Device Advice: Exploring the Role of Devices in Aesthetic Medicine w/ Dr. Christopher Zachary

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Welcome to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery.

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I'm your cohost Doreen Wu and I'm excited
to be here with Dr. Lawrence Bass Park

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Avenue plastic surgeon, educator,
and technology innovator,

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as well as our guest expert dermatologist
doctor Christopher Zachary from

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Irvine, California. The title of
today's episode is "Device Advice:

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Exploring the Role of Devices
in Aesthetic Medicine."

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We all know that lasers
can be a great beauty tool.

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Is that what you mean by devices,
Dr. Bass, or is there more to that?

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Well, lasers are certainly one of
the devices we're talking about,

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but there are a whole range of devices
that are useful in aesthetic medicine.

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And you can think about them in
various types of categorization.

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There are different energy sources.

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There are things that use lasers,

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things that have light. That's
not technically laser light.

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There are radio frequency devices.

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And more recently there are
some devices that produce plasma

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or that use microwave energy.

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So that's one way of thinking
about the range of devices.

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There are also devices in terms of

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what the, the method of effect

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is.

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And so there are devices that
use very short pulses in a

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photothermal or a thermal fashion.

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There are devices that produce
bulk heating, so a slow,

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but lower level heating over
seconds, or sometimes minutes.

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There are devices that don't
have thermal effects at all,

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but work in a photo acoustic fashion.

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So a shock wave or sound
energy method of action.

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Another way to think of devices is,

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are they fractional
exposing in discontinuous

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areas over the treatment zone,

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or are they full field over
the entire treatment zone?

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And there are technologies
that are noninvasive

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entirely that are microinvasive,

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or that are part of a
minimally invasive procedure.

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So anytime you think of a device,

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it's important to kind of split
out what category we're working in.

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And also there are some non-energy
based devices like microneedling devices

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that do not impart energy,

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but create an effect just by
creating microneedling and other

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types of aesthetic devices.
So with that introduction,

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I would like to welcome our guest
today, Dr. Christopher Zachary,

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and I've known Dr. Zachary for quite a
few years. We taught a course together,

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which he was gracious enough to
allow me to co-direct with him

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in

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all of the aesthetic medicine
techniques, a multidisciplinary course.

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He has been the chairman of
dermatology at University of

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California at Irvine,

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and he's extremely knowledgeable
and experienced in all

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of the topic area that
we're discussing today.

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So Dr. Zachary welcome.
And thank you for joining.

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Thank you very much Dr. Bass,

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or can I call you Larry since we've
known each other for about 15 years or

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so? Larry, it's a pleasure
to be with you today,

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and I'm excited to see what
this discussion brings.

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Let's kick off Dr. Zachary,

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can you tell us more about what
these types of devices can do?

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Well, I'd like to go back a little bit
to cover some of the history of where,

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when these devices came.

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During my fellowship in
dermatologic surgery in Ann

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Arbor, Michigan. In 1985,

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we did have a lot of
devices to use for aesthetic

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purposes. We had chemical peels, most
of which are extremely relevant today.

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Dermabrasiona very sort of rather
rudimentary collagen filler.

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And we also had a carbon
dioxide and argon lasers

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because of the problem,

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when you do ration is you get
this aerosolization of blood

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and what with hepatitis and HIV
people were, were not anxious to,

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to fill a room full of aerosolized virus.

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And so then came the concept of what
we call selective photothermolysis.

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Now for the lay person out there, you

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don't have to know that term,
but only know that it came from

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Harvard, from the Wellman labs where
Rox Anderson and Dieter Manstein,

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and John Parrish I should say,

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came up with the concept of selective
photothermal where you give a lot of

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energy in a very short time,

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and you can be quite selective in
the structure that you're hitting,

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whether it be a blood vessel, or
whether it be a hair follicle or pigment

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cells. And then of course came
the Q-switched lasers very,

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very short that allowed
you to take out tattoos and

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pigmented lesions,

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and then subsequently all the
resurfacing devices, body contouring,

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skin, resurfacing tightening, and
of course, combination therapists,

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because it's never about one thing.

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It's always a combination of
fillers and toxins and devices

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and plus, or minus surgery. But you know,

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if somebody needs a facelift
or a neck lift or something,

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then they need surgery.

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These devices are never going to
give you that sort of benefit.

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But on the other hand,

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a facelift by itself and somebody
who's got very extensive sun damage

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is never going to improve the quality of
the skin unless you add some of these.

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So that's,

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that's the history here of where
these devices came from and,

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you know, in terms of future devices we

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have to use our wide angle lenses.

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We have to know that for instance the

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amazing discovery that,

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that beta blockers could
help hemangiomas was found by

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a French cardiologist
who put his baby patient

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of his on beta blockers.

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And lo and behold is the
hemangioma disappeared. Well,

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that's opened up a whole new
sphere. And then just last week,

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he would've read about the early
stage rectal cancer treatment from MSK

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where this complete remission in
100% of patients treated with,

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with a particular program death inhibitor.

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So there are things out there that are
going to dramatically change the way we

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treat patients in the future. And
we just, we just need to think,

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we need to think carefully,
we need to be open minded.

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We can stay away from dogma
and enjoy working with our

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colleagues in the industry, our engineers,

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who are amazing if we only give them
some sort of indication about what to do.

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And I think that's true.

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And I'd like to circle back and just
touch on that history of selective

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photothermolysis because that
really was a watershed point in

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laser based treatments
and really opened up a

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door. Now, before that a
lot of the lasers, you know,

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you would step on the foot pedal and
the laser would go on and you would take

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your foot off the pedal and the laser
would go off and you might expose the 10th

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of a second or something thereabouts.

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But this ability to go into
millisecond treatments,

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which are thousands of
a second or microsecond
treatments, which are millions.

