Does Your MedSpa Know How To Treat Your Skin Color? with Dr. Steven Williams

Dr. Furnas (00:02):
Recently researchers found genetic mutations in Europeans living in the far north over 8,000 years ago. The mutations had bungled up their pigmentation resulting in pale skin. Their ancestors had dark pigmentation, which could block UV rays, but sunshine also helps us synthesize vitamin D. So the lack of pigment was perfect for English weather. Pigment and its lack can be a double-edged sword, not just with the sun, but also with certain cosmetic treatments. Welcome to Skintuition. I am Heather Furnas.

Dr. Korman (00:44):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for, when you're ready to hit refresh.

Dr. Furnas (00:57):
It is a pleasure to introduce my longtime friend Dr. Steven Williams. Dr. Williams graduated with honors from Dartmouth and received both his MD degree and his plastic surgery training at Yale. He practices in the East Bay near San Francisco where he runs a med spa and a weight loss center, and this year he is serving as the president of the American Society of Plastic Surgeons. Josh and I both belong, so he is our president. And he's not just any president. He's our Obama, the Society's first black president in its 93 year history. We are grateful he's carved out time between national media interviews and trips all over the country to speak with us. Welcome Steve.

Dr. Williams (01:46):
Dr. Furnas. Dr. Korman. Thank you so much. It's really an honor to be here, and it's funny you listen to that introduction and I really just see myself as a plastic surgeon who's trying to take good care of my patients and trying to move our specialty forward. So it's a real honor to be here with both of you. You both have long and distinguished careers that are essentially littered with amazing work for your patients and support of our specialty, so thank you very much for having me on. It's an honor to be here.

Dr. Korman (02:17):
Okay, now we've gotten through all the, how good we all are.

Dr. Williams (02:20):
Oh now the hard questions.

Dr. Korman (02:20):
Yeah. Now let's move on to the other questions. So as plastic surgeons and med spa owners, we pay attention to a patient's skin color. We even have a numbering system, one for the palest of Scandinavians, three or four for Asians and Hispanics, and six for the darkest shades like a native Nigerian. What is the danger of ignoring a patient's pigmentation when doing a treatment?

Dr. Williams (02:45):
And so again, as we all know, as board certified plastic surgeons, we really do pay attention to all parts of our patients, both from the physical to the psychological, to the emotional and skin color. The pigmentation that our patients present with is a critical part of establishing the right treatment for care. The reason why is those pigmentations can respond differently to different treatments. Sometimes they have different problems in terms of signs of facial aging or pigmentation spots from the sun, and so it's really important that we take that into account as we move forward.

Dr. Furnas (03:20):
Do you see different aging changes with different skin pigmentation?

Dr. Williams (03:25):
Yeah, it's a common thing that I think our patients focus on a little bit. I think that there is some truth to the fact that sometimes skin with less melanin, less pigmentation tends to have slightly thinner dermis. That thinner dermis sometimes can show wrinkles. We call them righted. Obviously, in the plastic surgery world, we usually refer to 'em as righted, but

Dr. Furnas (03:44):
There's yeah, righted. You say that in the common lingo and it's like, what are those? Yeah,

Dr. Williams (03:50):
Exactly. It took me a good four years of residency to learn what those were, but different skin can react to environmental exposure, sun, and also respond a little bit differently to aging. And subsequently, while sometimes more pigmented skin has thicker dermis, a little bit more elasticity, sometimes the scarring can be more significant with patients who have darker skin color. And so there's always pluses and minuses, and it's always important to be cognizant of the treatment type and the potential risk that those pigmentation differences between our patients can cause.

Dr. Korman (04:23):
So people with darker pigment are more likely to get dark blotches when healing what we sometimes call PIH or big word post-inflammatory hyperpigmentation, just dark blotches. What advice would you give to these patients before treatment and how would you treat them afterwards?

