Newest Anti-Aging Devices & Treatments with Dr. Brandith Irwin

Airdate: 4/24/12

Dr. Brandith Irwin, author of The Surgery-Free Makeover, shares the absolute latest and greatest in anti-aging dermatology.

Bryan Barron: Good evening everyone. Welcome to "Be Beautifully Informed with the Paula's Choice Research Team." I'm Bryan Barron online tonight with the co-host of the evening who is Kate Mee, our Product Development Director here at Paula's Choice. Hi there Kate.
Kate Mee: Hi.
Bryan Barron: Oh good, I can hear you. And tonight we are going to be talking with Seattle-based dermatologist Dr. Brandith Irwin.
00:00:30 I'll get to more details about Dr. Irwin in just a moment, but she is going to be online with us talking about the latest anti-aging treatments for an ageless face. She recently attended a derm conference in Paris, France where they discussed all the latest and greatest, present the new research about the devices, what's working, what's not, what's changing , the results that they have experienced in trials. So, she has some exciting things to share with us.
00:00:59 If you are listening to the show and thinking, wait a minute, I got an email about tonight being anti-aging tips with makeup, we apologize - that email was sent in error. And a second email actually went out to those who did not open the first one. We didn't want to bombard you with too many emails, but I do apologize for that. That show was a rebroadcast that we had originally intended to do this evening, and then due to some scheduling issues on both sides we had Dr. Brandith Irwin agree to come on the show tonight.
00:01:35 So, please stay with us though, because you are going to hear some great information. You can call in with your questions regarding any procedure that you have been considering, anything that has been bothering you about your skin that may need a dermatologist's attention. Of course, Dr. Irwin cannot diagnose over the phone, but she may be able to give you some helpful pointers. You are welcome to call in with questions at 347-426-3783.
00:02:03 And Kate, there was a couple of new Paula's Choice products and changes that you wanted to tell our listeners about.
Kate Mee: Yes. We are actually working on a lot of new products, but a couple ones that are coming up soon is a new mask for the Skin Balancing line. What's interesting about - and this mask will replace our current Skin Balancing Carbon Mask. And what's interesting is that our carbon mask gets such polarizing results when it comes to our customer feedback, which is unusual.
00:02:36 Typically we don't have such a conflict in terms of the product. So either people love this product or they hate it. So what we have done is we took the best of what people like about it, the great oil-absorbing properties, and we created a new mask with those properties but we improved all the things that our customers were telling us that they didn't like about it.
00:03:04 So we are hoping to launch it in the next couple of months. And the name is going to be the Skin Balancing Oil-Absorbing Mask.
Bryan Barron: I love the new formula. I'm one of those people that falls into the camp of not being able to use our current mask. And, Kate, you are right - it's interesting; we listen to all feedback about our products. We love the reviews that you guys post on the website telling us what you think, both good and bad.
00:03:30 And we decide after some consideration that that mask was polarizing enough that it deserved to go back to the drawing board, so to speak, and what Kate and the team came up with is really, really nice. So, I think anyone who is using the current version and really liking it will enjoy this just as much. And those who didn't like the current version will want to give this another try.
Kate Mee: Yes. We did some extensive panel testing on users that really like the current version, and they like this one just as much. So, hoping everyone will feel the same. And it has some great anti-irritants and skin-soothing ingredients, so we are excited about it.
Bryan Barron: One more thing I wanted to mention before we get to Irwin is that this is the last live broadcast that we are going to be doing until September.
00:04:18 We will back with live shows the Tuesday after Labor Day, which I believe is September 4th. In the meantime throughout the summer we are going to be doing rebroadcasts of some of our more favorite shows, so if there are any that you missed you can still tune in Tuesday night at 6pm.
00:04:36 All of these shows are also available on in our community section. Click Radio Show - you can listen to past broadcasts as well as see transcripts of past shows. So, without further ado, I know she is here online with us. Dr. Brandith Irwin, Seattle-based dermatologist, and she runs Madison Skin and Laser Center in Downtown Seattle.
00:05:01 She is the author of the book "The Surgery-Free Makeover: All You Need to Know for Great Skin and a Younger Face." She is Paula's dermatologist. I've been to her facility. Dr. Irwin, hello.
Brandith Irwin: Hello. How are you, Bryan?
Bryan Barron: I'm doing well. How are you doing?
Brandith Irwin: Good. I have to apologize ahead of time though because I have a terrible cold. So if I have to sniffle I might. You can take me offline for a minute. But I think I'm going to be fine. I'm just warning you, if I sound like I am underwater in a fish tank you will understand why.
Bryan Barron: I'm so glad that you brought that up because I kind of had that reflexive response of saying that I'm doing well, and overall I am, but I'm in the exact same fishbowl you are.
00:05:45 I've had the worst cold --
Brandith Irwin: I'm sure there are some people in the listening audience who are feeling the same way. There seems to be kind of a bug going around, I think.
Bryan Barron: Oh, you're not kidding. And then coupled with the high pollen count that we have had this spring in the Seattle area. I mean, if you have allergies and you get this cold, you are in a sorry state.
Brandith Irwin: I know. We are on a major whine mode here aren't we? But it's good.
Bryan Barron: All right, Dr. Irwin.
00:06:13 Well we will bear with you and to our listeners I apologize for sounding a bit nasal, but we are going to get through this hour...
Brandith Irwin: What can we do, right?
Bryan Barron: Exactly. So, Dr. Irwin, we came up with some questions for you, and one of the things that you brought up when we were corresponding is that you wanted to touch on the topic of a self-assessment in terms of how should a person assess their aging face to determine when they need to see a dermatologist for a corrected procedure, or maybe if they should just keep using skincare and hope for the best.
Brandith Irwin: Right. Okay.
00:06:53 I think that's important, because I mean I'm sure you all hear this a lot, and so do we here, where people call and they say, "I just don't like my face. Help me." But it's really hard, our front desk really does try to help them identify a little bit more what exactly it is that is frustrating them on the phone so that we can direct them in a way that will get them the information that they really want.
