PODCAST: Plastic Surgeon Reacts to 2023’s Hottest Aesthetic Trends

From the recent rise in interest for buccal fat removal to the downsizing of the rear end, Dr. Brahme gives us the full rundown on what’s trending in aesthetics as we head into 2023.

With 30 years of experience in aesthetics and 18 of them at La Jolla Cosmetic, plastic surgeon Dr. Johan Brahme has seen it all when it comes to the trends that come and go.

Listen as he shares his educated opinion on what can go wrong with buccal fat pad removal, weighs in on the lip lift procedure debate, breaks down the advantages and disadvantages of using fat transfer to alter breast shape and size, and more.

Please request your free consultation online or call La Jolla Cosmetic, San Diego, at (858) 452-1981 for more


Speaker 1 (00:07):
You are listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
Welcome everyone to The La Jolla Cosmetic Podcast. I’m your hostess, Monique Ramsey. And today we are going to be speaking with our longtime La Jolla Cosmetic plastic surgeon, Dr. Johan Brahme. Welcome Dr. Brahme.

Dr. Johan Brahme (00:29):
Hi, Monique.

Monique Ramsey (00:30):
Happy New Year. So because it’s the new year, we want to kind of go into some of the trends that we might be seeing over the next 12 months, during 2023. And so my idea is for today’s session, I’ll give you a surgery trend and then we’ll get your take on it. And then whatever wisdom you can share with us, just go from there. Does that sound good?

Dr. Johan Brahme (00:55):
Okay. Well that sounds great. Yep. After 18 years with La Jolla Cosmetic Surgery, I think I can figure out those trends a little bit.

Monique Ramsey (01:05):
Perfect. So we’ll start with the face and then travel down. And whenever we mention an article or photo for everyone in the audience, you’ll find that linked in the show notes. And then just a heads-up, we have some topics in this episode that are not for young audiences. So if you’re listening with kids in the car, let’s just save that. We’ve saved it for the end. And when we get to that, I’ll let you know. So here we go. Let’s start with, there’s a recent article titled “The Hot Plastic Surgery Young Stars Could Live To Regret”. And it talks about actress Lea Michele. She was on Glee if everybody remembers. And she’s talking about having her buccal fat pads removed. And Chrissy Teigen also admits to having this done. So Dr. Brahme, first of all, let’s talk about what is that procedure, and who’s it good for?

Dr. Johan Brahme (01:57):
Okay, so the buccal fat pad just anatomically is a little ball of fat that sits in the face. It sits right in this region here, right under your cheekbones. And it can be the size of anywhere from a hazelnut to a walnut. And it’s completely unpredictable and you don’t know how big it is. But removing it gives a little more sculpted look to the face. It’s not usually a dramatic change, but it is something that shows up well in photographs. And it’s good for some people and it’s not so good for other people. And the reason is, and what this article is really addressing is that one of the components of aging is that we lose fat in the face. Everything about the face changes. Even the skeleton changes, which is pretty amazing. But a major thing is that we lose fat in the face.

And so when I do a facelift on somebody in their maybe late fifties, sixties, or even seventies, I almost always add fat. And that makes a huge difference, huge difference. Because again, one of the things is fat loss with age. So the concern is that if all these young people are removing their buccal fat pad, we’re going to have a whole generation walking around with gaunt faces at the end. And I sort of agree and disagree with this article because I think in the right patient, this is a really wonderful little procedure. The procedure takes about 20 minutes. And it’s done through incisions inside the mouth so there are no external incisions. It’s not without risk, but if you’ve done a few, it’s super easy. And the recovery is not very much at all. And it can give, in somebody who has a round face like me, it would be perfectly safe to do this operation because I’m not going to lose that much fat that it’s going to be a problem.

But in somebody who is thinner and wants to go sort of ultra thin, it may be not such a great idea. But as with every trend, it can be overdone. And I think that’s the concern that they’re voicing that this is not for everyone. But then, not every operation is for everybody.

Monique Ramsey (04:38):
When you go in and you’re looking at it, is it all or nothing? Do you take it the whole thing out as one piece, or could you decide to take part of it out?

Dr. Johan Brahme (04:49):
Technically, you could take part of it out, but the change would be so minimal that you might as well not do anything.

Monique Ramsey (04:57):
And is this reversible? If say somebody takes them out and 20 years later they look really gaunt or 15, then would you do a fat injection?

Dr. Johan Brahme (05:09):
Yes. You can’t put it back in that space because that space is between a bunch of muscles and there are nerves there and blood vessels. So you can’t put it back into the exact space, but you can certainly put fat back into the face and sort of hide that. And we do that all the time. I mean, 10 years ago I would do maybe an occasional injection of fat with my facelifts. Now, I mean, I put fat in almost everybody’s face at the time of doing a facelift. So yes, it can be hidden, it can be camouflaged. It is not the end of the world. But I think that as with everything, you should choose your patients well.