Dr. Williams (04:42):
Yeah, and again, as plastic surgeons, most of the time we're thinking about scarring. When we use our scalpel, we want to make sure that these scars are feeling well. We're not getting keloids or hypertrophic scars that the scars heal as well as they can for all of our patients. When it comes to med spa treatment, when we're thinking about either peels or even topical products we're using or lasers, we want to really assess the patient's pigmentation because Josh, as you said, there can be sequelae from that. And one of them is post-treatment hyperpigmentation. One of the things I always talk to my patients about is tell me a little bit about your history. Tell me the other treatments you've received. Did they work well for you? Did you have incidences where there was some darker pigmentation around those treatment areas? How did it get better?

(05:28):
What did you use for that? A lot of times spending those few moments with our patients can really help to number one, come up with a better treatment plan for them, but to also let them know that as professionals, as plastic surgeons, we're all here to make sure they get the best results and the safest results. I think when patients do have a little bit of pigmentation around a treatment area, most of the time, most of the time it will improve with some time. Some of the modalities we use to speed that up a little bit is sometimes we'll do some microneedling, a little bit of topical steroid. Sometimes we'll do a little bit of hydroquinone or something like that to try to soften that a little bit. But most of the time it's a little bit of expectant management. It does get better most of the time with some time.

Dr. Furnas (06:09):
That is a good point to get the patient's history. We certainly have seen as surgeons, scars vary tremendously. I've seen very dark skin. People come in with beautiful scars and people with the pales of skin come in with very, very thick scars. So there's just a propensity, but it's not like it's written in stone.

Dr. Williams (06:29):
I also think that it's important for patients to recognize, especially with med spa treatments, sometimes myself as well, we're all kind of tempted to chase the deal that we are able to find. There's a group on or there's a coupon for some deal around the corner. It really does seem like there's a proliferation of med spas, but the important thing is you really want to go to a med spa that's associated with a practitioner who's there a practitioner that's associated with that med spa because most of the time those patients get higher levels of care because as plastic surgeons, and I will also say I think this is true for dermatology associated med spas, I think they're getting a higher level of care because it's not just a nurse who's phoning treatment recommendations into an outside provider who maybe isn't a core specialist. It's our practices, Josh, Heather, you're there. You are the number one person they call if your nurses or PAs or your staff has a question about patient treatments and you're going to want to make sure that your patients get the best care. And so it's really important that you do seek a board certified plastic surgeon. It's important even for what people think of as lesser or less invasive types of treatments.

Dr. Furnas (07:42):
You mentioned the core specialties. Do you want to go over what those are?

Dr. Williams (07:47):
Yeah, and so when it comes to plastic surgery, our board certification and our training allows us to essentially operate on the skin and its contents is kind of the famous thing that I think the three of us always kind of echo, but when you're thinking about Botox or filler or laser treatments, dermatologists are also, well-trained in this and it's also part of their board certification. I also think facial plastics, ENT doctors also have a relatively wide range of training, especially for facial types of treatments. I wouldn't go to a facial plastic surgeon, ENT doctor for a breast augmentation, obviously, but I think when you're looking for Botox, one of those three specialties or laser treatment to the face, one of those three specialties, it's all included within their board certification and their training. And so when you're thinking of core practitioners, not to say that an OB GYN is a bad doctor or a family medicine doctor is a bad physician, but their training isn't in these types of things. And most of the time when we see this kind of creep of scope, it's because some of these practitioners are attracted to the money, not necessarily that they're trained well and they're going to be able to shepherd their patients safely through the journey that we do every day.

Dr. Korman (08:56):
I think one of the things that's really to go along with what you just said is that when everything goes fine, it's no problem. It's when there is a problem, and that's where you, I think, are you meaning patients are in a more comfortable location when the person that can treat them are people with a long, many years of experience in course specialties rather than a little weekend course or a few months course of learning something. Speaking of which, are there alternatives or adjustments and settings that you recommend for certain treatments like lasers are, we so often talk about lasers as if they're one thing, and there are so many things, ablative, non-ablative. We won't go into that here, but it's just there's so many, many different techniques and modalities. So how do you, in your practice or how do you instruct what we call physician extenders, the nurses, the PAs who are running the lasers? How do you guide them based on skin tone?

