Device Advice: Exploring the Role of Devices in Aesthetic Medicine w/ Dr. Christopher Zachary

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost Doreen Wu and I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator, as well as our guest expert dermatologist doctor Christopher Zachary from Irvine, California. The title of today's episode is "Device Advice: Exploring the Role of Devices in Aesthetic Medicine." We all know that lasers can be a great beauty tool. Is that what you mean by devices, Dr. Bass, or is there more to that?

Dr. Lawrence Bass (00:37):
Well, lasers are certainly one of the devices we're talking about, but there are a whole range of devices that are useful in aesthetic medicine. And you can think about them in various types of categorization. There are different energy sources. There are things that use lasers, things that have light. That's not technically laser light. There are radio frequency devices. And more recently there are some devices that produce plasma or that use microwave energy. So that's one way of thinking about the range of devices. There are also devices in terms of what the, the method of effect is. And so there are devices that use very short pulses in a photothermal or a thermal fashion. There are devices that produce bulk heating, so a slow, but lower level heating over seconds, or sometimes minutes. There are devices that don't have thermal effects at all, but work in a photo acoustic fashion.

Dr. Lawrence Bass (01:54):
So a shock wave or sound energy method of action. Another way to think of devices is, are they fractional exposing in discontinuous areas over the treatment zone, or are they full field over the entire treatment zone? And there are technologies that are noninvasive entirely that are microinvasive, or that are part of a minimally invasive procedure. So anytime you think of a device, it's important to kind of split out what category we're working in. And also there are some non-energy based devices like microneedling devices that do not impart energy, but create an effect just by creating microneedling and other types of aesthetic devices. So with that introduction, I would like to welcome our guest today, Dr. Christopher Zachary, and I've known Dr. Zachary for quite a few years. We taught a course together, which he was gracious enough to allow me to co-direct with him in all of the aesthetic medicine techniques, a multidisciplinary course. He has been the chairman of dermatology at University of California at Irvine, and he's extremely knowledgeable and experienced in all of the topic area that we're discussing today. So Dr. Zachary welcome. And thank you for joining.

Dr. Christopher Zachary (03:29):
Thank you very much Dr. Bass, or can I call you Larry since we've known each other for about 15 years or so? Larry, it's a pleasure to be with you today, and I'm excited to see what this discussion brings.

Doreen Wu (03:44):
Let's kick off Dr. Zachary, can you tell us more about what these types of devices can do?

Dr. Christopher Zachary (03:49):
Well, I'd like to go back a little bit to cover some of the history of where, when these devices came. During my fellowship in dermatologic surgery in Ann Arbor, Michigan. In 1985, we did have a lot of devices to use for aesthetic purposes. We had chemical peels, most of which are extremely relevant today. Dermabrasiona very sort of rather rudimentary collagen filler. And we also had a carbon dioxide and argon lasers because of the problem, when you do ration is you get this aerosolization of blood and what with hepatitis and HIV people were, were not anxious to, to fill a room full of aerosolized virus. And so then came the concept of what we call selective photothermolysis. Now for the lay person out there, you don't have to know that term, but only know that it came from Harvard, from the Wellman labs where Rox Anderson and Dieter Manstein, and John Parrish I should say, came up with the concept of selective photothermal where you give a lot of energy in a very short time, and you can be quite selective in the structure that you're hitting, whether it be a blood vessel, or whether it be a hair follicle or pigment cells.

Dr. Christopher Zachary (05:20):
And then of course came the Q-switched lasers very, very short that allowed you to take out tattoos and pigmented lesions, and then subsequently all the resurfacing devices, body contouring, skin, resurfacing tightening, and of course, combination therapists, because it's never about one thing. It's always a combination of fillers and toxins and devices and plus, or minus surgery. But you know, if somebody needs a facelift or a neck lift or something, then they need surgery. These devices are never going to give you that sort of benefit. But on the other hand, a facelift by itself and somebody who's got very extensive sun damage is never going to improve the quality of the skin unless you add some of these. So that's, that's the history here of where these devices came from and, you know, in terms of future devices we have to use our wide angle lenses.

