Skin Science: Fresh Again w/ Dr. Julius Few

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "Customized Skin Science." Dr. Bass. It sounds like today's episode will be focused on the science behind skincare. Can you tell us what we're going to discuss?

Dr. Lawrence Bass (00:33):
Sure. There are literally thousands of skin products on the market, and there are many, many skin products that are available from doctors as part of their practice or that they've developed to try to help in the care of their patients. And so we're going to try to talk about what's happening in this area and some of the latest trends. I've been involved in skincare even though I'm a plastic surgeon since the 1990s because some of the companies that were putting together panels of doctors to help them formulate their products decided to include a couple of plastic surgeons along with the usual collection of dermatologists. And so that got me involved very early in my career in the science of skincare. But because there's so many products out there and it's always changing and always improving, I've brought someone who's a true expert on skin science. My friend and colleague, Dr. Julius Few, who also is a plastic surgeon in Chicago with a very busy and successful practice. He is a clinical professor of plastic surgery at the University of Chicago, as well as a health science clinician at Northwestern University. In addition to that, he's one of the associate editors of the Aesthetic Surgery Journal, which is the number one aesthetic publication in the world, and he's in charge of editing the aesthetic medicine portion of that journal. So Dr. Few, welcome and thank you for joining us.

Dr. Julius Few (02:19):
Larry, I'm truly excited and congratulations for a great podcast. I am somewhat jealous that Michael Kane beat me out to being first on this, but you know what, listen, since he and I actually, we just talked at the aesthetic meeting recently and is one of the main reasons I kind of got into the non-surgical space, I guess he deserves it. I am truly excited to be here. Larry, you've been a visionary in the space of non-surgical aesthetic medicine for more than two decades. I feel very lucky to have known you for that long, and it just helps to show that we're getting old. Well, I'm happy to be here.

Dr. Lawrence Bass (03:08):
We're getting old, but we still have a few tricks and contributions left up our sleeves. I know you do for sure.

Dr. Julius Few (03:16):
Absolutely.

Doreen Wu (03:17):
Exactly. So let's jump right in. Dr. Few, you're a plastic surgeon like Dr. Bass. Maybe you can tell us a little bit about how you got involved in skincare.

Dr. Julius Few (03:28):
Well, Doreen, hi to you as well. I got involved in skincare initially, much like Larry came from a background, really kind of a diverse perspective in that my major in college was biochemistry. I've always been interested in skin science. When I was part of the core faculty at Northwestern, I worked on a couple of projects very closely with the dermatologic department. They actually were our next door neighbor for our administrative offices. And we in fact developed a couple of applications for dermal delivery that are to this day still patent protected. And so when I started to look at in particular, skin science, the honest answer, and this is one of the things I love about Larry's podcast, is that we kind of try to put the BS aside. So for me, it really was a vanity project at first. I had, when I was younger, had so much trouble with different skin products even into my adult life.

(04:40):
I would try something, I looked at a neat package, I said, "oh, this would be great. Let me get this." And I would put it on and then I would be broken out for weeks and then I would spend the time trying to chase it using applied science to deal with the side effects. But as most know, one of the challenges in skin of color is if you get a breakout, you're left with hyperpigmentation. So for me, I wanted to come up with a solution initially that would, to be quite honest, just help me and relatives and people who were challenged by the same types of things. And then as I kind of moved along, the patient feedback became more and more specific that there was a true following. People were giving it to their friends. I had given patients that were fairly well-known individuals who I would periodically see a picture of them in some post and I'd see my product in the background. So it kind of became this very organic thing that led to where we are now.

Doreen Wu (05:56):
Awesome. And so what are some of the key features or key products in the skincare line?

Dr. Julius Few (06:02):
So I, like anybody who's been in the skincare game, they have gone through, so I've been at this now on a commercial level for about a decade, lots of iteration. I've worked with lots of different manufacturers in the US that tried to keep everything on domestic soil, but along the way you learn a lot. And so now I'm very happy with the chemistry team that I work with. They're in Southern California, everything is sourced there. And we kind of all come together, the three of us in core that come up with different kind of, if you will, formal ingredients that then we try to center around kind of a botanical approach. So using things like gren tea extracts, the polyphenols that go with that using hyaluronans on a topical level. And most lately, and I think the thing that really catapulted or differentiated us was the use of CBD.

