57  

Just did the phenol peel, and she went from having deep-deep like 85-year-old wrinkles to having no wrinkles without a facelift. So, if somebody didn't need to also do a facelift along with it and was just the phenol peel, what would that cost a patient? 

Dr. Robert Kotler  20:15  

Yeah, they're totally separate modality modalities. And then by the way, you cannot do, what if a patient needs both, there has to be a three-to-four-month interval between. The order it can be peeled and face, neck, lip, or vice versa. That's depends on the particulars of the case. $21,500 is the fee that we charge and includes the outpatient surgery center, the doctor anesthesiologist, that's a complete package fee, so to speak. But the additional service of the recovery hideaway is additional, which today comes to almost $2,000 for two days. If they want to have a private duty nurse, they can. That's the patient's choice. But we do have to have someone responsible for them.

Trina Renea  21:08  

Well, I feel like if somebody, if lasers are not an option, and facelift is not an option. And they have these deep-deep wrinkles, and you can walk out and a month, or even in two weeks, like you said, look at your face and have no wrinkles. I mean, that to me would be worth it. If I looked like I was 85 when I was 55.

Dr. Robert Kotler  21:35  

Well, I agree. And by the way, I've done my wife, family members, I get to see the long-term results. And it's an impressive procedure.

Trina Renea  21:49  

Do you have people that tell you, the people who've done it like your wife that they wouldn't have done it if they would have known what the downtime was?

Dr. Robert Kotler  22:01  

No, I'll tell you why, because it's very clearly outlined, we have, I think, a good in-house educational program, and I spend the time with the patient. I do all the counseling because I also need to be learning from them as we're speaking, you know, I have to make a decision, by the way, whether I think it's appropriate or not, it may not be appropriate, even on psychological grounds. And I think that's what that's what separates experience from inexperience. As we all continue in practice and in our professions, we learn and we learn that when we deal with patients, no two are the same. Yeah, different concerns, different worries, there are many factors that come in, and I need to be able, as any physician would need to read the patient, you know, and because the successful outcome isn't just a matter of physical appearance, they have to feel good about a psychologically feel that the time off. And the dollars expended were worth it.

Trina Renea  23:06  

Dr. Dunn, you obviously learned this in school, right? Or did you? Or you found out about it?

Dr. Dunn  23:16  

Yeah. Good morning, everyone. Good morning, Dr. Kotler. It's nice to be talking with you. This is something that we learned in my training, but it was a pretty peripheral learning that we had, when it came to this, it was mostly through textbooks and reading literature. A lot of the providers that I worked with weren't using it. Mostly just because of you had to be an expert to be able to perform this peel and really be able to kind of decide who's the right person to treat. And I'm sure you guys have already discussed a lot of this. And also, it's not just the right person, but making sure that you know, poor outcomes don't happen. And there are serious risks that can occur with this if you don't select the right individual. And so, a lot of the skin resurfacing modalities that we would use and that I was trained with were much more gentle, did not give nearly as impressive of a result, and oftentimes needed multiple treatments. And so, you know, this was always thought of the gold standard, and what everything that we would compare it to and nothing really would meet it. And one comment that I would make that you guys were talking about is, you know, and Dr. Kotler mentioned this as well as a facelift and skin resurfacing are two completely treatments and the facelift is a skin quantity procedure where you remove the quantity of skin and you're taking away some of that and the skin resurfacing modalities like chemical peels. As phenol peels, lasers, that's a skin quality. And so that's really dealing with the top layer in the surface and the appearance of the skin. So, two completely separate things. So, if you have excess skin, a phenol peel will tighten the skin but it doesn't remove excess skin, it just will tighten. So, yeah.

Dr. Robert Kotler  25:20  

Well said, I've always felt that a face, I call it a face and neck lift, and most people the neck is 80% of the victory. The truth is that people talk about facelifts and they pull their cheeks up and all that. But the big win is across the neck and jawline, in my opinion after a very aggressive neck surgery, whether it's part of a face and neck lift, or it is a lot of extra skin or some people just have imperfect neck sculpture or a neck kind of profile, they've got too much fat there, there's a physical muscle that's hanging and that actually can be corrected without a full face and neck lift. You can do it through a single incision under the chin. We've been doing that since 1980. 

Trina Renea  26:09  

How do you do that? Sidenote.

