Transcript, References, Relevant Links

Transcript

JCPM2023.06.20

Charles Runels:

Welcome to The Journal Club. Tonight we have a special guest, Sylvia Silvestri. She's been teaching for us for over a decade. When I met her, she already had worldwide renown as the Beverly Hills RN, having worked in the plastic surgery arena in Beverly Hills for years and understanding many of the technologies and lots of observation working in the OR there.

So extremely experienced, and she's been both teaching and performing Vampire Facials now for a decade as part of her practice, often with celebrities, people you would recognize coming to her, recognizing her as one of the best.

So you're in for a treat. She's going to give some of her best tips. We also have some research to talk about in regard to other uses for microneedling, like scarring and hair and acne and such. But let's just go ahead and open up the mic here for Sylvia. And let's see. Here we go. You should be able to talk now. Sylvia, are you there?

Sylvia Silvestri:

Yes, I'm here.

Charles Runels:

Thank you for making time for us. I know you're now... You're teaching in routinely now in California and Tennessee, correct?

Sylvia Silvestri:

Correct.

Marketing Tips for the Vampire Facial® Procedure from the Beverly Hills RN

Charles Runels:

Beautiful. So can you just start off by... I'm looking, we have a lot of people on the call tonight. And often, we have, as we do tonight, a mixture of people who have been in the group for years and those who are new to our group. Can you just start off by talking about what's your top two or three tips for someone? They just bought their microneedling device. They don't have a following like you do. As far as marketing the procedure, what do you tell your people when you teach your classes?

Sylvia Silvestri:

I think that microneedling is something that people who are just starting out, whether it be the vampire procedures or injectables, microneedling is something that everyone can do when they're first starting out, and they can make money doing it.

They can use it obviously with PRP for the Vampire Facial®.

You can do it on any skin type, male or female. You don't have to worry about burning anyone. There are a lot of different indications that you can use it for. And you can just use it basically on anyone because it will help anyone's skin look better.

And the theory is the needles go into the skin. It originally was called collagen induction therapy, meaning that when the little needles make channels in the skin, your body says, oh my gosh, let me make new collagen. So it was started out with the rollers.

As we know now, the rollers will cause micro tears as they're rolling back out of the skin. So now we have different pens on the market, and there's a myriad of pens that one can buy.

They all do the same thing, in my experience.

But back to your patients. So you could do it on any skin type. It doesn't matter what age they are, obviously over 18, up to however old.

This will help for acne scars, milia, fine lines, the little tiny, tiny little crepey lines that you really can't do anything with filler because they're too superficial, large pores. Let me see what else. Large pores, acne scars, milia, fine lines, crepey skin, when people have really dry skin. Say they don't exfoliate a lot; microneedling will help them just produce new collagen and give new vibrancy and give a new glow to their skin. And it really doesn't have a lot of downtime.

If you use the Altar Cream™ that we have and put it on their face right after the procedure and send them home with it and tell them, "Just use this cream for the next week. Don't use anything else," it really, really helps them. The redness will be cut dramatically, and they will get a faster healing response.

Charles Runels:

So back to the... I know you could go on, and you do go on all day long when you do your hands-on classes about pearls. And I want to get to your best pearls for actually doing microneedling in relation to both effectiveness, pain, and efficiency, but a little more about marketing.

I know you use social media, you have a website. Can you maybe give your best tips for how you think about your website and how you think about your social media as far as marketing microneedling and the Vampire Facial® in particular?

Sylvia Silvestri:

Yeah. So you have to do social media. It's just the way it is these days. If you don't want to do it or don't know how to do it, find someone in your office that can do it for you because it is really critical that you do that and post about what you're offering and microneedling.

I love to really push microneedling right after summer because everyone's been out in the sun, and they want to reverse things. And it's a good thing to do in September to start really pushing forward, but you can do it any time of the year.

But yeah, social media, Facebook. People still go to their Facebook. Instagram. TikTok is now gaining a lot of traction as far as social media advertising. I

'm seeing a lot of plastic surgeons on there. It's really important. Then you can also do an email to your patients, write a little blog about microneedling, and then attach the Vampire Facial® website. So if they have any questions, they can also go there and read about it before they decide they want to do it.

And I think you can also offer it to somebody that knows a lot of people, like a real estate agent or something like that. So there are a lot of different avenues that you can do as far as marketing and getting the word out about Vampire Facial®.

Charles Runels:

Just to add to what you've said, and a couple of things.