(07:09):
So CBD and skincare has been dabbled with, you typically have to go to, especially if you're in California or New York, you have to go to a health food store to find different forms of CBD that are used topically. The problem is they're infiltrated with other impurities such as various forms of CBM that are not as effective and other forms of cannabidiol that really get lost on the surface of the skin. And so we were able to not only come up with a 99% pure form of cannabidiol, but also a water soluble version of it, which for somebody like me who I deal with kind of challenged skin, even as an adult, you're talking to somebody, by the way, who will travel with my own body soap just because I'm so afraid a hotel cleanser will make me break out on my body.

(08:06):
So it is a situation where with the CBD that is water soluble, we've really come up with something that is quite special. And in fact, what we did is we did a controlled blinded study that ultimately not only showed clinical efficacy, which we can get it to later if we have time, but also it was published in the Aesthetic Surgery Journal. And again, for the sake of time, I won't go into what all the metrics mean, but in terms of looking at the viral nature of that publication, it is the record setting publication for metrics for the Aesthetic Surgery Journal. So it's a subject that has been referenced extensively, including by the FDA, even though it doesn't technically fall under the purview of the FDA because it a nutraceutical, whereas the Cosmoceutical. But nonetheless, big, big pharma has actually taken note of our research and have proposed actually the use of it in the treatment of psoriasis. So it's literally taken a series of turns that had I not gone to California, I did open a clinical practice in Los Angeles. That's when I really became curious about the cannabinoid.

Doreen Wu (09:37):
That is certainly very interesting. So let's shift gears for a moment and discuss some important points about skincare that patients may not necessarily realize.

Dr. Julius Few (09:48):
Well, I think the biggest one is more is not better. I think there are lots of products out there. As you initially said, there are thousands of options. But at the end of the day, it's about finding compatibility. It's about finding a routine that is easy to do. Like the three of us, I mean, we're all busy. We don't have an hour every night to spend or an hour every day during the morning to spend on skincare or these very complicated elaborate routines that may have diminishing returns. So again, as in full disclosure of vanity project, I wanted to come up with something that I knew I could be compliant with. And so I do think the key essence of skincare is good cleansing, but not over cleansing, good hydration and protection of that hydration. And then something that facilitates cell turnover and elimination, again, not stripping, but enhancing that process. And so I think if you look at the approach to really skincare circa the seventies and eighties, it was very much so geared towards stripping and then replacing. And that is, it had its place. But in reality, if we look at the big, big picture, really there should be no role for the stripping or removing of the protective barriers of the skin just to try to use a replacement with the synthetic alternative.

Dr. Lawrence Bass (11:27):
I think you raised a number of really important points. And in my practice, I have always pursued the same approach with the skincare program. It's got to be a limited number of products that you can keep up with on a practical basis without naming names. A very famous product line based Southern California would often have patients on seven or more products. And it was almost impossible for anybody who had less than three hours a day to play with their skin, which is basically a hundred percent of people to do that regimen correctly. And I'm not sure it was necessary, but it was impossible to be compliant. So that's critical. And exfoliating, which was the mainstay of skincare in the early nineties is okay, but as you said, beating up the skin is never productive. Teenagers do this when they have acne, they're frustrated and they want to punish the skin in the hope that the skin will behave. Adults are seeing dryness, scaling wrinkles, rough texture, and they want to again, force the skin to behave the way they want. And by stripping the protective barrier, the skin needs to defend itself. It's like putting the skin out in winter or in summer sun without any clothing on. It's very damaging. So gently cajoling the skin in the direction you want to go is probably the productive pathway for all skincare. And we're Americans, we'd always like it more and faster, but sometimes we actually lose the game by taking that approach.

Dr. Julius Few (13:34):
I couldn't agree more. And at the end of the day, it really is, we have to remember that the skin is just engineered to do all the things. I mean, their skin actually on the surface has powerful, powerful factors even included in sebum, which smells awful if you have overproduction of it. But sebum as an agent on the surface of the skin is actually the most studied component or one of the most studied components in science because it is a natural antifungal, antibacterial, antiviral, and it's one of the most potent, I mean, even there are antibiotic resistant strains of bacteria that cannot survive see them in its pure concentration. So I think that if you start to realize that that is not you, Larry, but in general, if your audience, people are listening, start to realize that the skin itself has its own barrier, its own factors. So then it becomes much easier to think about, okay, well then I want to then structure my skincare program not only around not overdoing it, but also thinking about the important variable which is hydration. If you're hydrating internally, ultimately all these things work better. So if somebody hasn't adequately taken care of their internal health, systemic health as we call it, then ultimately what we're doing on the outside the skin is its, it really is our largest organ, then we're not going to see the benefit either.

