Less Invasive, More Affordable Cosmetic Surgery and Skin Care

  

  

  

  

  

  

  

Host: Anti-Aging Psychologist Dr. Michael Brickey

Expert Guest: Dermatologist Dr. James Fairfield

Broadcast: 1-28-08 on webtalkradio.net where the latest shows are broadcast and posted as podcasts

 Dr. Fairfield is author of Erase the Years: How Today’s Cosmetic Procedures are a Fountain of Youth. He leads a thriving dermatology practice in Philadelphia. He has a weekly radio program, Erase the Years. He certifies physicians around the country in the use of cosmetic lasers and works closely with the University of Pennsylvania in the treatment of malignant melanoma. The Consumer’s Research Council recognized him as one of the nation’s top physicians. His website is http://www.cmderm.com/

TRANSCRIPT ©Michael Brickey–excerpts permitted with attribution

MB: This is Dr. Michael Brickey with Ageless Lifestyle Radio, cutting-edge thinking for being youthful at every age. On each program I interview experts on what it takes to live longer, healthier, and happier. Our program takes a holistic approach in addressing anti-aging psychology, medicine, alternative medicine, fitness, nutrition, and wellness. Our emphasis is on innovative thinking and practices that have solid data and results. Today’s expert guest is Dr. James Fairfield. Dr. Fairfield is author of Erase the Years: How Today’s Cosmetic Procedures are a Fountain of Youth. He leads a thriving dermatology practice in the Philadelphia area, has a weekly radio program, “Erase the Years,” and he certifies physicians around the country in use of cosmetic lasers. The Consumer’s Research Council recognized him as one of the nation’s top physicians. Dr. Fairfield, let’s start with a huge breakthrough treatment in dermatology – Fraxel laser treatment. What is Fraxel treatment?

JF: Fraxel laser actually pioneered what is known also as fractionating laser treatments, in which little spikules or spikes of laser energy penetrate the skin – very, very much like the gardening shows you’ve seen that aerate your lawn with like spikes in them – go through the skin. The breakthrough is that the technology is the laser light is attracted to water. So these microthermal zones, microscopic little treatment zones, leave the surface skin alone because there is no water there. And the damage to the skin is in fact a coagulation of the collagen in the epidermis and the epidermal and dermal junction, and in the dermis itself. The treatment is done via computer so the energy is laid down in a computerized array, much like pixels in a photograph. It’s done in a series, so in any particular treatment, the operator might choose 17 to 23% of coverage, allowing then about 80% of the normal skin to do the exchange. Within two to three days, the coagulated spikule of collagen is replaced by brand new collagen. You take a 61-year-old and he then, at this site, has brand new dermis and epidermis. A series of treatments then, of course, get you towards 100%. The effect is a transformation underneath that affects the surface by getting rid of brown spots, breaking up blood vessels on the surface of the skin, and ultimately an amazing tightening of the skin, so that the skin is lifted and tightened.

MB: I understand that it can even get the color back in the scar area?

JF: To a certain extent. The color cell is called the melanocyte. Melanocytes are mobile cells. If you picture these microthermal zones targeting the scar tissue itself and coagulating it, the neighboring melanocytes are capable of migrating across the defect and populating that area. The scar itself also is softened, and the in the course of months that follow, the elastic tissue is laid down and the scar is elevated. This thing is now the gold standard for the treatment of acne scars.

MB: So somebody with severe pock marks from acne or smallpox or something could actually have those pretty well erased?

JF: The depressions are the best kind of scars to eradicate, of course – the shallow hollows, the depressions of chicken pox or of acne itself. The – what we call ice pick scars – those are treated differently. We basically remove them with a very tiny circular scalpel called a punch. The body fills it right in. So the ice pick scars are modified that way, but all of the other shallow scars and rather deep scars are actually elevated by the Fraxel laser.

MB: Is this pretty painless? Are people getting an anesthesia shot?

JF: The computer generates the energy based on the square inches of each person’s different face, and the measurements taken by the machine prior to the treatment onset, so the entire face then, for an hour prior to the procedure, we coat it with an ointment that is a very potent topical anesthetic. It is a heat reaction, so the sensation is that of heat, little spikes of heat that are just momentary, only when the laser fires. The person then holds a vacuum hose – well, it’s actually not a vacuum hose; it’s a blower hose – that blows refrigerated air. Whenever it gets a little too warm, you simply point it at the spot and eradicate the heat sensation. I myself have had six of these. I am 61. And three or four months later, my clients who have not seen me before-

MB: They didn’t recognize you?

JF: They – well, if they’ve never seen me before, will place my age between 48 and 54.

MB: Wow.

JF: That’s how much significant tightening there is, eradication of the brown spots, tightening of the pores – it is rather amazing. And the condition women get called melasma, the mask of pregnancy – this breaks all of that up, the resident cells that are manufacturing the color are broken up and the skin returns to a normal color.

MB: Is this replacing what we used to call facelifts?