Dr. Christopher Zachary (06:23):
We have to know that for instance the amazing discovery that, that beta blockers could help hemangiomas was found by a French cardiologist who put his baby patient of his on beta blockers. And lo and behold is the hemangioma disappeared. Well, that's opened up a whole new sphere. And then just last week, he would've read about the early stage rectal cancer treatment from MSK where this complete remission in 100% of patients treated with, with a particular program death inhibitor. So there are things out there that are going to dramatically change the way we treat patients in the future. And we just, we just need to think, we need to think carefully, we need to be open minded. We can stay away from dogma and enjoy working with our colleagues in the industry, our engineers, who are amazing if we only give them some sort of indication about what to do.

Dr. Lawrence Bass (07:27):
And I think that's true. And I'd like to circle back and just touch on that history of selective photothermolysis because that really was a watershed point in laser based treatments and really opened up a door. Now, before that a lot of the lasers, you know, you would step on the foot pedal and the laser would go on and you would take your foot off the pedal and the laser would go off and you might expose the 10th of a second or something thereabouts. But this ability to go into millisecond treatments, which are thousands of a second or microsecond treatments, which are millions. And then as you alluded to with the pigment lasers, eventually nanosecond which is even shorter, pulse treatments really changed things from a controlled burn to targeting a specific pathologic absorber within the tissues. So maybe hemoglobin, maybe melanin, maybe water in the tissues, but that gave us control. So that it, wasn't just a little bit of a burn with a little bit of correction and a little bit of unwanted effects, but really something much more precise ice.

Dr. Lawrence Bass (08:57):
It's interesting that from there a lot of the evolution and this was the 1980s to put a decade on it. And if you look at evolution of devices in, let's say the, the early 2000s, there were probably two other principal trends and, and you I'll name them and you weigh in on how you think that changed things. But I think we circled back to understanding how to exploit bulk heating, to shock and damage tissues rather than to actually coagulate them. And also a development from Rox Anderson and Wellman Labs. We went to fractional treatments where instead of exposing the entire field, we learned we could create injuries. That would be unacceptable if they were full field. If we only did it in 20 or 30% of the target area,

Dr. Christopher Zachary (10:04):
You know, you're absolutely right. The extraordinary thing with the fractionated treatment where you are treating these very, very, very narrow cylinders of tissue down to about 1.5 millimeters into the skin. But they're so narrow that about the 10th of a side of a hair you can with these ablative or non-ablative devices, you can actually ablate 10% of the skin from the face and it heals up within a week without any scarring. I mean, it's absolutely dramatic. And people have found out since then that you, the minimum diameter should, I should say the maximum diameter is about 500 microns, which is tiny, but you will not induce a scar. I always tell my patients when we're going to do any surgery at all, if we're using a knife, I say, whenever you cut the skin, you're always going to get a scar. You might not be able to see it because it's hidden away somewhere.

Dr. Christopher Zachary (10:56):
But with these micro ablative zones, they heal up without any scarring. That is the extraordinary thing. And, and I think over the future, you're going to see more intelligent devices being developed, more specific, less downtime, there'll be a dumbing down of devices make them safer, for instance for whether you treat an aesthetic problem or a skin cancer or a port wine birthmark or burn scars. And that the whole story, by the way, the treatment of burn scars for these kids coming back from Afghanistan or Iraq or wherever, I mean that's dramatic, but what you can do to help these burn scars. But I, I can just say that in the future five, 10 years, we're going to see dramatically improved devices. And then the whole situation is, well, who should use these devices? You know, I've always wanted to for instance, with a skin cancer, to be able to scan it and then press a button and have something happen to it so that it goes away.

Dr. Christopher Zachary (12:05):
Well, we're almost there we have using optical coherence, tomography and incorporating that into what they call a monolithic scanner. The company's site on is making this where you can simply heat up the skin, 55 degrees for 60 seconds. And you get rid of the cancer. It's been known for 2000 years that you can treat cancers with with heating. The only problem is until recently, we haven't really been very clever about being, being specific and measuring what we do. So this is all about a combination of physicians working with, with the engineers to come up with things that will have a tissue response, which is much more acceptable, that where there's less discomfort where there's faster healing, less residual, redness, swelling, and so forth, so that it'll allow people to get back to work and live normal lives

Doreen Wu (13:08):
With all of these exciting developments and evolving techniques on the market. How should patients pick the right device for them?

