Future of Devices w/ Dr. Vic Ross

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost, Doreen Wu, here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. Today we are joined by Dr. Vic Ross to talk about the future of devices in aesthetic medicine and the role of the partnership between professional societies and industry in producing these devices.

Dr. Lawrence Bass (00:26):
Delighted that Dr. Ross has agreed to join us again on the podcast. Dr. Ross is a board certified dermatologist who works at the Scripps Clinic in San Diego, California. He is, had a long career in laser and device based research. He has served as the past president of the American Society for Laser Medicine in surgery, as well as on the board of directors of the American Society of Dermatologic Surgery. He completed the laser clinical and research fellowship at the Wellman Labs at Massachusetts General Hospital that launched him on his career in lasers and devices. But he's contributed tremendously in the, if I can say it, decades since then to this field. So welcome Dr. Ross.

Dr. Vic Ross (01:24):
I'm glad to be here. Good to be back.

Doreen Wu (01:27):
Dr. Bass, we've talked about the role of devices in aesthetic medicine before. In a capsule summary, what were the main breakthroughs that gave rise to this revolutionary role of devices?

Dr. Lawrence Bass (01:37):
The big sentinel breakthrough was the recognition that by delivering very short pulses of laser light, and by selecting the amount of energy and the wavelength or color of light, that you could confine the effects of laser treatments to the target within the skin, to the abnormal part of the skin that you were trying to damage or change instead of just damaging the skin globally. And that went by the term selective photothermalisis. That was something that was first published in the early 1980s from the Wellman Labs by Dr. Rox Anderson and the then director of the laboratory, John Parrish. And that really revolutionized the use of these devices for skin disorders and cosmetic skin treatments.

Doreen Wu (02:37):
Okay. So devices are here to stay. What is happening now? I'm wondering what are the main developmental avenues in technology taking place currently?

Dr. Vic Ross (02:46):
Yeah, I think they're twofold. Well, one is incremental improvements in some of the devices we already have. So from an engineering perspective, efficiency perspective, cost, and size devices are certainly more reliable than they were 25, 30 years ago. More powerful. And they tend to do a better job and cover larger areas faster. So let's take laser hair removal, for example. The early device may have had a 10 millimeter spot size the size of a penny, and you have to go maybe at one pulse per second. So imagine doing a whole back that way for laser hair reduction or leg, that would take quite a while. Now, devices typically have spots that are three or four times larger. They can fire at two pulses per second. So you're talking about covering a back and maybe eight minutes or less whereas that might have taken 45 minutes to an hour before.

Dr. Vic Ross (03:40):
So some of the technology involves better reliability, speed, comfort, safety, those types of things. Also, we've seen what I call navigational aids added to several devices. For example, there's one device that measures the skin pigment with a little meter, and then that provides settings for the provider based on say, if you're tanned or untanned. So that's one thing. The other thing is the devices oftentimes have application driven menus on like a tablet type of thing. So you push a button and let's say you want to treat a leg vein, for example, the laser may have settings. If you push leg vein and you push the size of the vein and where it is on the face versus a leg, it'll provide you some recommended settings from the manufacturer that are built in. So those are some incremental things that have been done.

Dr. Vic Ross (04:34):
They're not necessarily revolutionary, but on a daily practical level, they mean a lot to the practitioner and to the patient. And the other side of the picture, we have just brand new things that are happening. In other words things that have involved different types of technologies altogether. For example, using cold to destroy fat, the advent of fractional lasers over the last 15 to 20 years, we've put little holes in the skin and that's really allowed us to do lots of new things. I think in the future, we'll see as Dr. Bass has talked about in the past, maybe optical diagnosis. In other words, you use a scanner, some type of tool to tell what is in the skin. So you might not have to get a biopsy, you would just be able to go over the skin and find out whether somebody has a tumor or not. So these are some things, and there are a lot more things, but just very briefly, these are some things that are happening and will happen. Robotics that'll happen even probably later. But, so there's a lot of new things on the horizon.

Doreen Wu (05:34):
Let's move into application. What clinical problems are being chased or might be addressed more effectively by these technologies?