JF: It is an adjunct. I have had clients come in who were troubled by sagging jowls and they had such terrible skin quality due to smoking and excessive sun and whatnot, and they recommended to them that we improve their skin first and see what happens, and we’d undergo a Fraxel series. And sure enough, at the end of the Fraxel series, they really didn’t need a facelift.

MB: Wow.

JF: This is useful also for what we crepiness of the neck, the décolleté area with all of the brown spots and very thin skin that one sees in the sunnier climates, and of course where you see a lot of aging changes, the back of the hands and forearms – the Fraxel’s fair game for all of that. We also use it for stretch marks, because it can thicken those up again, and for surgical scars.

MB: With a facelift, you’ve got swelling and weeks of recovery. With this, there’s practically no recovery, just a bit of redness the next day, or…?

JF: From personal experience, I would have a treatment in the morning, see clients in the afternoon, and be accused of being out in the sun and not listening to my own advice. So yes, there is puffiness, but it’s not true swelling. By that night, my face would feel warm. I’ve break up a pack of peas, frozen peas, and hold them on my face, sleep elevated for the next three nights to keep the puffiness to a minimum. But I’d be back in action the next day. We treat models who have a photo shoot within three days and they’re fine.

MB: Is there anything else that would be helpful for us to know about Fraxel treatments?

JF: Very much so. The Fraxel is the gold standard, the Reliance Fraxel machine. One of the best – I’ve been doing lasers for 26 years. I was trained by Leon Goldman, who was the father of medical lasers, the very crude, old CO2 lasers of the 1980’s – I’ve never seen technology like this. And one of the best indicators that you have a winner is that imitators pop up all over the place. And if the other laser companies, especially the ones that have what we call multi-platform boxes in which the purchaser buys a single unit and then gets different hand pieces that ostensibly perform different functions – and rapidly there were appearing fractionating hand pieces on these things, which wavelengths didn’t approach the wavelength necessary to do what the true Fraxel does. I would recommend, having a lot of laser experience, that you stick with the actual original Fraxel. They have gone to an upgraded version called the Fraxel SR1500, better known as the Fraxel Refresh or something like that, and they’re now coming out with a new one that is a combination of fractionating laser and resurfacing. And the catchword of the day nowadays is nonablative. Nobody has the time to be down from work, so nonablative – that’s what the Fraxel is. When they introduced this newest version, they did introduce some ablation. But it’s so scattered and so minor that it triggers tremendous skin tightening with very, very little downtime. Not much more than the original Fraxel. So it’s a good, good product.

MB: So it’s like a brand new then?

JF: Fraxel is a brand name.

MB: How would a patient know if his dermatologist was really experienced, or whether you were his first laser patient, and better to go with someone with a little more experience?

JF: Ask for referrals. Ask for names of clients who would be willing to talk to them about their procedure. The experienced physician has plenty of those who are just back-flip happy to give their testimonials. I have clients here who are at the ready to speak to anybody. That’s a wonderful sign that you have a physician that really knows what he’s doing or she’s doing. It’s a great way to get some assurance that you’re in the right place.

MB: So physicians are allowed to do testimonials?

JF: Oh, absolutely. I use them constantly, because what others say about you is far more powerful than anything you could say about yourself. We use those in all of our marketing pieces, on our website. We rarely send anything out that does not contain at least one testimonial.

MB: Now, one of the things fascinating about you, Dr. Fairfield, is that you’ve tried virtually all of the treatments on yourself-

JF: I have.

MB: Including recently doing liposuction on yourself?

JF: I sure did. There’s a reason for that. Number one, I – you know, at 61 I need some help. I’m a fly fisherman. I’ve been a pilot in the past. I’ve been exposed to a lot of ultraviolet damage, and especially the most damaging ray, which is ultraviolet A light. People are unaware of that. It’s present year-round and it does most of the deeper damage to the skin. So I actually needed some help. And as far as the liposuction I did, it was done in conjunction with four of my expert laser staff. This was done with the newest device on the market, even newer than the Fraxel, called SmartLipo – laser-assisted liposuction. SmartLipo is also a trade name. And in this case, what one does is inflate the fat layer with lidocaine, epinephrine, and a buffered solution, basically a bag of numbing medicine that is introduced under the skin through a previously numbed-up spot. There’s a larger cannula introduced and you blow up the fat. You basically make it tumescent. That’s the word – tumescent. And it makes the fat easier to extract. But the magic of lipo is that this very thin cannula is introduced. The cannula is no more than 2 mm wide. It might be 15 inches long, but it’s very tiny. You put it through a tiny 2-mm punch hole and it’s a YAG laser that then vaporizes and liquefies the fat, the fat cells, so the fat never comes back. But the most important difference is that it treats the underside of the dermis, the underside of the skin at the dermal fat layer. This triggers a consequent contraction of the skin over a period of weeks so that when you are done, your skin is not hanging in loose folks, as one sees after traditional liposuction. Now, this occurs whether or not you – say you have a small area, like under the next or in the jowl area, that’s all you do. You just do the SmartLipo and then aspirate the liquid. But if, as in my case, I had significant love handles – of course, nobody loves love handles. The love handles had some substantial fat underneath, so we did the SmartLipo treatment to treat the underside of the skin and vaporize the top 10 mm or so of fat, and then introduced a larger cannula to vacuum out the rest of the fat, down to the muscle layer. The nurses were a bit, shall we say, tentative in their approach to that part. So I said, “Hey, give me that thing,” and I put on a pair of sterile gloves and had at it!