First of all, let me flip over. Want to not get too far behind on what you're talking about. You mentioned different skin types. There is... Here we go. This one is regarding acne and skin of color and the different options.

And of course, microneedling comes out on top as one of the options. I don't think I told you this. I don't know if he would want me to say who he is, but there's someone in our group that's extremely expert at lasers and quite a number of people that are experts in lasers. And when I spoke with him recently, he said he hardly ever even uses his laser anymore, even though he's very well known nationally for his expertise, because the microneedling works so much better in many cases, or at least as well without the downtime or the problems.

Here's the paper. And let me put this in... Actually, I put this one in the handouts, which will go away after we do the call. So if you open them now, they’ll be there after we end the call.

But these are all recent articles. This one came out this year where they compared laser with microneedling for scarring and hypertrophic scars, and they were equally effective. And so let me give you that link. Anyway, back to what you...

I'm just catching up with the other thing about Facebook and social media because, as you know, I'm not as much into social media. But with the microneedling, it often attracts a younger crowd. And in that case, I think it has more pull and effectiveness, say than social media for O-Shot®, for dyspareunia after breast cancer. That's more of an email or a Facebook communication.

And to me, Facebook is almost as old school as email these days. Any tips about... I know you mentioned just filming someone who's well-known in the community and who's willing to do that.

Any other tips about producing?

Because you've done a lot of it, obviously, you've done a lot of it for a decade and very successfully done it, enough to have a nationwide...

Actually, I know you teach in other countries. So what are your top two or three tips about actually producing the material? But for people like myself who are not really extroverts, we don't want to sing songs or something, but how do you tell your people to make those social media posts as far as content?

Sylvia Silvestri:

Yeah. If they're unfamiliar with it, I highly recommend having someone help you, someone in your office, or a friend or family member. Everyone has a younger family member or somebody that can help them do a quick video or a reel. And it's really important to do that these days.

Charles Runels:

Yes.

Sylvia Silvestri:

So, for example, my medical director in Beverly Hills, Dr. Minniti, did not want to do social media, and his practice was slow.

And I said to him, "You need to get on Instagram." And he said, "I don't want to." And I said, "Well, then hire someone to do it, come into your OR three days a week, pay them whatever you want to pay them, but have them film content three days a week."

And now, he is so busy. I think he has a hundred thousand followers, if not... I don't remember. But he is really, really busy because of Instagram. And he doesn't do it at all. He has a girl in his office do it.

Charles Runels:

Yes. I think that's probably... You had to say it three times before I actually realized what you were saying, that that is the best tip you guide, and I think it's probably the best tip. Because when I think about people like... Dr. Miami's in our group, and he's up there with the Kardashians, millions of followers. I was lucky enough to be in his office watching. And he's a hardworking, brilliant physician, but he doesn't really carry the camera around. He does what you're saying. He has someone who's following around and filming when it's appropriate. And so he'll stop or they'll film the patient if the patient's consented to it. And it takes almost no time and is tremendously more content because someone is thinking about it while he gets to think about being a doctor.

Sylvia Silvestri:

Right.

Charles Runels:

And when I think about people who are super successful with social media, you're right, they have that person. And it could be part-time once a day thing for someone who's there already, as in a receptionist or whatever, but young enough to understand the medium.

But I think most physicians, whatever they're doing, greatly underestimate the amount of content. They're afraid they're going to pester people when really, your patients want to be voyeurs. That's really what made the Kardashians billionaires was allowing others to watch them.

And so allowing... For most people, what we do is so exotic. Much of what we consider mundane is exotic to them, so allowing people to be voyeurs in appropriate ways is extremely compelling.

And then I think I'm still... I have to say I'm still old school for long-form emails. You pull them into your website, and you get them to subscribe to your email. And I think a minimum of once per week with an email and once a day if you're going to really go all out on social media. Probably should be a once-a-day thing at least. Don't you think?

Sylvia Silvestri:

Yes, or even three times a week is fine to get started.

Charles Runels:

Okay.

Sylvia Silvestri:

You don't need to do something every day because sometimes it's hard to think of content every day. But if you can have someone help you three times a week. That's the biggest tip on how to get that done, just have someone help you and have someone do it for you in your office that's savvy with social media.

Charles Runels:

So the biggest difference I saw between Dr. Miami's, he's a marketing superstar, so you have to take note, is that there's no big warmup. Most of the physicians I see, whether it's their writing email, they have to feel inspired like it's a Walt Whitman literature exercise. And if they're making a video, it's all about they have to pause and think about makeup and what their hair's doing and what the light and what they're going to say, and then practice it three times, where the people that are very good at it's just, "Oh, this is interesting. So film me doing this."

