Providers might not often talk about sexual health with their 65-and-older patients, but they probably should, according to a recent online poll of more than 1000 adults between 65 and 80 years.

More than three-quarters of older U.S. adults think sex is important for romantic relationships at any age, and two in five are sexually active. But only 17% — about one in six — seniors reported speaking with their healthcare providers about their sexual health in recent years, according to the May 2018 National Poll on Healthy Aging, sponsored by AARP and the University of Michigan

Armed with a growing arsenal of medications, noninvasive devices and surgeries aimed at improving sexual function and addressing cosmetic concerns, plastic surgeons are among the providers helping today’s patients address sexual health issues. For example, more than 26% of plastic surgeons perform nonsurgical and surgical vaginal procedures, according to the latest statistics by the American Society for Aesthetic Plastic Surgery.

What Plastic Surgeons and Other Providers Need to Know

While many older Americans are satisfied with their sex lives, there’s room for improvement.

Researchers found 37% of respondents said they were extremely or very satisfied with their sex lives; another 36% indicated they were somewhat satisfied, according to Erica Solway, Ph.D., MSW, MPH, co-associate director of the National Poll on Healthy Aging at University of Michigan.   

“It’s interesting. When you look at people who are sexually active, 49% say they’re extremely or very satisfied with their sex life. But among people who aren’t sexually active, 29% say that they are extremely or very satisfied with their sex life,” she says. “Some people are very satisfied without being sexually active but for a lot of people sexual activity is an important part of their life and an important part of their quality of life.”

More than half of respondents said they strongly agreed or agreed with the statement “Sex is important to my overall quality of life.” But like several other poll findings, there were gender differences in the responses: 40% percent of women versus 70% of men agreed with the statement.

Among the other findings: People who self-rated their physical health as excellent, very good or good reported more interest in sex and more sexual satisfaction than those who rated their health as fair or poor.

And age does matter, according to the poll. Adults between 65 and 70 years of age were nearly twice as likely as those in their late 70s to be sexually active. One-third of those in their late 60s said they were extremely or very interested in sex, compared with 19% of those in their late 70s.

Medicine, supplements and the doctor-patient relationship

Nearly 20% of men reported taking medications or supplements in the last two years to boost their sex lives, while only 3% of women said the same. Three in four seniors taking medications or supplements to improve sexual function said the treatments were helpful. The poll didn’t ask for specifics on which medications or supplements. And the researchers didn’t ask about respondents’ having procedures to improve their sex lives, according to Dr. Solway.

It was clear, however, that the majority of older Americans don’t talk with healthcare providers about their sexual health.

“Just 17% of respondents spoke with their healthcare provider about their sexual health,” Dr. Solway says. “Interestingly, of those who had spoken with their healthcare providers, 88% said they felt comfortable having the conversations. So, I think one of the messages is that healthcare providers don’t necessarily need to worry that having these conversations might make their older patients uncomfortable.”

When researchers asked who initiated sexual health conversations, it was more often the older patient than the healthcare provider, she says.

The findings suggest that sexual health is important to many older Americans. And healthcare providers could be talking much more about sexual health, not only for older patients’ quality of life and wellbeing, but also to address sexually transmitted disease risk, potential drug interactions with medications and supplements for sexual health and more, according to Dr. Solway.

Disclosure: Dr. Solway reports no relevant disclosures.

No matter how good your marketing efforts are, the bottom line will suffer if you don’t have the time or staffing available to respond in a timely fashion. That’s according to eRelevance cofounder and CEO Bob Fabbio and what inspired the company to launch their Response Follow-up Service.

“Our patient engagement service generates significantly more responses than our aesthetic practice customers have received through other prior email blasting efforts,” Fabbio tells The Aesthetic Channel. As a result, practices have had a hard time keeping up with the response and thus, the service was born.

“Our new follow-up service does the work for businesses — chasing people down according to best practice to ultimately increase conversion and revenue,” Fabbio explains.

eRelevance data shows that up to 60% of marketing-generated patient requests never convert to revenue, due in large part to businesses with a small-sized staff that lack the time and resources to keep up with the number of responses that their marketing campaigns generate.

By successfully overcoming this critical marketing need, clients are ensured they do not miss out the finite window of opportunity when a prospective patient may be ready to schedule an appointment, according to Fabbio.

The service offers proactive response management that:

• Offloads the work required to connect with patients and prospects to get them scheduled.

• Uses best practices for effective follow-up that combines phone, email and text.

• Helps reduce revenue leakage from unscheduled patient and prospect requests.

Fabbio notes that while industry best practice is six follow-up attempts within three days of a customer reply, eRelevance data reveals that the average number of follow-up attempts across the company’s entire client base is less than one attempt per patient or prospect response.

An eRelevance suite of tech-powered follow-up services starts as low as $400 dollars a month.

“Our goal is to help small businesses grow in a more cost-effective way,” Fabbio states.

Johns Hopkins’ researchers recently published results from performing a modified muscle transplant operation to restore the ability to smile in patients whose faces had been paralyzed.

The paper, in JAMA Facial Plastic Surgery, shows the gracilis flap can be designed as a functional double paddle muscle flap for a multivector facial reanimation. 

Facial plastic and reconstructive surgeon Kofi Boahene, M.D., and colleagues performed facial reanimation for complete paralysis in 12 patients. Instead of the standard approach for people with one-sided facial paralysis of using transplanted muscle tissue from a patient’s thigh to pull up on the paralyzed side of the mouth, they did a modified procedure, using gracilis muscles placed in two or three directions. They placed the muscles at the corner of the mouth or the upper lip to the cheek and eyelid to recreate an authentic smile that shows teeth and gum on both sides of the face, according to a Johns Hopkins’ press release.

Dr. Boahene, professor of otolaryngology–head and neck surgery and dermatology at the Johns Hopkins University School of Medicine, says in a video about the procedure that his aim is to create normalcy in people’s faces who are paralyzed — meaning that if it takes a lot of muscles to create a smile, he tries to replace as many of those muscles as possible.

“Previously, the best we could hope for most of the time with surgery was a smirk, where just the corners of the mouth upturn in a smile like the one Mona Lisa has in DaVinci’s famous painting. But that isn’t a joyful, expressive smile where the lips move up, teeth show and eyes narrow. Now we’re able to really restore a true smile,” Dr. Boahene said in the press release.

The multivector design results in significant improvements in the dental display, smile width and correction of paralytic labial drape, the study authors write.

The study included 10 women and two men, ages 20 and 64 years. All experienced functional muscle recovery. Smiles that emerged post-treatment included, on average, exposure of 3.1 additional maxillary teeth and mean exposed maxillary gingival scaffold width improvement from 31.5 mm to 43.7 mm. Asymmetry was reduced from an average of 9.1 millimeters to 4.5 millimeters post-surgery.And four patients even noted dynamic wrinkling in the periorbital area.