MB: Wow.

JF: And they said, “How can you do that?” And I said, “It doesn’t hurt. I’m as numb as they can be.” And I showed them what kind of power is necessary is go after serious fat removal. And one by one, they got the idea, and then they finished me off. They did my flanks and all the way to my spine. And today – oh, I had a full schedule the next day, by the way.

MB: Wow.

JF: You wear a compressive garment, and I swear there was no discomfort. The feeling is one of having had a good workout at the gym. That’s about it.

MB: So the SmartLipo compared to the lipo that we see on the TV makeover programs – we’ve got a smaller wand, we’ve got less folds of skin afterwards. Are there other differences?

JF: Well, it’s done in an outpatient setting. This is serious, because in the news, of course, we’ve had far too many deaths reported from liposuction, and the deaths uniformly are done in the hospital under general anesthesia, usually done with multiple procedures, such as liposuction, breast reduction or augmentation, and perhaps even an eyebrow lift or something – it’s far too long under anesthesia. And with liposuction, there’s a significant exchange of fluids. You put a bunch in and then you suck it all out. The electrolytes get out of whack. Young people – people in their 30s – have died on the table from this. They couldn’t get it back. The safety of SmartLipo, laser-assisted liposuction, is that you’re not tempted to go and treat multiple areas. It takes too long. So you pick – we segmented into areas such as the upper abdomen and the lower abdomen, plus the love handles, upper inner thighs, knees, saddlebags, and a new term I learned from my staff called “bra fat.” I had no idea what that was. But they object to the indentation create by their bras. And it is due to fat that is between the skin and the back. And of course, you take out a wide swatch gently of just a centimeter or two of fat, and then the bra does not indent, of course, so much. And it’s very popular. And it’s a wonderful way to tighten up that turkey-wattle neck. You introduce the cannula of the SmartLipo just under the chin through a tiny hole and vaporize the fat right under the jaw line and up into the jowls. And then take and just run it underneath all that loose, flappy skin, put on a compressive garment that goes up over the head for a couple of weeks, and that neck skin tightens right up beautifully and you look just tremendously younger.

MB: So the SmartLipo is infinitely safer, much quicker recovery, and you don’t have the folds of skin hanging down.

JF: The folds of skin obviate the need for a tummy tuck. You don’t need it.

MB: Wonderful. So now you can look your patients in the face – look them in the eye, rather – and say, “It doesn’t hurt.” Is there anything else you learned from doing these procedures on yourself?

JF: Yes. Safety, efficacy, and proof. We’re big on absolutely being our best advertisements for what we do. And when I tell a client in a consultation – when they ask me, “Well, what does that feel like? What do clients say?” I say, “Well, I’ve had it done. This is what it’s all about.” And I tell them my story. And the credibility from that alone – now, as an aside, prior to doing the SmartLipo, we did a fair amount of what is called mesotherapy. Mesotherapy is an injection series of fat-dissolving natural products – one’s a soy product and the other’s a bile salt – that dissolves fat, and it’s very effective. The problem is it’s done in a series, and not all clients really respond very well to it. So for years, I had one side done. I had my left side of my abdomen and love handles treated with mesotherapy, and that was quite flat. The other side hung over the belt. And so when a client was interested in mesotherapy and wondered if it worked, I’d just pull my coat aside and say, “See?” And there’s no better testimonial than that. It was obvious it worked. Similarly with Fraxel, I’ve had one of my staff Fraxel my right hand. The left hand has – really, years ago – lost all of its elastic tissue. I can pull the skin up and make a pup tent that stays.

MB: Entertain the grandkids, huh?

JF: The skin is thin enough you can see through it. You can see the tendons. On my right hand, the skin is thicker, you cannot see the tendons, and when I pick that skin up, it snaps back like a 17-year-old’s. There’s nothing more effective than showing somebody something like that to convince them that, yeah, wow, this thing really works.

MB: The meso you’re talking about is spelled M-E-S-O?

JF: Mesotherapy, yes. The French originated this years and years ago and it’s really – a lot of homeopathic remedies are injected in the face, for instance, for rejuvenating the face. And then the science morphed over to removing fat. And the solution for fat removal became sodium deoxycholate, which is a bile salt, and phosphatidyl choline, which is an emulsifier, really – it’s a soy product. Sort of like throwing dish detergent on a place with some grease on it – you’ve seen it sort of bead up and go away? Well, that’s how that works. And when the fat would be dissolved, the lymphatics then would pick up the fat, and of course the cells would be destroyed. It was quite effective. But this SmartLipo, of course, it’s a one-shot deal. You do not need the series of treatments. You know, you wear your garment. You are done, and it’s just wonderful.

