Cosmetic Dermatology

Cosmetic Dermatology

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Thanks. So much Nora it's such an honor to be here can, everyone hear me okay this is the microphone great, so. Again so glad to be here tonight and, certainly. Honored that you would all come out I'll. Be talking about laser and aesthetic dermatology, tonight it's, a really, informal, talk so I look forward to answering. Hopefully. Lots of questions at, the end but. With, that let's. Begin kind. Of the outline of the, talk is just to talk about, how to demystify, you. Know aesthetics. And. Treatments. That that, we do, do. In the community, and that we hear, and see on the media and, so I'm gonna treat you kind of like I would treat a, medical, student our residents. And kind of talk about a little bit of what, we do and why we do and I think with, a little bit of that education, we. Can parse out some, of the noise that's out there about cosmetic. Therapies, and then also tell you a little bit about our, practice, and how we've built our clinic and kind, of our goals really. In achieving, excellence. In terms of outcomes, and and certainly in terms of patient service. As well. Okay. So it does anyone know who this is. Any. Ideas, it's. A lady, you. All right. Does. Anyone know who this is this. Is the same person this is both Renee Zellweger. This. Is her when she's younger and then when she's a bit older and, I think you know it's, always interesting to me that it's, really hard for me to say that second photo is is. Renee Zellweger but, it's hard to to, know why you, know I think if you're just kind of looking at that photo you, know and you look you compare them both it's like well something is definitely, different but. But what is it and it's hard to put our finger on so even, small changes in, the human face or anesthetics really, impact us all and we all see it but, it's hard to know what, the difference is why and how do we achieve that difference or maybe avoid. Avoid. Attaining that difference and yet, there's so much media out there that, promises, so, much you, know in terms of beauty and in terms of changing, our skin and here, are different, treatments. To do that and different creams to do that so there's, a lot of snake, out there but at the same time small, things can make a big difference so. Again my goal of this talk is not to give a basic science lecture but, just to demystify, aesthetic. Therapies, and try to introduce you all to the. Way that we practice, here which is an evidence-based, approach just. Like there's good, evidence for, cardiology. Practices. And neurosurgery, practices, and others we're. Developing that in the realm of dermatology, now as well and that's what we really abide by at Stanford I know it's all kind of just hopefully, you'll find find, it interesting to kind of see some of this when. I see patients in my clinic and we see lots and lots of patients. Patients. Typically come in and say well I don't I don't like this or I don't you know I'm noticing, changes in, my skin or I feel like I'm I did, did well for a long time but I've really aged lately, and what. I really have to do is help the patient interpret, what they see into. A target because that's the name of the game in medicine, in general and. Certainly in laser, and cosmetic dermatology. It's what's. A target and what is the best safest. Tool for, me to hit the target so that's my job that's. What I do every. Day and that's kind of the intellectual, part of of. The of esthetics, okay. So, with that as kind of our background, let's start with some basics. And. This is where you guys are medical, students so, this is a patient who comes in and it's a photograph of one of my patient patients. Who says you know I don't like how my nose looks so, what do you guys see on the nose that could be a target. Yeah. There's blood vessels right and so we know that blood vessels are filled, with blood and blood is comprised the red blood cells and within red blood cells there's hemoglobin, well hemoglobin haps happens, to be an excellent target for a certain laser so, you've already got it this is exactly what I do I see a vessel, called telangiectasia, it's, red that means it's oxygenated.

Not Deoxygenated. Like a vein that's important, and. There's hemoglobin, I say oh yeah I can help you with that that's no problem, okay. How about this patient this is a little bit more difficult, does anyone see. Yeah. This is a young, woman who unfortunately. Had an accident, in her youth in Russia and this was sewn. Up maybe. A little bit imperfectly, and so, this is a scar, and when I look at skaars I don't. Just see a scar I see different types some scars are thick some. Scars are thin or atrophic, and, that's what this one is some are red some or brown some are white this, is a skin, colored atrophic, thin skin. It. Is enough enough, collagen and the dermis of her skin so to treat this we have to come up with a way to grow some collagen, and we do that by targeting water so, you guys kind of seeing this is how how I interpret, skin so here's. Another another. Patient who came in what, do you guys see here. These. Gills yeah he's kind of a mark on you guys for doing great mom I'm very impressed, so, yeah he's gonna write so this is we have lots of bicycle. Accidents, in the Bay Area and this, is just a patient who had a bicycle accident and scraped his face on the road so usually. It's not just one target when I'm looking at patients, it's actually multiple so it's not what is the target it's what are the targets and in, this case he has an atrophic scar a thin scar and unfortunately. I don't think my pointer will work on the, screen, but. You can see that the scar is pigmented, that's actually asphalt asphalt. From, the road gets into the skin and creates a tattoo it looks just like a tattoo so there's tattoo there. Yes. You're exactly right on his lip there on the field that's called the philtrum, of the lip that area where it rises in that scar I'm, glad you picked up on that that, scars a little bit thicker whereas, the one on his cheek is indented, like the prior room at atrophic so we have a thick, scar that's called hypertrophy. Hypertrophic, a thin. Scar atrophic and there's tattoos so there's multiple targets, okay, here's another bicycle, accident, so. I'll just cut to the chase another another, scar here but this one you can see I think is thick, it's. Hypertrophic. It, has blood, vessels in it just like the first patient I showed you so there's hemoglobin, again that's good we can work with that and then, it's also hypo, pigmented, there's less pigment, and her skin or skins turned white and that's, a normal reaction that the skin has to trauma where the melanocytes the, cells that give the skin color they'll, do one of two things when they're injured one thing is they'll spit out pigment and make a dark spot another. Thing they'll do is just shut down production say I've had it I've been hurt and that, will leave the skin white so we have to figure out a way to restore all those things okay. Here's more of a cosmetic patient. This is a woman who said you. Know I I, just have noticed I feel like I'm getting some wrinkles and just lately. And. So. This is another case where we have to find a target and all this and I. Think there are several she has some some of these who wrinkles we call them right it's in dermatology, we make up fancy names it makes us sound smarter, so we call wrinkles righted and they. Are static, so at rest without movement she has wrinkles and. She grew up in Australia she had a lot of sun damage and so there's some of this photo damage there's some Brown I think you can see on the background of her cheeks if you look closely and. There's, also just volume, depletion you know as we get older the, bones of the face received.

