Dr. Evil (00:00): Begin laser ignition sequence. Frau (00:00): Begin laser ignition. Announcer (00:03): Attention. Speaker 1 (00:15): You're listening to The La Jolla Cosmetic Podcast, with the LJC Chief Community Officer, Monique Ramsey. Monique Ramsey (00:24): All right, everybody. Welcome back to another episode of The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey, and today I am joined by Brittany Haley, who is our laser expert. She's going to talk about the Halo, the MOXI, the BBL, all the different things that we do here at La Jolla Cosmetic to make your skin glow. So welcome, Brittany. Brittany Haley (00:52): Thank you. Happy to be here. Monique Ramsey (00:55): Yeah. So tell us a little bit about your background. Brittany Haley (00:58): Well, I've been in the cosmetic industry for the last 11 years, which makes me sound really old. But I've been in cosmetic aesthetics since I was 22 years old. I first started out working for a couple different independent practices at the same time. I learned a lot of different devices, I worked with a lot of different skin types. It was all very helpful for me to make my long-term journey here at La Jolla Cosmetic, where I used all that experience to help start our nonsurgical practice here. So I've been here for eight years. We have a lot of different devices here. A lot of them are handpicked by myself or by other nurses and PAs at our location. Monique Ramsey (01:43): We're going to dive into all of those. That's really exciting. So you've been working with us for eight years, but with lasers for ... did you say 12? Brittany Haley (01:52): 11 years. Monique Ramsey (01:54): That's a lot of experience and a lot of different skin types and a lot of different skin problems that people are trying to fix. What do you like about working with lasers? What kind of makes that your passion? Brittany Haley (02:07): So, I mean, the best part, of course, is seeing happy patients, fixing problems, seeing lovely, beautiful results. But it's also kind of fun to get into the science of lasers, and that's what I like, too. I like combining different lasers and learning about different ones, how they work, why they work, different things I can do with each one. So I'm not going to bore everyone with all that science part of it, but it's something that I do have a personal interest in and I enjoy quite a bit. Monique Ramsey (02:34): Well, and I would think that having a passion for the why ... why do they work, or why does this one work better than the other ... is going to help the patient at the end of the day, because you're going to have a better result. Brittany Haley (02:47): Absolutely. Monique Ramsey (02:48): You're the one doing the research on the back end and bringing all those years of experience to the table. Brittany Haley (02:55): Definitely. And the longer you work with certain devices, the more you see, the more you're going to be able to do and the safer you can make these treatment plans. We have a lot of things that people don't realize you can treat with lasers. I think under that term of laser skin resurfacing is where it's really broad and we have a lot of different categories of skin resurfacing, what a lot of our devices do. We have a great arrayment from very mild to very aggressive treatments. Monique Ramsey (03:21): So let's start with, kind of, for the patient, how do they start that process for deciding? You know, do they go look on the website and try to narrow it down, or is it better for them just to come to you? Brittany Haley (03:36): I love that question because I was doing Zoom consults yesterday all day, and a lot of my consults are for laser patients. And sometimes they're really tricky laser patients, but I find them fun to work with and rewarding, too. But a lot of times, people think "Oh, I'd like to do a treatment to help my skin. I don't know what treatment. There's a million devices out there. I don't know exactly much. Maybe I watched a TikTok video on something and it looked kind of cool," and that's all they know coming in. So we have that kind of type, and then we have those who have done tons of research and they kind of have their mind set on something. I feel like the consult is what matters the most with both of those people, because sometimes they say, "I want this," and I look at their skin and what they want and what they need and I'm like, "That's not going to work. We got to do a whole different treatment plan for you." Brittany Haley (04:20): So, there's a lot of things going on with the skin, and they call can be treated very specifically. If someone has redness, we have a laser for that. If someone has large pores, I have a laser that I can do a different setting specifically for large pores for them. So these are things that are customized completely, and that's something that just takes experience to know which device to select, which combination, and how can I customize this person's particular needs to make it the safest possible and the most consistent, reliable results? Monique Ramsey (04:51): And let's say they're coming to you for melasma, the brown pigment that people get. Sometimes they get it from pregnancy or they have sun damage. Do you look at certain lasers that treat certain problems? Brittany Haley (05:09): Definitely. I think, so melasma is always going to be like that, that tricky, tricky one. And some people know they have it and some they don't, and I point it out to them and they're all in a fluster about it. And there's no cure for melasma. It's caused from hormones, which we don't have a lot of control over all the time, and sun exposure, combination of both. And then depending on your skin type ... So when we treat patients with laser, a lot of the things we're targeting are chromophores in the skin. So if your skin has more chromophore or pigment for us to target, it will affect the treatment that we use and the settings that we use. So you have to kind of analyze that when you're doing the consultation. Brittany Haley (05:47): And there are lasers that are better and safer for darker skin types or that are more effective for lighter skin types. Sometimes we have to take in a little bit of history on that too, like I see little signs of melasma. I ask, you know, when did that start? Has it gotten worse? Has it gotten better? Did it get worse with birth control? And then, how do you respond to the sun? If you go out in the sun, do you tan, do you freckle, do you burn? And then even how you scar. Some people, if they get a little scratch on their arm, it'll turn a little red and then heal and go away, and some people it'll turn brown. So those type of things are how I determine, based on the amount of chromophore in the skin, what combination is the best for them. Brittany Haley (06:28): I think in darker skin types, it's particularly difficult. I have a lot of experience working with darker skin types, Asian skin types, even African American skin types, and we have a lot of modalities here now that can treat things like melasma for them very successfully, which is huge. Monique Ramsey (06:44): Because in the past, they really didn't necessarily have an answer that's safe. Brittany Haley (06:49): Right. Or people would give them treatments that really weren't safe and it would cause them problems for a long time. I think the addition of our newest device, the MOXI laser, is a real game changer for those with that kind of issue for darker skin, melasma. As I'm getting to use it more, I'm getting more and more a fan of it. It's just so easy, it's very comfortable. You can resume normal schedule very quickly, and it's very effective at removing difficult pigmentation. Monique Ramsey (07:16): Since we're talking about the MOXI and that's kind of the newest thing. Just kind of give us a description of how you use it or who you use it for. You know, what does that treatment plan look like? Brittany