MB: Do you still do mesotherapy, then?

JF: We offer it. Some people are really skittish about lasers or injections – they don’t like the idea of having a numbing medicine put in them, but they’ll tolerate the fire ants of the little tiny-tiny needles of mesotherapy. So we still offer it, but we do recommend the SmartLipo as a quicker alternative.

MB: Any other reasons that some patients might prefer more traditional surgeries or treatments?

JF: Well, of course, somebody who’s in their 70s or 80s who has had significant sun damage – for instance, who has lived at the shore or who has a long history of smoking -may have wrinkles and sagging to the extent that none of our lasers could really do justice to the skin. They’d really need a standard facelift. They need tissue removed. So that’s a more traditional approach. The unfortunate thing about traditional facelifts is that it’s actually in the wrong direction. It’s in the direction toward the ear, and almost in parallel to the ground, which gives that wind-tunnel look to those you’ve seen with facelifts, or at least to those you’ve seen who’ve had too many facelifts. I won’t mention names of any celebrities because we happen to know that they – a couple are clients of ours and they really do regret having had the traditional facelift. But it is the option for somebody with really too much baggy skin, if you will. The other areas where traditional approaches are still done, although new ways of doing it, are breast augmentation – anything involving hospitalization – breast reduction, tummy tucks, those things. Those are pretty much standard bread and butter for the plastic surgery folks, although the breast augmentation science has really taken a turn to being able to be done without any evidence of scarring whatsoever. It’s a far neater procedure.

MB: For most people – are we no longer talking about facelifts, but rather the treatments, the Fraxel laser treatments, too?

JF: Now, Fraxel will tighten the skin. Those are new treatments. Botox, Restylane, you know, the fillers – those are the old standards. They’re still extremely popular and have a definite daily place in our practice.

MB: So you still sometimes recommend to people to get facelifts?

JF: Yes. Somebody might come in and want my mini-facelift, which we call the Aesthetic Quick Lift. The Aesthetic Quick Lift is my modification of the – if you were to Google “S-lift,” you would see a certain kind of facelift, and that’s at a more natural angle. It’s more of a 45-degree angle vertically. After all, when we lose our collagen and we lose our elastic tissue due to aging and sun damage, the direction is down, not toward the nose. So obviously, the direction to reverse the look is to go back up. And the S-lift is – it’s called S-lift because of the shape of the tiny little scar that circles the ear, comes from behind the ear, follows along directly in front of the ear, disappears under and behind the earlobe. But in that procedure, what we do is do a circular, elevating suture under the skin – not putting tension on the skin, but putting tension on the fascia, which is the tough, saran wrap-like membrane over the fat. It’s a circular suture directed toward the chin and directed upward in an angle of about 45 degrees toward the top of the ear. Now, when that’s pulled tight and knotted, it elevated the jowls, elevates and sharpens the jaw line itself. And then a subsequent U-shaped loop is taken down under the skin and sewn in to – in a circular fashion – to the platysma muscle of the neck. Now we’re getting kind of medical here, but the platysma muscle is what you – if you were to grimace your neck, is what pulls the skin up tight. And it lies just under the fat of the skin of the neck. And if you put that little loop of skin into the fascia of that muscle and pull it up, again, toward the front of the ear on both sides, it tightens up the turkey neck. So now you have somebody who had jowls and a loose neck, walking out two hours later with an elevated mid-face, sharp jaw line, and no turkey neck – the neck looks absolutely normal.

MB: Wow.

JF: Now, of course, this results in redundant skin. We’ve moved the deeper tissues, and now the skin where the incision was made in front of the ear is now laying on top of the ear. And we simply trim that away and use tiny little sutures to reattach it right along that little fold right in front of the ear. And that scar disappears within weeks to months. You’d never know it happened. And these people go back to work in a day or two.

MB: So only your doctor knows, huh?

JF: Yeah, how about that?

MB: Let me take a break here. This is America’s Anti-Aging Psychologist, Dr. Michael Brickey, with Ageless Lifestyles Radio, your source for cutting-edge thinking on being youthful at every age. Today’s expert guest is Erase the Years dermatologist, Dr. James Fairfield. His website is http://www.cmderm.com/. The CM is for Central Montgomery, referring to Montgomery County, a suburb of Philadelphia, and the Derm, of course, for Dermatology. His website has lots of information, free reports, his blog, and the media section has a link to his fascinating radio podcast that I highly recommend. Information on Anti-Aging Psychology and my free Defy Aging Newsletter is at DrBrickey.com, or you can just go to NotAging.com and it’ll take you to DrBrickey.com. Dr. Fairfield, is treating cellulite different from treating fat deposits?

