Laser skin resurfacing treatments involve the use of light beams that use a short, pulsating beam of light to target different areas and layers of the skin to create small punctures and micro-injuries to activate the skin’s own natural healing capacities. Newer laser technologies allow cosmetic surgeons a great degree of precision in targeting very specific damaged areas while leaving the outer layer of the skin well protected.
I recently had the pleasure of interviewing Dr. Joel Cohen on my podcast, The Beauty Doc. Dr. Cohen is an internationally recognized specialist of skin cancer, laser surgery and aesthetics and has been named as US News and World Report Top Dermatologist. He is also widely respected amongst his peers. This interesting conversation can be extremely enlightening for all those who are looking to understand current dermatological procedures uses to enhance the skin, to combat skin problems, to slow down the aging process and to treat skin cancer.
The interview with Dr. Joel Cohen has been broken down into 3 easy parts so that it digestible and easy to understand. This interview truly gives you insight into the cutting edge facts about how cosmetic lasers are being used in the offices of plastic surgeons and dermatologists, as well as highlights some of the limitations of current laser skincare treatment. We want you to have realistic goals of what we can achieve when you are thinking about getting a laser treatment at any of our offices.
Part 1 – Benefits of Laser Skin Resurfacing and Microneedling
Flawless, smooth and a blemish free complexion are important components of youthful beauty. Over twenty-five years laser resurfacing and micro-needling have evolved as minimally invasive technologies to smooth wrinkles, tighten skin, restore evenness to your complexion and significantly reduce hyperpigmentation. These techniques have also emerged to reduce recovery downtime so that you can return to your personal and professional schedules in a matter of days rather than weeks.
Part 2 – Lasers in Combination with PRP Therapy
Centrifuged blood is fractionated into three parts. At op layer of plasma, a small layer of platelet rich plasma (PRP) and a larger portion of red blood cells. It has been shown that the platelet rich portion has growth factors that can accelerate healing and stimulate hair growth when injected into the scalp.
Part 3 – Skin Pigmentation and Scars
Irregular skin pigmentation and hyperpigmentation is a distressing cosmetic problem for many patients. Treating the skin with the aim of lightening these dark skin spots has been a challenge for decades.
Full Podcast Transcript
Dr. Joel Kopelman [00:00:00] Welcome to the Beauty Doc podcast. I’m your host, Dr. Joel Kopelman, a cosmetic ocular plastic surgeon in New York City. You’re going to hear from interesting guests who are authorities in their specialty. We will cover topics on health, beauty and cosmetic surgery. And you will receive unfiltered, truthful information about all these procedures.
Dr. Joel Kopelman [00:00:25] Dermatologic aesthetic treatments have revolutionized aesthetic medicine, particularly in patients who wish to avoid risks and downtime from surgery, where they find these surgical risk are unacceptable. And they’re seeking out procedures that are faster to recover from, as well as a greater degree of safety related to them. According to statistics, there’s close to 16 million noninvasive cosmetic procedures a year that are performed.
Currently, I see dermatologists dominating the aesthetic field, which was once the exclusive domain of plastic surgeons, facial plastic surgeons, oculoplastic surgeons, etc.. Dermatologic surgeons and laser specialists are very much part of this epicenter and leaders pushing the limits of of of where we’re going with aesthetic medicine. My guest today, a dermatologic surgeon, Dr. Joel Cohen, very excited to have him as a guest who’s board certified nationally, internationally renowned and has a practice located in and around Denver, in Greenwood Village and in Lonetree, Colorado.
I’ve never been to either one, so I’m sure it’s a beautiful place to live. And his expertise is in laser surgery, cosmetic treatments of various kinds, as well as Moh’s skin cancer surgery. And he is an associate clinical professor at University of California at Irvine. He’s published over 200 articles and coauthored three textbooks, including the aesthetic rejuvenation, a regional approach with other authors, and he participates in FDA clinical trials. And he has too many other accolades to mention today, because that would be the entire conversation. I welcome him as a guest. I’ve met him at person and spoke with him in the past. And I’m here to learn as much as I can. And I hope everybody is taking notes today. Dr. Cohen, I like to first open up this discussion about bipolar radio frequency, micro needling. I know that’s a big mouthful for some of our non-medical listeners. So could you define what that is, please?
Dr. Joel Cohen [00:02:40] Sure. So bipolar fractional radio frequency is using radio frequency energy positive and negatively charged poles to penetrate into the skin to create columns of heat that actually tighten the skin. And that’s probably a really good segue way that we can go back to what you were introducing in terms of dermatologists are really now at the forefront of cosmetics, where traditionally it was plastic surgeons. I think really, if you look at the chronology of the history of many of the procedures that have been done and have been done to lead to that, I think it’s interesting. So first of all, dermatologists are the ones who discovered hair transplantation, dermabrasion, Allaster Carruthers, along with his wife, who’s an oculoplastic surgeon. But Allaster is a dermatologist, discovered the cosmetic use of Botox.
Many of the lasers we use for pigment, fractional lasers, cool sculpting and even future treatments that I’m sure we’ll get into in the segment. So derms have been really involved in the innovation all the way through. And that really exemplified by the fact that dermatologists are really right now at the cutting edge, as you indicate, with all these different cosmetic procedures and fractional bipolar radiofrequency is one of them built on the whole concept of using fractional energy. So penetrating the skin not completely consistently, but penetrating the skin in these little columns. And that’s fractional lasers. People know the name Fraxel, but that’s also revealing. And in this case, this is using micro needling pins that actually have on the tip of the needle radio frequency energy.That induces dermal heating that tightens lax skin. And we see really nice results with that for acne scars. And I think that the technologies are getting better for it, for some laxity as well.
Dr. Joel Kopelman [00:04:33] Okay. But how did we end up here? I mean, we were doing lasers for decades to remove wrinkles and aged sun-damaged skin and now these radio frequency devices evolved. And tell me why they have either replaced or complemented laser treatments.