The approach can help to restore authentic facial expressions of joy to select patients with one-sided facial muscle paralysis due to birth defects, stroke, tumors or Bell’s palsy. Most facial paralysis patients are candidates, regardless of how long they’ve been paralyzed. Other muscles can be used if patients have weak gracilis muscles, according to a Johns Hopkins’ press release.

Sponsored

This device’s patented needle cartridge features 33-gauge stainless steel, gamma sterilized needles that oscillate as high as 120 revolutions per second (7,200 rpm), allowing increased maneuverability for operators. In addition, the unit’s patented radiofrequency identification (RFID) system provides unparalleled and accurate needle penetration depth by automatically and consistently calibrating the needle cartridge with the device. Proprietary Advanced Oscillating Vertical Needle (AOVN) technology mechanically calibrates the motor speed, pressure and penetration, allowing the operator to perform scar treatment at 3.0 mm, which was not previously achievable in a microneedling device.

“Not only is Dermapen 4 loaded with the latest technology, clinical results include increased procedural efficacy, which promotes patient safety without the usual risks associated with other microneedling devices or rollers,” stated Tijion Esho, M.B.Ch.B., M.R.C.S., M.R.C.G.P., a cosmetic surgeon in London, U.K.

Dermapen is a go-to treatment modality for skin rejuvenation that works with all skin types, said Sheila Nazarian, M.D., a plastic surgeon in Beverly Hills, Calif. “When I started my practice, a lot of my patients had darker skin types, and I am also pigmented. Some laser-based devices burn the skin, and when pigmented skin burns, we turn brown. So, I was looking for something mechanical that I could offer my darker skin type patients that wouldn’t produce pigmentation disorders. It also
does a great job on acne scars.”

“My first reaction was ‘wow’; it is like having a Knight Rider in your hand,” Dr. Esho commented. “You have so much precision over a greater area. I fell in love with it, not just because of the design, but because of how easy the glide was and how powerful it is in comparison to other devices.”

According to Andrew R. Christie, M.D., a medical trainer and health science specialist in Paris, France, “Dermapen 4 is the fastest automated pen on the market. It has 1,920 microchannels per second. Nothing beats that. You can work a lot faster, and it makes for a more profitable procedure. Ultimately, the speed of treatment also makes it more comfortable for the patient. I can treat a full face in around four minutes and maximize the use of puncture channels that I’m actually working with, as well.”

Practical for all Skin Types

For years, Anne Wetter, M.D., a dermatologist in Stockholm, Sweden, was looking for a device that could work well with the skin’s structure and various types of scars. She had previously used a dermaroller to treat hair loss and acne scars.

“When I moved to the Dermapen, I found that it used a completely different technique: an array of needles that worked very close to the skin in an organized pattern like a fractionated laser, but without the adverse effects associated with light energy,” Dr. Wetter shared.

In Dr. Nazarian’s experience, Dermapen is a very useful tool for collagen production in the face. “What I explain to the patients is that we are basically tricking the face into thinking it is injured. We’re creating all the small microinjuries that help send in the fibroblasts, which are the collagen producing cells. And you start boosting collagen all over the place. It creates little microscars so that the wound can heal.”

Dermapen 4’s ability to treat faster and deeper is a huge benefit, added Dr. Esho.

“With the older pen, the penetration would reach 2.5 mm, but Dermapen 4 can reach 3.0 mm. Obviously, when it is set to that depth you won’t be able to glide, but you have the functionality to slow the rate of puncture at particular sites, which is amazing,” he said.

Enhanced Ergonomics Improve Efficiency

In addition to technical enhancements, Dermapen 4’s handheld ergonomics are a major advancement over earlier versions.

Improved balance and weight distribution require less pressure to achieve needle contact on the skin, which also reduces or eliminates operator fatigue and discomfort. The new device also offers integrated Bluetooth connectivity, allowing practitioners to wirelessly update Dermapen 4’s calibration tables and firmware, which secures the physician’s investment into the future as it can be continually upgraded. Additionally, it now incorporates a rechargeable battery in addition to the standard power cord; and features an onboard real-time display.

“I love Dermapen 4’s ergonomic design,” Dr. Esho expressed. “The LCD screen allows for the very visual way we work these
days, and the ability to see what power levels are being used directly in front of us makes the process a lot more responsive than when we had to turn the dial on the older pens.”

The versatility of having both corded and battery power is highly desirable, Dr. Christie added.

“I do a lot of traveling, so I’m not always that familiar with the surroundings of the treatment room that I’m in. In addition, you now get the same level of power from the battery as what you get from the main cord,” he pointed out.

Protocols for Scar Treatment

A traditional treatment modality of microneedling addresses scars, and this is where Dermapen 4 really shines, Dr. Esho stated.

“We have a lot of patients suffering from acne scarring, and there is a big psychological connotation associated with this indication. These patients become depressed and very anxious because they have already tried several other therapies, including peels and skincare products, and the scarring hasn’t improved,” he explained.

Dermapen 4 offers dedicated treatment protocols for scar revision, including deep, atrophic scars, striae and post-acne scars.

“It is important to look at the origins of how people have worked on scars over the last 30 or 40 years,” Dr. Christie noted. “I like the fact that Dermapen 4 has this specific scar treatment setting. I have utilized some of the pioneering techniques of subcision and some angled techniques that get to the very core of hardened hypertrophic scars. A benefit of this device is that it includes some stamping innovation for changing the angle so that I can minimize downtime and pain to the patient while maximizing needle penetration.”

Beyond scar procedures, Dermapen 4 can be customized to expand the number of indications that can be treated.

“A single needle cartridge stretches over a large surface area, which makes the treatments very affordable for patients coming in to get a full-face procedure from the forehead down to the chin,” noted Dr. Christie. “I can also treat the neck, décolletage, backs of the hands and thighs in the same session while still using the single needle cartridge. I just change the glide or the products I’m infusing into the skin for these areas. I like that flexibility. In addition, there’s no scabbing, grazing or bruising.”

Versatile and Combination Applications

“Of my patients, 99% are eligible for procedures using Dermapen, and I like that flexibility,” Dr. Esho reported. “It means I can treat the face and other body areas in a single session. This device gives the practitioner so much range in depth. There’s physically nowhere that I cannot use it.”

The company is also very open to helping practitioners create new treatment protocols, noted Dr. Esho.

“I’ve engaged in a dialogue with the developers to suggest how to make the product even better. They have really responded well, and I’d say they have included nine out of the ten new features and functionalities that I wanted in Dermapen 4 before I even mentioned them; and surprised me with a few others,” he said.

Part of the dialogue has involved new ways to employ Dermapen in combination protocols. Users have found that the system works synergistically with various modalities such as energy-based systems and other therapies.