00:07:22 But I think a lot of women do look at their face and go, "I just don't like the way I'm looking these days," but it's hard for many women and men to pinpoint what it is exactly that's bothering them.
Bryan Barron: You know what we hear sometimes, and let me know if you have heard this too, but we will hear from women, because mostly the people we hear from are women, and they will say, "You know, I don't know what it is, but just one day I got up, I looked in the mirror, and I looked old."
Brandith Irwin: Mm-hmm.
Bryan Barron: And it just seemed to happen overnight. And it doesn't necessarily see to be beholden to a certain age.
00:07:57 Although, if I guesstimated I would say that it would be like mid-30s.
Brandith Irwin: You know, that's funny because I hear that, too. And I honestly don't think it's something that happens overnight, and I'm guessing most of the people in our audience would agree with that. But it's almost like we notice it all of a sudden. Because I do think the changes take place very gradually over years. Let's just be honest, if you look at a 16 year old face, that 16 year old face is quite different than a 35 year old face, and is quite different than a 55 year old face.
00:08:28 And then every day, you know, let's just be honest, we are changing and then environmental stresses and what we are eating, our exercise, if we have been ill, weight gain or loss, all of those things effect our skin, any illnesses, that sort of thing. So, I think it is almost more an accumulation of small things over time, but then all of a sudden we wake up and we go, "Whoa, this is not the direction I want to go." And it is more like the realization is sudden, I think, more than the actual changes themselves.
00:09:01 But it doesn't matter, really, because if we suddenly notice it then we notice it, and we want to do something, so that makes total sense to me.
Bryan Barron: So how do you advise someone to go about doing a self-assessment so that they can pinpoint what they don't like rather than calling with that nebulous, "I just don't like my face."
Brandith Irwin: Right. I'm going to try to make this - you know, with all of the technology we have now, and all of the things we know about aging faces and skin, there's a lot. And I think you and I - I'm hearing a lot of confusion from consumers because there is just so much out there, and how do you know what to believe, and how do you know what to do?
00:09:39 What works for what? And so what I want to say is I think one way to think about this is to make it kind of simple, is to say aging skin is kind of about surface and volume. So, you want to start by looking at your skin and saying, is this a problem that mostly has to do with the surface of my skin, in other words acne, acne scarring, texture problems, little bumps, fine lines, brown spot, red blood vessels.
00:10:14 Is this a surface issue, or is it a volume issue meaning I'm losing volume in my cheeks, or there is hallowing in my cheeks, or sagging at my jowls, hallowing in my temples, those kinds of things which are volume issues. And then, of course, a lot of women especially age 50 and over, 45 and over, there is both. It's pretty rare to see people over the age of 45 who don't have a little of at least both of those going on, because we do start noticing volume changes more as we get older.
Bryan Barron: Right. And you are definitely noticing more of the effects of sun damage by that age, too.
Brandith Irwin: Absolutely. Although I have some 50, 60 year olds in my practice who have almost no sun damage, and they have very few surface issues, but they have volume issues. And it is the same thing with African American skin. Like if you look at the way African American or women of color age, sometimes they will have pigmentation issues in that the surface of the skin there may be more pigment, for example, in certain areas of the face than others.
00:11:17 And so that is troublesome sometimes. But, in general, if their pigment is really nice and even as African American women age, for example, or some Hispanic women too, it's more of a volume issue - it's sagging. And because that extra color is protective, because that color is just melanin, right, that's all that is. And melanin is protective. So, the darker you are the more natural sunscreen you have in your skin.
00:11:42 Well that doesn't mean you can't really damage yourself. You can. I have some patients with darker skin types who have just baked themselves, but they have to do a lot more baking to see the damage than someone who is a red head for example. And that makes kind of logical, intuitive sense I think, too.
00:12:00 I think sometimes in looking at African American women and their faces as they get older, you can see more purely the volume issues. So then you have to say, "Okay, if it is surface, or it is volume, or both, what is bothering you the most? Is it the sagging at my jowls? Is it the fact that I am getting those upper lip lines? Is it my crow's feet? Is it my frown lines?" And I think it sometimes helps women to make a list of the top three things, and then start with those. Start with those things first, and then branch out into some of the things that are there but not bothering them as much.
Bryan Barron: Okay, got it.
00:12:41 I think it's a very easy way to think about it in terms of surface versus volume. The one question I had is that when it comes to dark circles one could argue that that is a surface problem, but it's one that is make worse by a loss of volume in that area.
Brandith Irwin: Right exactly. And sometimes, and there are different kinds of dark circles.
00:13:04 Sometimes the dark circles are more the visibility of the purplish veins underneath. And sometimes it is actually more melanin in that area. And then, you are right, the volume loss around the eye aggravates that.
Bryan Barron: So in terms of - is there anything new under the sun so to speak in terms of treating dark circles that are genetic or that are made up of the vessels showing through that thin skin?
Brandith Irwin: I mean the answer to that is yes in that fractionated lasers work really quite nicely for dark circles that are pigment.
00:13:48 So, because you can slough some of that pigment off, like if you do a treatment with a fractionated laser, a lot of times you are sloughing off about 15%, maybe 20% at the most of this skin that is present, the old skin. And you are sloughing it off and allowing new skin to grow in. And so many times you can make a difference with a fractionated laser around the eye for those type of veins.
00:14:15 And then for the type with the blood vessels, there are some lasers for blood vessels that can be used around the eyes, some can't. So, that is a little trickier. But then sometimes just replacing volume in that area with a little bit of gentle filler. For example, Restylane is not FDA approved for that area, but expert-injectors only please being used sometimes to fill that tear trough area.
Bryan Barron: Okay.
00:14:44 And then by filling in that depression, the dark circle is less apparent?
Brandith Irwin: Yes, absolutely.
Bryan Barron: So you mentioned Fraxel, fractional laser devices; that is kind of the new thing as far as like ten years ago the big daddy of the lasers was the CO2 resurfacing where you were down for about two weeks afterwards. It was quite impressive results if you could handle the side effects. There was definitely some issues with loss of pigment if the treatment was too aggressive, and certain skin tones were absolutely out of the running for it.
