What’s New, What’s Hot, What’s Cool, What’s Not? with Dr. Tiffany McCormack

Dr. Furnas (00:12):
What's new in cosmetic medicine? Is it really new? Too new? Who knew? Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:24):
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 (00:39):
It is a real pleasure to introduce our guest board certified plastic surgeon, Dr. Tiffany McCormack. Dr. McCormack is based in Reno, Nevada, and she has co-chaired global hot topics for The Aesthetic Society's national meeting for the past six years. At Hot Topics, world experts share the hottest, the newest, the most innovative cosmetic treatments available today. Welcome, Tiffany.

Dr. McCormack (01:12):
Thank you. Such a pleasure to be here with both of you.

Dr. Korman (01:15):
So Tiffany, with so much technology that's around, that's new, that's newer, that's the very best, and everyone claiming that it's the new thing and the newest thing and funny that I learned the word that news, the word news is actually from north, east, south, and west, like the museum in Washington. So do we rush and take the risk or do we just wait? How do we decide?

Dr. McCormack (01:41):
I think this is a lesson that I had to learn for sure. As a freshly minted plastic surgeon, I was excited right out of residency about everything bright and shiny available, things I had never heard of in residency. Not to mention, a lot of us are pushed by those selling these devices to be the first to market to offer X, Y, and Z and said community. I find that maybe there's a short term financial gain in so doing, but in the long run it can be a very risky strategy. So I've had to teach myself in particular how to sit back a little and see how these treatments pan out. Are they really doing what they say they will? Who's the best candidate will this device prove to be safe in the long run, and even knowing what I know now, I still get stumped once in a while.

(02:29)
And I think a great example of that is in the treatment of cellulite. I've tried to make it my mission to rid the world of cellulite and for whatever reason, I haven't been able to get there, even though I think I've bought every device known to mankind only to discover that these treatments, they work on certain types of patients, they work on certain areas of the body, but it's never as much as what's promised when you buy these devices. And it always pans out to be the same thing. I think I finally learned my lesson after my fourth device on cellulite.

Dr. Korman (03:01):
So that's a good question because there's different devices and they say that non-surgical devices are synergistic. Do you think that putting your four devices together actually was better than using one at a time?

Dr. McCormack (03:15):
No, not at all. And I think the first device that I had involved energy along with supposed cellulite treatment that turned out to be a coat hanger in my closet, so I won't name the name. And then there are newer devices where I find that they work really well, maybe on the buttocks or in areas where they're really defined pull down dimples, not a lot of skin laxity, but honestly, 90% of the patients who consult with me about cellulite have all these other issues that these particular devices alone won't fix.

Dr. Furnas (03:48):
Tiffany, could you explain, we talk about cellulite really, what is cellulite? And you mentioned energy and how would energy impact cellulite and what are these different modalities?

Dr. McCormack (04:00):
Yeah, great question. So cellulite is caused by these little fibrous septae that connect from the dermis of the skin down into the subcutaneous space and they compartmentalize fat. And so some people with puberty and genetics just naturally have some of these dimples. But as we get older and maybe the skin becomes more lax or we have weight fluctuations, then you might see a different type of cellulite that is caused originally by the same thing, but more pronounced because of the skin laxity. And so when I talk about energy that is supposedly not only treating those fibrous EP day, but also treating the lax skin above to try to get a smoother result

Dr. Furnas (04:43):
With heat based energy,

Dr. McCormack (04:46):
Heat based energy, which I think we'll be getting into for sure today.

Dr. Furnas (04:50):
Well, there are all these different modalities are coming out, but they can't just jump into market, just it's not a free for all. Can you explain how the F D A plays a role in what is off-label usage and on-label and early adoption and how did things get rolling?

Dr. McCormack (05:12):
So that's a great point. The F D A is there to regulate all of these devices and medications and a whole bunch of other things. As we all know, sometimes something is F D A approved for one thing, but then it's used off label for other uses. For example, Botox for a long time was only approved to treat the wrinkles in between the eyebrows, right? The elevens or the frown lines. But we were using that in a lot of different areas of the face because we typically know it to be safe and effective in these areas. And that was just a long drawn out process, I guess is one way to put it. But you have to be really careful about what you consider using that is maybe off-label. And I guess the example that comes to my mind would be stem cells. Stem cells are only approved for a very small niche set of treatments, yet they became the miracle drug of the two thousands, right?