As stated by Dr. Esho, “We are combining the pen with more treatment modalities. For instance, I will combine the Dermapen with a fractional laser to achieve some amazing results. In the future, we will move away from single modality pens. I think the trend is towards dual or triple modality devices.”

Dr. Christie agrees that microneedling has logically moved away from straightforward collagen induction into novel aesthetic modalities and unexpected areas of medicine. “The challenge with microneedling is that it has always been associated with collagen induction therapy, but we must remember that a fibroblast produces not only collagen and elastin, but also hyaluronic and glycol proteins,” he said. “I see so many new innovations with microneedling. It has certainly developed above and beyond just scar tissue treatment.” 

Another area where Dermapen 4 pushes the envelope is in tattoo removal where integration of the separate Dermapen Tattoff Activator Infusion Device, and a new Tattoff Needle Cartridge allow for non-laser, all color tattoo removal that can be used alone or combined with standard laser-based techniques to achieve full tattoo clearance. Furthermore, the device’s fast treatment times can be helpful for clinics that experience patient attrition due to the number of sessions needed to achieve full clearance using other modalities, such as lasers.

“Look at traditional tattoo removal using a Q-switched laser,” Dr. Christie began. “It is very easy for a patient to turn up for a single appointment, but it can be more difficult to get them to come in for subsequent sessions. It could be because the treatment is painful or too time consuming. Dermapen eliminates many of these kinds of problems.”

Whether practitioners use Dermapen as a standalone procedure or in combination with other modalities, “it is far quicker and effective, as well as more comfortable and affordable for the patient, and they come back,” Dr. Esho stated. “I look at the modern patient and they are a unique phenomenon. They want the world, they want it now and at minimal cost. They also want it with minimal pain and without any downtime at all.”

“Practitioners will tend to combine microneedling with their own serum or growth factors, which can be more affordable to patients, especially when utilizing the unique protocol products developed specifically for microneedling,” Dr. Nazarian reported. “Patients see a glow to the skin and a little bit of tightening or shrinkage.”

Dermapen 4 can infuse PRP, mesotherapy and other serums utilizing the company’s new Meso-Infuse Needle Cartridge, which promotes pinpoint delivery and precision. “So, we’ve seen great success in dealing with acne, melasma, hyperpigmentation, hypopigmentation, even alopecia. Therefore, microneedling, and the Dermapen 4 in particular, are quite versatile,” Dr. Christie continued.

PRP Infusion Applicator

Dr. Esho noted that Dermapen 4’s implementation of PRP infusion is novel.

“One thing I discovered about delivery of PRP is that when you use it with a syringe it just wants to go everywhere,” he said. “When that would happen I kept thinking, ‘why can’t there be a way for the PRP to stay inside the chamber and made available only when it is needed?’ One of the new Dermapen 4 needles actually has an applicator that allows you to pump the PRP into the microneedling chamber through a tube and directly into the skin, so that the fluid is confined to a specific target area. It is such a simple alteration, but it is ingenious. I can see a lot of practitioners using that, including myself.”

In Dr. Christie’s experience, using the Dermapen to infuse PRP takes less time than other methods, “And that translates into more money for me,” he said. “I’ve had great success with PRP, taking into consideration the time needed to administer a single technique. Also, when it is at that level of treatment time, it increases comfort for the patients.”

Responding to Contamination and Cost Concerns

With microneedling, an important concern among both patients and practitioners is needle sterility. Dermapen 4’s gamma-sterilized cartridge and needles include retention valves that alleviate the build-up of procedural pressure within the needle cartridge. The new cartridge also has an anti-contamination management system built in to every unit, guaranteeing there will never be any fluid back flow into the device itself. These innovations remove the risk of cross-contamination while confirming pressure-free contact with the skin during procedures.

According to Dr. Christie, “With rollers we would reuse them. I’ve never been a fan of that practice, and thankfully we saw the industry advance into automated devices. One of the first things I would look at was making sure the needle cartridges were sterile and only single use.”

“As microneedling developed into what you could say is a blood treatment and for infusion of mesotherapy and PRP, etc., one concern has also been related to protection for the device and the patient,” Dr. Christie continued. “My question was, ‘so where is that fluid actually going? Is it going into the pen or onto the pen?’ Dermapen 4 contains mechanisms to guarantee that there is no contamination. Fluid cannot get into the needle cartridge, which means there is no compromise in quality or safety from patient to patient, and it is less expensive for the practitioner, too.”

Furthermore, some of the microneedling-related expenses are affordable when compared with other modalities, Dr. Christie added.

“The nice thing about microneedling is the cost of consumables is quite low,” he stated. “If I can treat a whole face in four minutes, then theoretically I could see more than four patients an hour. The cost of that treatment is just the needle cartridge. This translates into an incredibly small investment. We’re not paying the high cost of a laser or a vial of filler. In my  view, it is the easiest and quickest way for a practitioner to add revenue.”

In addition, DermapenWorld cares for its customers very well, expressed Dr. Wetter.

“The company’s technical support is excellent. They not only listen to the customer, I do a lot of clinical studies and they are very open to helping me. For instance, I’m doing a study right now about how to stimulate collagen growth in the décolletage area for skin rejuvenation. They support this work 100% and make it very easy for clinicians to advance and create new Dermapen protocols.”

Overall, Dermapen is poised to advance microneedling therapy in innovative ways, said Dr. Esho.

“My patients that have had microneedling procedures in the past and now receive Dermapen treatments comment on how easy it is on their skin, how easy the glide is and the quality of results,” Dr. Esho expressed. “If I didn’t believe in this technology, you could pay me all the money in the world and I wouldn’t use it. I’m getting great results with Dermapen.”

As stated by Dr. Nazarian, “I'm very happy with microneedling technology. It offers a very quick, easy procedure. Also, microneedling with PRP is on everybody’s mind right now. Whenever I give my talks about return on investment on devices, I always say microneedling systems will get paid off quicker than any other device you’ve ever purchased.”

Treatment with pulsed dye laser treatment prior to surgical excision does not improve the appearance of surgical scars, according to the results of a pilot study presented at the American Society for Laser Medicine and Surgery annual conference last month in Dallas.

The 595nm pulsed dye laser (PDL) can be used after cutaneous injury to improve the appearance of scars, so researchers wanted to test whether use of PDL prior to surgical excision can prevent scar formation. 

The study included ten patients aged 18 to 65 due to undergo surgical excision for any reason. Immediately before excision, half of each surgical site was treated with a 595nm PDL at varying fluences and pulse durations to achieve an endpoint of transient purpura. The other halves of the sites (controls) received PDL at minimal fluences or were left untreated. Patients and blinded observes were asked to assess the scars at two, four and six weeks, and 8-12 months after the procedure, and digital photographs of the surgical sites were also taken.

There was no clinically significant difference between the treated sites and controls, according to the patient assessment scores at week six (p=0.8798) and month 8-12 (p=0.8773) and the blinded observer assessment scores at week six (p=0.9378) and month 8-12 (p=0.3341).

