Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There's no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Welcome back to Meet the Doctor. I'm Eva Sheie, your host, and my guest today is Ricardo Rodriguez. And I understand that you're both a plastic surgeon, a professional wrestler, and a professional soccer player. Is that correct?

Dr. Rodriguez (00:46):
No, no, only a plastic surgeon.

Eva Sheie (00:49):
Alright.

Dr. Rodriguez (00:50):
So I did wrestle in high school.

Eva Sheie (00:52):
Oh you did? Okay. Little known fact about you already. Where did you go to high school?

Dr. Rodriguez (00:59):
In Puerto Rico. And so then I went to Colgate University mainly because I loved the snow and it was in the hill and it was very romantic. And then after that I went to the University of Wisconsin for medical school, and that was like, you're really cold, but really flat in the mountains. So that was entirely different experience. And then after that I went for my surgical residency at Tulane University, which was again, a completely different experience. New Orleans felt like Puerto Rico, but in English. And the surgical residency was heavily, heavily surgery oriented because it was in a hospital. It was basically run by residents. So from a very, very practical experience of surgery. Then I went for a very intellectual plastic surgery program, which was at Yale. And before that I spent a year in England at the Royal Marston Institute. And that was again, a completely different approach to surgery than in the United States. So I really have had a really, really varied experience both in life, geography, surgical approaches from the type of country that I trained in. And it is been really a wild ride.

Eva Sheie (02:28):
It sounds like it. And I have to ask you, when you got to Wisconsin, did they think you were so exotic?

Dr. Rodriguez (02:36):
I didn't know They noticed me. I noticed them more. I remember the first day I'm walking down the stairs in the auditorium. I just saw a sea of blonde hair and very, very tall people. I am five foot six and had black hair then. And so I stood out.

Eva Sheie (02:57):
When you think back on all these places that you've lived and worked, if you could go back to any one of them, is there one that you would choose?

Dr. Rodriguez (03:06):
New Orleans for sure. Like I said, it felt like Puerto Rico. Well, my wife is for New Orleans as a matter of fact.

Eva Sheie (03:15):
Did you meet her there?

Dr. Rodriguez (03:16):
Yes. Yes. So she was in the petroleum engineering business and very smart. She's the one that runs my office now and designed the website. If you've seen pictures of the office, you've been to my website. That's all her design too. And it's a beautifully designed office.

Eva Sheie (03:39):
I know I told you before we started recording that I happened upon your beautiful design many, many years ago, and I always held it up as an example. So if you're listening, I would say definitely go look at that. It's cosmetic search.net, which is one of my favorites still. And you can see what the office looks like too. And it's so nicely aligned with the website and you really get a feel for what you're going to get if you come there. So

Dr. Rodriguez (04:05):
Well, it is an entire vision of being, from being a person to the kind of environment you work in to the type of relationships you want to build with people. It's all sort of the one thing all tied up.

Eva Sheie (04:25):
I feel like you, it was your wife. We'll give her the credit

Dr. Rodriguez (04:29):
Yes.

Eva Sheie (04:31):
Ahead of this idea that what happens online is sort of cohesive with what happens in real life. And you can tell her thank you for being great at that early because I think you kind of led the way, especially up there. You're in Baltimore now, right? Yeah,

Dr. Rodriguez (04:47):
Yeah. We're in Baltimore, but I've been in this office since 2007 with the surgery center and all of that, and it's a place I love walking into every day. Beautiful. And the last thing I wanted was feeling like I'm going to work. And so I opened the doors and immediately there's this white open space with a colorful furniture and there's just two central hallways. So it's a very simple layout, but then again, a lot of the great layouts are very simple. It's a pleasure working here.

Eva Sheie (05:27):
Is there something procedure wise or treatment wise that you're known for now that you've been there in Baltimore area for a while?

Dr. Rodriguez (05:36):
Yeah, there's two or three things that sort of stand out in my practice now. One is lip lifting. I started doing lip lifts in 2002, and it seems like it should be an easy procedure, but there's a lot of subtleties into it. And then there's also understanding the whys and the how of it. There's been many interesting studies looking at what they call eyes saccades, which is how the eyes look at a face or look at anything really. And the eyes really shift back and forth very quickly to create an image. And they've tracked how following those eye movements, how people look at faces. And as it turns out, what they're looking at is this inverted triangle that goes from the eyes if that were the base of the triangle to the mouth, if that was the apex of the triangle. And that's really where people focus at when they're looking at you, which is really funny because when people go to the plastic surgeon and they want a facelift or something, they're looking at their jowls and the neckline and other people don't really look at that.

