Forty-ish: Best Anti-Aging Treatments for Your 40’s

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Hey, Dr. Koehler.

Dr. Koehler (00:09):
Hey, Kirstin.

Kirstin (00:12):
Do you know what we have today?

Dr. Koehler (00:14):
What do we have?

Kirstin (00:16):
Well, if you missed it, on our last episode, we talked about how to take the very best care of your face for people in their thirties, but today we're back to talk about people in their forties. Would you say forties is a good combination of preventing and reversing, or are we still preventing in our forties?

Dr. Koehler (00:37):
I think we're always preventing, should always be on the preventing side. Reversing, that's a tough one. I'd say certain things we can reverse to a certain extent. So yes, there is a little bit of that, but a lot of it is just we're expanding the preventing we're doing more and maybe what we started in our thirties, hopefully developing some good skincare habits and things like that. Now we're starting to put it more to use because now we're starting to notice some changes in our forties that we didn't see in our thirties. And so this is typically when people start hitting the panic button. They're like, yeah, I didn't do anything in my thirties. And now all of a sudden they're seeing things, they're starting to see changes, and now all of a sudden it's an emergency. We got to start doing some things. But really, again, as I said in my podcast on in your thirties, start establishing those good habits then and now we're just sort of expanding what we're going to be doing.

Kirstin (01:39):
Well, we talked about what to do every day in our 30-ish podcast, which was take care of your skin, wash your face, wear your sunscreen, every few months we want to start microneedling like every six weeks for a little session of three or four treatments, and we want to do Botox, sometimes fillers. So is there any additional skincare when you're 40 ish that you should use like retinoids or any must haves that you should start?

Dr. Koehler (02:07):
Yeah, definitely. If you can tolerate it, now is the time to start considering using a Retin A as part of your skin regimen. So in your thirties, probably don't need it. Your skin is probably fine without a Retin A, but starting to get into the forties and certainly into the fifties, you should be in a Retin A. Now, the thing about Retin A is a lot of people have a hard time tolerating it. So many people, they're like, oh, I can't use that. It just makes my skin X, Y, Z, whatever it flakes, it's dry, I hate it. And the vast majority of people, they'll use it and then they quit it and every time they quit it and then they start it back up again, they go through the same process again. And it's just a vicious circle. So the only way you get through that is to push on through and use it and use it and use it until you can get past that.

(02:58):
So let me explain a little bit about how Retin A works, because this is, you'll see what the benefit of it is and why people have such a problem with it. So when we're young, let's just say our skin is like this thick. And so our skin is the top layer of skin is the dead skin cells, okay? They're flaking off constantly. And so a new skin cell is formed and then over the course of about six weeks kind of works its way to the top and then poop dies and it flakes off, it loses its nucleus along the way, and then it falls off, flakes off. So that's constantly happening cycle after cycle after cycle. So new skin cells are formed, old ones fall and flake away. Well, that very top layer, it's called the stratum corneum, it's like dead skin cells. And when we're young, it's a thin layer of dead skin cells.

(03:58):
But as we get older, that layer starts to become thicker. And that's why our skin, when it's kind of shinier, has a better complexion when we're younger. And then as we get older, it becomes sort of duller, maybe not as bright in appearance is because that skin has got a thicker layer of dead skin cells. So the goal is to get that layer back to being thin again. And what Retin A does is it speeds up the rate of skin turnover. So when a newly formed skin cell is formed to when it goes and flakes off, it speeds that process up. And in doing so, these dead skin cells are flaking off at a quicker rate. Well, when that first starts to happen, so you go from having this thicker layer of dead skin cells and now they become thinner. Well, your body's ability to hold moisture changes.

(04:57):
It's used to having that thicker layer at that point in your life. And so when you lose some of that surface skin, it's drying out, it's losing water. And so that's what makes people have that red flaky, dry cracked, doesn't feel good feeling. Okay. And so new skin cells are forming quicker, but the dead ones are falling off. And it takes about, well, you got to use these skincare products for about, we say about three skin cycles. So if a skin cycle is about six weeks, so 18 weeks of using a Retin A to really get past a lot of these problems. And so what typically happens is people use a rein a and they get red and flaky and they go, oh, I'm going to quit. And then two weeks later, I'm going to try it again. And they try it again. And every time they try, they go through the same thing.

