Behind The Business Woman
My passion is teaching and taking care of my patients. This is what drives me to come into the office at the Penn Medicine Radnor Center (of the Dermatology Department of the University of Pennsylvania School of Medicine) where I am the associate professor of Dermatology and Director of Cosmetic Dermatology and the Skin Enhancement Center. My interest in skin and hair started very early when I studied Cosmetology (while in high school on night and weekends) and noticed early on that a lot of people were suffering from hairloss as well as skin diseases. I identified this cosmetic concern of hair loss as one that could also arise from a medical problem. It was when I joined began my dermatology residency at the University of Michigan studying under Dr Terry Headington that I could identify various types of hair loss and their etiologies based on histolpathology using Dr Headington’s method of Transverse-sectioning. I introduced this type of histopathology for evaluating hair loss in 1990 to Philadelphia at a Philadelphia Dermatological Society Meeting.
Three physicians have played a pivotal role in my career in dermatology: Dr John Voorhees, Dr Albert Kligman, and Dr Eugene Van Scott. Dr John Voorhees, was my chairman at University of Michigan, had recruited me to do anti-aging studies with Retinoids starting in my first year there. We were quite successful in getting our studies published in the New England Journal of Medicine. Dr Albert Kilgman at University of Pennsylvania was very encouraging and I have always been fascinated by his savviness and his innovative mind which led to the discovery of retin A and its derivatives. With Dr Eugene Van Scott I developed a glycolic acid peel system for skin rejuvenation.
THE LATEST ADVANCES IN AESTHETIC DERMATOLOGY
What are the major changes in terms of patients’ skin concerns?
To me, the major changes in terms of patients’ concerns are centered around younger patients those in their 20s, 30s and 40s who want to stave off the signs of aging and do not want to look “like their mothers”. They want to get rid of the wrinkle before it’s begun. “Nip it in the bud so to speak”.While women who are in 50s, 60s and 70s want to look as though they are “aging gracefully”. They are not interested in looking like the “Real Housewives of Anywhere” but a little better version of their aging self.Men too are concerned about looking angry around their coworkers or employees and don’t want those frown lines or aged brown spots and more recently have been asking about face volumization as they see the success with their wives or girlfriends. They do not want to gain weight but they want to put the volume back in their faces and reduce the wrinkles and lines. Nowadays, people want to look fresher… they want to look like they are just back from a relaxing vacation.
What have been the major advances in Aesthetic Dermatology?
To me, HA fillers and Botulinum Toxin A have revolutionized my Aesthetic practice offering major breakthroughs as well as a paradigm shift in Aesthetic medicine. Though I started with fillers as a resident, back then we had Fibrel, and I advanced into chemical peels as well as sclerotherapy, it was not until the advent of botox and the hyaluronic acid fillers in the late 1980s and early 1990s that really catapulted the changing “face of dermatology“ and the practice thereof.
Botulinum toxins have revolutionized not only Cosmetic Dermatology but also many Medical conditions not the least of which is Hyperhidrosis. With Hyaluronic acid fillers, we are able to almost instantly fill patient’s faces and restore the volume that they lost due to aging and sun damage. In addition, patients can be reassured since both have stood the test of time with safety and efficacy and if they feel too “filled” we can reverse the excess with an enzyme that counteracts the filler namely hyaluronidase. This then gives patients the confidence and can provide almost instant gratification. Those patients that want to volumize over time and not have that instant reversal opt out for agents like Poly-L-lactic Acid types of fillers namely Sculptra, which also has a wonderful track record and thereby offer that patient a more delayed gratification.
What is your approach to determine which cosmetic treatment patients should have?
First and foremost, it is about having a conversation with my patients to identify their concerns and understand their expectations. The most important part of this discussion is to set realistic expectations which may be difficult. In addition, your vision is to correct the lines and wrinkles that are very evident and causing a more aged appearance, in fact, it could be one spot bothering them elsewhere on their body. So my approach is to hand them the mirror,and ask them to show me what bothers them first.
- For my younger patients, their concerns my simply be acne lesions, oily skin. For this, I prefer light chemical peeling options and/or cosmeceuticals.
- For my middle ages patient population, lines and wrinkles both in between the eyes (the glabella) and crows’ feet as well as their nasolabial lines and folds have become more visible. For them, we consider fillers for the folds, botox for the forehead and crows’ feet and cosmeceuticals for the age spots / lentigines as well as chemical peelings and sometimes even light lasers.
- For my older generation of patients, it is more pan volumization of the mesolabial or marionette lines and folds as well as nasolabial folds and tear troughs and cheeks. Botox also is necessary to help the dynamic rhytids and wrinkles while lasers are useful to tighten their skin and brighten their complexion in an office procedure and maintain with cosmeceuticals at home.
What is your favorite aesthetic procedure?