Dr. Joel Cohen [00:04:54] So in terms of many of the laser technologies that we use, they’re working really on the superficial surface of the skin. So when I treat somebody with pigmentation that’s really operating on the surface of the skin, I’m using typically a Q-switched laser or broadband light BBL. If I’m treating redness similarly, that’s usually on the surface of the skin, although we do in addition to pulse dye laser, we use like a long pulse laser if somebody has this bluish veins which are deeper from just the surface. And then when we resurface lines and wrinkles, which is a lot of what I do, the heavy downtime resurfacing, we’re really peeling away the skin. And that’s still operating within a couple hundred microns of the surface of the skin.
Dr. Joel Kopelman [00:05:39] But even with a CO2 laser, carbon dioxide lasers which penetrate deeper, it only gets down a few hundred microns.
Dr. Joel Cohen [00:05:48] So we’re peeling off the epidermis and we’re in the superficial dermis. And then when we talk about these bipolar radio frequency devices the needles are actually going well into the skin. We’re going three millimeters or three and a half millimeters. So that’s targeting something completely different. On one hand, I think it really does effectively target some of these areas of acne scars to cause some tissue contraction and to improve the areas of acting scars. And I think that that’s the sweet spot for these bipolar fractional radio frequency treatments is minimal downtime, deeper penetration, and they have efficacy for acne scars. That is something that is quite consistent in terms of laxity. Laxity is not something that we see all that much consistency with for every patient. I think patients have different degrees of solar elastosis and laxity. However, with a series of treatments for patients who don’t want to necessarily have surgical results and understand that we can’t give them surgical results, but we may be fine tuning something, they may have had a facelift before, they may have had a neck lift before, and we may be just sort of tweaking things as three or four or five years later. That area starts to fatigue. I think we do see some nice results. We see results from bipolar, fractional radiofrequency from that mechanism of action using energy. And then we see results from technology like ultrasound, micro focus, ultrasound, like all therapy. I don’t think it works for everybody. And I think it’s not something that we can actually say is consistent. But for those small little tweaks, oftentimes in combination with bipolar fractional, we can see some nice results.
Dr. Joel Kopelman [00:07:30] Some of these devices have been promoted by corporate sources as as a replacement for a facelift. Would you would you go that far?
Dr. Joel Cohen [00:07:40] Absolutely not. Anybody who comes in and they start saying that they want this type of improvement. They need to have a facelift. They need to have a neck lift. You know, when you’re really pulling on an area, when you’re talking about a couple millimeters. And as I really tried to say very carefully, we’re doing small tweaks, then I think these technologies can offer that. And there’s certainly not a face lift. And I’m not sure the companies have actually done that. I think that some people out there who bought the technology are starting to tout that.
Dr. Joel Cohen [00:08:09] So if you look at something like Ultherapy, we’ve done several clinical trials for Ultherapy. We have many patients photos that show really nice improvement, but we really pick our patients carefully and we make sure that these are people who are not expecting a home run of surgery, but may be happy with a double or a triple, usually a double.
Dr. Joel Kopelman [00:08:28] So in other words, it’s kind of a tradeoff in a sense, because some patients, they want an improvement, but they don’t want to take the risks of the surgery or the downtime or they don’t have the inclination to, you know, spend that time recovering what maybe they don’t have the finances to do it either. That’s another factor. There’s another indication you can treat pigmented patients, whereas in the laser treatment of patients, they can get hyperpigmentation from ablative lasers or even non-ablative lasers. And yet the RF micro needling devices can can deliver tightening without creating hyperpigmentation.
Dr. Joel Cohen [00:09:07] You hit a very important component where many of these patients, whether it’s acne patients or laxity, have various different skin colors. And we have skin color type one, which is really, really fair, versus type six, which is darker skinned African-American skin. And these bipolar Radio-Frequency treatments can be used on all six skin types. So it is something that is colorblind. So we we do we don’t use high, high energies, you know, in terms of of some of these patients that have darker skin types, because we’re still concerned about protecting the epidermis and the number of passes. But we do use it on all skin types and it is really beneficial for acne. There are lasers that we can use on all skin types as well. The Thulium laser we can use carefully 1927 on different skin types and even erbium resurfacing as opposed to CO2 we can use on darker skin types. But you’re right, there is a risk of pigment alteration afterwards and really diligent sun protection, even in a population of people who may not be used to wearing sunscreen and some protection and hats and seeking the shade is really important.
Dr. Joel Kopelman [00:10:13] So tell me about the procedure itself. Is it is it painful? How do you prep the patient? How do you how do you get the patient prepared for this procedure?
Dr. Joel Cohen [00:10:21] Bipolar fractional radiofrequency has many different devices that are available at this point. We in our office use a device called Genius, made by Lutronic. I have done some of the studies in the projects on this and there are some publications out there on this type of technology that I’ve participated in as far as trials in my office. And the original version that Lutronic made was called Infiniti. Infiniti is a very good system, but the Genius is actually better. It’s what called smart technology. So when the handpieces in contact with the skin, you actually see from a green light, if you’re delivering effective energy, if the handpieces in contact with the skin appropriately, which is seems something that you would think is obvious. But when you get to a contoured area like the temple and the four head or you’re in the jaw line, that becomes very important or over the cheekbone. So that type of smart technology is helpful. It also really tries to distribute the energy over the course of the delivery of the pulse a little bit more evenly. So it’s less painful. So it’s that what we call area under the curve. If you’re not feeling as much peaks and troughs, you’re actually feeling more sort of consistency. And I think that the results are overall better. So these are actually needles that are coated. So the very, very tip of the needle that goes into the skin is not coated. But the rest of the needle, more proximately is coated. So it sort of protects the epidermis. And there’s other technology out there that don’t have the coated needle. So there’s different thoughts and processes about this and why people favor one company over another. So the needle tips create columns of heat in the skin and they deliver that energy to a specific temperature, to up-regulate some of the cytokines and chemo- kines and various things and pathways that cause heat shock proteins and tightening overall. You know, this can be something that can be painful. So from a standpoint of your original question, as far as discomfort, I think that we’ve gotten to a point where we can really try to control discomfort pretty well and not everybody has as much discomfort as others. First of all, I think the newer technologies where you’re avoiding the peaks and troughs in terms of the energy delivery are more comfortable inherently because you’re not feeling that spike. So the Genius RF is something that does that This is something that penetrates deeper than topical anesthetic. So if somebody is you know, is concerned about discomfort, you have a couple of choices. One is you can use a device called ProNOx, which is a patient administered nitrous unit.