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And then as you alluded to
with the pigment lasers,

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eventually nanosecond

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which is even shorter,

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pulse treatments really
changed things from

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a controlled burn to targeting a specific

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pathologic

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absorber within the tissues.
So maybe hemoglobin,

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maybe melanin, maybe water in the tissues,

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but that gave us control. So that it,

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wasn't just a little bit of a burn with
a little bit of correction and a little

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bit of unwanted effects, but really
something much more precise ice.

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It's interesting that from there a
lot of the evolution and this was

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the 1980s to put a decade on it.

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And if you look at
evolution of devices in,

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let's say the, the early 2000s,

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there were probably two
other principal trends and,

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and you I'll name them and
you weigh in on how you think

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that changed things.

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But I think we circled back to
understanding how to exploit

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bulk heating,

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to shock and damage tissues rather

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than to actually coagulate them.

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And also a development from
Rox Anderson and Wellman Labs.

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We went to fractional treatments
where instead of exposing the

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entire field,

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we learned we could create injuries.

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That would be unacceptable
if they were full field.

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If we only did it in
20 or 30% of the target

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area.

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You know, you're absolutely
right. The extraordinary

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thing with the fractionated treatment
where you are treating these very, very,

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very narrow cylinders of tissue down
to about 1.5 millimeters into the skin.

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But they're so narrow that about the 10th
of a side of a hair you can with these

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ablative or non-ablative devices,

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you can actually ablate 10% of the skin
from the face and it heals up within a

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week without any scarring. I
mean, it's absolutely dramatic.

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And people have found
out since then that you,

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the minimum diameter should,

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I should say the maximum diameter
is about 500 microns, which is tiny,

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but you will not induce a scar.

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I always tell my patients when we're
going to do any surgery at all,

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if we're using a knife, I say,
whenever you cut the skin,

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you're always going to get a scar.

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You might not be able to see it
because it's hidden away somewhere.

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But with these micro ablative zones,

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they heal up without any scarring.
That is the extraordinary thing.

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And, and I think over the future,

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you're going to see more intelligent
devices being developed, more specific,

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less downtime, there'll
be a dumbing down of

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devices make them safer, for instance

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for whether you treat an
aesthetic problem or a skin cancer

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or a port wine birthmark or burn scars.
And that the whole story, by the way,

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the treatment of burn scars for these
kids coming back from Afghanistan or Iraq

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or wherever, I mean that's dramatic,

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but what you can do to help
these burn scars. But I,

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I can just say that in the future five,

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10 years, we're going to see
dramatically improved devices.

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And then the whole situation is, well,
who should use these devices? You know,

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I've always wanted to for
instance, with a skin cancer,

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to be able to scan it and then press a
button and have something happen to it so

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that it goes away. Well, we're almost
there we have using optical coherence,

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tomography and incorporating that into
what they call a monolithic scanner.

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The company's site on is making
this where you can simply heat

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up the skin, 55 degrees for 60 seconds.

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And you get rid of the cancer.

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It's been known for 2000 years that you
can treat cancers with with heating.

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The only problem is until recently,

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we haven't really been
very clever about being,

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being specific and measuring what we do.

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So this is all about a
combination of physicians

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working with,

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with the engineers to come up with
things that will have a tissue

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response, which is much more acceptable,

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that where there's less discomfort
where there's faster healing,

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less residual, redness,
swelling, and so forth,

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so that it'll allow people to get
back to work and live normal lives.

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With all of these exciting
developments and evolving techniques on

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the market. How should patients
pick the right device for them?

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Oh, well look, it's a whirlwind. I mean,

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let me just spend a couple of minutes
telling you about some of the new devices

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on the horizon.

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I think one of the most exciting
ones is by a company called Ellacor,

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which is micro coring
of tissue using these

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circular aspiration systems
that can take out again,

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a little narrow cylinder of tissue
all the way down to the fat.

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And these patients heal up
within less than a week again,

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without any scarring. So look out for
Ellacor. So micro coring is going to,

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is going to be very impressive.

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We're going to start a study soon
on neck tightening using using that

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device. And then for instance,
rapid acoustic pulse technology,

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it is quite interesting.

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It was developed originally to help
the improvement of treatment of

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tattoos with the Q switched lasers.

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But it's been found since then to be
very effective at improving cellulite,

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which, of course, 95, 97% of all
women have, and some guys, actually.

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I think the study with the 1726
wavelength for sebaceous glands, which,

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in other words, if you take
out the sebaceous glands,

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the patients will not get acne.
It'll essentially cure acne.

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There's 2 companies there,
AviClear and Accure. Fascinating.

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The nano-pulse technlology story. Again,

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you're going to be hearing all about
these over the next several weeks.

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This is like trying to
drink out of a hose.

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it's impossible to understand it all
but it will come to you very soon.

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the nano-pulse technology is going
to be very good for treating cancers,

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melanomas and so forth. Then
there's the drug delivery.

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These devices will help
increase the absorption of any

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topical agent by 20 to 40 times.

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I don't know if you've heard
of photodynamic therapy
but that's very good for

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treating patients who've had
a lot of sun damagethat again,

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will be helped with these devices.

235
00:15:31,760 --> 00:15:35,040
I think we've been disappointed
with the new prima device,

236
00:15:35,041 --> 00:15:37,640
which is the sort of the second
generation pulse style laser.

237
00:15:38,780 --> 00:15:39,640
But on the other hand,

238
00:15:39,660 --> 00:15:42,880
Lutronic has now come out with a Derma
V I don't know if you've had a chance to

239
00:15:42,881 --> 00:15:47,440
look at that Larry, but that it will
challenge the pulse style laser, frankly,

240
00:15:47,440 --> 00:15:50,880
for port wine birthmarks.

241
00:15:51,660 --> 00:15:56,120
There's all the Ultherapy, the
ultrasound devices. There's

242
00:15:57,680 --> 00:16:00,640
a second generation ultrasound
device coming out from MERS.

243
00:16:00,641 --> 00:16:04,520
And then of course the soft wave, which
is really capturing the imagination.