JF: Absolutely. Cellulite is not excessive fat. It has the appearance of it because there are bumps, but what we’re really looking at is an optical illusion. Our skin is suspended on our muscles by fibrous tissue called myocutaneous fiber and cellulite or cellulite, however it’s pronounced – and it varies across the country – is a process of shortening of these little fibrils due to inflammation which nobody understands. It is poorly worked out. There have been no solutions as to what – no information about what causes the inflammation or what one can do to treat it. So the problem is really retraction, much like a guide wire would pull down on a tent, rather than excessive fat. And we have been experimenting with the SmartLipo. Think of it this way. If you just take the SmartLipo laser and traverse along, just under the skin, the area of cellulite bumps – it looks like bubble wrap – and break up those little shortened myocutaneous filaments, the skin pops right up, absolutely pops right up. And then it looks nice and smooth and normal. Now, the only issue is only a certain percentage of myocutaneous fibrils are affected. And the question is, is over the long term, will the process continue? Will the client develop more shortened fibrils and need the procedure again? That has not – you know, the machine hasn’t been out that long; we have not had the chance to really evaluate it over the long term.

MB: Fascinating. Have there been advances in treating varicose veins?

JF: Varicose veins are interesting because there are a complex of veins called feeder veins or reticular veins. Those are the bigger, bluer ones. They respond extremely well to sclerotherapy. They’re a variety of sclerosis – those are the chemicals used to inject into the vein to make it collapse. I prefer saline, normal saline – not normal saline, it’s 23.4% hypertonic saline, and it basically – it’s a very physical reaction. It buns the interior of the vessel, the vessel swells itself shut, and the little PacMan cells called macrophages come along and chew up the dead vein and cart it off – very effective. However, most women and men don’t have just blue veins. They have these starbursts and arcades of red veins – little tiny, tiny, less than a millimeter red devils, that really people hate the most, typically appearing on a woman’s thigh in an arc or combined with blue and red. They’re very picturesque. Breakthrough now is the YAG laser, which will target the red in the blood, in the vessel. Laser lights divide it up into different wavelengths – that’s what makes laser a laser and not just a light bulb. A light bulb has multiple wavelengths; a laser has a singular wavelength. It’s colonnaded to come out in a parallel fashion and then focused, much the way we as kids used to focus our magnifying glass and fry ants on the sidewalk – except that the sunlight was not a singular wavelength. The laser is much more powerful than is a singular wavelength. Well, each wavelength has what is called a chromophore, that to which it’s attracted. So you’ll have a green light laser that’s attracted to red, and we use green light lasers then for the red in the vessels on the face. The 1064 or YAG laser, we use to target the red in the hemoglobin, in the blood, inside the vessel. And all that one has to do is pass that wand over normal skin and nothing happens, but the second it hits a vein, all that energy is absorbed because it’s red inside and it’s a heat reaction instantly and it cooks the vein, bakes it. And then again, the same process of healing. The macrophages, or the little cells that clean up debris, come along and clean up the mess, and you are vein-free. Now, I say “mess” – postoperatively you don’t see much, because all of this is happening microscopically.

MB: Sounds like it would make a great video game, too.

JF: You know, that sounds like a fun game.

MB: Are there any other cosmetic advances you can tell us about?

JF: There are some substantial changes in the area of holistic wellness. And I really liked your opener to your show where you talked about your holistic approach, talking about wellness itself. And that’s how we have structured our practice. We call our consult, for instance, a “skin wellness evaluation.” We got away from the old consult word because it’s all about wellness of the skin, and there’s so many variables affecting the skin. There are free radicals that one gets from the outside and free radicals one gets from your diet. And all of these set up inflammation, and we happen to believe that inflammation is the cornerstone of most skin disorders or skin diseases. And so the breakthroughs have been in the area of – now these are two words that are new to your listeners, probably – cosmeceuticals and nutraceuticals. And a cosmeceutical is nothing more than a product that you apply to your face, much like, say, Eucerin from the drugstore. It’s a cream. The difference being, these companies that sell them to us, these are medical grade bioactive products that actually produce results, and they produce results rather rapidly. There is a DNA repair cream that will actually produce discernable results in repairing sun-damaged skin within four months. That’s without any other treatment – just the person putting it on twice a day. There’s Vitamin C products that actually do work. The problem with over-the-counter Vitamin C creams is that Vitamin C is extremely unstable and is usually useless by the time it gets to your skin, or if that doesn’t happen, your skin takes care of it. So the cosmeceuticals are tremendous advances in products that actually work, available only, again, in physicians’ offices that have the knowledge to use them and use them properly.

MB: Those are literally prescriptions, then?

JF: Well, one could not – like I could not prescribe, say, Citrix, and have the person go down to the drugstore and get it. We have to obtain it from the company and sell it ourselves. And so what we have done is we’ve decided what we want to accomplish with our topical products, and typically we will formulate them to accompany, augment and prepare the skin for laser procedures, and also have a whole group for those who really would prefer not having procedures at all and still want results. Well, fortunately we can with these cosmeceuticals. Now, the newest kid on the block are the nutraceuticals. These are vitamin combinations, essential minerals and other products, coenzymes and all of these things, specifically designed to assist the skin in eradication of free radicals and in promotion of healthy oxygenation, healthy blood flow, and restoration of normal skin function, all from within by a pill you take just like any other vitamin pill. So these are very strong advances in the field. And fortunately, doctors are starting to pay attention to it.

