The Rise of Regenerative Medicine: Breathing New Life Into Aesthetic Care w/ Dr. Steve Cohen

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 co-host Doreen Wu I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator, as well as our special guest plastic surgeon, Dr. Steve Cohen from San Diego, California. The title of today's episode is "The Rise of Regenerative Medicine: Breathing New Life Into Aesthetic Care." Dr. Bass, regenerative medicine is creating a lot of buzz in the media these days. What exactly is regenerative medicine? And will this become the future of cosmetic medicine and plastic surgery?

Dr. Lawrence Bass (00:40):
Well, regenerative medicine is basically a branch of medicine or medical research and investigation that's designed to get the body to regenerate or restore itself to normal structure and function when there's a disease or an aging change or some other problem. And in broad strokes, this falls into a few different categories. So there are molecular materials that can help with tissue regeneration. There are cellular materials, and then there's tissue based regenerative medicine using either natural or biomaterials or artificial materials that are designed to help the body regenerate. So there's a whole range of things that are being used to help enable tissue regeneration in the body, restoration of normal function in a cell or an organ or a tissue. In a lot of ways, plastic surgery is really the right field for this because I always said plastic surgery where the biomaterial specialists of the body and the entire history of plastic surgery has been using a biomaterial that's borrowed from somewhere in the body, a skin graft, a bone graft, a fat graft, or a nerve graft, tendon graft to rebuild or restore surgically some kind of body function.

Dr. Lawrence Bass (02:22):
So this is really something that plastic surgery has done since time was, and in the last 50 or 70 years research into wound healing and then tissue regeneration growth factors and all kinds of cellular biology that relates to the issues of interest to plastic surgeons has been an increasing part of plastic surgery on an academic level. So that's really why plastic surgery is involved. Let me turn to our guest today, Dr. Steve Cohen. He is a very talented and very experienced plastic surgeon from San Diego, California. We've been friends for a number of years and have lectured together at a variety of meetings, and he is a true expert on what's going on in regenerative medicine in plastic surgery. He teaches a whole range of instructional courses on techniques to use this kind of approach to best advantage. So Steve welcome. And we're delighted to have you with us today.

Dr. Steve Cohen (03:36):
Thank you, Larry. Nice to be here.

Dr. Lawrence Bass (03:39):
So tell me what are some of the leading examples over regenerative medicine in healthcare generally and in reconstructive plastic surgery?

Dr. Steve Cohen (03:49):
So I think, you know, there are two main fields right now, we have within plastic surgery and really we're a good example of both of these. We have regenerative techniques that are designed to reconstruct injured tissue, congenitally, absent tissue, or deformed tissue. And then we have techniques that are designed to be more antiaging or replacement of losses that occur through the aging process. And I think that both have become much more mainstream than ever. And I do think as you had alluded to Larry, this is a going to be a breakout area that as industry becomes involved and realizes to what extent this is going to be effective, this will start to really pick up and become even more mainstream. And, and so right now, at least most of the focus within our specialty are directed to things like rebuilding breast tissue rebuilding facial tissue for reconstructive needs healing wounds that are difficult to heal improving blood supply and circumstances where blood supply has compromised, the ability to heal and in also performing these techniques to modulate inflammatory conditions to reduce them.

Dr. Steve Cohen (05:23):
So there are probably many areas in plastic surgery and dermatology that heretofore have not been treated, but are good targets for instance, psoriasis and many autoimmune diseases that lead to wasting like scleroderma. These are ideal conditions to be treated with, you know, regenerative approaches.

Dr. Lawrence Bass (05:47):
Well, that's a fantastic summary of the playing field in plastic surgery now could you share with us some of the potential applications in aesthetic medicine and anti-aging,

Dr. Steve Cohen (06:02):
Well, the exciting part about being around today and things I'm sure that Doreen will find out as her future, you know, begins to unfold is that, you know, with our understanding of the human genome, we know at birth in many situations where we're headed, even without the genome, we can look at our parents or our grandparents and our family and get a glimpse into our future. And if one starts to think about aesthetics as more of a moving picture versus just one moment in time that a patient walks into our office, but a life cycle of aging, then we can start to devise regenerative approaches that begin to really, really make sense and resonate, not only with our clients and our patients, but our, our colleagues, because again, many people are resistant to change and, you know, they get comfortable treating things in certain ways, using fillers and using Botox etcetera, and they pooh-pooh the events that are lying in front of their nose, which I think are becoming to me much more clear than ever as to what the potential is.