Monique Ramsey (05:54):
Now, another small procedure with a really big impact is the lift lift, oh wait, excuse me. The lip lift or lip advance.

Dr. Johan Brahme (06:05):
It’s a tongue twister.

Monique Ramsey (06:07):
Yeah, it is. I know you’re a really big fan of this procedure, so can you tell us what it is and how it helps people?

Dr. Johan Brahme (06:16):
Yeah, the first one I ever did, I was still in training in plastic surgery. And I had a patient and I had done her facelift and she had a really long upper lip. And she said, “Can’t we shorten that?” And I’m talking, this is like 30 years ago, over 30 years ago. And I said, “Well, I don’t know. I’ve never done that. I’ve never read about that.” And she said, “Well, I thought if you just took a little piece out under my nose, it would look better.” And I said, “Okay.” And our professors always tell us, listen to the patient. And so I did. And it looked really great and she was really happy. Well, time goes by and I forget about it. And then a few years later I had a man come in for a facelift. And as we grow older, just like we lose fat, the lip grows and loses fat. So it hangs down and hides your upper teeth.

And if you look in the mirror and open your mouth and smile, and you don’t see a couple of millimeters of your upper teeth, then you have a lip that’s too long. And many, many, many people have that. So I started doing this again, and I did it on this gentleman. He was from Alaska and he flew down to have his face lift. And after the surgery and he was flying back about 10 days later and he said, “Thank you for giving my smile back.” That was, I mean, it was so moving. I mean, I still get goosebumps, such a nice guy. And so I started doing it a little more frequently and a little more frequently. And I would say I do it on maybe 30% of my facelifts now.

It’s a great procedure and it heals the fastest of any of the procedures on the face when you do a facelift. So once the stitches come out, you almost forget that they had that little procedure done. And it’s the first thing that the patients say, “God, I really love my new smile,” so I like it. You have to be careful, again, choosing your patients. You certainly don’t want to give them too short an upper lip. But this is an easy thing to do, easy thing to have done. And if somebody wants to do it as a standalone procedure, you can do it just under local anesthesia. And I do that not infrequently.

Monique Ramsey (08:58):
I was about to ask, now, is there an age range that’s best for that procedure? Like is somebody too young or too old?

Dr. Johan Brahme (09:07):
No, it is strictly anatomical. If you were born with a long upper lip, you can change that. And I’ve done it on patients from their, I would say thirties to seventies. Certainly more common the older patients get because the lip gets thinner and longer. So I probably do more in the older population. But it’s an anatomical thing rather than an age thing.

Monique Ramsey (09:36):
I remember the first time I saw one of your results for this procedure and I was wowed. And I had no idea, this was a couple years ago, I had no idea that was a thing. But with all the trends of people wanting to have their mouth more youthful and lip flips with Botox, and like you say, you could put filler there, but that doesn’t always look very natural and it’s not going to help change the length.

Dr. Johan Brahme (10:01):
Yeah, if you have a long lip with fillers, it just looks really strange. So I have to thank my patient during my training for suggesting this to me. And I forget her name, but she did give me a good turn and many of my patients.

Monique Ramsey (10:17):
That’s neat. All right, so we’re going to move down the body and look at the next three trends that we should be calling them fat trends. So the first one is from CNN a few days ago. They reported on data from the ISAPS, which is the international Society, and claim that liposuction not breast augmentation is now the world’s most popular procedure. So breast augmentation has for years and years been the number one, and now all of a sudden we’ve got lipo in the number one slot. So Dr. Brahme, do you think that that’s true that there’s been a shift or not necessarily?

Dr. Johan Brahme (10:57):
I think that there may have been a small shift. And I think that that probably is due to a couple of things. One is something we’re going to talk about a little later, and that’s fat transfer. And so a lot of people want to move their fat around to areas where they don’t have fat. And then you have to get the fat from somewhere, so you got to do some liposuction to get that fat. So that’s one issue. The other issue is that I think we’re doing slightly fewer breast augmentations because of stuff that’s on the internet that’s negative about breast implants. So I think that there are fewer primary breast augmentations than there were say maybe 10 years ago. So I think it’s a matter of a little more lipo and a little bit less breast augmentation.

Monique Ramsey (11:53):
Moving into the next section is really talking about breast augmentation with fat. And so there’s an article in New Beauty magazine that said if you wanted to increase the size or shape of your breasts, in the past it’s always been breast implants, and now people start have started to use fat transfer as an option, or at least some surgeons might be, or as an addition to a breast implant. And so tell us, is that really true that you could have implants and fat or fat only?