244
00:16:05,060 --> 00:16:09,120
These devices are there
to tighten the skin

245
00:16:09,900 --> 00:16:13,840
of the face and neck. They don't
do a whole lot, frankly, but again,

246
00:16:13,841 --> 00:16:16,280
if you don't want surgery,
then it's a good way to go.

247
00:16:17,920 --> 00:16:21,920
I don't actually use the body
toning devices or electro

248
00:16:23,640 --> 00:16:28,160
magnetic, muscular stimulation. Two
devices there. Cooltone and Emsculpt.

249
00:16:29,620 --> 00:16:33,960
But they dramatically increase the
ability for you to use the muscles that

250
00:16:33,961 --> 00:16:37,920
you've actually toned up there. So
I think honestly for rehabilitation,

251
00:16:37,921 --> 00:16:39,080
that would be really good,

252
00:16:39,100 --> 00:16:42,240
but of course it's all going
towards the cosmetic way.

253
00:16:42,241 --> 00:16:44,880
So these are just a few of the
devices that are coming out.

254
00:16:45,180 --> 00:16:47,200
And for everyone that I know about,

255
00:16:47,201 --> 00:16:49,960
there are probably two or three
out there that I'm not aware of.

256
00:16:50,020 --> 00:16:51,680
So but what about you, Larry,

257
00:16:52,460 --> 00:16:54,960
have you heard any other
types of devices that you're,

258
00:16:55,310 --> 00:16:57,480
that you know about or are working on?

259
00:16:58,460 --> 00:17:01,830
Well, I mean, there are a number
of things that are coming,

260
00:17:01,831 --> 00:17:03,670
there are microwave devices

261
00:17:05,180 --> 00:17:07,870
that are being introduced
for the first time in the US.

262
00:17:07,940 --> 00:17:12,630
This is kind of going a little
higher on energy compared

263
00:17:12,810 --> 00:17:17,430
to the radio frequency devices
and whether it will give us an

264
00:17:18,190 --> 00:17:23,030
evolutionary step forward in what we
can do compared to some of the older

265
00:17:23,160 --> 00:17:26,230
radio frequency devices
remains to be seen.

266
00:17:27,270 --> 00:17:30,550
But I want to circle back to some of
these things that you mentioned and,

267
00:17:30,650 --> 00:17:35,430
and discuss a little bit what may
be going on with some of them.

268
00:17:35,810 --> 00:17:37,510
So, you know,

269
00:17:37,570 --> 00:17:42,150
we talked about fractionated
treatments and the ability to create

270
00:17:43,550 --> 00:17:46,030
injuries or wounds that are,

271
00:17:46,850 --> 00:17:51,400
that are different than what we,
we create in a full field fashion.

272
00:17:51,740 --> 00:17:56,040
We can go deeper than what would
heal normally by doing that.

273
00:17:56,060 --> 00:18:01,000
And you mentioned the Ellacor micro
coring that doesn't use high tech

274
00:18:01,070 --> 00:18:04,800
like laser to do that, but
is a mechanical device.

275
00:18:05,740 --> 00:18:10,440
But it has been observed that even
these full thickness injuries,

276
00:18:10,610 --> 00:18:15,520
which if they were made with a
scalpel in surgery would heal with a

277
00:18:15,590 --> 00:18:18,000
scar heal in a scarless fashion.

278
00:18:18,380 --> 00:18:23,350
So there's a different kind
of healing here that we've

279
00:18:23,351 --> 00:18:27,030
known about really for
better part of 20 years,

280
00:18:27,170 --> 00:18:30,470
but we haven't done a lot of
biological investigation of,

281
00:18:31,050 --> 00:18:33,390
to really understand, you know,

282
00:18:33,391 --> 00:18:36,750
there are some rough
thresholding to how big,

283
00:18:36,830 --> 00:18:40,150
a core you can take before
you might land up with a scar,

284
00:18:40,530 --> 00:18:43,110
but we don't really
understand biologically why.

285
00:18:44,010 --> 00:18:48,990
And I'm curious to hear your thoughts
on that and to hear your thoughts about

286
00:18:49,220 --> 00:18:54,070
whether you think it's just a reduction in

287
00:18:54,071 --> 00:18:55,350
the cross-sectional area.

288
00:18:55,570 --> 00:19:00,550
If you take out a thousand micro cores
from the neck and you've taken out 10

289
00:19:00,551 --> 00:19:02,030
or 15% of the skin,

290
00:19:02,050 --> 00:19:06,430
is it just reducing the amount
of fabric that gives you the,

291
00:19:06,690 --> 00:19:10,230
the more even contour
and reduction in laxity,

292
00:19:10,330 --> 00:19:13,510
or is it actually part and parcel of,

293
00:19:13,511 --> 00:19:17,710
of the healing that gives you
remodeling on top of that?

294
00:19:18,010 --> 00:19:22,910
Or some other effect producing
the clinical improvement?

295
00:19:22,910 --> 00:19:25,390
Larry, very good. Very
good question. Without

296
00:19:27,470 --> 00:19:28,430
getting too technical,

297
00:19:29,030 --> 00:19:32,510
I do not want to talk down to anybody
here because all your lessons I'm sure are

298
00:19:32,511 --> 00:19:35,630
very familiar with
these concepts, but the,

299
00:19:36,410 --> 00:19:40,590
the fractionated ablative laser, when
they lay down their cylinders of injury,

300
00:19:40,591 --> 00:19:45,150
there's the error of
vaporization surrounded by a core

301
00:19:45,660 --> 00:19:50,270
of a sponge-like material
that actually prevent

302
00:19:51,200 --> 00:19:52,990
those holes from healing up quickly.

303
00:19:53,810 --> 00:19:58,470
And so what you get is the skin doing
what it's always able to do it repairs

304
00:19:58,471 --> 00:20:01,470
itself with new collagen, new elastin.