Dr. Christopher Zachary (13:16):
Oh, well look, it's a whirlwind. I mean, let me just spend a couple of minutes telling you about some of the new devices on the horizon. I think one of the most exciting ones is by a company called Ellacor, which is micro coring of tissue using these circular aspiration systems that can take out again, a little narrow cylinder of tissue all the way down to the fat. And these patients heal up within less than a week again, without any scarring. So look out for Ellacor. So micro coring is going to, is going to be very impressive. We're going to start a study soon on neck tightening using using that device. And then for instance, rapid acoustic pulse technology, it is quite interesting. It was developed originally to help the improvement of treatment of tattoos with the Q switched lasers.

Dr. Christopher Zachary (14:15):
But it's been found since then to be very effective at improving cellulite, which, of course, 95, 97% of all women have, and some guys, actually. I think the study with the 1726 wavelength for sebaceous glands, which, in other words, if you take out the sebaceous glands, the patients will not get acne. It'll essentially cure acne. There's 2 companies there, AviClear and Accure. Fascinating. The nano-pulse technlology story. Again, you're going to be hearing all about these over the next several weeks. This is like trying to drink out of a hose. it's impossible to understand it all but it will come to you very soon. the nano-pulse technology is going to be very good for treating cancers, melanomas and so forth. Then there's the drug delivery.

Dr. Christopher Zachary (15:12):
These devices will help increase the absorption of any topical agent by 20 to 40 times. I don't know if you've heard of photodynamic therapy but that's very good for treating patients who've had a lot of sun damagethat again, will be helped with these devices. I think we've been disappointed with the new prima device, which is the sort of the second generation pulse style laser. But on the other hand, Lutronic has now come out with a Derma V I don't know if you've had a chance to look at that Larry, but that it will challenge the pulse style laser, frankly, for port wine birthmarks. There's all the Ultherapy, the ultrasound devices. There's a second generation ultrasound device coming out from MERS. And then of course the soft wave, which is really capturing the imagination.

Dr. Christopher Zachary (16:05):
These devices are there to tighten the skin of the face and neck. They don't do a whole lot, frankly, but again, if you don't want surgery, then it's a good way to go. I don't actually use the body toning devices or electro magnetic, muscular stimulation. Two devices there. Cooltone and Emsculpt. But they dramatically increase the ability for you to use the muscles that you've actually toned up there. So I think honestly for rehabilitation, that would be really good, but of course it's all going towards the cosmetic way. So these are just a few of the devices that are coming out. And for everyone that I know about, there are probably two or three out there that I'm not aware of. So but what about you, Larry, have you heard any other types of devices that you're, that you know about or are working on?

Dr. Lawrence Bass (16:58):
Well, I mean, there are a number of things that are coming, there are microwave devices that are being introduced for the first time in the US. This is kind of going a little higher on energy compared to the radio frequency devices and whether it will give us an evolutionary step forward in what we can do compared to some of the older radio frequency devices remains to be seen. But I want to circle back to some of these things that you mentioned and, and discuss a little bit what may be going on with some of them. So, you know, we talked about fractionated treatments and the ability to create injuries or wounds that are, that are different than what we, we create in a full field fashion. We can go deeper than what would heal normally by doing that. And you mentioned the Ellacor micro coring that doesn't use high tech like laser to do that, but is a mechanical device.

Dr. Lawrence Bass (18:05):
But it has been observed that even these full thickness injuries, which if they were made with a scalpel in surgery would heal with a scar heal in a scarless fashion. So there's a different kind of healing here that we've known about really for better part of 20 years, but we haven't done a lot of biological investigation of, to really understand, you know, there are some rough thresholding to how big, a core you can take before you might land up with a scar, but we don't really understand biologically why. And I'm curious to hear your thoughts on that and to hear your thoughts about whether you think it's just a reduction in the cross-sectional area. If you take out a thousand micro cores from the neck and you've taken out 10 or 15% of the skin, is it just reducing the amount of fabric that gives you the, the more even contour and reduction in laxity, or is it actually part and parcel of, of the healing that gives you remodeling on top of that? Or some other effect producing the clinical improvement?