Dr. Joel Cohen [00:13:09] We use that very commonly in our office for bipolar fractional radiofrequency treatments, as well as all therapy microcircuit ultrasound treatments and sometimes for heavy laser resurfacing that I’m doing. We also use lidocaine injections for especially acne scar patients. We may use what’s called a mesoneedle, which is a needle that has multiple prongs on it that allow you to anesthetize large areas of the face. And you can anesthetize a cheek very quickly in probably three minutes or so. So for people with really significant acne scars, that’s a lot of times what we do to make them feel during the treatment.
Dr. Joel Kopelman [00:13:56] How do you adjust for doing it in the neck? So in different parts of the face, do you have to change the rheostat, the amount of energy that you deliver to different parts of the face.
Dr. Joel Cohen [00:14:08] So there are different energies that we deliver. And there are different depths that we’re comfortable delivering that energy at. And on the face, the thickness of the dermis, that second layer of the skin is is thicker and we have the ability to sort of heal through some of the follicular structures. When it comes to the neck, the thickness of the skin is different. You don’t have those follicular structures. But nevertheless, the target is is oftentimes the same. It’s the laxity in the skin or in some cases, the acne scars. So we do have to deliver the appropriate amount of energy. The neck is not nearly as painful as the face, often times because it doesn’t have those bony convex surfaces, you know, below it. But nevertheless, there is some discomfort with that and people seem to tolerate it much better than the face when you get to this. Little submental area where you have a little bit of bony contact positionally for patients can be difficult. That’s the area that sometimes patients have a little bit more discomfort. And we simply just take some breaks along the way.
Dr. Joel Kopelman [00:15:11] How long’s it take to see manifest good manifestations or let’s say the final result? And do you have to do it multiple times?
Dr. Joel Cohen [00:15:18] So bipolar for a fractional radiofrequency treatments are a series of treatments. We really have patients typically do a series of, three or four treatments, and then we compare before and after pictures. So with three or four treatments in an acne scar patient with rolling acne scars, you can see very marked improvement and they really haven’t had much downtime. You can do the treatment on a Friday. These kids take the weekend off, in some cases hang out with their close family and friends and they may have a little bit of red or pinpoint bleeding for a day or two. But by Monday, generally, they look fine. And after four sessions of that, we can see pretty noticeable improvement. And there are other things that I do along the way. Non-ablative lasers for actual treatments are a good way to also see improvement and to to try to minimize these acne scars. And in some cases, these kids only have a half a day or so of being pink. So they can go about and go back to their lacrosse games or whatever it is that they have going on or some sort of social function that weekend. But when we do decide to do things like heavy subcission and using ablative lasers, that’s a long downtime. That’s when these kids oftentimes will have, you know, ideally a week off of work for some break. Winter break, fall break. You know something? They’re going to camp in the summer, but they just finished school. And that seems to be a window where some of these kids have been sort of saving up the time to do something ablative. But with people who have significant acne scars, it’s really a full spectrum of treatments that we do from non-ablative for actual treatments to bipolar fractional radiofrequency to ablative fractional treatments. And typically, with the ablative fractional treatments, I’ll do some subsequent subcission using a No-core needle. The area of the rolling scars. And then I’ll actually subcise like a windshield wiper, that whole area that may actually be bound down. And then we also use something called the cross technique, which is using high concentration T.S.A. for the ice pick scars. So we talked about the rolling scars and those that I have a little depression that are rolling, but the icepick scars are really discrete scars. They can be very difficult to treat. And we put a little high concentration T.S.A. on the end of a very focused cotton tip applicator of the wood part of it, or a 30 gauge needle.
Dr. Joel Kopelman [00:17:39] Yeah, I’ve done that myself. Do you combine these procedures simultaneously and how do you do it on the same day? Can you do non-ablative laser treatments and RF micro kneeling on the same day?
Dr. Joel Cohen [00:17:52] Well, first of all, that that led that question led to the development of the laser called Halo, which is a laser that I use everyday in my practice. So in about 2010, 2011, Dr.Vic Ross, who is a major laser guru, I did a clinical trial. It was published in JD a year or two later about using a non-ablative fractional laser and an ablative fractional laser together on the same day, just versus just on the other side of the face, just the ablative fractional laser. What that study essentially found is that there was similar results. There was less downtime because of the coagulation of the of the non-ablative fractional laser. So Sciton laser company based in the US and in Palo Alto, California, was able to really use the non-ablative wavelength, 1470 and integrated with the ablative wavelength 2940 and come up with the Halo and they really optimized the energy. So not not only do you see, you know, tissue coagulation, but you can actually see synergy between the two actual treatments. So Halo has become a really common treatment for people who have significant sun damage, who don’t want to have significant downtime, but nevertheless, they want to see improvement in pigment. They may want to see improvement in in acne scars. Halo is a great way to tackle somebody who has a lot of photo damage, is apprehensive about doing something.
Dr. Joel Kopelman [00:19:35] But do you use it in conjunction with the micro-needling?