00:15:21 So now fractional laser devices seem to be taking over, but once again, going back to what you said about it being just so confusing, I think I lost count at about eight or nine fractional devices that of course is led by Fraxel, which is a brand name, yes?
Brandith Irwin: Right. Fraxel is a brand name. And it is an erbium fractionated laser, but there are lots of other ones out there that are also erbium lasers.
Bryan Barron: Does it matter which one?
Brandith Irwin: Well it does actually.
00:15:55 So the main two groups, again, I'm going to try to make this as easy as I can. There are two main groups. There's carbon dioxide fractionated lasers and erbium fractionated lasers, of which the Fraxel was the first on the market. It was a great laser. It still is a great laser. And that is an erbium laser. In general, the erbium lasers, and again there are some exceptions to this, so I'm not going to go - but in general, the erbium lasers are more effective for younger patients because they don't go quite as deeply.
00:16:29 And they are more effective for fine lines and less so for deeper wrinkles. And, they can be a little bit better for pigment though, particularly the new Fraxel Dual which has a pigment laser now embedded in the original Fraxel, which was a really great improvement in that laser. So, yes, in general the way I kind of like people to think of it is if you are younger you have more pigment issues and fewer wrinkles, or very mild acne scarring, I would probably direct someone to the Fraxel.
00:17:09 If someone is older, has deeper wrinkles, needs some skin tightening in addition, because CO2 is better for skin tightening, the I would probably direct them toward this carbon dioxide laser, or had deeper acne scarring. So, it really depends a little bit on the person. That's why you need your doctor for that, because I think it's almost impossible for the average person out there to read all the stuff that is out there online and go, "Okay, I know what I need."
00:17:40 Because there just is too much. And many doctors are confused about it, too. And the different lasers are actually quite different. For example, if you look at the carbon dioxide fractionated lasers, and I won't go into this too much, but for example some of them call themselves fractionated carbon dioxide lasers, and I'm not going to name any names here, like maybe the [Alma Pixel] and some of the other ones, but they are generally under powered, they use a stamping technology which is really not a true fractional device.
00:18:07 And sometimes it gives very uneven and inconsistent results compared to, for example, a Luminous Ultra Pulse Active, or a DEKA Dot, or one of those, which tend to be, in my opinion, a higher quality laser. So, I think it's really - those other lasers are kind of cheap, but they also don't work very well. You know, they can be cheaper but they don't work well. And you are not get getting the kind of consistent really great results that you want.
00:18:31 So the technology matters, and the average person can't figure it out a lot of times. Sorry, I kind of went long on that one.
Bryan Barron: No, no, that is fine. It's nice to have a voice of reason amongst all the insanity about the different types. And, because you do, you can absolutely get lost reading about all of this online, you know, do a Google search for fractional laser resurfacing. So, Dr. Irwin, what would be the cutoff in terms of when would you direct a patient to have a Fraxel versus doing an IPL? If money is not an object, if they are not saying to you, "Okay, I can only spend $250 to $500 right now," how do you decide whether to say start with IPL or let's just go right to Fraxel?
Brandith Irwin: Right.
00:19:20 Okay, and I just want to say first, too, a lot of this information is on, my website. And if you go to the laser section you can find a lot of this there. So if somebody really wants to read more in depth they can do that.
Bryan Barron: Perfect.
Brandith Irwin: Yes, And then if you go to Topics and then go to the Laser section there is a lot of it there. So, the IPL versus the Fraxel. So, you want to think of the IPL or it is sometimes called photorejuvenation, think of that more for color. You do get a little bit of collagen rejuvenation with it, or generation with it, but it's pretty superficial and it's not very much. So, if you are red and blotchy or brown and blotchy, as long as those brown spots aren't too deeply entrenched or raised, an IPL might be perfect for you.
00:20:09 If you are really trying to target wrinkles better, or brown spots that are a little more entrenched, then you may want to go the Fraxel route, particularly the Fraxel Dual.
Bryan Barron: So could Fraxel Dual be used on like moles? Or are those not treated with Fraxel?
Brandith Irwin: No. We don't treat those with...we try to general we try not to laser over moles.
00:20:37 It happens a little bit, but you are not trying to ever, I mean, most people... - Put it this way: it's not a great idea to try to remove a mole with a laser. And you probably wouldn't be successful with it anyway. And you could potentially change that mole and what if that generated a process in the mole that then later caused it to become cancerous?
00:21:00 We don't laser moles. Again, occasionally a little bit of energy will got that direction just because the person is passing over. But in general I would avoid lasering moles. It's not a good idea, and we really don't have long-term data on the outcome.
Bryan Barron: Okay, good to know. So what about some of the newest non-surgical treatments that remove fat, like using intense cold or heat. I have been reading about the Zeltiq Coolsculpting, the Liposonix. The Zeltiq uses cold. Liposonix uses heat and ultrasound technology.
00:21:35 What do you think about those?
Brandith Irwin: Okay, these sound pretty fun, don't you think? I mean everybody who talks about this goes, "Oh, wow, these are kind of cool." I mean, we all love the idea don't we that maybe some of our little extra spots could be shrunk without liposuction or surgery or something, right? I know a lot of women and men who would be interested in these.
00:22:01 So here is the thing, though. I mean, these technologies are new, very quite new. They are promising. And the question is, of course, is do they last. Because you don't want to go spend thousands of dollars, look great three months later, and then a year later be right back where you were. That's just not a reasonable thing. So, some of these technologies, for example, there was one on the market called [De Zerona] and the problem with that was that the technology, what it did is it punctured a little whole in the membrane of the fat cell --
00:22:37 The fat drained out, it was carried away. And the person looked great three months later. Unfortunately then the [unintelligible] backup, and then a year later people looked pretty much the same, because the fat cells filled back up again. So, you sort of get the picture about the problems with these. So, so far, for example those Zeltiq has, in my opinion, the best, most consistent record for longevity and results.