(05:53):
So how do you get through that? Well, first of all, you want to make sure you're the lowest concentration that you can possibly tolerate. And then as your skin adjusts and you are able to tolerate it more, you can go to a more potent form of the Retin A. So you want to start at the lowest concentration and then start working up to a higher concentration. Sometimes you can kind of go to every other day application. So you do it Monday, don't do it Tuesday, do it Wednesday, don't do it Thursday. But at some point you're going to have to go to everyday application. So that may give your skin a little bit of break, but it's not too long of a break that you're starting from ground zero every time. So that's one way of doing it. And then of course, making sure you're keeping your skin moisturized during the process, but you got to get through it.

(06:37):
And so unless you're willing to push through and get past all of that, you're going to keep experiencing that every time you do it. So if you do push through, then over a period of time your body does adapt and now all of a sudden your skin is not red and cracking and flaking and that top layer of skin has become thinner and your skin will have a more youthful appearance. And Retin A has been just over and over again in studies, the one skincare product that consistently can improve the appearance of fine lines and wrinkles, and it also will help with some pigmentation problems. So you go to any dermatologist, that's going to be something that they're just generally going to recommend. Now, you do need to also understand Retin A's will sensitize your skin to if you're out in the sun and you're going to get a sunburn much more easily.

(07:27):
So if you're on it, you got to be careful and especially when you're living in the south, and if you're not wearing sunscreen and a hat and all that kind of stuff, you're going to get burned.

Kirstin (07:35):
Excellent education.

Dr. Koehler (07:36):
Yeah, that's just one. I mean, the other also probably in the forties is when you may start considering more medical grade type skincare. I think when you're in your thirties, I think something like Cetaphil, which is just, I have no financial interest, I don't own any stock, but it's an inexpensive, I recommend it for patients after laser resurfacing. It doesn't have any perfumes or additives. It's very gentle on the skin. So after laser resurfacing, we use that because it just doesn't irritate the skin. But when you're in your thirties, some simple face wash and some moisturizer, you're probably good, and then sunscreen. And then as you start getting older, then that's the addition of a Retin A.

(08:21):
And then we start looking at more prescription skincare products, maybe some of the vitamin C line to kind of help with, again, that skin tone or sort of that glow, youthful glow to your skin. And again, skin types are very different. Some people have oily skin, some people have dry skin. So there's not a one size fits all when it comes to skincare. And also I noticed, especially with women, there's lots of preferences. Sometimes the skincare product can work really, really well, but if you don't like the smell of it, you're not going to use it. And so if it smells bad, you're like, oh, I'm not using that. And so those are all things that into people choosing their skincare product. But one thing I will say, and I have just seen this so many times, family members or other people, let's say I have samples and you're like, oh, here, try this skincare product.

(09:06):
My mother-in-law's sweet as she can be, but she'll be like, oh yeah, she's used it for three days. Oh, I think I already see a difference in my skin. I only used it for three days. I mean, no, three days. Anyhow, she's sweet. I think she's just being nice to me. But the point is, is that you're not, skin, I already mentioned it takes six weeks for a new skin cell to form, come, flake off. So if we're using skincare products, which are really are to help with the physiology of the skin, so it's working on these skin cells that are forming, it's going to take time to see a difference in your skin. These are not things that you put on and you see immediate change. Now that may smell good, it may feel good, and that's great, but to really see a difference in your skin, you got to be patient.

(09:53):
And if you're going to make a judgment on your skincare product, you need to be using it for a few months to really see if you like it. And your skin sometimes takes time to adapt. So just something to keep in mind when people are trying stuff is like, you got to be okay, I'm going to try it for three months, and if I do it for three months or six months and I'm not seeing the kind of improvement that I'd like to see, well then talk to one of our staff and they can make recommendations.

Kirstin (10:19):
Agree.

Dr. Koehler (10:20):
Yeah, agree.

Kirstin (10:21):
What about facials in your forties?

Dr. Koehler (10:24):
Facials are great anytime, but so facial is not, all a facial is really doing, it makes your skin feel good. You're removing the dead skin surface. That's what you're really doing with a facial. It's not going to give you any long-term benefit like microneedling or some of the other laser treatments. But if you had something coming up and you just want your skin to have a nice little glow, it just gets rid of the surface, dead skin cells, it feels good. When you're done, your skin, it just feels so smooth. It looks good. So it's a nice little pick me up. But that's, it's kind of like doing your nails right? I mean, it's not permanent, but you like it, so you do it. So that's what a facial will do.