Dr. Joel Cohen [00:19:38] So that’s what I was getting to. So. But those two wavelengths, you know, we can use together. So that kind of led people to say, well, what else can we do in tandem? So if you think about it, we often use the bipolar fractional radiofrequency treatments like GeniusRF in concert with the treatment algorithm with fractional ablative lasers. So if somebody wants to minimize their downtime and have the benefit of having the bipolar fractional treatment, let’s say for acne scars and a weekend recovery, then that’s a stand alone. We’ll do that. We’ll do the bipolar fractional radiofrequency on a Friday. And they should look good on Monday. But if somebody has photo-damage and laxity and they say, hey, Joel, I really want you to do some resurfacing, you know, and I’m ready for the week and a half of downtime of the heavy duty resurfacing, then there’s no problem. We will integrate a bipolar fractional radiofrequency treatment.There’s no problem with integrating those two technologies together. In fact, there’s been a few publications at this point showing that the synergy of the two, even in the same session, is safe and effective.
Dr. Joel Kopelman [00:20:55] I want to now Segway to laser resurfacing, in particular because we’ve been using the term of ablative or non-ablative. To me, these terms are a little confusing because I have two erbium yag lasers. I’ve been using it for almost 20 years and a fractional erbium-glass laser. First of all, can we define for the audience ablative of versus non-ablative. And I’d like to also know the longevity of these lasers treatments. Some people say ablative laser treament last much longer than non-ablative treatment.
Dr. Joel Cohen [00:21:33] First, there are different types of laser energy that are delivered. Some that that penetrate the skin and cause something like coagulation on a target. In this case, water. And there are some that penetrate and hit the skin and affect pigment or affect redness. So those that are not creating a wound and those that are not vaporizing the skin are called non ablative. And when you when you encounter the skin and you’re actually vaporizing, then you’re using you’re using an erbium laser. 2940 wavelength or CO2 laser 10,600 wavelength. So those are the ablative lasers. So if folks out there want to know the word ablative substitute vaporizing the skin or y basically it’s just creating a wound. But non ablative lasers do not create a wound.
Dr. Joel Kopelman [00:22:27] Okay, well, I see a wound when I use my erbium glass laser, I believe I see a wound. Am I wrong when I say I create a wound with my erbium glass as well?
Dr. Joel Cohen [00:22:36] You see some redness. But, you know, if histologically, you see a little coagulation zone and microscopic epidermal necrotic debris. But that’s not what patients are thinking “wound”, they’re thinking that they see bleeding or they see something that is significantly swollen and something that’s going to take several days to heal.
Dr. Joel Kopelman [00:22:57] Okay. But now let’s go back and talk about erbium ablative versus carbon dioxide, ablative lasers. I’ve noticed that in your office you primarily have erbium, a laser you prefer over CO2.
Dr. Joel Cohen [00:23:15] There are times where I’d like one over the other. But, you know, just to to to to start with the old discussion about CO2 versus erbium and when you’re doing resurfacing for really heavy, heavy smokers lines or something like that. So, you know, we see a lot of people with sun damage all around the country. And in Colorado, we actually have three hundred and twenty days of sunshine. We have people who really spend their lives outdoors. They hike, they fish, they ski. They they do Iron Man or iron women and spend a tremendous amount of time outside. We see lots of skin cancer here. And, you know, we see the effects of of the sun on the skin where people have really photo damage, skin. They have etched lines and wrinkles. So if somebody truly has significant etched lines around the mouth, something that we typically have called smokers line in, some of these people may have not even been smokers. It’s just that they have enjoyed the outdoors for so many years. You know, first, I think they should see a dermatologist and have a full skin check once a year. Many of these people have fair complexions and they’ve already had pre-cancers or skin cancer. So sometimes we’ll see them, you know, twice a year if they have a family history of melanoma or a personal history of some type of skin cancer. You know, we see them pretty frequently because, you know, I spend a good part of my time doing MOH’S surgery, the microscopic skin cancer surgery. And this is, you know, a state where we see a lot of sun damage. Florida, New York, wherever you EXCESS SUN EXPOSURE. You know, in California, people have a lot of sun damage as well. You mentioned. I have a faculty appointment at at University of California, Irvine. Patients that we see there, you know, have a tremendous amount of sun damage to play, you’re at a higher altitude, too. You do get about about six to 10 percent more you the penetration for every thousand feet. So right now, mile high. But when I go up in and ski over a weekend or something like that, we’re at two miles high. So we have to really think about using sunscreen with the right ingredients like zinc and titanium. And you’re applying every couple of hours and other sun strategies. I usually have zinc sunscreen on and then a face mask, balaclava even on a pretty sunny day. And if I’m sweaty and riding the bumps, then I’ll take a break and take my helmet off and my balaclava off and go inside. But, you know, it’s we really go to great lengths to try to protect ourselves. It was funny this past weekend I was at Miami Cosmetic Surgery and I walked outside to get an Uber with Steve Dayan, who ran the meeting, and Jay Burns . So we all were going three different directions. Jay was going to his hotel. Steve was going to a coffee shop, and I was actually going back to my hotel and leaving for the airport. We all three called Ubers. I was the only one standing in the shade and the two of them are are directly at the sun. We’re about two feet apart. And I finally said, guys, you know, look, you can move over two feet and you can stand right with me. But I said this is the difference between a derm and a plastics. I would never imagine waiting for an Uber for sitting in direct sunlight.
Dr. Joel Kopelman [00:26:25] And I guess, because you see a lot of cancer all day long. Good guess.