Dr. Steve Cohen (07:21):
So it's a long statement, but I think if one starts to think about why people come into a cosmetic surgery office, they really come in for only a handful of reasons. So let's take facial aging as an example, because that's kind of the area I'm most interested in. You know, people come in with really three major things we treat. We treat sun damage, we treat facial volume loss, which is not like air it's loss of specific tissues from thinning of the skin to loss of the bone or genetically deficient bone to loss of the, if you will, functional matrix of the face, the fat compartments and the soft tissues. And those along with laxity are the three things we treat. Every device is designed for them. Every surgery is designed to treat these things. And so educating our ourselves and our patients about what they're able to accomplish with that in mind is critical.

Dr. Steve Cohen (08:26):
These are now super imposed on our genetics. So, you know, you're born with a, a weak chin. Yes, you're probably gonna develop laxity in the neck more rapidly than somebody else. Or, you know, if you're born in a family that is prone to melasma, you know, instead of laughing at, you know, being in Hong Kong and seeing a mom and their little daughter with parasols and hats, instead of laughing at that, we can realize that this is an attempted epigenetic modification. And by that, I mean, these folks know that sun will create hyperpigmentation. So the more they protect their children from day one, the less of that kind of sun damage, irregularity and injury to their skin tissue. They're gonna see. So as we start to turn the light on these matters, we begin to look at things more dynamically. So for instance, in my practice, it comes up frequently.

Dr. Steve Cohen (09:27):
What's the difference with fillers versus for instance, fat grafting? And I think we've explained this in some ways correctly and in other ways incorrectly, because we tell people, well, fat is like a natural filler. And then we say, yeah, but there's more variability. It disappears more rapidly in some people, it doesn't work in others instead of going, when we're using your material such as fat, if you are older, you have more cells that are already senescent. You can't expect that that's gonna perform the same way as youthful tissue. That's number one, two. We can say, look, you know, based on genetics, there are rapid agers and there are slow agers. You know, you go to a high school reunion, you look at some friends, you go, "my God, I can't believe how great they look. They must have had surgery."

Dr. Steve Cohen (10:17):
You look at other people, you go, "my God, I hope I'm not that old. We're the same age." Because in many ways, and this has been the difficulty with these studies is the genetic variation of how our tissues respond to environmental injuries are different for all of us. So now that we're using our own tissue, we have to take that into account that it's not necessarily a failure of a procedure in regenerative medicine. It's a combination of using cells that may already be in states that are aged and working with people whose genetics may not be as ideal as someone else. And in addition, using our natural materials, that of course are never, you know, synthetics and programmed to disappear within a certain amount of time. Once we have that in mind, we can actually start to look at patients more like a moving picture.

Dr. Steve Cohen (11:11):
You know, it's kind of like Leonardo DaVinci. He was the first person to start drawing an arm in different motions because when we pictured an hand or an arm and it was in one motion or one position by an artist that was a hand or an arm, what Leonardo said was no, the function is as important as the appearance. So when we are thinking about hands and arms, we need to be thinking about each step of motion and function. And as we start to think about aging, we start to think about the gradual decline. And you come to realize that when a patient comes in for more than one filler, that reason is not because they see hollowing and we go, oh yeah, I see the hollowing. It's because they're losing specific tissue in superficial and deep fat compartments. And we can actually put that same tissue back in.

