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Dr. Anil Shah:
I am honored to be joined by our esteem, uh, dermatologist from South Carolina. This is Dr. Todd Lesinger. Um, he has a ginormous practice. Um, he is super knowledgeable. What we’re gonna talking about, which is acne scars. He’s written over 100 peer reviewed publications. He’s a mour clinical investigator trained at Cleveland clinic, um, has a three office dermatology and dermatologic surgery, uh, practice. Um, and his area of research is kind of all over these areas that we’re gonna be discussing, which is inflammatory dermatologic processes, cutaneous oncology in cosmetic dermatology. We’re gonna be focusing on acne scars. I know we could talk about these things for a long time, so I’m super honored to be resenting our guest today. Uh, Dr. Todd Lesinger, how are you doing today?
Dr. Todd Schlesinger:
Very well. Thank you. And that’s, uh, you know, some wonderful things you said. I appreciate that, but first and foremost, I’m a dermatologist and, and, um, you know, excited about taking care of my patients.
Dr. Anil Shah:
Love it, love it. Okay. So super common, uh, thing that goes on is, um, uh, we’re gonna be just kind of jumping into this acnes cars. So, um, you’re an expert in acnes cars. I kind of wanna know, um, before we get started talking about acnes cars, let’s get our audience just a little bit of background about it. So what are at acne scars?
Dr. Todd Schlesinger:
So acne scars are basically, uh, different, um, uh, depressions or, uh, problems with the skin that occur after the inflammation that occurs, you know, when acne, and, you know, it’s a little bit of a complex cascade to how we get there, you know, to an acne scar, but basically what you have is the, the core, the core problems, inflammation. And when you have inflammation, have a breakdown of collagen through, you know, kind of the Nate immune system pathways, you know, these are the pathways that occur when we’re, you know, first cut our skin, we’re injured by back, you know, injured and we get bacteria, fungus or yeast in our skin. We have inflammation. And so the first part of our immune system that will come up and attack that is Nate immune system. So what happens is you have breakdown of collagen and, you know, our body, you can never really break, never really restore collagen as well as it, uh, you know, as well as it was when it was first made after inflammation. So when you have that breakdown of, of collagen from inflammation, you’re talking about matrix cell proteases, things like that, that destroy collagen with inflammation when that’s rebuilt, when that collagen’s rebuilt, it’s never gonna be as good as it. And it was new. And then you end up with, you know, with various types of acne scars. So that’s sort of like the, in a nutshell process of how we get there.
Dr. Anil Shah:
Do, do you like the term acne scar? Because you know, when I think of a scar, you mentioned this a little bit earlier. It’s like a scar is an abnormal healing process. When I think of a scar, sometimes we get, we think of things like the Frankenstein jagged Rayd scar through here. I think of the term acne scar is kind of a misnomer. I think, of an acne scar as being sort of a, it’s like an, I think a better term might be acne depression, because it seems like almost all the time we’re trying to, you know, create the void that’s been left behind by these inflammatory processes you just described.
Dr. Todd Schlesinger:
Yeah. And I think that’s one way of looking at it. I mean, I feel like there is scar tissue there. So, you know, while you do have an abnormality in the contour of the skin and in some cases, uh, you know, underneath the underlying that you have, uh, abnormal collagen deposition. And so by definition, I mean that inflammation creates an AB you know, that inflammation creates abnormal collagen deposition, you know, as it, you know, as that healing process occurs, you know, after it’s been broken down your body, you know, your body creates collagen, you know, via a certain pathway. Um, you know, in, in, as we’re born or as our bodies develop as our skin develops. But when you destroy that collagen, whether it’s by surgery or radiation or whatever it be, it just never can heal quite the same, even with fillers. I mean, we’re creating, you know, uh, inflammation with even fillers that we use, and that creates some type of abnormal deposition, which I would consider to be, you know, definition of scar.
Dr. Anil Shah:
Okay. Um, so for patients with acne, so I have some teenage daughters, um, they have acne, what percentage your patients are you gonna say are gonna have this abnormal process with developing acne’s cars? How common is this?
Dr. Todd Schlesinger:
Um, you know, statistically, I think it was, it’s actually fairly common. You know, I don’t know the guess of what the prevalence is, but I would just sort of say, uh, you know, most of my patients probably that have acne, you know, end up without, you know, permanence scarring. They might have erythema, you know, which could be, you know, treated as, you know, they’re scarring under maybe some scarring underneath bed, but most of the time, you know, they, they end up doing okay, it’s when you get that inflammatory cases. So it kind of would correlate in parallel with the, the prevalence of our more inflammatory, uh, cases of acne. So, you know, I’m guessing probably <affirmative> 10 to 20% of my, you know, of patients that have acting generally are gonna have a more severe form that’s gonna result in scarring probably at the minimum.