00:23:08 Now this is not a technology that you can use for large amounts of fat. I mean, this is for love handles that are small, sculpting. You know, a lot of us have a little bit of baby fat on our tummies, even though we are in good shape. And they are developing some [heads] for other area. They don't have them yet, but they are trying to develop one for the underarm area which bothers a lot of women, and maybe the inner thigh.
00:23:37 But so far it's approved for the abdomen and love handles, too, I believe on that one. And people are getting pretty consistent results with that. And I have talked to various colleagues of mine across the country and they are really quite happy with it. Again, as long as it is the right person and the expectations are realistic. So, I think that is definitely a consideration. The Liposonix, I think the jury is still out on that.
00:24:00 I think there are studies. I recently read through the papers on that and there are studies out to three months. Okay, that's nice, but I really want to see data for a year, or a year and a half at least. I'm kind of waiting on that one to see what really happens over time.
Bryan Barron: And at least from what I understand on the Zeltiq Coolsculpting, it's not a procedure that you will have and then the next day, "Wow, look at that new slimmer you." It actually takes time for the body to break down that excess fat and excrete it.
Brandith Irwin: Actually all of these technologies work that way.
00:24:36 There are some of them that have been marketed, and I would say buyer beware on these, which is they promise you results and then they have you on some amazingly strict diet and exercise program. I mean, I think for one of these technologies to be legitimate it's got to work without diet and exercise. Because we all know diet and exercise work. So, I think to say, "Well we are going to couple this technology with a lot of diet and exercise," well then you don't really know if it is working.
Bryan Barron: Exactly.
Brandith Irwin: So that bothers me.
00:25:08 And I would avoid those companies that say, "Oh yeah, but now we are going to put you on a 1,500 calorie-a-day, or 1,000 calorie-a-day diet or something."
Bryan Barron: Or less than that. Yeah, my neighbors are on this eating plan and the first two weeks were like 750 calories. And it's like, well of course you are losing weight. You are starving yourself!
Brandith Irwin: Do they use a technology in addition to that, too?
Bryan Barron: No. Not that I know of.
00:25:38 Not that they are revealing, and they are pretty much no holds barred when it comes to that, so I would imagine if they were doing that they would tell me. So, it seems like in terms of the fat dissolving techniques that are non-surgical, really the ideal candidate would be someone who exercises, is at a healthy weight, certainly not tipping the scales towards being obese.
00:26:02 And just has that last little bit of stubborn fat that they can't get rid of no matter what they do.
Brandith Irwin: Yes. Exactly. [Unintelligible] is a perfect example, because he is actually very lean --
Bryan Barron: I'm sorry, your husband?
Brandith Irwin: My husband. My husband is the perfect of somebody. He is actually very lean, he is in good shape, but he has love handles. And he would love to get rid of those. That's just genetic in his family. And I think there are a lot of people out there like that. And, again, women I think particularly, that little bit of know I have it, that little bit of baby fat that I just can't get rid of through exercise, so.
Bryan Barron: All right.
00:26:38 I mentioned E-Prime to you earlier, and you were just kind of like, eh, so E-Prime is...I will fill the listeners in. E-Prime is a - I guess you would call it an invasive technique to a certain point that uses finely tipped needles that supposedly reach down to the dermis to heat collagen to a certain temperature which is supposed to be optimal for collagen remodeling.
00:27:06 It sounds exciting. The fashion magazines are talking it up. But when I mentioned it to Dr. Irwin she basically said let's proceed with caution.
Brandith Irwin: Well I just, again, I think we just don't have enough information yet. It's really all the rage now, and it's very faddish, and I'm really skeptical about fads. I think it is a fad because their marketing department is doing a really good job.
00:27:31 And that doesn't necessarily correlate with results. Again, I feel like, okay, we women - we don't want to go out and spend a whole bunch of money and then find out, okay, oops, this didn't work very well after all. I think we want to save our - spend our time and money wisely. And I'm not convinced yet, and I have to be honest, I have not pulled all the studies on this. I looked at it a little bit. I was at the Paris Conference, I don't remember it there, but they did have it at - I went to the American Academy of Dermatology meeting in San Diego that was about a month ago.
00:28:04 I did look at it there. I'm going to pull all the papers on it and see if I can make sense out of the science. But I'm just saying, just give it time. It may be in a year everybody is going, "Oh, let's not waste our time." I'm skeptical. So I'm just saying it sounds really cool, who knows; it's getting a lot of press because they have a good marketing department.
00:28:26 But I'm not convinced at all that it's - I mean the thing is, is it better than a technology that we have currently for tightening like Thermage, for example. Again, which is not perfect at all, but...
Bryan Barron: Well, that's actually an important point is that none of these procedures, despite the hype, and despite the dermatologist enthusiasm, none of them are perfect and you always have to keep your results realistic. Every one of them has limitations and none of them are a replacement for what is possible when a surgeon actually cuts into you; the changes that can be made in that realm versus what can be done topically via what is typically called a non-invasive procedure are still pretty far apart.
00:29:12 But we are getting closer.
Brandith Irwin: Yes, we are. And that's exactly right. And we can get a little bit of tightening now with Thermage, with Tighten, with Ulthera. Again, I still think Thermage has an advantage in that it is not painful and you can do it in one treatment, whereas the others you have to do in a series of three. And the Ulthera for sure is more painful. Tighten not so much.
00:29:36 So it's like if you are comparing those three, we know we can get a little bit of tightening with those three. And is this going to be better? I don't know.
Bryan Barron: Right. The jury is still out.
Brandith Irwin: Yes. The jury is still out I think. I mean, I would love it if it worked. And I think in a year we will probably know whether there is really something to it or it is just really hope over realistic results.
Bryan Barron: Exactly.
00:30:04 Now are you still offering Thermage at your practice?
Brandith Irwin: I still actually really like it. And I think of the three technologies out there that are like that, it still has an edge in terms of being something you can do in one treatment that is not painful, and for the right person you can get a nice result. I think, again, I choose my patients really carefully for that, because it is great for maintenance of the jaw line in older women. I think it helps with that. And I think it is great in younger women; you can get a little bit of tightening in about 90% of patients.