Doreen Wu (15:19):
Dr. Few, you mentioned this earlier, but if we could go back to another important focus for people of color tackling hyperpigmentation and dyschromia, if you could both talk a little bit about that.

Dr. Julius Few (15:31):
Absolutely. So that's what led to the genesis for a beauty line or skincare line is also around hyperpigmentation, dyspigmentation and dyschromia, coming up with medical grade options that did not require our patients to go to a pharmacy to get their needs because frankly, I think most of, or not most, but many of the options that are pharmacy derived have disadvantages because again, they may have components that are harsh. And so we have a product that does require physician oversight. It does have a component of hydroquinone, however, it has a lot of other components that are nurturing to the skin that have free radical scavenge capability and so on that then allow for a delivery of a pigment cell or melanocyte friendly solution. And at the end of the day, the most important factor, especially if you're treating any kind of dyspigmentation hyper, hypo, is sun protection or prevention.

(16:48):
We can't even in my skin tone, darker skin tone, which my skin tone because I have a dark brown hue to my skin, has a natural sun protective factor of anywhere from 12 to 15, just innate. However, if you're treating a dyschromia or a hyperpigmentation, especially if it's my skin or somebody's skin is darker, you even more so need protection because the melanocyte activity is going to be hyperactive. And if you're putting an agent on, especially a skin lightning agent, it tends to also by definition photosensitize because it actually destabilizes the melanocyte production process. That's how it works actually by preventing more deposition of pigment. But at the same time, because modulating the melanocyte activity, it also makes that melanocyte irritable. And so then you can have a situation where ironically, sun exposure, or for that matter, if you have a patient who's a picker or is playing with things or what have you, like so many of our patients do, they actually can make the issue worse.

(17:57):
And so one of the most common causes that I see in my practice, we deal with a lot of skin of all types, whether it's African, Asian, Latin or Caucasian skin, is really this idea of occasionally people will come back and say, well, I feel like it's not working fast enough. And then if you really drill down, it's either lack of sun protection or they're picking at it, or the worst of all is they're not using it. They have it, but they don't use it. And the easiest way to smooth that out is to say, "you know what, do you mind bringing it back?" And because we've done a lot of, because it comes in a pump, it comes in an airless pump, and so we'll have them bring it back. And we have the ability to weigh the container because we do so many clinical studies, we've clinically studied most of our stuff, so we can ascertain literally how much of the product they've used. And if we do the math, and it's not hard math, you can say, well, honestly, using it once a month doesn't quite work. So I think these are the things, it's slow and steady wins the race and using these products, any of the products I would tell any given person, even if they want maintenance to get beautiful skin, it's a minimum of six weeks of doing a hopefully very easy process to get to their stated goal.

Dr. Lawrence Bass (19:30):
And again, you've raised some really, really critical points there. Every skin product, it's six to eight weeks to really judge if it's working or if it's the right fit for you. And a lot of people, if they either react to a product as they initiated or if they look after a few days or a week and don't see an effect or ready to switch it up again, and that's a mistake. But pigment issues in certainly darker skin tones, but even in fair skin people are one of the major aging changes that occur as decades start piling up. And it's something that historical products have not done amazingly well with and have really done quite poorly with in people with darker skin tones. And in fact, a lot of the treatments in my view that were widely endorsed for clearing pigment are problematic in people with darker skin tones, alpha and beta hydroxy acid peels and products are big promoters of hyperpigmentation in people who are olive skin or darker. And they may work very nicely in someone who's very fair-skinned, but it's the wrong treatment for, you can't just apply that to the entire human spectrum and expect it's going to work equally well.

Dr. Julius Few (21:12):
A hundred percent. And this is having, even going to medical school in the eighties and certainly before that, there really were not any good viable options if you had skin of color or you had combination really significant ethnically combined skin, there just wasn't, I mean, this didn't exist. And I think that probably to go back to the original question, that probably heavily affected my choice to go into skincare because at the end of the day, I think that so much of what we do, I mean, Larry is probably one of the most gifted thinkers in our space, and you have to be passionate about what you're doing. And I think from my viewpoint, I'm passionate about it because it was a need, it was an unmet need in my mind that then combined with an area of expertise led to this evolution that now we have our product being sold commercially and very visible outlets. So it's Larry, you timed this interview and subject very well. We just launched, we have a clean version of a product that we just launched on Gwyneth Paltrow's site Sunday. So in all of our, like I said, our products, we back with clinical studies. So I think it's been quite a journey in our process.

