Stackable Beauty Treatments w/ Dr. Julius Few

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "Stackable Treatments." Okay, Dr. Bass, you've done it again. This is another of those episode titles that spark my interest. Where are we going in this episode and where does the title come from?

Dr. Lawrence Bass (00:35):
Well, there's always been this concept in plastic surgery of the reconstructive ladder. So if someone has a trauma defect or a congenital malformation, there's this approach that starts with the simplest ways to reconstruct it. And depending on the complexity of the problem and the likelihood of success with the simple approach goes progressively up the reconstructive ladder to more complex, more involved, more extensive kinds of reconstructive surgeries. And in aesthetic plastic surgery, it's really the same idea. We always try to start with the small or simple option and go up the chain as need requires. Separate from that, plastic surgery has become multimodality. We don't pick one thing to address a problem, but often we're picking a few things. And so we have a guest joining us today on this episode, Dr. Julius Few, who has lectured and written extensively on these sorts of concepts. And Dr. Few is a plastic surgeon who is a clinical professor of plastic surgery at the University of Chicago. He is also a clinical provider at Northwestern University, and he runs a very busy and very popular practice based in both Chicago and Beverly Hills. In addition to that, he is an associate editor of the Aesthetic Surgery Journal, which is the number one journal on aesthetic surgery in the world where he edits the aesthetic medicine section of the journal. And he's written a textbook for plastic surgeons that discusses a lot of the issues that we're going to discuss in this episode today. So Dr. Few, thank you for joining us again on the podcast.

Dr. Julius Few (02:50):
Thank you for having me. It's a lot of fun. Only correction I'm going to make is that you actually contributed and helped me write that book. So much appreciated.

Dr. Lawrence Bass (03:02):
Well, I should really say you edited the book in addition to writing many of the chapters, but yes, along with a variety of the usual suspects who you and I have lectured with year after year, I did contribute in a small way to that wonderful book.

Doreen Wu (03:25):
Welcome, Dr. Few. So let's get started. Can you explain what stackable treatments are and how you first came up with the idea?

Dr. Julius Few (03:34):
Well, it's the concept. This is really full circle because as a number of people may not know before going out to Beverly Hills, I actually was fortunate enough to work out of Larry's office on Park Avenue and back during that time, because originally it was more so focused on taking care of predominantly broadway entertainers that I had known over the years, as well as national news agency providers, the journalists, et cetera, that basically said, look, if you come to New York periodically, we'll bring our friends and we'll make it worth your while and you can do your nonsurgical thing. And so back then you have to realize that the prevailing thought in dermatology, and obviously dermatology was ahead of plastic surgery on the nonsurgical space, but nonetheless, in dermatology, if you go back 12 or more years, the idea of doing multiple non-invasive things at once was largely considered heresy.

(04:53):
It was too risky. The idea of, for example, putting a filler in with a micro-focused ultrasound treatment like Ultherapy, if you're doing them together, that was a bad thing. You can't do that. The person will blow up or something. And so ultimately what happened out of necessity when I was coming to New York and I was seeing patients who ultimately had skin issues combined with volume issues and who really combined with drooping or sagging of their tissue was the idea that it was really a multiplane or multi-level rejuvenation. We want it to rejuvenate the skin with the laser. We want it to rejuvenate volume by replacing it with either a natural or a paddle aesthetic option, and then ultimately to do something like an Ultherapy or a thread lifting procedure that I helped to develop.

(05:53):
But we wanted to do it all at the same time for efficiency think because I was going to primarily be there for a set period of time, and the people I was taking care of were on a very tight timeline as well. And what we found ultimately, which was applied again to clinical study, was that not only could it be done safely and that you could sequence things in a safe and effective way, but actually there was the true definition of synergy. You actually got a result that was better than what you would've got doing one of them by themselves. And actually, my patients were the ones who pointed it out. I literally, I had one patient in particular, woman, at the time on a major network as a daytime news person, and she was the one who pointed out she would come to Chicago and get a filler here or a laser treatment, but she never did it all at once.