Haley (07:27): Absolutely. MOXI is what we call a nonablative laser. So that means that it's not breaking the surface of the skin. It's just sending heat down into the skin. This makes the downtime minimal to nothing. You can wear makeup right after, sunscreen, you can go on about your normal activities. There's very little risk of complications like infections. It's safe for all skin types, so for light and dark skin types. It's a quick treatment in office. We usually do a little numbing cream and a little bit of heat for a few minutes and let you cool down a little bit. It very gently lifts off deep pigmentation. It also does a little bit of resurfacing for the skin, so helping with some texture, crepey-ness to the skin, making it softer and smoother, minimizing pores a little bit. Brittany Haley (08:10): And because of the certain wavelength that it is, it's very safe in terms of risks of hyperpigmentation after laser, because that's something we worry about with our darker skin types. So we've had great success with MOXI with darker skin types with melasma. So that's a very hard market to have consistent, reliable treatments and I feel like we've really found that with MOXI, which is a miracle in the melasma world. Monique Ramsey (08:35): Now, so that's a lighter treatment, you said. So does that mean they do more of them? Brittany Haley (08:42): Absolutely. It's spot on. Nonsurgical treatments, typically ... I mean, they're going to be treatments you do more than once. They're for skin maintenance. We have you do a series of treatments initially with most of our lasers here, with the exception of TRL. So they're not going to burn your face off and have you have six weeks of downtime like a surgery procedure. They're going to gently and slowly help you without making a major effect on lifestyle. You can still do your normal daily activities while doing these. Monique Ramsey (09:12): And is there, like a laser season? Because here in Southern California, we have a lot of sun and we have to protect ourselves. So, you know, do you find that there's certain times of year that people will sort of wait until, or- Brittany Haley (09:25): So, I love that question because that always comes up. What is enough coverage from the sun when you're doing a treatment to remove sunspots? In San Diego, it's sunny all the time. Honestly, right now in May ... May gray, June gloom ... it's pretty gloomy. I would say it's one of the best times to do a laser. But the right time for doing the laser is when it's the right time for you in your lifestyle and what you're doing to stay covered from the sun. And that could be any time of the year. For teachers, summer could be the best time. For a lot of people, winter break could be the best time. For some people who naturally don't go in the sun, well, that could be any time at all. Brittany Haley (10:00): And when I say, you know, being careful in the sun, what I mean specifically when you're doing a laser treatment is wearing sunscreen whenever you leave the house, whenever you're outside or by a window, which, you know, putting it on in the morning, and then reapplying in direct sunlight every 90 minutes ... that's every hour and a half ... and then also wearing a covering. So wearing a hat, wearing a hoodie. My favorite covering these days ... I kind of look like a little bandit, but I love it. I put a little baseball cap on, I put a light hoodie over it ... my favorite brand's Vuori. They make the best hoodies. Monique Ramsey (10:31): I know. I'm wearing their sweatpants right now. Brittany Haley (10:33): They're lightweight. They're great. I put the hoodie and that on. I put my sunglasses on, I'm good to go. I'll go to the playground, I'll have my kids crawl around, and my skin's completely protected. I've done that actually, like, a day or two after healing from a procedure and it's fine because I'm taking those extra precautions. So it's more about patient commitment to doing that, and it's for generally two weeks before a procedure and two months after any laser. Monique Ramsey (10:59): Wow, okay. Two months after. So, and really, that could be the thing that changes your results, if you're not compliant ... Brittany Haley (11:07): Absolutely. Monique Ramsey (11:07): ... if you're not really committed to taking care of the result. And as you heal with every 90 minutes of sunscreen and , you know, really thinking about it, you could go from a great result to ... Do some people get- Brittany Haley (11:22): Complications, like hyperpigmentation. Absolutely. Yes. I'm very blunt with patients who I'm a little nervous with. I know they're very active and they're out every day, I'm not sure about their sunscreen commitment because I'm seeing their skin and treating them and I know they've got a lot of sun. And so I'm very blunt with them. I say, "If you don't follow ... These directions are here for a reason. We want to get your pigment gone. We want to help you with your skin, and if you go out in the sun without sunscreen unprotected in the next two months, your skin could turn brown." So it's a very real risk. It's very treatable if it happens, but I feel like doing that, making it very, very clear and specific, it's just so helpful with getting patients to keep their results. So keeping their results longterm, maintaining their results from their treatments. Monique Ramsey (12:04): So let's shift over to the Halo. Tell me about the Halo. Brittany Haley (12:10): I'll add, too, that MOXI and Halo and BBL, they're all lasers made from the company called Sciton, which is ... It's kind of the Lamborghini of lasers. They make very solid, consistent, excellent products. But we do have lasers from other companies as well, so it's not the only one we carry, and there are other great lasers out there. Monique Ramsey (12:27): Just to interrupt, because we didn't talk about this at the beginning. You are a national trainer for Sciton. And what does that mean? Brittany Haley (12:35): So, obviously, of course, I'm fully committed to La Jolla Cosmetic Surgery, my home. But I do work per diem for a laser company called Sciton, and so, I will, when asked, I will go and do trainings for them. So ,typically, it's when someone has a new system and they need to get started, or when they have a new employee who needs to get certified, or if they simply want additional training on a new module. They will send me out and get them set up on the device. I've trained all over Canada and the United States. I mean, I've been from Palm Beach to Spokane, San Antonio ... I was there last week ... and I've been all the way up to Evanston in Canada, so all over. Monique Ramsey (13:10): Wow. Wow. Brittany Haley (13:11): It's really fun for me, seeing different offices and different demographics, because every office has their own niche, and just really fun and rewarding seeing people get up and running with these treatments, so I love it. Monique Ramsey (13:23): Oh, that's neat. Okay, so as we digress, back to Halo. Brittany Haley (13:27): Halo is my very favorite laser. What I love about Halo is that it's so flexible. There's so many things I can treat with it and I love having that multi-modality approach where I can change a setting and treat someone for rosacea, I can eliminate blood vessels, I can definitely treat melasma for lighter skin types. When done in a series, Halo has the same results as a resurfacing laser, so it can eliminate wrinkles. So it's a very, very tunable laser. It has a little bit more downtime than MOXI, but it's 100% worth it in my opinion. Monique Ramsey (14:00): Now, when you talk about downtime for Halo, what does that mean? Brittany Haley (14:05): So downtime is time where you're not going to look your best and you probably want to avoid social activities, like being in person meetings, birthday parties, special occasions, that kind of thing. We didn't have a lot of that last