Dr. Anil Shah:
Okay. And let’s define acne scarring just even a little further. So you mentioned, uh, inflammatory, so there’s that post-inflammatory hyperpigmentation or PIH, which is super common after a lot of things, but especially acne scarring, there’s the depression aspect of scars that we kind of alluded to earlier. And then, uh, some patients, I think that’s less common at least I see, uh, patients with raised scars from acne,
Dr. Todd Schlesinger:
Right? So it’s totally, totally accurate. Uh, you know, you can break down acne scars into sort of three broad categories. One is the hypertrophic scars, which you had mentioned is a change of in the contour sort of an elevated change about 10, 15% of the scars are that, uh, you know, and then you have, of course your pigmented lesions, where you just have flat, you know, dark discoloration, which is a small percentage, but the vast majority of the scars that we see in Clint that we deal with on a day to day basis are a trophic AC scars, you know, 85 to 90% of the things we deal with are a trophic. And then when you have a trophic scars, you can break those down into three more detailed categories, which a lot of people know is number one, you have ice pick scars, which are your small, um, sort of depressions, less than two millimeters.
Dr. Todd Schlesinger:
You’ve got your rolling scars, which are more of a curve, more of a, like a, a bowl four to five millimeters generally in diameter. And then you have your sort of box car scars box, scar scars look just like that, like a straight edges straight down edge, and then a flat base, which would be kind of more consistent with, um, you know, sort of, you know, a, a, you know, just think of a, um, a shipping container sort of that kind type of scar. And those can range anywhere between 1.5 and four millimeters sort of on average. So, um, most of the scars that we deal with that we can treat easily are the rolling scars or that middle category. Um, but you know, certainly those are the most common ones we see.
Dr. Anil Shah:
Okay. So, uh, what have you used to try at any scars in the past, and then what are you doing and why did you switch?
Dr. Todd Schlesinger:
Right. So I can say there’s been a really interesting evolution in the treatment of acne scars. Of course, you know, we have all kinds of things that we used to use. Uh, uh, we might have used, uh, in excision of various kinds, depends on the type of scar, you know, subs, precision, excision, punch, excision thing like that have been around for a long time. Of course, we’ve used lasers in lighter skin, uh, you know, depending on what type of skin we have, uh, we’ve used ablative, non ablative. We use peels, uh, you know, all kinds of different things that we’ve used, but I think we’ve evolved more into being more nuanced in how we treat our acne scars and especially sort of as it relates towards skin type, uh, especially, you know, skin of color versus not skin of color. So, you know, with skin of, you know, that is lighter color, of course you can be a little bit more aggressive on using ABL of lasers or maybe non-ablative fractional devices to sort of help us with our rolling Acki stars box cars are tough.
Dr. Todd Schlesinger:
You know, they really need surgery for the most product, you know, excision, some, you know, is more resurfacing is great. Uh, but now we have the advent of all these new energy based devices. So we’ve got, um, a radio frequency devices, uh, high frequency, ultrasound devices and things that can sort of help us more, you know, with those rolling scars, you know, the there’s still like the easiest ones to treat in general sense, we’ve microneedling. And then, then the advent of, you know, fillers has sort of come along in the, the past few years, that’ve been able to really learn how to use fillers better. And then combination therapy is really where it’s at. And it, it really depends on the type of scar you’re dealing with, uh, the patient’s pension for downtime and then the skin type. So really those are the three main categories you sort of think about when, you know, deciding how to treat a patient with, you know, the scarring.
Dr. Anil Shah:
Okay. So let, let’s kind of break this down a little further. We’re gonna kind of go into some nuances here. Um, so a fair skin patient, we’ll start with that. Um, how effective do you think just pure ablative lasers? So for the audience, we’ll kind of define ablative, um, uh, ablative, uh, lasers are those that take off that top layer. So you’re gonna kind of ABL layer after layer of skin until you get deeper into the, uh, depth of the skin to kind of improve that. Um, and so, um, which ablative lasers have you tried and which ones are you still using, uh, for your fair skin patients?
Dr. Todd Schlesinger:
Yeah. So on, those are great questions and a great explanation of how you, you laid that out. Uh, we’re still using, uh, a non ABL fractional, such as a 1540 laser. Um, other, my others might have a 1927 laser, you know, when you’re dealing with, uh, the acne scars that are more superficial. So they’re not really too deep into the second layer down and not the epidermis, but the dermis. Uh, then that’s a great place to, you know, to using ablative, laser and ablative laser or something like carbon dioxide, laser, where you’re really, um, ablating the surface off and the patient’s gonna have recovery in downtime. That’s really a one to 1.5 millimeter depth at the most that you are, you know, gonna be going down, you go too much deeper and you’re gonna be, you know, creating more scarring from that, which we don’t want to do.