(06:11)
So we had all these people promising that stem cells were going to cure cancers and make people walk again and treat joint disease and make your skin look like you're 10 years old again. But none of that was necessarily approved by the F D A. So I watched them kind of come in and start to crack down on these practices that really advertised what stem cells can supposedly do that has not been proven or approved by the F D A and in some cases that could be dangerous. I think there are cases where stem cells stimulated the growth of tumors, but more commonly it was just the inability of the cells to work as expected.

Dr. Korman (06:50):
So from a consumer standpoint, since it's a big morass and all these different things, is Mel Brooks really right? That everything is marketing and how well something works is just secondary, that you bought four machines and none of 'em work. We all have bought machines and humans and consumers. How many things do people buy that for the promise of something? Is it really marketing or is there really any stake behind the sizzle?

Dr. McCormack (07:17):
I think Mel Brooks is right about a lot of things, but I think it's a really dangerous idea to apply to medicine because medicine can be harmful. And we're taught in medical school to first do no harm. I don't always blame the provider in these cases. Look, there's a whole industry around these devices and treatments and sometimes even the providers get fold. Companies have a very strong sales force and they're very, very good at their job. They're very well-trained. They'll even sometimes market a product for you. And that's really tempting when you're trying to get off the ground, especially as a new practitioner, let's just say I'm less naive than I used to be, but it's really promising when they come in and say, we're going to market this product for you. You're going to be the first to market in your community. You're going to make thousands of dollars off of this. It's bright and shiny, and I think the provider is typically very well-intentioned at the beginning, but over time you really learn to watch out for these kinds of pitfalls

Dr. Furnas (08:15):
With America struggling with girth control, not to be confused with birth control, getting rid of fat is sort of the new thing. So besides the new injections which we're hearing about ozempic and that type of thing, what nonsurgical devices can work?

Dr. McCormack (08:35):
The one that comes to mind to me is CoolSculpt. It's the one I'm most familiar with. And yes, it does work for some people in some cases, but one thing we have to be careful of is the concept that if you're holding a hammer, all you see is nails or the whole world is a nail. So you have to be careful about who receives this treatment and what the expectations are. I think we're lucky as plastic surgeons in that it's only one tool in our toolbox. So we're able to use it where it's indicated, but we're able to offer other options such as in a postpartum abdomen with skin laxity and maybe muscle separation, we're able to offer an abdominal plasty instead. Or if we analyze someone and find that they have more visceral fat than subcutaneous fat, which is the fat that wraps internally around the organs, no liposuction, no tummy tuck, and no CoolSculpting is going to help. So it's really just analyzing what's in front of you and guiding that patient in the right direction. Is it weight loss first? Is it a surgical treatment or is it a pocket of fat that just doesn't go away despite diet and exercise and would be very amenable to CoolSculpting?

Dr. Furnas (09:49):
So Tiffany, if somebody is looking in the mirror, they've got a belly that sort of is protruding, they're kind of tired of it, how do they know if they've got fat above the muscles or as you mentioned, fat wrapped around their organs, we can't touch the fat around the organs. How do you know before you go and talk to somebody who's offering CoolSculpt or tummy tucks?

Dr. McCormack (10:15):
Yeah, I think there's kind of a pinchable aspect to subcutaneous fat. So it may be a little bit looser. You're able to really grab it with your hands and separate it from the muscle wall. Or if you are standing in front of the mirror and you're trying to pinch your abdomen and it's definitely full and protruding, but you can't pinch anything, it's firm like a barrel. Well, that tends to be more of that visceral fat. And sometimes it's a combination. Sometimes I have patients who have a lot of that visceral fat, but maybe on the lower part of the abdomen they can pinch a lot of skin and that can be harder to differentiate, but a provider can definitely help you with that.

Dr. Korman (10:51):
So one thing that I find as a practitioner of both surgical and nonsurgical is that so many patients say, oh, I have so much fat and they bend over and they squeeze and they pinch. But I know that that's not fat, that is just loose skin. And so can you help us to understand the difference between skin laxity and skin excess?

Dr. McCormack (11:15):
Absolutely. I think that there is a difference because sometimes there's just loose crepey skin without a lot of excess necessarily. And that's the skin that I often see on maybe the upper arm or the anterior thigh or areas like that where people come in and say an

Dr. Furnas (11:33):
Anterior thigh?

Dr. McCormack (11:33):
The front of the thigh, front of the thigh. Patients will come in and say, what can I do to tighten this up? And it's not necessarily enough skin to warrant skin removal, it's more just lax skin, which can be amenable to product in some cases, although not always. And maybe some of the energy tightening devices.

Dr. Furnas (11:54):
Like what type of energy?