Dr. Williams (10:01):
Again, another great question, Josh, and I know that both you and Heather do the same things in your practice. Part of it is constant training and constant updates, making sure that our teams are well-versed in not only how to use the machines and what to expect, but also the changes in technology and the science around these things. And I always tell our staff, listen less to the reps and more to the science because it really is important when you're looking at endpoints or what you're treating to assess that in a clinical manner. But when it comes to differences in pigmentation, it depends a little bit on what the laser is designed to do. So the entire principle of lasers is that the energy can be absorbed by a certain wavelength, and that's known as a chromophore. And what happens essentially in the most direct and easy way to explain it is in some wavelengths that energy won't be absorbed by, for example, skin, but it might be absorbed by brown pigmentation.

(11:01):
And so as Josh said, there are many different types of lasers that we all have at our practices. Each one of those is designed to be absorbed by a different type of pigmentation or different. And so it's important that some of those lasers you can use on every skin type relatively safely. Other lasers, especially ones that see browns or reds, you have to definitely be a little bit more careful about how you're treating patients. And sometimes it means adjusting the energy that those lasers are delivering. Sometimes it means adjusting the pulse duration because not only is there wavelength and energy, but there's also how long that laser is applying that energy. And so all of those things may need to be adjusted for patients with darker pigmentation, but it really depends on the type of laser and the area you're treating and what the wavelengths that the lasers are designed to emit. The other thing, which I kind of recommend, especially because there's a lot of those question mark cases, those borderline cases, I think doing a little test spot and coming back in a few days and seeing how it worked, that makes a lot of sense. And I know it can be inconvenient for the patient, but sometimes that can really save a patient a little bit of a burn, which again, usually heals fine, but can be inconvenient and can delay overall treatment going forward.

Dr. Furnas (12:14):
So if you do a test spot, what is the protocol, the follow-up? What do you do if there is a problem compared with if there's no problem, I assume you just go ahead and treat.

Dr. Williams (12:27):
Yeah, and again, usually this comes up not with, oh, this is laser hair removal things that we're doing. Commonly it comes up with lesions that are a little bit more unusual or a little bit kind of those borderline pigmentation things. Sometimes the laser struggle more if you're seeing a relatively dark spot you're trying to, a facial aging spot that you're trying to get on someone who's a little bit darker because that laser is going to have a hard time differentiating where that energy is supposed to be absorbed in. And so sometimes in those situations, a little bit of a test bot makes some sense. I usually will treat kind of undertreat a little bit because I think it's important to do no harm obviously first, and then I'll have those patients come back usually within 48 hours, 72 hours, that's usually more than enough time to see if they're going to get a thermal injury or if they're going to get any efficacy from the absorption of that energy.

Dr. Korman (13:14):
So one thing I find always a little bit confusing from the patient's perspective is that essentially we are creating burns, we're creating controlled burns in order to affect change on the skin. And yet obviously it's that well, either it didn't look like anything happened, doctor, or Oh my goodness, you burn me, doctor, and how do you deal with this? How would you guide patients or future patients to understand the post-treatment period when they're not magic, they don't have the magic wand and make them all better the moment they walk out?

Dr. Williams (13:58):
So again, I think all three of us, we kind of go through this process it seems like every day with all of our patients in every aspect of our care because again, we do this routinely. And so for us it's kind of expected and it's normal. And so if we're doing laser hair removal and the patient comes back three weeks later and says, I have new hair is growing, how come your laser hair removal didn't work? You have to kind of explain that hair goes through a growth phase and laser is only treating certain follicles within that phase and you have to do it in a serial fashion over time to really get effective hair removal. Or if we're treating a vein, that compression's a really important part of that component. And even though you treat one vein, your body is very sometimes resilient and it may open up other small veins that may need to be treated.