Dr. Todd Schlesinger:
So if it’s more ALO scars and sometimes for, you know, softening box scar scars and, and for making ice pick scars more soft, but not completely ablating them and removing them cause you can’t all the way down you have surgery. Uh, you can use the, the various lasers when you have dermal scars, you know, where you have the, the rolling scars that are a little bit deeper. The non-ablative, if you’re talking lasers, non-ablative lasers would, uh, 1540, you know, anything in that wavelength range, I mean, 1540 to 1927, all the way up to your Uum, 29 40 lasers, that’s the range you’re gonna be working in the most, but mainly if you’re working in that non-ablative range of 1540, that’s where you’re gonna get a penetration deep into the dermis without ablating, without causing more scarring. And I’d like to talk to people in thinking about it as aerating, a golf course, you know, you see, they make these little plugs in the golf course, and the goal is to, you know, lay, let the grass grow in stronger when you make those plugs. That’s kind of what you’re doing with these non ABL lasers is you’re making plugs that go into the dermis of the skin, but you don’t ablate the surface. So, you know, you can heal with healthier skin.
Dr. Anil Shah:
Um, how many treatments do you need with a non ablative, laser and ablative laser to, um, get a, a difference in a difference where a patient’s gonna be happy? Can you do it in one treatment? Does it need three treatments? Does it need five treatments?
Dr. Todd Schlesinger:
So the treatment number depends on the patient’s, uh, ability to tolerate downtime. And of course the depth of the scar. So for a carbon dioxide laser, typically that’s a onetime treatment. You know, you’re doing the, uh, a resurfacing of the scars. Uh, but many times what we’re doing is we’re doing, um, you can really tune that laser. So you can really tune a carbon di laser to be a more ablative or less. You can set. You can make a lot of changes in the settings. So sometimes you’ll do a series of five treatments that are lighter ablative and get some nice results with that. Uh, and oftentimes with the non ablative fraction of the 1540, all those different ones, those are typically at least five treatments for acne scars. I’d air on the higher side error on a little bit less power and a little bit more treatment time. You a little bit more treatment number now, depending on the skin type with lighter skin, you can tolerate a little bit, you know, higher settings and you can maybe do it less treatments, but, you know, it’s an evolution in, you know, with acting, you know, access tos to sort of get them to turn around and build that new collagen. And sometimes you need maintenance depends on the depends on the patient.
Dr. Anil Shah:
Okay. So we’re going from lasers. We’re gonna kind of shift over to some of the other devices you mentioned. Um, so radiofrequency devices, um, and with rate frequency, needling, um, uh, for the audience, again, these are devices with energy at the tips of the needle. Um, you can go a little bit deeper than we’ve talked about. You can go half a millimeter, one millimeter, two millimeter millimeters, four millimeters. What’s been your experience with rate frequency devices. Is there a divisive choice you like, and is there anything you’re looking for in those,
Dr. Todd Schlesinger:
You know, there’s not a device of choice. I haven’t, for me. I mean, I haven’t really jumped a lot into these devices cuz there’s been so many coming out. Um, I’ve focused mainly on laser devices and microneedling and fillers in my practice. Um, you know, I think with COVID and um, I have an article in practical derm kind of coming about this in January. Speaking about the change of occurred during COVID was very careful about what devices I purchased during this time, the, the, the pandemic and the financial crisis that occurred. I think, you know, for a lot of people really, I think made a lot of people think about what they were buying. So there’s so many devices out there and there’s still as of yet unproven, you know, I think that, um, there’s a substantial equivalence. So a lot of these radar frequency by I stay on the markets.
Dr. Todd Schlesinger:
When I have like one I would pick, I know everybody’s got their favorite device. Um, but I feel like being real careful about what you buy is important and really understanding it and what your return on investment’s gonna be, because, you know, nowadays you can’t just buy things that sit in the corner, you have to be very careful about what you buy, you know, because you know, you know, people are still recovering from, you know, we’re all busy back again, but we’re still recovering. So, you know, I can’t say I’ve jumped heavily into the RF microneedling. I think it would be great for patients, uh, who have darker skin. So if you’re looking to treat acne scars into our darker skin patients, that’s actually a nice thing to do because you’re generating, you’re still generating some heat. So you still run the risk of the postal inflammatory hyperpigmentation, which is a also generally inflammation based. But at the same time, you know, you’re also able to, uh, affect a better outcome than you might just get with micro with micro Newling alone, but still, I’m not sure the data’s really there to support it full, you know, full bore yet.