Kirstin (11:10):
Feels good. Looks good. Short term.

Dr. Koehler (11:12):
Very short term. And then there also are so some chemical peels that people may start doing in their forties and chemical peels, they're not all the same. The very superficial peels are the ones that aestheticians can do. And again, those are going to be more involved than a facial. But again, it's not going to be, these aren't aggressive things. They're not going to make big changes to your skin. But the peels go to different depths. But once you start to get to these medium depth and deep peels, those are not done by aestheticians. Those are done by physicians only. And my recommendation, if you're going to do a medium to a deep peel that you do it by somebody who does a lot of them. I trained with Gary Monheit, who's a dermatologist in Birmingham, and he's a great guy, but he's developed some of his own peels that have become very popular throughout the world, but he does lots of peels.

(12:09):
So if I wanted a peel, that's what I'm going to see. The reason that some doctors like to do peels is because from a cost standpoint, the chemical peels are a lot more affordable for patients, but also for the doctor, cuz you don't have to purchase expensive lasers. But for me, and I do peels from time to time for certain circumstances, but I have a laser and I've invested in this laser, and the CO2 laser is great. And the advantage of a laser is the depth. When you push that little pedal and it releases the energy you've made all the settings the way you want, it goes to the depth that you told it to go to. With chemical peels, if you paint it on a little too much or maybe there's a little grease on the skin, so it doesn't go as deep in certain areas and goes deeper in others, there's a lot more finer skill, not finer skill, but there is a skill that you have to be good at doing 'em, and you have to have done a lot of 'em. And even then, chemical bills can be a little scary. So the deeper ones, the superficial ones are great. And those are things that people do in their forties in the office.

Kirstin (13:15):
Can we talk a little bit more about the laser?

Dr. Koehler (13:19):
The laser, the CO2, laser two?

Kirstin (13:21):
Yeah.

Dr. Koehler (13:21):
Yeah. So the CO2 laser is great for photo damage, skin fine lines and wrinkles. Again, it doesn't work on dynamic lines. That's back to Botox lines you have during movement. So one thing that I see a lot of people coming in complaining of is, oh, I've got smokers lines, but I've never smoked a day in my life. And I'm like, yeah, well, people call 'em smokers lines, but most of the people I see aren't smokers. So again, genetics, diet, all sorts of things come into play. Those are difficult to treat. You can't fill these little vertical lines in. Some people come in and go, can you just put some filler in those lines? I'm like, it's not like spackling. I'm not just filling the cracks in. And if you put filler in there, it sometimes gives people this sort of plumped out duck bill type of look, and it doesn't look good.

(14:12):
So occasionally filler can be beneficial. Sometimes you can use Botox around the perioral region to kind of prevent the pursing of the lips. So when you purse your lips, you make the lines worse. But the disadvantage of that is people will get it done. They're like, well, it really helped the lines, but I couldn't drink out of a straw. Well, yeah, well, because that muscle can't contract now, and you got to be careful and you have to keep the dose really low. I always say for Botox around the mouth, for people, it's like they either love it or they hate it. And there's usually no in-between, it's not like I kind of liked it. People are like, no, I'm never doing that again. I couldn't speak properly. I suck out of a straw. I hated it. Or there's people that I see that they notice a benefit, so we'll do it.

(14:56):
So laser works well for these lines, but microneedling is also something, and that we talked about the radio frequency microneedling. So that really is more, I know we talked about it for people in their thirties, but really in the thirties, they don't need the microneedling. I mean, that's great if they want to do that, but that's really more something that we start looking at in your forties and fifties. Microneedling is good. You don't have the downtime. CO2 does have downtime. It's surgery and the depth that I do, the laser and the aggressiveness at which we do the laser, you really can't do that under topical or local anesthesia. You really need to put to sleep for it. Now it's brief anesthesia, but you're out because afterwards, yeah, it's a little uncomfortable. It's not terribly painful. It looks painful, but most people are like, it doesn't hurt.