Botox and fillers have become my favorite procedures because they provide gratification in a short period of time. I love to hear patients tell me that ” I took 10 years off their lives”.
I also have a passion for chemical peelings. It is my background and it is fun to talk with my patients to identify what is the right peel for them.
What have been the major advances?
Major advances in Aesthetic Dermatology are to me the new techniques that can be used on patients from all skin types, especially types IV, V and VI.
- Microneedling has been compared to doing laser without the heat so people from all skin tones can have it done and not worry they are going to risk hyper or hypopigmentation. It is used for acne scarring but we also use it for wrinkles for patients who do not want to deal with the heat of the laser because they do not want the downtime or other life events that would prevent them from the necessary pre and post op medications (such as during pregnancy and nursing). Typically, we can predict up to 5 days of downtime depending on the depth we take the micro-needling into the skin. It has really improved many skin types and conditions to a great extent. It is fascinating to see the results and we hope for more data to come in some areas such as the prevention or the treatment of scarring post-laser treatment for example.
- Another new exciting technology is a 40% hydrogen peroxide based topical treatment for seborrheic keratosis or thick age spots and this too can be used for all skin types including types IV, V and VI. This is revolutionary (as before this now FDA approved treatment) we, as physicians, could only offer electrodessication, curettage, freezing, surgical removal that would very often induce scars or dyspigmentation. This is easy to do and patients love it.
How do you classify the different Cosmetic Treatment options available to you?
- Resurfacing agents: light chemical peels, microdermabrasion, micro-needling +/- radiofrequency to tighten and resurface the skin, then micro-needling with or without PRP that can be done for acne scars, or in the scalp for hairloss. In this category, I would also include topical products such as retinoids and their derivatives as well as AHAs to help resurface and brighten the skin.
- Filling and volumizing agents: Neurotoxins and fillers- A little bit more invasive for the dynamic wrinkles such as the forehead and crows feet as well as static wrinkles like the folds namely nasolabial folds and melolabial folds. Fillers with Hyaluronic acid will provide instant volumization while some others such as Poly-L-lactic acid need a series of treatments over time. Polymethyl methacrylate PMMA microspheres types of products will provide more longevity and have been reported to last between 5 and 10 years.
- Specific needs agents: lasers or devices or products for neck tightening and lifting. More information studies with topical antiaging products and also better longevity with thread lifts to mention a few.
Can you tell us more about Platelet PRP?
We take 5 ccs of a patient”s blood and spin it down with special chemicals to separate out the white blood cells and get the platelets out. We then apply them on a patient’s skin or their scalp before and immediately after a microneedling treatment if so desired. There is a lot of growth factors in this extract and the idea is to heal faster and look better. I would love to see a split face design study with and without PRP.
Your View on Skincare Education
What about the Scientific Evidences in Cosmetic Dermatology?
For me, topicals like retinoids and AHA have been studied at length and have been proven effective for most. We have done our due diligence and they have great science behind them. For retinoids, there is many studies done in the USA and worldwide confirming their efficacy. Chemical peels have also been largely documented though I would like to see more studies. For Botox and fillers, they have stood up to many well documented studies as well as having stood the ultimate test of time having been around since the 1980s. Seeing that Botulinum toxin has been used for not only cosmetic indications but also medical conditions is truly inspiring. It is gratifying to learn that both medical and cosmetic science can both enhance the health and welfare of our patients while making them look better too.
What I think we need to study more and that we need to educate our patients about is the challenge of counterfeit toxins and fillers. Where are the products coming from? The other big rising question is around the biofilm, how do we clean the skin before and after these injections?
Are there any unmet needs?
There is still a lot left to be further researched and better understood. We are not yet at the pinnacle of this when it comes to both hyper and hypopigmented conditions such as Melasma and Vitiligo. For melasma for example, we can use higher strength hydroquinone, we can recommend the use of the topical Kligman formulation, we can use peels or lasers but patients can improve and then have the hyperpigmentation return once again if exposed to heat or sun. It will be interesting to see if micro-needling can help this condition.
What is driving you everyday?
My mission has been to help my patients, the young resident in training as well as my colleagues who have not yet had the exposure to cosmetic dermatology. Today, patients are trying to look and feel better about their skin and overall health . Once they look better they genuinely feel better and have been shown in studies to perform and give back to the community due to the positive outlook they hold. For me, it is a pleasure to come in everyday and see patients that are anxious to do these treatments. My patients drive me. I love their enthusiasm, their willingness to try new things. Together, we can forge ahead to be the pioneers in this field that seems limitless. Our patients are the new frontiers driving us to go beyond simply scientific curiosity and really develop new tools and treatments for the future. In addition, my residents with their bright eyes and sharp inquisitive minds are a constant source of inspiration and motivation because of their willingness to learn and explore.
From the patients I see everyday to the residents I teach, I know that I won’t be growing old anytime soon and they keep me moving forward with a great feeling of fulfillment.
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