The. Muscles of the face diminish, and yet, the skin stays the same and, loses, elasticity. Father. Time is undefeated, gravity's, undefeated, so everything starts to come down and I think you can see that in her face so sun, damage wrinkles. And then just volume, depletion we turn we could kind of go from a grape to erase and as we get older okay. That. Is kind of the first like introductory, that's what I try to do every day we're, trying to demystify what we do in aesthetics so hopefully that gives you you know some some background, some ID on how to evaluate patients, so. Let's go to vascular. Lesions, red things that are red is basically this category, and, take it a step further and talk about how we actually target, and treat these things so you, all have probably heard, of rosacea. It's very common so we will call it adult acne, it, can have acne bumps just like teenagers do but most of the time in adults who live in the Bay Area where there's lots of Sun this. Manifests. Itself as just red irritated skin, sometimes. With, those vessels, those telangiectasias that. We saw in the gentleman's nose earlier, so, this is just standard patient, of mine who comes in and says my, face is red it's irritated, I feel like I have windburn all the time what can you do and then. I break that down further and it's too technical to go into I'm afraid you would all fall asleep if I went through all these details but. Rosacea is a really good example and that's something we'll talk a little bit more about but there's other things that are red too right we saw some scars that were red scars. After trauma, scars. After surgery, I saw a woman today after a thyroid, surgery with a very red skaar those can be really bothersome. To patients, acne scars sometimes, start off really red in fact most scars do because. What the body is doing is bringing in blood vessels to provide nutrients, to the harmed, area of the skin and then. After, the skin heals those vessels just stick around and they leave a red a red area, and. There's other things for something called POI kilo derma that chicken, skin look on the neck that people get sometimes with, lots of sun damage there's, stria are stretch marks typically, start red and fade to white cherry. Ng almost many of you may have little red bumps on your body those are little groups of blood vessels called cherry angiomas we, start developing and when we're about 30 years old and then, port wine stains are just groups of blood vessels and these are those babies. And children that you see that have big red patches on their face all, of these are vascular, lesions I can, break these all down into a treatment, target and we can treat those and again that targets hemoglobin. So. After we know the target the, next thing to do is find a device find something that hits that target, and so, we use different lasers. Which, produce. Light of a specific, wavelength that. For whatever reasons, excites, hemoglobin. And that just means that heats up hemoglobin, but. It doesn't heat up the surrounding, skin and so if you can kind, of imagine that it's almost like a heat-seeking, missile just, hitting hemoglobin. But, not burning the skin, so. We, really, are trying to have a laser that hits a selective, target and then, depending on the size of the blood vessels and other factors, we can change other features as well. And. Then as a doctor my goal is to just after, I'd know what I'm gonna do what I'm trying to treat what, device I'm gonna use to treat it then I have to have, to be, very vigilant and understanding, how aggressively, to treat you know we, there's a fine line between no, improvement, or no, response, a perfect, response and, then burning or blistering or scarring someone and the way I do that is watching the skin and the vessels and the redness change, color with my devices I use it, and. Of course it's always important, to discuss realistic, goals and expectations many. Of these treatments, take. Multiple. Sessions. And. There there are side-effects every time we do laser treatments, things like swelling, and redness is, sometimes bruising, for these vascular. Lesions. But. I find a few if you discuss these things beforehand, with patients, that really patients. Really understand this and are grateful, and. Kind of become partners with care so, let's go back to rosacea, I'd mentioned rosacea earlier that was that gentleman with the red face some, rosacea has a lot of just blood, vessels and you can see patients almost look like little spider webs on their face that are red other.

Folks Just Falaschi, they just flushed that's called erythema but they don't have vessels we have to target those in different ways but, here's that first nose I showed you this, is a gentleman I think some who saw me for skin cancer and, then he just said hey can you do anything for this nose and so we just treated it a couple, times with this laser and you can see with a couple treatments, you know significant. Significant. Improvement in his nose and he was like this, is great I don't want anymore treatment so I'm super happy and, that, was that so this is a case where there, wasn't background, flushing, but there were big vessels, and I can just tailor the laser to hit those hopefully, you can see some improvement, there here's. Another patient this is a fireman, a really. Nice guy who found, that he just had very irritable. Skin and he would get this flushing, this redness in his cheeks especially, when he was fighting fires or, when, he was drinking a cup of coffee or a glass of wine at night there are certain known triggers, for this and this is rosacea, this is erythema, and, so, we were able to use the same laser but adjust, it to, hit the teeny tiny vessels. That, caused this flushing, so we saw big vessels earlier but, now I can target the the tiny, vessels, and improve, that so obviously, he. Went from a pretty tough looking hombre there on the left a pretty happy guy after, just a few treatments, so he's done well also, here's. The original patient I showed this patient has both this patient has diffuse, redness, and, individual. Vessels, and actually, had some acne with this at all with. This as well but but did great you can see how that redness is really improved. So. Just. You know it's not rocket science with, this but it's pretty, straightforward and these. Technologies really work this, is that woman I showed earlier with the scar from a bike accident, that thick scar so. We put a little bit of an intro lesion 'el steroid medicine, to thin that scar out treat. It with that same laser for redness a little. Bit of tincture of time for some of the pigment and I've actually seen since this follow-up photo and it's very hard to see her scar now so she's done exceptionally, well but you can see some real some, real improvement there with just a little bit of org here's. A younger, patient I'd mentioned that scars are often red acne scars are absolutely, red so if. We really looked at this patients skin we would notice that he, has little divot of scars remember that term I use for indented, things for thin skin it's a trophic squeeze atrophic, acne, scars that catch, a shadow and break up some of that natural light, reflects, off his cheeks but. The biggest problem that I saw when he came in was there so red you know they were just so darn red and just, by treating them with our pulsed. Dye laser or the laser we used to treat red alone twice. He. Really got some nice improvement, and now we can start working on that hat trophy and, starting to smooth out his skin as well but he's very very happy with just this, much improvement easy to do takes about ten minutes. We. Do a lot of treatment. Of medical disorders, with lasers in my clinic it's something that I've really, worked. Hard on and it's I find it very rewarding, and our residents, find it rewarding and the nurses love it everyone, loves it but the insurance companies we typically have to fight those guys tooth. And nail but this is a woman with breast cancer who was treated with the radiation, and radiation oftentimes, will cause these, big nasty blood vessels to develop, and this really bothered this woman because she gotten past her breast cancer but there was this daily reminder, of it on her chest every day, difficult. To hide you. Know with anything but a turtleneck, but, we can treat these the same way you know and it's almost like magic and make a real a real, difference in someone's life so I enjoy, doing that for these blood vessels also, for breast cancer, tattoos.