(06:55):
And in New York, I did her treatment all at once, and she's the one that pointed out, she said, "I can't believe this. Am I imagining things or is it the situation where it's better than when I did things separately?" So then the nidus for us doing clinical study work, which indeed has shown this. And so then that I ultimately, I came up with really the idea of stackable treatments. Really when I was watching my two boys, they were very young at the time, playing with their toys and stacking things, and I was literally in front of my computer working, trying to watch them. And I realized, wait a minute, this is what I'm doing. I'm stacking nonsurgical modalities or techniques and a way to build this as Larry were saying almost like a ladder or a pyramid, which ultimately was bigger than the sum of the part.

(07:54):
And so I wrote about it. I published it actually in a dermatologic journal back then because there's no way a plastic surgery journal wanted to hear about this at the time. And as I was formulating these ideas, I published it 12 years ago. I really started thinking about it more like 15 years ago. And this was at the end of the day, as you bring it together, now it's commonplace, but nobody at a major meeting would talk about the idea that you couldn't do laser on somebody who you just put filler in that nobody would even say that's even an issue, let alone doing more than that. So I think we've come a long way. And I think the other thing to remember about medicine and science is that it is inappropriately. So it is incredibly conservative in its concept, but it's conservative because of the scientists behind it. We all are taught to approach things in a very, very almost like religious way. Oh, you can't do that. You can't look at this a certain way. But then until you've actually scientifically vetted or tested the concept, can you then build from there? That's one of the things that I thoroughly enjoy about studies I've done with Larry as well as our clinical work together.

Dr. Lawrence Bass (09:19):
And this happens a lot in surgery and probably in medicine generally. A lot of things that were taboos when they get thoroughly investigated, completely transformed the way we deliver care.

Dr. Julius Few (09:37):
A hundred percent.

Dr. Lawrence Bass (09:39):
I mean, when I started training in surgery, everyone came in the hospital the night before an operation, stayed the night after at a minimum and would not be permitted to eat or drink until they could prove their digestive system was working, which causes your digestive system to stop working because you're not putting anything into it. And by the time I finished my surgical training, a good measure of those rules were out the window. And plastic surgery, popular plastic surgery might be a few hundred thousand operations a year in the United States. Just to give listeners a sense, the kinds of treatments that Dr. Few is talking about stacking or combining are done millions of times a year. There'll be a couple of million injections a year of neuromodulator of almost that many a filler, similar number of energy-based treatments of all stripes. So there's a lot of very robust experience compared to the much more limited experience with surgery at ascertaining the right way to do it, what the effects are, how that happens over time when it gets repeated over and over because we don't do surgery repetitively, but we do a lot of these treatments repetitively.

(11:18):
And that experience informs the clinical management approach, the care planning or beauty planning that the experienced plastic surgeon will bring for you on particularly the nonsurgical side.

Dr. Julius Few (11:35):
I completely agree, and I think what's interesting and someone who also practices on Park Avenue, and I consider a friend as somebody who, he was one of your teachers, Larry, but he was also somebody who I was able to spend time with when I was doing fellowship work for oculoplastics in New York. And the reality is you see even him at the later stages of his career, and I'm talking about Sherrell Aston. Where Sherrell is now applying energy based modalities to his facelift surgery. And again, I think if you look at concepts and things of that sort, you and I remember specifically, I can't remember which city we were in, but at being at an surgery meeting and you and I were talking about the idea that any day, all day if we had a surgery like a facelift and the ability to add a laser or a skin tightening nonsurgical device, we could outperform just about any surgeon who wanted to do just the surgery alone.

(12:50):
And so it's very interesting or exciting for me to see at this stage of our collective careers where somebody as bright as incapable as certainly Sherrell is to now say, "okay, I get it. Now I'm just start bringing this into my fold." I think it tells you something. So you and I, we were on the early side when people kind of looked at people, meaning plastic surgeons looked at this idea, and I remember some, not Sherrell, but I remember other plastic surgeons saying to me at different meetings when these concepts are just coming to bear, "this is a waste of time. Why are you doing this? Surgery is the gold standard. You've done all this great training, why would you waste your effort on non-surgery?"