00:30:39 And everybody builds collagen with it. We know that from biopsy studies. So, I think if you want a little bit collagen regeneration and a little bit of tightening, that's a good way to go. But it's not going to be dramatic at all.
Bryan Barron: And to our listeners, what Dr. Irwin just said about carefully screening her patients for Thermage, and I know that she and her team do that for all the procedures that they offer, but of course, yes, I'm tooting the horn of Madison Skin and Laser here in Seattle, but that screening process is absolutely what you want any cosmetic dermatologist to do. If a cosmetic dermatologist you are seeing is pushing one treatment, and is just making it sound incredibly wonderful and can't go wrong and everyone loves it, and isn't presenting any drawbacks, isn't sounding realistic as far as like, "Well this is about as far as you can get, but you are not going to see this, this, and this."
00:31:35 That's not the kind of dermatologist that you want to give your money to, because they don't have your best interest at heart.
Brandith Irwin: Exactly. And you want them to say, "No, this is not going to give you - you can try it if you really want to, but I really don't think you will get much of a result with this." You want the person who says that. I really feel strongly that I don't want my patients wasting their time and money. I want people to get good results, and I want them happy.
Bryan Barron: There is a whole psychology behind that, but it is consumer good. I'm purchasing a service from you that is supposed to do this, and if it doesn't, I'm upset.
Brandith Irwin: Right.
Bryan Barron: Much the same way you eat out at a nice restaurant, and the dish that sounded so wonderful on the menu just tastes awful and is cold in the middle, you are not going to pay for that. You are going to send it back.
Brandith Irwin: That's right. I think that's right. And I think with Thermage, I mean, one of the good things is we have enough data on that. We know about 10% of people don't get any visible result with it, even though they build collagen. And you can just tell people that. You might be that 1 in 10 person.
00:32:40 And then most of the patients that we have who have done it for a long time over the years, who are the right people for it, love it. But it is not for everyone by any means.
Bryan Barron: We know that dermal fillers, which we haven't touched on yet, but there has been an explosion of those. There are really only two or three main kinds. We know that they are great for pumping lines and wrinkles, particularly the lines along the side of the mouth, the nasal labial folds.
00:33:06 But are there any less common uses for dermal fillers that you found that actually produce really great results and you think, "Why doesn't anyone every talk about this?'
Brandith Irwin: You know, there are. I feel, it's one of those things where I don't necessarily like to talk about this on air because they are for expert injectors to do because a lot of those uses, let's just be honest, they are off-label. And I think -
00:33:34 And so I think it is one of those things where if you have an expert injector who can identify a dermal filler as a solution for a problem that is slightly different than the usual things, well that person, I would say, "Okay, yeah, that person is an expert injector. They know how to handle complications." But I have found kind of through my blog, and my Q&A on my website that people are asking me about things and I have to constantly say, "This is for expert injectors only." Don't go to your person who may not be very experienced and say, "Hey, can you do this for me?"
00:34:09 Because I think that is not a good idea. The doctor may be trying to be helpful, but certain things should really just be done by experts-only I think, who have a lot of experience.
Bryan Barron: Yes. So changing gears, but in that vein, as a patient, how can I tell if a certain dermatologist, because let's say if you are dealing with an expert in terms of skin, how can I tell if that dermatologist is an expert injector?
00:34:39 Do I just ask? Is there a certificate I should see? Pictures?
Brandith Irwin: That is so hard, isn't it? I mean the certificates are useless because to be honest these companies will - I mean this part drives me a little crazy, too. It's like if you are an RN working in a plastic surgeon's office and you have just been hired, they can send you to a one-day training thing and you have a certificate. And that just means nothing, really.
00:35:07 But they have "certified you" in the technique. But you still know nothing because you don't have any experience in my opinion. So it's really tough, I think. And you are right - it's like sometimes doctors might be embarrassed to say if you ask, "How good are you at this?" It's really hard for a patient to ask that I think. And then it is hard for doctors, I think, sometimes to admit, "Well, okay, I have just started learning this, so..."
Bryan Barron: It's a delicate...
00:35:38 I know from talking with you, and I know that you have done some dermal fillers on Paula, and I know that you know what you are doing. When the time comes for me to get dermal fillers, I would feel absolutely comfortable sitting down with you.
Brandith Irwin: That's so nice. Thank you.
Bryan Barron: Well you are welcome. But I completely understand that anxiety of - the patient/doctor relationship is almost always like a parent/child relationship. And the doctor is the professional; they are supposed to know best. You are kind of at their mercy so to speak.
00:36:11 And it can be awkward in that situation when you are feeling vulnerable in there because there is something you don't like about your appearance to speak up and say, "Wait a minute. How much experience have you had with this? How many patients have you treated? Why should I trust you with this?"
Brandith Irwin: Right.
00:36:29 One thing to think about is doctors with a lot of experience in one area, it's pretty obvious. Like in our practice, we do everything in dermatology. We have Dr. Rogers, a fabulous skin cancer surgeon. We all do skin exams. We are focused on everything from warts to the most complicated skin cancers to the most complicated lasers. You might think, well oh gosh, are they are spread too thin? But, no, we actually have a lot of depth in each area.
00:37:00 I don't do surgery. You know, she does all the surgery. I do the lasers and anything complicated in injectables. And so there is a lot of depth in our practice. But you are right, it is like you want those centers where you can sense from it that there is really a focus on this. They are dedicated to the aesthetic side of dermatology. It's not just, "Okay, I'm going to do a little Botox on the side to make a little more money."
00:37:32 That there is a dedication and an interest and a commitment to continually being educated, and sorting out the technology and doing a lot of it. So, doing a lot of it, so, you are right, it is hard to know that when you go into a doctor's office. I think you can kind of tell maybe from the way the person is presenting themselves online and in their office. And if it really just seems mostly medical, maybe that is not the right office, I don't know, for something complicated in cosmetic.
00:38:04 I mean, again, just basic Botox could be just fine there. But if you were thinking about more complicated procedures, then you might want to go to someone, yeah. You are right, it's hard.