A Lot of women get tattoos when they have radiation, treatment, that, guides the radiation. Oncologist in terms of how to use the radiation therapy but you, know you end up with that tattoo on, the, breast for the rest of your life and we can make, those go away with one shot and that's really liberating, for, many women and, rewarding, for me okay. So that was vascular, lesions so okay so far is just kind of on target and you guys are with me great okay, we'll keep rolling let's. Move to the. Most common, thing probably that I see besides Vaska lesions is just sun damage we're in California but this is a group that, I would categorize all, in one category just dark spots so, most of what I see is caused by Sun but, some like this patient we saw earlier or it's caused by other things real, professional, tattoos or asphalt. Tattoos. And so we treated that on him and you can see kind of his before. And afters their sun. Damage the the group of words we use for that is usually lentigines, that's, those liver spots just brown spots that we get on the skin from sun. Sun. Also causes, blood vessels we, know how to treat that now and also, causes something called melasma, that's, the mask of pregnancy where, you kind of see this sort of modeled. Butterfly, distribution. Of kind of brown pigment, in the skin so. Let's talk about brown, spots talk about photo damage so I wish, all my patients looked exactly, like this when this woman came in I I just knew we've, got you we can really really improve you so if, we think about her targets, there are some wrinkles here there's some collagen, that we could bulk up into and develop but, really the main thing I see is a fair skinned woman with a lot of sun damage you get can you guys see all that mottled pigment, all those, sunspots on our cheeks that's just from growing up in California. So, those are good targets to hit and when we when. We target. These pigmented. Spots that you can see on this woman's cheek our, targets, no longer a haemoglobin its melanin, and that's what our melanocytes, the cells that make color in our skin it's what they make them Akmal in and that gives her skin and our hair color and, we have lasers, and devices, that target, that beautifully, while, sparing the, rest of the skin so this woman came in and said I hate this one spot I like everything else can you please make it go away and. One treatment again, it's, not always like this I promise, but a lot of times it's like magic and we can just make these things go away and patients come in very happy. The, backs of the hands are really telling. And. The reason why they, show our age is because UV a light penetrates. A window glass and the, side windows, of our car and that, causes, sunspots. And it also causes melanoma, we've just found out recently it, doesn't cause sunburn it doesn't cause most skin cancers but it definitely ages our skin and I find that the, hands really show our age so this is a woman who did not like these spots on our hands and we did, just one treatment and were able to get get rid of many of those for her so fun. Easy treatments, when you have, real target, a real brown spot with, a background, of, a blank canvas, really light fair-skinned, is very very helpful, to work on because the device can just see its target, and hit it so. Asian skins interesting, Asian skin I think, is the most beautiful skin, out there those, are very challenging to treat because, the. Skin is light but it has the ability to tan and, and so for, that reason, if. We're too aggressive, with any device or if, a patient just gets good Sun they, tend to darken and so, we run a real risk in these patients of, worsening. Their condition which I never want, to do someone coming comes into my clinic healthy the last thing I wanted to is make them worse off and so these are tough so an agent scan we have real success enough probably 40% of my patients are Asian this, patient this is gonna take a few treatments she's getting better but it's slow she's very happy and if you look at the lower part of her cheek she is improving but it just takes a little bit more time here's another Asian woman similar.

Situation, Nice improvement. But you'll see we, have to take it very very slow and again that's because our target starts, to blend in with some background camouflage. And that, can lead to side effects. Okay. Melasma I mentioned that earlier that's the so called mask of pregnancy most, common in young women, but. Folks, get it really all ages, in it it's a little tough to appreciate here but this woman had quite, a bit of melasma all over her forehead that bothered, her melasma. Is about the hardest thing to treat in the whole world. It, really is hard, to get rid of we don't understand exactly what causes that there's a hormonal, component, there's, also a sunlight, component, and. You, know I would just be, really honest we just lucked out with this treatment I use kind of a different laser called a halo that I'll mention a little bit later and. Just totally cleared her in one session, which. Was exciting and we can do this every once in a while but again in women with darker skin very, very difficult to do okay. So that's sun damage that's brown spots and, now. We'll transition into wrinkles, rightit's is what we call them they. Are multifactorial. So. I always started kind of figure out why does this patient have wrinkles you know what's the cause when. We think about that I sort, of try. To think about what causes aging and they were both in trends. Internal. And extranet. Extrinsic, factors that, cause aging so I mentioned, earlier as we get older we lose volume we, lose muscle we lose bone mass and. That causes aging that causes or wrinkles but. Then extrinsic. Aging, is more like art what our environment does to us just living here a lot, of sun damage things, like smoking. Bad. Habits, all the fun things in life drinking alcohol, all of that sort of causes, wrinkles, it reduces collagen, and elastin, in the skin it makes the skin not. As supple when. We think about a target, we don't have as pure of a target, for wrinkles as we do for red spots from a hemoglobin, brown spots melanin. Really. What we're trying to do is grow collagen, with wrinkles we're trying to refill, the, skin where, it's lost a, lot, of the the, deeper layer the dermal, layer of skin and we do that by targeting water heating it up and that has been shown to kick off College and to make our skin actually turn. Back the clock to when we're 20 or 25 years old and really grow some collagen. Okay. So, wrinkles are great they're probably my favorite thing to treat but, we really have to consider the patient, their goals and it's kind of a you. Know I hate. To say no pain no gain but there is some relationship, between what a patient's willing to go through and how. Aggressive we can be in treating wrinkles so. We talk about diet downtime, also, so I'll walk you guys through this, a little bit a. Long. Time ago when aesthetics, kind of were first coming into vogue I guess, on the west coast of our country, in the 50s and the 60s in, Los Angeles, chemical. Peels you guys may have heard of or the name of the game okay and basically with a chemical peel you're just trying to destroy, the skin with a chemical, and these dermatologists, would mix up all sorts of amazing things in their office put, it on the skin and then watch it burn the skin off and then wipe it off and then great things would happen usually, except. When they didn't and then it would be scarring and all sorts of these horrible problems so, we've really gone away from, chemical, peels now. And. I wouldn't really have a peel deeper. Than a very light peel unless, your dermatologist is, 75, years old or older because no one younger than that really knows how to do them properly and the reason why is because lasers, came along and lasers, again allow us to be very, specific, and targeting. Certain things so, the. First thing that came along with these full-face, ablative. Strong, strong lasers that would basically the same thing as peels do but, in an organized, controlled fashion just basically vaporize, the superficial, layer of the skin and, they were great and they still work very very well but. You can imagine if you remove the entire skin barrier boy it takes a long time for a patient to heal it, is uncomfortable. There is a high risk of infection, and. What, we also found is that if you remove the entire surface layer of the skin you take out those melanocytes, again, and many, of these patients ended, up with just permanent. Hypopigmentation, permanently. Very white skin and. You can still see that if you look closely at. Certain people who have a young looking skin that is just totally white they've probably had one of these these older lasers. Next. Non ablative lasers, came along and these were lasers that spared, the surface of the skin they didn't vaporize, it they left it intact so no real risk of infection, but, they penetrated, deeper in the skin to hit some of that collagen, and heat it up and help this can grow.