Dr. Steve Cohen (12:04):
So just as we reconstruct, you know, things with like tissue, we use a skin graft to repair a skin injury. We use fat tissue to rebuild the breast. Now we're starting to think more on a smaller histologic and morphologic basis. And we start to use those materials to actually replace what we're losing. And again, I'm sorry to be so long-winded, but if you think of nuclear decay as kind of a comparison, you know, it's the amount of material you start with and the amount of material you end with and how rapidly you get there. So the rate of nuclear decay is based on a lot of factors. The rate of our tissue decay is based on many factors, but by definition, if you replace what has been lost, that curve of decay changes, now you have more material, you have a slower rate of decay. So, you know, just like we're beginning to realize that diet, exercise and other kinds of epigenetic modifications are going to keep us alive longer. It's no different for facial tissues. This is why regenerative medicine has to be looked at in a dynamic way, much like integrative medicine, because that's really what it is. We're now not only aesthetically improving our patients, but we're marrying this by altering the physiology of aging and slowing that process. And in some cases reversing it.

Dr. Lawrence Bass (13:42):
Well, that's really beautifully said and something that I tell my patients and I've said on this podcast multiple times, is that aesthetic plastic surgery is a process. It's not an event.

Dr. Steve Cohen (13:55):
I think that's a good

Dr. Lawrence Bass (13:56):
Point, what you started by saying that people don't come in and get one hit and it's all over. But a lot of the synthetic materials, injectable fillers, things that we bring in with energy devices have a nearly monolithic approach to what they do to modulate the equation where regenerative techniques are multidimensional and much more dynamic as we really unlock some of the secrets to how these things work. We're going to be able to push them in many directions and maybe several directions at once in terms of restoring normal physiology and normal anatomy, normal morphology. So I've paraphrased what you said in a much more simple minded way, but, but I agree completely. That's really the essence of what's going on in this field.

Dr. Steve Cohen (15:06):
Very exciting, because it begins to help you focus on so many different things. It's the same with it's the same with sports injuries. These are required injuries early on. We treat a knee injury, that's, you know, ongoing or early arthritis with steroid injections. They get better symptom-wise but the steroid actually decreases the cartilage interface. However, when we use regenerative techniques, even though we might only be getting a 20% improvement, that's 20% more than zero. That's an enormous improvement relative to our present therapy that has no improvement. And if anything reduces symptoms while accelerating the disease process that they're trying to treat. So that's why I think our thinking has to change and we have to become much more open-minded about using our own tissue repair mechanisms, because, you know, we're a complex organism. My God, we find amazing things like digoxin in a plant we're bound to find more complicated things in a human being that will help us survive longer and live better.

Doreen Wu (16:20):
Continuing our discussion of anti-aging and turning back the clock. What is here and now in regenerative medicine?

Dr. Steve Cohen (16:27):
Okay, good point. So we just published an article in the aesthetic surgery journal a couple months ago, showing progressive improvement in facial volume, following a anatomic and regenerative fat grafting procedure. And what that means is when we look at a patient and we diagnose all areas of deep fat loss, superficial fat loss, skin thinning, and bone deficiency, and we treat them by replacing the anatomic losses with a structural fat graft. And we add the cells from fat to the skin and tissues, and we send them home with a biocream of their cells that they apply topically. And we follow those patients for two years. And we look at the midface as a, as kind of a glimpse into what's happening with volume. When we do isolated fat grafting in somebody under age 55 with that approach. So we're using theoretically younger cells, less cells that are already senescent or aged.

Dr. Steve Cohen (17:38):
We see at a month, a 60% improvement in facial volume at six to nine months, we see only about a 25% improvement. And, and at 19 months we see almost an 80% improvement because what's happening is you're putting fat in. Most of the fat cells are dying. The stem cells in fat survive at lower oxygen tensions. And they begin to turn into fat cells. So you see this kind of, you know, bimodal kind of curve that at the end actually shows progressive improvement in facial volume. This is irregardless of weight gain. So when you do statistical analysis on these patients to say, was weight a factor? There was no gain in any of these patients point. I think there was a, a 0.3% or a 0.3% loss, but no gain. Two. When you look at the amount of fat that you put in, it has nothing to do with the amount.