And it's not always something earth-shattering. They were... I don't know if he still does it, but at that time, at the end of the day, he would just do shout out birthdays to...

And not in a goofy way, just in a kind, thoughtful way. Almost like, oh, it used to have be a kid’s show we had when I was a kid centuries ago, Captain Kangaroo and they'd do birthday stuff. And it was almost like a little kid thing, but lighthearted, just so lighthearted shout out to patients.

Sylvia Silvestri:

Right.

Charles Runels:

Okay, so let me get away from the marketing just a little bit, and I want to just throw up a couple of... Don't go away. I want to mention a couple of papers and then come back for your pearls about the anti-aging part. I also have done a few celebrities that I don't feel right to mention, and they are seeking this out. If you go to... It's a really expensive and continuous battle that we're doing every day to maintain the integrity of our brand. But for example, I'll show you one that was just out in Allure Magazine.

So this is typical sort of stuff. This one is just out, you can see May 31st, so a couple, of three weeks ago. And they talk about the Vampire Facial, and then they throw in a lot of PRP and they blur the lines. This article actually was astute enough to at least make some difference between the two, but failed to recognize the great distinction that keeps people from getting hurt. Just to remind you guys... Let's see, Rolling Stone. Here we go. This article was about how people got hurt. Actually, Rolling Stone interviewed me, and this was me trying to protect our reputation when someone got hurt pretending to do the Vampire Facial who didn't know what the heck they were doing, gave people HIV. So when people do stories like this and they don't make the distinction, in my opinion, it's dangerous.

So I'm trying to... Every time one of these articles comes out, I reach out to the people. Sometimes I get my attorney involved, and I try to get things corrected.

But the way the group can help... Because eventually, it could go generic, and then I just can't protect it. As of now, it is not generic. And our new company BrandShield, they're just so deadly effective. And if someone is advertising using Vampire Facial® and they're not in our group, their website or their social media account will just go away. It might take a few days to a few weeks, but eventually, they will have it taken down through the ISP provider.

But we don't want that to happen. We'd rather people just understand. And the way the people in the group could help, the way you guys could help is by always writing the name with that R symbol, which you do by hitting, if you're a Mac, it's an option and then the letter R, and it puts the ® symbol behind it.

And this recently happened when we were tangled up with the AMA.

We have a lot of David and Goliath stories.

And part of what happens with the examiner, with the attorneys, is they go look to see, well, is this really a mark?

And they look to see that we have a protocol and that people are following the protocol, and it helps if people using the mark make a note of that by putting the R symbol on their website.

Anyway, I didn't mean to get rambling too much, but it's still hot. It's still in the news. Just people love vampires. And this was, what, three weeks ago in Allure Magazine? A

nd if you go look at what's come out in the press, a lot just within the past month or two. Anyway, jump back in Sylvia and give some... I'll wait for more of this research, but I got off track.

Pain Control with the Vampire Facial® Procedure

But give us some of your pearls about; let’s start with pain. How do you think about pain control? What are your best pearls for making it comfortable?

Sylvia Silvestri:

Well, you definitely have to use numbing cream, for sure. Because if you don't, it can be uncomfortable unless they want a really, really light treatment. But I will always put numbing cream on them. And just make sure you get a good cream compounded at your pharmacy, like a BLT, Benzocaine, Lidocaine, and Tetracaine.

I like it when it's kind of like a, almost like an ointment because it seems to be absorbed into the skin better. I've had all different consistencies of numbing cream, and the ointments tend... Even for the O-Shot too, to me, the ointment compound absorbs better.

And again, make sure they have obviously no makeup on. But as far as pain control, as long as you have a good amount of numbing cream on their face, they should not feel anything.

And when you're finished, they should not have any pain either. It may feel tight and it may be red, but they should not have any pain by the time they leave your office.

Patterns of Microneedling

Charles Runels:

Okay. So talk to me about... I see a lot of discussion about... It's almost like tomato versus tomato, but a lot of discussion about patterns. When you're doing the Vampire Facial, are you doing circles? Are you doing... How many times are you going over the same spot? And how are you judging depth? So patterns and depth.