Dr. Joel Cohen [00:26:31] Dayan and I, for many years, we have pictures of he and I in different places where where I’m literally in the shadow of the building and walking right outside that we have one and the beaches of of Grand Cayman, where literally I’m wearing a sun protective, had a long sleeve UPDF shirt and and very long bathing shrugs. And he’s wearing, like, flip flops in a Speedo. I mean, that’s that’s the difference between some plastics in some cases. It’s great. A great story. So for people who’ve enjoyed a lot of time out to work, it may or may not have been smokers when they have very severe etch lines around their mouth. Oftentimes, they’ll have severe etching around their eyes as well. And, you know, some of these people, honestly, people could walk in. And first of all, many people have misinformation and they think that, oh, they have some lines on the upper lip. They can use something like botulinum toxin, Botox or Dysport, whatever the flavor that you carry in the office. And that’s not the case. Those lines are actually etched in the skin. So you can inject a neuro modulator. And that’s an off label area. And there’s a great chapter in my botulinum toxin textbook on the peri-oral area. But we inject it very, very commonly. But that’s only to stop the muscle from imprinting those lines further, just like in the crow’s feet, just like in the glabella. So there are in many of these patients, way too many of these lines and wrinkles to get into with the filler. So you really have to think about something that can treat the whole field. And if you use a fractional laser. First of all, fractional ablative lasers can give very nice results for acne scars. They can give overall good results for photo- rejuvenation. But when it comes to really severe etch lines like upper lip lines, they’re not the treatment of choice. In my office. My my treatment is fulfilled. Erbium, resurfacing. So we’ll have fractional CO2 and fractional erbium on different devices. And I have the opportunity on one of the devices to use full field CO2. I usually always use erbium, and that’s because of that downtime is less correct. It is more effectively absorbed by water and you are able to recognize your end point. So with erbium, there is less heat that’s generated. You can actually see pinpoint bleeding and that is your point. So when I resurface the area around the mouth and you see these areas of pinpoint bleeding, that’s your end point. And that is very important because that has a more specific endpoint than full field CO2. And so I use a lot of the Sciton 2940 erbium resurfacing. In fact, we have two of those units in the office and you know, you can you can smell that even in a big office of eleven thousand two hundred square feet. Our main office, like, you know, when that laser is being used, even with a buffalo and another air evacuate or and then air evacuating from the ceiling. So we really pick the time of day that we do that for for poor folks. But that is major improvement.
Dr. Joel Kopelman [00:29:34] I agree with you totally. I don’t know if you know this, but I was one of the early adopters or of erbium in the United States, and I actually published some papers on Erbium. You probably didn’t read them right?
Dr. Joel Cohen [00:29:48] I may have seen them when I recognized your first name as being an awesome first name.
Dr. Joel Kopelman [00:29:53] I mean, I think it’s a tradeoff. I went towards Erbium because I didn’t want this long prolonged. Recovery. And I didn’t want the hypo pigmentation associated with CO2. However, I’m not sure that I get the as long lasting result as I would with CO2 ablative because I mean, CO2 ablated goes deeper. The heat goes deeper. Don’t believe that.
Dr. Joel Cohen [00:30:19] I don’t. So it depends how many passes you do and what energy. All I do. My erbium, heavy skin resurfacing patients oftentimes have post inflammatory redness for even a couple of months. So I think there’s too many variables to make those conclusions. But Jay Burns in his article does tackle that question about the difference between the penetration. But in terms of more effectively absorbing water, erbium is more effectively absorbing things by about a fold of 16 times and erbium can actually penetrate deeper overall with less heat. So really, I think we could have this discussion for a long time. But what it boils down to is safety and efficacy. And with erbium, you are by far less, less, less likely to see the pigment loss, that porcelain color that you were with CO2. And I believe that is because of the erbium. And I believe that’s because you can recognize your endpoints. And then in terms of durability, it all boils down to what settings are you using and how aggressive are you in the first place? And I have great pictures.
Dr. Joel Kopelman [00:31:21] I mean, I see I have great results as well. I’m not saying I don’t. I use Erbium and I and I that’s all I have in my office . I don’t have CO2. What do you think about shortening the inflammatory stage of this post treatment? In other words, after laser, you get this erythema and an inflammatory stage. If you shorten that by steroids or whatever reason, do you think you get less of a result? In other words, is it beneficial to have that that prolong redness?
Dr. Joel Cohen [00:31:58] So the prolonged redness is something that we see with heavy, erbium resurfacing, and it is something that we expect to see. I show my patients my pictures. I don’t show them somebody else’s pictures published in a paper or some companies brochure. I show them my pictures of patients who had significant etch lines. I show them what the patient looks like right after skin resurfacing a couple days later, a week later or two weeks later. A month later. It’s it’s not until about three months that you see the full degree of improvement from that resurfacing session. And it’s usually between the one month and the two months, but sometimes it’s between the two month and the three month that that erythema goes away. And I’ve always been concerned about really treating that erythema too aggressively with topical steroids. Having said that, Mitch Goldman has published an article that shows that it’s actually OK and you’re probably not interfering with the overall efficacy. However, I’m not sure that I really want to potentially even interfere with things. So I just kept patients on. What I really think is a good course. They understand what they’re going to look like. And I tell them what Jay Burns has said for years, that the redness is the highway to get to the destination. It’s something that we expect and it’s something that for everybody, it’s going to go away at a different time in my personal patient population. I think the people who have have fair complected skin and they have rosacea and they have more evidence of facial flushing and dilated blood vessels. In the central part of their face are the ones that I see with prolonged erythema. I’m talking about eight weeks, in some cases 10 weeks. But I will say, number one, it goes away. And number two, it’s important that people sun protect. And I’m not talking about going to CVS and just grabbing some sunscreen and putting it on once a day. I’m talking about using zinc sunscreen or a titanium sunscreen that is of sufficient concentration. Usually five, six percent more are plus with each of those and then rubbing it in effectively and applying it every two hours. Ideally, I’d like these people to avoid intense sun exposure in that timeframe right afterwards. I had a patient a few years ago that went on a kayak trip, didn’t wear sunscreen, wear a hat. But just all that light reflection, she ended up getting a little bit of pigmentation. It was something that we treated A with sunscreen, B with some tropicals, and C, with some peels. But we do have ways to treat that. I’d like to avoid it, but I think in my practice, the couple of sunscreens that have made a huge difference are the ones that are that are tinted that have at least six plus percent zinc. And the one that I like to use right now is called Revision Tru Physical. It’s a sunscreen that came out last last spring. It’s new in the Revision line. It has many different gradients, including zinc and titanium. But it’s what they’re calling a five and one. So it’s a moisturizer. A sunscreen. It’s a tint. It has some peptides in it. And most importantly, people don’t mind using it. So the women that use it, they don’t mind using it because it’s not burning or irritating and it’s actually quite elegant and cosmetic. And I think that’s a home run for these people, because I really feel like they’re getting great sun protection and they’re able to effectively camouflage that redness. And the only times where that doesn’t work is if somebody swims, you know, and then some of that comes off. You really have to just underscore the importance of being careful and that several week interval after treatment and maybe swim indoors. And, you know, some of the sweaty sports, somebody plays tennis and and wipes their face with a sweatband or something like that. They have to be careful to reapply. But we take it pretty seriously. And I think that post inflammatory erythema is something that we expect. And, you know, from the data at this point, I’m not sure if we if we can conclude that it’s absolutely necessary. But nevertheless, I don’t usually treat it unless it’s really a problem for people.