(14:47):
So it's not that the laser caused other veins or more prominent veins, it's that your body has adapted to us treating one of those veins. I think when people think about what did you do to me, I look burned, we're really talking about laser resurfacing. In the old days, those were CO2 lasers and the energy, the more current technology is probably erbium and those are fancy chemical compounds, but what it really means is those lasers put out energy that's absorbed by water. And when you're lasering someone's face or skin, the first thing that that laser is absorbed by is skin. And so those lasers are really designed as Josh as correctly pointed out to be ablative lasers to really give you a superficial burn that allows that skin to regenerate. Now as technology has progressed, there's a lot more fractional types of systems and it's still the same type of laser in the same type of energy, but there is now a system that you're kind of doing these controlled burns with a little bit of normal skin in between, and that tends to decrease downtime.

(15:56):
It tends to get away from that. I look like a burn victim for four weeks type of thing. That was true in the seventies and eighties, but a lot of times we're using a combination of therapies, we're using some ablative, some full field resurfacing, especially for these deeper wrinkles, and then we're doing that kind of fractional treatment over them. And so it can look a little crazy for the first week or two. And so even with the newer technologies, I warn patients, if you have an event that's coming up in three or four weeks, you should not do this because there is a process of overall healing. Again, it's really just a matter of walking patients through what to expect. But typically if we're doing that kind of full face resurfacing, we're like, yeah, for that first week or two, you're going to look like you've got some burns because that's what we're doing in a controlled fashion.

Dr. Furnas (16:41):
I'm going to shift a little bit away from the energy devices to skincare products. Are there specific considerations related to pigment with skincare products?

Dr. Williams (16:53):
Yeah, I think so. I think a lot of times people are seeking different things when it comes to skincare. One thing that everyone benefits from is sunscreen because the sun does an enormous amount of damage over time. And the earlier you start sunscreen and the more consistent you are with sunscreen, the better your skin's going to be. And that's true for everybody. I do think it's true that people with a little bit more melanin may have a little bit more resistance to UV radiation, but it does not mean that they don't need sunscreen. I have patients who come in who are African-American or of Asian descent and they say, well, I've got brown skin so I don't really need sunscreen. I'm like, that's not the right way to look at it. You're still getting that UV radiation. When it comes to things like moisturizing cream and those types of things, I generally think a lot of it's kind of the same.

(17:41):
I don't, and I don't know if this is blasphemy from some of the other professionals out there in the world. Again, I've both of you for over a decade, and I think that generally some sort of regimen makes some sense, but I don't think people need to spend thousands of dollars on a sunscreen. I don't think people need to spend thousands and thousands of dollars on moisturizer. I think that tends to be a little bit more equivalent. I think they should find what works for them. And I think the most important thing is consistent care from well-trained practices and individuals like yourselves. I think when we're looking at medications that are prescribed, medications that we're using, things like Rettino and or Retin A, I do think there can be some differences between people with darker skin color and people without. I think that Retin A tends to probably be more effective.

(18:25):
Sometimes people with lighter skin, I think that Tretinoin or other types of agents, you have to be a little bit more careful sometimes with patients in darker skin. I think steroids, especially if we're injecting steroids around scars, if we're using steroids for some sort of topical treatment, we've all seen patients who have a little bit of that hypopigmentation where a little that steroids kind of worked in an uncontrolled fashion, and those things can be very difficult to manage long-term. And so it's really important to think about those things in our patients that have a little bit more melanin.

Dr. Korman (18:53):
Yeah, I think that's really good. I dunno, I always tell my patients when they say, what kind of sunscreen should I use? And I said, it doesn't really matter as long as it goes on at least half an hour before you're out in the sun as opposed to five seconds before you jump in the pool. So let's shift a little again to the very current topic about weight loss and you have a weight loss center. So tell us a little bit about the evaluation. Who would qualify, what sort of protocol or regimen you have and are you able to prescribe ozempic or any of the other glides in your office?