Sylvia Silvestri:

So I always start at the top of the face and work my way down. So I'll test it out on the forehead because that's thinner skin and more sensitive. And I'll usually start at 0.5 millimeters and just see and let them see what they think about it, what it feels like, if they're comfortable. Then I look at the skin. Okay, is it getting red? Am I getting some pinpoint bleeding, petechiae? Do I have erythema? And if I have all of those things and they're comfortable, then I'm good. So what I do is I do four passes, vertical, horizontal, diagonal, and diagonal in one section, which would be the forehead. And then on the cheeks, I would do the same, and on the chin. Now, under the eyes, on the nose, upper lip, it's smaller areas, so you can't do that. The under eye, I'll also kind of do a lower setting because that's also the really thin skin.

But around the cheeks and the chin, you can turn it up until you get your pinpoint bleeding or petechiae. And then once I do the whole face... And if they have some acne scarring or something else, like mild sunspot or something, I'll go back over there and do some circles in a one particular spot. But make sure you don't go over any moles or any active acting because then you can spread it around. If you go over a mole, you can actually cut the mole off and have a lot of bleeding. So try to avoid that too. But yeah, I started the forehead and I work my way down to the chin.

Charles Runels:

So you divide the face into the sections of forehead, cheek, chin, and then under eyes and upper lip? That's how...

Sylvia Silvestri:

Nose and... Yes.

Charles Runels:

Yes. Okay, under eyes, nose, and upper lip. And mention more about what you mean... I was listening for that. That's what I look for, those petechiae. How do you... What's deep enough? Tell me more about what you're looking for.

Sylvia Silvestri:

So some people do it until the patient is literally a bloody mess covered in blood, and you really don't need to go that extreme.

As soon as you get petechia and the redness and a little bit of bleeding, you can move on to your next section.

There's a guy that, I think he still works for Dermapen in Europe, Andrew Christie, and he trained me years ago. And he says he does a whole face in about five minutes. And he doesn't like to use numbing cream because he said it causes vasoconstriction, and then you can't see how red the person is getting, which I understand that, but it's really painful, so I personally don't think I could do the procedure without numbing cream.

But yeah, they don't have to be extremely dripping blood on their face like you see some of these Instagram people doing, just redness, pinpoint bleeding. Okay, cool. I can move on to the next area.

Charles Runels:

Okay. Let me mention a couple of other papers, and then I'd like to talk more about what and when you're applying your PRP and any other things.

You mentioned the Altar cream, but I want to get more detail about that. For those of you who joined late, Sylvia Silvestri has not only been doing, and the person who's taught the longest in our group and doing microneedling now for a decade, but...

So doing it and teaching it in multiple states and in other countries, and so much experience. If you guys have questions, type them in and I'll... Or maybe I'll unmute you if you want, but definitely, you've got an expert on the call, so this is a great time to get your questions answered. A couple of more things came out recently in the literature, this one recently out this month.

Radiofrequency and BoNT

Someone looked... I thought about this a lot and someone finally answered the question about using your radio frequency microneedling, what's an effect on Botox?

And it does seem to attenuate, but best I can tell, things were still working and not that big a deal, but that's the question that comes up. Probably better to delay them, not do the same day.

This is something, I'm just bringing it up because I don't know what to do with it and it's a question for the group.

Hopefully, someone in the call can educate me, but I'm seeing more and more in the research about these detachable microneedling devices. So you... That. It has the material, whatever it is. In this case, they use triamcinolone. And then it just delivered. It goes in, and then it stays in the tissue and delivers the product.

So I'm thinking of all sorts of ways this could be used, like with lichen sclerosis and scars, and you're seeing lots of research come out. This could be the next thing. I've reached out to one of the manufacturers and see if I can get some kind of deal, and I see Jeff's on the call and other people that might want to be involved. But our group is big enough. We should be able to get some sort of deal on something like this. Of course, the worry for me is what's that thing made out of? And I'm still educating myself on the possible downsides to it. Someone on the call, have you seen this use Sylvia, or any comments?

Sylvia Silvestri:

I have not.

Charles Runels:

Yeah. To me, it seems like something that I would not want to be... It complicates it. So if something's working, and it is. With our microneedling, with PRP alone, with nothing detaching, just opening the skin is working, so why complicate it with a possible foreign body type reaction.

But if you had something that was more resistant, like the sclerotic tissue of lichen sclerosis or maybe a keloid or something, I'm imagining things like that where it's harder to penetrate into the tissue, and maybe there's more of a pathological disease process that warrants a more powerful delivery maybe. I don't know.

So I don't see anybody commenting, so... Excuse me. Apparently no one, at least no one on the call has experienced they want to share. But I'm bringing it up. And I'll put a link to this paper in the chat box, but I'm bringing it up because I think it could have some usefulness down the line for some of the difficult problems we treat.