Dr. Joel Kopelman [00:35:59] So if if you use a pulse-dye laser do you think that’s a negative?
Dr. Joel Cohen [00:36:05] I don’t think it necessarily is, but I don’t tend to do that very often because there is a potential that it could be. And I just don’t want to interfere with the results. And this is something that we expected. . You know, these alpha agonists,like bromidine where you can topically apply it and you don’t see a great vasoconstriction of the redness, but you do see probably a little bit. So all in all, a little pulsa-dye laser, a little non-ablative fractional. . And, you know, whatever you use, you can see some improvement with that. And then, you know, if if all else fails, you can try some topical steroid. But, you know, keep in mind, maybe interfering with the overall beneficial result.
Dr. Joel Kopelman [00:36:48] Do you ever use ERP platelet rich plasma and or growth factors immediately following laser treatment?
Dr. Joel Cohen [00:36:56] You could not have asked that at a better time.
Dr. Joel Cohen [00:36:59] PRP is something that until about September of 2016. I was a very significantly skeptical physician in this regard. It just didn’t make a lot of sense that you could draw your blood, spin it down in one of these proprietary units, and then you could take the platelet rich plasma and then do something with that. And most commonly, what we see in dermatology is taking that platelet rich plasma and injecting it for Andrew genetic alopecia. So I have some friends who started doing that in some cases at really respected institutions like the Cleveland Clinic. And they actually saw very significant results. And I was starting to do that in September 2016 at this point. I have seen many people who have hair loss, hormonal hair loss, androgenic hair loss, mostly guys. But it’s not like extreme cases. There are areas where, you know, they lost the crown. And I can share great photos with you of patients that I’ve treated. But I also use PRP very commonly in practice in conjunction with lasers. There is some data about using it to try to expedite the healing process. There’s some indication that it may decrease by about 15 percent some of the redness, some of the crusting and some of the pain. So it’s very common for me to use it in my practice after heavy resurfacing for people with lines and wrinkles. It’s very common for us to use it after fractional skin resurfacing for people who have sun damage or acne scars. We use it often after bipolar fractional radiofrequency. In some cases, we use it with micro needling in the office. And the whole concept is, you know, is this leading to a synergistic response or is this just helping the recovery as some of the data shows? And in both cases, they’re both positive cases. So there’s many patients that are willing to try. And I think the people who are more willing to try are the people who’ve heard of this before. So, you know, Colorado being a very outdoors state, many of these people have actually heard of PRP or even use PDRP for their original use. And they use that. It’s actually has the FDA clearance for which which is basically after orthopedic procedures. So many people have heard of it. Many people are already on board with it and they’ll be more more likely to use it. And I’ll end with not only do we use it injecting into the scalp, not only do we topically apply it after some procedures, but there is actually some new data from your alarm at Northwestern about injecting it into the face. Now, sometimes people have really overstated this as the ability to give some sort of a facelift type of results. I think that’s way, way, way, way. Infinitely, exponentially overstated. But I think if if you’re talking about a patient who doesn’t want to have filler for some other reason and you may be doing PRP for androgenic alopecia and you may be thinking about a focal area that they want to try to inject, you know.
Dr. Joel Kopelman [00:40:22] Also seems to be catching on as well in terms of injecting it under the skin. How about growth factors? Any any other any other? There are some people in the past were saying you put these growth factors. I don’t know what what’s contained in the. And the growth factors. But they say they get better results with those.
Dr. Joel Cohen [00:40:41] We have a very robust clinical trial unit that I run in our office. It’s a separate division called about can research. And we do a lot of clinical research. We do botulinum toxin research. We do filler research. We do some of these radio frequency devices, various types of lasers from the Halo stuff to thallium. And and then we also do a lot of skin care, as well as medical dermatology, topical product projects. So I’ve worked with and I’ve done a clinical trial on the neo cuties growth factor line. I think it works well. And Michael Gold, why publish something so years ago using it after micro laser peels just to try to augment the healing response? So, you know, typically we you know, if it’s a lighter peel, like a micro laser peel, you can start right away. If it’s something that’s really heavier than then we wait. More recently, I’ve I’ve done a clinical trial on a snail derived growth factor. And it’s not human derived, such as the Skinceuticals or the Neocutis line. And all of these products are actually very good products. We use all over. And the data’s out. You know, it’s very hard to do a split face study because oftentimes when you do a split face study, you have somebody use something on one side of the face and not on the other side. First of all, there can be a bit of a neighboring effect in certain areas along the midline. And then secondly, you know, people are supposed to wash their hands very, very carefully in between applications. I’m not sure everybody follows those instructions. And then third, I think it’s very difficult because when people are doing split, they studies by and large, sometimes people pick a favorite. Something may sting and something may feel better. And then they may just sort of shrug their shoulders and say, you know what? I know there’s some bias. So so you want to make sure that, you know, split based studies are done because they’re helpful. But oftentimes in the lateral part of the face, they’re probably more helpful.