MB: Wonderful.

JF: I mean, you’ve probably been ahead of the curve on that one.

MB: Trying to be, yeah. Any predictions about where dermatology will be in the next ten to twenty years?

JF: I believe that there’ll be a trending away from insurance-based practices for general dermatology. I think the influence of the insurance companies in mandating what you can and cannot do, arbitrarily changing your prescriptions without your knowledge, frustrating your results that way – dermatologists are just dropping insurance companies and going to a fee-for-service practice model, which is a better business model anyway, and let the market decide. I see increased research and development in heritable skin disorders. Dermatology has always been big at the NIH and in other research centers; all the tertiary medical schools that have dermatology program are very big into skin research, and especially in the area of heritable skin disorders. These are terrible things and very much in need of solving. And then in the cosmetic realm, I see more further inroads developing into more targeted responses to specific problems – for instance, like the Fraxel targets specific problems, the SmartLipo targets specific problems – all with minimal downside, minimal discomfort, minimal marks or bruising, minimal downtime. Those are the things I see. Obviously there’s a huge market. I’m one of the boomers, I’m leading the wave. Hot behind me for the next ten to fifteen years, there’s going to be a lot of people interested. So the market’s there and you can bet industry’s going to be paying attention.

MB: It’s an exciting time to be a dermatologist.

JF: I think so, yeah.

MB: I know from listening to some of your radio programs that you have a very sophisticated assessment process. Who’s inappropriate for cosmetic surgery?

JF: That’s a great question. We bump into this on occasion, and it’s primarily those with inappropriate expectations. And I can expand on that. Usually you can reframe the expectations. I have a phrase I actually use with clients. “You know, my job is to lower your expectations until I can meet them.” And if they’re with it, they’ll appreciate that. And then we actually break down what it is that bugs them the most, and then I tell them if we could wave a magic wand, make that go away suddenly, what would be the next thing that would bother you? And we develop a list, and it’s a realistic list. And then we, of course, ‘fess up to the limitations of what we can do and what we can’t do. And then it comes out that, you know, all they want is improvement. Well, that’s a good client. However, those who have imaginary ugliness – those are dangerous people. And I don’t mean dangerous to us; I mean dangerous to themselves. There’s nothing you can do for them that will help them appreciate a change. They think of themselves psychologically as ugly, no matter what you say to them or what you do. I don’t operate on them. I won’t touch them, because they need help from a different direction. And then, of course, the absolute worst client would be those who have a serious, real body dysmorphic disorder. And those are dangerous not only to themselves, but to anybody who operates on them – because they get hostile. You could move their nose over to the left side of their cheek and they wouldn’t notice it. And those are people you really have to watch out for, and they’re rare, fortunately. Most people are reasonable. You can usually talk them into understanding, you know, we are not faith healers. We are helpers. We are their most trusted advisors. We can improve their skin, we can improve their perception of themselves, make a huge difference in how they look, and actually roll the clock ten to fifteen years. But you know, in terms of turning them into something that they’ve never been – forget it. It doesn’t happen.

MB: So it’s a process of identifying the rare cases of people who would never be happy, and otherwise adjusting expectations and developing a good relationship.

JF: Relationship and trust, absolutely. It’s all about that.

MB: Except for injuries and cancers and birth defects – and even then, only some of those – cosmetic surgery is an out-of-pocket expense. How much does it cost?

JF: Oh, somewhere between – I mean, products, you could buy some products for $50 to $200, and you can end up having a SmartLipo of a large area for $6,000. You could have a series of laser hair removal, if it was a large enough area that might take eight treatments in eight months, might get you up towards $8,000. But not much more than that.

MB: So a series of half a dozen Fraxel treatments…?

JF: A series of Fraxel comes in around – actually, Fraxel runs between – it depends on where you are in the country – between $1,200 and $1,500 a treatment, in that range. What we do is for control of what they’re using on their face, we give them about $400 worth of our products to use during the Fraxel treatment, and a full set of material to use after their treatments, so that we can optimize their results. We like that control over what they’re putting on, and frequently asking them, “Bring in the bag of stuff you’ve gotten from Macy’s and Penney’s and the CVS and the thrift store,” and they’ll come in with this horrendous bag of stuff that is absolutely useless. And you know, we hearken to that when – after we, one day, we’re telling a person, you know, “Now, you put this on in the morning, put this on in the evening, and your sunscreen, and you’re good to go.” And they said, “That’s all? And when do I put on my…?” And they name five more things. And that’s when we went, uh-oh, we better put a lid on this or we’re going to get conflicting results. So we make them stop everything they use at home.

MB: But you want to make sure they have every chance of getting great results.