Dr. Christopher Zachary (19:23):
Larry, very good. Very good question. Without getting too technical, I do not want to talk down to anybody here because all your lessons I'm sure are very familiar with these concepts, but the, the fractionated ablative laser, when they lay down their cylinders of injury, there's the error of vaporization surrounded by a core of a sponge-like material that actually prevent those holes from healing up quickly. And so what you get is the skin doing what it's always able to do it repairs itself with new collagen, new elastin. And so when you say, if you take out 10% of the skin from the neck, for instance then your body is going to heal that, and you won't get so much. In fact, we've been disappointed, ready with the amount of contraction, but with the Ellacor system, that's different.

Dr. Christopher Zachary (20:17):
There is no heat. There is no sponge like collar that, that prevents them from healing up. And consequently, these actually heal up within a couple of days in an elliptical manner. You might take out a circle, but it actually heals up very quickly along the lines of relaxed skin tension. So called and, and as such, I do believe that it will be superior to the fractionated, ablative lasers, which I love I was involved in the early studies with those. But as we progress, we understand that there are other advances to be made. And I think the Ellacor is, is one of them. So we'll see where that goes. Let say one other thing, there's a concept out there, which is very difficult to, for us to you and I, for it's very difficult for us to encourage some older fashioned physicians to understand.

Dr. Christopher Zachary (21:19):
And then when you cut the skin, when you get a scar, it's actually much better to get in there early than wait for a year or two, and many people are told by their surgeons. You should wait for a couple of years before you do any laser surgery or cosmetic surgery. It's absolutely not the answer you should get in there within a week or two to use these fractionated lasers, ablative non-ablative, doesn't matter what they, they all allow new collagen formation. And when you have a burn scar, which provides a sheet of new collagen, which reflects the light in a certain way. So that's why the skin of a burn victim looks shiny and white. If you actually create numerous fractionated areas of injury, you are going to provide a pixelated new collagen, new elastin, which will reflect the light in a very different manner. And, so I'm actually I'm so thrilled that our joint operations between our plastic surgeons and dermatologists and others interested in laser surgery, have been able to work together with particularly patient kids who have been burnt in fires and so forth to dramatically improve their appearance. So, anyway, that's me rambling on a little bit.

Dr. Lawrence Bass (22:42):
Well, I'm curious. I mean, I agree wholeheartedly. I think the fractional lasers, while it's on the surface, counterintuitive that creating more burn vaporization, you know, again, whether you do it ablatively, which clearly is coagulation, I'm sorry ablatively or non ablatively, which clearly is coagulation. You're creating a more thermal effect in what's already burned tissue. So on the surface, that's a little counterintuitive, but it does create the ability in this very safe, controlled way to remodel that scarred tissue in, in a way that the body doesn't overreact to doesn't make a hypertrophic scar. And you see both an immediate dynamic improvement in, in the compliance of that tissue. So if you have a burned hand that you can't flex and extend immediately after that treatment, there's a good improvement in mobility. And it then facilitates the ability to go in there with physical therapy and get more motion and a cosmetic improvement of the scar. But separate from that, some people will use pulse style lasers or other vascular lasers early in a scar's life. And early is important. Exactly. As you said, I agree completely to try to reduce the amount of vascularity in the scar and maybe circumvent some of the inflammatory response that's taking place in an effort to, to board the development of a nascent hypertrophic scar. Do you think that's an important component as well, or you think the fractional lasers have kind of eclipsed the use of the pulse style laser and other vascular therapies?

Dr. Christopher Zachary (24:40):
No, I agree. 100%. we, we treat scars particularly red scars with, with the pulse style laser. We might do that before we use a fractionated device. I think, I think every case needs to be assessed independent one from the other. And I think, I think that the pulse style laser, as you say, if that's all you have, then you can actually do a lot of good with it. Here's the problem though, Larry, you and I have probably got, you know, 10 or 15 devices, maybe more at our availability. Most people aren't, they might have one or two, if that, and then, then they have a dilemma. First of all, what to do when this sort of patient shows up in the clinic and secondly, what, what is their next device they should get. And, and I might just ask you the question. I want to turn the tables on you. What is the number one device you would get if you were going out 25 years ago? I don't know how long you've been in practice, but what's the number one device you'd get if you were just starting up.

Dr. Lawrence Bass (25:45):
So, you know, and that's a question that gets brought up a lot of times at medical meetings, especially in a laser training course or a laser panel. And the answer is, of course it depends.