Cleft Palate and Other Scars Treated with Microneedling

This one, I just wanted to... I think this was a Dermapen they used, and it was so dramatic. We've looked at studies like this before, but it's always so heart wrenching to see what's... Think of a child dealing with a cleft palate. And then to see what can be done with microneedling, that's a life-changing thing for a child. That almost brings me to tears. So that's what we can do.

And some of you are treating acne scars, some of you are facial plastic surgeons on the call, and I think it's worth educating our people that this sort of possibility exists. I'll put a link to this. So realize every one of these papers is a potential marketing opportunity too.

Because if this is something you're interested in doing, any one of these papers, you could take the link, shoot it out, whether you're social media or email and let people know that, "Hey. Yeah, I know how to treat scars.

This is something I do in the office. Have this very same device." Yeah, that's a derma pen. "So I have this very same device in my office and let me know if there's someone you can help."

I think it's useful to never forget, ever, ever forget, especially if you're hesitant with your marketing, if you're the mother of a child that has cleft palette, and you happen to have a surgeon that's not into microneedling, it's not her job to figure out that there's a doctor down the street that knows how to do this.

I think ethically, it's our job to make sure we get the word out about what we're able to do.

Once you adopt that idea, that ethical duty to let people know what you're capable of and it gets in your bone marrow, then I think... If you're visualizing this scar or acne scars in a teenager who's worried she's not going to be, or he's not going to make it to the prom, like happened with me with my acne as a senior, then I would love to have had something like Facebook to pop up and some concerned doctor say, "Hey, I've got something that might help you."

Everybody knows that thing. But I think not marketing when you have this capability is, in some ways, not doing your best duty as a physician in your community. Anyway, I love this article. We've seen these before, but I love that.

Let me stop. We have a couple more papers I want to show you, but let me stop.

And can you jump back in, Sylvia, and talk more about, whether it's you're treating scars or for cosmetic purposes, what's your method and process for applying the PRP and/or whatever else you're using?

Sylvia Silvestri:

So when I do the procedure, I usually will put my PRP into a 10 CC syringe, and I am right-handed. So I have the syringe in my left hand, and I'll drop some PRP on the skin and then immediately microneedle it with my right hand. So I just kind of follow my left hand around, drop some drops. And PRP can be really drippy so I usually put some gauze around their neck and in their ears and protect their eyes. And I'll put it on topically. And then, as soon as it hits their skin, I want to be using my pen to get it in those micro channels.

Charles Runels:

Okay. And I know some of the devices include an HA lubricant sort of glide that can be used as a standalone instead of the PRP with their disposable needles.

Sylvia Silvestri:

Yes.

Charles Runels:

Do you use that as part of your process?

Sylvia Silvestri:

I do. Sometimes I will mix the two together because the HA is usually a pretty thicker gel and it kind of helps the PRP stay together. So sometimes, I'll mix PRP with HA. Or if I have leftover HA, I will send that home with them. I do not send PRP home. You're not supposed to. You don't know what's going to happen to it when it gets to their house. It is a blood product. And I know people that have done that, and I still hear people that do that, and it's a really dangerous thing to do. But the HA, I will send home with them. And then at the end of it, I'll put the altar cream on top of that, and then they can go home with their HA and the Altar Cream™.

Charles Runels:

Like it. And then they use both of those that evening. What do you tell them about cleansing their face? When do you tell them they can and with what?

Sylvia Silvestri:

So if they come in the morning and have the procedure done, they're probably going to want to wash their face that evening. So I just tell them, use a very gentle cleanser, like a Neutrogena type products. No scrubs, no facials, no kind of acid product, just a very, very gentle cleanser for the first week, and continue using their Altar cream. Or if they don't have Altar cream for some reason, just a very gentle moisturizer because the skin does tend to get kind of dry for the first five days.

Also, sunscreen, the following day, they can start. They can put moisturizer on the following day. If I do the procedure in the evening or later in the afternoon, I just tell them, "Go home, leave all this on your face and just sleep in it. And then in the morning, you can just gently use a gentle cleanser and wash your face."

Charles Runels:

Okay. Good. By the way guys, as you probably can tell, Sylvia knows her business, and she teaches an amazing class. I just put a link in the chat box to her website, which offers training, not just in our procedures, but also Botox or whatever newer modulator you're using.

And she will also go to your clinic and train your people if you want. So that's in the chat box.