Bryan Barron: Be wary of cosmetic procedures offered as more of an afterthought, or seemingly a la carte, like, "Hey, you are here for you annual mole check, but let's do some Botox."
Brandith Irwin: Yeah. My personal opinion is honestly that only board-certified dermatologists and plastic surgeons should be doing aesthetic work, because now you get these weird places that are springing up all over where you have a gynecologist or a dentist offering Botox.
00:38:43 You know we have in our - we have a guy here who I think was an ER doctor. And he opened up a skin center. Well the state closed him down. He had so many confrontations - it was awful. I mean, he decided he was presenting himself to the public as a dermatologist. And then people would say, "Well, are you board-certified," and he would say yes.
00:39:01 Well, yeah, he was board-certified in ER medicine. But he wasn't board-certified in dermatology or plastic surgery. So, you have got to be even careful with that question.
Bryan Barron: Yes. You want to ask, "Are you board-certified in dermatology?" Because, yes, you are right; they could say, "Well yeah..."
Brandith Irwin: Or plastic surgery.
Bryan Barron: Yeah, in plastic surgery. You are not a board-certified podiatrist.
Brandith Irwin: Exactly. We have another person in town who was an anesthesiologist, so it's like they don't have any training in skin at all.
00:39:36 They don't know how to counter the complications. They don't know how to treat - it's just crazy. And I don't, I guess well partly for me I feel like why is it that our laws allow that? I think if you are board-certified in something, you are board-certified in that. And you shouldn't be able to sort of suddenly switch just for the fun of it.
Bryan Barron: So just out of curiosity, does your practice see a lot of - do you guys do a lot of corrections on botched work where people basically went to the wrong place and then they come to you and say, "Fix this."
Brandith Irwin: Yes. We do. And, you, most of the time it's pretty easy to fix the problem or soften the results for over time.
00:40:21 Like if it is a Botox problem, sometimes you just have to temporize a bit until it wears off. But there are some ways - I had a patient not too long ago who the Botox was injected in the wrong place and she got a facial droop where the corner of one her - her mouth turned down instead of up when she smiled. So, I can't totally reverse that, but I could support that corner - I can do lifting with some fillers to kind of camouflage it so it is not so obvious until the Botox wears off. I mean, there's some various things that we can do now to help people. And I feel like that is part of our job as people who are experts in this area is to really help people who are having problems with complications.
Bryan Barron: Yes.
Brandith Irwin: I don't actually [don't charge a lot for that]. I shouldn't say that. But I figure if I can help somebody they will probably be a fan for a long time, and it will all come out in the end, so.
Bryan Barron: And it's a bad lesson to learn. I mean, my heart goes out to people who have - basically they have been swindled, or didn't look into something well enough.
Brandith Irwin: Yeah.
Bryan Barron: It's tough because oftentimes the desire to do something procedure wise to make yourself look better overpowers rational thinking.
Brandith Irwin: I totally understand that, too.
00:41:44 And I'm actually very sympathetic. And again, just as you have touched on it, or you mentioned, too, Bryan - it's hard for a patient to assess a doctor's skill level and to ask sometimes even those hard questions. Yeah, I'm very sympathetic too, because we have all had days when we look in the mirror and go, "[Unintelligible]."
00:42:05 And do we really need to do something now? No, we don't , but we see [unintelligible] at the moment and I think sometimes it is best just at that moment to take a few deep breaths, take few breaths and go, "Okay, this didn't happen overnight. I don't need to fix it today," and then run off to someone's office where you can get in but they might not be the best person.
Bryan Barron: I think we are about ready to move into some caller questions if you are game for staying on the line.
Brandith Irwin: Absolutely.
00:42:38 I think that would be fun.
Bryan Barron: Okay. Kate, who's up first?
Kate Mee: We have Joanne from Canada.
Brandith Irwin: Hi Joanne.
Bryan Barron: Hello Joanne.
Joanne: Hello. Thank you for taking my call.
Bryan Barron: Do you have a question for Dr. Irwin?
Joanne: Yes. My question is whether there are any benefits for acupuncture.
00:43:00 Whether there is any skin tightening that can be achieved through acupuncture.
Brandith Irwin: You know, I love acupuncture. I think there are lots of wonderful uses for it. And, again, maybe some of my medical colleagues would criticize me for saying this, but I kind of think someone that has been around for thousands of years probably does have some merit, we just can't always prove it. But you know what? I honestly don't think it works for skin tightening. I kind of wish it did. I do think it works for lots of other things, though.
00:43:31 And I have patients, many patients I have actually sent to acupuncturists for certain things, particularly rheumatologic disorders that involve the joints and some nerve problems. I mean, I had an acupuncturist basically fix without surgery a nerve problem in one of my feet years ago. And so I think there are some wonderful uses for it. But I don't think skin tightening is one of the really. I kind of wish it was.
Joanne: I've had really good response to acupuncture for other things, and I know this acupuncturist does what she calls, what she refers to as skin tightening, but I was dubious.
00:44:11 And I welcome your opinion.
Brandith Irwin: Yeah, that's a tough one, because I don't think there is any data on one side or the other on that.
Joanne: Okay. Thank you very much.
Brandith Irwin: You are very welcome.
Joanne: And I have to say I love Paula's products.
Brandith Irwin: Oh good. She makes some wonderful things. Keep using them. They are excellent.
Bryan Barron: Thank you Dr. Irwin.
00:44:33 Joanne, we are going to be sending you a bottle of our new retinol serum from our Resist line.
Joanne: Okay. Thank you very much.
Bryan Barron: Thank you. So we will get that in the mail to you and you can check it out, let us know what you think. And thank you for your question. Kate, who's up next?
Kate Mee: We have Rebecca from Maine?
Rebecca: Hi you all. Good to talk to you.
Bryan Barron: Rebecca, were you part of the freak snowstorm?
Rebecca: No.
00:45:03 We actually had rain while everyone south of us had tons of snow. So, an odd year. I wanted to first of all thank Paula, and you guys, have saved me so much money because I don't buy any neck creams anymore. I'm hoping - is there anything is suitable, I'm 51, and I'm getting, didn't Nora Ephron write something about [unintelligible], but I'm there.