(06:48)
A very common thing I do with my patients is after I'm explaining all these same things I'm talking about with you, and then I'll put my hand over my chin and I'll ask him, do I have lines in my neck? And I clearly do. You can see them here, but nobody in 15 years has been able to tell me if I have lines in my neck. And then I'll cover my eyes and I'll say, you know what color am my eyes? And you can see on the camera, I have narrow slits for eyes and that they all say brown. So they know right away. And the reason is that when we're looking at a face, we're trying to communicate and we're looking at the two things that matter a lot, the eyes. We want to see if there's sincere or whatever. And then we're also looking at the mouth.

(07:30)
What are they saying? We use it as a cube. So that forms my whole approach to the rejuvenation of the face. Those are the areas I focused on rather than the neck and the jowls and all of that. I'll do the same thing I'm doing with you. And they answer and they say, so what do you want me to fix now? And of course then their focus changes. But anyways, what happens with the mouth is that it's a round muscle that surrounds the mouth and a sphincter really. And with age, with talking gesticulating, chewing, whatever, that circular sling underneath the nose sort of gets stretched and it goes down and to the side. So the mouth, the lip looks longer and wider. And so that was one of the first things I started noticing when I started doing lip lifts was that the people looked younger, even though the procedure was so small.

(08:26)
And it's because it's one of those key areas that people are always looking at. And most people that are doing the lip lifts, now they're lifting in a straight vertical vector because it's a lip lift. But really to get the complete rejuvenation, you have to also centralize a lip lift. And so I do it not only lifting, but bringing it more towards the middle. So that makes the lip less wide. And on top of that, the upper lip acquires a better relation to the lower lip than regular people, because most people, as they age, the upper lip will tend to look wider than the lower lip. And so by centralizing those, it gives the lip also more of a sense of volume. It tends to look flatter as you get older. So anyways, the procedure has a little scar underneath the nose, which although it's visible, it's not perceptible and there's a difference.

(09:25)
So you might see it or it might show on a photograph, but when somebody's looking at it, they're not perceiving it because it is a natural boundary. And people don't tend to notice natural boundary lines. So the scar tends to be very well hidden even though it's right in the middle of the face. So that's something that people don't quite appreciate and they're fearful. And many surgeons are fearful of doing the procedure because of that scar. And the final thing that's important in the lip lift is that you have to tie it to something stable because the structures of the nose also move. So if you do a lip lift and you're just tying it superficially to the skin of the nose, it'll move the nose. And so some people, when they get a lip lift, they'll say, oh, my nose got longer, or My nostrils got wider.

(10:19)
And it's because of the pulling effect of the skin or the shortened lip because it still has to do the same things it did before. So I anchor my lift repair to deeper structures on the nose and to the septum. So I mean, you could say, oh, this is talk. And every surgeon will say, this is talk. But the best thing I have going for me is I get very good reviews on real self, and I am not asking for those people are just putting them up spontaneously. So that's where I get a lot of my referrals.

Eva Sheie (10:52):
Interesting. Yeah. How many would you say that you've done? You've clearly thought about this a lot.

Dr. Rodriguez (10:58):
Oh, I have hundreds and hundreds. I don't keep count. I love doing them. But that's the one thing, because I told you there's two or three things. The other one that's been also, and it also has to do with this concept of aging. How does the face age, how do we rejuvenate things? And all that was fat grafting. And as you know, fat graft have stem cells in it. And so right around 2008, right after I built this surgery center, I stumbled on the fat grafting thing. And so immediately we started focusing on how to get the best fat graft. And again, this is another one of these great suggestions from my wife. She says, it's process engineering because of course she's an engineer. And so I started applying an approach of process engineering to the fat graft. A lot of people when they get a fat graft, they'll just get a syringe or a vacuum and they'll just suck it out and then they'll re-inject it.

