Speaker 1 (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. And I'm happy to tell you that I'm joined today with Julia Jowett. She's one of our physician assistants in our medical spa and she is a laser expert. And so Julia, welcome.

Julia Jowett (00:33):
Hi, good to be back. Yeah. So today we're going to talk about Dr. Swistun and his wife. They came in for treatment with you. They were having a couple's date. And if you guys haven't heard that podcast with Dr. Swistun, it's great. It's kind of the before he walked down the hall to have the laser treatment. So we caught him before that happened, and then we'll follow up with him in about a week to see how he's healing. But we wanted to talk to you today about that day, how you came up with the plan and what you were helping him with that day. And so first, let me ask you, how was it to treat one of your own surgeons?

Monique Ramsey (01:12):
It was fun. It was so much fun. I was joking with him because it's always when you're the provider, you're not the vulnerable one. And so to be a surgeon or to be an aesthetic provider, you're constantly doing things that are slightly uncomfortable to people. For me, I'm injecting and poking people with needles or zapping them with lasers all day. That's my day, every day. And so when you're in those shoes of all of a sudden being the one being poked and prodded at, it's fun. It's a good reminder for all of us as providers for what it feels like to be in patient's shoes.

Julia Jowett (01:41):
When he came into the clinic did a full consultation and we took his photos on our VISIA analysis system, pulled them up, looked at what his specific concerns were. And then what I also saw that I knew we could improve.

Julia Jowett (01:53):
And the few things that he mentioned to me that he wanted to address were fine lines that he just can't really get with Botox, texture, any sort of sun damage. He had some sun spots on his left cheek that were bothering him. And then when I pulled up his VISIAs, there's different filters that we can turn on, that we can look at how much redness you have under the skin, pore size, just overall skin health. And I definitely saw some redness that was kind of focused to his mid cheeks and nose. He had a good amount of sun damage and definitely more on the left side. He had very fine lines, not much textural, but one of his problem areas is around his eyes. He definitely feels that he's ready for a blepharoplasty, but he just doesn't have the time quite frankly, for what he said. Busy surgeon.

Julia Jowett (02:39):
So this is something that he wanted to do to just kind of tie him over and see if he can get some tightening benefit. So we decided to do a combination of BBL, which stands for broadband light and that's more of a photo facial that we started with. The company that makes the device that we use for his treatment is called Sciton. And they created a really great platform that has different modalities on one machine. So typically when somebody comes in and they're having a variety of lasers, the patient lays on the table and I'm just switching over hand pieces and really customizing it to what their skin needs. So for him, it was a combination of broadband light and HALO. I would say that's one of my favorite combinations because it can address everything with pigment, red, brown. It can address pores. It can address deep and fine lines. There's a wide array of settings that I can use. And so that's what we chose for his plan.

Monique Ramsey (03:28):
And so the broadband light component, what's that specifically targeting?

Julia Jowett (03:34):
Yeah. So it's using light energy, so scattered light energy to target the redness in skin or the hyperpigmentation in the skin. So typically I'll do this and even on its own for patients that can't have social downtime, it's a really great option to be able to still get a really noticeable improvement in your skin without having a week of healing associated with it. It's good for people that have mild rosacea or just some little broken capillaries that they want to improve. Sun damage, whether it's those little sun spots on the skin or just overall kind of dull skin, it helps with pigment. What I do see usually with treatments like broadband light, I'll do a series of corrective treatments. So say for example, three treatments, each treatment's spaced one month apart and then maintenance after that. And I will see people even get textural improvement from broadband light on its own. So that is something that I'll do mostly for pigment, but sometimes in the longer term plan, textural improvement.

Monique Ramsey (04:32):
And then you layer that with, I don't know if that's the right word.

Julia Jowett (04:35):
Yeah.

Monique Ramsey (04:35):
Layer. Layer with the HALO. So the HALO's more targeting than maybe I'm assuming the fine lines?

Julia Jowett (04:43):
Yeah. So if people want a more fast improvement in texture, a quicker result and they're okay with some social downtime, then doing some sort of skin resurfacing is really going to get them there. The HALO is a really nice middle ground laser. It's not the most aggressive laser that we have. It's not what I pull out if somebody wants their lines erased with one session of something and they can have the two weeks of healing. HALO is beautiful because no matter how aggressive I go with it always stays around five to seven days of downtime. It's always a very predictable healing. There's no surprises. And it gives a really great result. I use it for people with fine lines, people that want tightening in their pores. I do it often for scars, if they have surgical or traumatic scars. I found that it gives the best results.

