Seth Matarasso, MD, is a Clinical Professor of Dermatology at the University of California School of Medicine in San Francisco. He is an expert and key opinion leader in the field of cosmetic dermatology and has published over 90 articles in the peer reviewed literature and has presented over 400 lectures both nationally and internationally. He served as Treasurer and was on the board of the American Society of Dermatologic Surgery and is a past President of the California Society of Dermatology and Dermatologic Surgery. He joined The Dermatologist prior to his live demonstration session entitled the State of the Art of Aesthetic Dermatology at AAD VMX 2021.
What is your process for evaluating a patient with cosmetic concerns and choosing the appropriate technique to address those concerns?
When a patient is evaluated for general dermatology concerns, the consultation is often focused on visible issues. Conversely, the cosmetic patient may not know exactly how to articulate the area that is troublesome to them. As opposed to projecting my personal bias, the dialogue becomes very patient-centric. To facilitate communication, I hand them a mirror and ask, "What bothers you? When you look in the mirror or see your image on a zoom call, what is the first thing that strikes your eye that you would like to improve.” Once they describe what bothers them, the next step is to anatomically analyze the area of concern and then go through the potential list of therapeutic options that are available and suitable to them. When indicated, it would be remiss not to consider a multidisciplinary approach and suggesting a surgical option and provide them physician names would be appropriate. Many patients might not be ready for that type of commitment, but they do appreciate the honesty and the option.
I will segue into the lasers and discuss resurfacing, and tissue tightening technologies. If they are new to the aesthetic world, like surgery, they also might find this initially too invasive and a little overwhelming for them. Often with new patients it would be prudent recommend that they start with injectables and gradually graduate” to lasers.
Toxins are an ideal way to introduce patients to the cosmetic arena and I often will say tongue in cheek that they are a “gateway drug” to other cosmetic procedures because the results are gradual, safe, predictable, effective and if they are not pleased, their appearance will ultimately return to baseline. However, if they do like it, it can be done a few months later, with longer lasting results. I inform them that botulinum toxin is primarily indicated in the FDA approved areas in the upper third of the face. As the patient feels comfortable, we can venture into the lower third of the face and the neck. Neurotoxins can be injected safely and effectively into the muscles of the neck, the chin, the perioral area, and the masseter. However, as a precaution, I recommend starting slowly adding other areas over time. One of my mottos is “a little bit is good; a lot is not necessarily better”.
Once the patient is comfortable and their level of confidence increases with toxins, I will introduce dermal fillers. They can be a bit more uncomfortable to administer, so a topical anesthetic is a nice way to maintain patient loyalty. Historically fillers were primarily for the lower third of the face and perioral area. “However, we no longer simply chase lines but rather have become interested facial shaping with injectables.”
During the consultation if the patient does not get treatment, they will at least leave with an understanding of what is available to improve some of senescent changes in an ambulatory setting. Additionally, I rarely will see a patient without encouraging them to have a full-body skin exam to look for skin cancers or atypical nevi. Towards that end, I always educate them about the importance of daily sunscreen and sun protection. I also encourage them to get a prescription for tretinoin cream. It is not only a form of chemoprevention but is very helpful for reversing photoaging and photodamage. The use of sunscreen and tretinoin not only serves as a nice entree into the cosmetic arena and but this simple skin care regimen also gauges the level of patient compliance.
Aesthetic literature acknowledges its lack of diversity across research as a whole. Whether it is gender, age, or ethnicity, how can dermatologists counter this and improve their practice for all patients?
Unfortunately this is a very valid reality, and I am afraid that the lack of diversity also parallels the lack of diversity in the physician population. We can counter this is through education, and outreach. I am encouraged to see that there has been a concerted effort at increasing diversity in the medical community and in the age of social media, patients seem to have become more aware of available treatment options.
I have been in practice for about 30 years, and when I started in practice here in the Bay Area, I would estimate that the majority of my patients were women. Presently, I think we are seeing a much broader cross section of the population. Those seeking aesthetic treatments has evolved to include all skin types and ethnicities, both genders, and we are even seeing a younger population that is more concerned about maintenance and preventative measures.
One of my biggest concerns, and an important reason for patient education is that I routinely see patients treated by nonphysicians who have lured patients in by highly produced and commercialized websites with “canned” before and after images. For example, I had a woman in yesterday who had an aggressive facial laser resurfacing performed by somebody with no background in laser dynamics or wound healing. She came in with remarkable hyperpigmentation. Similarly, I had a woman come to the office recently, who had so much filler injected by a non-dermatologist that she literally could not move certain body parts.
In short, to get a patient population that genuinely reflects our society, patient education and outreach are important. It is equally as important to be prudent and to make sure that patients get the appropriate treatment by the appropriate physician. To improve diversity, we need to continue to improve education. The education should reinforce to patients that we, as dermatologists, have been thought leaders and pioneers in the aesthetic arena.
What aesthetic techniques for treating the aging face and neck are on the horizon? What benefits can you foresee from utilizing these techniques?
Coming full circle, if a patient’s concerns are not within the scope of practice to adequately meet their needs and they require surgery, then it is not in their best interest nor is it ethical not to provide them with a wide array of options. If a patient anatomically has laxity, or has sagging skin, have a frank discussion with them and see if they are ready for surgery. Of late, I have consistently seen where patients have had so much filler injected into their face to reverse gravity that their appearance has dramatically been altered.