(12:05)
We started looking at every step in the fat graft from at what pressure, I took it out, what kind of diameter cannula took it out of, what size of the hole was it? And then the steps in refining the fat, do you filter it? Do you wash it? And started looking at each one of those critically. And then finally, how do you inject it? What particle size you inject it? So each one of those steps has taken me on a little journey, like learning new things. And the final injection phase, which is what I have been focusing on lately, has led me to do things literally orthogonal. And if you don't know what orthogonal means, it means a particular angle than everybody else, which is I now inject right underneath the dermis. I inject right on the most superficial aspect that I can. And there's a couple of reasons for that.

(12:59)
One of them has to do with the way tissues. The soft tissues are organized in the body. And there was this wonderful French surgeon that took an endoscope, went underneath his skin and filmed it, and he discovered that the skin, the muscles and the bones and the blood vessels, they all have this interconnecting mesh of connecting tissue that acts as what they call a tensegrity system. Everything is held by tension and fixed elements, which are your bones, and then the movable sliding elements and all that is everything else. And you got to understand really where the things hang from and how much tension to apply there so that now when I'm injecting fat or when I'm rejuvenating a phase, rather than thinking, what am I going to cut and stretch, I now understand that really cutting and stretching are the last things you should do.

(14:02)
The first thing you have to do is restore all the pillars and restore all the basic structure before you go on to the last superficial edge. And even then, at the superficial edge, what I've sort of been reading about lately is this layer of tissue right underneath the dermis. It's called a dermal white adipose tissue, and it's a different type of fat because it derives from the skin itself and not from the deeper tissue. So it comes from a different place, and it's much more metabolically active, has a much higher content of stem cells in it than regular fat. And that layer that's right underneath the skin as it turns out, it's also connected different with those little ligaments. And that was what this guy, Guimberteau, the one that made the films underneath the skin, he worked out that layer that had a lot of tighter little ligaments.

(15:03)
So the reason the skin sags is not because it got stretched, and it is not because it hungs more, it's that it went from being like a thick layer, a thick piece of suede to being a very, very, very thin piece of suede. And I'm talking about suede because lately I've been interested in suede. But it's like comparing horse height suede, which is very thick and firm and heavy to lamb suede, which is literally like folding paper. You could use it like a shirt. And so that's what happens to the skin of the face. So when I'm rebuilding and rejuvenating a phase with fat grafting, I focus more on what are the pillars that I want to strengthen and where do I want to make that layer of suede thicker? There are, for example, older ladies who will have more fat content in their face, but yet the skin will look very crinkly, which is they need above all to thicken that superficial layer.

(16:13)
So it is possible even on a heavier set woman for me to be fact grafting right underneath the skin and yet liposuctioning under in the deeper layers, which is a concept that a lot of people at the national meetings will call me crazy for doing. But it works out in clinical practice that it's that top layer of skin that works well. So the fat grafting thing has been one of the things that leads you in a lot of different directions. So for example, I'll be doing fat grafting for reconstruction is great for radiated breasts, it actually heals the tissue. There's nothing in medicine that heals radiated tissue except for fat grafting. But again, that's a byproduct of that. Looking at the fat graft in a process engineering way, how does it work? Where does it work? Et cetera, et cetera. So that's my other major thing.

(17:14)
The fat grafting use it a lot. I think it's great for facial rejuvenation. It's actually probably the first thing a woman needs as she's sliding, oh, I forgot to mention one thing is that it's very estrogen sensitive, that layer the DWIT right underneath the skin. So as a woman starts going into menopause and the estrogen levels start becoming irregular or deteriorating, that's when it begins folding and thinning out. So usually when younger women come to me, the first thing that I recommend to them injecting fat under the eyes and into the cheekbones because mostly where they need that. And that's a permanent solution that doesn't work like a filler because a filler can only give you volume and it's a little volume not that much. Whereas a fat graph gives you all the volume you need, plus it changes the character of your skin. Your skin will actually look more like it did when it was younger and it'll function more like when it was younger because the sebaceous glands on it will start working again and pouring out more oil into the skin. So it makes the skin a little bit more shinier that gives it that youthful. The youthful glow really is a reflection of light on the skin, and that's created by the skin oil. So that fat graft underneath the eyes is another great thing that I've stumbled upon that small procedure and it makes a ton of difference.

Eva Sheie (18:44):
That's really remarkable. I want to ask you a question that I thought of quite a long time ago when we were still talking about lip lift, but it's relevant for both in that when we start to reach the age of needing facial rejuvenation, let's use 47 for example. We can't either for financial reasons or schedule reasons or even just the way we feel about it, maybe don't want to do everything all at once. And so I think one of the things I heard you say was if you're going to have to choose at least this is my interpretation, if you're going to have to choose between several things, start with your eyes because of the way that we look at faces.