Julia Jowett (05:29):
So for him, with the combination of things that he wanted to address, it was all of those. He wasn't a candidate for somebody that needed the really aggressive laser, nor does he have the time with his schedule. But we knew that we could do this. We did it on a Friday and he had clinic on Monday. So he was going to be seeing people. But usually by that third or fourth day, you look more back to yourself. So he knew that he would have that weekend to heal. And then even if he looked a little bit red and swollen, it wasn't that dramatic downtime by the time he had to go back into clinic.

Monique Ramsey (05:58):
And was he a good patient throughout the procedure?

Julia Jowett (06:03):
He was a good patient. He was nervous I think for what it was going to feel like. We used something called corneal shields, which for those that are not in the laser world, there's different ways to protect your eyes when you're having a laser procedure. So as the patient, you either wear metal shields that go over the surface, almost like tanning bed goggles. Or if we want to treat around your eye a little closer, we put in, they're almost little metal contact lenses and they're painless. You don't feel them. I put numbing drops in your eye before they go in. They just kind of slide right in, slide right out. But as a provider, I think that component of it made him a little nervous because he was just looking at them like, okay, I've never had this done before.

Monique Ramsey (06:49):
But they don't hurt. Right?

Julia Jowett (06:50):
That doesn't hurt. No, you don't feel anything. But it's still just, you're that vulnerable patient that you're not used to being. So I think he was nervous, but yeah, it's completely painless that portion. What he decided to do because he did want to just drive himself home after the procedure, we only did topical numbing cream and then we did some Tylenol and ibuprofen beforehand. And then he used our PRO-NOX, or laughing gas during the procedure. That's what a lot of patients will do if they don't like to take narcotics. They don't want to have somebody drive them home. They want to feel normal the rest of the day. They don't want to be kind of drowsy. They'll just use the laughing gas and the numbing cream. And he did great with that combination.

Monique Ramsey (07:25):
Good. So it's not that painful if you can kind of get away with that combination.

Julia Jowett (07:32):
I think knowing what to expect makes it tolerable. Because if you do it with that combination, I would say the procedure itself is not bad. It kind of builds up. You think it feels like little warm pop rocks on your skin. Afterwards for the first five to 10 minutes, it just feels like a really intense sunburn. So think of the worst sunburn of your life and that annoying nagging feeling where you're just aware of it. That's kind of how it feels. And then that tapers off and then you feel fine.

Monique Ramsey (07:55):
I saw him with the, in the video. So everybody in the audience, we have some video of this process and he was putting the blower. He had the little cool air blower and he was sort of doing that around his face with this little hose, with cool air coming out, which probably felt really good.

Julia Jowett (08:14):
That's blowing on your skin throughout the treatment. There's actually an attachment into HALO with the Zimmer chiller. So you have cold air blowing. And then when you're done, just sitting with that on feels amazing. When I had my HALO a couple of months ago, I just sat in my car with the AC blasting. And just that cold air, it just feels so good.

Monique Ramsey (08:32):
Oh I bet.

Julia Jowett (08:32):
And then all of a sudden you just feel like you don't need it anymore.

Monique Ramsey (08:35):
Oh, well that's good. So do most patients need any pain relief, let's say that night or the next day? Or is it mostly just right after the procedure that they're a little uncomfortable?

Julia Jowett (08:47):
So most patients, I would say 99% of patients, if they need anything, they're fine with just Tylenol. They don't need anything prescribed to them. Some patients who maybe are anxious or know that they have trouble sleeping or a lower pain threshold might want something just to have, for peace of mind. But usually it's not even something we need to prescribe post treatment medication for pain.

Monique Ramsey (09:09):
Yeah. He talked about his vitiligo.

Julia Jowett (09:13):
And he said his was worse that day for sure. He said that normally, it's actually not as noticeable. He's felt like it's been just more flared lately.

Monique Ramsey (09:21):
Yeah. And so is there anything that you had to take into consideration in treating him with that condition to ward off either it getting worse or is there any way to make it look better?

Julia Jowett (09:34):
It's such a hard condition to really treat anytime. Re-pigmentation is just not something that we can guarantee your body will do. For him I think the main benefit that he will see is deep pigmenting where he has a lot of sun damage where it causes that harsher transition zone. And so he told me before when we were speaking about everything that he had tried a peel on himself a few years prior, and he felt like that made a big difference just because it kind of took away sun damage from the skin nearby. There's certain types of lasers I wouldn't do aggressively. I would not do a full field ablation on somebody with vitiligo, but something like a HALO, that's a little bit more gentle. We didn't go into it thinking that it's going to improve his vitiligo at all. We went into it thinking that it might take away some of that sun damage around where he has lost his pigmentation so that that is not as noticeable.