Dr. McCormack (11:56):
Like radio frequency maybe, or even something like Renuvion. But these all work basically by generating heat. They're all different devices that generate heat, which causes collagen to denature, and then that collagen is trying to remodel and correct itself over the course of several weeks. And so that should lead to tighter skin. However, not all patients are able to generate a lot of collagen. So you have to be careful in that a patient who's maybe on the older side, no matter how much heat and energy you apply to that tissue, or someone who has very little elasticity for other reasons, they're just not going to respond to that. And there's honestly not a lot of art to that is what I tell patients. I can only apply so much energy without burning you, and then it's up to your body to either respond to it or not. And I'm kind of getting into the radio frequency conversation, but just to take it back a little bit to the excess skin that you were talking about, Josh, that's different if there's a lot of loose hanging skin, I really think it's probably a waste of time, money, and energy to try to just apply radio frequency or any other form of energy to that. Really the gold standard for that is excision.

Dr. Furnas (13:11):
Well, when I look at social media or magazines or whatever, I see that there are a lot of home treatments for the very treatments that I see advertised in med spas, skincare, and laser caps for hair growth. And does anything really work at home? Can I just forget the med spa? Forget the doctor's office.

Dr. McCormack (13:32):
I would say it's synergistic. I do believe in good skincare products. I tell patients it's like taking vitamins. It's difficult to physically see what that's doing for you on a daily basis, but you are contributing to the health of your skin. So over time, I think it's great for prevention if you start young enough, I think it's good for maintenance after procedures like laser resurfacing, facelifts, et cetera. And when I talk about products, I guess I'm specifically speaking about retinols, antioxidants, growth factors, sunscreen, et cetera. I think there's a lot of garbage out there too. So it's a good idea to discuss what products are beneficial with your provider before you spend a lot of money on these things. I am still trying to figure out how pill and powder form collagen gets to the dermis to tighten skin, but that's a conversation for another day.

Dr. Furnas (14:24):
Yeah, there's a stomach acid.

Dr. McCormack (14:28):
I just dunno how that gets to the dermis in particular, but that's a huge market. And then with respect to laser caps, I think there's some benefit there maybe when combined with a great hair supplement like NRA fall, but I'm guessing there are good ones and not good ones, and I think there's probably a big range out there.

Dr. Korman (14:46):
So let's talk about radio frequency. It seems to be that the energy of the IS radio frequency. Everything is radio frequency, it's kind of outside radio frequency, inside radio frequency, and it's mixed with all different things like Renu Vion, it's helium gas and sculp. NEO has radio frequency coupled with muscle contractions. So under the skin, over the skin, heating the skin to tighten but not to burn, how should we actually think of this energy or any other energy? How should we think about it?

Dr. McCormack (15:19):
Yeah, I'll go back to kind of what I said earlier. All of these generate heat within the tissue, and the idea is that you are tearing down collagen to rebuild it, to tighten and firm things up. In the case of radio frequency, it's low frequency magnetic waves, but other energy devices use other ways to generate heat. So again, the trap here is in assessing a patient as to whether or not you think they're going to respond to this because I can only apply so much energy. It's not like surgery where we determine how much skin we want to take out and where and how. And there's a lot more art to that with this. You really are just literally applying energy, different degrees of it. But again, you can only go so far without causing damage or burning a patient. So I'm very careful in my practice as to who I would ever offer these to. And it's very limited. It's never what the device salesperson says I'm going to be doing with it because I just don't think it has that broad range. I think it's an adjunctive tool, but I don't think it quite lives up to the hype, at least in my experience. I think it's the second best thing we have next to excision. But excision, unless there's very little excess is really still the gold standard.

Dr. Furnas (16:40):
Several radiofrequency devices treat female tissues like vaginal laxity and stress urinary incontinence. And then there's ultrasonic shock therapy for treatment of erectile dysfunction in men. And most of these treatments are off-label, which we already talked about. So you're a little bit off the reservation as far as the F D A, so to speak, but it is legal. So are they safe and do they work?

Dr. McCormack (17:09):
Let's start with the female issues. So it's probably important to understand that radiofrequency or CO2 laser like the Mona Lisa or the FemTouch device, we're only getting to surface level here. So maybe some tightening of the vestibule, some mucosal tightening or thickening, which can help with some of the issues that you spoke about. But you're not getting deep. You're not treating pelvic muscle dysfunction, for example. So you have to be really careful about promising what these devices can do for somebody, especially something like stress urinary incontinence. It just may not be treating the underlying cause. A patient may be better off with something like a bladder sling depending on the etiology of their issue. With respect to erectile dysfunction, my husband's a urologist, so I did ask him about this. The word on the street is that really is definitely snake oil, so I'll leave that one on the table.