305
00:20:02,370 --> 00:20:06,830
And so when you say, if you take
out 10% of the skin from the neck,

306
00:20:06,850 --> 00:20:10,270
for instance then your
body is going to heal that,

307
00:20:10,610 --> 00:20:13,190
and you won't get so much. In
fact, we've been disappointed,

308
00:20:13,191 --> 00:20:16,870
ready with the amount of contraction,
but with the Ellacor system,

309
00:20:16,871 --> 00:20:21,590
that's different. There is no heat.
There is no sponge like collar that,

310
00:20:21,591 --> 00:20:25,270
that prevents them from
healing up. And consequently,

311
00:20:25,600 --> 00:20:29,950
these actually heal up within a couple
of days in an elliptical manner.

312
00:20:30,050 --> 00:20:31,470
You might take out a circle,

313
00:20:32,130 --> 00:20:36,790
but it actually heals up very quickly
along the lines of relaxed skin tension.

314
00:20:37,970 --> 00:20:42,670
So called and, and as such,
I do believe that it will be

315
00:20:44,430 --> 00:20:47,360
superior to the fractionated,
ablative lasers,

316
00:20:48,360 --> 00:20:51,000
which I love I was involved in
the early studies with those.

317
00:20:52,460 --> 00:20:54,240
But as we progress,

318
00:20:54,340 --> 00:20:57,680
we understand that there are
other advances to be made.

319
00:20:57,681 --> 00:21:01,240
And I think the Ellacor is, is one of
them. So we'll see where that goes.

320
00:21:01,241 --> 00:21:04,150
Let say one other thing,

321
00:21:06,220 --> 00:21:10,230
there's a concept out there,
which is very difficult to,

322
00:21:10,610 --> 00:21:12,390
for us to you and I,

323
00:21:12,391 --> 00:21:17,030
for it's very difficult for
us to encourage some older

324
00:21:17,031 --> 00:21:20,950
fashioned physicians to understand.
And then when you cut the skin,

325
00:21:20,980 --> 00:21:22,030
when you get a scar,

326
00:21:22,500 --> 00:21:27,430
it's actually much better to get in
there early than wait for a year or two,

327
00:21:27,450 --> 00:21:30,910
and many people are
told by their surgeons.

328
00:21:30,911 --> 00:21:34,230
You should wait for a couple of years
before you do any laser surgery or

329
00:21:34,430 --> 00:21:35,263
cosmetic surgery.

330
00:21:35,380 --> 00:21:39,550
It's absolutely not the answer you should
get in there within a week or two to

331
00:21:39,570 --> 00:21:44,270
use these fractionated lasers, ablative
non-ablative, doesn't matter what they,

332
00:21:44,500 --> 00:21:47,110
they all allow new collagen formation.

333
00:21:47,690 --> 00:21:49,950
And when you have a burn scar,

334
00:21:49,951 --> 00:21:52,750
which provides a sheet of new collagen,

335
00:21:53,040 --> 00:21:55,270
which reflects the light in a certain way.

336
00:21:55,330 --> 00:21:59,750
So that's why the skin of a burn victim

337
00:22:00,000 --> 00:22:01,350
looks shiny and white. If

338
00:22:03,270 --> 00:22:08,070
you actually create numerous
fractionated areas of injury,

339
00:22:08,570 --> 00:22:12,910
you are going to provide a
pixelated new collagen, new elastin,

340
00:22:13,000 --> 00:22:16,350
which will reflect the light in
a very different manner. And,

341
00:22:16,690 --> 00:22:21,630
so I'm actually I'm so thrilled that our

342
00:22:22,710 --> 00:22:26,910
joint operations between our plastic
surgeons and dermatologists and others

343
00:22:26,911 --> 00:22:28,110
interested in laser surgery,

344
00:22:28,111 --> 00:22:32,950
have been able to work together
with particularly patient

345
00:22:32,951 --> 00:22:37,110
kids who have been burnt in fires
and so forth to dramatically improve

346
00:22:37,111 --> 00:22:40,910
their appearance. So, anyway,

347
00:22:40,911 --> 00:22:42,310
that's me rambling on a little bit.

348
00:22:42,860 --> 00:22:45,790
Well, I'm curious. I mean,
I agree wholeheartedly.

349
00:22:45,791 --> 00:22:50,190
I think the fractional lasers,
while it's on the surface,

350
00:22:51,290 --> 00:22:55,070
counterintuitive that creating more burn

351
00:22:55,630 --> 00:22:58,750
vaporization, you know, again,
whether you do it ablatively,

352
00:22:58,751 --> 00:23:03,230
which clearly is coagulation, I'm
sorry ablatively or non ablatively,

353
00:23:03,640 --> 00:23:05,510
which clearly is coagulation.

354
00:23:05,970 --> 00:23:10,750
You're creating a more thermal effect
in what's already burned tissue.

355
00:23:10,850 --> 00:23:13,230
So on the surface, that's
a little counterintuitive,

356
00:23:13,850 --> 00:23:16,870
but it does create the
ability in this very safe,

357
00:23:16,871 --> 00:23:21,670
controlled way to remodel that scarred

358
00:23:21,690 --> 00:23:23,190
tissue in,

359
00:23:23,210 --> 00:23:27,790
in a way that the body doesn't
overreact to doesn't make a hypertrophic

360
00:23:27,980 --> 00:23:28,813
scar.

361
00:23:29,090 --> 00:23:33,550
And you see both an
immediate dynamic improvement

362
00:23:33,890 --> 00:23:36,310
in, in the compliance of that tissue.

363
00:23:36,330 --> 00:23:39,910
So if you have a burned hand
that you can't flex and extend

364
00:23:40,940 --> 00:23:42,750
immediately after that treatment,

365
00:23:42,980 --> 00:23:46,040
there's a good improvement in mobility.