Dr. Joel Kopelman [00:43:49] These are proteins. Do people get sensitized to them?
Dr. Joel Cohen [00:43:52] So I have not seen contact sensitization the way that we have seen historically with other products like vitamin E derivatives and those types of things. So these are really elegant products that are delivered that usually it’s at the point where some of the wound in the skin has already covered up. So it’s not going that deep into the skin. But you bring up a really good concept there. The concept of laser assisted drug delivery lad is is blossoming right now. And there is a there’s been articles from 10 years ago advocating doing a laser on the surface of the skin and then doing something like putting photodynamic therapy agent over it, allowing that to penetrate the skin and having an augmented response.
Dr. Joel Kopelman [00:45:14] I know the Miami group has done work on drug delivery.
Dr. Joel Cohen [00:45:17] Jill Waible has done some excellent work on using fractional lasers over scars and then drizzling. Not injecting, but drizzling over a steroid like catalog and then rubbing that in. And that’s that’s something that I do every day. We see people who’ve had breast reconstruction. I just saw somebody last week. And in terms of that, we use the pulsatile laser for some of the redness and then we use the fractional lasers to poke little holes and try to break up some of the scars. And then we drizzle over some of the scar some of the steroid. And then I have my assistant really rub it in into these areas. And that can be very, very effective. And Dr. Waible has published some excellent articles on that. And then for people who have a tummy tuck or C-section scars that may have gotten thick skin, that’s ways that we approach them as well.
Dr. Joel Kopelman [00:46:07] I use 5FU quite a bit. I don’t know if you do that.
Dr. Joel Cohen [00:46:11] I personally use a lot of 5FU in scars that are thicker. And there’s been some publications on that at this point of a mix of of intravenous steroids and both you and in the rare circumstance where somebody has like a delayed inflammatory reaction to some injectable product, that that’s what I tend to use.
Dr. Joel Kopelman [00:46:34] Pigment. I know you have an interest. And my interest as an oculoplastic surgeon is in under eyelid dark circles .
Dr. Joel Kopelman [00:46:44] And how do you approach a patient, say, of South East Asian descent who has these dark owl like dark pigmentation under their eyes?. Do you have any secret approach?
Dr. Joel Cohen [00:46:57] So first of all, I mean you’re you’re you’re laughing and I’m laughing because undereye hollow’s and discoloration, particularly dark circles are really the most challenging thing that we treat as plastic surgeons and dermatologists. So you’re laughing and I’m laughing because that’s really a tough issue. So I think if you poll every dermatologist and every plastic surgeon there epitaph, they would love to say, you know, cured under eye discoloration or cured melasma. I actually want mine to say, you know what? For father, husband and physician. But but I think that we we we really want to make sure that we focus our energy on areas that that patients can benefit a lot from. And I think there’s a lot of research going on in these two areas, like melasma and like dark circles under the eye.
Dr. Joel Cohen [00:48:11] Let’s first talk about pigment in general and then we can talk about the under eye pigment. So we see, you know, again, people who enjoy the outdoors. So people who are outside riding the road bicycle almost every day, somebody who runs every day, someone who plays tennis every day, somebody who skis in the winter and hikes in the summer. So we see people who have very significant sun exposure. So not only are they causing the college in to break down and they’re getting lines and wrinkles and etching in the skin and they’re getting what we call last ptosis that lost of some of the elasticity of the skin. But they’re also getting discoloration and patchy pigmentation. So we have ways to treat this pigmentation. So in our practice, if somebody wants to have absolutely minimal downtime and wants to see, you know, results, but they’re willing to do a series of treatments and may be pink for a day or so, I’ll typically start with BBL plus Halo, the 2.0 version of Halo at this point. And generally speaking, three or four weeks later, they will have had very significant improvement from that combination of BBL and Halo.
Dr. Joel Kopelman [00:49:35] Is BPL like IPL?
Dr. Joel Cohen [00:49:37] Yeah, you can choose your filter like five fifteen is the filter. Right? But when you get to that point of downtime, you know, some people say, well, what about a chemical peel? Because, you know, that’s four or five days of downtime, too. But this you’re targeting the specific pigment better. We do use peels in our practice is more of a maintenance and we do lighter peels as a frost. But in this case, you’re seeing. More improvement. I have great pictures from that webinar where I show somebody literally three weeks later, she came in in the beginning of December and she wanted to look like a whole different person with a lot less sun damage. By the time of Christmas and we were able to achieve that. So in some cases, people want one more sort of one procedure that’s going to give them a little bit of downtime, that’s going to give them more results. So in terms of more isolated areas of pigment like freckles, see a dermatologist make sure that the lesion do not have any atypical features that we would suspect melanoma. It’s very common that we see somebody come in that has a stubborn spot that they’ve been somewhere in. Somebodies tried to treat it with a laser or chemical peel. And then I look at it and say, I don’t really like the way this looks. I look at it with a dermascope and I see thick pigment irregularities with that polarized light. And I do a biopsy and they have a melanoma in situ, and that is treated surgically with a five to nine millimeter margin. So that’s significant. We need to diagnose those early and not treat or attempt to treat those with some type of laser procedure because it’s not a treatment. We really need to diagnose those atypical pigmented lesions and sometimes they’re tough. So when somebody has an isolated blend to go, that’s out of proportion in terms of size, color borders, you really need a Dermascope . But you can you can always default to what Gene Bologna called the ugly duckling sign, where something just looks like it’s out of proportion and everything else and that should be looked at. But if if everything looks OK, then, you know, I use a Q switch laser. And we can see very, very significant improvement right from the get go on these. The one caveat with a Q switch laser is you have to make sure nobody’s ever had systemic gold exposure. So for people who have had you know, they may live in Canada or the UK or some place elsewhere from the National Health Insurance and socialized Medicine, they may have not gone right to a biologic. They’ve may have tried something else like a gold type of regimen. You have to make sure nobody’s been exposed to gold because that can cause with acute interaction. These gold particles that are residual in the skin to have this silver stain . And you don’t want that to happen. So I’ve always screened for that. But then you get to the point where you asked, in addition to sunscreen, what else can you use topically? Everybody has always touted the efficacy of hydroquinone Kligman, regimen. And we still use regimens like this where we have a retinoids and hydroquinone and then we have a steroid. But there are concerns about long term use of that for many reasons that we could get into. So people have for years been looking for alternatives to hydroquinone and there are some alternatives. There’s Kojic acid and Azelaic acid. And this point, you know, people are really interested in tranexaminic acid, even topically and orally. So there has been a resurgence of really people around the globe looking for something that can replace hydroquinone, because in some countries or in some, you know, areas of the world like Europe and Asia, it’s not even available anymore.