Dr. Johan Brahme (12:30):
Yeah, I mean this sort of started, I would say about 10 years ago, maybe a little bit longer, fat injections into the breast. And the big concern initially was what happens to that fat? And part of the fat doesn’t survive and can turn into little calcium deposits and things that can be seen on mammogram. But the studies have all been done now and the calcification from the fat injections look very different from the calcifications that you see in breast cancer. So I’ve talked to many mammographers and radiologists and they say, “We can tell the difference, don’t worry about that.” So we stopped worrying about it and then started putting fat in the breast. And yes, you can make the breast fuller with fat transfer, you can reshape it a bit. If somebody comes in and wants a larger breast, fat transfer is not a great option. To make a fuller, larger breast, you really do need to put an implant in.

You don’t get any projection from the fat injection. You can make the cleavage a bit better, you can make it a little fuller on the outside or on the top. You can do some shaping with it. And I think it’s great for that. And we also use it in breast cancer reconstruction. We use it as one of the ways that we shape the new breast. And I was head of the breast cancer unit at UCSD for a couple of years, and I think that that’s a wonderful way of recreating a natural and nice breast. A fair amount of the fat gets absorbed though, so it’s not a one time thing. You may have to go back and put some more fat in. But it’s your fat and so it doesn’t get rejected. It’s accepted by your body. So it’s really a transplantation, like a skin graft.

You take a piece of skin from one area and put it where you have an open wound. The body recognizes it as yours and is not going to reject it. So it’s a great new tool. And I think the breast is one of the areas that we use that. The most common is the BBL, where we put it into the butt. So you have to tell patients that not all of it survives and it’s going to shrink. But usually what you have at about three to three and a half months, four months, that’s yours to keep. And that will be there forever. But it behaves like the fat in the rest of the body. So if you lose weight, that fat loses weight too.

Monique Ramsey (15:23):
So before we move on to the BBL, have you noticed in terms of trends, that breast implant sizes have changed over the years sort of with fashion?

Dr. Johan Brahme (15:35):
Oh yeah. Everything changes. Fashion changes and breast implant sizes change too. And I think we are doing smaller breast plants than we used to. I can’t give you an exact number, but many of my patients now are going smaller. And that’s not only true for women who have had children and may have had big breast implants in the past and want to go smaller and more conservative now. I did two breast augmentations on girls in their twenties this morning and both of them had implants in the 200 cc range, and that is much lower than we used to see many years ago. And I always ask the patient a question in the consultation because it gives me an insight into their mindset. And the question I ask is, if I were to make a mistake and make you either a little too big or a little too small, which would you prefer?

And it used to be that 90% of people say, “Oh, a little too big.” Now it’s about 50-50, little too small. So I think that it’s moving to a more natural look. And everything is really, I mean, natural look has always been something that most people really desire. Whether it’s a nose, the noses we’re doing now are not the noses that they were doing in the seventies, the little ski slope nose. People want to look like themselves. They don’t want to look like somebody different. The same with facelifts. People don’t want other people to know that they’ve had facelifts. But they still want to look better. And we can do that. We don’t have to overdo it. So I think that that’s the subtle change in plastic surgery is to a more natural result.

And some people come in and say, “Well, I don’t want a facelift because God, I see these people who have had facelifts and they look so artificial.” And my response is, “Yeah, but you’re seeing 10 times as many who look great and you don’t know they had a facelift because the surgeon did a good job.” So the trend in everything, noses, faces, even BBLs, is much towards the more natural and shapely and proportional change that people are looking for.

Monique Ramsey (18:29):
Yeah, there’s really been, I think a tremendous effort by plastic surgeons to get the word out about safety with the Brazilian butt lift procedure. And we do have some blog posts about that, so we’ll put those in the show notes. So there was a recent article from Insider, they say on TikTok, there’s tons of videos mentioning the BBL era is over, and talked to an Atlanta surgeon who’s marketing a BBL reversal. Do you think the BBL era is over or is it just a modification?

Dr. Johan Brahme (19:04):
I think it’s a modification, totally. It’s not over. People still want to look shapely and proportional. And so I think we will be putting fat into butts for a long time to come. But not in the way that you see in Hollywood. The era of the exaggerated sort of cartoonish big butt, I think that’s pretty much over. I think that we will still be putting fat in more and more in a lot of places, but we will be doing it more judiciously, more carefully, and not do the exaggerated things that you see coming out of Los Angeles. And another thing about the BBL reversal, you have to be very careful with that because some patients come in and they’ve had their BBL done outside of the US. I recently had a patient who had her BBL in Dubai. She felt she was too big, and so I said, “Oh, we’ll just suck it out.”

