Laying Down the Law of Cosmetic Procedures With David Goldberg, MD, JD

Dermatology Times®’ Editorial Advisory Board member, David Goldberg, MD, JD, recently presented 2 cosmetic sessions at the SCALE 2023 meeting in Nashville, Tennessee. Goldberg, the director of cosmetic dermatology and clinical research at Schweiger Dermatology Group, a clinical professor of dermatology at Mount Sinai, and an adjunct professor of law at Fordham Law School, presented “Update on Non-Invasive Skin Tightening” and “Laser Complications and the Law.”

As both an expert dermatologist and attorney, Goldberg provides a unique perspective on performing cosmetic procedures and how to avoid unwanted lawsuits.

Transcript

Goldberg: So I'm Dr. David Goldberg. I am the director of cosmetic dermatology and clinical research for the Schweiger Dermatology Group. I'm also a clinical professor of dermatology at the Icahn School of Medicine at Mount Sinai. And lastly, an adjunct professor of law at Fordham University School of Law in New York.

My first talk that I'm going to talk about is on updates of non-invasive skin tightening. And really, when we discuss this, we're talking about the face and the body. So, in the area of the face, in terms of what's going on and what's new, there are new approaches to radiofrequency microneedling. This is not a technique that's all that new, it's actually been around for about 15 years, but there are tremendous changes in the area. So, the first thing that's changed is we look at the needles that penetrate the skin. When this all started almost 15 years ago, the needles didn't penetrate the skin at all, so there really wasn't much of a change in the skin. And then there were piercing needles. So that was the first big change. And that led to new collagen formation, skin tightening improvements in acne scarring, and the ability to treat all skin types. But those needles are pretty coarse, the angles were not right, and there's a fair amount of trauma, which led to a fair amount of downtime. For the most recent changes, the needles are much sharper, they're better angled, so they penetrate the skin much more smoothly. That leads to not only better results, but also less downtime and less pain for the patient. The second area that radiofrequency microneedling has really changed aesthetic dermatology is in the area of treating what we call fat bags below the eyes.

Historically, those of us who are dermatologists would send these patients for blepharoplasty to a plastic surgeon or an ocular plastic surgeon. These needles have now been designed to simply penetrate the skin into the fat and literally bubble the fat and melt that fat away. So, in a non-surgical approach with minimal downtime, we can actually improve fat bags below the eyes without any surgery required at all. Sometimes these patients do need more than one treatment. Occasionally we treat them twice. And sometimes the results are not quite as good as surgical improvement. But in that sense, surgical improvement can lead to the loss of too much fat. Soin the area of aesthetics, we often try to have minimalism, we want improvement, but not necessarily perfection that's too good. And now we're able to accomplish that with this new technique. Also, for the face, we've seen changes in ultrasound approach focused ultrasound treatment for skin tightening. Typically, the depth of penetration would be up to 4 millimeters which was often too deep with ultrasound. And because there was such depth that we saw with the older techniques, we'd need ultrasound visualization. With newer approaches getting to about one and a half millimeters in depth. We don't need visualization anymore, the technique doesn't have to go as deep in the skin. And with that, although the technique is not painless, it is much less painful than the older techniques. Not only are we able to improve skin quality and tightening of the skin with newer focused ultrasound approaches, but we've also shown that acne scars can be improved and even cellulite.

As we then move to other approaches, whenever we do these approaches, we can create a wound. We now have better wound care dressings, so there are all kinds of cosmeceuticals out there, but exosomes have entered into the arena and exosomes essentially are packets that allow cells to communicate with each other and when applying exosomes to the skin, we can actually promote better healing, better approaches, and better safety. And lastly, hyperpigmentation particularly since we're treating darker skin types now, is an increasing issue as well. Where there are newer products with more concentrated cysteamines in them that also lead to better results and less hyperpigmentation. That's the update on the face.

On the body itself, again, a tremendous, tremendous improvement over the last few years. Historically, we've done body contouring with lasers, and radiofrequency devices, we tried to tighten the skin and maybe lessen the fat, but not much of an effect on muscle. Newer approaches now allow applicators to be applied to the skin that allows us to combine radiofrequency with what's called high-intensity focused electromagnetic waves. And when we do that together and that approach is known as EMSCULPT NEO, what we see is improvement in muscle tone, less fat, and also skin tightening all happening at the same time with a really minimally uncomfortable procedure. And so all of these approaches really lead to great changes on the body as well as the face. And lastly, this approach of combining radiofrequency and these electromagnetic waves has now been applied to the face. So, that instead of just tightening the face and also lessening fat, we can actually improve the muscle tone. So that's the update on non-invasive skin tightening.

Dermatology Times: What are the key highlights from your session, "Laser Complications and the Law?"

Goldberg: So in terms of laser complications, this is where of course I'm both a physician and an attorney, and so I get to see the good, bad, and the ugly of all these procedures. When I talk about laser complications, it's not that complicated. Because when I say laser complications, of course, that really applies to all energy-based devices. That can be a laser, a light source, ultrasound, microwave, we can go on and on and on. In the end, the key is not to create too much heat. If you create too much heat, human skin does not like that. And that creates too much of a wound, a blister, and perhaps a scar. How do you get too much heat? Perhaps too high energy, perhaps too short of a pulse duration, or too short of a zap, perhaps the wrong wavelength when treating darker skin. That really all creates heat. And so when I talk about the concept of negligence, which really is complications, and leading to a lawsuit, I really treat physicians the way I treat my law students when I teach them; it's not that difficult. There are 4 elements and a cause of action for negligence, that leads not to a lawsuit, we all can get sued, but leads to a successful lawsuit against us. What we have to do in everything we do is we have to practice in accordance with the duty, the reasonable duty, what do our peers do. As long as you're doing what your peer does, there can be a complication. But that doesn't mean you committed malpractice. That doesn't mean there's negligence. But if you don't practice with the reasonable duty, you've then breached that duty. You can breach the duty as long as no connection between that and any damages. But if there's a connection between the breach of duty and damages, that's called causation. And that leads to what are the damages in our area? Mostly scarring. Scarring has economic value. So if you breach the duty, and there's a connection between that breach of duty and scarring, then you potentially are going to lose a lawsuit. All you have to do is practice like your peers, do the reasonable duty, give informed consent, and then you're potentially not going to lose the lawsuit.

Dermatology Times: What makes SCALE a unique dermatology conference?

Goldberg: So you know, SCALE is a very unique conference. So I've been to this meeting so many years. Of course, coming to Nashville is always a lot of fun. And it used to be a small meeting. It's a big meeting now that encompasses every aspect of medical dermatology and cosmetic dermatology. And although I personally run my own meetings and lecture at so many meetings, I will tell you, there's no better meeting in the country that combines medical and cosmetic dermatology in one venue.

[Transcript edited for clarity]