Dr. Lawrence Bass (22:56):
Well, but again, it sounds like a very rational journey. It was need-based, not a me too product, it was data-driven, which is still not as common as it ought to be in the actual medical side of things and is really not as commonplace in product-based items. So that's really important that you're doing it in a way that sets the bar at a new height rather than just following along into the marketplace with something with your name on the front. You don't want to put your name on the front unless you know there's science, there's data, there's an unmet need. And congratulations on getting listed on goop, and I'm sure you'll have great success with it.

Doreen Wu (24:00):
So Dr. Few, what kinds of things can happen if you pick the wrong skin products for your skin type?

Dr. Julius Few (24:06):
Well, this is Doreen, a really, really important point and question. Picking the wrong topical agent for skincare can lead to significant inflammation or in a worst case scenario, a reactive dermatitis. And so dermatitis is just a catch or grab bag term for inflammation of the skin. The problem is if you have skin of color, the inflammation will often manifest dist pigmentation or discr, and it's much easier to get pigment than to get rid of it. So you can so many things, you get the issue and then you will spend easily five or 10 times the amount of time trying to get rid of it. So this is probably the first and foremost thing. I think the other, which again, a lot of times people don't realize is that what you put on your skin and the sequencing of how you put it on the skin does matter because again, the skin behaves differently at night compared to the day.

(25:23):
And so anytime that I want to, for example, do a restorative treatment on my face, I tend to do it at nighttime because that is the time when actually our body's not just repairing things on a neurologic level, but it actually is repairing on a systemic level as well. And so in general, if you want to optimize kind of, for example, a hypersensitivity or if you have a low grade dermatologic issue that's going, the best time to treat it is at nighttime. And certainly when you're sleeping. I think also the other thing to remember is know your skin depending on the season. So if you're in the middle of the winter in a cold climate like Northeast or in the Midwest, you will easily run into a situation where the skin is dynamically very different. And so what tends to happen is because of the skin having a tendency when it's colder to be drier, you may only have to wash the face once a day instead of twice a day.

(26:38):
And that's one of the things, I mean, it won't mean that you're selling more skincare product, but the truth is it's better for the skin if your skin tends towards being very, very dry. I'd rather have a situation where I strategically once a week lightly exfoliate the skin, but then during the balance of the week and when it's really, really cold for my friend's, family, patients that have very dry skin, to have them just wash their face at nighttime before they put on their actives. And again, this should be no more than a five, 10 minute process. And then when they wake up in the morning, think about it, you've done anything that requires a stripping of the skin that's purely to get whatever active residue you have, which by the way, typically has been reabsorbed by the skin. What really matters? And it's just the carrier of the vehicle that's on the surface, which frankly very easily comes off the skin.

(27:37):
And in fact, the natural oil of our skin is actually that cleansing agent. You don't need to apply a cleanser on top of that if you tend towards dry skin because again, there's no reason to strip only to try to protect or replace the oil that you stripped off the skin. And in fact, if you go back in time, certainly to Egyptian times, oil was used as the primary cleanser of the skin in times when you couldn't predict clean water supply. Actually oil was the bathing agent. You used the various forms of botanical oils that were non stripping to clean the skin. So again, everything, if you go back far enough in time, you can find examples historically of how and why a lot of old application were frankly some of the most effective application because what's the mother of invention? So I think that's one thing.

(28:44):
I think the other is that we also should know that as the skin gets older, like all things, it becomes less reactive. So when you're dealing with skin that is older, you have to change your gears perhaps a little bit in terms of skincare from the standpoint of protection of moisture, because older skin tends not to be as effective at hydrating itself or maintaining the intracellular matrix of fluid. And so doing things that are focused more on hydration and older skin can often yield a much better result just in terms of outward visual appearance of the skin as compared to just hammering it with a bunch of different agents that are trying to strip the skin. So again, it's these things that philosophically use common sense and really the skincare should match.

Dr. Lawrence Bass (29:46):
And that's very important. Skin is individual, so the product your friend used and worked well on them, unless you're genetically identical, your twin, your twin sibling maybe is a good example of someone you should try their product if it worked well on them, but not maybe for your friends, even if you're roughly the same age, because everyone's skin is going to age differently, it's going to react differently to different things, and it's going to have different needs in terms of what the problem areas are. And I love the idea of the seasonality because I've always done that with my patients, cycled their products in different seasons, which is efficient. Usually they'll use up a product and then they can move on to something different in a new season that's matched for what their needs are going to look like in that season. And certainly where you live, Julius, and where I live, weather is really different at different times of year. We're not sunny and warm 12 months out of the year or 10 months out of the year. We're hitting very different seasons in terms of the amount of sun, the amount of moisture in the air and the temperature. So that's a really important thing to build into the approach.