Dr. Vic Ross (05:41):
Yeah, probably the hottest thing right now is is acne. There are two devices now that have, one is already FDA cleared for acne. The other hopefully will be cleared soon. And these are using devices that target sebum directly, directly. So all of us have these glands that reduce grease on our skin called sebaceous glands. And if you don't have sebaceous glands, you won't have acne. That's largely why little kids don't get acne. Their skin always looks nice, even if they're going to have bad acne when they're 12 or 14, if you see a six year old kid, they look pretty darn good. So if you can destroy those glands or make them smaller, the acne should diminish quite a bit. And so we have new lasers that target those glands specifically. But it's a challenge because the targets are hard to treat without damaging the normal skin. It involves a lot of complex interactions between cold and heat. So that's one of the biggest frontiers, I think, as far as something entirely new that we haven't done in the past.

Dr. Lawrence Bass (06:44):
So I'm curious to hear your thoughts about how industry decides what technologies to work on and how they choose clinical problems.

Dr. Vic Ross (06:57):
Yeah, I think the first thing that industry looks at is how common the problem is. I mean, if it's a common problem, it's more worth pursuing, like body contouring with Coolsculpting, for example, or cryolipolysis. Everybody has some fat somewhere they probably would like to remove or move around to a different position. And likewise, acne, 97% of people have acne at some point in their lives. So I think if things are common, that motivates the laser industry to pursue that problem. Cellulite, another, I mean, these are things that are very common. Skin looseness and the alternative means skin tightening. Again, everybody has some loose skin somewhere after age 50. So I think common things happen commonly, and that's the greatest motivator for device industry to move toward solutions.

Dr. Lawrence Bass (07:47):
And you know, I think aesthetic medicine is such a mainstream concern of the public nowadays, that the companies really put a big effort into market research, trying to understand what things really bother people bother them enough that they want to get some treatment for it, as well as, as you said, looking at what's most common. And in that sense, I think they've gotten much more on the job in recent decades compared to 30, 40 years ago where it was more happenstance. Whatever they thought they could chase, they might try to do it. Now they're really drilling down on what bothers most of us most often.

Dr. Vic Ross (08:36):
No, that's right. And sometimes there are common problems that you would think a device would work well for and in fact would work well for. But it hasn't been quite as successful as you would predict. An example, there's a microwave device for sweating underarm sweating. It works remarkably well when my daughters had it done, and we've had patients who've lauded as maybe the best thing they've done in their life, but yet the device, I don't, I mean, it's been somewhat successful, but market research said like 30 million Americans or 40 million Americans have excessive under arm sweating. But there's a very small percentage of those patients who will pay money to have their sweating treated, even if it's something that interferes their lifestyle. So oftentimes market research, I think, although it's helpful and I'm always amazed when I see some companies say, Well, we actually queried all these patients, and all of them said they would do this or this if they had this problem.

Dr. Vic Ross (09:32):
But I look at it and I say no, I don't think they would. I think when people fill out these questionnaires, I don't know who they're talking to. I think sometimes the companies are too optimistic. And I'll use an example as my brother. My brother has severe underarm sweating, and he would never do a microwave laser procedure. He just, because he wouldn't want to pay for it, you know, he's just not something he would do. Although on a questionnaire, he'd probably say, "Oh, underarm sweating impacts my life." And so the company would say, "Well, this would be a guy who would do it." So there's a little disconnect, I think. And same thing with acne. Even though all these people have acne, I'm a little bit concerned, you know, how many people would actually undergo a somewhat painful procedure to treat their acne that wouldn't be covered by insurance.

Dr. Vic Ross (10:13):
So there's a lot of I think, and you don't necessarily know until you do it. I think the companies aren't at fault sometimes for pursuing these things because I'm not a businessman and I might think this is great and it's fun to pursue these different projects from a scientific perspective. But in the end, the procedures cost money and some procedures people are willing to pay for and some they're not. And it's odd. You can't always predict what those procedures are going to be.