year, of course, so it was a very popular laser season last year. Because sometimes there are things people need to plan a bit for in their schedule, depending on their level of comfort. I have some patients who are very comfortable going to work when they look a little poofy or a little red and they're like, "It's fine. I did a laser. I'm not caring." And then I have Instagram influencers who cannot look bad for one second, so they really need to plan these times very carefully. Brittany Haley (14:41): But for Halo, it's about a week where you look a little puffy, a little swollen, face looks a little bit, tiny bit gritty. I'll let you wear some makeup on day three, so most people can return comfortably to doing things outside and in person on day three. By a week, it looks back to normal. By two weeks, it looks great. And then over the next three months, it looks even better. Monique Ramsey (14:59): Now, does it peel in sheets, or is it more, like you say, gritty, and then does it sort of rub off? Or what is the process that the skin goes through? Brittany Haley (15:09): Really good question, too. I think what that depends on a lot is the practitioner doing the treatment and what level they're comfortable operating their device at, because there's different levels. There's safe start levels and there's more advanced levels. I do both. I think with a typical Halo, what you can expect is some grittiness to the skin and the gritty bits kind of flake off. But when you are doing some deeper treatments, there can be some active peeling, so that's something that patients need to be counseled about and it's kind of on an individual basis. Monique Ramsey (15:38): Now, getting into maybe some of the complaints that people have if we're talking about either acne scarring, or like you said, large pores, or you know redness, or pigment problems, sun damage, wrinkles ... I mean, there's so many different things that people might be trying to make better, and you talked about combining lasers. Tell us a little bit about how you might combine a laser for somebody who ... let's say somebody who's got moderate wrinkling but they've got some large pores, maybe some acne scars, and they want just a new glow. How would you go about that? Brittany Haley (16:18): Love that. So, I mean, there's different ways you can approach that. We can do gentle treatments and do more of them, or what I love doing, what I love patients to do, is let's do one or two good treatments that are going to give you an amazing result. Let's combine a couple things. Let's really give you a glow. In those cases, they have to be a little more flexible with maybe having a little downtime, but it's so worth it. And then I can do a lot of things. If someone has acne scarring in particular, that's where a lot of things can be done. I think where people get in trouble with treating acne scars and where they get bad raps and reviews is that they're treating every acne scar as the same, and they're not. Brittany Haley (16:51): There's different types and you've got to attack them with a few different ways, and sometimes different acne scars on the same face need different modalities of treatment. So that's something that's highly customized. I have different lasers I use to do different things. Sometimes I'll use a full erbium resurfacing, like our TRL laser, to kind of break down the edges of an acne scar. I'll use our ProFractional, which is a fractional deep treatment to go to the base of the acne scar, because they can be really deep. And then sometimes I'll just Halo right over the whole thing and it's just gorgeous. So they're getting that- Monique Ramsey (17:22): And all in one day. Brittany Haley (17:23): All in one day. We'll do them all in a row. Then that Halo on top just is the icing on the cake. It's going to get pores so well. It'll help with their pigmentation, with redness. So I combine things all the time. I feel that also with new technology coming out, the concept of just burning your whole face off ... In the past, doing full CO2 or full erbium resurfacing, that's not as popular anymore because we have such options like Halo where I'll resurface a small part of their face. So I'll resurface maybe just their lip lines. And with lasers like our TRL laser, we can actually vaporize lip lines. I've seen astounding results with this laser. There is downtime, but it's worth it. Then I'll do something with the Halo or the MOXI on the rest of their face. They're not going through that downtime all over, just where they need it, and they're also getting a beautiful result on the other areas of their face. So I love doing treatments like that. There are still some who just want to resurface the whole thing, and that's very doable as well. But I think that that's way more popular. Monique Ramsey (18:21): And what about under the eyes? What is, I think that's something that people don't realize that you can treat, is the area under the eyes. Brittany Haley (18:29): The eyes are so tricky, and they're just such a common complaint. You know, who doesn't want a little bit of brightening under the eyes or a lifting of those dark circles, crepey-ness of the skin? There's so many things going on there, and we have so many different things to address it because there's so many things ... There's volume loss, there's dynamic wrinkles from smiling really big, there's separation of fat pads, there's all sorts of things. So we have all sorts of treatments from laser treatments to address pigmentation to discoloration, laser treatments to address wrinkles to actually resurface and vaporize the wrinkles there to tighten the skin a little bit. Then we have things we do as well with other modalities we offer here. We can correct volume loss with small bits of dermal filler. And in the full spectrum, you know, with part of our surgery practice, we offer treatments to help surgically revise that area. So there's just so many options, and no one's treatment plan is the same in that area. I feel like you've got to address a lot of different things. Monique Ramsey (19:24): Now, for the eyes, can the laser do the upper lids also, or is it just the lowers? Brittany Haley (19:29): No, we can very safely laser the upper lids. We have very safe eye protection that we use during those treatments to make it very safe, very comfortable for the patient. It could be done while they're awake, not just asleep, and it's a beautiful result with tightening under the eyes. I'm seeing a lovely result combining a couple of new fun things these days, doing some light resurfacing and some Halo over it for a really nice tightening in the eyelids. Monique Ramsey (19:55): Ooh, that's nice. So not just smoothing. It also tightens and shrinks it up. Now, what is the typical ... I'm sure it depends on which treatment they're having, but what's sort of the typical postoperative? What's it feel like that night? What's it feel like the next day? What are you having them do? Brittany Haley (20:14): Yes, that's awesome to address too, because laser patients, they, you know, they can require sometimes a little bit extra care than a typical ... like our Botox patient, especially if they're laser naïve and it's a new experience for them. So we provide a ton of support, emotional and otherwise, during the healing process. I kind of call myself , like, their personal concierge during that first week of healing, so I'm available after hours usually by email. We do followup calls or Zoom calls the next day as needed, and then I'm available for any questions they have. We work really closely with their esthetician as well during this process, because she's a vital part of the skin maintenance part of the process. Brittany Haley (20:53): So when we do our stronger treatments like Halo or resurfacing lasers, we follow up with them closely for the first two weeks and then they actually come in the office for an in-person