Monique Ramsey (10:23):
Do you think it hurts for the patient pain wise?If you're having more than one laser? In this case we've got BBL and HALO. Does that change anything in pain or post-op?

Julia Jowett (10:37):
Post-op, not at all. Whatever the most aggressive devices that you're having is kind of what dictates your post care. And so if it's HALO, then that's kind of the post care that you follow and that trumps the other post care that's less of a protocol. For pain I think it's typical for me to do either BBL or V beam, which is a redness laser before I do something like HALO, because almost everyone doing this procedure has some sort of sun damage or redness that we want to also address.

Julia Jowett (11:03):
Those two devices are a little bit more startling. They're not more painful by any means. And it doesn't increase your pain. I think that they just feel different than the HALO does. The BBL, It's like a little warm rubber band snap feeling, and there's a bright light associated with it. And so you're just kind of aware of this flashing bright light as we pulse around your skin. But pain wise, it's less painful. When people do that on their own, I almost never give pain medication for that one. It's really tolerable. But I think that one for people that are a little bit more anxious and jumpy, that one is actually worse for them just because they're like, "There's a bright light and it makes me feel [inaudible 00:11:35]."

Julia Jowett (11:35):
And then the HALO they're like, "Okay, this isn't bad." The factor I always consider when I'm doing multiple treatments is the numbing cream. As soon as that numbing cream comes off of the skin, I work quickly to make sure that I'm finishing everything that I'm doing within, I would say an hour to an hour and a half. Because once it gets longer than that, then some of that numb sensation starts to wear off. And then you might feel the usually the most intense part, which is at the end, more. So I want to make sure that numbing cream is on until the moment I come in the room. And then as soon as it's off, we start working and I work quickly.

Monique Ramsey (12:09):
How did he look right after you finished the treatment?

Julia Jowett (12:13):
He was pink and he swelled up immediately. And I kind of had a feeling he would, because we treated aggressively around his eyes. The eyes just swell right away. So if you saw some of the pictures, I mean, he definitely had some inflammation and he was joking that they were going to go out to dinner that night. Should he wear sunglasses? And I was like, "Yes, you should wear sunglasses."

Monique Ramsey (12:33):
He was talking about that. And I was like, "Wow, that's an aggressive goal. You could always get takeout." But I'm like, okay, more power to him. My dad had a quad [inaudible 00:12:45], upper and lower eyes done and went to a Christmas party the same night.

Julia Jowett (12:48):
Really?

Monique Ramsey (12:49):
Yeah, he did. They did it under sort of a local and he just wore sunglasses and rocked his post-op. It was hilarious.

Julia Jowett (12:57):
Well, that's what I think when you work in this field, especially, and even just living in Southern California, there's so many of these procedures happening. I went out to dinner when I had one and people... You forget you did it because you're not in pain, but it looks like you should be in pain. So when people see you, they're just staring at you. I'm like, what are you staring at? So he was the same way. I mean, he was puffy, pink, but if you didn't know him well, you wouldn't look at him and say, "Oh my gosh, what just happened?"

Monique Ramsey (13:22):
So has he checked in with you since then? Have you seen him since?

Julia Jowett (13:27):
No, I actually.

Monique Ramsey (13:28):
What is today? Today's Tuesday.

Julia Jowett (13:29):
Today's Tuesday.

Monique Ramsey (13:30):
So he had it on Friday.

Julia Jowett (13:32):
He had it on Friday and then he was in clinic yesterday. I think he's in surgery today and I think he's doing great, but we haven't had a pop in, a post check in the clinic yet.

Monique Ramsey (13:41):
Not yet.

Julia Jowett (13:41):
Usually we do that at two weeks after, and he'll probably get his post laser hydration treatment and then we'll do his VISIAs and kind of check on everything.

Monique Ramsey (13:49):
So when do we expect to sort of see a final result with a patient who's having HALO?

Julia Jowett (13:56):
You see a good result in pigment after about two weeks. You can really see once that flaking has finished, everything just looks really clear and vibrant. The texture takes time and that's part of the waiting game. For anyone that's ever had laser before your skin feels good and then it feels better. And then it feels better. And every month that goes by all of a sudden more people start complimenting you. And so there's not an end point to it. I would say two months is a really good time to do a check in. Usually I'll do a two week follow up after HALO and that's more of a wound check. How's your healing going? How's everything doing? And then a two month follow up and that's more looking at results. But personally, even as somebody that's had a couple HALOs, the results continue even beyond that. You just start to get more of a glow.

Monique Ramsey (14:39):
Now, is there any, I know for something like ultherapy, that's triggering sort of collagen remodeling under the skin. Does that happen with HALO?

