Neil S. Sadick, MD, FAAD, is a clinical professor of dermatology at Weill Cornell Medical College in New York, NY. Dr Sadick is president-elect of the Noah Worcester Dermatological Society. He’s also past president of the International Society of Dermatologic Surgeons, the American Academy of Cosmetic Surgery and the Cosmetic Surgery Foundation. He serves on the Board of the American Hair Research Society, and is board-certified in dermatology, internal medicine, hair restoration surgery, and cosmetic surgery, and is a diplomate of the American Vein & Lymphatic Society. He joined The Dermatologist to discuss his upcoming 2021 Summer AAD session, “Comprehensive Approach to Neuromodulators and Fillers in 2021”.

What are some of the key features that dermatologists and physicians should look at or consider before going into a volumetric structural rejuvenation with their patients?
I am trying to educate physicians around the world in that the concept of filler, filler means filling. To me, the concept of filling means ballooning, and that is not what we were trying to do with these agents. Rather, we are trying to give volumetric support to the signs of aging, which include loosening of the ligaments, decreased volume of the fat pads, or structural support in the entire face. The aging process is panfacial. If we address the upper-, mid-, and lower-face fat pad and ligament zones with deep injections, we give what I call “the New Natural,” or natural support rather than ballooning or filling.

How do you balance the patient's cosmetic desires with what you know as the expert and the physician?
The most important thing is the initial consultation. When the patient comes in and says “I want my wrinkles gone,” you take a step back and have a short discussion. I give them a visual presentation about what aging really is, and I explain that it is better to have a more long-term structural program that will last for a lifetime and provide a more natural look vs artificial as we see in many magazines. It is about education during the initial consultation to explain the aging process and the best panfacial approach, rather than just filling, which can give improvement of the symptoms in an unnatural fashion.

Do you approach that conversation with the patient any differently for an older patient vs a younger one?
Our research group is exploring the concept of age prophylaxis, or slowing down the aging process, and the new natural. These goals are a lot easier if you have a prophylactic antiaging approach to structural support. Later in life, when the skin is extremely relaxed and there is very little fat pad or ligament support, it is about trying to reverse that process.

The major concepts for any antiaging program should start in the patient’s late third or early fourth decade and focus on protection, cell turnover, dermal matrix remodeling, and volumetric support. The concept is panfacial structural rejuvenation, and ultimately the new natural, so that when a patient leaves the physician’s office, they should not know that anything in particular has been done. If you improve barrier function with sunscreen protection, do things that upregulate the growth factors associated with dermal remodeling, and use these so-called “filling” volumizing agents on a rational basis for volumetric support, you are going to have a long-term approach to most cosmetic requests.

How has cosmetic dermatology changed over time, and how have newer products at our disposal changed how you approach the cosmetic patient?
The modern cosmetic dermatologist is all about using a multimodality approach. Again, volumizers, dermal matrix, stimulators, and epidermal technologies are starting to be used in younger patients, and now we brought these concepts away from the face for a full-body rejuvenation as well. What we have done in the face, we are now doing on the neck, chest, arms, legs, and belly. It is whole-body rejuvenation, another major advance in aesthetics. The concept of a multimodality approach is whole body rejuvenation, age prophylaxis starting early, and using the concepts of protection, cell turnover, dermal matrix remodeling, and volume.

With volumetric structural agents, the concept is to educate the patient and let them know their dollars are best spent on the right treatment approach rather than trying to fill in a local area that concerns them, which will not look natural or last long.

Are there any other tips or insights that you’d want to share with your colleagues in dermatology?
The most important concept is, as you approach your patient, to understand the aging process and know that there is not one technology, volumizer, laser, or radiofrequency device that fits all. Instead, it is usually a multimodality approach. You want your patients to look natural. You want them to understand that these programs require maintenance treatments over the course of a lifetime. They should be started early. If you do that, the concept of age prevention is a lot easier.

Reference
Li YM, Flessinger L, Wu D, et al. Comprehensive approach to neuromodulators and fillers in 2021. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.