JF: Absolutely! I mean, they’re laying down the big bucks. We don’t want to be dumb about it and not know what it is they’re putting on at home – because that’s our bad if we don’t find that out.

MB: Now an awful lot of people shower every day, and I noticed you advised northerners not to shower every day in the winter. Why is that?

JF: The dead skin layer plus your natural oils form a film. If you want to remove your dead skin layer, just take a piece of scotch tape, lay it on your skin gently, and pull it off. You just pulled the dead skin layer right off. Now, in the northern climates, we have no humidity right now. And for a period of time, the ambient air gets its water from the drywall, from the furniture, the carpets and whatnot, but come January through March, it comes out of people. Unfortunately, people, when they start to get itchy from dry skin, think of course, “Gosh, I’ve got something.” And so what do they do? They wash more. The use of wash clothes, loofah sponges, scrubbing mitts, and abrasive cleansers is an absolute no-no. You need your dead skin layer. In the winter time, you’re not out there grubbing in the garden. You’re not dirty. And I quite frankly, I tell them, you know, whatever runs past your back and your legs from when you shampoo and you wash the odor areas – the rest of it’s just water washing. That’s plenty. And then you pat dry – no chafing. You don’t want to remove that dead skin layer. And then slop on a good quality moisturizer. And in this case, it doesn’t have to be medical grade. You can buy the cheapest thing on the market. None of them work in the bottle. They only work on your skin. So I tell them, “Get it on.” And then the other time where this infernal itch hits is when they take their clothes off at night – the back of the hips, the back of the arms, the ankles and the legs. You sit there on the edge of the bed, scratching and scratching and scratching. I tell them to hold off, put more moisturizer on – whatever you like, whatever’s cheapest from Costco or Sam’s Club or whatever. Put it on and let it evaporate. It’ll cool your skin. Your skin will thank you. And you will have helped repair your dead skin layer. Because if you shower and shower aggressively, absolutely your skin will microscopically look like the Utah mud flats, all cracked and fissured, and you’re asking for trouble. That saran-wrapped layer of skin and oil is your best barrier against evaporation, penetration by bacteria and all sorts of other toxins.

MB: So it’s going to keep you healthier as well and fight off diseases.

JF: Absolutely.

MB: There’s so many skin care products. How does a person sort through all the hype and find the products that are best for them and appropriate for their budget?

JF: It all depends on what they’re after. As I just mentioned, moisturizers in the wintertime – pick the one you like. Try a few. Now the creams – if you have skin that’s already itching and burning, even to the point where water even burns a little, a cream is going to really annoy you, because they have alcohols in them. So you may want to move over to an ointment which is more petrolatum-based. I’ve even had people just put some water on their skin, take a thin film of Vaseline and just smear it around. Makes a mess out of their clothes but the skin likes it. But moving on up, if somebody wants something that will change the biology of the skin, then they have to go to the medical grade products available in a physician’s office. Barring that, it’s pretty much potluck on the shelves of department stores and the drugstores. And I would really counsel people to be careful there, because the hype is huge. Wrinkle creams are the rage. You can’t open a web browser without being hit by, you know, all these Botox alternatives, these creams that are supposed to work as well. Well, as an experiment, I went ahead and bought one. Turned out it was the Book of the Month Club. Not really, but it was a Cream of the Month Club – because I bought one, got a little bottle. Next month, another little bottle arrived, my credit card got whacked again. It was a marketing scheme. So I stopped with the program but I used the product on my face. And what it did was it tightened it. It was like putting shellac on, and of course the wrinkles disappeared. By the end of the day, it had worn off; the wrinkles were back. So it’s pretty much hype.

MB: And there you are, trying the products on yourself again.

JF: I had to know. I absolutely had to know.

MB: What would you say are the biggest myths or scams in skincare treatments and products?

JF: That’s a tough one because what I – the position I take is one that comes more from experience. The position a newbie might take would come from a representative from a laser company or from a product company. I would say the biggest scam being pushed on the clients today are the anti-wrinkle creams. When they ask me about it, I say, “You want no wrinkles on your face for tonight? Just give it a good smack. It’ll swell up and there won’t be a wrinkle on the site.” Because it’s edema – swelling produces no wrinkles. I know it comes across as a bit smart, but these are clients that are kind of used to me. They get the point not to fall for these things. There are lasers out there that are just some of the greatest cons perpetrated on people completely. For instance, years ago the IPL machine was very popular for hair removal. Well, it doesn’t work. It does remove hair but it’s like a long wax job. Your hair will come back, because it’s a light bulb with a filter on it – the intense pulse light, IPL. So they’re now fading into the past, like the CO laser faded into the past because it left people scarred and red and messy for months. No more belt sanders on the surface – everything’s done from inside out. There are other typing lasers that I call GP machines. There are a lot of doctors getting into the cosmetic business, simply because it’s a lucrative market. If you check the credentials of a lot of the doctors, you’ll find out they’re just GPs. And I can say this because I’m board-certified in both dermatology and family practice. And what I knew as a family practitioner about skin was zero. But they’re getting into it. I know an anesthesiologist, absolutely hasn’t seen an awake patient in his entire career, has been passing gas all his life-

MB: Oh.