Dr. Lawrence Bass (10:44):
Yeah, I mean, there's some testing bias in asking people in the abstract or even asking them if they're participating for free in a clinical trial. And we see this all the time where patients are very satisfied with the free treatment they got in a clinical trial, but in real world application where they have to pay to come in the office instead of get paid to come in the office, it's not quite as pleasing.

Dr. Vic Ross (11:13):
Absolutely. Absolutely. Yeah. Yeah. So sometimes the companies miss the mark, I think, and they, I think are a little bit, probably not skeptical enough about the number of people who walk in the door. I mean, tattoo removal's another issue where we would've thought 25 years ago, we'd have lines of people coming in for a tattoo removal, and in fact, we're better at tattoo removal than we were 25 years ago. But we still have lots of patients out there with tattoos. And frankly, a lot of people now since tattoos are so acceptable, they don't necessarily want their tattoos off like they might have 25 years ago. So some things changed, perceptions changed to certain things too. And so these things that people would say, "Well, so many millions of Americans have tattoos." And the the problem is the acceptance of tattoos is in flux. So maybe those denominators are large, but the number of people would have or want their tattoo off, particularly with 8, 10, 20 treatments would be relatively small.

Doreen Wu (12:12):
Dr. Bass, Dr. Ross, you are both members of professional societies and leaders in what they're doing. I'm wondering how do the societies contribute to the advancements of all these wonderful new treatments and really understand where and how they work?

Dr. Vic Ross (12:25):
Well, I think the societies, I think they establish some balance in some, I think they ground, I think some of the procedures in the sense that people are, I think looking at more peer reviewed publications and studies. If you go to industry sponsored workshops, and I've participated in those, they're always a little biased. You know, if you watch a Chevrolet commercial for their Chevrolet truck, they're going to say the truck is the best and it's better than the F-150 and the Ram and all that sort of thing, which is fine. And if you go to those types of events, you expect that. But the societies at least are supposed to. And I think largely they're pretty successfully doing it better than we have in the past. Having sort of a nonbiased venue to look at different procedures and different technologies and how they're evolving and how they might help people. And looking at also some negative features of some technologies. So I think the societies provide that type of venue for professionals and also they provide education in hopefully a relatively unbiased fashion. So I think the societies are helpful for providers and in the long run that's helpful for the consumer because those providers receive better education and better skills and hopefully take that back to their clinic.

Dr. Lawrence Bass (13:49):
I think that's exactly right. I mean, when new technologies come out and so many new technologies are coming out these days or, or improvements or iterations of existing technologies that it's hard to keep up. And so the society give a forum to hear about the totality of what's out there, to see some of the data presented and to have a critical discussion amongst a broad range of colleagues. And we've all been present when there are really diverse, contentious points of view, and that's really constructive in helping each provider stay up to date and make sure that they're really delivering everything they can to do their best for the patient.

Dr. Vic Ross (14:37):
Absolutely. I mean, sometimes we call out our colleagues and say, you know, I think that's a bunch of booey, you know, what you just said doesn't make any sense. So we were just at a controversy meeting in Santa Barbara a month ago, and there's always good banter. It's friendly, friendly, but it's good because I think it helps everybody to stay a little honest and critical.

Doreen Wu (14:56):
So what do you think are the main themes going forward in terms of modern energy tissue interactions?

Dr. Lawrence Bass (15:02):
You know, there's a continued role for short pulse treatments. These are picosecond pulsed lasers or even shorter. And some of the effects that take place with these lasers are not totally photothermal light being converted into heat, but photo acoustic or even biostimulatory. And so I think we're going to see more of that. And there's, even though we went to pulse treatments to confine the thermal effect and injury and not damage skin, there's been really a renaissance of bulk heating treatments for skin remodeling on the body and face and for tightening and lifting effects as well as for targeting fat. We will see continued refinement in pulse treatments, selective photothermalisis, there are still refinements and iterations coming along with hardware advances.