followup. At that appointment, they actually meet our esthetician, Cameron, who's amazing. She gives them a little bit of, um, some love on their skin, some hydration. It feels really nice and lovely after all the mean things I've done to them. Then we do our first set of progress photos and we get them on skincare. So we get them on things to help enhance their results from the laser while they're still actively healing and to maintain it. That's a really vital part of the process. We kind of follow it the whole way through. Monique Ramsey (21:31): And that's medical-grade skincare, so it's really actually ... Brittany Haley (21:34): Absolutely. Monique Ramsey (21:34): ... treating something or actively helping with the healing. Brittany Haley (21:39): We don't like fluff here. We like products that do something, that are actively maintaining. And I think with skincare, a lot of people get frustrated because they're like, "Oh, I used this for a couple months and my brown spots are still there." And you've got to always think about on the prejuvenation way of things. You know, if you hadn't used that product, would your spots be worse? Probably. If you haven't used Retin-A for the last five years, would your wrinkles be worse, would your pores be bigger? I think so. So that's the part that people forget sometimes. Keeping status quo is actually a win, right? Monique Ramsey (22:10): Yeah, that's actually a really good point, is- Brittany Haley (22:12): It's a win. If you look the same in five years, that's actually good. Monique Ramsey (22:16): Yeah, yeah. Now, you mentioned the ProFractional, and you were talking about CO2 lasers in the past. Can you kind of talk about the difference in sort of maybe the old lasers or the first lasers that came out and how they treated the skin versus now? Brittany Haley (22:33): Absolutely. And it's not that the CO2 lasers are old. There are newer CO2 lasers out. But when talking about resurfacing 15, 20 years ago, a lot of providers were doing full-field C02 resurfacing. So when I talk about full-field versus fractional, it's kind of a laser nerdy concept. But full-field kind of means if you envision the skin, we are removing a whole layer of the skin, and fractional, like ProFractional, means we're just poking holes in. So we're leaving healthy skin in tact. ProFractional and fractional treatments heal very fast because there's healthy, intact skin between, but you have to do more of them to see results. Full-field removes the whole layer, so there's more intense healing time, it takes longer to heal, but it will efficiently remove more things. Brittany Haley (23:21): With CO2, it's a wavelength, so the ablative wavelengths that are used really commonly in the US and most places are CO2 and erbium YAG. So with the YAG lasers, there's NYD and erbium. This is erbium YAG laser. And both of these wavelengths actually ablate the skin, so they're poking a hole in the surface of our skin. So they're , you know, creating an opportunity for infection, but also creating more opportunity for results. They can be done full-field or they can be done fractionally. And with CO2, that wavelength, there is a lot of heat tied into that wavelength, so that means more redness, more swelling, potentially more post-inflammatory hyperpigmentation. So risks with darker skin, and also risks with having hypopigment. So that's when you see people who have that kind of demarcation right along their jawline right there where they've kind of lasered off their face and now it doesn't match their skin down their neck. You see those sometimes. It could be from sometimes deep chemical peels too, but from that I feel like is kind of the most common. Brittany Haley (24:24): And the difference with an erbium wavelength is that it doesn't have that heat element into it. You can add it in very carefully if you wish to, but you also can take it out. So it makes it safer for all skin types, less risks of that hypopigmentation, hyperpigmentation, and just a little bit more tuneable. So the full-field resurfacing that we do here at our office is all erbium resurfacing. CO2 now is currently done more in a fractional manner and it is only safe for lighter skin types. Monique Ramsey (24:53): Okay. Now, did we talk about BBL? What is BBL? Brittany Haley (24:58): We didn't. We need to because BBL's amazing. Monique Ramsey (25:04): So this isn't the Brazilian butt lift that we're doing in our surgical facility. This is BroadBand Light? Brittany Haley (25:12): This is BroadBand Light. Interested enough, I've been doing some BroadBand Light on some tushes recently, which I'll talk about in a minute because it's been really, it's been fun. But BBL is Sciton's modality of IPL, and it stands for BroadBand Light. And it's filtered light at different wavelengths to do different things. It's a very powerful form of IPL. It has a lot of cooling involved. It's very comfortable. It treats large areas very quickly and it treats all of our, mostly our pigment issues, so hyperpigmentation. I use it a lot for even pigment from bruising, so hemosiderin type of bruising, any of your common redness concerns of rosacea, vascular lesions, redness in scars. And overall, it does help rejuvenate the skin. There's been an actual Stanford study done from a very sweet dermatologist up North near the manufacturer of Sciton in Palo Alto and he's done some interesting studies where we use the BBL to actually help delay aging. Brittany Haley (26:12): So now that same kind of that concept of where we, where at 10 years if we look the same, that's actually a win. We actually did skin histologies on someone who had BBL at baseline and then did a treatment every four months for 10 years and their histology of their collagen remodeling was the same 10 years later. So talk about a big win there. It's something that has virtually no downtime and is very easy to do and can delay aging that much. Monique Ramsey (26:38): That's amazing. That's amazing. So if you were doing that ... So every four months? Is that sort of what some people might do? Brittany Haley (26:45): Definitely. I think just as a general antiaging treatment, you could do a BBL every three to four months, maybe pair it up with something really lovely for prevention like Botox, and that could be a great treatment plan to keep you at status quo for a long time. Monique Ramsey (27:00): Oh, interesting. Now, the healing time for BBL, is that ... Brittany Haley (27:05): Very easy. Very easy. Monique Ramsey (27:06): Oh really? Okay. Brittany Haley (27:08): It's completely nonablative, something you can go back to work the same day, you can wear makeup and sunscreen right after the treatment itself. We have some nice cooling and it feels kind of like a little flick. It feels similar to some laser hair removal devices, and your skin feels a little warm for maybe 30 minutes after. Then what's kind of magic about it is any pigment in your skin, you actually see it kind of rise up to the surface. You're like, "Whoa," and it kind of pulls out, looks a little bit like little pepper flakes on the skin for a couple days, and then it flakes off. So you kind of see this magic process happening. It's very satisfying and you can cover the whole thing up with makeup the whole time. You have to be sun careful at that time, so practicing kind of the sun avoidance compliance. But it's something very easy to do on a normal day-to-day schedule. Monique Ramsey (27:54): Now, are your patients typically older, or do you see sort of everyone? And at what point do people ... You mentioned prejuvenation. At what point are people starting to say, "I want to get something done"? Brittany Haley (28:09): I feel like that demographic is changing, especially over the last two years. I'm seeing people as early as in their 20s doing these now. They're coming in fro prejuvenation, like BBL or MOXI, and maybe a little bit of