Dr. Anil Shah:
I’ve, I’ve kind of been a, a big fan of the RS, um, micro for, for me. Um, and, um, again, different backgrounds, you know, it’s, it’s cool that I love this. Um, you know, uh, Dr. Lesner the first time I met you was at a multi specialty conference and I love collaborating with, you know, so many people with different expertise and, uh, obviously your knowledge of the skin is gonna be vastly superior to mine. Uh, but again, I think more like a surgeon, which again, maybe that’s not the best approach for at star. Uh, but that being said, um, the radio frequency devices I’ve, I’ve jumped into the in mode, um, family. Um, I like the depth of penetration. I like the fact that probably I’m in Chicago, you’re in South Carolina where I have a lot of patients from, um, you know, I, I rarely have a Fitzpatrick, one patient who’s coming in, I have more on the, um, you know, kind of more of a multicultural ethnic pathway. So I, I really can’t use, um, you know, many of the other laser devices, um, you know, for me, uh, but that being said, it doesn’t mean one device is better or worse. It’s all about, you know, what has you, what have you tried and what experience have you used each advice with, um, for the CO2. And, um, and, and have you tried ever cross TCA or pinpoint or radiation of any other techniques out there, um, and, um, you know, for discrete scars, like APIC scars and stuff like that, are you that
Dr. Todd Schlesinger:
Yeah, so cross, cross technique, um, you know, we have tried that. I mean, I haven’t used that. I think you’re, you know, it’s, it’s an older technique about 2002, it’s been around for a while. Um, and basically what you’re doing is you’re doing, you know, you’re doing chemical reconstruction of skin scars. That’s what cross means. Uh, you know, in that technique you’re taking possibly, you know, either 99% or a hundred, percentt on an ice on a little, uh, toothpick, and you’re treating just the center of your IIC scar. We have done that. I like that for lighter skin patients and darker skin patients. You also have to be very diligent about wound care, uh, afterwards, because you can get hypopigmentation quite easily with that. So, uh, it’s something it’s not a go-to, I’m aware of it, we’ve tried. It I’d much rather use, um, a combination of, to excision followed by resurfacing.
Dr. Todd Schlesinger:
If I’m gonna be treating ice, pick scars, uh, punch sizing, the scars, and then resurfacing the whole, the whole field has worked well in my hands. And it’ll gives you a little bit more of a, and I do understand that, you know, we also have, um, a fair amount of skin of color, maybe not as big as your is a large percentage of our practices, yours, but, and the 25% range for us. So we do have to balance that. So, you know, in skin of color patients, it might be punching excision and micro kneeling or RF, things like that. And, you know, and other patients, it might be a combination of punching decision with, uh, laser. I just feel I get better control with the CO2 laser than I would with UHT across.
Dr. Anil Shah:
Yeah. I, I think I I’ve kind of moved on from acrosst as well. I think one of the issues I’ve had with cross TCA, like are talking about is number one is control. Um, you can’t control your depth, uh, quite as accurately. You worry about spillage, um, with thet going above and beyond the area that you’re treating. Um, but I think the con concept of treating justice scar a higher chains in the other area is kind of like a targeted, um, targeted fractionated approach. So kind that mind field, but you’re targeting that you wanna treat. I love the concept of that, but I think again, it’s a little bit of a higher risk higher reward. Um, I’ve dabbled in pinpointed radiation, which is similar across TCA where I’ve, I’ve done the CO2 and I’ve gone stronger with the CO2 with like a discrete beam into the scars themselves.
Dr. Anil Shah:
And, um, and then kind of vaccinated over that. And that, that seems to be a little bit more controlled than that. But again, I think they’re all, it’s all semantics. They all kind of work in a similar way. You’re, you’re using, uh, there, you’re using the punch. Um, I haven’t used the punch as much, so help help me understand that a little bit. So you’re around each car, use the punch. Do you suture it up? Do you remove the skin? Like what, what goes on with that, with that approach and then what do patients expect with thatt?
Dr. Todd Schlesinger:
Yeah, so I mean, my goal for punch is, you know, you know, if you look at the scar underneath the skin, you know, is it is gonna have some, some sort of roots, you know, to the scar underneath the skin. So you have to be careful not to use too small of the punch. If you punch out the scar to the center of the scar and leave the periphery of the scar present, then most likely that scar will recur. So you have to do a, a, a punch that’s large enough or, or a small excision that’s large enough. Sometimes the elliptical punches are very helpful and you’ve probably seen those, um, you know, they were kind of the craze for a while, but using a punch like that, and then bringing normal skin back to normal skin, and then, you know, helping those scars heal with silicone topical silicone, uh, you know, to really get a nice outcome, letting you know, having suture removal, silicone therapy after, and then moving into the CO2 laser has worked quite nicely.
Dr. Todd Schlesinger:
I think that that’s a nice technique to use. The key is you have to get normal skin back to normal skin. Cause you’re, if you punch it out too small, it’ll most likely come back, you get, you’ve got a recurrence of the scar of the depression will form in the same area. So it, you know, it’s not old full proof. You, you punch out, you know, 10 scars, maybe eight of ’em will do great. And a couple of ’em won’t. So sometimes you have to, you know, punch them again or, or, or, or treat those in other ways. So it’s not foolproof, but it’s very helpful. Um,
Dr. Anil Shah:
You mentioned subsystem earlier, um, do you have a, a filler of choice? Um, do, do you use filler with subs? Do you use them independently and do is filler for your scars
Dr. Todd Schlesinger:
Too? Yeah, so I think that’s, you know, one of the newer things that’s, you know, been talked about is, you know, so basically subs precision the way I look at it to explain it is BA you’re basically creating P R P. So when you subs subsid underneath the scar, you’re breaking up the, the collagen fibers that connect the dermis down to deeper tissue that’s created, right. But if you go in there and you sub subsid, you you’re breaking that up and you’re filling, you’re breaking up, creating a pocket and filling the pocket with blood. So the pocket will fill blood, you’ll get some regenerative tissue, you know, regeneration going on, and then you’ll sort of fill that scar. Some swelling will occur, uh, but over time that will settle. So, and then you’ll end up with a scar and maybe not as bad, but you’ll end up with a similar, you know, scar after time has passed.
