Written by Founder, Amir Karam MD
For most of my early career, I did not believe in skincare.
And when I say skincare, I mean what most people think of when they hear that word: lotions, creams, products promising miracles while delivering little meaningful change. As a surgeon trained to think critically about outcomes, my standard was simple: if something does not create real, measurable improvement, it does not deserve much attention. So I dismissed it.
At the time, I believed skin quality was improved through procedures. Lasers. Peels. Resurfacing. Not topical products.
Neda is also a physician, and we have essentially grown up together professionally and personally.
We met in medical school and experienced every stage of life side by side: training, residency, building careers, raising four boys, and eventually developing the philosophy that now guides nearly everything we do at KaramMD.
What I did not realize early on was that by simply observing her over time, I would completely change the way I understood aging, skin rejuvenation, and ultimately facial rejuvenation as a whole.
Neda grew up in Southern California during a time when sun exposure was not viewed as dangerous in the way it is today.
Anyone who lived through the 80s, 90s, and even the early 2000s remembers the culture around tanning. Laying out in the sun and developing a deep golden tan was almost a symbol of health and beauty. There was very little awareness of what chronic ultraviolet exposure would eventually do to the skin decades later.
Like many people of that generation, she never thought twice about it.
She was extremely active growing up. A varsity tennis player in high school and college, an avid runner, someone who eventually completed half marathons and even a marathon. Fitness and discipline were always part of her identity, but skin health simply was not yet part of the conversation.
That changed during our residency years.
During residency, we became close friends with a dermatologist who specialized in skin cancer. At one point, she had a long conversation with Neda about the importance of aggressive sun protection and active topical anti-aging ingredients such as retinoids and vitamin C. But what stood out to me was not simply the recommendation itself. It was the scientific rationale behind it.
The idea was straightforward but profound:
If you consistently expose skin cells to the correct biologic signals, skin can actually behave younger over time.
At the time, my background in biochemistry and molecular biology was still very fresh. When I looked at the mechanisms of action behind ingredients like retinoids, antioxidants, pigment regulators, and other active compounds, the science made complete sense to me.
This was not cosmetic fluff. This was cellular biology.
In many ways, this was a form of biologic engineering. We were influencing how skin behaved as it aged. Neda understood this immediately. And once she believes something is good for her, she commits fully.
In her mid-20s, she became highly organized and consistent with her skin routine. Every night I would watch her spend 10-15 minutes applying multiple products, including prescription tretinoin, antioxidants, moisturizers, and pigment-regulating ingredients.
At that time, I still was not convinced. I respected the discipline, but I believed procedures were the true answer for meaningful rejuvenation.
Over the months and years, however, I started noticing changes.
But what struck me most was not simply the improvement itself. It was the trajectory.
Her skin did not appear to be aging the way most people’s skin aged.
That observation fundamentally changed my thinking, and it led me to one of the most important realizations of my career: Skin and shape are not the same thing.
Those interventions address structure, volume, and facial shape.
Skin itself is its own biologic entity and must be treated as such.
That realization eventually became one of the foundational principles behind my entire philosophy of facial rejuvenation.
At the same time, Neda’s approach to wellness also evolved significantly over the years.
She had always been active, but like many people from our generation, exercise initially centered mostly around cardio: running, staying lean, burning calories.
Over time, her understanding deepened.
She began prioritizing resistance training, recovery, mobility, nutrition, muscle preservation, and long-term metabolic health. Today, her lifestyle is incredibly disciplined but also very natural and sustainable.
She starts most mornings preparing smoothies, bone broth, and healthy meals for the family before beginning a long walk, often with girlfriends. It becomes movement, stress reduction, social connection, and mental reset all at once.
Despite living in sunny San Diego, she remains extraordinarily disciplined with sun protection. Broad-spectrum sunscreen every day. Hats. Even facial protective coverings during walks.
Following her walks, she typically attends F45 resistance training classes, even when we are traveling internationally. She also incorporates stretching, sauna recovery, and yoga into her routine.
Over time, both of us came to appreciate something important:
Skin does not exist separately from overall health.
Likewise, people who consistently move their bodies, preserve muscle mass, recover properly, nourish themselves well, and maintain healthy habits over decades often age differently, both physically and visibly.
This eventually reinforced another philosophy that now guides much of our work:
Looking as young as you feel starts with feeling young first.
After our fourth son was born, Neda experienced something many women notice after pregnancy and hormonal shifts: significant facial volume loss.
At that point, she was around 35 or 36 years old.
Importantly, she did not yet have significant laxity. Her tissues had not descended meaningfully. The issue was structural volume loss.
So we performed fat transfer, and remarkably, that one procedure essentially carried her facial structure for more than fifteen years.
From her mid-30s until her early 50s, she did not require ongoing filler treatments or repeated volumizing procedures beyond a small amount of lip filler occasionally.
Her regimen was simply:
That experience reinforced another important lesson for me:
When interventions are done thoughtfully, conservatively, and at the correct time biologically, they can create extraordinarily long-lasting and natural outcomes.
By around 2006, because of both the science and what I was personally witnessing with Neda’s skin, I began integrating active topical anti-aging ingredients into my surgical practice aggressively.
From 2006 to 2016, every surgical patient underwent detailed skin analysis and planning. We organized patients onto comprehensive routines involving retinoids, antioxidants, vitamin C, pigment reducers, ceramides, moisturizers, cleansers, and multiple supporting products.