JF: Sorry about that one. And he has opened a mini-spa and puts himself out as a cosmetic doctor. How can that be? You know, the listening public has to be very prudent in who they choose. Plastic surgeons love to be in the OR, but they will have an office full of machines and lasers and highly-trained people doing a lot of good things, so they, by and large, are safe people. Cosmetic dermatologists have taken the time to actually study the skin and they understand the skin biology. Chances are, if they’ve got a decent bedside manner, they’ll be fine. But you have to watch out for the other ones. Now, there is a disclaimer to that. I graduated from medical school in 1975. None of this was in vogue, very little of it was known. So everything I’ve learned in the cosmetic field has come through postgraduate education. And I’ve made sure to make sure I have been educated and trained by the best. I’ve flown to Canada, I’ve flown all over the place to get the perfect training for various types of procedures I want to perform. And I get certified, and now I’m certifying others. But there’s an argument to be said that if you have a local family doctor who’s really sharp and has done his homework and gone and gotten all that training, he is an MD or a DO and is arguably okay for the average cosmetic stuff, like Botox and the fillers and some laser work. So I don’t mean to diss people. I just mean to tell listeners to be very, very careful.

MB: Well, you can certainly look for the board certifications.

JF: Absolutely.

MB: But what exactly is the difference between plastic surgery and dermatology?

JF: It’s pure training. Dermatology is the science of the skin itself. We’re the only ones who know anything at all about the biology, function, and histopathology of the skin. We know – in our training, we actually read our own biopsies. So when we look at the skin, we can actually visualize what it looks like inside. And so when we pick a laser or pick a procedure and when we operate on the skin, we’re finessing it. I use plastic surgery closure techniques. I can close an ear that is completely split in half by an earring and you cannot see the scar. That is what dermatology is. Dermatology focuses on that huge organ, the biggest organ on the body, called the skin, and of course, the subcutaneous tissue is part of it. A plastic surgeon – his training takes him through general surgery first, so they’re taking out appendixes, gallbladders, colons, and doing all the regular stuff. Then they get additional training, typically in the movement of large, bulky masses of tissue. That’s what is required in burn centers. That’s what required in reconstruction of birth defects. These people are the artists that will restore terrible, terrible deformities and give somebody their looks back, reattach a hand. There are subspecialties within plastic surgery – but they are surgeons and they do prefer to be in the operating room. Do they understand skin? Not any better than any other doctor. Only the dermatologist really, really understands skin. But I’m not going to do the breast augmentation. I’m not a general surgeon trained as a plastic surgeon. So have at it, guys. You know, they can do it.

MB: So they’re better at the big sculptures.

JF: Yeah, and I’m after the finessing.

MB: Well, Dr. Fairfield, I think you’ve frustrated a lot of our listeners because they would love to have you as their dermatologist and may not be ready to fly to Philadelphia to see you. I really appreciate you being on the program and sharing your depth of knowledge with us. Well done. People often ask me if I think cosmetic surgery is a good idea. I have several takes on that. First, if you are passionate, if you are enthusiastic, if you are a caring person, most people aren’t going to care very much how many wrinkles you have. I think good examples of that are Ruth Gordon and George Burns. Most of us, however, don’t have such winning personalities, and it’s true that people do judge a book by its cover. So it behooves us to look as good as we possibly can. There are a lot of ways to look our best without lasers and without surgery, and we certainly want to pursue those first. And if we’re still not happy with the results, it’s worth considering cosmetic surgeries or lasers. The facelifts of the past, particularly multiple facelifts, often looked very unnatural, giving that wind-tunnel effect. The good news that we heard today is that the treatments are not only looking much more natural, but also less invasive and safer. And for those who don’t want to pursue lasers or surgery, there’s cosmeceuticals and nutraceuticals, the more effective skin lotions and creams, to help people’s skin look as natural as possible. Finally, there’s the caveat that not all doctors are Dr. Fairfields, with his experience and knowledge and thoroughness, so you do have to do your homework. There are risks. But the bottom line is that this is an exciting time. We have new developments every few years and a lot more resources and choices on how to take good care of ourselves and help us look our best. This is America’s Anti-Aging Psychologist, Dr. Michael Brickey, with Ageless Lifestyles Radio, your source for cutting-edge thinking on being youthful at every age. Today’s expert guest is Erase the Years dermatologist, Dr. James Fairfield. His website is http://www.cmderm.com/. The CM is for Central Montgomery, referring to Montgomery County, a suburb of Philadelphia, and the Derm, of course, for Dermatology. His website has lots of information, free reports, his blog, and the media section has a link to his fascinating radio podcast that I highly recommend. Information on Anti-Aging Psychology and my free Defy Aging Newsletter is at DrBrickey.com, or you can just go to NotAging.com and it’ll take you to DrBrickey.com. I’d love to get your feedback and comments. Send them to radio@drbrickey.com.