Dr. Vic Ross (16:08):
Yeah, I agree. I think another thing that's going to happen is we're going to see more a true robotic type of treatments where the device, for example, might find a blood vessel on the face and target that almost like a drone over the face. And you would have a tool that would do your spectroscopy, which is a tool to find maybe red or brown, and then it would target those spots. So you would have the advantage of not even having to do the procedure. You could have a person turn on a machine and it would find the spots. You could go through a conveyor belt like a TSA like baggage going through TSA. You would have your body go through there and it would find the spots and target the spots. You come out the other side and red and brown spots, for example, or hair follicles might be selectively targeted.

Dr. Vic Ross (16:53):
And then you would come out the other side and be done which would be a faster way to do it. So that technology's evolving quickly. And some companies are already, I think starting to look at that. So we're going to see a lot more integration between diagnostics and therapeutics and the same tools that, although, you know, it always amazes me how long things take. So when I was in the lab starting in 1994 with optical diagnostics, there's a device called confocal microscopy. And one of my colleagues was working hard on that, and I would've thought 28 years later we'd have that at the bedside. You know, I would take a little tool, I would run it over the skin, but there are a lot of complexities and challenges there. So although I think some of these things are going to happen, maybe not as fast as we thought.

Dr. Vic Ross (17:41):
One of my other colleagues was working for a company called General Scanning, and they were looking at a way to target blood vessels. We had had rabbit ears, they would find the rabbit ear, find the vessel, and target the blood vessel in the rabbit ear. But now, 28 years later, we still don't have a tool that does that in real life. So things take a long time and I would've said in 1994, we're going to see, well, we probably throw away our punch biopsies. We don't need to be cutting people to find out what's going on. But we're not there yet. So maybe it's going to take longer than I think to get to the next step.

Dr. Lawrence Bass (18:14):
But, you know, you raised that issue of diagnostic modalities, either standing alone or mated to search out the pathology for therapeutic intervention. There is this big push to use optical devices, harnessing them to help evaluate skin lesions, sort of an optical biopsy. So how do you think that's going to play into the future of skin cancer diagnosis and treatment over the next decade? I know you just said, you know, it may not go there as fast as we think, and people have been looking at these things for decades now. But, but on another level, I feel like we may be at a watershed point. What do you think?

Dr. Vic Ross (19:02):
Yeah, I mean, again, I would've said earlier we'd be there, but you know, I think our training, for example, in dermatology, we do a lot of dermatopathology is a big part of our training, probably more than any other, especially we do a lot of pathology and we look at slides and we do typical biopsies and that's how we're trained. So it would be transformative to go through a training program where your first day of residency, somebody would say, "Well, look, we're going to have this bedside tool where we just scan the scan and you look at it. And that's another tool we have. And maybe that patient doesn't need a biopsy. That's just not happening. I don't know when that's going to happen. You have a lot of challenges. Who's going to interpret these optical biopsies? Do you send it to the pathologist?

Dr. Vic Ross (19:45):
The scan like ultrasound, You can do ultrasound, for example, at the bedside for veins. A lot of people do that when they treat leg veins. They don't send it to the radiologist to look at. They just look at it themselves and make a call right there. So who's going to be responsible for the final interpretation of these types of scans? And who's going to get reimbursed? I mean, reimbursement's a big issue if you're taking the time to do a procedure, a diagnostic procedure, and there's no reimbursement. That's been a big issue with these non biopsy tools or nontraditional biopsy tools. So these are things that are happening very slowly and it's hard to know how it's all going to kind of cull out over the next 10 or 15 years, but I think it's going to be years many, many years before we replaced our traditional biopsies. And the other thing is, traditional biopsies are the gold standard, and the other noninvasive biopsy tools typically are helpful, but they don't provide the same amount of detail or depth. So I think we have a long way to go.

Dr. Lawrence Bass (20:49):
It's tantalizing because you can see the potential, but you've very clearly pointed out a lot of the obstacles as well. You know, devices are an important modality in modern skincare, but there's also been explosive growth in our understanding of the biology of communication among cells in the skin and elsewhere in the body. And just like many medications have been overtaken for conditions by biologicals the same thing is really happening in skin. Do you think this will eclipse energy options or will there be some kind of synergy between these options?