Dr. Joel Kopelman [00:53:18] Is that because it’s carcinogenic?
Dr. Joel Cohen [00:53:20] The two issues are one, prolonged use of a hydroquinone has caused, in some cases, a paradoxical pigmentation called ochronosis.Very rare. It’s happened.I’ve seen people with it. So that’s a concern. And too, there are some primate studies out there that talk about potential for oncogenesis. So suffice it to say that some countries and some regions of the world are moving away from it. And at this point, you know, I think we’ve used it for a long time in the States. I personally think it’s safe. And I personally think it’s effective. But I don’t have people use it for longer than three or four months. And I really I don’t give them access to use it for longer than three or four months. And at that point, we think of alternatives and the alternatives are the ones we mentioned with Kojic, Azelaic acid, tranexaminic acid , retinoids even, and a host of other types of things. But now this five percent cystamine. You mean the brand name is Cyspera. It comes from a European company scientia which is marketing in the states from Sente. So Sente”s reps are distributing this. And this is something which is interesting because it’s short contact therapy. So, you know, if you if you think about it, one of the biggest issues that we have with our patients is compliance. And if people continue to get sun exposure, then nothing that we use is going to be really effective, whether we’re doing lasers or peel’s or a host of other types of procedures. So we want patients to be a co-participant in their care. And by having a short contact therapy, I’ve seen in the two years that we’ve been using Cyspera in our practice, it’s been available from Sente for just about six months. But I’ve seen people bit been more engaged in being a co-participant in their care because they only have to use it fifteen minutes a day. So ideally, I’d like my patients to use a retinoids at night. I’d like them to use maybe one of these other products with tranexaminic acid during the day and put sunscreen over that and layer the sunscreen. But I tell them when you get home from work or school, wash your face, wait about an hour, because you can’t put the cystamine directly on the skin after washing and it won’t work. So wait about an hour and then apply it to the region that has the pigmentation. This is great for my melasma patients. There is a little bit of a smell to it and it is a little bit irritating. So if people use it for longer than 15 minutes, I’ve had people use it for a couple of hours and they may get a little bit of irritation.
Dr. Joel Kopelman [00:56:11] That’s that’s a hot topic lately. I mean, orally or injectable. How do you go about using it? And how does that fit in with this new this new systemis?
Dr. Joel Cohen [00:56:23] First of all, tranexaminic acid is most commonly used topically and at least right now.And there’s a few different formulations. There’s one from Skin Medica that has it. And, you know, in terms of Skinceuticles has one as well. And I did a clinical trial for another company on one, a formulation. I think we’re going to be seeing more with tranexaminic acid. I use a lot of procedures for these patients, and I really love the thulium laser in our practice. We use the Lutronic has a new version of So it’s 20 watts. There’s no other Thulin laser on the market. That’s 20 watts. So it’s quick. It’s effective for melasma patients. We use really, really, really low heat. So we’re not doing a lot of passes. We’re not doing a high joules. And in the current issue of New Beauty magazine, there’s a section that I was interviewed for, actually wrote a good chunk of the section as well on. I’m using minimal downtime type laser procedures. And the Thulium laser, the laser M.D.
Dr. Joel Kopelman [00:58:06] Well, listen, you’ve been very generous with your time. I’ve learned a hell of a lot.
Dr. Joel Kopelman [00:58:12] I’ve gotten I’ve actually done a dermatology at a cosmetic dermatology fellowship today.
Dr. Joel Kopelman [00:58:19] So I appreciate that. And I can’t thank you enough, Dr. Cohen. And it’s really been a pleasure.
Dr. Joel Kopelman [00:58:25] I see you’re a font of knowledge, and I hope our listeners can digest all of the information you’ve conveyed. And I don’t know what else to say, except thank you for your time.
Dr. Joel Cohen [00:58:41] Thank you, Joel. I appreciate it. From one role to getting to know you at at meetings around the globe and spending some time with you and having dinner with you and and learning from an ocular plastic surgeons perspective. And if people out there are residents or fellows and they’re interested in spending time with cosmetic dermatologist or a laser person, there are specific preceptor ships through the American Society of Dermatologic Surgery and the American Society of Laser Medicine and Surgery. I have a preceptor ship for each of those, and there’s a lot of wonderful people in the country that have preceptor ships. I also have a MSDS fellowship as well. So, you know, there are many opportunities for people to get additional training in some of these procedures.
Dr. Joel Kopelman [00:59:27] The information expressed on the Beauty Doc podcast are the pains of myself and my guests, and they are not meant to replace a consultation with your doctor or beauty specialist.