Dr. Christopher Zachary (26:00):
<Laugh>

Dr. Lawrence Bass (26:01):
Because there's, there's no universal one. It depends on what, what specialty you are in and who your patients are. So if your patients are young, they might like laser hair removal and those sorts of treatments, or they might like a body contouring device, like CoolSculpting. Yeah. If your patients, if you have a facial rejuvenation practice like mine, I think, you know, a key component of what I offer my patients in addition to things like surgical facelift is the ability to treat wrinkles and photo aged skin by doing laser resurfacing. And so a laser resurfacing or fractional laser resurfacing technology would be key because I think the ability to just do the surgery and leave the photo damaged skin. And you said this earlier in this, in this recording that's really not adequate. And you're leaving a major component of the rejuvenation completely untouched if you don't have a technology to improve that skin.

Dr. Lawrence Bass (27:24):
So I think that's the big split. You know, the younger population will probably be in some kind of body contouring device or in IPL, it can treat hair and some early pigment change and someone who's treating more of a rejuvenation population that's middle aged and beyond is seeking a more aggressive laser for something like resurfacing. And of course there are devices that combine theseike the cyton technologies that you were mentioning earlier, you know, that has a multi modality platform where you can buy one and then add another modality later. If you discover that there is a substantial demand in your practice for that alternate technology.

Dr. Christopher Zachary (28:16):
Yeah, totally agree. And as always, you don't make any decisions until you see the patient, you talk to the patient, you sit down in front of the patient and you have a conversation, extended conversation, so you can see them sad, see them happy, look at the way they smile, look at the wrinkles, look at the laxity and so, so forth. So in your own mind, you think of what you can do to help them, but of course you have to ask them, what is it ma'am or sir, what is it that we can do for you? What troubles you? And they might point to something very different that you hadn't sort of noticed. And also in our therapeutic ladder, if we've got 10 lasers in the surgery rooms at the bottom of the therapeutic ladder, there are still things that work very nicely that are inexpensive and work very well. For instance, things like retinoids, that has been the biggest development in the last 50 years, the retinoids like Retin-A or Tazorac Adapalene, they've made a huge difference. And if our patients start off using retinoids for three months, six months, they were going to see a dramatic improvement in the color texture, tone, wrinkles, and so forth. So I think it's always a good idea not to jump to a device. And it's all about what can we do for this patient.

Dr. Lawrence Bass (29:51):
So, you know, that begs another question that I'd really like to ask you and take advantage of your medical dermatologic expertise that I, as a plastic surgeon, don't share contrast for me, the benefits of retinoids compared to alpha hydroxy acids and beta hydroxy acids, like glycolic acid, lactic acid, pyruvic acid, because this is one of my personal pet peeves that, that, you know, everyone jumps on glycolic acid because you can go to the local pharmacy and buy a bottle of something for $10. But I don't think you're getting the same out of it as you get working with a retinoid. So explain to me what the retinoid is able to do in the skin that the hydroxy acid like glycolic acid is not

Dr. Christopher Zachary (30:52):
Well, first of all, retinoids have been extremely well studied they've they have came out of Philadelphiawhere some basic science went into the development of these drugs, so that you know, that it's going to increase the amount of collagen, you know, that it's going to reduce precancerous agents, you know, it's going to get rid of, ofLentiginos those liver spots or brown spots. You just know, and you can see this, you can measure it. You can look at the amount of glycosaminoglycans in the skin and so forth. Now that's not to say that there haven't been some good studies on the alpha hydroxy acids. For instance, the problem is the pharmaceutical industry in this country is just not regulated. It's about a 10 billion business, and you can come up with a whole host of things that you can then sell pretty much,at Liberty,without, without,knowing much about it.

Dr. Christopher Zachary (32:00):
And it, so the difference really is that one has been studied thoroughly and has been evaluated. This has been approved by the food and drug administration and most of the cosmos have not. Now, there are some countries, and I believe Japan is one which are now regulating cosmos. And I I'd like to say, I think that should happen here, but here's the problem. If you regulate a cosmeceutical it is going to increase the cost of production from about, you know, $10,000 to develop it to maybe $10 million or maybe even a hundred million. So, so that's just not going to happen. And you have to be very careful of how you regulate things. I don't want to get into the politics of all this only to say that one has been thoroughly tested and the others mainly the cosmeceuticals really don't have a lot of background safety studies that our patients can rely upon.