366
00:23:46,340 --> 00:23:50,720
And it then facilitates the ability to
go in there with physical therapy and get

367
00:23:50,721 --> 00:23:55,680
more motion and a cosmetic improvement
of the scar. But separate from that,

368
00:23:55,710 --> 00:24:00,240
some people will use pulse
style lasers or other vascular

369
00:24:01,100 --> 00:24:06,080
lasers early in a scar's
life. And early is important.

370
00:24:06,190 --> 00:24:08,960
Exactly. As you said, I agree completely

371
00:24:11,200 --> 00:24:15,540
to try to reduce the amount
of vascularity in the scar

372
00:24:16,480 --> 00:24:21,420
and maybe circumvent some
of the inflammatory response

373
00:24:21,421 --> 00:24:23,860
that's taking place in an effort to,

374
00:24:24,680 --> 00:24:29,580
to board the development
of a nascent hypertrophic

375
00:24:29,730 --> 00:24:32,780
scar. Do you think that's an
important component as well,

376
00:24:33,000 --> 00:24:37,900
or you think the fractional lasers
have kind of eclipsed the use of the

377
00:24:37,901 --> 00:24:40,420
pulse style laser and
other vascular therapies?

378
00:24:40,800 --> 00:24:43,660
No, I agree. 100%. we,

379
00:24:43,680 --> 00:24:47,580
we treat scars particularly
red scars with,

380
00:24:47,581 --> 00:24:48,780
with the pulse style laser.

381
00:24:48,880 --> 00:24:51,660
We might do that before we use
a fractionated device. I think,

382
00:24:52,060 --> 00:24:56,020
I think every case needs to be assessed
independent one from the other.

383
00:24:56,120 --> 00:24:59,660
And I think, I think that the
pulse style laser, as you say,

384
00:24:59,720 --> 00:25:02,820
if that's all you have, then you can
actually do a lot of good with it.

385
00:25:02,821 --> 00:25:06,260
Here's the problem though, Larry, you
and I have probably got, you know,

386
00:25:06,320 --> 00:25:10,940
10 or 15 devices, maybe
more at our availability.

387
00:25:11,360 --> 00:25:15,060
Most people aren't, they might
have one or two, if that, and then,

388
00:25:15,570 --> 00:25:17,700
then they have a dilemma. First of all,

389
00:25:17,930 --> 00:25:22,380
what to do when this sort of patient
shows up in the clinic and secondly, what,

390
00:25:23,090 --> 00:25:26,220
what is their next device
they should get. And,

391
00:25:26,221 --> 00:25:29,940
and I might just ask you the question.
I want to turn the tables on you.

392
00:25:30,600 --> 00:25:35,260
What is the number one device you
would get if you were going out

393
00:25:35,261 --> 00:25:39,660
25 years ago? I don't know how
long you've been in practice,

394
00:25:39,720 --> 00:25:44,420
but what's the number one device you'd
get if you were just starting up.

395
00:25:45,360 --> 00:25:45,941
So, you know,

396
00:25:45,941 --> 00:25:50,380
and that's a question that gets brought
up a lot of times at medical meetings,

397
00:25:50,870 --> 00:25:55,220
especially in a laser training
course or a laser panel.

398
00:25:55,760 --> 00:25:59,620
And the answer is, of course it depends.

399
00:25:59,620 --> 00:26:00,500
.

400
00:26:01,570 --> 00:26:04,660
Because there's, there's no universal one.

401
00:26:05,840 --> 00:26:10,540
It depends on what, what specialty
you are in and who your patients are.

402
00:26:11,160 --> 00:26:13,020
So if your patients are young,

403
00:26:14,010 --> 00:26:18,980
they might like laser
hair removal and those

404
00:26:19,030 --> 00:26:22,900
sorts of treatments, or they might
like a body contouring device,

405
00:26:23,090 --> 00:26:26,220
like CoolSculpting.
Yeah. If your patients,

406
00:26:26,600 --> 00:26:30,540
if you have a facial
rejuvenation practice like mine,

407
00:26:31,980 --> 00:26:32,820
I think, you know,

408
00:26:33,220 --> 00:26:37,900
a key component of what I offer my

409
00:26:37,901 --> 00:26:42,580
patients in addition to things like
surgical facelift is the ability to treat

410
00:26:43,240 --> 00:26:48,040
wrinkles and photo aged skin by doing

411
00:26:48,090 --> 00:26:51,240
laser resurfacing. And so a laser

412
00:26:53,300 --> 00:26:58,270
resurfacing or fractional laser
resurfacing technology would

413
00:26:58,290 --> 00:27:03,140
be key because I think
the ability to just do the

414
00:27:03,141 --> 00:27:05,780
surgery and leave the photo damaged skin.

415
00:27:06,200 --> 00:27:09,740
And you said this earlier
in this, in this recording

416
00:27:11,320 --> 00:27:13,020
that's really not adequate.

417
00:27:13,840 --> 00:27:18,740
And you're leaving a major component
of the rejuvenation completely

418
00:27:18,770 --> 00:27:22,540
untouched if you don't have a
technology to improve that skin.

419
00:27:24,640 --> 00:27:27,780
So I think that's the big split. You know,

420
00:27:27,840 --> 00:27:32,660
the younger population will probably be
in some kind of body contouring device

421
00:27:32,920 --> 00:27:34,100
or in IPL,

422
00:27:34,101 --> 00:27:38,740
it can treat hair and some
early pigment change and someone

423
00:27:38,870 --> 00:27:43,780
who's treating more of a rejuvenation
population that's middle aged and

424
00:27:43,800 --> 00:27:45,780
beyond is seeking

425
00:27:47,340 --> 00:27:51,860
a more aggressive laser for
something like resurfacing.

426
00:27:51,861 --> 00:27:54,180
And of course there are
devices that combine these like

427
00:27:55,960 --> 00:27:59,620
the cyton technologies that you
were mentioning earlier, you know,

428
00:28:00,290 --> 00:28:05,060
that has a multi modality
platform where you

429
00:28:05,120 --> 00:28:09,020
can buy one and then add
another modality later.