Dr. Lawrence Bass (13:46):
Well, I'll answer that question for you. And the answer to that question is, I'm a surgeon. I love doing big operations. Like you said, I spend an awful lot of time and energy learning how to do that. But for the benefit of my patients, if I can bring a result that they want or need in a simple nonsurgical way, it would be completely inappropriate for me to say it's got to be a big surgery or nothing. So solving problems for people in the simplest way possible, the lowest risk way, the lowest recovery way is the minimum obligation we owe our patients. And I don't owe any obligation to the surgical profession to uphold the virtue of surgery over everything else. I owe all my allegiance to my patients, totally different thing. But I'll tell you, Dr. Aston was really one of my great mentors in aesthetic surgery. And one of the things I admire most about him is that even as a very senior surgeon, he is still integrating new things into his practice, into his clinical care. He's not doing the same thing he did 10 years ago and 20 years ago. He continues to update, and we all know surgeons who adopt every new thing or buy every new device without any discrimination of whether it's a worthwhile advance or just some new hype. He's very discerning in what he incorporates and very cautious, but he hasn't stopped adding new things and innovating on his own. And I have tremendous amount of respect for that,

Dr. Julius Few (15:46):
As do I, as do I. He's a true gentleman. And I think at the end of the day, it shows his intellectual curiosity. I suspect listen at him seeing the great work that you do, certainly influenced him. What's the saying? We've all watched our parents become almost like the ones who are asking us for counsel. And I think, listen, he trained you very well. Certainly his concepts were very, very significant in my surgical practice. But he now can see, look, the reality is it's multiples. You have surgery or you can only do so many in a year with all of plastic surgery involved, and literally a fraction of that pool of providers is doing 10 x what surgery is. So I think when you start to see those realizations and what it can do, it really does create this continuum of care where you can go from nonsurgical to multiple nonsurgical to pre-surgical to post-surgical.

(17:00):
And so it's not just a, because again, if I look at our meetings from 10 years ago, people would say, "oh, is it a facelift or is it an injectable?" Well, no, they're not mutually exclusive. You can get a much better result when you bring all these elements together. I mean, when you look at skincare, you look at the application of nonsurgical medicine and then surgery, it becomes dramatic. And now things that we thought, for example, and I'll segue a little bit. If you look at even things that, for example, I've reviewed in the journal prior to publication, a number of articles that are very dynamic that are interesting that are being submitted about how, for example, a filler can behave like a neurotoxin, so behave like a Botox, Dysport, Xeomin type product because of the way it modulates the muscle where it's placed. So for example, if you put filler and you can look, and again, this is a very dynamic subject right now, there's some really interesting articles that will be coming out in the next six months.

(18:11):
But for example, putting filler around the mouth can dynamically affect the way the lip musculature moves. And this is something that now we're just beginning to see. Or for example, there's an article that was just published about how using a neuromodulator like a Botox, Xeomin, Dysport can actually lift the face and very elegant objective studies that look at how positioning of musculature, it's no longer about using these agents just to get rid of wrinkles or to fill in laugh lines. It's actually about actually modulating and optimizing the way our facial anatomy ages and behave.

Dr. Lawrence Bass (18:56):
And then in addition to that, how and where things are applied and what you're applying can affect what the response is. And this relates to our increasing understanding of regenerative medicine and our attempts not just with stem cells and things like that, that are not really in clinical use yet, but with many of the modalities we do use, how we apply them affects what kind of regenerative result is produced. And I'll give you an example from that course that you came and lectured at a number of times, summit in and aesthetic medicine that I used to run in Southern California. And we had a Stanford bioengineer who was trying to regenerate cartilage and other tissues. And by using certain matrix materials, depending what you put them next to in the body, the body will produce a very different rebuilding of that tissue. And so we're understanding a lot of the rules that the body follows and how to lead the body where we want it to go in ways we didn't even imagine when we were sitting there practicing suturing in the bio skills lab as residents.