Julia Jowett (14:48):
That's exactly what we're trying to do with HALO. And so that's why it's one of those procedures where it gets better over time. Because part of it is we're causing a controlled wound where HALO is unique in that it has two different wavelengths of energy firing. One of those is ablative and one of those is non ablative. So there's a superficial ablative wavelength. That's really kind of flaking off pigment and causing a little bit of that tissue contraction at the dermal junction. And then there's that deeper wavelength that is causing more of a thermal collagen remodeling process. And so that's the part where if you have acne scars, if you have enlarged pores, if you have fine lines, a lot of people look good at two weeks and I'll tell them that's a really great sign. If you're already showing that textual improvement, that means it's just going to get better and better. But if you don't see any textual improvement at two weeks, that's okay, because that doesn't mean anything bad. It really does get better as your body heals.

Monique Ramsey (15:38):
Now, does anybody have to worry about... Let's say you've had Botox and maybe some filler in your cheeks or under your eyes, and now you want to have a HALO. Does that mess up? That's a technical term. Does it mess up what you've paid for to kind of do to your face in other areas? Do you have to wait a certain amount of time?

Julia Jowett (16:01):
So if I'm doing a consultation with somebody and part of their plan is Botox and filler, there's a timing line that I like to use. Especially even threads before you're doing energy based devices. So usually if it's in a shorter term plan, I like to do the energy based device first. And that really starts working on the skin, getting that tightening going, and then adding the injectables after. The exception to that is Botox. I actually would prefer to do Botox a week or two before your laser, because then all your muscles are relaxed. You're not going to be causing those animation creases as you're healing.

Julia Jowett (16:33):
But as far as filler, if we're timing it out perfectly, it's done after. If you've had filler or Botox before, say three months ago, I had some, these things are in different planes, so it's not like one is going to affect the other. Filler's actually placed, even though it's called dermal filler, it's not placed directly in your dermis. In most cases, it's placed beneath that layer when the energy from the HALO laser is focusing on the skin. So it's not going to melt or denature or change anything. But of course, if we're timing it out perfectly, I'd like to do it the other way around.

Monique Ramsey (17:03):
That's good to know. All right. And you mentioned threads. So if you have threads, you want to do-

Julia Jowett (17:08):
Thread's a little different because threads are placed a little bit more superficially. So if you're having say threads, and then a month later, you're having a laser, you might heat those threads, which would break them down faster. And the goal of the threads is to have your body break them down over time and produce collagen from them. So that's a consideration, I would say at least two months, for most cases, you want to wait after you have threads placed to do some sort of energy based device. The barbs are placed a little deeper. So same concept is not as much of an issue, but especially if, for people that are trying to build their dermis with smooths, and those are placed a little bit more superficially. If you just go and resurface right over those, then you're kind of taking away some of that benefit. So usually the order is, we do our laser. Then we do injectables with fillers and threads to get that lift. And it's like the icing on the cake with everything.

Monique Ramsey (17:53):
Yeah. Very cool. Well, any other treatment room gossip you have for us about his laser date with his wife now? And so she had laser too, right? Is that-

Julia Jowett (18:04):
She had laser too. She was a hoot. She was so funny. We were joking. I think I even saw it on the social media that we were like, we thought we love Dr. Swistun, but we love his wife more.

Monique Ramsey (18:14):
She's sitting there. She's so darling and she's got her high heels on and I had it up on our story and one of our viewers saw it. They're like, "The shoes. The shoes are fabulous." Oh yeah, that did not escape my eye either.

Julia Jowett (18:30):
Yeah. She's just puffing on her PRO-NOX, making us all laugh. It was really fun. They're such a fun couple. It was a treat to be a part of that and to treat them and I'm excited for their results. I think they're going to be really good.

Monique Ramsey (18:41):
Yeah. Well, thanks for joining us today. So everybody, if you haven't listened to the episode right before this one, Dr. Swistun talking about what he wants to accomplish and what his expectations were and about the day. And I think he was so cute, because he is like, "I'm not really scared of anything. I'm just going to be happy to have somebody else treating me. I'm not having to do anything." He saw it as totally relaxing. I'm like, "Relaxing? How is that possible?" But just to not have to be in charge for a few minutes and get treated yourself is always nice. And then we'll do a follow up with him. So everybody stay tuned for that. And we're doing video along the way. And we asked him to keep a little journal of pictures. So hopefully he's been doing that. And so stay tuned for more. Thanks, Julia.

Julia Jowett (19:28):
Awesome. Thanks for having me.

Monique Ramsey (19:30):
Okay. And we will see you all on the next episode. Thanks.

Speaker 1 (19:39):
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 I5 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. the axis.io.