430
00:28:09,200 --> 00:28:13,980
If you discover that there
is a substantial demand
in your practice for that

431
00:28:13,981 --> 00:28:15,100
alternate technology.

432
00:28:15,100 --> 00:28:18,110
Yeah, totally agree. And

433
00:28:19,970 --> 00:28:20,803
as always,

434
00:28:22,190 --> 00:28:26,750
you don't make any decisions until you
see the patient, you talk to the patient,

435
00:28:27,590 --> 00:28:31,630
you sit down in front of the
patient and you have a conversation,

436
00:28:32,630 --> 00:28:36,510
extended conversation, so you can see
them sad, see them happy, look at the way

437
00:28:38,070 --> 00:28:41,390
they smile, look at the wrinkles,
look at the laxity and so, so forth.

438
00:28:41,490 --> 00:28:45,110
So in your own mind, you think
of what you can do to help them,

439
00:28:45,210 --> 00:28:47,550
but of course you have to ask them,

440
00:28:47,551 --> 00:28:50,390
what is it ma'am or sir,

441
00:28:50,391 --> 00:28:53,710
what is it that we can do
for you? What troubles you?

442
00:28:54,110 --> 00:28:58,030
And they might point to something
very different that you hadn't sort of

443
00:28:58,030 --> 00:28:58,463
noticed. And

444
00:29:00,430 --> 00:29:03,410
also in our therapeutic ladder,

445
00:29:03,411 --> 00:29:08,250
if we've got 10 lasers in the
surgery rooms at the bottom of the

446
00:29:08,251 --> 00:29:09,051
therapeutic ladder,

447
00:29:09,051 --> 00:29:13,770
there are still things that work
very nicely that are inexpensive and

448
00:29:14,040 --> 00:29:17,530
work very well. For instance,
things like retinoids,

449
00:29:17,531 --> 00:29:22,450
that has been the biggest development in

450
00:29:22,451 --> 00:29:23,490
the last 50 years,

451
00:29:23,491 --> 00:29:28,450
the retinoids like Retin-A or Tazorac

452
00:29:28,451 --> 00:29:31,210
Adapalene, they've made a huge difference.

453
00:29:31,211 --> 00:29:36,210
And if our patients start off
using retinoids for three months,

454
00:29:36,211 --> 00:29:36,691
six months,

455
00:29:36,691 --> 00:29:41,360
they were going to see a dramatic
improvement in the color texture,

456
00:29:41,361 --> 00:29:43,840
tone, wrinkles, and so forth.

457
00:29:43,841 --> 00:29:46,760
So I think it's always a good
idea not to jump to a device.

458
00:29:46,761 --> 00:29:50,960
And it's all about what
can we do for this patient.

459
00:29:51,740 --> 00:29:52,573
So, you know,

460
00:29:52,990 --> 00:29:57,640
that begs another question that I'd really
like to ask you and take advantage of

461
00:29:57,641 --> 00:30:01,760
your medical dermatologic
expertise that I,

462
00:30:01,761 --> 00:30:04,160
as a plastic surgeon, don't share

463
00:30:06,590 --> 00:30:07,510
contrast for me,

464
00:30:08,490 --> 00:30:13,030
the benefits of retinoids
compared to alpha

465
00:30:13,180 --> 00:30:17,310
hydroxy acids and beta hydroxy
acids, like glycolic acid,

466
00:30:17,630 --> 00:30:19,350
lactic acid, pyruvic acid,

467
00:30:19,900 --> 00:30:24,750
because this is one of my
personal pet peeves that, that,

468
00:30:24,970 --> 00:30:25,710
you know,

469
00:30:25,710 --> 00:30:30,550
everyone jumps on glycolic acid
because you can go to the local

470
00:30:31,670 --> 00:30:34,910
pharmacy and buy a bottle
of something for $10.

471
00:30:35,930 --> 00:30:40,190
But I don't think you're getting
the same out of it as you get

472
00:30:41,250 --> 00:30:42,780
working with a retinoid.

473
00:30:43,440 --> 00:30:48,220
So explain to me what the retinoid
is able to do in the skin that

474
00:30:48,520 --> 00:30:51,860
the hydroxy acid like
glycolic acid is not.

475
00:30:52,570 --> 00:30:53,381
Well, first of all,

476
00:30:53,381 --> 00:30:58,060
retinoids have been extremely well
studied they've they have came out of

477
00:30:58,060 --> 00:30:58,733
Philadelphia where

478
00:31:00,740 --> 00:31:05,540
some basic science went
into the development of

479
00:31:05,541 --> 00:31:07,500
these drugs, so that you know,

480
00:31:07,530 --> 00:31:11,150
that it's going to increase the
amount of collagen, you know,

481
00:31:11,620 --> 00:31:15,510
that it's going to reduce
precancerous agents, you know,

482
00:31:15,511 --> 00:31:16,470
it's going to get rid of,

483
00:31:16,470 --> 00:31:20,790
of Lentiginos those liver
spots or brown spots.

484
00:31:21,770 --> 00:31:24,990
You just know, and you can
see this, you can measure it.

485
00:31:24,991 --> 00:31:28,470
You can look at the amount
of glycosaminoglycans in
the skin and so forth.

486
00:31:29,010 --> 00:31:33,310
Now that's not to say that there haven't
been some good studies on the alpha

487
00:31:33,420 --> 00:31:36,470
hydroxy acids. For
instance, the problem is

488
00:31:39,490 --> 00:31:44,310
the pharmaceutical industry in
this country is just not regulated.

489
00:31:44,860 --> 00:31:46,990
It's about a 10 billion business,

490
00:31:47,530 --> 00:31:52,270
and you can come up with a whole
host of things that you can then sell

491
00:31:52,610 --> 00:31:57,550
pretty much,at Liberty,without,
without,knowing

492
00:31:59,470 --> 00:32:00,710
much about it. And it,

493
00:32:01,290 --> 00:32:05,870
so the difference really is that one
has been studied thoroughly and has been

494
00:32:05,940 --> 00:32:06,551
evaluated.