Dr. Furnas (18:06):
One thing that the F D A has sort of sent some warning letters to some of the female devices. And if you look at the studies, a lot of the devices do studies with only one, what we call cohort one group of patients, the treated patients, but they don't compare with the untreated patients and there tends to be a large placebo effect that lasts for three months. And coincidentally, a lot of these studies lasted for three months.

Dr. Korman (18:38):
So that gets to the point of how do we as practitioners, how do consumers decide? So a new wrinkle relaxer comes out to compete with Botox that lasts longer or a new skincare product comes out to compete with retinols. Does new always mean better? Obviously it's a rhetorical question, but how do you think, do you think of something when something is new? How do you decide when to jump, when not to jump, and what goes through your head?

Dr. McCormack (19:09):
I think as scientists and physicians, we do have the advantage of being able to interpret scientific data. So it is good to look at peer review journal articles. It is good to really understand the science behind what's being offered to you. So you mentioned wrinkle relaxers or neuromodulators. Yeah, we happen to have a new one that presumably lasts longer, but I would argue that using Botox in a high enough dose may last just as long. So it's really kind of differentiating how is this different? Is it really different? Is it new? Does it cost more for my patient? Does it change anything? Now granted, I do think some patients respond to different neuromodulators differently. So just going back to brand names, for instance, Botox and Dysport, I have some patients who say, Botox doesn't work very well for me, but Dysport does and vice versa. So it is good to be able to offer a variety at the same time understanding is this something that's really truly better and different? And especially if it's going to cost more for your patients, you have to be very careful about that. With respect to retinols retinol, as you guys know, it works by reversing DNA damage in cells. And it's been around for a long time and I just can't think of anything out there that's better at doing what it does.

Dr. Furnas (20:34):
Yeah, that's probably one of the most studied and most FDA approved acne and wrinkles and yeah, it's a great product. Now, you mentioned earlier, Tiffany, that a lot of times the reps are really good at selling a product, and I've noticed actually that some of these new white papers, we call 'em the research papers, they can have some MDs and the right specialties, but they're often funded by the company or they may be advisors for the company, and so they may have a conflict of interest, but then who else is going to do those studies? And so how do you know as a consumer, as a patient, a client that what you're getting is worth the cost? How do we decide that whether what we're purchasing is snake oil and profitable for the provider, profitable for the company, but maybe not so great for the consumer?

Dr. McCormack (21:35):
I'm going to start by bringing this back to Amel Brooks quotes that I wrote down so I don't get it wrong.

(21:42)
Making it about the money is the worst thing you can do. Even in tough times if your happiness depends on money rather than the satisfaction of getting the job done and done well and on being there for your team, you'll never end up being happy with yourself. So the reason I brought that up is because I think those of us who've been in practice for a while or plan to stay in practice for a while understand that trust is an essential part of the doctor patient relationship. And I would argue that most of us really, we are in this for the long run. We're not trying to make a buck. We're not trying to quickly profit as much as we can. I think we all really want patients to come back to us. We want to build a reputation. We want to have something that is sustainable and maybe some legacy to it. So I don't mean to sound dramatic about that, but I do think that snake oil, it's a money pit really for you in the long run if you tend to run that type of practice. So I just think it's important that you have a trustworthy relationship with your patients and that your ethics come through. And again, like I said earlier, sometimes we get full too. We make mistakes. Nobody's perfect. But I think as time goes on and as our practices continue to develop, we all get a little bit better about that.

Dr. Korman (22:59):
I think that's so true. Now, some people come in as patients and they come in very, very knowledgeable, or they think they're knowledgeable because they were doing their research and their version of doing their research is they did a Google search. I know it's a shock here, but Internet University doesn't always give the most up to date or reliable information. Yeah, I know, that's just shocking to know. 

Dr. Furnas (23:20):
Shocking. 

Dr. Korman (23:23):
What is since you said a few minutes ago as physicians we're a little bit more, and I say a little more educated to know, but what does a consumer to do? How should a consumer learn enough information to give them at least the questions to be able to ask?

Dr. McCormack (23:42):
Yeah. Dr. Google, I like what you said at the end of that, at least the questions to ask. So I don't think there's anything wrong with the Google search and just being armed with questions to bring to your provider, because some people know nothing about what they're coming in to talk to their provider about. So it's probably good to look at that to some degree. But I think it's also important to be very open to what your provider explains to you and not just come in having your mind made up that what you read on Google is a hundred percent true, because as we all know, it often isn't. And just along those other lines, I'll make a plug for searching for your practitioner based off good credentials like board certification memberships to reputable societies like the American Society of Plastic Surgeons or the Aesthetic Society if you're going to a plastic surgeon, because there are a lot of fake credentials out there, which can be really confusing.