Let me pull up a couple of other papers here. This one is just sort of a one-off about wound care, but it refers to what I was talking about earlier, the idea that sometimes you have this eschar or whatever scarring or tissue that has to be worked around in order to help the wound heal. And I don't know if you guys know it, but one of the kits, Regen, actually just got... This is crazy big news. They just got FDA approval. They have FDA on label use for their kit for the treatment of pressure ulcers and diabetic wounds. So that's big.

Sylvia Silvestri:

That's awesome.

Charles Runels:

Yeah. And of course, there are many more indications that they know about, but they spent the money and went to the trouble to get that indication.

But back to this paper, when you're dealing with wounds, sometimes you can't just paint it on. You need to have some penetration that the microneedling helps with. So some of you guys are still doing primary care, and I know I snuck around to the nursing homes without telling anybody, and including...

Didn't bill the insurance because it was so insulting, what they were paying me. But I was medical director for a few nursing homes after I went cash, and this is a big problem. So there you go. Let's see. Well, there's a couple of questions that popped up. Let me throw them out at you...

Sylvia Silvestri:

Okay.

Charles Runels:

... Sylvia, and let's work on them together. So Eric says, "Any thoughts about the results of microneedling versus PRP versus Sculptra?"

By the way, before you answer that, this was an interesting paper where they looked at scars microneedling alone versus microneedling with PRP.

And of course, the two combined work better than just the microneedling, as you would expect.

But so back to the question. Really, there's some different indications, but compare those modalities, microneedling versus PRP injecting it versus Sculptra.

Sylvia Silvestri:

So the microneedling is going to treat the skin topically. So if you think of Vampire Facial® like a facial, you're going to be treating the skin from the outside in.

The other two, you're treating the face or the skin from the inside out. And Sculptra is a completely different PLLA. That's more of a full global... It's going to give you a lot more global volume in the face. It'll give you more volumization than a Vampire Facial. Vampire Facials aren't going to give you more volume, but the Sculptra will.

Charles Runels:

Good. I think that's exactly what I would say. I like the inside out versus outside in way of putting it. I think of it as Vampire Facial is more color texture, like tightening the sheet, and Sculptra, HA fillers, and even pure PRP injected subdermally in the adipocyte area and such is more like rejuvenating the mattress and creating more structure and volume, where the microneedling is more texture. Let's see. So another question is, "What do you use for pain when you're injecting the scalp with PRP?"

Sylvia Silvestri:

Some people do it without anything. And then some people need a nerve block, so I will do a nerve block on them if they desire that.

Charles Runels:

Yeah. I see everything from vibrating devices versus blocks versus nothing versus ice.

But it is one of the more... For some people it seems to be very painful. So I think that we have two ways to do a block that are on our website. And one's a ring block and one is doing near the inaudible 00:39:46

Sylvia Silvestri:

Through orbital nerve block?

Charles Runels:

Yeah. It's two in the front, two in the back, and near the insertion of the splenius capitus there in the back. But what kind of block do you prefer and why, when you do the block?

Sylvia Silvestri:

For the front, I do a super orbital nerve block, which is easy for people to learn in class. And then for the back, I'll do a posterior occipital nerve block.

Charles Runels:

Okay. So you're not doing a ring block. Those can be painful.

Sylvia Silvestri:

No.

Charles Runels:

I think those are probably more...

Sylvia Silvestri:

Too many needle sticks.

Charles Runels:

Yeah. They work well, but maybe more appropriate for when you're doing hair transplant. And you're using plain lidocaine or using with epi?

Sylvia Silvestri:

No, I'm using 1% plain lidocaine.

Charles Runels:

Okay. So another follow-up question from Eric, "Would Sculptra be better than PRP combined with Juvederm for the vampire wing lift?”

My thought is that I feel like I have more control with the Juvederm/PRP mixture, although could be that it's just I'm more familiar with it. I was trained in Juvederm before it was approved in the US, so I've burned up trainloads of Juvederm and not as much Sculptra.

And my feeling also is that even though it happens that we sometimes get a little nodularity after doing that combo in the labia majora, I feel like it might be more likely to happen and more of a nuisance, more long lasting nuisance with Sculptra. So that's my reasoning behind it, but I'm eager to be educated if that's erroneous. What's your thinking on that, Sylvia?

Sylvia Silvestri:

I think the Juvederm gives you more stability, especially in that area. I'm like you. I do more dermal fillers and HA than I do Sculptra. I haven't really spoken with anyone that's used S Sculptra in that area, so I can't really say, but I can say that your HA will give you more volume immediately. And I think it's a little easier to use, because your Sculptra, you need to prepare beforehand. And if your patient decides they want to do it there and then in the office, you'll have to use an HA.