Bryan Barron: She did. Yes, I told Paula about that book, and she said she was going to check it out on her next flight, so we will see.
Brandith Irwin: I should buy that.
00:45:43 And I read part of it. I mean, I thought it was really funny. Nora Ephron, she is really funny. She is a wonderful writer. So, on the neck, okay, I think this is - one of the things you want to look at - so on the neck, Rebecca, is it more under the chin, sagging under there. Is it more of those necklace lines that go around? Or is it more of just kind of loose crepey skin?
Rebecca: It's a combination of the loose/crepey and sort of under the chin, jowly.
Brandith Irwin: And do you have some little sagging right at the jaw line, at the mandible, right where -
Rebecca: Yeah.
00:46:29 Absolutely.
Brandith Irwin: Okay. So there's a couple things about this, and I always find this kind of interesting. If you take your hands and you put them on your face, and you do a little lift there, does it get better under the chin? It does, probably, doesn't it.
Rebecca: Yes.
Brandith Irwin: Okay. So part of what happens in the neck, particularly right underneath there and right at the jaw line is loss of volume. So, you may be somebody if you have a really great person who does Sculptra somewhere in your area, you or even somebody who is really good with hyaluronic acid fillers like the higher molecular weight ones, or ones that give you a little bit more lift like the Perlane or the Juvederm Ultra Plus, you might be able to get a pretty nice result just from replacing some volume in your face. That will help a little.
00:47:24 And then the crepiness on the neck. I mean, so far in my opinion the fractionated carbon dioxide laser is the best thing I have ever seen for that crepiness. Now, is it perfect? No. But it is way better than anything we have ever had before. And usually two treatments will give you quite a nice result. And you will get a result after one, you can kind of reassess. But I think two to three is kind of the magic number for really getting some good tightening there.
Bryan Barron: And Dr. Irwin, how are those spaced? If someone needs two or three treatments, how long do they wait between treatments?
Brandith Irwin: Well I think try - there is really no problem in spacing them out for a long time.
00:48:08 But then you don't kind of see the results either. So I usually tell people try to complete the two or three within a year period.
Bryan Barron: Okay.
Brandith Irwin: For sure. And you know, six months is probably nicer even, to be able to do one every couple of months. And sometimes people do two, then wait - because it takes about three months for that collagen to really - sometimes even longer.
00:48:28 Sometimes even three to six months to see the full results of a CO2. So it is more like they do the two maybe two months apart, or six weeks or something, and then wait a full three to four, five months, and then decide if you need a third. Because you will get some tightening sometimes even out to five or six months.
Rebecca: How long does this last?
Brandith Irwin: Well it is just subject to normal aging. Yeah. And use Paula's sunscreen on that area every single day.
00:49:02 You want to sunscreen your neck and chest. That helps, too, I really think that.
Bryan Barron: Thank you for brining that up. I was going to ask Rebecca if she was using the sunscreen. And, Rebecca, are you using a Paula's Choice sunscreen?
Rebecca: I'm not. I have not tried it.
Bryan Barron: Is your neck area on the drier side or more normal? It's probably not oily because there are so few oil glands on the neck.
Brandith Irwin: I would say pretty much everybody is dry on the neck, unless you are 18 with acne.
Rebecca: Well, I will definitely give it a try.
Bryan Barron: I will send you a tube.
00:49:47 Let's send the Extra Care Moisturizing Sunscreen SPF 30. It's got a nice blend of the mineral actives which are wonderful at blocking the production of melanin, so you are not going to get those brown spots. It's got a nice lightweight but moisturizing texture. And you can try it from the neck down - use it on your hands as well.
Brandith Irwin: Yes. Hands are a good place to put it.
Rebecca: Thank you so much.
Brandith Irwin: Thank you for calling in.
Kate Mee: We have Barbara from Washington.
Barbara: Oh, hi.
Bryan Barron: Hi Barbara.
Brandith Irwin: Hi Barbara.
Barbara: How are you?
00:50:22 Thank you so much Dr. Irwin for all your honesty about choosing the right dermatologist; it can make all the difference in the world.
Brandith Irwin: You are welcome.
Barbara: My questions is about all these wrinkle fillers that are being marketed now. Are they worth the money or should I just save my money and wait until I can get a treatment?
Brandith Irwin: Are you talking about the topical ones that you are seeing? You know, do they make you temporarily look a little better, yes. They are almost like a little bit of spackle. I don't know if you have looked at the labels, but a lot of them have like a little silicon, things like that, but do they give you any permanent change? No.
00:51:07 I still think, again, use your vitamin A creams. Those are still the gold standard for wrinkles.
Barbara: Vitamin A?
Brandith Irwin: As far as creams. Like Renova. You can use an over the counter retinol, but you want to use a good quality one. And Bryan can tell you about some of theirs. Paula makes a good one. SkinCeuticals makes a good one. SkinMedica makes a good one. You want the higher quality ones.
00:51:35 And then get that sunscreen. Put that vitamin A cream, it's a vitamin A cousin cream on at night, and then put that sunscreen on in the morning. You will get a pretty good result as long as the wrinkles aren't too deep.
Barbara: Too deep. Okay. Thank you so much.
Brandith Irwin: Otherwise if they are deeper, then lasers are going to be your best bet probably.
Barbara: Okay. Because I have done fillers in the past. I just stopped doing that basically because of money. But I had great success with that.
Brandith Irwin: Fillers are good, too. It kind of depends on what wrinkle and where it is, doesn't it? Because there are some wrinkles that respond really well to fillers, and others that don't.
Barbara: Right.
00:52:14 And I appreciate all the description of all the various methods also, especially on the Ulthera, which you said it is painful, because I have heard, "Oh, no, it's not painful."
Brandith Irwin: I don't agree with that. I think most people find it pretty uncomfortable. And, again, you have to do a series of three to get kind of the same result you can get with one Thermage. So, depending on what they are charging for that, you may actually do better in terms of time and money and results with the Thermage.
Barbara: Right. I get that. You have been really helpful.