Well, when I tried to suck it out, it was little squishy balls filled with some fluid. It was not a biological material and I couldn’t get anything out. I didn’t know what this stuff was. It wasn’t silicone, thank God. But it’s not something that’s approved in this country. So if you are seeing patients who are from out of the country, make sure you know what they have in their butt before you try to take it out. But it’s not a big deal to reverse it. And I have on occasion slimmed down somebody where we did put some fat in and she thought it was a little too much. And it’s an easy thing to reverse. It’s not a difficult thing at all. I won’t name any names. Look …

Monique Ramsey (21:09):
Some famous sisters, maybe?

Dr. Johan Brahme (21:11):
Some famous sisters, yes, who were really responsible for the whole trend in the beginning. And we thanked them for that. But the pendulum as always swings a little bit and then it swings a little bit the other side. And right now is sort of in the middle, I think, in a reasonable range.

Monique Ramsey (21:29):
And that actually reminds me because anybody who knows you, Dr. Brahmi, knows you’re a total fashionista. Your clothes and shoes and socks and glasses and everything are always on point. And you think about a catwalk on the runway with a hot couture fashion show. It’s always more dramatic for those people. But then-

Dr. Johan Brahme (21:48):
It’s always more.

Monique Ramsey (21:49):
That style gets distilled down a little bit watered down for the rest of us for ready to wear.

Dr. Johan Brahme (21:56):
Yeah, exactly.

Monique Ramsey (21:57):
It’s kind of maybe the same thing with celebrity surgery.

Dr. Johan Brahme (22:00):
Yeah, it’s the red carpet and then the street and sidewalks where everybody else walks.

Monique Ramsey (22:07):
Right. So on the last trend that we’re going to talk about, and our audience is mostly women, so we’re going to go into, if you’re a man, you maybe don’t want to talk about this so you don’t want to listen or the kids are in the car. I’m going to read a short quote from a piece on Scary Mommy that came out this morning. And then what they said is, “It’s fairly common to talk about sagging breasts, gray hair, chin hair, drooping bottoms, and wrinkly skin as you age. But why aren’t we talking about what actually happens to a woman’s vulva?” So she goes on to outline what happens down there as we get older. And what struck me about it is it isn’t really a vanity thing to have a labiaplasty, it’s much more about quality of life and self-confidence. So for those in the audience who don’t know what’s going to happen if you were to have some feminine rejuvenation, tell us what to expect with a labiaplasty.

Dr. Johan Brahme (23:07):
Yeah. I, about 13 years ago, went and did a fellowship in vulva aesthetic surgery and vaginoplasty, labiaplasty and so on. And it’s been a big part of my practice. And it’s been a great part of my practice because most women, A, don’t know what’s normal. What do other women look like, and am I normal? And I don’t sort of like this, but is it normal? And so I think the first patient I did out of my training, I did a labiaplasty and she was in her seventies. And she had large labia, she’d never liked it. And it’s a simple procedure. It takes about an hour. And the recovery is not bad. It’s the kind of thing you can do on a Friday and then pretty much go back to sort of normal things, not exercise, but normal things within a couple of days. And I do patients from 18 to really their seventies. And the labia and the vulva changes with age. We lose fat, it changes with pregnancy, it changes color, mostly due to the influence of estrogen. So the tissues get darker and they thin out, they stretch out.

And sometimes it’s uncomfortable to wear clothing or exercise or ride a bicycle. And a lot of women are very self-conscious during sex and it can be uncomfortable. So a labiaplasty or a recontouring of the labia majora or clitoral hood and things like that is a great solution. But as with faces and breasts and all the rest of the body, all labias are different. And so there are a lot of occasional labia surgeons. But I think that to realize and appreciate the subtle differences, you really need to see somebody who has a lot of experience because it’s hard to fix if it’s botched. When I first started and I’d go to meetings, there would be no lectures on it, no sessions on genital surgery. Now there are whole meetings devoted to this.

And so it’s one of the fastest growing parts of plastic surgery. And it is one of the most rewarding. I have had so few patients who have been disappointed. And I’ve done hundreds of these and everybody is happy. We also do vaginoplasties just to be complete on this, where we actually go in and tighten the vaginal musculature, which gets stretched out by pregnancy and vaginal delivery. And it’s very successful, and the women are very happy with it. And after a vaginoplasty, many of the husbands are very happy with it too.

Monique Ramsey (26:34):
You bring up a really good point. And for everyone in the audience, we will put in the show notes, Dr. Brahme’s podcast from last year on the lady bits because you do talk about more than just the Labiaplasty and you go into some detail about some of the other feminine rejuvenation procedures that you do and how you do them, what the healing time is like. So we’ll put that in there for everyone. Well, thanks Dr. Brahme for catching up with us today on what’s going to happen in 2023, some of the trends that you might be reading about. And it’s great to talk to you, a plastic surgeon who’s been there, done that and doing that all the time. So I appreciate you taking the time today to do that.

Dr. Johan Brahme (27:18):
Great. Thank you, Monique. And let’s make a great 23 out of it.

Speaker 1 (27:29):
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.