Dr. Christopher Zachary (33:02):
So that for me is the biggest difference. I don't, I don't really, we don't sell much in the way of cosmos in the, in the clinic. I believe in five things, I believe in sunblock, I believe in moisturization, I believe in, in retinoids some of the alpha hydroxy assets are absolutely fine. And, and as I say, there are very few other things out there that, that are going to make a big difference, but I think first as always, we should say, how can we prevent this from getting worse in the future? So it's a really important to the schools that they're educated about sun damage and how to avoid it. And then if you get it, how to treat it, because don't forget the bottom line is there are some very serious diseases that UV light can create, including not just basal cell cancer, squamous cell cancer, but the big killer melanoma. So I think education is important here.

Doreen Wu (34:02):
Well, this has been a thought provoking episode. Our listeners are always interested to learn about what's coming down the pipeline and hear about new things on the horizon. Before we close Dr. Zachary, what should our listeners take away from today's episode about the world of energy based devices?

Dr. Christopher Zachary (34:18):
You know, I think we should expect more of from our physicians and engineers and, and probably from the FDA as well. We need those of us who are in the healthcare business need to observe natural phenomena. Rox Anderson's very good at that. We need to use our wide angle glasses just to see what works, what simple things work. We definitely should expect to use more technology. You know, when you go for an opthalmology appointment, for instance, before you ever see a doctor, that they do an OCT of the back of the eye and so forth, I can imagine a time or in dermatology, you know, there's mole mapping and all sorts of things like that. I can see us requiring our dermatologists for instance, and plastic surgeons to become more familiar with and to request the development of devices that are going to make a big difference, for instance, with a multi photo microscope, which we have in our laboratory immediately in our imaging room, which is adjacent to our surgery rooms.

Dr. Christopher Zachary (35:26):
You can diagnose without doing a biopsy, you can diagnose melanoma inside you, which is a killer. And there are other devices that we have as well that can make similar diagnoses. So we should make sure that we fund research appropriately, particularly through the NIH and through the universities and so forth and, and help research institutions succeed. The institutions have been starved from money for over a decade. And I just think that not only should we appreciate the benefits that we're getting, but we should also as users of medical care, we should ask for more, in terms of more information, more safety information we should, we should make sure that we get the best advice, best education. And I can't think of a better format than this particular session. So thank you so much for asking me to be involved.

Dr. Lawrence Bass (36:26):
Well, thank you, Dr. Zachary for joining us. I always enjoy hashing through issues with you and putting my thinking cap on. I have to have my thinking cap to do it successfully with you and I appreciate your sharing your broad fund of knowledge on all of these subjects. We really spanned a surprisingly large number of different arenas. And there's a lot of content in there. Just reflecting on that. I think for patients I'll echo what Dr. Zachary just said, that, you know, we want treatments that are evidence based where we understand the basic science of how they work. And we have the clinical evidence that in fact, they do perform in a way that's useful and beneficial and better than what we had previously working with providers who understand how technologies work makes it easier for you as a patient to pick a technology or partner with your provider to pick an appropriate technology for your care. Of course, there's no one best device or one right device for any given condition. And many of the products that the aesthetic industry has gotten through FDA and put on the market are extremely useful for addressing aesthetic concerns. And there is that whole arena of medical concerns. As you heard Dr. Zachary discuss very eloquently during this episode,

Doreen Wu (38:12):
I'll let go, Dr. Bass and thank you again, Dr. Zachary for sharing your insight and expertise with us. Thank you to our listeners for joining us today, to hear about the evolving use of devices in treating beauty and aging concerns. I hope you found this episode as interesting and informative as I did. If you think of other exciting developments in plastic surgery that you would like to see us discuss in upcoming episodes, please reach out via email or Instagram. We'll see you next time. This is Doreen Wu thanking you for joining Dr. Bass, Dr. Zachary and me for this discussion of the role of devices in anti-aging and aesthetic medicine. Be sure to tune in next time. And don't forget to subscribe to our podcast, to stay up to date with all of the exciting content that is coming your way.

Speaker 4 (38:56):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.