Dr. Todd Schlesinger:
So the way to combat that is to introduce a filler into the scar. And also for a number of years, we’re using hyaluronic acid and different things, uh, to treat, but of course those are temporary and they don’t really have the lifting and holding power of some of the, uh, more long lasting fillers. So though the PMMA, the Polymac methylate filler has become the sort of filler of choice from my, and then one of the main reasons is it has an approval. So, um, it’s the only filler that’s got an actual approval for acne scars. Uh, so, and there’s, you know, paper published that’s 12 year, you know, 12, 12 months data on acne scars with two treatments. So that’s been, uh, out there for a while. So, you know, in, in my practice, I’ve been combining, um, bit combination of subs, precision plus Beil, and then microneedling as well.
Dr. Todd Schlesinger:
Those three things together can be quite nice for acting scars, micro treating the surface and treating the general, you know, dermis and epidermis and sort of getting tissue remodeling going. Uh, the subs precision followed immediately by placement of, uh, PMA, microsphere filler underneath the skin can help sort of lift that acne scar. So when you have that, when the blood goes away and with all the swelling goes, you’ve got that support left behind with that, uh, collagen carrier PMA filler, so that, you know, is a nice option, but really it’s best for treating rolling scars. It’s not good for ice pick scars, and it’s not good for scars. You, you really want to treat that middle scar with it.
Dr. Anil Shah:
Um, I think behi is kind of underreported. How, how great of a product is for at scars. Cause I think it’s been transformative for me treating at scars. Um, it is, uh, an amazing product Beil, uh, PMA it’s, it’s got two components it’s, uh, PMA plus the collagen. Um, I don’t, I, I don’t think I’ve ever had better results than when I treated patients with some sort of combin. I say, combination therapy with Beil, cuz usually it’s one component. Like you mentioned earlier, you’re gonna treat with Beil and then the other components of the scar, you may have to kind of break down and kind of use some sort of ablative or RF or needling a, a, a, a device to kind of work with that. Um, why doesn’t everyone use Belial like, what are some of the drawbacks of Beil and should everyone be using Belial or do you think it should be sort of like limited to, uh, certain expert injectors?
Dr. Todd Schlesinger:
You know, I think the latter, I mean, I think the main thing about bell you have to remember is that it’s a, it’s, you know, it’s a long lasting product. I mean, you know, we’ve got five year data for the nasal fold for this filler. So in, in essence, it’s a long lasting product, whether it’s permanent or not, you know, we don’t say that, but the bottom line is it’s gonna be there for a while. So the main things we’ve learned over the years of Beil is quantity should be small. It’s non filler. You want bolus, it’s a fill, you want a nuance, uh, in, and for acne scars, you know, you’re subsiding, whether you’re using the, the included needle 26 gauge five eight needle that comes in the package or using a, a new core needle or some other thing to some other, um, device to create subs submission.
Dr. Todd Schlesinger:
You know, it requires training. I think befo can be used by expert, you know, filler practitioners, but they should get some, get their, their hands on it and they should, you know, get some training with someone who’s experienced with it, cuz there’s a lot of nuances. It’s, it’s very different than it’s not an ha filler. It’s very different in the way. It’s much more viscus as far as the feel of it goes, the flow characteristics are much different than, uh, than ha fillers are PMA. I mean, or, um, calcium MUO ate in tight or, you know, sculpture, any of those other products. I mean, it’s, it’s, it’s it doesn’t push forward in the needle. So you, you can’t, integre that product, you can’t inject it forward. It’s always gonna be injected when you’re moving backward with the needle. For the most part, uh, for acne scars, you have to kind of create a little pocket for it.