495
00:32:06,551 --> 00:32:11,510
This has been approved by the food
and drug administration and most of

496
00:32:11,511 --> 00:32:14,670
the cosmos have not. Now,
there are some countries,

497
00:32:14,671 --> 00:32:18,030
and I believe Japan is one
which are now regulating

498
00:32:19,550 --> 00:32:23,050
cosmos. And I I'd like to say,
I think that should happen here,

499
00:32:23,070 --> 00:32:24,010
but here's the problem.

500
00:32:24,750 --> 00:32:29,370
If you regulate a cosmeceutical
it is going to increase the cost

501
00:32:29,950 --> 00:32:32,530
of production from about, you know,

502
00:32:32,531 --> 00:32:37,490
$10,000 to develop it to maybe $10
million or maybe even a hundred

503
00:32:37,491 --> 00:32:40,320
million. So, so that's
just not going to happen.

504
00:32:40,320 --> 00:32:44,120
And you have to be very careful
of how you regulate things.

505
00:32:44,240 --> 00:32:48,080
I don't want to get into the politics of
all this only to say that one has been

506
00:32:48,440 --> 00:32:52,880
thoroughly tested and the
others mainly the cosmeceuticals

507
00:32:53,420 --> 00:32:57,880
really don't have a lot of
background safety studies that

508
00:32:58,630 --> 00:33:03,600
our patients can rely upon. So that
for me is the biggest difference.

509
00:33:03,760 --> 00:33:05,400
I don't, I don't really,

510
00:33:05,580 --> 00:33:10,080
we don't sell much in the way
of cosmos in the, in the clinic.

511
00:33:10,200 --> 00:33:14,080
I believe in five things, I believe in
sunblock, I believe in moisturization,

512
00:33:14,760 --> 00:33:15,361
I believe in,

513
00:33:15,361 --> 00:33:20,120
in retinoids some of the alpha
hydroxy assets are absolutely fine.

514
00:33:22,430 --> 00:33:26,650
And, and as I say, there are very
few other things out there that,

515
00:33:27,120 --> 00:33:31,970
that are going to make a big
difference, but I think first as always,

516
00:33:32,030 --> 00:33:35,890
we should say, how can we prevent
this from getting worse in the future?

517
00:33:35,910 --> 00:33:40,650
So it's a really important to the
schools that they're educated about

518
00:33:40,710 --> 00:33:45,650
sun damage and how to avoid it. And
then if you get it, how to treat it,

519
00:33:45,880 --> 00:33:49,410
because don't forget the bottom line
is there are some very serious diseases

520
00:33:49,411 --> 00:33:53,930
that UV light can create, including
not just basal cell cancer,

521
00:33:54,410 --> 00:33:57,210
squamous cell cancer, but
the big killer melanoma.

522
00:33:58,560 --> 00:34:01,500
So I think education is important here.

523
00:34:02,970 --> 00:34:04,980
Well, this has been a
thought provoking episode.

524
00:34:05,120 --> 00:34:08,460
Our listeners are always interested
to learn about what's coming down the

525
00:34:08,660 --> 00:34:12,820
pipeline and hear about new things on
the horizon. Before we close Dr. Zachary,

526
00:34:13,130 --> 00:34:16,260
what should our listeners take away
from today's episode about the world of

527
00:34:16,261 --> 00:34:17,460
energy based devices?

528
00:34:18,320 --> 00:34:19,060
You know,

529
00:34:19,060 --> 00:34:23,900
I think we should expect more of from
our physicians and engineers and,

530
00:34:24,080 --> 00:34:27,860
and probably from the FDA as well.

531
00:34:28,560 --> 00:34:32,940
We need those of us who
are in the healthcare

532
00:34:32,941 --> 00:34:37,380
business need to observe
natural phenomena. Rox
Anderson's very good at that.

533
00:34:37,880 --> 00:34:42,660
We need to use our wide angle
glasses just to see what works,

534
00:34:42,690 --> 00:34:44,860
what simple things work. We definitely

535
00:34:47,120 --> 00:34:50,620
should expect to use more
technology. You know,

536
00:34:50,621 --> 00:34:52,900
when you go for an opthalmology
appointment, for instance,

537
00:34:52,920 --> 00:34:54,100
before you ever see a doctor,

538
00:34:54,101 --> 00:34:57,300
that they do an OCT of the
back of the eye and so forth,

539
00:34:57,740 --> 00:35:00,660
I can imagine a time or
in dermatology, you know,

540
00:35:00,661 --> 00:35:02,740
there's mole mapping and all
sorts of things like that.

541
00:35:03,060 --> 00:35:07,460
I can see us requiring our
dermatologists for instance,

542
00:35:07,461 --> 00:35:12,220
and plastic surgeons to become
more familiar with and to

543
00:35:12,221 --> 00:35:16,420
request the development of devices that
are going to make a big difference,

544
00:35:16,560 --> 00:35:19,260
for instance, with a
multi photo microscope,

545
00:35:19,261 --> 00:35:23,300
which we have in our laboratory
immediately in our imaging room,

546
00:35:23,301 --> 00:35:28,220
which is adjacent to our surgery rooms.
You can diagnose without doing a biopsy,

547
00:35:28,620 --> 00:35:31,500
you can diagnose melanoma
inside you, which is a killer.

548
00:35:31,500 --> 00:35:36,020
And there are other devices that we
have as well that can make similar

549
00:35:36,900 --> 00:35:41,800
diagnoses. So we should make sure
that we fund research appropriately,

550
00:35:42,320 --> 00:35:46,720
particularly through the NIH and through
the universities and so forth and,

551
00:35:46,960 --> 00:35:49,280
and help research institutions succeed.