Dr. Williams (19:27):
Yeah, we do have access to the semaglutide, and I've spoken about this previously. This drug is going to change the world. This drug, this is really kind of the first and one in 1.5 generation of drugs, and they're incredibly effective patients that tolerate some of the early symptoms like nausea almost universally lose weight. It tends to be in a relatively controlled fashion and it tends to be consistent. But when we're talking about weight loss, traditionally before surgery in the thirties and forties, it was diet and exercise. You just have to diet and exercise. And then surgery became more of a consideration, gastric bypass and then gastric sleeve, and that really opened meaningful weight loss up to a lot more patients. After that post-bariatric phase, people were looking at different medications and their ability to modulate weight loss. And so some of them were things like metformin or phentermine, which boosts your overall metabolic rate, and then cholesterol that you can absorb lipids and fats and you have horrible, horrible diarrhea.

(20:36):
This is really the first medication that has a relatively low profile side effect profile that really works for everyone and is generally safe for everyone. And so the way we're using it in our practice is we're using it in two fashions really as a gateway for patients who BMI are a little bit high and they still want surgery and we want to provide that as an option for them to help get them to there or patients postoperatively who are in that 25 to 35 BMI range. I generally think that patients who are BMI is of 40 or 50, I think that they need a more complete solution than the semaglutide offer them, but these medications are truly amazing. And again, the other reason that this is a game changer is the CEOs of food and beverage companies are restating their profits. The CEOs of airlines are saying, we have to figure out what fuel costs are going to be in another five years because instead of an 80% obesity rate in America in 2030, we're expecting now maybe a 50% obesity rate. Goldman Sachs came out and said, by 2030, they expect 20% of non-diabetic Americans to be on this medication on a version of this medication. That is a jaw dropping number.

Dr. Furnas (21:54):
That's huge. Yeah, like you said, game changer worldwide.

Dr. Williams (22:00):
Yeah. I think one of the challenges is as responsible physicians, we don't necessarily want patients to get addicted to this medication or see this as the only solution. And so what we try to tell our patients is this medication is definitely going to work for you. And we tell them to expect usually a five pound weight loss per week once they reach that therapeutic dosage. But if they stop the medication and they haven't modified their nutrition or if they haven't modified how they're working out, that weight comes back because all you've done is change your gastric emptying, so your stomach feels the way these medications work for our listeners, it makes you feel fuller because it slows down how fast your stomach kind of processes food and it changes the way insulin works a little bit. And so those two functions of these medications are incredibly powerful, but once you stop the medication, everything kind of goes back to normal. And so we always tell our patients that powerful medication, but it works best in combination with lifestyle changes.

Dr. Furnas (23:02):
So how does weight loss impact your patients both physically and emotionally?

Dr. Williams (23:07):
Yeah, I think that when we go back to looking at obesity and looking at the journey that patients go through from weight loss, again, it's kind of transformational because there've been so many things that patients have been promised that do not work. There've been so many times that myself, I've heard myself saying it, you just need to exercise a little bit more. You need to watch your calories, get into the gym, come up with an exercise program, and you're going to find that if the calories going in or less than the calories going out, you're going to lose weight. That is such a challenging thing for patients to be able to integrate into their lives, especially when they've got a career. They've got family obligations, they've got social obligations where people are having cocktails or eating around them, they are not able to get to the gym.

(23:54):
I think that even if you look at companies in that industry like weight washers, even weight washers is saying, well, diet exercise, but this drug too, because telling people they just need to exercise more, eat less does not work, and it consistently has failed. Patients really looking for change. And so it's really encouraging to have something that may be transformative. And when you see a patient get that initial weight loss, they're shocked and part of the reason why is because they've been promised so many times, you just need the AB roller, you just need the intermittent fasting, you need the X diet. Those things can all be effective, but they're sometimes harder to implement and this drug just works.

Dr. Korman (24:45):
So is there any advice you'd give to people wishing to lose weight with medical help? What should they look for to protect their safety?