Dr. Robert Kotler  26:12  

Well, just make an incision under the chin, you raise all the skin about that almost about two thirds of the skin of the neck. And then you liposuction the superficial fat, then you split the Participa muscle, go down deep and get the fat that sits on the trachea and larynx are rather invasive and it is, but you'd have to get this at some potential fat out right, Dr. Dunn, I mean, otherwise, you'll not pure liposuction, very obvious to me early on wasn't very good. The fact that the second source of the sagging and then you repair the Participa muscle by sewing it together as a tailor would. You know basically sew together personal vast. And then the skin just contracts and shrinks down. You put in platelet rich plasma, suction drains. And that's it. That's making light of it. But you know, those of us who used to do radical neck dissection, major head and neck cancer that spent a lot of time in the neck, I guess it's kind of standard fare. But that's another interesting point. I think Dr. Dunn will agree there's a lot of misconceptions about what a ‘face lift’ is, some people believe that you'd have to raise the eyebrows automatically. This is very much an art form. And I think physicians that understand the pathology of what's going on and what needs to be managed, and what doesn't need to be managed are leg up.

Trina Renea  27:49  

So, I understand that. There's a question that I have, I understand that we have to let you go Dr. Kotler, because you are on a time constraint here. But do you think that, so a Phenol Peel is around 20 grand and you get results immediately within the first month you're back out with some cosmetic makeup and things on and that will last their lifetime? Or like, will their face still ringing right back up?

Dr. Robert Kotler  28:23  

Well, I know this sounds unbelievable. But I've been doing them since 1977, I don't even count the years. No one has ever come back for a second one. I've had one or two patients come back who had some lip lines that occurred. And I may even caution against it because frankly, repeals are tricky. Because the skin is thinner is open to the original peel, right Dr. Dunn? So, I'm very concerned about re-peeling and talk about that in the book. But the truth is, I do see people that I did back then, and they have to say… yeah, this incredible procedure because you're essentially giving them new skin and I'll make one little comment. The late Dr. Larry Moya and I years ago just decided to do a real simple little study comparing the power if you will have the deep female appeal with the full-strength CO2 laser. What we did was we took skin from a lady that I had done a facelift. But before the skin was excised, one area was treated. He came over retreated one with the laser, next to it we peeled it and then took out the skin, sent it to the pathologist and we didn't tell him what we did. He said, tell us what you see, how much necrosis, what was the penetration? What was the effect histologically? And it turned out actually the phenol had a greater effect there was more necrosis and more, well, I should say more fibrosis, more of everything, more elastic, fibers, but the CO2 laser, I've seen some, they're excellent, the results are great, but even that, because of the potential for complications, and I've seen those too, of course. I think people shied away from that's why you have practice with fractionated lasers, you have a lot of varieties of less potent lasers, but those there'll be safer. And I think, again, like everything else. If you don't have the ideal training experience, you have to be very careful about taking on aggressive procedures because an imperfect result is better than a complication.

Trina Renea  30:49  

What about dermabrasion though there's like is that, that's not comparable to a stiff phenol or CO2 laser, the aggressive dermabrasion that removes skin that way?

Dr. Robert Kotler  31:01  

Well, I we did dermabrasion in the early days in my residency, and in my practice, that's a tricky procedure to because if you go too deep, you're going to have the potential for scarring. It's very difficult, actually the chemical peel is easier in a sense, you paint down the chemical easier and let nature do the work. And what happens, and probably dermabrasion is, it's all mechanical, it's in your hands. I never was really that happy with it. I wasn't as comfortable doing it. And once I felt that a handle on the peel never did another dermabrasion. I think they're fine for small little focal scars, perhaps and reconstructive issues. But I think as a full-face treatment, personally I'm not in favor.

Dr. Vicki Rapaport  31:57  

I have a quick question about the phenol peel and cosmetic units. Would you ever phenol peel just around the mouth? Or no? Because the color differentiation would be weird.

Dr. Robert Kotler  32:08  

Great question. Yeah, we've done it a few times, we've had some people come in their skin was as white as a sheet. That's very rare. And we've done that. That's right. That's what drives it. If you're going to do segments, and the face is obvious, divided into anatomical segments, you must be sure, as much as you can, there won't be a color difference, or the patient must accept the fact there could be a color. However, it's easy to say okay, I'm okay with the color difference. And then once they have it, oh, gee, I don’t like this. So, you know, it's a lot of thinking that goes into this.

Trina Renea  32:44  

And their mental state of mind, I'm sure. 

Dr. Robert Kotler  32:48  

Yeah, it's the application of liquids to the skin, but I wouldn't call my house painter to do it.

Trina Renea  32:53  

So, here's another question that I think is important for people. If you could get a what they have now, these hybrid CO2 lasers that are not as aggressive and give a pretty good result, and much less expensive. If you were to do, let's say it was $2,000 for one treatment, and then you did 10 of those, that equals up to $25,000. And so, you had less downtime, and you did it over the course of time, will you get the same result that you would get with the phenol peel after 20 of these over the course of two, three years? Are you going to have that beautiful result that you get from the female appeal immediately?