Dr. Steve Cohen (18:41):
So neither one of these affected the statistics of that curve when you were under 55. However, if you had that same procedure and you were older than 55, gradually the facial volume trailed off to 30% residual at 19 months later, which is consistent with most of the studies in our literature. Now that's still a 30% gain at two years, but it's an indication that more useful tissue is important to be using. And that is the first study that's ever shown a nearly 80% volume effect or volume improvement two years after a treatment. So we're not talking about stability, we're actually talking about an improvement. So I think that in my opinion represents a very important article because it is, it contradicts every article about fat grafting. So instead of being, not just the surgical artist where I put it, where it looks pretty now we're the surgical anatomist and we're also regenerative medicine experts. So we know that when we microneedle these cells into the skin, the skin actually becomes healthier. The pigment actually becomes reduced the age changes and the sun damage changes become reversed in elastin, in collagen fibers. And there are enough, very good studies that now show this very definitively. So to me, we're still talking about things that are already either passe or very poorly studied.

Dr. Lawrence Bass (20:21):
And that's really the point. I read that article with a great deal of interest. And the challenge is in meticulously assessing the patients, because so many of the articles, the metrics by which you're measuring outcome are so crude or so haphazardly applied that the data is only a very rough indication. And so you are much more careful analysis of the patients is really what led you unlock that nuance of the biology, younger fat graft patients versus older, and rather than putting everybody into a giant grab bag and sort of losing the granularity of the data.

Dr. Steve Cohen (21:10):
Yeah, I think, I think as we have more of these, and again, Larry, as you know, we're both practicing plastic surgeons. So we know that data doesn't convince always our colleagues because people form habits. And, you know, I always was taught you form a habit and you learn to break it because you find something that's better. And other people are taught. I want to imitate my mentor and what they did and be as good as them versus we want to make things even better and stand on the shoulders of our mentors and move the field beyond what they've been able to accomplish.

Dr. Lawrence Bass (21:46):
And I agree with you completely. I think that's the point that to move things forward, you have to unlock the principle and then learn how to amplify it. And so many people look at something at a rudimentary stage and say, well there's an effect there, but that's just not enough. And they abandon it rather than saying, how can we harness it? How can we really control it? And how can we magnify the effect to, to an extent that is clinically relevant you know, a 20% improvement, I mean that you age over 30 years, 50 years. And if you can undo 20% in a single step, that is a massive change. So it is clinically significant.

Dr. Steve Cohen (22:36):
And, and there's gonna be some things coming down the pipe, Larry, that are gonna be so exciting and potentially, you know, relatively straightforward and simple kinds of things. You know, that, I mean, for instance, that you may be familiar with a company, Elysian Health but they make a product called basis, which is a NAD product, you know, so it basically, you know, it leads to cell repair. They have five or six Nobel laureates on their board. This is an MIT founded company. You know, these people are not stupid, but you need to take this medication and, or vitamin or whatever you want to call the over counter use on a regular basis. If you want to succeed, just like, you know, you want more muscles, you gotta go to the gym, you know, nobody's gonna just hand them to you. At least not in my family.

Dr. Lawrence Bass (23:34):
No, <laugh>, that's true. There's always going to be some steps that have to be taken and getting those steps as efficient and focused as possible is always the trick. So as we look at this, let's talk for a second about exosomes and what role they currently play or what role they might play going forward.

Dr. Steve Cohen (24:01):
Well, it's not a well understood area by most plastic surgeons. And I have to say, you know, I still feel like I'm at the tip of the iceberg myself, but I think, you know, exosomes may turn out to be the active ingredient in the fat graft that leads to regenerations. So what exosomes are their cell to cell messengers. They're responsible for what we call these hormonal effects that cells can can do, or paracrine effects, you know, sorry to be medical, but that's what they do. So they communicate to other cells and what they do is they repair, they reduce inflammation. They probably survey for cancer and cells that are degenerating, they're able to repair. But what's really fascinating about exosomes as in terms of antiaging in an ordeal are one, something called parabiosis. So parabiosis was a study that was done and published in nature many years ago.