Dr. Julius Few (20:27):
This is so true. And I mean at the end of the day, I love, and this to me what you just touched on is really the next door in aesthetic medicine. It's the idea of pro-aging, restorative modalities that really in a positive way influence the way that we externally show signs of aging. And I think if you look at most medicine, it's about prevention. You have anti-hypertensive to prevent a stroke. You have cholesterol lowering medications to present to prevent athe, sclerotic disease. But in aesthetics, we have not taken that approach until now. So I personally have, because I've always been curious about this, if you actually modulate certain features that we know are age related kind of signs of change, then does it delay the outward appearance of that age? And what I found, and I have a cohort or for your audience, a group of people I followed for 20 consecutive years who we can show in a very tangible way how the outward signs of aging has been significantly delayed nonsurgically.

(21:53):
And so really, I do believe, and you can say that we heard it first on your podcast, but I would argue that towards the end of our kids' generation, facelift surgery will not be a thing. I do not believe it will because I think within the next 25 years, technology will definitely catch up, and our understanding of these concepts will come to full fruition, and we will then be able to do what was unthinkable right now. Because as it is, if you look at 25 years ago, it was unthinkable that we could have beauty in a syringe. I mean, it was unthinkable that you could do these things. And so I do believe the idea of stackable anatomy based, kind of targeted therapy is going to prove to be the most effective way to age in the most graceful way.

Dr. Lawrence Bass (22:57):
I'll just provide a very crude metric that I've experienced. And when I first went into practice, which is a little over 25 years ago, basically average facelift age was 50. Now if you look at The Aesthetic Society's statistics, they break it down into a certain age range, but it's late fifties to early sixties now 25 years later. Now, why is that? Well, there's a lot of reasons. Some of it is lifestyle. We smoke less, we drink less, we exercise more, we put sunscreen on. But a lot of it is the recurrent support of a youthful anatomic state with energy treatments, with neuromodulators, with fillers, all the things we're doing with skin products, all the things we're doing to maintain the morphologic state of youth and the biologic state of youth has shifted that age. And we still see patients at that age group, which is the average, who clearly don't yet need a surgical lift. So that's a very crude metric. It's not absolute scientific proof, but it's very bottom line.

Dr. Julius Few (24:31):
It is. And I think that there's plenty of evidence to support that being more than just anecdote. So I think it's interesting. It makes what we do, I think interesting because it never gets boring. The idea that we can be as creative with these tools, which by the way, on an annual basis, the toolbox keeps growing. We keep having more tools, more options. It's one of the reasons why, to be honest, I've been one of the longer serving associate editors for the journal, and I come close to saying, it's my time. I'm going to hand it over to the next person. But the truth is, it's honestly one of the most dynamically interesting, intellectually challenging areas is to serve in that capacity. And also to frame it historically, cosmetic medicine or aesthetic medicine is rapidly approaching the largest segment of the journal by submission. If you look at submissions to the journal, it's coming really close.

(25:45):
We've had exponential growth so much though that we brought in, I brought in with the insight of Foad Nahai and Jeff Kenkel, who I couldn't respect two people more, brought in a co section editor, associate editor for me because the volume's so great. And by the way, the other thing that I would add just subtly is so much of this data is coming in from Asia. I mean, I would say that the exponential growth of material coming in, which is very dynamic from China, Korea, that again, it's taking conceptually what we've looked at and then trying to expand it. Because again, you're talking about populations that are exponentially larger, that are wanting to look at modalities and frankly deal with some of the same challenges that African or Latin skin would have to deal with. So the future is very interesting.

Dr. Lawrence Bass (26:47):
I think that's an important point. I don't think it's an accident, and I don't think it's purely the difference in population size, why we're seeing things from there. The American approach is take it all away in one step quick, and we're very impatient, and I think many other cultures around the world understand the need for an ongoing process of maintenance, not only of our health and other wellness issues, but of our appearance. And so they're teed up culturally to pursue this approach in ways that the average New York City person is so busy running down the street that if you stop to check your phone or sightsee, if you're a tourist in New York, you just about get bowled over. And that kind of impatience is not what this process is about, but it's probably a much more rational way to approach your beauty care.