Botox here and there, and they're doing it before things get to that point. They're already compliant, they're already on good skincare, they're already wearing sunscreen, so they're ages ahead of anyone, of any of our X generation. These are the millennial generation, and they're on top of these things. So, I do also have a very solid patient base of patients who are older, you know, are really in their 40 to 50 range. And then I'm doing BBL treatments on people up into their late 70s. I did one just yesterday on someone who was 77. Monique Ramsey (28:50): Wow. Brittany Haley (28:50): She does it once a year and she loves it. Monique Ramsey (28:53): How fabulous. So it's never too late. We have a thing at the center every Wednesday, we have Wow Wednesdays, and so internally, there's an email that goes around and it shows a result from either one of the plastic surgeons or one of the med spa providers. So yesterday, a result went around that was stunning, and it was of breast lift scars that I believe you treated. And talk to us about that, because I don't think people know that you can treat scars. Brittany Haley (29:22): Yes. Scars are difficult to treat. They're not something that you can just pick up a laser and start treating. It's taken me many years to feel comfortable to get consistent results with scars. And I've really lately had a lot of really beautiful results like the one you saw with combining a few different lasers, specifically Halo with another treatment for vascular that we have here called Vbeam, which is ... It's called a PDL laser. It targets redness very effectively. And I've kind of mastered down this setting. It's taken me a while to get it down, but I've got it down now and I'm now feeling really confident getting beautiful, consistent results, just like the one you saw yesterday with this. Brittany Haley (30:05): And they're life changing. I mean, for anyone who has those inframammary scars from a breast lift, breast reduction, they can be very debilitating and they can really make you not appreciate the beautiful result you've gotten from your surgery, especially if they're red or raised. And I'm finding that with Halo, I can do very specific settings that can help flatten them. I can improve the texture even on white scars, and I've seen them virtually remove what I call track marks. Those are those little suture lines that are kind of in the scars right there. So I think that it's definitely a game changer, and I'm excited for people to be more aware of the things that we can do with that. I think that it's amazing. I'm really glad that we got to share those results with the practice yesterday. It was really- Monique Ramsey (30:47): Yeah, and it was fascinating to see because I think none of ... The surgeons can't predict how you're going to heal, because your skin, so much of it is just the way your body heals. And your body might make raised scars or it might take longer for the redness to go away. So we'll put those photos in the show notes for everyone so you can see what we were talking about with the breast lift scar correction. Now, how long does somebody have to wait if they're going to have a scar correction or a treatment? About when do we say those scars are mature? Brittany Haley (31:26): A really good question, because a lot of laser providers have a lot of different opinions about this. You know, some are saying treat the day the sutures are out, prevent that thing from forming. Some are saying let it be, let's see. Most scars go away and look better on their own. The typical course of scars is to be red for six months and then by a year, they fade out to a tiny white line. So should we mess with them if they're going to do it on their own? I'm more on that second part. I used to think maybe hit them right away, but now I'm like, no, let's see, because these could improve on their own. And then if they don't, you know, by the year mark, I'm comfortable doing the laser treatment series on them. So that's kind of my approach. Monique Ramsey (32:05): And do you sometimes work with the physician about that, or the surgeon? Brittany Haley (32:09): All the time. Yeah, we have lots of patients who unfortunately, yeah, they do have scarring problems. And it's no one's fault, it's just the way their body healed. And so the surgeons, they send people up frequently to have scar treatments done, and we have a really nice program that we offer our surgery patients to help get discounted treatments for their scarring that I think is a real ... something that sets our practice apart that's really nice to offer. Monique Ramsey (32:37): Now, we talked about so many different kinds of lasers. Can you treat pretty much any body part? You were talking about tushes. Tell us about it. Spill the tea, Brittany. Brittany Haley (32:48): Something that I've been having a lot of fun with. So we, uh, recently upgraded our BBL to a platform called BBL HERO, and what it is ... it's High Energy Rapid Output IPL, basically, so it's faster. The pulses go in very quickly, and that's something really important in laser nerdy talk. It's called the pulsteration, so how fast the energy is going in. And they have a greater amount of cooling, so you can do very, very quick treatments of lots of fast little pulses. I'm having a lot of fun with this. I'm treating some fun things. What I've actually been combining it with is a very, very new treatment that we're kind of sort of dabbling into at our practice called Qwo. Qwo is brand new and it's an injection that actually dissolves the tethering in cellulite bands. Monique Ramsey (33:31): Sort of that dimple that ... The dimple is being pulled down by a band, right? Brittany Haley (33:37): Correct. It's- Monique Ramsey (33:37): So this is- Brittany Haley (33:39): It's that layer of tissue in that fat that's pulling it down. And honestly, to get rid of cellulite, the only way you can do it is by destroying that band. So, you know, these nonsurgical RF type of treatments, I'm sorry, they're just not going to cut it. You've got to snip that band to see that cellulite go away. This isn't a problem for just larger people. Everyone, even people at very healthy weight levels, can be bothered by cellulite because it's genetic and some people have more of a disposition for acquiring some more than others. So we're kind of figuring out how we can combine BBL HERO, which does skin tightening, as well as firming of the area, and also pigment clearance. Brittany Haley (34:17): With Qwo, one of the side effects is bruising, and it's not fun. I've been coining it blueberry butt. No one wants to be seen with a blueberry butt. I would just die if I saw someone walking around on our San Diego beaches with blueberry butt. I would know exactly what they did. It'd be hilarious. I bet there's people that probably would. But what I'm doing is trying to make this treatment manageable for people who don't have time to have blueberry butt by combining it BBL HERO. And so BBL HERO is clearing the bruising and helping with pigment and discoloration and also adding in that element of skin tightening, and then in addition they're getting the smoothing with the Qwo. Monique Ramsey (34:52): That's really cool. I love that. I love that. Brittany Haley (34:54): Yeah, it's fun. Monique Ramsey (34:56): Now, you mentioned veins. How do we treat veins, or what kind of veins are we treating? Brittany Haley (35:02): So with laser, the best kind of outcome with veins is treating ones that are just kind of small reticular red veins. Deeper veins I'm very careful with. Sometimes people have a lot of vascular issues going on. They do require consultation about their certain veins, and in some cases, they're better treated with other things besides lasers, so things like sclerotherapy or even endovenous ablation. But once they've completed that and they have those little pesky red ones hanging around, laser