Dr. Steve Cohen (25:08):
And what they did was they joined the circulations of an old mouse to a new mouse, a young mouse. And what they found is over a period of time after they sacrificed the mice, that the older mouses organs, the heart, the brain, the lungs, the liver, all got younger. Why did they get younger? These are not vampires sucking on somebody's blood. These are mice. And the younger mouses had something in their blood that circulated and caused repair and regeneration. And those were exosomes. The study was duplicated by taking the blood from that young mouse and injecting it into the tail of the older mouse. And they saw some very similar findings. When, when you hear about these things, we're steps away from exosomes being used as anti-aging agents. Now, where do you get exosomes? Well, you get them from humans, and this is where the FDA and the regulatory issues become tricky because you know, to, to get exosomes from humans requires you to culture stem cells. And culturing stem cells,

Dr. Steve Cohen (26:20):
they go through many iterations, they age themselves. And we don't always know what's in the packet that we get from the exosomes and these human stem cells. Now that said, animal exosomes are close to ours. You know, obviously monkeys are the closest, but, but things like bovine kinds of exosomes. So exosomes that you can get from, from the cord blood of a calf without even having to sacrifice the calf, those exosomes can actually be used in a variety of forms. And it's conceivable that they can be turned into a pill form that we begin to take on a regular basis. But these are things that are very exciting about exosomes systemically and for antiaging, for aesthetics, topical exosomes are also very exciting, but again, they face the same problem. There is no FDA labeling. Those of us that are using these exosomes are using them really in a way that is not considered to be FDA approved.

Dr. Steve Cohen (27:28):
So we may be practicing medicine feeling they're very safe and likely they are, but as we start to move towards some of the products that can be in the US and on shelves, even in places like Nordstroms that are significantly more powerful than the most powerful agent in any cosmetic, which is retinol, we're gonna start to see exosomes really blast off and they may blast off not so in medical treatment, they're blasting off because that's what our vaccines are made from. But in, in cosmetic treatment, they may blast off on the shelves of Nordstroms before they even enter the doctor's office. So

Dr. Lawrence Bass (28:14):
Yeah, they are exciting. And one of the ways I think about this, and you can say whether you think this is worthwhile form of thinking, but for the listeners, you know, when we take something like a growth factor, well, that's a molecule that the body uses to signal cells to increase inflammation or decrease or increase collagen synthesis or decrease. And when we dribble that onto a problem wound, that's being slow to heal. The body's getting some of that message that it uses itself to tell itself how to heal a wound and it may help with a problem wound, but the dosing and presentation of that growth factor really doesn't resemble very closely how the body signals itself and exosomes transferring message cell to cell comes closer to resembling that kind of messaging. Although we still have a lot to understand about the pharmacodynamics and dosing of how we would ideally use exosomes. They're probably going to resemble more closely. And that's the way I think about it.

Dr. Steve Cohen (29:34):
I think that's a good way to think about it. I think that's actually very valid

Doreen Wu (29:39):
On this podcast. We like to talk about recent developments and new research directions. And Dr. Cohen, you already briefly touched upon this earlier with NAD, but I'm wondering what else is in the works that we can expect in the next five to 10 years?

Dr. Steve Cohen (29:53):
Well, I think, you know, understanding more about the effect of intermittent starvation, will be interesting to learn more about. There are many medications that are being tested on humans to see if they do have antiaging effects. You know, these are gonna be systemic effects. Early diagnosis is going to be critical. Again, all of these things play into the role of, you know, in my opinion, you know, the discovery of the human genome, we know it's broken at birth. So I think some of some of the way medicine will change, it'll become a much more proactive and preventative kind of approach versus wait until you get a disease and then come in and we hope we can cure you with a big operation. It's gonna be, look, you're going to get this disease. We need to do everything possible to modify it. You know, every one of your, you know, male relatives died at age 38 of a heart attack.