Dr. Rodriguez (19:31):
Yes, eyes and lips are a great first step or the area around the eyes, I should say, the area around the eyes. Yeah.

Eva Sheie (19:39):
I think you're giving me permission not to worry about what my neck looks like as much as I actually do.

Dr. Rodriguez (19:44):
I mean, the funny thing is people care a lot about it, but other people don't.

Eva Sheie (19:50):
Don't care.

Dr. Rodriguez (19:51):
Right. The person looking at you doesn't care even though you care.

Eva Sheie (19:56):
I like that a lot.

Dr. Rodriguez (19:58):
And so a lot of times it comes to that, I'll ask the patient, okay, we can do the surgery for one or two people. We can do the surgery for you or for the rest of the world. And some people say, well, I don't care what the rest of the world thinks. I want those neck lines gone. And a lot of other people say, well, I want to look younger to other people, of course. So thankfully the eyes and the lips are things that can be pretty cheaply because a lip lift is done under local anesthesia. It's not a big procedure. And the other one around the eyes, there's several things you can do. You can do injection of fat underneath the eyes. The one thing I don't recommend that a lot of people do is the upper blepharoplasty or they're taking the skin out of the upper eyelids because

Eva Sheie (20:42):
You don't recommend that?

(20:43)
No, and there's a physiological reason for it. First of all, let me start out from the muscles of the face. That's another subject we haven't broached. That's really important. We approach it indirectly in the mouth how the mouth ages by pulling away from the nose and all of that. But the eyes sort of works the same way when every time you close your eyes and you start focusing and in your thirties you start losing visual acuity. So like a camera lens. When you narrow a camera lens, it actually allows you to see further and see more definition. You pay a price in light, but it's okay. You turn up the lights, you do it in sunlight. So people start focusing, they start narrowing and squinching their eyes, and that starts pulling all the tissues of the brows down. So what do people do in response to that?

(21:29)
They start raising their brows to get their eyelids out of the way, and then they get the creases in the forehead. So the first thing those people come asking for in their mid thirties is they start wanting Botox to the forehead. So then I have to start explaining to them, look, the better approach the Botox is not to paralyze everything because then your brows will fall because of gravity. You want to neutralize those muscles that bring your brows down and not worry so much about the forehead. We will hit the forehead but not heavy. And so the muscles that bring your brows down are those elevens right in between your nose and then the crow's feet. Those are muscles that constrict the brows and bring them down. So the minute you knock those two out, what happens is the brows open up because now they're unopposed. They're being elevated by the forehead muscle without even being conscious of it or trying. It's just the muscle is working unopposed against without resistance. So now it's much more efficient because it's pulling a lighter weight and then it opens up your eyes more, which is another marker of youthful appearance is a wider distance between the brow and the eye. It's a bright eye and bushy tailed,

Eva Sheie (22:52):
There's that engineering again. It's in everything that you've talked about today, you've pulled the engineering in there.

Dr. Rodriguez (23:00):
So then you open up your brows and now there's hardly any excess skin. So I'll rely on neurotoxins until they get sick of it. And then they say, do I have to do this every three months? And then I say, well, you can't get an endoscopic brow lift and the endoscopic brow lift, it's not like the old fashioned brow lift where you cut skin and you pull because that creates a permanent surprised look. It has to because you just pulled it up physically by cutting out skin and putting it together. So the endoscopic brow lift works by neutralizing the same muscles that you injected with Botox. It neutralizes those muscles so that now the brow comes at a higher place because of the unopposed action of the muscles. And that gets rid of the excess skin on the upper eyelid without even trying. Now when you do, when you say, let's say you don't do that and you just go ahead for easy, which is the taking out the skin of the upper eyelids, what happens is since you don't have that thing bothering your eyes anymore and your eyelashes anymore, your brow is going to drop more.