Although not statistically significant the blinded observers rated the treatment sites worse in appearance than the control sites, whereas patients rated the treatment sites’ appearance as better.  There were no significant adverse events, although three subjects experienced surgical wound dehiscence.

PDL had been expected to change the appearance of the scars based on the theory of selective photothermolysis — that PDL targets oxyhemoglobin the predominant type of hemoglobin present in erythematous and hypertrophic scars — the expectation was that PDL would prevent the formation of excessive vascularisation during the scar formation.
Catherine DiGiorgio, M.D., a fellow in Clinical Laser and Cosmetic Dermatology at Wellman Center for Photomedicine at Massachusetts General Hospital in Boston, told the conference that while the results indicated that laser treatment before the surgeon doesn’t really change the outcome of the scars, the question is why? “Are we limiting the inflammatory response or are we increasing the inflammatory response?” she asked.

She speculated that PDL was increasing the inflammatory response. There wasn’t a significant difference in any of the variables looked at, she pointed out, other than the treatment sites a different color to normal skin when compared with controls.

In terms of the limitations of the study, four patients were lost to follow up, and the majority of the surgical excisions that were performed were performed on the trunk. “We know that excisions performed on that area of the body have poor outcomes to begin with,” DiGiorgio said.

REFERENCE
“Pulsed Dye Laser Treatment Prior to Surgical Excision,” Catherine M. DiGiorgio. American Society for Laser Medicine and Surgery annual conference, Friday, April 13, 2018, Dallas.

Cosmetic dermatologist Paul M. Graham, D.O., noticed a side effect after using the radiofrequency Pelleve device (Hologic) to treat periorbital lines. It appeared patients were emerging from the noninvasive treatment with higher eyebrows.

So, Dr. Graham and David H. McDaniel, M.D., investigated whether it made sense, clinically, to use Pelleve as a brow lifting option. The study of 30 male and female patients looking at safety and effectiveness of radiofrequency for brow lifting, was presented in April 2018 at the 38th Annual Conference of the American Society for Laser Medicine & Surgery (ASLMS) in Dallas.

“Radiofrequency has been used for a long time — usually for facial wrinkles and skin rejuvenation,” Dr. Graham says. “…but our study demonstrated an innovative new nonsurgical, no-downtime, radiofrequency procedure for nonsurgical brow lifts.”

Study subjects had brow laxity and were between ages 35 and 65, with Fitzpatrick skin types ranging from II to VI. They received five treatments with the 4 MHz monopolar radiofrequency device at four-week intervals, on the forehead and in the periorbital area.

Researchers used Pelleve’s existing attachments — FDA cleared for other indications — for off-label brow lifting. They used both the 10 & 15 mm hand piece to treat the forehead and eye area, targeting an epidermal temperature of 40 to 44 degrees centigrade. Average treatment time was 20 minutes, according to the abstract.

“We treated the forehead, which contains the orbital retaining ligament…. Then we treated the upper and lower eyelids,” he says. “What sets that device apart is the small hand piece and the articulating arm. The hand pieces move and are able to conform to the treatment area. It’s not just one rigid rod that we’re putting on the skin. It has an articulating end to it, where we’re able to put it in an area of concavity or convexity, and it’s able to conform.”

According to results, 81% of study participants responded to treatment, according to the average eyebrow height measurement.

“We also found that 82% of subjects were satisfied at 120 days of follow-up,” Dr. Graham says.

In some cases, the brow lift radiofrequency treatment resulted in a noticeable skin contraction right after the first treatment.

“The immediate changes were temporary. When we brought the patients back, though, after a cumulative amount of treatment, that’s when we were able to see that eyebrow lift,” Dr. Graham says.

Side effects included erythema and edema for up to 24 hours post treatment.

“Twenty-four hours is an overstatement. Most patients are not even red when they leave the office,” he says.

In the bigger picture, radiofrequency brow lifting is among the more conservative treatments that cosmetic physicians perform, according to Dr. Graham.

“It’s for patients looking for skin tightening and subtle brow lifting, but don’t want to undergo the downtime associated with more invasive lasers or procedures, such as surgery,” he says.

NEXT: The RF Brow Lift in Practice
 

Dr. Graham says using the radiofrequency device to lift brows is a viable alternative to ultrasound for the same indication. And while patients say that radiofrequency brow lifting feels like a hot stone massage, ultrasound treatment can be painful, he says.

Radiofrequency might also offer a different alternative than using neuromodulator injections to relax the forehead and lift the brows, according to Dr. Graham.

“… people looking more for a brow lift with [neuromodulators may get an unpredictable brow lift, meaning we don’t know how far that [neuromodulator] is going to diffuse. There’s no exact location to inject that’s going to give a defined amount of lift. It’s all based on how active the patient’s lateral frontalis muscles are and how much depressor movement or pull-down there is from the orbicularis oculi muscles,” he says.

This radiofrequency device tested in the study creates heat in the skin and has been shown to cause collagen to contract and stimulate wound healing and new collagen, thus it lifts the brows, according to the dermatologist.

Since conducting the study, Dr. Graham says the Virginia Beach, Va., practice at which he is completing his fellowship, has been promoting the use of Pelleve for brow lifting to the younger set.

“If we’re using this device on someone with a lot of photodamage and skin laxity, you’re not going to see that effect, because we have to harness that collagen percentage in the skin and that skin elasticity to get that lift,” he says. “This is a good treatment for patients in their 30s and 40s with minimal to early photodamage.”

The vast majority of online breast augmentation reviews in a recent study were positive. But the 12.5% that were negative were characterized as more verbose and only half listed “poor aesthetic outcome” as a driver for dissatisfaction. Negative reviewers often pointed out that they didn’t think surgeons listened, were competent or acknowledged or took responsibility for poor outcomes.

Another surprise? Close to 40% of the negative reviews were written by people who didn’t go through with breast augmentations by the surgeons they reviewed. Rather their impressions of rudeness, curtness and consultation brevity prompted them not only to not proceed with breast augmentation surgery but also to write negative reviews.

A Matter of Why

The study is the first comprehensive analysis of factors that drive online breast augmentation reviews, according to the authors.

In the study, researchers analyzed patient ratings in 1077 breast augmentation reviews on Google, Yelp and RealSelf. Reviews were from the metropolitan areas of New York, Los Angeles, Chicago, Houston, Philadelphia and Miami.

Having a better understanding of why patients write positive and negative reviews is important, given that online reviews are growing in popularity and are powerful ways in which today’s consumers do or do not recommend surgeons. One-third of Americans indicate they are greatly affected by online reviews, and nearly 60% think of online reviews as at least somewhat important, the authors report.

The online review trend is expected to intensify. Online reviews for breast augmentation alone have grown an average 42.6% annually from 2011 to 2016, according to the study.