The. Problem with non ablative lasers is that they really didn't work as well as the ablative dead so in, not, a total, waste of time but they just didn't quite have. It together and so. What's come along recently is, fractionated. Resurfacing. So and. I don't want to get too technical here but you can kind of walk along these diagrams the one on the left is that first ablative, just vaporizing. The whole top of the skin this is kind of the skin in cross-section and. Now. We have, fractionated. Treatments, that just basically, drill teeny, tiny holes into the skin almost like aerating, a golf course screen or a lawn and those. Tiny holes can penetrate very, deeply, stimulate. Water stimulate, collagen growth, but, when you just have tiny. Little holes there's a lot of skin around it that can reseal, those holes quickly and heal really nicely so. The downtime, is significantly. Less the pain is less the risk of infection is much less because that skin barrier is intact so that's where we're at now kind. Of over the last ten years I'm. Going to show you some slides here these are actually microscopic. Slides, of. The. Skin and so. You can actually see, these, channels. The lasers drill into the skin this is tiny tiny stuff, I mean we're talking about fractions. Of a millimeter, but. Relatively, deep in the skin by wounding the skin deeply, like that. But. Then sparing, the top part of the skin quick, healing and and good result so that's, kind of your laser science lesson for the day and, what we also find, is that these lasers spit. Out sun, damage after. Two or three days to treat treatment and that's what that black glob is at the very top of the skin that's sun damage just getting spit out we're. Still trying to figure out exactly why that works. Okay. So. Here's more of these histology, photos the dermatologist get excited about I know I don't want you guys to fall asleep now let's go back to pain, and gain okay so this, is the woman that we saw earlier in, the, presentation who. Had. Been noticing some aging and wanted a really aggressive treatment, she said really give it to me and we, did boy her husband I thought was gonna punch me in the face on day one when, she came in looking like this but this is a hundred percent expected. For a really, aggressive. Treatment. By, day four she's still not looking too great but she's. Looking better and her husband was kind of you know he made eye contact with, me again I'm. Just teasing we always talk I always show photos and we talk about what patients will go through but it's a lot to go through and, so it's really important, that we build a treatment plan now, in contrast to that this, is another patient. With, a similar. Laser but a much lighter, setting, so we really have to tailor our settings not only in terms of the target we're trying to hit but, in terms of treating the patient as a whole and if someone's young and it's working, and. Just can't have much downtime well, we can do a different, laser that has a nice result maybe not as good as I'll show you this other woman will get but. One, that doesn't slow her down too much okay. Before we do that there, are complications. I mentioned. Asian skin tends. To pigment if it's treated now this is not my aggressive my patient force fortunately. But, this woman you can see her skin darkening, after laser treatment it's pretty easy to treat and make that go away but it does take months, I mean four to six months for that to be gone and there are other potential. Complications. As, well, okay. So let's, go back to wrinkles so, this is a patient, with a light laser treatment, this is a halo laser that I mentioned this really really light and. This is just one treatment and so if you look at kind, of her smile, lines you can see that they've softened I would say hey, that's pretty good that's probably a 10, to 15 percent result, it's not a grand. Slam home run but for not having any downtime, she's, done really well here's her other side. Here's, a patient that I showed earlier very. Fair skin lots of sun damage in wrinkles, as well you can see kind of coming like spokes on a wheel from her eye and. Around her mouth also, and then. Here's kind of her before on the left and after just, that light treatment, one. Laser focusing, on melanin, for sun damage and then, the other on, collagen, for wrinkles and so you can kind of see her, her sun damage is gone and her. Wrinkles on her lower cheek and around her eye have really improved also so a, pretty nice result, for not, having, really any downtime she was able to wear makeup the next day after treatment, so fun, to do treatments, like this and.