Charles Runels:

I think to elaborate on what you just said, as far as satisfaction goes, when you use sculpture, you inject it, then you have to wait for it to work. And when the right place and when you look at the science behind it, it's a truly rejuvenating process where someone would argue more so than an HA and that it's stimulating new tissue growth. So I see the idea behind it. On the other hand, for example, you would never use it in the mouth because you don't have good control of the shape you're making, or at least not as exactly as you do with an hyaluronic acid filler. And you risk granulomas or nodularity that would be unacceptable. So when that same idea, I would not want it in the area of the labia, which to me has a similarity to the mouth as far as your... It's unacceptable to have longstanding nodularity there.

But then the other part, just from a marketing patient satisfaction standpoint, as you just said, Sylvia, which is what reminded me, that when you put a filler there, it's there. You get to go home with it. Where you put Sculptra, it goes away and comes back. When you put PRP, it goes away and comes back. So the beauty of the wing lift, or one of, I think, the big selling points of the wing lift and the facelift combining PRP with an HA is that they go home with the benefits of the HA and they have something to smile about that day, and then it just gets better when the PRP kicks in. But it is common to have, even with the HA, and I don't know why, but for some reason there's a common complaint of a small nodule in the labia majora after doing a wing lift.

I've had it happen to me. I think it probably happens to everyone who does it.

And I think it may be from just not being super diligent about homogenizing the HA with the PRP by repeatedly transferring it back and forth through that luer-lock connector. But I could be wrong about it. It could be something else going on because I know it's happened to me. But the good thing is with the HA, we have yet to have someone complain of that being long-lasting, where with Sculptra, it could be long lasting.

So that's maybe more answer than what was warranted, but that's my thinking about. It sounds like we're in sync with it. Let's see what else I got here for research, and then I think we call it... Oh, this was a nice little just review article that about... And it covers PRP, someone just mentioned here. So it covers PRP, but it also covers the minoxidil and the laser and all of it.

So I'll put a link to this one in the chat box. And I think it's open source. Sometimes I forget if I... I usually spend hundreds of dollars getting ready for journal club because some of them are open source and some are not, but I'm pretty sure this one's open source. And I want to remind people that minoxidil is not particularly benign. I never did the EKG because I don't want to know. But some people get atrial fib from minoxidil.

Sylvia Silvestri:

Oh my gosh.

Charles Runels:

... not the drug for me. But if you go online and look at it and just go to PubMed, I'll just do it. You should never do a blind demonstration when you don't know what's going to happen. But just watch. I just want to show you this. I don't think most people realize how much has been written about... Just watch. I'm going to go to PubMed and put in monoxide and heart prob, just put heart. And watch what pops up, unexpected refractory hypotension investigation, all these cardiac events. It is not a benign drug. Systematic.

So obviously, it's not freaking doing crack cocaine, but it's not without its problem.

There are 272 articles about problems with the heart related to minoxidil. So it's worth reminding ourselves when people throw errors at us, which I like because it keeps us smart. But we have one of the most safest, benign things that exist in the field of medicine.

And we may not get everybody well, but we seldom hurt people. Anyway, so that's a really nice review article and it frames... It's basically a nice meta-analysis and review that frames how PRP fits into an algorithm.

Anything you want to add to that when you're treating hair? And then I think we'll call it a night, Sylvia. Because I know you've treated some people's hair that others would, people on the call have seen them on television. And you know your business. You get great results. So when you're treating hair, talk to me more about what's your favorite adjunctive therapies that you use along with the PRP.

Sylvia Silvestri:

So some people will put ACell and add that into the PRP. Some people... ACell is expensive, so you don't have to do that, but you can, and that's supposed to help the hair grow in even quicker. But just remember it takes about two treatments for you to really start seeing a result. And remember that you need to take photos of every visit because your patient is used to looking at their hair all the time and they won't really realize, when it starts to grow in, that there's a difference. So make sure you show them their pictures each time they come in. I'm trying to think what else.

Charles Runels:

All good tips. Are you using any of the laser caps or not?

Sylvia Silvestri:

No.

Charles Runels:

Okay. Well, most of the people are not, even though... And I don't have them in my office, but the research is good on it and it's probably something to think about. I have a baby sister that's still battling breast cancer and that's one of the biggest things that is disheartening for those who do. We covered a study here recently about where they looked at the possibility of PRP helping during chemotherapy, and the prospect was not so good. But there was some sort of cooling device that's been approved for that purpose and that indication and...