Dr. Robert Kotler  33:44  

I don't know. I don't know how many people would stick with that program. I don't know. I guess that's what I liked about the phenol peel it's one and done. And that it's very gratifying. There's no question. And I'll part was then I believe early but unfortunately, obligation. But I'll part with one comment. The patient that he'd mentioned, that I took care of her sister was, but looks very similar. And she came down once and was blown away by the result. And so, Vicki’s patients said – well, why don't you have Dr. Kotler do it so the lady doesn't live here. She lives up in Northern California, I believe. And she visited a couple of doctors have they said, yeah, we can do something like that, and it was less expensive to wherever she was going to be and she had it done. And her sister said, Bad move. Our patient said she made a terrible mistake. But she didn't get the result her sister had and part of it frankly was dollars, she didn't think it was worth it. And that's a purchasing decision. Right? You know, we may think that a BMW isn't worth it and other people think it is, everybody views dollars differently. But it just shows you how some people think. If you had a sibling that's explicitly ashy. And by the way, they're both extremely successful business women, I don't think money per se, is a problem for them. But some people don't get to spend it. See, that's another thing.

Trina Renea  35:33  

Also, when you're doing some procedure like this, that is so invasive and intense, you want to go with the best doctor, you don't want to mess around with that.

Dr. Vicki Rapaport  35:42  

Dr. Kotler, you know, you just said no two patients are the same. But when you compare sisters like that, you know, twins would be even better because they have similar genetic makeups. But sisters, like the way you were describing, you did that procedure with Moy, you know, one half of CO2 and then cut out skin and one half was phenol. So, you have now two sisters, one did the phenol peel, the other one did the CO2 laser, and I bet you that there is no comparison as to which one looks better. And it's definitely the one who had the phenol peel, which I just love. And if maybe I can get pictures of that, we're going to post that. And we're definitely going to post your befores and afters that you included with the emails all the back and forth getting today's prepared and ready. And we thank you so, so much for this incredible appearance and all this information. We know you have to go. But hopefully Dr. Dunn will stick around for a couple minutes and just kind of finalize some of our last-minute questions. But Dr. Kotler, Bob, we love you, and we so appreciate you.

Dr. Robert Kotler  36:45  

Thanks for inviting me, I'm glad to share my experience that it's fascinating procedure. All cosmetic procedures are fascinating. And I'll leave you with one quick thought. I wrote a textbook for the public called Secrets of Beverly Hills cosmetic surgeon. And we looked at the benefits economically of having a nose job when you're young. In other words, if you front the money, your nose job when you're done, and that's another once in a lifetime procedure. And that's actually that's my practice now is using that direction. So, it's very interesting. It was like 15 cents a day. That was the cost of acquiring a good nose for the rest of your life. You can't get a Coca Cola for 15. So, that's one way you have to amortize the cost. That's what accountants would say, well amortize the cost. If you're going to spend $21,000 that’s going to last you the rest of your life, you have it when you are 55. Yeah, well, guess what? Good deal. If you live old, you'll really have a good deal.

Trina Renea  37:52  

Yes. We have some of those pictures from you that we're going to share because we saw a 55-year-old lady and she's 75-80 now and she I mean, her skin looks the same like it never wrinkled. It's amazing. 

Dr. Robert Kotler  38:06  

It’s cool. So, I'm glad to share and educating your listeners, and it was certainly the best. Thanks for the opportunity to be with you.

Trina Renea  38:15  

Thank you so much. 

Dr. Vicki Rapaport  38:16  

Thank you, Rob. You are wonderful.

Trina Renea  38:18  

Dr. Dunn. Stay on if you can.

Dr. Dunn  38:20  

Of course. Thanks.

Trina Renea  38:24  

Okay, so, Dr. Dunn, are you going to take over this procedure?

Dr. Dunn  38:34  

Not sure I'm ready to take it on quite yet. Definitely don't have the extensive training that Dr. Kotler does, but it's a pretty fascinating procedure. So, it's something that I would like to say that, you know, maybe at one point in my career, I wish I could offer but, you know, I think, in the modern day cosmetic surgery market, I'd say, and I wasn't here for much of the earlier discussion, but you know, the downtime for phenol peel and the potential complications, you know, have moved people away from it. And I think as a result, a lot of the physicians that are performing this are, you know, towards the end of their careers, and so I think it's a very interesting.

Trina Renea  39:21  

Do you performing it? 