Anatomy of a Positive Review

More than 87% of the reviews studied were positive, which the authors defined as four or five stars on Google and Yelp, or a Worth It rating on RealSelf.

The top five most cited reasons for patient satisfaction among the 935 positive breast augmentation reviews were:
• A good aesthetic outcome (643)

• A good bedside manner (573)

• A friendly and/or helpful office staff (520)

• The surgeon’s expertise (405)

• Provider listens to patient (332)

Reasonable cost was the least likely reason for patient satisfaction in the study.

And unlike the negative reviewers, all of the positive reviewers had breast augmentations with the surgeons they reviewed.

Dissecting Negative Reviews

Researchers defined negative reviews as a one- or two-star rating on Google and Yelp or a Not Worth It rating on RealSelf. The top five reasons among the 142 negative reviews:

• Poor aesthetic outcomes (71)

• Provider doesn’t listen to the patient (57)

• Lack of competency (50)

• No acknowledgment/responsibility for a poor outcome (47)

• Cost too high (40)

Asymmetry and implant malposition were the most common factors associated with poor aesthetic outcomes. But the researchers also report seeing recurring disagreement between surgeons’ and patients’ perceived outcomes, where surgeons were happy with the work but patients weren’t.

This discordance between how patients versus physicians perceive aesthetic outcomes has been demonstrated in the literature. By misinterpreting aesthetic outcomes patients might be more likely to think surgeons aren’t taking responsibility or not listening, the authors write.

We Can Overcome

In a secondary analysis, researchers found aesthetic outcome, surgeons’ perceived skills and surgeons’ attentiveness had the most impact on patient satisfaction.

“… reviewers often expressed the sentiment that even though they encountered negative experiences, they ultimately left a positive review because they liked their aesthetic result,” according to the authors.

When they looked at whether a poor aesthetic outcome could lead to a positive review, chances were slim but it was possible. Less than 6% of reviews that mentioned a poor aesthetic result were positive. Further analysis revealed that these patients left positive reviews because they had realistic expectations that their outcomes could be poor. And because of surgeons’ proactive follow-up, they were able to overcome a poor outcome in their reviews.

In the end, a good aesthetic outcome remains critical to and protective of a surgeon’s online rating, even if the patient had positive and negative experiences with a practice, the authors write.

Tips for Better Communication

David B. Sarwer, Ph.D., author of an accompanying editorial and associate dean for research in the College of Public Health at Temple University, writes that, in several respects, negative reviews are more informative than positive reviews to plastic surgeons and their practice staffs.

“Analysis of negative comments suggests a couple of areas that even high-functioning, successful practices should target in an effort to further improve overall patient experience and to minimize undesired patient experiences,” according to Dr. Sarwer, who has been studying the psychosocial aspects of cosmetic surgery for more than 20 years.

One observation Dr. Sarwer says he has made as a psychologist working with plastic surgery patients pre- and post-surgery is that most patients minimize the risk of undesired outcomes.

There are things surgeons and patients should communicate effectively to avoid misunderstandings, unrealistic expectations and more. 

“… I think that new patients should be able to articulate and cosmetic surgeons understand three fundamental issues,” Dr. Sarwer writes in an email to The Aesthetic Channel.

1. “Patients should be able to describe their concerns about their appearance specifically and in a manner where the surgeon can both see the feature of concern and understand why it is of concern,” according to Dr. Sarwer.
It’s more useful, for example, for a patient to say, “I don't like how my crow’s feet make me look older than I am,” and for the surgeon to be able to see those wrinkles, than for a patient to say, “I look old,” leaving the surgeon to guess what feature is of greatest concern.

2. “Patients should understand and be prepared to explain their motivations for a given procedure,” Dr. Sarwer writes. “They should want a procedure to not only improve their outward appearance, but also improve their body image and self-esteem. Patients who are motivated by external factors, such as perceived pressure from a current or future romantic partner, may be setting themselves up for disappointment.”

3. “Patients should have realistic expectations of the impact of the procedure on their daily lives,” he writes. “While some surgical procedures can be quite noticeable to others, many of the minimally invasive procedures may not be noticed by others. Patients should not be disappointed if others do not notice the change in appearance and should remind themselves that the procedures are designed to improve their body image and self-esteem. The procedures may not impact social interactions with others.” 
 

New scientific research conducted by Estée Lauder suggests that the scalp aging may closely parallel facial skin aging and maintaining healthy hair requires preventive care for both hair follicle and the surrounding tissue.

“Many of the haircare concerns of our guests, such as thinning, color change and a decrease in luster, are related to aging,” says Alison Pawlus, Ph.D., a senior research scientist at Aveda (Minneapolis, Minnesota), an Estée Lauder company that funded the research.

“While many changes with age have a strong genetic component, there is growing support that many nongenetic factors can influence healthy aging,” Dr. Pawlus tells The Aesthetic Channel. “For instance, hair health is dependent upon not just the hair follicle itself, but the surrounding tissue as well, both of which can be impacted by both internal stresses and external/environmental stressors.”

Dr. Pawlus, who presented findings at the 2018 International Investigative Dermatology (IID) meeting in Orlando, Fla., in May, was surprised by not only how much the scalp skin changes with age, but by how soon changes in the hair follicle become visible. “Histologically, we found that scalp aging closely parallels facial skin aging, with the same smoothing out of the rete ridges and changes in collagen.”

Additionally, the researchers observed changes in a number of matrix metalloproteinase enzymes and other extracellular matrix proteins, which partially explains some of their histological findings.

“I had anticipated that the thick terminal scalp hair would provide protection to the scalp and we would see a more delayed appearance of skin aging relative to facial skin. But this was not the case,” Dr. Pawlus states.

One of the major takeaways of the research is that in order to maintain optimal hair health, “We need to think of the scalp more like we do facial skin and give our scalp the attention that it needs if we want to maintain optimal health of our hair,” Dr. Pawlus explains.

Likewise, not only is it important to protect the scalp from environmental stressors, “but we need to do this starting at an early age, as changes start happening within the scalp before they are noticeable in the hair,” Dr. Pawlus says.

The company’s ongoing research supports the use of products with adequate concentrations of antioxidants that are particularly beneficial against a number of stressors.

“Actives that target some of the age-related changes, such as reduced blood flow and hormonal changes, are also important,” Dr. Pawlus says.

Furthermore, a healthy scalp barrier is paramount. Dr. Pawlus recommends avoiding extremes like washing too frequently with harsh detergents or not cleansing sufficiently.

A revolution is taking hold in medical aesthetics. Increasingly, the use of stem cell-based therapies is starting to replace the need for more invasive surgery, as well as drug or chemical-based treatments.

The use of a patient’s own tissue and blood for repair and regeneration appears poised to transform the entire medical industry – specifically the dynamics of aesthetic medicine – presenting new opportunities for practice growth.