If a patient is not interested or there is a contraindication to surgery, I will suggest neurotoxin injections into the platysma muscle. Sometimes, in conjunction with treating all the depressor muscles in the lower third of the face, the platysma muscle, the depressor anguli orris, the mentalis and the masseter muscle can give a bit of a sharper cervical-mental angle and a more youthful profile. With age the ideal facial shape morphs from the ideal heart shape into a more rounded or squared appearance. Strategically injecting toxin into the masseter muscle will atrophy that muscle and reintroduce more streamlined facies.
What's on the horizon? There are going to be new toxins and fillers that will have longer duration even more creative uses. Additionally, whether they be ultrasound, radio frequency, or needling devices, skin-tightening lasers are effective. However as with all cosmetic procedures, it is especially important to balance patient expectations. Unlike injectables where there is immediate visible improvement, these devices are helpful but often the results are more subtle. They also tend to be a little bit painful, but fortunately we have been able to mitigate that discomfort with nitrous oxide and some oral medications. Ideally, we no longer treat the patient with monotherapy, but combine all the options to give a more homogenous and rejuvenated appearance.
Finally, what is quite new, and still generates a fair amount of interest are thread lifts to reposition lax skin. This is approximately the third or fourth iteration of them, all with different materials. Presently I believe there are two primary thread-lifting manufacturers: silhouette instalift, and PDO threads and each has certain FDA indications. For the most part, they are ambulatory, relatively non-invasive procedures that can reduce redundancy primarily in the lower two thirds of the face and are effective for the nasal labial fold and provide some degree of improvement in the jaw line.
On the horizon, between neuromodulators, non-ablative skin-tightening machines along with a thread lifts we will have some options for our patients to reverse some of the laxity. Although, I have seen patients with “injector fatigue” and they look over inflated with no facial muscle movement. A frank discussion of other options is warranted, so that the correct treatment is matched to the appropriate deficit.
For residents, trainees, or derms looking to add aesthetics to their general practice, what advice can you share when it comes to choosing which techniques/procedures/products to offer?
For any resident coming out of practice or a physician who has been in practice and is considering introducing cosmetic procedures for their patients, the first thing I would ask is, "Is the aesthetic patient compatible with your personality?” Ask questions like, are you more comfortable taking care of cutaneous oncology or pediatric patients? See if this fits in to your lifestyle and demeanor. I want to emphasize that with an aesthetic practice there is a high rate of physician burnout. As patient expectations are often not realistic it can be challenging. Keep that this in mind when you make your decision.
Additionally, as physicians it oftentimes is not in our vernacular, but you need to know how to say “no” to a patient, or how to say they have had enough. There is a very fine line where upon a patient will go from looking good to overdone.
Secondly, I would encourage physicians to stay educated. It seems that everyone is now pretending that they are a dermatologist because they want to do aesthetics without the heavy lifting that is required such as knowing the anatomy, the technique, alternatives, and complications and how to recognize and treat them. I had a patient referred to me with a vascular occlusive with pending skin necrosis event following the administration of a filler. The non-physician injector did not appreciate the severity of the complication and attempted to incorrectly treat the patient with an oral antibiotic. There are countless didactic courses offered at the AAD and at the ASDS as well as incomparable hands-on courses where practical knowledge is taught. As a caveat to that, I would encourage reaching out to mentors and manufacturers who can also assist in learning proper techniques. Similarly ask colleagues if they allow for a shadowing preceptorship. Observing the patient from the consultation to the treatment and post procedure care provides invaluable real-life experience.
Once the commitment has been made, start slowly. I suggest starting with small amounts of toxins in FDA-approved areas. If your staff or family allow, start with them so that you can appreciate the evolution of the treatment. With an increase in comfort, move on to off-label indications.
Although fillers give immediate satisfaction and the patient can see the results right away, they can be a little uncomfortable which can be disconcerting, so I prefer to add fillers after the patient has acclimated to toxins. As there might be some concomitant down time with laser techniques and resurfacing, I often recommend adding it after a good rapport with the patient has been established. Many lasers can be cost prohibitive so sharing with a colleague or leasing machines might be more affordable. Also do not forget chemical peels which are inexpensive, effective and a nice entrance to your resurfacing repertoire. Additionally, there are handheld micro needling devices that are helpful with resurfacing that are effective and affordable.
Finally, to learn from mistakes follow-up with your patients to observe what was done correctly, and what was done wrong so that a modification in technique can be implemented.
What pearls of wisdom would you like to share with your colleagues regarding aesthetics?
“Do unto others as you would do unto yourself” and treat the patient, like you would like to be treated. Appreciate and understand the indications and contraindications, stay current with techniques and the management of adverse events. New literature is published in our journals at a rapid rate, and it is important to stay current. As a Mohs surgeon, and as a dermatologist that enjoys seeing general dermatology and pediatric patients, it can be a daunting to stay abreast of the state of the art in medicine, but it unequivocally is worthwhile.
“Slow and steady wins the race”, a dramatic and sudden change of appearance is not what most patients want. If a patient needs more toxin, filler, or resurfacing, have them return for “fine tuning”. It is always easier to add than it is to reverse the treatment. Once a patient has had too much or a complication it is virtually impossible to regain their confidence and reverse the untoward result.
It seems that everybody wants to be a dermatologist and as true dermatologists, we are remarkably privileged to be able to practice this specialty. I truly enjoy what I do and am constantly reminded how fortunate I am to be a part of this wonderful specialty and have found that if you take pride in what you do, treat patients, and staff with courtesy, succuss will inevitably follow.