Dr. Todd Schlesinger:
You want to under correct. When you’re treating with Beil, you wanna plan on two treatments. So you, you can correct in layers with that product. And then you can go back, you know, three months later, I mean, the studies were done with one month between treatments in the, in the 12, 12 months data. But in reality, I find that the collagen remodeling process takes longer. So, you know, there’s a whole nother, you know, we could talk for hours on just befell alone, but the reality, you know, from what you said, I feel like it is something that should be used by, by practitioners who are very comfortable already with using all of the other products on the market. And then they should most likely receive some training from someone who’s experienced at using the product because you know, it’s not one you can reverse easily. So
Dr. Anil Shah:
For sure, for sure. And I think this product, I think it probably should be limited to, if you’re gonna get treated with Beil, I probably would encourage anyone listening to go to someone who is, uh, very, very experienced injector. And I almost think that it’s really nice if the injector has some sort of surgical training and, and for you, for example, you have the MOS and you have the, you you’re used to doing surgery on the face. You’re used to kind of working with that. So if you do run into a problem, a you know how to handle it and B the other thing that’s interesting with behi is that, um, you almost have to prep it like a surgery. Like it’s not like normal H a where you prep it and prep the face. You almost have to, you have to assume that there is some sort of there’s bacteria on the skin. No matter how many times you prep it, do you have to be treating this super sterilely? This is, I think at least the way I injected it, it’s almost like a sterile procedure.
Dr. Todd Schlesinger:
Right? I agree with you a hundred percent. I think that, um, we’ve learned a lot from the original studies because when the original five year study was, was, is done, it wasn’t really made clear to the investigators how to prep the skin. So I think they saw a little bit more complications. They saw a little more bacterial infections, things like that occurred, not a huge number. It’s still very small, but could be better. So now it’s, you know, full hypo cleanse, you know, scrub, uh, you know, clean as you go clean that inject constantly, you know, never, you know, everything’s sterile and you know, that we’re touching, uh, the patient is advised, you know, come in with clean skin, no makeup, things like that. So we’re, we’re, we’re doing exactly what you said. We’re being as clean as we can. Now. I think the other, um, thing you should remember with Bellfield our listeners should remember is that, you know, again, it it’s a non it’s, non afil wanna bolus, you know, so you’re using small quantities, linear threading, or small quantities deposit under acne scars.
Dr. Todd Schlesinger:
You’re talking about 0.05 or 0.1 ML at the most per site, more on the smaller side. Um, and then when the, the areas that can be a little bit higher risk for, um, infection are more the cheeks when we’re treating the cheek area. That seems to be the area where I have seen in, in, you know, I was a trainer for that company for, for three solid years and had a lot of experience with different tra you know, different folks out there across the country. And what I saw was the area that was fr most likely to have as far as infection com, like absces would be the cheek area. Uh, and the other thing about befo to remember is that where it’s not to be used, uh, it shouldn’t be used in underneath the eyes per orbital tear troughs, probably not the best place.
Dr. Todd Schlesinger:
And then it’s really contraindicated for lips. So anywhere we have that orbital muscle, that movement, uh, is an area probably to stay away from, with Beil, but it’s very handy when it comes to, uh, treating nasal Livial folds for lifting in the, in the lateral face. I use it a lot. And then on acne scars, you know, it’s really a winner, like you had said, it’s a hand sound of very, um, nice product to use. And I think once you’ve train on it and learn how to use it. And I do agree with you, the surgical training’s very helpful, knowing the layers, knowing the planes, knowing your anatomy is key, you know, and then knowing the nuance of how to inject that product in a safe way, uh, and what to look for as far as complications, because it’s, it’s not, it’s not easy. I mean, you can probably work on dissolving and doing some of the things you would normally do if you had a intervascular event, which is very rare, very rare with Beil. I mean, I can’t even think of it. I mean, it’s been really didn’t occur in the studies, so, uh, but you should at least have some options.
Dr. Anil Shah:
Do you think the skin looks better after Beil? Like, not from a, like an acne scar perspective, but just better. I’ve had some patients tell me maybe it’s the collagen component, but they feel like their skin just looks healthier after being injected with it. Have you noticed that observed that your thoughts?
Dr. Todd Schlesinger:
Yeah, I think that’s, that’s a way. I mean, I think that the thing about Beil is you’re really creating almost normal collagen with Bellfield. If you look carefully under the microscope, you’ll see the micro spheres or whatnot, but you’re creating collagen. That’s pretty close to normal, you know, so you’re really not creating scar tissue with that product, which is nice. And so therefore it’s, I don’t, I don’t, to my knowledge, it’s not been studied, you know, because with, uh, with, uh, P a with sculpture, you know, we’ve got some studies that show dermal thickness improving. So I think with Bellfield that is something. So I think you’re on something there. Uh, as far as I know, I haven’t seen any kind of data, you know, showing der increase in dermal thickness with, but it would make sense from a skin quality standpoint, if we’re building new collagen, then we should have increased skin
Dr. Anil Shah:
Quality. I, I know that about sculpture, but as an observation, a lot of my patients who use sculpture, they just look better. Their skin looks healthier, but I guess that, uh, that makes sense.
Dr. Todd Schlesinger:
There’s some data behind that. Cool.
Dr. Anil Shah:
Okay. So, um, so with bell, we kind of jumped in that, but that’s not for everyone. Okay. So can you, if a patient comes into says, I wanna travel all the way to see Dr. Schlesinger, I want you to do 20 treatments on me at once. Will it work? Can you treat someone’s acne scars with one treatment, or is it gonna need a couple treatments or is a patient by patient?