(24:37)
I'll just use the example, the American Society of Liposuction Surgery, they don't have the same rigorous board certification and training process that we do. So it is very different, and I think it's important for the public to understand that. But coming back around to your point, I think coming in with a list of questions is a great idea. I don't think there's anything wrong with starting that list on Google University, but your knowledge or your learning process shouldn't end there by any means because there is a lot of confusing information out there. We all know that

Dr. Furnas (25:08):
Now there are scholarly articles. You can actually do a Google search and then put scholarly article at the end, and up comes real like from JAMA or Archives of Surgery or whatever scholarly article. How does the individual make use of that?

Dr. McCormack (25:30):
I think it depends on one's background. If you're able to interpret data and you understand how statistics work and what a peer reviewed journal is,

Dr. Furnas (25:40):
What is a peer reviewed journal?

Dr. McCormack (25:42):
So basically in a peer reviewed journal, not just anyone can publish a paper in a peer reviewed journal. So for the Plastic and Reconstructive Surgery journal, several people have to look at an article and agree that is statistically sound and that the science behind it is accurate and that it's a well done study. So it's not like writing an article or an op-ed or something like that where it's all opinion based. So you can be assured that if it's been peered reviewed, not a hundred percent of the time, but I'd say 90% of the time that it's a good study or an accurate or worthwhile study to look at.

Dr. Korman (26:21):
So many things that are new are really just repackaged old things. I think we know that in all kinds of consumer products. Do you think it matters?

Dr. McCormack (26:33):
Yeah, and I think it's really fascinating because we do have an advantage here. If something comes back around and we experience this product or device, let's say 10, 20 years ago, and then it went away for good reasons, and now it's coming out again, repackaged. We at least have the advantage of knowing, look, we had issues with this in the past and this maybe wasn't as efficacious as we were told it would be. Maybe it doesn't last very long. Maybe these are all the downsides, X, Y, and Z. So sometimes there are product improvements which can change that, but sometimes it's almost coming out almost exactly as it was. And one example I would use is thread lifts, and this is my opinion, but I remember them coming out in 2003 is kind of the non-invasive, non-surgical facelift. There were issues. It fizzled, it went away for years. And now probably in the last five to 10 years, it's made a resurgence and we see it a lot in medical spas, et cetera. The advantage to me is I know about this device and I know what happened to it, and I know what the pitfalls are. So there is an advantage to that. But I think we just also have to be careful about the repackaging of it and understanding if it's improved to the point where it's much better than it was when it fell off the face of the earth in the first place.

Dr. Furnas (27:51):
So every year you've, for the last six years, you've been co-chairing the global hot topic. So every year, people from all over the world present the newest things. How do you choose, how do you find out about this?

Dr. McCormack (28:07):
Oh, so choosing the speakers, well, first we really try to come up with things that haven't been talked about every single year. That's not always possible, but we try to bring to the audience's attention something that they've never heard of before, good, bad, or ugly. And then we also try to find things that are innovative. I think a good example, obviously these companies, these device manufacturers come up with these machines, so to speak, but we also have a lot of plastic surgeons who have found in their own practice that there's a need, there's a niche. There's something we've all been operating and thought, gosh, it would be so nice if we just had X to close this wound better, or something like that. So we like to bring those things in too, because there are a lot of innovative thinkers that don't, they aren't part of these big companies.

(28:58)
They're just people who've discovered something that would help someone in our profession. And I think a good example of that would be like the Brijjit Wound Closure system that we have now to help take tension off of scars or maybe the Interi drain system where there's more of a vacuum suction to it. It's not just a bulb suction drain. And I know I'm kind of getting away from what the lay public wants to understand here, but that's all included in how we decide what to bring forth. And sometimes we do like to bring in really controversial things, hence the name Hot Topics, because it just stimulates better debate and more interest.

Dr. Korman (29:35):
Well, that's really exciting, Tiffany. It's really always a pleasure talking to, and we really, really appreciate it.

Dr. McCormack (29:44):
I just want to say I appreciate you guys bringing me on. It's such an honor and always great to see you both of course. And hopefully we'll get to do this again sometime.

Dr. Furnas (29:53):
Oh, we love that. Thank you for listening to this episode of Skintuition. 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):
Follow us, comment, ask questions, and keep in touch. We'd love to hear from you.