Dr. Steve Cohen (30:55):
Well, you're two years old. What do you think's gonna happen to you likely, unless, you know, you've got the luck of the draw. You're gonna have the same genes. So why wouldn't we start to be thinking about putting those patients, even as children on things like Lipitor or certainly diet modification and things like that, as we become more intelligent, if we're able to change our habits, then I think we're gonna actually be able to apply so many of these different things to ourselves. Same thing with aesthetics. If we start, you know, Doreen at your age versus at my age, you know, you have the opportunity to really slow down your aging process. You know, other people are, you know, not able to do that quite as effectively or without the knife, et cetera. So I think that in aesthetics, we're gonna see some amazing changes.

Dr. Steve Cohen (31:49):
The other thing I should mention about new things coming down the pike, we just finished a study. I think we've done now, 50 patients. It hasn't been written up yet. It's been reported overseas, but women that are not able to get pregnant and go through, you know, huge amounts of financial burdens to try to, you know, you know, create an embryo and then implant. It still have kind of high rates of failure. We've now done women where we've injected the ovaries with stromal vascular fraction, which is the cells in fat minus the fat cells. We've injected their endometrium with stromal vascular fraction. And we've been able to achieve 85 to 90% success rates in implantation in those patients now. So that's another example. There's so many different things, you know, genital rejuvenation, you know, for vaginal rejuvenation and, you know, for erectile dysfunction, hair loss you know, sports, medicine, and wellness. These are all things that, in my opinion, if they're used properly, not like sensationally, but properly all will make huge amounts of sense now to be doing.

Doreen Wu (33:17):
Lastly, I want to wrap up our episode today by asking both of you for some key takeaways from our discussion of regenerative medicine. If Dr. Bass you'd like to go first.

Dr. Lawrence Bass (33:26):
So I think you can hear from this discussion that we are really at the dawn of what regenerative medicine is going to be able to do for us and how central a role it's going to play. Not only in aesthetic plastic surgery and aesthetic medicine, but in all fields of medicine. So this is the beginning and as the capabilities expand as careful study accelerates, which is happening now, we are just going to see this torrent of application kick in at some point that really transforms in a major way, the entire way we approach clinical care of patients. And again, not just in aesthetic plastic surgery, but in medicine generally.

Dr. Steve Cohen (34:20):
Yeah, I would echo what Dr. Bass just said that, you know, we're at the beginning of a new era and, you know, we've, I've spent 20 years in this industry and I've watched companies who've raised 600 million fail and go bankrupt because the expectations have not been understood. The studies are so difficult to carry out. There's not a single study that controls for the genetics of this. So for instance, if you look at the methylization processes on a chromosome, which is a way of looking at the youthfulness of your cell, some people already are kind of too late, sorry. And other people are just right. If we can factor these things in and understand them, we'll have home run studies, but right now we're still kind of going this side, we put fat in, this side, we put fat with cells in, and we don't see a big difference. And that may not really be the right studies to be doing. So I think just like bone marrow transplantation has no FDA approval. Just like the heart lung machine has no FDA approval. There's certain things in medicine that are going to happen irregardless of the FDA, because they make too much sense and using our own body parts and materials and recycling them and using them to our advantage makes so much sense to most people. And the safety is just, you know, unparalleled because it's us now.

Dr. Lawrence Bass (35:56):
It's going to be a brave new world. Well, Dr. Cohen, I'd like to thank you for joining us. It's been a tremendous pleasure and very appreciative to have someone with your level of expertise in this field sharing perspectives on what's happening.

Dr. Steve Cohen (36:12):
Thank you, Larry. It's been a pleasure.

Doreen Wu (36:14):
I'll let go, Dr. Bass, and express my thanks to Dr. Cohen for taking the time to share your insight and expertise with us, and thank you to our listeners for joining us today, to hear about the growing and exciting potential of regenerative medicine. I hope you found this episode as fascinating and informative as I did. If you think of other exciting developments or trends in plastic surgery that you would like us to discuss in an upcoming episode, please reach out by email or Instagram. We'll see you next time. This is Doreen Wu thanking you for joining Dr. Bass, Dr. Cohen and me for this discussion of the role of regenerative medicine in the future of plastic surgery and anti-aging. Be sure to tune in next time and don't forget, 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 (37:02):
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.