Dr. Todd Schlesinger:
I I’m sure it’s very patient by patient. I always wary of that patient who comes in and says they wanna have for everything done at once. It always makes me a little nervous. Uh, I also want to be able to follow up on my patients. So I don’t, I’m not really too thrilled about someone that says they’re coming in from somewhere far and they’re gonna, I’m not gonna be around. So I might defer that one and just not, maybe choose not to be the doctor for that patient. Um, I want a patient who’s going, you know, that will follow up, uh, someone that will allow me to design a plan for them that Sur that, that focuses on their needs. So, um, you can’t rush it, you know, you can’t rush that you can’t ride be, even be, is at least two treatments. Uh, sometimes we’re doing more, uh, smaller amounts to sort of build those scars up instead of, you know, not over cracking, but a little bit under cracking a little bit, and then having it build and building on top of that. Uh, so, and, and then of course, you know, active scarring, as we know from, you know, a lot of publications in our experience, it’s a really a, a, um, a combination of therapy. It’s a combination treatment condition. Not only not, there’s not one thing that treats, I believe, you know, everybody, or nor can you blast them of, you know, a lot at once.
Dr. Anil Shah:
Yeah. You’re definitely worth traveling to see. It’s just as long as the patients committed to seeing you for, you know, three or four treatments and willing to take that extra step to follow up with, but definitely you’re worth seeing,
Dr. Todd Schlesinger:
I can say the same thing about you. I know you’ve got a fantastic practice and the fact that you’re doing all these great educational things, it’s, it’s great. Um, but you know, just a general sense you, if the patient’s gonna be committed, follow key.
Dr. Anil Shah:
Yeah. Yeah. Okay. So, so that, that bit of it, um, do you think there’s any skincare products that work for at cars? So is there any topical product you’ve seen that someone can put on their skin and they will get rid of ATS cars and prove at cars? What’s your
Dr. Todd Schlesinger:
So, no, I think the short answer is there’s not one thing I would recommend. That’s really gonna make a difference. Uh, um, in combination with things that we already do to sort of help the health of the skin, you know, I would recommend the things that you might as well looking for growth factors, looking for, you know, things that I know will sort of help the collagen, but skin, you know, skin care products are very super, you know, very surface oriented. We’ve got a little bit of penetration data for a few. You, you know, a few of the topicals, but I think in combination to help skin quality, it’s great, but, you know, can you prescribe a topical product that’s gonna really affect acne scars in a meaningful way? I, don’t not so sure I would hang my hat on that, you know, at this
Dr. Anil Shah:
Time. Yeah. It it’s something that, you know, patients should be concerned about their skin, of course, but will it get rid of their scars? And sometimes if you see an infomercial talking about removing acne scars, I’m like, oh my gosh, I would love to have be careful product it’s, it’s probably not gonna work if it’s Saturday morning or late night on a infomercial.
Dr. Todd Schlesinger:
Yeah. Yeah. Usually when I’m watching them, <laugh> <laugh>
Dr. Anil Shah:
Okay. So, um, can you completely erase an acne scar? Can you make it so it’s gone. If someone comes in, like, I want my scars gone, I will do whatever it takes. Can you make my skin, um, completely scar free?
Dr. Todd Schlesinger:
I always remember that adage to, um, under promise and over deliver. So I think that’s the thing to think about there. So do we have great results sometimes? I think we do. Um, can we pro you know, guarantee that, or can we legislate that to happen? I think no. Uh, but I, you know, I try to put together the best combination I can for the patient and tell ’em it’s a partnership. So we’re working together on it. We’re, you know, we’re doing this together, we’re choosing our treatments together. We’re working with their lifestyle, their scars, their goal. And, but, uh, you know, is there no, there’s no perfect in medicine. So I would say the answer to broad answer would be no. Uh, but you know, sometimes you hit a home run
Dr. Anil Shah:
It’s it’s improvement. It’s um, it’s, I have not, um, you know, been able to erase anything, but it it’s about improvement in saying, Hey, guess what? I feel more confident. And I, I think of things that sometimes in terms of a radius that maybe you can see your scars from 12 feet away, and then they, maybe after the first treatment, it might be eight feet away and then six feet away. But if you’re looking to look in that big mirror and look to see if you can see a scar, that’s a really hard test, I think for, um, you know, especially for a really deep pronounced scar that’s
Dr. Todd Schlesinger:
That’s right. People tend to do that, and that’s completely understandable. You know, if you have one thing done on your face, you’re gonna be scrutinizing, you know, and that’s, you know, that’s hard. I mean that, you know, we have to, you know, be grateful for what we have and I think, you know, be grateful or improvements that we can get, you know, go, like you said, go experience practitioners, do the best thing you can. Um, but you know, in the end we’re we are just looking for improvement.