And Really rewarding. Okay. Let's go back to this other patient so this patient we used our what we talked about options and decided to use our very strong fractionated. What's called a fractionated, carbon dioxide, laser again. Really beat her up. But her outcome is pretty great you know just I think this was at about six weeks her. Sun damage is gone and. Many. Of her wrinkles are gone wrinkles, around the mouth improved. But very very tough to treat those without being highly aggressive but our cheek wrinkles and her forehead wrinkles are really really, nice she was really happy with this, okay. So. Again. I like to treat medical things in my in my clinic also and, sometimes. Instead of having not enough college. And like with wrinkles, we have too much collagen, and this, is something called rhinophyma it's, a type of rosacea, that. Manifests, itself in the nose and so, this was a gentleman who you, know is notice that gotten bigger and bigger and bigger and, again. Those grandkids, were after him and we. Came in and I could use a similar, laser and. Another device and just reshape. His nose so that's, a fun treatment, and you can see kind of his before and, his after there and. Here he is from the side also, so, too. Much collagen, sometimes, is not is a good thing. Okay. We're. Getting close to concluding so I hope you have you have good questions lined up a, couple, more of these patients this is another combined target patient this is someone with sun damage it's a big swimmer and wrinkles. Who could not I thought she would be great for that larger laser just, couldn't do it she's just too busy and has too much going on in her life but. Able to use a combination, of something targeting melanin, again. That light halo treatment, and, just with one treatment she saw some real real improvement, in her skin. She's. Very happy with, that so, again an improvement both in the sun damage and in wrinkles as well okay. Last couple of things just to mention scars, and, this. Is a woman, that I should at the beginning of the talk with this atrophic scar this, is just one of those halo treatments trying to kick off some collagen I cannot make her scar go away we. Talked about just having, having me you know cut it out Andry stitch it but that was too much for her to go through but just with one of these treatments, saw some improvement I treat, a lot of acne scars and skin of all types so you can see these are these atrophic, right. Dented. And scars, on the left side and then we grow some collagen, with that that, same halo laser and actually cut out some of the larger ones and see. Improvement. Her scars aren't totally gone but um but. Really something that she was very happy with. So. A couple more photos there and. Then also stria so these are stretch marks stretch marks are exceedingly, common and I, have long been skeptical, of our ability to treat them although with our new generation of lasers were seeing real improvement, this, is a really special patient, of mine who has a rare disorder called Wegener's granulomatosis, horrible. Disorder affects the whole body, the, kidneys, and the liver and it can be deadly and due. To that disorder in her treatments, which involved chronic, steroid, doses, she, developed these terrible, stretch marks and and I don't mean that as a cosmetic dermatologist, who says they're terrible looking I mean they're so they, were so painful she couldn't walk she couldn't work because her skin is tissue paper, thin she came in in a wheelchair and, with. The same device this halo laser that's very mild, and can grow collagen, we, did multiple treatments, and, it's. Hard to appreciate in photographs, probably, but this is the same leg and those, guys were really filled, in she's able to walk and she's able to work again so I've been really excited about about. Treating her you can see your other leg year and kind of the before on, the left and then after so, again. Those are some of the most rewarding patients. For. Me. Okay. We. Talked a little bit about our practice and the philosophy, here and, kind of how we built our clinic I, work, at Stanford and my. Clinic, is in Redwood City at the outpatient, center and. I do most surgery that's a surgery for skin cancer, basically. Every day and then every afternoon I do laser, and cosmetic dermatology. And I direct that when. I came to Stanford about, a little over three years now three, years ago we, really didn't have.

Much. To speak of really any any cosmetic, or laser dermatology. And now, we are going, gangbusters I, think we did something like almost, 2,000, visits in. My last year and so, I wanted to talk to you guys a little bit about how, that's happened, I think one reason that that, we've grown is that. We're really committed to things that are evidence-based I've talked a lot about that tonight, lots. Of snake oil out there that, I see every day but. We really try to be honest with our patients, you know about goals. About, risk, about, is this worth that or not I probably spend, half my day talking patients, out of treatment I'm, not a good salesman, I would not be doing well in private practice I don't think with this sort of stuff but, it's really important, to, you. Know build some teamwork with, with patients I think and, really get on the same page we're. Really highly involved as, doctors, in our treatment plan and in actually doing the treatments, at, Stanford, and so with. That we do a lot of studies that I think are really interesting. Stanford's, such an amazing place and our, dermatology, departments fabulous, I think the crown jewel of it is our basic scientists, you may not realize this but at, Stanford, most departments, have clinicians people, who do treatments, like me and then, they also have scientists, and dermatology, is no exception we have a lot of folks who are in a, lab all, day every day and our. Dermatology. Basic science department is the best in the world by far it's not even close we publish in the very top. They tell me which I've never published a single thing don't, know that ever well but I'd love to we. Published more than all the other dermatology, departments, in the world combined, it's, just not even close so I'm so lucky that I have these true, basic. Science experts, to work with and so, I'll do things like give them skin, cancer tumors to study, cancer and, try to come up with drugs to treat not just skin cancer but all cancers the skins a really good model for cancer and then, also things like longevity. And aging which I also find really interesting, so, we did a study where. We used a certain device that we use for sun damage and. Treated. Patients forearms. Like 65, 70, year old patients forearms with a few treatments and then we did biopsies, of untreated, skin and then treated skin and we ran what genes are expressed so, what genes are making the skin in that area and we, found that in the treated, area the, genes that were expressed was that of a, 20 to 25 year old person so, really. Exciting stuff I'm not really sure what to do with it it makes Sundy much go away but we're doing follow-up studies to try to figure out if we can really reset. The genetic clock so to speak so that's. Another been another built real component, of our clinic and I think the last thing and the most important, thing is. We really try to build a strong culture of patient service, that's what we're here to do is to serve patients. And. So, we train everyone. From our front staff to try to answer the phone within 3 or 3 rings all. The way through every employee, we have in terms of just really treating. Patients like their family members and we've done great this is our we were talking about metrics earlier Nora and, I this, is our likelihood to recommend practice. When you guys get these mailers from Stanford we take them very seriously, actually, and. We have been at the 99th, percentile. Basically, the whole time. That we've built this practice, and that's something that we really really. Take pride in and, hope, to keep keep going, so. Yeah I mentioned how we kind of trained our staffs and, really. Work on this and then we also try to select, treatments, that. Work. And that, exceed. Expectations. And there's been studies on this that show different treatments. And how how expensive they, are versus. How much patients, like them and so I really like to be out of the end of the curve where it's relatively. Inexpensive. And, a high patient satisfaction. So. We always aim toward that - I think some. Folks really. Try to just hammer, nails in in clinical practice but again. You know we, really try to pick. Out our targets, you can use the best device the most efficacious treatment. For patients, okay. So that's basically adds, just, to conclude, you. Know just like you all were or my good, med students and residents tonight, you know in valuating, patients we're trying to translate, this, global, view you, know into, a target, that we can work on do, something that's actually good for the patients and not just something done for the sake of doing it and then we try to build a partnership with our patients, and then executed, treatment plan and then be very honest about outcomes whether this worked whether it worked a little bit whether it didn't work at all and it was a total waste of money and we'll never do it again all, of that helps us improve, as we go forward in the future.