Dr. Julius Few (27:50):
I completely agree. I mean, I think that, and listen, at the end of the day, global perspectives make the entire specialty better. It's one of the reasons why I'm very proud, and you said it correctly, the Aesthetic Surgery Journal is the largest aesthetic dedicated journal in the world. And this is in no small part due to the Herculean effort of Foad and Jeff, along with our editorial board, which I'm honored to be part of, really saying, look, we are better if we have input from the international stage. And honestly, the concepts, even though you could argue Asia was a little later to the party, they're making up in gangbusters. And it's just, again, conceptually it's a little different. The approach is different. And I personally have learned from it. I think the minute that anybody in this game takes the view that they figured it all out and you should just stop, you should call it every time I think I've figured out one part of this specialty, there's something that comes along and I look at it and I say, how in the world did I not think of this? Literally as I'm reading and reviewing manuscripts that are submitted, there's just so many clever things. And it's also fun to know that like Larry, your work has been sourced a lot. My work has been sourced, but it has created the backbone of work that is in the current literature cycle. So I think it all kind of flows together.

Doreen Wu (29:40):
So Dr. Few, what are some of the new additions to the stack since you first came up with this concept? Can you give us some examples?

Dr. Julius Few (29:47):
Wow, there's so many. To be quite honest. I think certainly the second generation of micro-focused ultrasound, Sofwave is something newer that has come to the scene using the laser platforms, which Larry, I think I've often asked your opinion on different lasers before I brought them in. So you were in this space at the very beginning. But nonetheless, I think certainly some of the newer lasers really have been game changers for us in stacking because they deliver a targeted, very effective, but also time effective treatment that then makes it easier to stack. Because at the end of the day, the old version of stacking took a long time. I mean, I'd have somebody in my chair for a couple of hours because the modalities were slower. Now they're much faster, which means you can do more. And certainly the integration of threads, which I helped bring on the scene about six years now, seven years ago, that's fairly pervasive as well. So if we move it all together, it really is the three prong approach, which if I simplify it, it's managing the skin, managing volume loss, and then managing sagging and all in kind of total as a stackable approach.

Doreen Wu (31:14):
Lastly, before we conclude Dr. Bass, can you share some takeaways with our listeners today?

Dr. Lawrence Bass (31:20):
So selection of the right treatment is really about the right time based on the severity of aesthetic needs, what stage of aging you're at, and that requires a careful clinical assessment by an experienced plastic surgeon or dermatologist to rightsize things because fortunately, we have all these options that Dr. Few has been talking about and talking about, so we're not forced to do it one size fits all. Multimodality is the name of the game, and I think if Dr. Few expressed that very eloquently during this episode, if you use a treatment for what it's good at doing in combination with another treatment at a level that it's good at doing, you get a synergistic effect. You get a more complete correction. It's better than taking one modality and pushing it too hard, which doesn't really give you a better result. It just gives you more risk of a complication. And if you listen to everything we've been talking about, it's not just about correcting. Aging changes already exist, but it's prevention and maintenance as well to really slow the aging process going forward.

Doreen Wu (32:48):
And Dr. Few, any takeaways you'd like to share with our listeners?

Dr. Julius Few (32:52):
I can't beat what Larry just said. It's perfect. Honestly, I think you summarized it elegantly. I thank you Doreen, so much for being a great host and Larry as well. And this is very informative.

Doreen Wu (33:07):
Thank you so much for joining us today and sharing your perspective on how to plan plastic surgery care at different stages of aging.

Dr. Lawrence Bass (33:14):
And Dr. Few, it's been an absolute pleasure having you. You're a very dear, not old, but very dear friend, but listening to the intellectual thought process and getting to discuss some of these issues that I know you've spent thousands of hours thinking about over decades as I have, was really very informative for me, you refined my perspective despite again, a field where I feel I understand it reasonably well. You still added to that understanding.

Dr. Julius Few (33:51):
Well, I'm honored. I'm honored and as have you, so it's a lot of fun. I'm honored to be here.

Doreen Wu (33:58):
Thank you for listening to the Park Avenue Plastic Surgery Class Podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.