But there was one major problem.
Not everyone was Neda.
Most patients could not sustain complicated 8-to-10-step routines consistently. The regimens were too harsh, too expensive, too confusing, or simply too difficult to maintain long term.
Even highly motivated patients struggled.
And honestly, so did I.
The irony was that although I fully understood the biology, I personally could not consistently commit to these complicated routines either. If a routine was not fully comprehensive, I did not see the point. But fully comprehensive routines were simply too cumbersome for real life.
That frustration became one of the turning points in my career, because I knew something very important:
True skin rejuvenation is not episodic. It is behavioral.
Skin is constantly aging beginning in our mid-20s:
The only meaningful way to influence that process is through consistent daily biologic signaling using active topical anti-aging ingredients.
And that consistency only works if people can realistically sustain it.
Around 2016, I began quietly working on a solution.
This was not some grand entrepreneurial vision. I had no social media platform at the time. No community. No intention of building a skincare company.
I simply wanted to solve a problem for my surgical patients and my practice.
Most people creating skincare lines go to a lab and choose products from an existing menu. Different concentrations of retinol. Different vitamin C serums. Niacinamide. Hyaluronic acid. Variations of products that largely already exist.
That was never going to solve the problem.
I needed to create something from scratch.
The challenge was enormous trying to combine multiple active topical anti-aging ingredients that normally existed in separate bottles into a unified system that remained:
Originally, the goal was a single product. But over time I realized that in order to include all the biologic pathways I wanted to target effectively, the formulation needed to be separated into different steps. Eventually this evolved into both a serum and a cream. At the same time, I also learned how important skin preparation was, which led to the development of the cleanser.
Version after version was tested. Patients provided feedback. Formulas were refined repeatedly. Most people told me this could not really be done well. But eventually we landed on something special.
I knew we finally had the right formulation when one of my most sensitive-skinned test patients in her late 50s, someone who had never tolerated active skincare previously, was finally able to use it successfully after a brief adjustment period.
At that moment, I knew we had removed the two greatest barriers to long-term skin rejuvenation: complexity and intolerance.
Over time, I realized that the same principles governing successful skin rejuvenation apply to nearly every meaningful pursuit in life.
I eventually began calling them the 3 C’s:
First comes commitment.
The willingness to thoughtfully evaluate a path and decide it is worth pursuing.
Then comes consistency.
The daily actions repeated over and over again.
Finally comes continuity.
The understanding that meaningful results are maintained through ongoing effort.
This philosophy applies to:
And it absolutely applies to skin.
Biologic aging is continuous. Which means rejuvenation must also be continuous.
That philosophy became foundational not only to Trifecta, but to my entire perspective on aging well.
Ironically, Neda initially had very little interest in trying Trifecta.
She already had an extremely sophisticated routine and had worked very hard to stabilize her melasma over the years. She had no desire to disrupt something that was already working.
At the time, she did not even really view me as someone developing skincare products because this entire process had happened quietly in the background.
What finally changed her mind was watching many of her own friends begin using the products and seeing dramatic improvements in their skin.
Eventually, she began slowly integrating one step at a time into her existing routine.
And over time, something surprising happened.
Eventually she transitioned completely to the system.
Today, after years of consistent use, she believes her skin looks better than it ever has. And honestly, she was by far my most difficult critic.
If it was good enough for her, I knew it was truly good enough for anyone.
No matter how well someone takes care of their skin, however, one biologic reality remains inevitable: Laxity eventually occurs.
Skin care cannot reposition descended tissues. It cannot restore youthful facial geometry once structural descent occurs. That is where surgery has a role.
By her early 50s, Neda began noticing the same thing many patients eventually experience. She no longer liked seeing herself in photographs. She felt a growing disconnect between how youthful and energetic she felt internally and what she was beginning to see externally.
This disconnect is one of the deepest emotional realities of aging. People often feel significantly younger than they appear, and that discrepancy is largely driven by changes in facial shape.
The goal was never to look different. Like nearly all of my patients, her greatest priority was naturalness. She wanted to look like the youthful version of herself not a tighter or altered version. And because her skin quality had been maintained so carefully for decades, the surgical result became dramatically amplified.
Over years of practice, I have repeatedly observed that patients with healthy, youthful skin consistently achieve more youthful and natural-looking surgical outcomes.
Young people have youthful skin and youthful facial shape.
True rejuvenation requires both.
Today, when Neda looks in the mirror or sees photographs of herself, she recognizes herself again. She feels aligned with how she feels internally.
And perhaps most importantly, it has quieted the constant awareness of aging itself.
If there is one thing I hope people take away from Neda’s journey, it is this:
People have far more control over how they age than they realize.
Most of the aging journey does not require surgery. It does not require extreme procedures. It does not require chasing trends.
It requires:
Surgery plays a role at a very specific point in life when structural aging eventually occurs. But the overwhelming majority of the journey is determined by the choices we make every day.
Neda’s story is a perfect example of this.
Aging is inevitable. But how we age is highly modifiable.
And ultimately, the goal is not to chase youth.
It is to preserve alignment between how we feel and how we look.
To continue looking as young as we feel.
11 comments
Georgia Cito
Beautiful life journey story!
Lots of love, Georgia
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