552
00:35:50,280 --> 00:35:55,200
The institutions have been
starved from money for over a

553
00:35:55,520 --> 00:36:00,400
decade. And I just think that
not only should we appreciate

554
00:36:02,750 --> 00:36:07,270
the benefits that we're getting, but we
should also as users of medical care,

555
00:36:07,470 --> 00:36:11,030
we should ask for more, in
terms of more information,

556
00:36:11,670 --> 00:36:13,350
more safety information we should,

557
00:36:13,630 --> 00:36:17,430
we should make sure that
we get the best advice,

558
00:36:18,150 --> 00:36:18,983
best education.

559
00:36:19,030 --> 00:36:22,710
And I can't think of a better
format than this particular session.

560
00:36:23,190 --> 00:36:25,510
So thank you so much for
asking me to be involved.

561
00:36:26,510 --> 00:36:30,360
Well, thank you, Dr. Zachary for
joining us. I always enjoy hashing

562
00:36:32,320 --> 00:36:35,280
through issues with you and
putting my thinking cap on.

563
00:36:36,000 --> 00:36:40,200
I have to have my thinking cap to
do it successfully with you and

564
00:36:42,920 --> 00:36:47,720
I appreciate your sharing your
broad fund of knowledge on all of

565
00:36:47,721 --> 00:36:50,120
these subjects. We really spanned

566
00:36:52,080 --> 00:36:55,800
a surprisingly large
number of different arenas.

567
00:36:56,500 --> 00:36:59,560
And there's a lot of content in there.

568
00:37:00,310 --> 00:37:01,920
Just reflecting on that.

569
00:37:02,160 --> 00:37:07,120
I think for patients I'll
echo what Dr. Zachary

570
00:37:07,121 --> 00:37:08,480
just said, that, you know,

571
00:37:08,500 --> 00:37:13,320
we want treatments that are
evidence based where we understand

572
00:37:13,340 --> 00:37:15,280
the basic science of how they work.

573
00:37:15,340 --> 00:37:19,000
And we have the clinical
evidence that in fact,

574
00:37:19,030 --> 00:37:23,760
they do perform in a way that's
useful and beneficial and better

575
00:37:23,910 --> 00:37:28,200
than what we had previously working with

576
00:37:28,640 --> 00:37:33,550
providers who understand how
technologies work makes it

577
00:37:33,570 --> 00:37:37,390
easier for you as a patient
to pick a technology or

578
00:37:39,140 --> 00:37:44,110
partner with your provider to pick
an appropriate technology for your

579
00:37:44,140 --> 00:37:47,670
care. Of course, there's no one
best device or one right device for

580
00:37:49,490 --> 00:37:50,710
any given condition.

581
00:37:51,090 --> 00:37:55,950
And many of the products that
the aesthetic industry has gotten

582
00:37:55,951 --> 00:38:00,630
through FDA and put on the market
are extremely useful for addressing

583
00:38:00,631 --> 00:38:01,790
aesthetic concerns.

584
00:38:02,570 --> 00:38:06,030
And there is that whole
arena of medical concerns.

585
00:38:06,090 --> 00:38:10,790
As you heard Dr. Zachary discuss
very eloquently during this

586
00:38:10,940 --> 00:38:11,773
episode.

587
00:38:12,390 --> 00:38:14,350
I'll let go, Dr. Bass and thank you again,

588
00:38:14,370 --> 00:38:17,510
Dr. Zachary for sharing your
insight and expertise with us.

589
00:38:18,080 --> 00:38:20,470
Thank you to our listeners
for joining us today,

590
00:38:20,530 --> 00:38:24,750
to hear about the evolving use of devices
in treating beauty and aging concerns.

591
00:38:25,030 --> 00:38:28,350
I hope you found this episode as
interesting and informative as I did.

592
00:38:28,930 --> 00:38:32,310
If you think of other exciting
developments in plastic
surgery that you would

593
00:38:32,311 --> 00:38:34,350
like to see us discuss
in upcoming episodes,

594
00:38:34,410 --> 00:38:37,920
please reach out via email or
Instagram. We'll see you next time.

595
00:38:39,500 --> 00:38:42,310
This is Doreen Wu thanking
you for joining Dr. Bass,

596
00:38:42,410 --> 00:38:46,990
Dr. Zachary and me for this discussion
of the role of devices in anti-aging and

597
00:38:46,991 --> 00:38:49,630
aesthetic medicine. Be
sure to tune in next time.

598
00:38:49,650 --> 00:38:51,390
And don't forget to
subscribe to our podcast,

599
00:38:51,930 --> 00:38:55,270
to stay up to date with all of the
exciting content that is coming your way.

600
00:38:56,680 --> 00:39:00,710
Thank you for joining us in this episode
of the Park Avenue Plastic Surgery

601
00:39:00,800 --> 00:39:05,350
Class podcast with Dr. Lawrence
Bass Park Avenue plastic surgeon,

602
00:39:06,150 --> 00:39:07,990
educator, and technology innovator.

603
00:39:08,290 --> 00:39:10,790
The commentary in this
podcast represents opinion.

604
00:39:10,940 --> 00:39:13,390
This podcast does not
present medical advice,

605
00:39:13,650 --> 00:39:17,870
but rather general information about
plastic surgery that does not necessarily

606
00:39:17,930 --> 00:39:21,030
relate to the specific conditions
of any individual patient.

607
00:39:21,370 --> 00:39:26,110
No doctor patient relationship
is established by listening
to or participating

608
00:39:26,250 --> 00:39:27,083
in this podcast,

609
00:39:27,340 --> 00:39:31,190
consult your physician to advise you
about your individual healthcare.

610
00:39:31,490 --> 00:39:32,870
If you enjoyed this episode,

611
00:39:33,130 --> 00:39:37,430
please share it with your friends and
be sure to subscribe to our podcast on

612
00:39:37,431 --> 00:39:41,310
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613
00:39:41,610 --> 00:39:43,910
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