Dr. Williams (24:54):
It's a great question. And even though these medications have a low chance of complications and have a very good safety profile, it's really important that you're not just getting this mail-in pharmacy type of medication. I think again, fast forward five or 10 years, I do think this is going to be a medication that people are going to be able to get off the shelves. At our practice, we have both compounded an injectable form and an oral form, and we vary which one we're offering patients depending on their needs and their weight loss goals. But right now it's really important that I think that patients are getting it from a physician or a center that they trust someone who's going to follow up with them, someone who's not just going to ship them the medications without checking on their weight, checking to see if they're having any liver issues, any kidney issues, making sure that they have hydration, and then also making sure that they're saying the things that all three of us have just said, which is, this is an amazing drug, but it's not going to be useful without some lifestyle modifications.

Dr. Furnas (25:56):
You're just over halfway through your presidency of the American Society of Plastic Surgeons, what is a thing or things you're most proud of having accomplished or being in the midst of accomplishing?

Dr. Williams (26:09):
Again, thanks for the question. It's really an amazing organization, and I will say that over time the organization has gotten bigger and more complex and the things that we're working on. My background is a little bit in technology, and so we have some wonderful technology things that we're kind of rolling out, but these things take some time. And so the more short-term goals, I'm really working on scope of practice types of things. I think that for patient safety, scope of practice is a major issue. I'm really trying to focus a little bit on diversity and making sure that patients are heard. I think that as America becomes more diverse in its population demographics, it's really important. Not necessarily that every plastic surgeon looks like the patients they're treating, but that we recognize that different backgrounds, different education, different levels of income, those are all things that can be barriers to healthcare, and it really does behoove us all and most importantly helps our patients that we're able to listen and understand some of those perspectives.

Dr. Korman (27:09):
Yeah, I think that's really an important concept. I think it's important in both directions. I find that I do a lot of Asian eyelids, and I think a lot of my patients who are Asian, they think, oh, you're not Asian, so do you know how to do Asian eyelids? And I think, like you said, you don't have to look like your patients. Hopefully we can all be colorblind and make it work for that. It's not even an issue. It's about quality

Dr. Furnas (27:38):
And really learn the caveats and techniques and limitations that we see. We've talked about pigment, but there are a lot of other differences. My husband is also a plastic surgeon, and I joke that just by looking at the peck insertion, we can get a pretty good assessment of the race of the patient without actually seeing the patient when we're doing a breast augmentation. So there are anatomic differences, eyelids and shape of nose, many different things. And I think no matter what race or sex or gender the surgeon is, if we're operating on somebody, we should be familiar with all of those limitations.

Dr. Williams (28:20):
I think you both make a really good point. We're all well-trained, and when people say, well, and again, I've been interviewed a fair amount of times, and every once in a while I get asked the question, well, shouldn't black patients come to see a black plastic surgeon? And I say, not necessarily. And the reason why is we're all equally trained to take care of anybody because these things that I'm saying about dermis, you guys know about dermis, these things that I'm saying about pigmentation, you guys also know. And so I think the most important part is that all of us need to listen, and all of us need to understand that each patient has a different perspective and maybe coming from, again, may have barriers in their life to effective care that we don't fully appreciate. And that ability to listen, taking that few moments to kind of really understand where they're coming from can be really, really helpful.

Dr. Korman (29:09):
Well, it's really been a true pleasure to have you with us, Dr. Williams. And is there anything else you'd like to add to anything else you've said today?

Dr. Williams (29:19):
I just want to, again, thank you guys for having me on. I think it's, again, I've known both of you for a really long time and I really respect what you've done in our communities. We kind of in the same general area, and I'm always happy for your success and for what you've done and for what you do for your patients. So I want to say thank you. I also just want to, for the listeners out there, it really is important to find a board certified plastic surgeon. It's important that you find someone like these esteemed people that are interviewing me, that are going to take the time and have the expertise to really take good care of you because it's your safety, it's your life, and there's no one better to accomplish these things than a board certified plastic surgeon.

Dr. Furnas (29:57):
Thank you, Steve. Thank Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Korman (30:10):
If you liked this episode, please rate us, review us, and subscribe the music by Diego Canales, production and Engineering by the Axis. Thank you.