(24:16)
And then when your brow drops more, now there's excess skin again. So what usually happens is actually there's an old surgical saying for the upper eyelids, you never take out enough skin. So they recognized right away, an old wisdom of plastic surgeons was that whatever much you took out is probably not going to be enough. They're going to have some leftover and you're going to have to take it out later. But that left people with too little skin. And then people get symptoms like dry eye and a lot of that. And then if that person comes saying, none of this solved my problem and now my brows are low, you can't raise their brow then because then they won't be able to close their eyes at night. So my approach is very conservative in the beginning, neurotoxins like the Botox or the Xeomin, to essentially open up the brows, bring 'em out open, make 'em look younger that way, and then when they're ready for it, I'll do the endoscopic brow again, very little scars in the hairline.

(25:20)
It's an interruption of muscles, so it's not even cutting across the scalp, a very minimally invasive thing. And when you combine that with fat grafting underneath the eyes, it makes a dramatic improvement in the person's appearance with two very minimally invasive procedures rather than the old facelift and all of that. So the approaches that I take in my practice, I guess, come from that central inverted triangle. It's where people are looking at, that's where the money is, and it's that inverted triangle from the eyes to the lips. And so that's as far as the geolocation of your problem. And then the under girders of your problem are the structural supports and the quality of the skin. So my work tends to focus on that muscle balance.

Eva Sheie (26:20):
Before we wrap it up, I want to know what do you like to do away from the office? I'm sure you are constantly thinking about solving these problems, but I'd love to hear what you do when you're not.

Dr. Rodriguez (26:33):
Okay. I read a lot of history. I have a grandson that I love and he's half Chinese, and it's a constant source of wonder to me how he's growing up culturally, half Chinese, half American. So that's a source of fascination for me. And I play squash. I stay in shape. I am a decent squash player, but I am, like you say, I'm always thinking, my brain's always running.

Eva Sheie (27:05):
I can see that. We have another podcast called Where Before Meets After, and I am hoping you'll come back and talk to us more about procedures and that we could bring much more of this to the audience in the future.

Dr. Rodriguez (27:18):
Oh, I would love to. And there's a way to bring in illustrations or something to make people understand, but

Eva Sheie (27:23):
There is a way.

Dr. Rodriguez (27:25):
Okay, great. Yeah, no, I would love to because all of this is, all of surgery is process engineering, and the problem is that it's taught as a final product. This is the procedure, which is the endpoint of a whole process of elimination, of eliminating alternatives and all of that. And all of those alternatives, by the way, are still available. They will lead to a different pathway, but it has to be done coherently, and then people will divide themselves into this camp of doing it this way or doing it that way. And you can't do it other way depending on which choices you make, so.

Eva Sheie (28:03):
We've done about a hundred of these episodes this year. So I've talked to a lot of doctors and there's a really tiny percentage that I'm going to, I'm putting you in this group who have a discovery or see something, and then they start pulling on the thread and they have to figure it out and they keep going. And that's how the innovation is happening. And I've only seen it a handful of other times so far, and it's so exciting when I run into one, and I just think it's such an honor that I get to even ask these questions in the first place. So I thank you for doing that today.

Dr. Rodriguez (28:37):
No, and I thank you for being entertained because my wife says I talk too much.

Eva Sheie (28:43):
No, you can talk to me. If we're listening today and want to find out more about you, your website is cosmetic surg, surg.net. Is there an Instagram? Is there somewhere else you can

Dr. Rodriguez (28:54):
Yeah, there's an Instagram, cosmetic surg. I'm not that active on it. I used to be. I'm not that active now. It's the website. But honestly, I have to tell you something. And when I asked my wife yesterday, what should my message be and all of that is the best way to get to know me is to talk to me. The whole experience of me. And that's how I approach my patients. I mean, my consults are like an hour long or 45 minutes. And just like you got to figure out all the surgical techniques and all, you got to figure out the patient. You got to figure out what they want. What they're telling you they want is very rarely it is their first attempt at verbalizing their problem or they're angst or whatever it is that's happening in their life. And you got to really work hard to figure out what it is so that you can bring them the best solution you can. And it's not always going to be the one they ask for you, or it's not always going to be the one that you think in the beginning it might be something totally different. I mean, so certain things in life can't be abstracted and certain things in life has to be experienced. And for me, the website and all that, okay, try. But the best thing is experiencing the whole office from the office staff to me and all of that.

Eva Sheie (30:24):
Thank you so much, Dr. Rodriguez. I look forward to having you back.

Dr. Rodriguez (30:28):
Well, thank you. I'd love to be back.

Eva Sheie (30:31):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the Doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis T-H-E-A-X-I-S.io.