Okay. That is it thank you very much. Thanks. Yes. Question in the. Everyday. Yeah I'm so glad so sorry let me repeat the question the question was do we ever recommend, creams. Or. Other products, rather than surgeries. Or laser treatments, the answer is absolutely I, mean that that's really the cornerstone, of. Taking. Care of our skin I'll, tell you a little more about that so. The. Most important, thing you can do for your skin, I guess could all guess that I'm a very, pale dermatologist. His worth sunscreen, broad-spectrum. Sunscreen and, that's not just to prevent skin cancer but also for aging and sun damage there, was a recent study published in, Australia, that had two groups of patients one group of patients. Wore. Sunscreen every, single day and then the other group of patients wore, a placebo, cream, every day and the, sunscreen, group after two years they looked, at him and took all these standardized, photos they didn't age at all now we're all gonna age I mean I don't totally believe that study but. The fact is that sunscreen is is 95. Percent of the battle when we think about extrinsic, aging again. UVA light comes through window glass and. So even folks that are. You know true. You know introverted, you know workaholics. Also. Age from the Sun just by being in their office so sunscreen. Every morning critical, SPF, 30 or higher and, broad-spectrum is important, broad-spectrum, means, it blocks all ranges, of light UVB, and UVA. And. Then the next thing that I recommend. For some people is to, use something with a vitamin, a derivative and, it called retinol, or retinol, and, that's. Really the only substance that's ever been shown, to. Grow. Collagen, to reduce wrinkles into even. Skin tone now, to get, a retinoid, that packs enough punch to, see a difference you probably need to see a dermatologist and. Get a prescription for, it and there are certain side effects and there's a proper, way to use those creams, but. Most of my patients are on certainly, sunscreen, a lot of people are on a retino. It as well ok. And then that brings us to over-the-counter products. So. I, get. Interviewed, for for, you know different news and media sources, all the time and every month it's a new cosmetic. Product with a new ingredient you know it's oh gosh. It's been all sorts of things from you know collagen. To, deer. Hyaluronic. Acid for a while, different. Retinols. It's just oh I call it the molecule, of the month you know there's always some hype around something and. I always kind of say the same thing I would love for it to work but we have no idea whether it does and we never will and the reason we never will is, because cosmetic, products things you can buy at the mall the department store the drugstore are not, regulated.

Extensively, By the FDA. For. That reason there are companies that make them don't have to do any studies, to show that they work and they don't want to because they know it probably doesn't work they, just want to advertise, it and sell it now they have to show that it's relatively safe so. I don't think you can go wrong with most of the things out there but. The. FDA is very stringent, in calling something a cosmetic, product and that. Restricts it to not changing, the structure or, the function of, the skin so by definition, anything. Over-the-counter can't, change, the true structure or function of the skin so, what, that really means to me as a dermatologist is that those medicines can't penetrate the outermost layer the skin they just sit in it so, basically everything out there's a glorified moisturizer, but. Moisturizers. Are very important, and can make the skin look fabulous so a good night cream can really really help yes. So. Great follow-up question the question is you've, heard that retinol, makes your skin sensitive, the Sun should you only use it a night the. Answer is yes okay that you're, right on target. Certain. Of these retinols. These vitamin, a derivative products, can, make the sun sensitive, in general but also sensitive to the Sun now, if we're talking about an over-the-counter product, again that's been dispensed. Sort of diluted, so much that it's probably not doing a whole lot and, so you can wear those during the day but. If we're talking about a prescription. Retin-a. Or as Iraq or, Tretton. Owen type cream we have our patients wear those at night and wash, them off in the morning. Any. Other questions, yes. Question. So the, question is when we're talking about growing collagen. Our lasers, or fillers, more, effective, and I think you're probably referring to Juvederm, which. Is a type. Of filler. And. The answer is, you. Know yes and yes probably for. That when. I think about, you. Know what we're trying to do with different products whether we're talking about lasers, or fillers, and. I have this conversation every day the. Example, I use is so, certain, were you know you were in a car and in to. Me fillers, treat. Dents, in a car really well they treat volume, loss really, well okay, but. Lasers treat scratches, in the car lasers treat superficial. Things so. If you're someone with fine wrinkles. You know very superficial. Kind of these sort, of sun damage sort, of fine little thin accordion, looking wrinkles Laser is gonna treat, those the best that you know laser, really buff, out those scratches, really really nicely but. Now if you're talking about someone who is starting, to have some, saggy ass and the skin hollowness. And the cheeks I would, call that dense in the car that's the great kind of turning into the raisin that's, filler, they, work in total different ways now, lasers, truly, stimulate, collagen growth, we know that they do that fillers. It's a little more it's. A little more controversial, so. Most. Of the fillers we use now are comprised, at least that I use are comprised of something called hyaluronic, acid that's. The most common molecular component. Of the dermis of the deeper layer the skin and we lose it as we get older and so, it's a synthetic form of that that we'll inject into the skin now, there is some and so the body just each set up over a certain time period they go away whether it's nine months or even out to two years now now. There is some evidence that certain of these hyaluronic. Acid fillers actually. Produce some endogenous, collagen, growth to. Where in the future after the filler wears off a patient, may need less filler in the future and so I do see, that but, you can't hang your hat on it that's not the goal really with the filler you're trying to pop that dent right out of the car and that's the fun thing about it versus a laser is, filler is instant gratification I, mean there's the dent and then there it's gone so you, know two different two different games entirely, but great question, yes.

