#13 – Brett Kotlus, M.D.: How to look younger while we live longer

Kotlus distinguishes SPF (measures only UVB, the redness wavelength) from broad-spectrum labeling (which indicates UVA coverage). He recommends medical-grade brands available online or in physicians' offices: MD Solar Sciences, Replenix, EltaMD, SkinCeuticals. His practical note: if you hate the scent or feel of a product you will not use it consistently — trial several formulations until you find one you will actually wear daily. Hands and chest are the second- and third-most exposed areas and are frequently overlooked.

Kotlus applies tretinoin all the way to his eyelash line: 'I close my eyes I apply it to my upper lids I apply it all the way up to the eyelash line.' He calls the 'don't apply near eyes' warning a myth — the eyelid skin is actually thinner and may absorb the product more efficiently, though he notes you may need to use it less frequently there. Generic tretinoin 0.1% is available but not cheap; the newer formulations (e.g., tazarotene) have fewer irritation side effects while matching efficacy.

Kotlus acknowledges patent wars between vitamin C serum manufacturers over stability formulations (notably the CE Ferulic-type patents). His practical summary: 'You'll find a lot of stuff out there and if your vitamin C can oxidize over time in the bottle that's why they always tend to come in very dark bottles.' The synergistic triple (L-ascorbic acid + tocopherol + ferulic acid) is supported by the most evidence for photoprotection enhancement.

Kotlus describes nuanced frontalis anatomy: the muscle's footprint varies between individuals and can be asymmetric. He palpates and asks patients to move before marking injection sites. His clinical rule: if a colleague or trainee watching him injects the same pattern in every patient, that is a sign of a cookie-cutter rather than individualized approach. The goal over years is gradual muscle atrophy that makes deep etching impossible, not perpetual paralysis.

Kotlus explains the Tyndall effect and why filler selection matters: the periorbital region requires a softer, less hydrophilic formulation to avoid visible light scattering through the thin overlying skin. His technique is informed by his blepharoplasty anatomy — he visualizes the fat compartments he has operated on and places the filler based on that three-dimensional map. For lips: 'Look back at your photo from 10 years ago and look what your volume status was then' — restoration to a prior natural state rather than augmentation beyond it.

Kotlus frames the fractional concept clearly: 'The fractional laser is creating dots and leaving some normal skin in between' — the intact islands re-epithelialize the ablated columns rapidly, reducing healing time. He distinguishes between the genuine resurfacing modalities (erbium, CO2, TCA peel) and the tightening devices (RF, HIFU), where he alludes to the 'emperor's new clothes' dynamic when a practice has financially committed to a device regardless of evidence. His filtering question for patients seeking a device-based treatment: 'Look for a provider you trust rather than a specific device.'

Kotlus acknowledges it remains a hypothesis, not a proven mechanism. The parallel is striking: cryo-lipolysis and laser fat-reduction devices work at the subcutaneous level, and UV radiation penetrates to roughly the same depth. Patients with lifelong UV protection — described as having 'white porcelain skin' — consistently show less cheek deflation and fewer contour deformities than equivalently aged peers. The practical implication is that the most critical window for sun protection is not cosmetic vanity but preservation of the facial fat scaffold.

Kotlus differentiates between the OTC retinol (less potent, better tolerated, good starting point) and prescription tretinoin. He notes retinol products often contain co-formulated moisturizers or hyaluronic acid that offset drying. A 45-gram tube lasts several months when applied in the thin layer required. The myth that retinol causes photosensitivity is partially reversed — the bigger reason for nighttime use is that the compound degrades under UV exposure, not primarily that it makes skin more sun-sensitive.

Kotlus explains that if the goal is long-term line reduction rather than short-term smoothing, repeated light treatment over time atrophies the muscle enough that lines gradually soften. Over-injecting to get immediate smoothness trades functional brow mobility for a cosmetic result that wears off in four months anyway. The 'Spock brow' and the 'frozen forehead' are both artifacts of the same underlying error: too many units in the frontalis without sufficient treatment of the lateral depressors to maintain a natural arch.

The tear trough shadow develops when the orbital fat pad enlarges (visible puffiness) while the cheek fat simultaneously deflates, creating a groove at the junction. Filling this groove with the correct hyaluronic acid formulation — one matched for the thin, low-movement tissue of the periorbital region — blends the boundary. Kotlus notes that under-eye filler lasts one to two years for most patients and can persist four to five years in some, owing to the minimal movement in that area compared to the lips.

Kotlus clarifies the SPF definition (the ratio of time-to-redness with and without product) and notes that the incremental benefit from SPF 30 to SPF 50 is small. The key practical errors he observes: not applying enough product, not reapplying every two hours, and forgetting the hands and decolletage. He specifically recommends brands sold in medical offices (Altruist, MD Solar Sciences, Replenix, EltaMD) while declining to brand-endorse any single product.

A 20% TCA peel done three times achieves comparable results to a fractional CO2 session on Fitzpatrick I–III skin. Phenol peels require EKG monitoring. The fractional approach (leaving islands of normal skin between ablated dots) reduces healing time and risk compared to full-field resurfacing. CO2 causes more tightening and collagen remodeling; erbium is more precise and has a shorter recovery. The 'tightening devices' (Thermage/radiofrequency, Ultherapy/HIFU) Kotlus calls underwhelming — he alludes to the 'emperor's new clothes' problem when a device purchase financially incentivizes its use.

Kotlus's critique of PRP quality consistency is methodological: there is no standardized concentration, activation method, or platelet count protocol across providers. He draws blood into 8×8 cc vials (~80 mL), performs a double-spin, and activates with calcium to produce ~8 cc of concentrated PRP — but notes many providers inject platelet-poor plasma labeled as PRP. He had his own scalp injected for hair loss and was personally 'underwhelmed.'

Kotlus has treated patients in their 20s and their 80s and states there is no single age threshold. The family-history trigger is practical: if a patient comes in and their parent has etched lines they want to avoid, that is the signal to start a preventive program rather than waiting until the same lines appear. The goal is never to freeze the face but to modulate muscle contraction enough that lines cannot etch in.