New approaches with stem cells are being explored in fat grafting and volumization technologies; platelet-rich plasma (PRP); platelet-rich fibrin (PRF) matrix; stromal vascular fraction; growth factors; and other tissue- and cell-based techniques; are starting to replace the need for more invasive surgery, as well as drug or chemical-based treatments.

“Regenerative medicine is the future,” stated Ryan Welter, M.D., Ph.D., CEO and medical director of Regeneris Medical (Attleboro, Mass.).  “All of these therapies are starting to converge into one specialty of regenerative medicine that utilizes all facets of scientific technology to repair damaged tissue. If we can achieve this, then anything is possible. This is where all of medicine will merge.”

Understanding the importance of this rapidly expanding field, The Aesthetic Show (TAS) will offer multiple courses and scientific workshops focused on the major evolving trends within the field of regenerative aesthetics.

The first course is the Regenerative Aesthetics Symposium, which will take place during the pre-show education program on July 5, 2018. As an expert in this field Dr. Welter, will co-moderate this full day symposium, in which expert faculty will provide an in-depth examination of the latest trends, clinical findings and techniques, as well as how to use these revolutionary new procedures to expand your practice.

Topics covered include a market outlook, microfat and SVF applications, treatment of androgenetic alopecia, advancements in amniotic stem cell procedures and cell-assisted lipotransfer.

“Regenerative medicine is becoming more mainstream in our field,” noted Tess Mauricio, M.D., a dermatologist, regenerative aesthetics specialist and TAS faculty. “The pre-conference symposium is going to be comprehensive, and TAS is realy the only place where you can obtain this kind of information.”

The Aesthetic Show will also cover regenerative aesthetics during the main program starting with the opening session: The Aesthetic Visionaries on Friday, July 6. Dr. Welter will discuss the coming of age of regenerative aesthetics and Charles Runels, M.D. will discuss lifting techniques using PRP.

In addition, The Regenerative Aesthetics Revolution session on Saturday July 7, will be entirely dedicated to this rapidly growing, evidence-based anti-aging therapy. Featuring top experts discussing the most current and relevant treatments, technologies and practical applications. Notable topics and presentations include PRP vs. Surgical Face-Lift, The Role of Senolytics in Regenerative and Aesthetic Medicine, Renuva Adipose Matrix Applications and Techniques and The Fastest Ways to Adapt Regenerative Medicine into Your Practice.

The learning doesn’t end there. There will also be multiple scientific workshops on Friday and Saturday focused on various regenerative aesthetics products utilizing PRP, PRF, growth factors and stem cells.

Aesthetic treatments will no longer revolve around just a single product or device, noted Farhan Taghizadeh, M.D., a plastic surgeon in Phoenix, Ariz., and TAS faculty member who will present during the Regenerative Aesthetics Symposium. “It is the integration of lifestyle education, in addition to these products and therapies that we already use.”

Interested in expanding your knowledge and experience with regenerative aesthetics, and incorporating these exciting new therapies into your practice? Learn more about what The Aesthetic Show 2018 has to offer!

Ready to register? Click here.

When explaining the skin barrier and its importance to patients, more help is needed from the industry. For instance, a simple “Got Milk?”-type slogan that makes you immediately think of the skin barrier has not yet emerged. Physicians and scientists need a straightforward way to describe the skin barrier without getting too technical.

As described by Alice Prethima Michael, M.D., founder and managing medical aesthetic physician at Ageless Medi Spa (Kuala Lumpur, Malaysia), “The skin barrier, or stratum corneum, is the outermost layer of the skin, which provides critical defensive functions, including protection against all sorts of damage such as pathogens, major temperature changes, etc.”

In addition, the skin barrier is the first line of defense against the penetration of ultraviolet light, filtering much of it before it reaches deeper into the skin, which is where most of the pigment or ‘melanin granules’ reside,” she continued. “Melanin is, in fact, only a second line of defense against ultraviolet rays. Overall, any kind of disease condition will only worsen if the skin barrier is not maintained.”

On a deeper level, the skin barrier is composed of two different structural components, stated Nantapat Supapannachart, M.D., a cosmetic dermatologist in Bangkok, Thailand. “The corneocyte and inter-corneocyte lipids are arranged together with the cells providing structural support and acting as a hydrating reservoir for adequate enzyme processes,” she explained.

“The lipid bi-layer, a thin polar membrane made of two layers of lipid molecules, provides the boundary between the hydrophobic and hydrophilic interface, which regulates what goes into and comes out of the skin,” Dr. Supapannachart added. “Disturbing the function of this layer can have a significant effect on skin quality.”

According to Joel Schlessinger, M.D., a cosmetic surgeon and dermatologist who runs the Advanced Skin Research Center in Omaha, Neb., “The skin barrier is the difference between healthy skin and damaged skin. It is probably something that most dermatologists don’t think about at all. However, the reality is that the skin barrier is a very important concept to articulate to patients.”

Many people have been schooled to understand that the skin has seven layers," stated William Philip Werschler, M.D., F.A.A.D., F.A.A.C.S., a dermatologist and assistant clinical professor of medicine/dermatology, at the University of Washington School of Medicine in Spokane, Wash. “However, this really only refers to that millimeter or so of thickness of the epidermis,” he said. 

“When we think of the skin, meaning we in the industry, what we are mostly thinking about mostly is the dermis and the collagen,” Dr. Werschler indicated. 

The skin has several functions, and the first is the skin barrier, said dermatologist Carl R. Thornfeldt, M.D., the developer and founder of Episciences, Inc. (Boise, Idaho).

“This permeability barrier keeps the aqueous internal environment protected from the dry external environment, which includes all the toxins and contaminants in our environment,” he expressed.

Armed with an anatomical and technical understanding of the skin barrier, practitioners must then find a straightforward way to describe it to patients without getting too scientific. Dr. Werschler thinks physicians should consider how they might explain the skin barrier to a child. “I use a simple brick and mortar analogy,” he described. “The bricks are the skin cells and the mortar holding them together is the intercellular cement substance. At the bottom of the barrier you have the retaining wall foundation, otherwise the bricks would fall apart.”

Furthermore, there are specialized structures in the epidermis, Dr. Werschler continued.

“Imagine every ten bricks or so you place a decorative brick. Those are the melanocytes,” he said. “Your pigmentation is in the epidermis, and you are constantly shedding your pigmentation, as well. In addition, you can also have pigmentation after injury.”

Another visual way to explain the skin barrier is to conjur up the image of a shield, said Peter Lio, M.D., a clinical assistant professor of dermatology & pediatrics at Northwestern University Feinberg School of Medicine, and founding director of the Chicago Integrative Eczema Center (Chicago, Ill.).

“Our skin is designed to protect us from things in the world. When it is healthy, it acts like a shield for our skin. If the skin barrier is not working correctly, your skin can become inflamed and uncomfortable,” he illuminated.