Oh. Yes. Oh yes we knew lots of pillars all, day every day. Yeah. So the question is whether we treat veins, answer is yes we, treat, a lot of veins now, you're, right in your comment about varicose veins so veins, are of different sizes right, from those little tiny vessels we saw in that gentleman's nose earlier through big big vessels. I think of veins almost. Like you can think of a a tree with a trunk you know and that trunk kind of heads back and brings blood back to your heart all, the way out to these fine little tiny branches and leaves at the very end we're, really good at treating those tiny branches and leaves those little spider veins we can inject medicine into and make them go away the. Bigger veins. If you have those there's, no sense in treating the leaves at the very end if you've got a big trunk problem we got a treat the trunk problem so, for those I work with our, vascular, surgeons, here at Stanford, very, closely and they can kind of take care of the bigger ones I do treat veins there's also a woman, here named. Airy fukaya, a few, ke aaya who's. In the Department of vascular surgery and has a clinic in Portola Valley she's, fabulous at veins, also so we both do those do, you have a question in the front. It's. A great question fabulous. Question so question. Is when, we treating sun damage and brown spots with a laser, are we actually killing the melanocytes those, cells that give the skin color, and. If so it, stands to reason that we'd have permanently white skin the answer is I hope not that would be bad you're totally right so those lasers from. Several. Decades ago that would just shear, off all the skin they would do that they would kill melanocytes or at least turn them off permanently. Where they'd never make pigment again and so people would come out of their very very pale but no the goal here is to treat the pigment, itself okay and the way melanocytes, will, work and this is a beautiful. Aspect. Of physiology. Of this again so, melanocytes, are, there presumably, to protect us from the Sun right they're just a factory. Producing melanin and that's the pigment, okay and actually, each mallanna site is associated, with a certain number of keratinocytes, keratinocytes, are skin cells so, they have a good relationship and there's a distribution. Mechanism. Where the melanocytes will cook, up some melon and cook up some pigment and then shoot it out to protect different cells and that melanin, will lay right over the cell and protect, it from UVA light coming in to try. To attack and cause mutations, and the in the nucleus of the carrot and a side of the skin cell that would cause skin cancer so, all. Of that has been getting excited about your question from a basic science standpoint we're, only treating the melanin, that has been packaged, and sent out we want to get rid of that but, we spare the molana side itself. So. The question is how right. Question. Is how long do these laser treatments, last, well, it depends on the laser treatment that we do now we were talking about Mallon we're talking about sun damage right now well Sun image you keep what you get if. It's gone it's gone forever but.

We're, Living in California, and you've got to be if unless you're a total, hermit right I mean maybe if you are a really good dermatology. Patient you were a wide-brimmed hat broad-spectrum, sunscreen twice, a day they. Won't come back but, the fact is that I even have patients, who are doing great and a year or two goes by and they say oh you know I just forgot whenever I leave that you know if I'm not gonna be outside much for the day I just forgot to wear sunscreen and then, it absolutely, comes back but, if it's gone it's gone it's, just fun yes, question. Yes. So the question is about, fillers which, we inject into the scan when. We put in fillers can it leave nodules. And irregularities in, sirs yes absolutely, there can be nodules. Although. Not not commonly, at least in our practice. But. You know fillers you're injecting, something, outside, into the skin so typically that hyaluronic. Acid the fillers we have these days that at least the ones that I use are, really great so you. Didn't ejected into the scan and if you took a biopsy of it the next day you'd see a glob of filler, you see this click glob okay. But if you let it there and you took a biopsy Oh. Two months later you'd, actually see, that that hyaluronic acid, has made friends with the other hyaluronic, acid, in the skin and intercalate, it into it so, a lot of times I'll have patients, a week after we inject some filler say hey there's a little bit's a little bumpy and I, always ask well can you see it and if, the answer is no, then, we leave it and it inevitably, just softens out now, if you can see it then we have an issue and then a lot of times we'll do a little massage or, you, can even inject a medicine which thank goodness I've never had to do this just. Knock on the podium it, reverses it we can make fillers these h.a fillers high ionic acid fillers just go away like magic and so that's an option but yeah lumpiness. And nodularity is a known complication. Of fillers but it's certainly the exception, and not the rule. Yeah. Great question so so. Because we talked about this so the question is if you use fillers, does, the skin type matter and, no. It really doesn't, unlike, laser lasers, are really tricky in darker skin types but. Feel that we're going beneath the epidermis, beneath the skin so it, was kind of one size fits all it works well for everyone yeah. Okay. This. Is great yes. Yes. So the question is about bruising. Yes. Yes so question, is do we work with skin that bruises easily of course you. Know every. Day and there's different types of bruising, that we see now you, see red streaks on people's forearms, sometimes, called solar purpura when the skin gets thin and you don't even think that you've bumped anything and then you've got this horrible looking bruise that's really really common or, with, what I do when I'm treating patients yeah we see we bruise patients all the time when we do fillers get, a bruise almost every time what. Can be done to mitigate, the bruising well the, first thing is to really think about what. Medications, the patients on including. Over-the-counter supplements. So things, like aspirin, low-dose aspirin, really increase bruising vitamin E fish. Oil, and. Other, over-the-counter supplements. As well so patients are able to not be on those that, really, helps okay but the fact is some patients need those medicines, for their heart another reason so we can't always work around that is, there anything you can apply to a ruse to make it go faster nothing. With convincing, evidence behind, it there vitamin K cruise or something called arnica, there's all these sort of things out there that really, don't stand up. To the test of evidence in my opinion, one, thing that we do if we ever run into a bad bruise in my practice if i injected a filler or Botox, or something like that we get unlucky and we hit a vessel and someone gets a horrible bruise it happens about once a year I haven't. Come back the next day we, used the same laser I've talked about all night that treats hemoglobin. And, we can make bruises go away and about half the time or a third of the time they normally resolve on their own which is pretty fun to do just by treating with laser. Could. You use a laser to treat an external, bruise yes. I. Had, Troy genic type bruise yeah any any type bruise I I've, never had someone you know bang, their arm and just come into class hey you got to help me with it but we could we, absolutely could it'd be kind of fun I don't the the ER should have this laser right you just kind of go right down simply like, yes.