Dr. Vic Ross (21:34):
Yeah, that's a great point. I mean, I'll use psoriasis as an example. You know, we use an excimer laser, which is a ultraviolet laser for psoriasis in vitiligo. At the same time, we have these great biological tools. One of the creams just got approved for vitiligo recently with these new so-called jak inhibitors. So we kind of are having two roads that we have this biological road and this energy based road. And I think there is some synergy between the two. I think eventually for systemic skin diseases like psoriasis the biological tools will win out. I mean, I say if I was building UV lasers for the future, I would think you might be going the way of the elevator operator. You know, I don't know if you'd have great job security, because I think with the advances, like you pointed out about cell to cell connections and cytokines and the better understanding of the biology of these different diseases, that it could be that these types of drugs are going to take over and devices would be displaced completely. Other things, so like blood vessels, broken blood vessels, brown lesions, I don't think that's going to be an area where these types of biological tools are going to be as helpful.

Doreen Wu (22:48):
On the more technical side of things, I'm curious, what engineering details could manufacturers develop to make devices more user friendly?

Dr. Vic Ross (22:57):
Devices, I think that's a tough question because there's a lot of simultaneous things going on. We say user friendly for the provider. I think it's going to be cooler, quieter, smaller lasers, more application driven menus where the provider has more input from the device. The device interrogates the skin, maybe provides some input to the provider. As I was talking about before, navigation aids you have a backup camera in your car. You could have tools to example, maybe measure the redness of the skin or the pigment of the skin built into the system. From a consumer standpoint, I think all these device improvements are going to make treatments more comfortable, safer, and faster. And that's critical. I mean, one of the things that's improved the lasers is I think the calibrations are tighter. Everything's tighter. So I can remember 25 years ago, we had lasers where the energy would vary from pulse to pulse by 10 or 20%. That's largely like 2 to 3% now. So every pulse is kind of the same. And these are engineering improvements and they're largely driven by more computer control, more efficient lasers. We have fiber lasers now that are inherently more efficient. So you're going to see a lot of progress on the engineering front, which will I think make lasers, like I said, safer, faster, more comfortable.

Doreen Wu (24:21):
Next, I'm going to ask you to pull out your crystal ball and make some predictions about the future. So, Dr. Ross, what would the realistic treatment of the future look like? And do we have reasonable research options to get there or is industry just likely to keep developing minor variations for the next decade?

Dr. Vic Ross (24:40):
I think minor variations are going to drive most of it. I think the biggest advance might be in trying to use again tools to interrogate the skin where you have a scanner, we go over the skin, find different pathologies, and then target those pathologies accordingly without the provider having to kind of target them themselves. So I think that's going to be the biggest change. These true robotics. They already have it with hair restoration. There's a device that actually finds the hair follicle and kind of targets it and drives it out the little biopsy, these little plugs. And so I think that's going to also be seen in the skin rejuvenation kind of future. More feedback between imaging and treatment. So I think that is going to be the future or part of the future and that's more than an incremental change.

Dr. Vic Ross (25:35):
But these are expensive changes for companies to integrate and it's like this self-driving car and there's always going to be some resistance. But I think that's kind of where the future might be with lasers, that you would just press a button and voila everything happens and I might be out of business. I don't think I'll be alive to see that final change, which is probably good <laugh>, because then I'd have to be an Uber driver. Well, we won't have Uber drivers because everything will be self-driving, but that's sort of the future I think.

Doreen Wu (26:05):
Well, Dr. Ross, it has been a pleasure having you on here. Thank you for coming on and sharing your insight and expertise with us. And thank you to all of our listeners for joining us today to hear about the future of high technology devices like lasers and aesthetic medicine.

Dr. Vic Ross (26:19):
You're welcome. I enjoyed the opportunity.

Dr. Lawrence Bass (26:20):
And I'll add my thank you to Dr. Ross for joining us today and sharing his expertise. It's really been wonderful hearing your viewpoints on what's happening in this fascinating industry.

Doreen Wu (26:33):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. If you enjoyed this episode, be sure to share it with your friends. Follow us on Apple Podcasts and Spotify and leave a review. We'll see you next time.

Speaker 4 (26:45):
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.