As tissue migrates to the surface it matures and differentiates to form a shield or a brick-and-mortar type of barrier, Dr. Thornfeldt agreed.

“It has lipids and oils in an exact ratio and specific oil groups are required for function in a precise pattern,” he said. “When the skin barrier is damaged, the three barrier oils – cholesterol, ceramides and free fatty acids – are the first things made by the body to repair itself. Notably, 50% of that has to be linoleic acid and there are some other fatty acids, as well.”

A key skin barrier function is the connection between cells within the stratum corneum and epidermis called “tight functions,” stated Nikolay Turovets, Ph.D., CEO of MediCell Technologies, LLC (Carlsbad, Calif.), a developer of stem cell- related therapies.

“The tight junctions are complex structures of very specific proteins and extracellular matrix molecules, produced by skin cells. If the connections are well-established, in other words there are no gaps between cells, then the skin will hold water and it will not be released by the skin,” he explained.

At the bottom of the epidermis, the dermal-epidermal junction (DEJ) is the tough layer between the epidermis and the underlying dermis. “It is made of collagen and gives us the strength to our skin, noted Dr. Werschler. “It is in that layer of the collagen that you have blood vessels, nerves and all the action of living tissue.”

On the other side of the DEJ, the basal or “basement layer” could be considered as the bricks sitting on top of the foundation. Those cells divide, and as they do, they move up to the skin’s surface to be shed.

Of all the damage possible to the skin barrier, at the top of the list is the environment, Dr. Prethima Michael said. “That is why we often see patients with photo-aging, which is characterized by wrinkles, pigmentation, rough skin and loss of skin tone. When accumulated in our bodies, environmental toxins, such as lead, can weaken the skin’s integrity, as well as promote darkening of the skin.”

In addition to the attacking environmental elements, infection can disturb the skin barrier, as well, Dr. Schlessinger indicated. For example, if a person ends up with a fungal infection, it can impair the skin barrier allowing bacteria to enter, which further impairs the skin barrier.

“What we have found is that with nearly every skin condition we deal with, from psoriasis, eczema to even poison ivy, the skin barrier ends up disturbed and bacteria swoops in and takes a further toll,” he said.

When that complex skin barrier requires protection, a wide range of products are at hand. According to Dr. Schlessinger, anything that improves the skin barrier is, by design, going to take into account a number of factors, the primary of which is moisture and any disease conditions that are impairing the barrier.

“That doesn’t mean that in order to improve the skin barrier you have to have creams,” he said. “Sometimes improving the skin barrier is nothing less than improving the biome on the skin, which is the collection of bacteria that is out of whack or in some way out of sync with a healthy skin barrier.”

There are many products that claim to address the skin barrier functions, so it can be overwhelming for both clinicians and patients, Dr. Lio admitted.

“Many people are interested in the ‘best’ moisturizer or barrier repair cream, but it is all relative to the indication,” he said. “A more apt analogy may be to cars; for example, a Ferrari might be the ‘best’ car by some measure, but if you are hauling a trailer, it would likely be among the worst. With moisturizers, we are blessed with a huge array of possibilities and formulations.”

Dr. Lio often meets patients that have tried several products and weren’t happy or experienced adverse reactions to them. “Part of my specialty is to read the skin and observe carefully so that I can pick a product that will meet patient needs, both in medical and cosmetic patients. I rely on over a dozen favorite products depending on the skin type, body location,
age, and type / severity of skin condition,” he said.

In Dr. Turovets’ experience, some skin moisturizers that claim to protect the skin from water loss and preserve the skin’s barrier actually provide only a masking effect. “After applying moisturizers on the skin, we may feel that it is hydrated, but that is nothing more than a feeling. Our actual skin barrier remains damaged and unrepaired.”

Worse yet, some skincare ingredients will actually harm rather than help repair the skin, Dr. Thornfeldt added. “It is the retinols, propylene glycols and lactic acid that damage the skin and activate varying degrees of inflammation. Physicians need to know about products that help repair and even optimize the skin barrier.”

“It is the retinols, propylene glycols and lactic acid that damage the skin and activate varying degrees of inflammation,” explained Dr. Thornfeldt. “Physicians need to know about products that help repair and even optimize the skin barrier.”

Only barrier balancing and repairing creams can genuinely help restore the skin barrier, Dr. Turovets concurred. “These creams restore barrier function by repairing cell membranes, and they may also contain ingredients, such as defensins that restore tight junctions,” he said.

Improving the skin barrier can be as simple as using the correct topical or oral antibiotic to reestablish the skin and its cohabitants, Dr. Schlessinger stated. “We see a lot of people walking around with a skin barrier that is disturbed, and via a simple regimen they could re-epithelize the skin and end up with a healthier and more robust epithelium.”

Most of the products traditionally used on the skin barrier have been abrasive in nature, expressed Dr. Werschler. “These include microdermabrasion, light chemical peels, alpha hydroxyl acids and RetinA to some degree. All of these have been designed to exfoliate the skin one way or another, to thin out the stratum corneum for a smoother, prettier air corneocyte interface, which makes the skin look healthy and glowing.”

Some available therapies make use of microneedling and infusion to perform pre- and post-procedure skincare treatments, Dr. Werschler stated.

“A more accurate term to use is diffusion rather than infusion. Developers should use a fixed depth and accurate delivery system. If an energy-based system is involved, then it may involve damage to the skin via laser or some other method to strip the skin and deliver products into the different layers of skin,” he explained.

“Energy-based systems work by damaging the skin barrier,” Dr. Thornfeldt said. The key with those systems is you want to deliver a lot of ingredients before inflammation in the skin kicks up. The problem with a lot of the nutrients you put into the barrier is that they are proinflammatory, so they accelerate the inflammation. The patient will get plumping for one or two days, or until the inflammation goes down. However, some of what you’ve put in there will also damage the skin and destroy the extra cellular matrix.”

Dermalinfusion from Envy Medical, Inc. (Long Beach, Calif.), is an example of such a product that applies an advanced, non-invasive skin resurfacing technology to perform exfoliation and extraction, as well as accommodate the infusion of condition-specific serums to improve skin health, function and appearance. This system offers customization features that result in immediately noticeable improvement in volume, hydration, tone and texture. As with other dermal infusion-type products, it can also be used in conjunction with other non- and minimally invasive procedures to enhance results.

Among other energy-based microneedling solutions, Secret RF from Cutera, Inc. (Brisbane, Calif.), is a novel fractional RF-based microneedling system for tissue coagulation and hemostasis, designed to stimulate and remodel collagen and address the common signs of aging. Secret RF delivers precise, controlled energy at various depths to target patients’ most common skin concerns – fine lines, wrinkles, scars, photo-aging and striae – on the face and body with limited-to-no downtime.