is the perfect thing to get them off of the skin. We have a few different lasers that can treat vascular. We have a YAG laser that does treat really nicely leg veins. We have our Vbeam laser, which treats veins on the face very effectively. It also is kind of the golden standard for rosacea, and I combine it with a lot of things like red scars as well. And then our BBL as well will help treat vascular. Then I've even seen some vascular clear from the Halo laser on certain settings, so there's a lot of options. Monique Ramsey (35:59): Interesting. And, I think that's something that maybe most of us don't realize as the general public. You've got all these different types of lasers. But then on any one laser, there is a multitude of settings, so there's different- Brittany Haley (36:15): Absolutely. Monique Ramsey (36:16): You know, it's not just turn it on and turn it off. And that's really where, as we as laypeople go shopping for ... I'm thinking about getting a laser done. Where do I go? What am I looking for? And so how would you help someone do that shopping process? Brittany Haley (36:33): Awesome question, and I get asked this on my Zoom consultations all the time because even, you know, lasers like Sciton where I go and educate people and ... I get them up and running. When I leave, they can perform a consistent treatment and I make sure that's what they can do, but can they really master this laser? Can they take it in their own hands and start treating all sorts of things? That takes time and experience. And, you could have the same laser, a beautiful laser, and have someone do a horrible treatment on it, absolutely awful, and then another person might do something totally different because they know how to work their machine. Brittany Haley (37:06): And I think what matters most is the person behind the laser, the person holding it. So ,that's going to be. kind of, the indication. A lot of people think, "Oh, this laser, it's a very nice, it's a very expensive, that's going to be my go-to." But if you have a novice on this laser who's not very comfortable, you're not going to get a great treatment. And in opposite, you might have a laser that's a little bit dated, but you have someone who really knows how to operate that laser, even though it is dated. That person could give you an amazing, stellar treatment. Monique Ramsey (37:32): Well, it's sort of like ... I don't know if many people out there are going to understand my analogy. But like I think about like race car drivers, you know, an Indy One or Formula One Indy driver, and they've got this beautiful multimillion dollar machine and if it's your first day behind the wheel, are you going to take it around the track at the same rate of speed and in the same efficiency as somebody who's been driving for a really long time? And that's- Brittany Haley (37:57): That's such a good analogy. I love it. Monique Ramsey (37:58): Oh, well, thank you. I'm watching a series on Netflix right now about Formula One. Brittany Haley (38:03): Well, and does the car matter? Yes, it does. The car matters. But what might matter more is the person behind the wheel. And the patient matters too, you know, with their underlying health history, which is a very important thing that we view before we do these treatments and make sure that they're going to be healthy good candidates who are going to get the great results that we expect. So there are the all different elements on there. Monique Ramsey (38:26): Now, one of the things that I've seen in the office ... and I've never done it myself, although I want to ... is you have ... Well, that's a long list, sorry. But no, I'm specifically talking about the VISIA. The VISIA is a- Brittany Haley (38:39): I can't believe you've never had one. I'm shocked. Monique Ramsey (38:41): I know. I know. Is that ridiculous? Brittany Haley (38:43): Yes. Monique Ramsey (38:43): No I haven't. But explain what the VISIA is and how you use it in the consultation process and in the treatment process. Brittany Haley (38:51): Yes. I use the VISIA every day and for all of my laser patients, and there's a lot of cool features on it. I think the most important thing on it, and maybe the most valuable, is that it takes photos in a very consistent manner. So it's photos at the exact same angle and the exact same light and it's done in a very consistent matter, and that matters a lot when you're looking at the skin. So that is something that really helps us get consistent results with beautiful before and after pictures. And then the VISIA also takes photos in a few different types of light, which helps me. I can see UV damage below the surface of the skin in this light, and that helps me a lot with determining what type of melasma you have. Is it deep? Is it superficial? How can I best attack it? So I always view that photo before I treat a melasma patient. Brittany Haley (39:36): It does have a feature too on there that's kind of fun to play with where it kind of gives you a little score on your skin. I think that's fun and patients like it, but for me, it's the least important thing on there. Me, I really like the consistent photos and I like the different lights that it takes. Monique Ramsey (39:50): And can they see ... Let's say you take it before a Halo or a TRL and then in a few months you take another one and you put it in that UV mode. Do you really see how much stuff was cleared out? Brittany Haley (40:03): Absolutely. You know, you can see the black splatters of the sun damage and how much is gone on the sub-second. It does a photo in that light. It does a specific photo for redness, so when I do vascular treatments, I show the redness and how much it cleared out underneath the skin as well as on top of the skin after their treatment series. Monique Ramsey (40:23): How fun. Because I think it's ... you know, before and after photos for laser treatments can be tricky. You know, like you say, lighting is everything. So sometimes it's a subtle result and we want to make sure that they see that from the beginning to the end, you see how much the skin has changed, how much the skin has improved. Now, if you're having a patient ... if you're recommending that they look at before and afters before they're making a decision, how can they look at before and afters? How can they make a good judgment? What do they look for? Brittany Haley (40:55): Good sources of research is a really good thing to talk about because a lot of people see a TikTok video and they think, "Oh, that's the treatment for me," and that's really steered people in the wrong direction. You need to look at patient-verified sources, so great sources. We have before and afters posted on our website. In addition, we have before and afters that are authorized only for uses during consultation. And then just knowing good resources to find reviews and photos. I think that Instagram is a source people use a lot these days, and it can be a very good source and a very bad source. There's actually quite a lot of providers and professional doctors, nurses who have Instagrams that show beautiful, realistic photos and results. And then we have influencers, other things who play their cute video of their dramatic treatment, and those are not good sources. Brittany Haley (41:43): So knowing where you get your sources from is important, and then going into that, reading reviews, too, is important. We are lucky that we pair up with patient-verified reviews at our practice. So we work with a company called Real Patient Ratings where every review they write for us is for a patient who actually had a treatment, so, and you can trust they had a treatment. They were a patient of that office. It's not just someone who got mad at you and went on and wrote a bad review, which could happen. Monique Ramsey (42:10): Oh, things on Yelp! We don't know who ... Were they really a customer of that restaurant? Did