Sylvia Silvestri:

The cold cap.

Charles Runels:

Yes, exactly. Have you used that at all or recommended it to people? Sounds like a good way to get a headache.

Sylvia Silvestri:

No. I've had such a good result with just PRP. And I teach more than I see patients these days. I'm kind of retired from seeing patients, so I just see the people that come in that are my models that I stay in touch with and follow up on.

Charles Runels:

Yeah. I've treated a number of people after they finished their chemotherapy with good results. And I think in that case, you just tell the patient, "Quite honestly, you'll probably get your hair back without us doing anything. But if you want me to help speed the regrowth along, this is something that might help."

And that's a good day's work. Anything else you want to throw out there? Again, I appreciate you being on the call. You have a really, one of our most experienced people. So if you have questions, this is the time. Oh, so Dr. English says, "Are you microneedling or injecting when you do the scalp?"

Sylvia Silvestri:

I inject. I don't personally think that microneedling goes deep enough into the hair follicle as injecting it.

Charles Runels:

Okay. I usually do some of both. There are some places where you just can't get the, or they have enough hair where it seems to hinder the microneedling device. We did one study here a few weeks ago where it indicated that maybe you get a better result with the microneedling. But to me, it's a nice study, but it doesn't take into account that sometimes you just can't get the device in there. And so usually, I'm probably 50-50 when I do to do that. Let's see.

Oh, here's a couple more questions. Yeah, I saw that study, Jeff, about adding something else in. By the way, and don't added time to think about it, but I saw an amazing lecture by someone who claims that their lab just passed FDA inspection. This is huge. And this just happened last month. They just passed FDA inspection for the production of amniotic fluid and cord blood, which is, as you guys know, when we were able to use it, it does... To me, there's a spectrum. You have people that... You don't need anything.

Think about it. When you're young, you scrape your knee, it grows back. Or even when you're not young, you get a surgical procedure and the wound closes. So there's a spectrum of things you don't need anything at all. And I think there are probably some problems that would be made much better if you just injected whole blood. Many people get great results with our PRP, but not everybody. And so I think it was encouraging to me to hear this PhD talk about his lab. They spent millions, and they were able to pass inspection. So I'm hoping I can cut some kind of deal and figure out a way to bring that to the group as an adjunctive therapy. And I just haven't had a chance yet, Jeff, to look at that. But I do agree that the idea of just sticking to PRP and not looking for something that's safe and approved to add when needed is just not the way to go.

I

haven't heard of Fotona, so I can't say anything about that. inaudible 00:53:42. Tell me the deepest... When you're micro kneeling the face, tell me the best and deepest, while still safe, and the needles to buy. Yeah, I think we hit on that earlier as far as just looking for, and we recorded if you came in late, but just looking for punctate hemorrhages without turning things to a bloody mess. Just in other words, when I see the punctate hemorrhages start to look like confluent red blood, I'm overdoing it. But if I see...

Sylvia Silvestri:

It's usually 0.5 To 1.5, is usually the average.

Charles Runels:

Good. That's a good guideline. So 0.5 in the thinner tissues, up to 1.5 in the cheek and around the chin. Good, thank you. That gives some... That's a real number. Anything else you want to add. To remind you guys, I put a link to Sylvia's class. Highly recommend it if you want to do some hands-on training with Botox or PRP. Anything else you want to add, Sylvia? And if not, we'll shut it down.

Sylvia Silvestri:

I think even in the other class I teach, people get really overwhelmed. And I tell them always start out with PRP, because number one, it has a great ROI. Number two, it's safe. And people get freaked out when they hear that you can cause occlusions with fillers and you can have more issues. If it's not done, you have to dissolve it. And so people get really...

And there's a trend now to not look as filled as the past few years. And so people are wanting a more natural look. And I tell my students all the time, just start with PRP, start with... Or start with Botox and hair, or Botox and under eyes, or start with two things. You don't have to start with everything because you're going to get yourself overwhelmed. And that's what my students do, and then they add things until they're fully capable of doing everything. But don't feel like you have to do everything when you're first starting out because it is overwhelming.

Charles Runels:

Great advice. And I really am... I don't know if you guys picked up on it, but Sylvia's been... She's just an amazing person.

She's been dear to me...

... and hardworking and kind and ethical and ferocious. Whatever she needs to be, she could be all those things. So thank you for being on the call, Sylvia..

hopefully we'll talk again soon.

Okay, you guys have a good night.

Sylvia Silvestri:

All right, thank you very much.

Charles Runels:

Okay. Good-bye.

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