Dr. Julius Few (31:15):
Absolutely. And I think also the truth is just like we would for our diet, we all know as we get older what agrees with us and what doesn't agree with us. And so typically how I approach skincare is very much so from that vantage point, which is there are basics that frame good skincare and then you build from there. And again, being science-based. So I think that's really where things are. And especially being out in California, there are skincare products that come out literally every day, and they may be hyped in different ways. And at the end of the day, with all due respect, it becomes a question of, okay, well what is this really doing? And then can your claims be backed by scientific study? And I guess that at the end of the day, it's really the biggest eyeopener I've had in this space now that I'm kind of playing with some of the big boys and girls is just the idea of have you subjected your product to scientific study?

(32:38):
And I was just on a panel with two other skincare companies. One was based in Switzerland, and I mean really interesting products, interesting conceptual ideas. However, when I asked can I see the data, basically I said it the nicest way, and I did this offline. It wasn't on the interview. And so their chief scientist had promised that they would send links to different things and so on, because there was no published literature I could find. There was nothing to share. There was nothing to share. So I think that, and I understand, and Larry certainly you do too. I mean, to do a clinical study takes a lot of time, energy, and money to do it and then to orchestrate it. And so for me, I feel fortunate that I've been involved in a lot of different clinical studies. So we have an apparatus at our institute where we can do the formal process an IRB, FDA level, even though it doesn't go to the FDA, but an FDA level study that would stand up to just about any kind of clinical trial. And I would challenge most skincare manufacturers to say that they've done the same because that's not common.

Dr. Lawrence Bass (34:04):
Yeah, I mean, they often don't do it because they simply don't have to. But a point that I make very often to my patients is you may have a really good idea of what ingredient might be useful in a product, but unless you've done a study, how do you know you've dosed it correctly? If I give you five milligrams of aspirin, it's not going to get rid of your headache. You're a full grown man. If I give you 500 milligrams or 325, probably your headache's going to go away. But skin products are like that. Sometimes. They've got a great ingredient, but not very much of it. And unless you've demonstrated that the formulation has the desired effect that the product is there inadequate amounts by gauging clinical response, you're just shooting in the dark.

Dr. Julius Few (35:05):
Could not agree more, could not agree more.

Doreen Wu (35:08):
Now, Dr. Few, to wrap things up toward the end of our episode, can you share your overall philosophy about the role of skin products in an individual's beauty plan or their skincare regimen?

Dr. Julius Few (35:21):
Well, I think that overall skincare is the low hanging fruit and beauty care, especially in the nonsurgical space. It can be the most cost effective solution to anyone's beauty regimen or beauty care self-care approach. I think that it's often overlooked. I think people will jump to even surgery faster than they do looking at a good balanced skincare routine. And so I think that's the biggest takeaway is that remember, good skincare especially ideally medical grade skincare is a necessary adjunct to plastic surgery, to non-surgical injectable care and to beauty as a whole, both as a preservation tool, a restorative tool, but ultimately as well can facilitate outcomes in a synergistic way.

Doreen Wu (36:23):
Dr. Bass, any parting takeaways you would like to add?

Dr. Lawrence Bass (36:26):
I think it's important for people to realize the skin is like a puzzle. That's how I think of it, because everyone's different. So it's figuring out in as few steps as possible, which products are going to be most effective to address the prevention and restoration needs that you have in your skin. It's ideal if you can do that with your beauty doctor who has extensive experience and can gauge with you if the products are being effective. But if you're doing it on your own, again, you have to look at least six or eight weeks down the line and assess the effect of what a product has.

(37:19):
And we said early in the episode that product overload is a mistake, and constant changing is also a mistake. That's the grasses greener fallacy that, oh, there's always, if I just switched to this product, suddenly magically the skin will transform. And it is a process, but it's a process that's very worthwhile. So Dr. Few, I'd like to thank you for joining us. It was a really engaging discussion, and I think you have such a well formulated and productive perspective on how to think about these things that I think will be really informative for the listeners when they tune into this episode.

Doreen Wu (38:07):
Thank you, Dr. Few for joining us today and for sharing your insight and expertise with all of us.

Dr. Julius Few (38:12):
This was a lot of fun. Thanks a lot.

Doreen Wu (38:15):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.