they really have that treatment? Brittany Haley (42:16): Who knows? Monique Ramsey (42:16): You don't know. And Real Patient Ratings, it's all ... they survey our patients after consult, they survey our patients after their treatments or surgeries, and so then it's really true ... And they all get published on the website. Brittany Haley (42:29): Yeah, no filter. Monique Ramsey (42:30): Yeah, no filter. So we've made it a priority to really have reviews not just for our surgeons, which seems like a no brainer, but then all of you med spa providers. I think that's something that you don't see. You might see something device based, or you might see the Halo is this many stars out of that many stars, but you don't necessarily see, oh, Brittany's satisfaction rate with her own patients. And you happen to have a lot of reviews, and here's one that we have for a Halo that you did, and we're going to talk about the P word. "It was painful, but Brittany made me feel as comfortable as possible. There were no surprises as the procedure, materials, and the pre-consultation advised me what to expect as far as discomfort and the healing process." So when you know something's going to be uncomfortable for them, what do you do to mentally prepare them for helping them be comfortable during the treatment and afterwards? Brittany Haley (43:31): Yeah, it can be scary for patients, especially those who are naïve to treatments. So it's something that you, it does require a little extra touch sometimes. It's something that is appreciated, and I think there's so many things we do to relieve anxiety and to relieve discomfort. I mean, besides actually treating it physically. For some procedures, we do offer pain medication. We do have a very light form of laughing gas called PRO-NOX that helps tremendously. There's so many things we can do to mediate. I use a lot of cooling during my procedures. I utilize that a lot to make you comfortable. Monique Ramsey (44:03): What does that look like, when you say cooling? Brittany Haley (44:05): So, I use all sorts of things. Ice packs, we have a little cool little hose that blasts cool air on you that sometimes I'll let patients hold and they feel better being in control. There's cooling built into all laser devices in some mean or manner. So using that effectively can really help make treatments more comfortable, and then what I call talk therapy. Whenever you have goggles on, I mean you want to know what's going on. You can't see. So I talk the whole time. I'm kind of talking about everything I'm doing and why and what to expect and there's no surprises. Surprises are not good. Monique Ramsey (44:38): Right. So if they're about to feel a little snap, you tell them. "Hey, now it-" Brittany Haley (44:43): I warm them, I tell them. I cool them. I'm doing it all. Yes. And sometimes too, we do do a lot of distraction technique as well. We have some little devices that can help, like little pulses that can be done in strategic places that can help alleviate kind of what's going on in one area to the other area. So all those things help, and then just making sure patients are feeling good. A lot of times, if I know a patient is a little nervous, I'll make sure they have a little snack before. We keep some tasty little treats on hand, gluten free and all that, too, if needed. So we make sure they're not hungry, they're feeling good. If someone's just generally not feeling good that day, I mean, I might even just say, "You're not feeling great today. This is maybe not the best time to do your treatment." Monique Ramsey (45:26): Now, have you seen people who have had laser treatment at other places and either they got no results or, worse, maybe they've gotten a bad result or had a injury? Brittany Haley (45:36): Sure. Yes, I think that the longer that you operate these things, the more you're going to see of that. It's not that I inherently don't trust patients. I do. But until I've built a rapport with them, sometimes I kind of have to analyze the situation, like, "Is it your expectations? You know, did the person you were working with just really not get it? Like you wanted this and you didn't get it and they did something else? Or were you noncommittal? You know, did you go out in the sun after and this happened to you? Did you not follow instructions?" I kind of do that little social eval and think through it, and then I really carefully from there kind of gauge either how to fix them, help their problem. Or maybe they weren't even targeting what they really wanted, and that could have been part of the problem too. Monique Ramsey (46:19): And I think the other thing is people don't realize how many different lasers there are, and we have a whole bunch of them, and ways to treat a lot of things. And if they went to an office that maybe only had one laser ... Brittany Haley (46:31): Exactly. Monique Ramsey (46:31): ... and that's the laser they got treated with ... Brittany Haley (46:34): Of course, yeah. Monique Ramsey (46:35): ... even if it wasn't maybe the perfect laser for their skincare problem. Brittany Haley (46:40): I think that happens a lot. You know these devices are expensive. It's really a luxury to have many to choose from where you get to make choices where they get to choose the best one for them. Monique Ramsey (46:49): Or make combinations, like you were saying earlier. Brittany Haley (46:51): Totally. Yeah, not everyone has that opportunity or availability. If they've only got one tool in the toolbox, then of course, they're going to use it, but that's something that would be hard from a patient perspective to understand. It's confusing. There's too many things out there. So having a good consultation before is really important. Monique Ramsey (47:12): Yeah. Now, I'm going to embarrass you with another review now. Get ready. She said, "I loved the results I received from my Halo laser treatment on my hands, neck, chest, and face. Brittany is the absolute best at what she does. I was so nervous, but she put me at ease and made sure I was comfortable every step of the way. She was extremely thorough and never rushed. I always feel so spoiled and well taken care of at LJC SC Med Spa. I've already started saving for my next treatment, Halo on my arms to help reverse some sun damage." So, how does that make you feel, Miss Brittany? Brittany Haley (47:51): Lovely. I was like, "Wait, I don't even know if I've heard that one before." That's a lovely review and I'm so happy to hear that because that's my goal, is, you know, to help patients feel better about themselves and their skin and more confident. I want to make the experience ... even though it may be, at times, a little bit unpleasant ... as comfortable as it can. Monique Ramsey (48:12): Now, she mentioned her hands, neck, chest, and face. So we all think probably laser, face, okay great. But that's really interesting that there's other places, and now she's talking about her arms. So tell us about how you go about helping people decide what areas to treat. Brittany Haley (48:30): I think that a lot of people neglect other areas besides their face. I did a consult the other day with a woman who'd had several BBL treatments on her face over the last five years and she sent me her pictures and I was like, "Oh my gosh, well, when are we going to treat your neck?" Like it looked like totally different skin. Monique Ramsey (48:46): Oh wow. Brittany Haley (48:46): At that point, I almost have to intercede, like, "Hey, we've got to treat your neck. You're just not looking like you have the same skin." So it's something that some people aren't always aware of. But I think that a real age determiner for ... it's kind of a dead giveaway ... is the chest. The hands, too. With the hands, classical like, "Oh, well, look at their hands if you want to see how old they are." But the chest, too. If you're ignoring that skin there and the