(15:48):
But getting it done hurts, it hurts. And you really to get it done at the depth that we want to do it, you have to be put to sleep. So people with more advanced fine lines and wrinkles, that's when we do the CO2. I typically recommend doing the CO2 more in the fall and winter when we don't have as much sun exposure. And you also, not everybody's a candidate with CO2 laser if you've got a darker skin type. So if you're like Asian Mediterranean, you've got pigment to your skin, you can't really do CO2 safely, you'll have permanent pigmentation changes in your skin, and so it's just not safe. But if you're pasty white or you've got a little bit of skin color to your skin, well laser's fine, and you can do that safely. I mean, there still can be potential pigment changes, but it's not like you would see with people who have a lot of natural pigment, but microneedling you can do on all skin types. So that's the nice thing. You can do it. People who have darker skin, there's options. You might not do CO2, but you can do radio frequency microneedling. That's safe to do.

Kirstin (16:54):
I love microneedling, all day every day.

Dr. Koehler (16:56):
Yeah, no, it's a great preventative thing. I'm a fan of it for sure. I think you had mentioned earlier about doing Botox in your forties.

Kirstin (17:06):
Yeah. Well, when we were talking about 30 ish people, we talked about doing forehead and crow's feet when you first start out getting Botox. But when you're in your forties, do you go to other parts of your face to treat?

Dr. Koehler (17:21):
Well, we mentioned around the mouth potentially. Sometimes we'll treat, so people will say, well, it looks like I'm frowning or my mouth looks like it's turned down. So there's muscles that raise the corner of your lip, and there's muscles that pull down on the corner of your lip. And the big one over here is the depressor anguli oris, and it runs from the corner of your lip down. This muscle is what makes you turn your lip down. Well, the thought is if you put in that muscle, it's kind of like a tug of war. This muscle's pulling up, this muscle's pulling down. Well, if we inactivate this muscle, this muscle potentially wins the tug of war and it lifts the corner of your mouth up slightly. It's going to be subtle and it won't fix jowling. It's not going to fix that marionette line. But if it's truly the corner of your mouth, sort of downturned, sometimes people have it done, they're like, yeah, I noticed a big difference and I've done it for others.

(18:15):
And they're like, I didn't really see much of a change. Doing Botox in the lower half of the face is not nearly as predictable and successful as it is in the upper half of the face. And part of it is because we're dealing with the muscles that move our mouth and smile and getting that without affecting how we speak, how we eat. It's just you got to be careful in those areas. Up here you have a lot more safety and what you're trying to achieve. So typical areas in thirties and forties is going to be forehead, glabella, and crow's feet. And if you're late in starting and you already have, so if you look in the mirror and you have a line at rest and you're like, I want that gone and you come see me, I'm going to tell you, well, we may not be able to do that, but we can help at least help prevent it from getting deeper because static lines are not affected by Botox.

(19:14):
However, if you started it in your forties and you had these static lines and you were consistent with it, it's possible that once that muscle has not been working for a while, that that crease might soften up a little bit. You're not having any muscle activity there. But there's a male patient of mine who is actually in his sixties, and he came to see me and he had this crease that started right here in the middle of his eyes, and it went literally three quarters of the way up his forehead. And it looked like he walked in the room and he looked like he was going to tear somebody's head off. And he is the nicest guy, nicest guy, business owner, just really nice. But whether it's when he's concentrating or whatever it is that he's doing, he has really strong muscles in his forehead and his brow area.

(20:08):
And over time, he's just created that permanent crease in his skin. And I was like, man, if I could have got ahold of you 20 years ago, we could have maybe prevented this from happening. So male patients are not going to typically do skincare and all that stuff, although more men are. But still, if I could just get for men, if I could pick one area to treat and you would do it consistently, I would be like this area right between your eyes. Because all the other lines on our face, most guys, they don't care about crow's feet. They do not care. I don't care about my crow's feet. I don't care. That doesn't bother me. Forehead, I mean, yeah, I got a lot of real estate here, so I've been treating it. But the thing right here, between your eyes, the only lines on your face, forehead lines, no big deal, crow's feet, no big deal.