Brandith Irwin: Oh good. Thank you.
Barbara: Thank you.
Bryan Barron: And Barbara, we will send you our Resist Retinol Serum so you can give an over-the-counter option a try.
Barbara: Is that the vitamin A one?
Bryan Barron: Yes.
00:53:06 What Dr. Irwin was getting at was that the cousin to prescription vitamin A is retinol which is the over-the-counter version. And then the version that is prescription-only, there are a few different forms. The most common is called tretinoin. You can get that as a generic. Renova is a brand name. Actually, Dr. Irwin, we heard awhile back that Renova is harder to come by.
00:53:30 Is there something going on with that? Are you still prescribing it?
Brandith Irwin: No. We haven't had any problem. I wonder it is was, Tri-Luma is hard to get right now. That's a different thing. But, no, we haven't had any problems with Renova. And, again, as you said, they are pretty similar. The only reason that I like the Renova is because rather than being formulated for kids with acne and oily skin, it is formulated for older, drier skin, so it is less irritating.
Barbara: That's good to know.
Brandith Irwin: If you can tolerate the generic tretinoin, go for it.
00:54:04 It's cheaper.
Bryan Barron: All right, Barbara. So we will get you that. And I'm also going to send you a sample of our Resist Cellular Defense SPF 25 Daily Moisturizer, so you can give that sunscreen a try. It's an incredibly gentle sunscreen that is great to use around the eyes. And I know Dr. Irwin is a big fan of using sunscreen around the eye area.
00:54:28 A lot of women who are using eye creams during the day, most eye creams don't have sunscreen in them.
Barbara: Exactly. And I have been hesitant about what to use on my eyes.
Bryan Barron: Yeah. Generally speaking because the closer you put a product to the eye, the more likely it is to irritate the eye or get into the eye itself. The mineral sunscreens such as titanium dioxide and zinc oxide are the gentlest options for use around the eyes. And the better eye creams with sunscreen have one or both of those actives.
Brandith Irwin: Exactly. I totally agree with that.
Barbara: I love this program. I'll be waiting for you to come back in September.
Bryan Barron: All right.
00:55:07 We'll be back. And you can catch our rebroadcasts. And we will have Dr. Irwin on again in the fall.
Brandith Irwin: That would be fun; I always like being on with you guys. It's great.
Barbara: All right. Thanks.
Bryan Barron: Thanks Barbara. Kate, I think we have time for one more question.
Kate Mee: Okay. We have Ann from Iowa.
Ann: Hi.
Brandith Irwin: Hi Ann.
Ann: Good evening Bryan, Dr. Irwin. I was in a car accident like 8 years ago, and I got two black eyes.
00:55:38 I had like black eyes for 9 months. And of course it is much better, but I still have some darkness under both eyes. And I was wondering if there is any intervention that could be done with the laser treatments you were talking about, of if you have any other suggestions.
Brandith Irwin: Well, you know this already, you have a really individual situation.
00:56:05 And so without - no one would be able to say for sure without seeing you. However, I would say that your best bet in my opinion would be to someone, an expert near you, who has a DEKA Dot fractionated laser and uses it around the eyes.
Bryan Barron: DEKA Dot. Okay.
Brandith Irwin: Because, again, with the different fractional lasers, there are some other good ones, too, but for the eye area, I think that particular one is outstanding, and I'm guessing - so what happens when you get a really bad bruise like that, like those really difficult ones, is that you get a little bit of hemosiderin deposited. Hemosiderin is just the iron in your red blood cells.
00:56:52 When you have a big, really deep bruise like that, sometimes what happens is it heals, but some of that iron pigment is left in the skin, and it shows up as being kind of brownish usually. Is it kind of brownish pigment? Or purple?
Ann: I think it's probably more brown.
Brandith Irwin: And I think you would have to get your doctor to look at it. But if it is hemosiderin, then the CO2 would have a reasonable chance of removing that. You would need more than one to do it. But, I think it would be very reasonable to see someone and ask them about it. I think there is definitely hope in terms of that being a possible solution.
Bryan Barron: And Ann, you are calling from Iowa?
Ann: I am.
Bryan Barron: Dr. Irwin, off the cuff do you know of a good dermatology center in Iowa or no?
Brandith Irwin: I do.
00:57:49 On our website,, if you go to the Topics section, and there is a section called "Finding a good dermatologist," there is a regional resource guide where we have listed excellent dermatology and laser centers across the country. And I'm pretty sure we have some people from Iowa in that section.
00:58:10 So, again, you go to, go to Topics, go to "Finding a good dermatologist," and look at the regional guide. You should be able to find someone there.
Ann: Perfect. Thank you very much.
Bryan Barron: All right, Ann. Thank you so much for calling, and good luck with that. Boy, I had never heard of that. What is that type of Fraxel called again?
Brandith Irwin: The DEKA Dot is the fractionated carbon dioxide laser that in my opinion is -
00:58:38 I mean, there are a couple that are close, but it's I think the best one. It's just a really well-engineered laser that allows a lot of customization. And so you can customize it for various situations like the lovely woman from Iowa who has - and we use it on scars a lot . It does really well in all sorts of situations like that that are unusual.
Bryan Barron: The DEKA Dot. All right, Dr. Irwin, once again thank you so much for taking the time to join us tonight. It's always great to talk with you. You have got so much information. And once again Dr. Irwin's website where you can find a lot of information on topics that we covered tonight is
00:59:20 And Dr. Irwin, thank you again. And we will hopefully talk with you before the end of the year.
Brandith Irwin: You are so welcome. It was really fun, Bryan. Talk to you soon.
Kate Mee: Goodbye Dr. Irwin.
Bryan Barron: Thank you. Well, that is our show. And that is it for live shows until September 4th. We will be back on air with you then with a whole new range of topics. Our upcoming rebroadcasts: on May 1 we are going to rebroadcast Beauty Risks versus Rewards; on May 8th, 10 Skincare Tips to Transform your Skin; and on May 15th, Secrets to the best hair color at home, or in the salon. That was a fun show. Good night everyone. Thanks for listening. Have a great summer.
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