Yes. The, question is do we treat the I'm sorry I have to repeat this for the camera so I'm not nurses. Do, we treat excess eyelid skin yes and so there's a there's a couple good ways to do that one things lasers work to, tighten the scanner on the eyelids really nicely, but. There, gets to be a point where there is so much eyelid skin as we age sometimes, that it impedes vision, it, actually impedes the visual field how broad that you can you can see a lot of times patients don't realize that's happening, it happens. And in those cases surgery, is the best option, for sure, and, I work with some, Facial. Plastic Surgeons, and oculoplastic, eyelid. Plastic Surgeons at Stanford all the time on those cases sometimes, we'll do a little laser or sometimes, we do a laser and surgery, sometimes just surgery that, is a surgery I think so I'm a surgeon and, I'm married to an attorney but I think it's always good to avoid surgeons. Lawyers. When you can. Except in this case I do think that I loves the upper eyelid, that. That that skin redundancy. Is a surgery I will have it is the best iron surgery, out there the, risk are so low of having complications, and it looks great it helps you see better Medicare. Pays for it if it if it obstructs. Your visual field and so when it's just a homerun to me. Yes. Gentlemen. Can. Tattoos be totally, removed I, really like how you phrased that question with the totally. So. It's, a lot easier and a lot cheaper to get a tattoo on than, to get one off okay, we. Can totally, remove them we, can't totally remove every single one of them certain. Tattoos, do better than others. The. Way we treat tattoos is kind of like sun damage we target, tattoo. Pigment, and, we explode, tattoos you can think of tattoo so these big chunks, in, the body and the, body the body cells needs to eat them up and get rid of them the, problem is it's like trying to take a bite out of an elephant, the body cells just can't eat these big chunks so we have to explode, them so we explode them with a laser and then, the body eats up some and then two months later we bring patients, back explode. More the tattoo and so. Different, patients, and different tattoos respond differently typically. Tattoos, that are non-professional. So, tattoos, that are, you, know just done by a friend or by you, know someone in prison or something along those lines that's, like a one treatment deal and they're gone they do great a professional. Tattoo with lots of ink and lots of colored ink very, difficult. Very difficult and, a lot of times I'll tell patients with, this particular tattoo if you hate it we can start treating it but, if you don't hate it you want to keep it because we may not be able to get rid of it entirely what black, yes. I will. Have a daughter in three weeks and I will be telling her from day one about. To have that tease. The. Question is about skin. Looking. Young and even as I mentioned genetically. Being. Young it is our telomeres. Involved, in that so, great. Question so for those of you who don't know what telomeres, are tumors are really, an. Interesting, part of the. DNA and you can kind of think of and so DNA is what makes genes which which basically, gives us our. Lives and our bodies at. The if you can think of telomeres.

Almost. Like the little plastic. Portion. Of shoelaces at, the very tip and so. Over time that little plastic telomeres, start to fade away and, it causes fraying, of the shoelaces and the shoelaces are like the DNA and so for. A time there there was a lot of excitement, about telomeres, and if, we can maintain those can we maintain you, know life, life forever, and. Unfortunately, it doesn't appear to be so you know even if we preserve the telomeres, there are so many other, aspects. To aging. And genetic aging it's, not as simple as that you know it's not even as simple as knowing the entire genome which we do now we, actually have to know why certain, genes are, picked, by the cell to be expressed, and so that's a whole another field called epigenetics. It's really exciting I'm actually doing a lot of work on that in our department, what, we do see with certain devices is that the genes that are expressed. Are. The ones that produce skin, cells that produce collagen, that produce other components, of the skin and as we get older we make less collagen we, make less elastin. Which gives our skin elasticity, and recoil, and. So certain of the devices actually induce. Those genes to be expressed again. So that's what we see a great question about telomeres, yes. In the front. So. Yes the question is about tattoos, and in the FDA control, over the dice I don't. Know if I can totally answer this question definitively, the. FDA. With, tattoos, is pretty, restrictive. In terms of. The. Type. Of needles, that they use and the, safety, of administering. The tattoos because getting. A tattoo for a for a time was highly associated with, diseases. Like hepatitis C, or, were. Transmitted, by dirty needles and things at tattoo parlors now, the inks, themselves. Oh my goodness they are full of known carcinogens. All sorts of crazy jet fuel all sorts of things that, the FDA does not take a close eye on but, you know tattoos, have been around a long long time, and I do surgery, on skin cancer basically. Every day and I can't think of the last skin, cancer that has grown out of a tattoo that I felt has been due to the tattoo, so, how much of a cause and effect is there I don't know that we know but it's a really interesting question in Europe. The, EU is actually restricting, tattoo ingredients, now over the last I think a year but. The FDA is behind on that. Okay. Question. Yes. As well somebody was I don't think you've had your hand up a long time this yes. Right. So the question is when, do insurance companies. Cover. These, type procedures, very. Rarely, so, for, an insurance company, to approve. A laser procedure, in general, you, have to show that you're not doing it for a cosmetic, purpose but you're doing it for. A true medical purpose, so certain. Things we. Can get covered so things like a baby, with a port-wine stain with its entire face covered, in red well that's gonna have real psychosocial.

Effects. On on that baby and a child so insurance covers things like that I'm, sometimes able to get other things covered, rare. Genetic diseases that would be improved by lasers sometimes. We can get those covered, patients. With certain chronic wounds, that benefit from lasers but, it's a battle I'll tell ya outside, of one or two things like port wine stains and babies we, have to really. Prove to insurance companies that we're doing it for medical purposes but there are definitely, medical, reasons to do laser therapies, not, just cosmetic if, it's cosmetic we just say sorry it is what it is they're not gonna cover it but. There are certainly I, have. A whole clinic, just full of patients. Especially at Stanford, with really rare and, debilitating. Diseases that benefit from laser and we're, not always able to get them covered but we certainly try and if not we usually can't give people a discount. No. So, the question is do we use lasers for liposuction no, there is such a thing as laser liposuction so we don't do that. At Stanford that the evidence for that is not is not outstanding and. I do not personally do liposuction, I believe. That some of the plastic surgery faculty, here do, liposuction but we don't do it, okay. I would love to continue answering question I could do this all night I'm, sorry I've, got yeah two toddlers and, then this third on the way so I I have, to run but just honored to be here and thank you all. It's. Easier, to work than it is at home sometimes thank you guys.

2017-11-30 16:43

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