Dr. Vicki Rapaport  39:27  

I fear this is like a dinosaur procedure that's not a dinosaur in a bad way. But like it's going to be extinct. And, you know, given that it is only for some specific skin types, and you know, you obviously have to prepare the patient, it can be a miracle. It's not the common procedure. And you know, one of the things that Dr. Kotler said that I really appreciated was that it takes such a long time to master. So, a lot of these doctors don't want to take the time to master there's so many other technologies that you know lasers are so much easier or to master. So, I totally hear you. And when trainer said, you know, I wonder if Dr. Dunn has it, and in my mind, I thought, God, I hope so, but I doubt it. But you know, what I would love to do is maybe go into Dr. Kotler’s office and take a video, and start to really revamp this, it's really not down being used often, we just have to bring it back.

Trina Renea  40:22  

We need to find a doctor who's willing to take on this amazing procedure, because honestly, I feel like the general public is being fed, like a no downtime procedures. And I mean, Dr. Vicki, and I were talking earlier, before we started the podcast like these no downtime procedures mean that there's no results, no downtime, no results, you know, so people who are paying for these are, I feel like it's a placebo effect when they pay $2,000 three times to get a laser, and then they're like, I think it looks better. But they're just not sure. And when they say I think it's because they're, they're tricking their brain, I feel to believe that their money did something, you know, but at the end of the day, they probably wouldn't do them again, and they're not getting the results that they want. And there's downtime to results, whether it's a facelift, a deep chemical appeal, or like CO2 laser, there, you have to have downtime, you have to be okay with that. If you really want to see a result otherwise, you're throwing your money away. 

Dr. Dunn  41:37  

We oftentimes, you know, people will ask for a mini facelift compared to a full facelift or, you know, and the thing is, is if you're asking for a mini facelift, you're going to get a mini results. I mean, that's really what it is. 

Dr. Vicki Rapaport  41:53  

I love that, I’m going to quote. You're asking for a mini face.

Trina Renea  41:59  

And also, if you're asking for a mini anything, like, can you just put a little bit of this in a little bit about, can you do a little? You're getting to get just a little? You have to be okay with that.

Dr. Dunn  42:13  

No. I mean, I think the big thing that comes down to all of it is the provider communicating realistic expectations for the patient and the patient understanding what is possible with this, and I think, full transparency is I mean, it's something that I strive to have in my practice, just because I think it doesn't help when you get to the other side, and someone has spent a lot of money and they are frustrated, you know, so I think it's important to have full transparency as we move forward. And, you know, even with the phenol peel, full transparency, it takes a long time, you may have complications, there may be issues, you know, just understanding that there's no free lunch, none of this is without potential risk and complications and you know, imperfections.

Dr. Vicki Rapaport  43:10  

And I want to say one thing about the price and that is, you know, there is no facelift for 2150 right there, you can get a facelift for $21,500, which is what the phenol peel is costing and a little bit more I guess for the you know, this day, so and truly those results last, it looks like 20 to 40 years for some people. And I get it's not for everybody. It's not for every skin type. But when I do talk to my patients, I don't tell everybody about the phenol appeal, I also pick and choose the ones to say like you need to go see this doctor to have a console. So, I think it's an amazing procedure that is out there for the right person. But 100% it is not for everybody.

Trina Renea  43:50  

Right. And most people just want to a little bit of result over the course of a long time these days. They don't want the downtime. I mean, even with peels in general, me as an esthetician. I've tried to like dive into peels, and people, at least in Los Angeles, are not interested in doing that anymore. Like I can't even convince them to do it. And I've tried a couple times in my career to like, take lots of classes and I bought all these pills and I'm like telling everyone like let's do this and everyone's like, nah, I don't want to stay home for a week and I don't want to peel for days and they just don't want to do it. So, they're willing to not have such a great result. 

Dr. Vicki Rapaport  44:36  

Do you find that Dr. Dunn with peels are people like afraid of that word?

Dr. Dunn  44:41  

Yeah, definitely. Well, I think I agree laser is such a more frequently used word. Yes, sexy word and more frequently seen in the cosmetic world. And so yeah, it's a much lower barrier to entry. It's like brow lift with eyelid surgery, you know, people have a few bad players out there that we see with, you know, poor outcomes and then everything kind of latches on to that. And so that's like a universal thought. So, yeah, I definitely think peels can be challenging to sell as well. 

Trina Renea  45:19  

Okay, yeah. Well, I think rounds us up for this episode. And we really appreciate you jumping in here at the end. And we look forward to seeing you again soon. I know we have a future episode with you about the psychology of plastic surgery. So, we look forward to seeing you again soon.

Dr. Dunn  45:46  

Of course. Looking forward to it. Thanks for having me.

Dr. Vicki Rapaport  45:48  

Thank you, Dunn. See you very soon.

Trina Renea  45:50  

Bye, everybody.

Dr. Vicki Rapaport  45:51  

Bye-bye, everybody.

Trina Renea  45:55  

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