decollete, that can really age you. Monique Ramsey (49:13): Yeah. I actually was at breakfast ... I remember this, a few years ago, I was at breakfast and I was looking at this lady and she'd obviously had a beautiful facelift. I mean, just perfect. And I thought, "Wow, you know, I wonder who her surgeon was." Of course, I'm in the business, I'm thinking about this stuff all the time. And then I saw her hands, and I kid you not, it was like 30 years' difference. I mean, I was, like, taken ... It was just such a stunning change and I thought, "Wow, she's put all this money and investment into her, you know, the top of her face, but her hands ..." And I didn't see her neck or decollete, but, you know, I thought, "Wow." People have to think, if we're going to be trying to make ourselves look good for a long time, that there are things that you can do. And tell us about what you can do to hands. Brittany Haley (50:01): So many things. We have gentle lasers like BBL that remove age spots and brown spots. We do dermal fillers in the hands that actually can help cover the veins and plump up the hands so they look for youthful. Monique Ramsey (50:14): I'm sitting here ... I'm analyzing my hands right now, Brittany. Because as we age, we lose some of the fat in that area? Is that what it is? Or collagen, or- Brittany Haley (50:22): It's not just our face. We lose it everywhere in a lot of places. Yeah, you can tend to ... And the skin thins as we age. It becomes more lax, it has less elasticity. And the hands are constantly out in the sun, driving, taking a lot of that grunt, so they shouldn't be ignored. You know, when you rub sunscreen on your face, rub it on your hands, too. Monique Ramsey (50:47): Yeah, yeah. And I think even with your products, you know, at night, if you're putting products on your face and you have a little extra ... Brittany Haley (50:53): Rub it ... yes. Monique Ramsey (50:53): ... rub it on your hands. Every time you do that, don't let it go to waste. Brittany Haley (50:58): I agree. Monique Ramsey (50:59): So this has been so informational. I think every, like we said, we could talk about this all day long. And so most people will ask something about, you know, how to set up a consultation. So, you mentioned virtual consultations. How does that work? Brittany Haley (51:12): Yeah. So, I mean, as a maybe silver lining of COVID, we did start doing virtual consultations, and so each of the providers here has a consult day that we do our consultations for new or existing patients on new treatments. And it's completely virtual. We'll do phone or we'll do Zoom calls, and you're able to talk to the provider, determine what might your concerns be and the best way to go about them, so that when you actually come into the office, you're ready to go. You know the information, you know everything, and you're ready to start working on the fun part, you know, getting the treatment and the results. And I think that that is a huge convenience factor for a lot of people, and for some who just really aren't ready to do a treatment, it saves that trip in office. They get all the information they need ahead of time. It's been, I think, a really great change we've made, and I think we're going to continue doing it as of now, just because it has been convenient. Monique Ramsey (52:02): And what are some of the things that people might have to do before being eligible, let's say, for a laser treatment, or like pre-treating? What are common things that you have people do? Brittany Haley (52:14): Number one thing would be, of course, being compliant in the sun. So when I have someone who comes on and they're like, "Yeah, I go in tanning beds," I'm like, "Okay, so we got to start from phase zero." I didn't even know people did that, but I did have one yesterday and I'm like, "All right, so you got to get out of there. Until you get out, then we'll start. So let me know when you're done." So she's like, "Okay, I'm done, I'm done." Then we get her on sunscreen, get her out of the sun, wearing sunscreen consistently for two to four weeks and we can start doing some treatments on her to help her reverse the sun damage that she's caused. Brittany Haley (52:45): In some cases, I will have patients prep their skin as well by doing some products, some medical-grade skincare before, so doing some pigment suppressors to help suppress hormonal pigment or risks of pigment after the laser, or some retinols to help turn over and exfoliate their skin a little bit faster. And in some cases, I'll even have them do some skincare first. I'll set them up with our esthetician, get them on skincare, maybe have them prep their skin, maybe do an aesthetic treatment with our esthetician, like a HydraFacial or a chemical peel before they start their treatment series. Monique Ramsey (53:16): And is that something like ... Say they have, you know, adult acne. Are they automatically not eligible for a laser, or- Brittany Haley (53:26): That's a perfect one, because this is a great example of someone who I would have see our esthetician first. I do a lot of treatments for acne scarring, but if people are actively breaking out, you know, and they're doing a treatment for scarring, it's like they're just going to keep breaking out. So we got to get those breakouts under control before we start tackling the scarring. Monique Ramsey (53:44): That makes sense. So everything that we've talked about today we'll put in the show notes in terms of links to the different laser treatments that we do. We've got pricing there on our website. We give ranges. We also have our GLAMfam to save money. We have financing. We have great payment options which really makes it affordable and where you can really say, "Okay, I'm committed to making my skin look better. How do I bundle it into a monthly payment?" So our patient care coordinators can help you with that. And then once you're ready to reach out, just check our show notes. We've got details about how to reach us by phone, text, or through our website. So one last thing that I want to ask you. So we have, you know, our brand promise is, "Where dreams become real." Helping people turn that dream, whatever it is, into reality. So tell me, Brittany, about a dream of yours that became real. Brittany Haley (54:41): Well, I mean, I guess definitely my family. You know, I have a beautiful family. I have two little ones. My son's 15 months and my daughter's three and my husband and I have been married for five years now, so that was a dream that became real. The whole time that I've been working at La Jolla Cosmetic. Monique Ramsey (54:57): Yeah. And that's really, it's awesome that you've, you know, been able to continue to be a working mom and sharing your talents with those of us who need it. Brittany Haley (55:06): It can be done. There's challenges, definitely, with having children and maintaining a career, but if it's something you love, it's definitely part of your identity and you should keep doing it. My husband, of course, and then we've had lots of help from our parents, and we've definitely been able to keep that dream possible for me. Monique Ramsey (55:23): Aw. Brittany Haley (55:23): So I apparently La Jolla Cosmetic also working with me on that aspect. Monique Ramsey (55:28): Yeah. It's nice. So well, thank you again, Brittany, for sharing your expertise and your time with us. Brittany Haley (55:34): My pleasure. Monique Ramsey (55:34): This was really fun. Brittany Haley (55:35): Yeah, this was great. Monique Ramsey (55:37): We will see you all next time. Thanks for listening. Speaker 1 (55:43): Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment, or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed building on the Scripps Memorial Hospital campus. To learn more, go to LJCSC.com or follow the team on Instagram at LJCSC. The La Jolla Cosmetic Podcast is a production of The Axis, T-H-E-A-X-I-S.io.