Similarly, Vivace RF from Aesthetics Biomedical, Inc. (Phoenix, Ariz.), combines targeted microneedling with RF-based energy to help stimulate and tighten the skin. The system reportedly minimizes the appearance of pores, fine lines and wrinkles; reduces secretion of skin oils (seborrhea); smooths scars; improves delivery and absorption of medical-grade skincare products; and reduces the occurrence of acne.

After any energy-based procedure, “You need to slam that skin barrier shut,” Dr. Thornfeldt continued. “Positive ways to accomplish this include skin preparation so that you have a consistent response. Two to four weeks before you do anything, you want to get the skin barrier in shape. Eliminate inflammation, decrease the microbes, get the biome back in
balance, etc. That will give you the best, most predictable result.”

When considering the side effects of using some energy-based systems for skin barrier work, Dr. Supapannachart was less encouraging. “Many of these devices rely on disrupting the skin barrier to create a wound that brings about new collagen formation,” she began.

“Examples of this technique include laser-based resurfacing, skin needling, plasma-based resurfacing and chemical peels.” The use of energy-based devices in particular can lead to post-inflammatory hyperpigmentation (PIH), which is a serious concern among Asian patients,” she continued. “Thus, in my region, machines that can deliver active ingredients into the skin without disrupting the skin barrier are more popular.”

Safer approaches, such as phonophoresis, electrophoresis and electroporation can temporarily increase the permeation of skin,” noted Dr. Supapannachart. “Exposing the skin to a light electrical field can reduce the cell wall’s resistance, rendering it more permeable. We can then transfer a wide range of naturally nurturing solutions or oils into the skin cells – a treatment that is painless with no side effects.”

Along those same lines, a popular approach among APAC-based practitioners utilizes oxygen jet technology. “It is basically a ‘pressure wash’ that uses water to deep clean by infusing saline and oxygen into the skin, which is ideal for treating acne and rosacea,” stated Dr. Supapannachart. “The procedure deep cleans pores and works to eradicate bacteria from underneath the skin.”

Dr. Prethima Michael has used this type of approach for around 15 years. “Oxygenation therapy produces micro molecules, which allows us to deliver vitamins or serums into the skin,” she said. “First, we clean the skin by way of cavitation and scaling, then we inject molecules deep into the skin. This helps to produce the fibroblasts that will contribute to repairing or rejuvenating the skin.”

Recently, Dr. Prethima Michael adopted a newer hydro-jet technology, which exfoliates the skin without the use of crystals or abrasive wands. “We can infuse the skin with a soft rubbing action applied simultaneously with the micro-jets, which carries the serums and vitamins into the skin,” she said.

What if you use an energy-based system that delivers product into the skin barrier, but the products have not been tested for internal use?

“We have seen this with microneedling, for instance, where there are punctures made within the skin and products are attempted to be introduced into these punctures. This is concerning and potentially harmful to the patient,” Dr. Schlessinger warned.

Unknown chemicals, formulations and preservatives, as well as many ingredients that are intended for topical use have not been tested for internal use, Dr. Schlessinger continued.

“There are risks associated with injecting substances into the skin without testing. Keep in mind there are certain skincare products that are perfectly safe to be internalized, but I’m less certain about introducing different fragrances or colors, and other components of skin creams,” Dr. Schlessinger said.

Mesotherapy can offer an effective system of delivery, but is more popular across Europe and Asia than the United States. “In certain countries, mesotherapy can be used to reduce fat as it contains bio salts and compounds that already exist in the skin, for normal skin structure. Those therapies do have measurable benefits,” stated Dr. Thornfeldt.

Dr. Schlessinger even noted the value of regenerative medicine to repair the skin barrier. “People use platelet-rich plasma (PRP), which is reintroducing your own autologous serum into yourself,” he said. “It may offer benefits, and it doesn’t seem to result in any harm. That is a lot different from compounding formulations like Minoxidil and then putting it into the skin via mesotherapy.”

Dr. Prethima Michael noted a recent focus on regenerative medical methods for the whole body, including attention to the skin barrier. “We can infuse the skin with growth factors and PRP via mesotherapy to increase the skin’s health.”

In addition to slowly emerging regenerative approaches, a few relevant skin rejuvenation technologies have entered the APAC marketplace in recent years. “I believe the newest is plasma technology, in which an ultra-high frequency (UHF) generator excites inert nitrogen gas, which is converted into activated ionized gas,” Dr. Supapannachart revealed. “This plasma-containing heat energy is directed to the skin via a handpiece equipped with a quartz nozzle tip.”

Specific to the APAC region, combination therapies that merge new and old approaches are likely to remain the norm when it comes to addressing the skin barrier. “We use multiple delivery systems and techniques to optimize results,” expressed Dr. Supapannachart. “For instance, we’ve applied emulsion infusion, micro-encapsulation, the molecular patch and nano technology to place substances under the skin. In addition, phospholipids, liposomes, microcapsules and hydrogels are all different molecules that allow active ingredients to bypass the outermost layers of the skin, which can provide better penetration.”

Unpredictable side effects are an overarching issue when using devices and infusion-style therapies to heal the skin barrier. In addition, most regulatory bodies, including the U.S. Food & Drug Administration, have offered no regulations or advice regarding anti-aging skincare and delivery systems, including microneedling and the wealth of cosmeceuticals that are routinely applied to the skin barrier.

“Thousands of cosmeceuticals have been tested in multiple clinical trials for customers or patients, but none of those trials deal with introducing cosmeceuticals into the skin or into the patient,” stated Dr. Schlessinger.

Cosmeceuticals do not exist in the eyes of the FDA, Dr. Werschler said. “The regulators should establish a third category of over-the-counter (OTC) skincare products that have limited effects, but the FDA will not do that. Unless you are a soap made from animal fat and lye, you are regulated by the FDA. For instance, Dial and Dove are considered OTC drugs because they are designed to affect the surface of the skin.”

However, some standards and methodologies do exist at the practice level. “Before a procedure, use a skin barrier renewal cream to ensure normalization of barrier functions; followed by a cleanser that would reduce the number of microbes on the skin; and then a rebalancing toner to obtain the proper pH,” Dr. Thornfeldt outlined. “I do this before a procedure to get a predictable result and minimize side effects.”

Under the current conditions, it is nearly impossible for the average patient to find the best method or approach to repairing the skin barrier. As such, “It is up to the practitioner to improve patient care and the health of peoples’ skin,” Dr. Thornfeldt advised. “We have the technology to do this and patients need to understand that, and search for products that work to control inflammation and optimize skin barrier function.”

Aesthetic practitioners and dermatologists must be clear and focused when approaching skin barrier repair, Dr. Supapannachart stated.

“In the aesthetic field, only by understanding the function of the skin barrier can we determine the best way to deliver active ingredients into the skin. In the dermatologic field, we should provide rational therapies that keep the skin in good shape and with good barrier reflex, which also addresses barrier-disrupted skin disease,” she concluded.