(20:58):
But these vertical lines look like you're angry, you're upset, you're concerned. It's a negative emotional response that comes along with those lines. And we don't want to look that. We don't want to be negative. We want to be positive. So if you could prevent that for the guys that might be listening, that's the one area. Just treat between your eyes. That's it. Leave your forehead alone. Leave your crow's feet alone. Guys are harder to treat too, because we typically have lower set brows, and sometimes when you treat a forehead, this is the muscle that raises your brows. So if you treat it and get too low, yeah, the wrinkles won't be there, but your brow is going to drop and it'll feel heavy. So for a lot of guys, you got to be careful treating brows, but treating here is pretty safe. And again, if you don't want to look pissed off now, I don't know if you're a police officer and it helps you in your job, I mean, go for it. I don't know. You might have to look tough sometimes.

Kirstin (21:50):
You know why my husband will never have to treat right here with Botox?

Dr. Koehler (21:53):
Cuz you're so sweet. Right? And he never frowns.

Kirstin (21:56):
No. Well, yeah. Okay, never mind. We'll go with your answer. Never mind. He has so much hair there. You can't see wrinkles.

Dr. Koehler (22:03):
Okay, well, there you go. So just grow a monobrow and then you don't have to worry about it. There you go. Simple solution. I didn't even think about that.

Kirstin (22:11):
Yeah. Okay, so we talked about needles, chemical peels, CO2 laser. Real quick, let's talk about surgery for 40 ish people. What are the most common surgeries that you do for people in their forties?

Dr. Koehler (22:24):
Well, I'd like to just back up a little bit.

Kirstin (22:27):
Oh, sorry. Okay.

Dr. Koehler (22:28):
No, because I'm going to make a comment before I talk about surgery. I mentioned it when we were talking about people in their thirties, but it really starts to become more applicable to people in their forties. And certainly once we start getting into our fifties, so late-ish forties, starting to get into the fifties, that's when I start to see more people requesting filler. So in the thirties, people want filler for lips, but in the forties, late forties, and certainly in the fifties, I hear certain things like, okay, well, first of all, the thing people notice is I never had this line, and all of a sudden I woke up this last week and I had this deep line or whatever. And I always tell people, look, that line's probably always been there.

(23:10):
Yes, it's probably more noticeable to you now, but my daughter who's in her twenties, she's got that same crease. Everybody has it. It's just when we get older, this fat pad in our cheek starts to descend. And so the fold becomes a little bit more prominent and more noticeable. So the goal of treatment, if you don't like this line, yes, you can put filler into that nasal labial fold, but the goal should not be elimination of the line because you're supposed to have a little, most people do, okay, now, I guess shouldn't say everybody has it. Some people don't, but most people do. Anyhow, bottom line is don't try to overdo it with filler. Filler is subtle, make some changes. But so often I see people who have surgical problems that are just trying to do everything possible to avoid surgery. And what they've basically done is over treated with something like fillers, and it looks worse rather than better because they've just over treated with something that they should have maybe been looking at other options.

(24:11):
So another sort of misspoken thing that I hear people come in, they're like, I'd like you to put some filler in my cheek to lift up this and to lift up my jowl. Now, first things, first, filler doesn't lift anything, nothing. It's jelly. It will add volume, and it will maybe give the illusion that you've got a little bit of lift because now your cheeks are higher or that the cheek is fuller up here, but it truly is not lifting this. It will not correct your jowls. It will not crack these lines. But yes, putting some filler in the cheek, many of us have lost volume there. As we get older, that fat pad descends. So yes, putting some volume in there can be a good thing, but it's not lifting anything. So yeah, when you get into your forties, that's when people start maybe putting fat in their cheeks, in their nasal labial folds.

(25:04):
Sometimes people will try to camouflage marionette lines, not typically in the forties. That's typically more start talking about fifties and sixties when people are getting the marionette lines. But sometimes we see it in younger people, and then occasionally, sometimes people after weight loss, they'll have some hollowing of the temporal region. So we might add volume there. But anyhow, forties are going to be the time when people are starting to maybe restore some volume that's lost with age, with fillers. Then that leads into when do we pull the trigger for surgery, and what surgeries do we do? So again, there is not an age. I saw somebody this week that was in their forties and had some weight gain and some weight loss, but really had a fair bit of laxity in the neck and jawline region. And even though typical facelift patient is going to be more mid fifties, early sixties type of range, that's where most people are starting to consider their first facelift.