Dr. Anil Shah:
Perfect. Um, okay. So if you had one thing, the biggest thing you had to explain to a patient about acne carts that you wish they knew beforehand, is there like one piece of knowledge you wish that every acting scar patient knew before they saw like, okay, before I come in, I wish they already knew this.
Dr. Todd Schlesinger:
Um, you know, I, you could, if I could roll it back to the prevention piece, uh, it’s more like, how could we prevent them? So, you know, when you have acne, get it treated, you know, I, you know, wish I could tell people when they’re younger that not to let their acne go, you know? So I try to do a very good job of treating my patient since, you know, from the medical practice of treating their acne, uh, and try to prevent that inflammation because once inflammation’s set in the scarring is set in you now you’re dealing with that problem, which is a little bit harder to deal with. Um, I think, uh, nothing specific I can think of, you know, it’s really just all about prevention as far as, you know, you know, when you already have the scar in place, I think go to someone experienced. I think that’s the key, um, you know, you do, I do see a number of patients, I’m sure you do as well, that, you know, go from place to place and, you know, and they may not be selecting the practitioner that’s best for them at the outset. So I think it’s important to listen, ask questions of your, of the physician. You’re going to see, you know, uh, you can go to someone who go to someone who’s got the experience that does it all the time.
Dr. Anil Shah:
Yeah. I, I think that just hearing you talk, you can tell that you are, I mean, besides reading all your, your, your studies, and you can tell that you’re so well versed and understand this on such a, such a deeper level that, um, why would you go to someone who doesn’t have that bad, you know, that background. And so for me, it’s like, if you’re gonna choose someone, you know, choose someone who’s passionate about that, who’s focused on that who, who can treat you on multiple levels. Uh, and, uh, um, I, I’m not gonna bash any other, um, levels of providers, but for something like Beil, I would definitely encourage, uh, providers, uh, for patients to go, go to someone with experience. If you’re gonna go to someone with acne scar, you need to have a lot of tools in your belt. And, um, that, that’s my, my take on it because, uh, sometimes I see so many patients, I’m not sure if you do, but so many patients who go to less experienced providers and some, maybe not up to standard of care stuff is being practiced.
Dr. Todd Schlesinger:
Right. I mean, and it’s so common because it, um, some of the things we use have been commoditized quite a bit. So they’re in the hands of a lot of people. So, and you know, again, I agree with you, you know, I mean, I want everyone to do a great job. I want any practitioner that’s gonna pick up a syringe of both talks or a filler or anything like that to do an excellent job when we well trained. And we all have to do, we’re comfortable doing, I advise, you know, patients not to do something they’re not comfortable with. I advise per practitioners as well, not to something they’re not comfortable with. I mean, you know, use that sort of your, sort of your sixth senses, you know, your, maybe your spy sense, whatever you call it, your sixth study, if you’re not comfortable, don’t treat.
Dr. Anil Shah:
And that’s key. So I have a nonrelated question. So you’re a photo. You have like the cleanest cut hair. And when I saw you, you had like a matching ponytail. I was, I was looking forward to seeing this, uh, there was only like two or three people who had ponytails. I was like, now that’s a guy. I know that, uh, I want to talk to so
Dr. Todd Schlesinger:
Well, if you turn the recording off, I’m more than happy to show you. <laugh>
Dr. Anil Shah:
That’s okay.
Dr. Todd Schlesinger:
Well, but I, but I don’t mind. I mean, I’ve been to all the meetings and everything I, I have. Yeah. My ponytail, um, you know, I think after the pandemic, I just, uh, I, I start growing it and I’m like, okay, I’m just gonna let it roll. See it goes, and, and it’s just, I just never changed it. And, um, I’ve now gone to a lot of meetings and seen a lot of people and they’re used to
Dr. Anil Shah:
It. When are, um, I I’ve had this debate. We’ll see. Who’s gonna cut. When are, are you ever gonna cut your ponytail? Is it gonna be one of those kind of, uh, I’m getting sick of it or it’s a hot South Carolina today, or is it sort of, uh, who knows? Who
Dr. Todd Schlesinger:
Knows? I don’t have any plans yet too. I actually had a patient ask me that today. I was doing fill around, asked me about it. I said, you know what? I really don’t know. I I’m grateful for every single day that I wake up, uh, on this earth and I’m gonna just enjoy each one day by day.
Dr. Anil Shah:
Love it, love it. Well, I thank you so much for joining me on a, uh, a late Monday night. I mean, you are such a wealth of knowledge to, uh, uh, to me, I, I mean, from just talking to you and, uh, um, keep, keep doing what you do to, uh, bring all of us, bring all of our games up to, uh, um, with everything in every area of, um, of cosmetic and aesthetic, uh, surgeries
Dr. Todd Schlesinger:
The same. And thank you for providing this important service to our patients. And it, since, you know, you, you, you, you can’t say enough about how important it’s to get the word out and to, for us to have these kind of conversations so people can really hear. So, uh, thank you for that
Dr. Anil Shah:
Service. Cool. Thanks so much.