(26:10):
This girl's in her forties, and she's absolutely a candidate for a lower face and neck lift. So age is not the only factor, and some people, their first facelift might be 70. But again, it depends on your health, your genetics. At what point do you want to do this? Some people are, I don't want to wait until I got a big turkey neck before I do this, so I want to do it younger. So we will sometimes do a lower face and neck lift on somebody in their forties. A lot of times if the jawline looks good, sometimes we can do some isolated procedures to the neck, like a deep neck lift or isolated neck lift. So that's an area in the forties that we may consider doing. Upper eyelids start to maybe become a factor. People start to get sort of extra loose skin on that upper eyelid.

(27:00):
And so when they go to put their makeup on in the morning, these women are like, I can't see my eye makeup because my eyelid skin is hanging over 'em. We might do an upper eyelid surgery, or sometimes even a lower eyelid surgery. People sometimes genetically have that bulging of their fat pads on the lower lids. When it's mild, we can sometimes camouflage with filler in the hollow areas to kind of make it look so it's not bulging so much, but there does come a point where if you actually start putting filler there, it'll actually look worse. So if there's a lot of bulging, you got to do something surgically. So we do a lower eyelid surgery to remove the herniating fat, tighten up the skin. So those are the things that you start to maybe see in somebody in their forties.

Kirstin (27:43):
Well, with all of the people that are losing weight on these new weight loss medications, is that something that you're seeing a little more of, is younger people who've lost a lot of weight who now need or want facial rejuvenation because they've got some skin laxity due to weight loss?

Dr. Koehler (28:01):
Yeah, I mean, we see it on the body as well. So the face is no different. If you carried a lot of weight and you lost a lot of weight, it's just different for each person. I always tell people, if you watch that show The Biggest Loser where people were on there and they lost all this weight, some people, their skin did really well. You look at 'em and you go, gosh, they lost that much weight and their skin looks great, and in other people it doesn't do so well. So some of it's your genetics, so not every person that loses a lot of weight has lots of lax skin and needs procedures, so it's just on the individual basis. But yes, with weight loss and depending on how much weight loss, we will see people that they feel like they've really aged in their faces because this is gone now.

(28:45):
It's not like they're used to having a full face. And in fact, there was a study done on identical twins, and it's interesting that up to a certain age, looking thinner is more youthful, but actually as you get older, if you're heavier, it actually, you look younger because you've got more fullness in the cheek. So sometimes being a little overweight when you're older actually can make you look more youthful. So anyhow, it was interesting study they did on identical twins, but they were looking at all the different factors that could affect aging and genetically identical individuals. But yeah.

Kirstin (29:22):
Okay. Do you have anything else to add about 40 ish people?

Dr. Koehler (29:27):
You're about to be 50, and then you're going to need the bigger surgery.

(29:34):
Again, the thing that I mentioned in our last podcast is the best thing that you can do is be consistent. So get a regimen, get your routine, try to be consistent with it. And when you come and see our aestheticians or whatever, they're going to make recommendations. And there's things that you can do. You don't have to do every treatment at every modality, but if you've got a problem area, I'm sure that not everything has a solution, but some things we do have some treatments that are very helpful, and sometimes people have no idea. I had one lady I saw for a surgical consultation, and she had this big sort of venous lake on her lip, and I dunno, somehow it came up in the conversation. I must've said something, but I was like, oh, have you had that for a long time? And she started talking.

(30:25):
She goes, oh yeah, I've hated this, I've had it. She goes, I had somebody try to remove it surgically and anyhow, blah, blah, blah. I'm like, well, we have a laser that it's like one or two treatments gone. She's like, really? I had no idea. I'm like, yeah, we treated her. I think we ended up doing her facelift, but I think she was more happy about getting that venous leg gone with a couple of zaps with our laser. So anyhow, sometimes people just don't realize there are things that are available and they can be simple. Not everything's a big surgery. Some things are simple.

Kirstin (30:55):
All I have to do is ask.

Dr. Koehler (30:56):
That's right.

Kirstin (30:57):
If you don't like it, there's a fix for it.

Dr. Koehler (31:00):
Well, maybe,

Kirstin (31:01):
Maybe. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at alabamathebeautiful.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (31:14):
Alright, thanks Kirstin.

Kirstin (31:15):
Get back to making Alabama beautiful.

Dr. Koehler (31:17):
Alright, talk to you soon.

Announcer (31:19):
Got a question for Dr. Koehler. Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.