Dr. Amanda Lloyd featured on CLn Skin Care with Dr. Anwar

Host: Hi Dr. Lloyd, how are you?

Dr. Lloyd: I’m going to see if the light is better over here.

Host: Yeah let me turn up the volume up here a little bit can you hear me okay?

Dr. Lloyd: Yeah can you hear me?

Host: Yes super – love that Dr. Lloyd – from Encinitas, California. We are speaking on lasers and fillers and a few other things. We were on last week and we had a great reaction and people wanted to hear you again.

Dr. Lloyd: Alright! I’ll be better this time

Host: Yeah good. You are doing well?

Dr. Lloyd: Yeah! Excellent

Host: Good lets jump into it – tell us your name and a bit about you. You have a lot of new visitors.

Dr. Lloyd: Alright I am Amanda Lloyd, I am a board certified dermatologist in Encinitas which is north of San Diego. I do a little bit of everything so I treat cosmetic patients, you know helping them to kind of restore the youth of their skin, I treat skin cancer so I do Mohs surgery, and then I also treat venus disease. So I do a little bit of everything.

Host: Ok good – Venus disease as well

Dr. Lloyd: Mhmm

Host: Fantastic. Alright so last time we were on you really gave us some good information and I actually had a few calls and emails from my friends who want laser. They are in the Dallas area so I sent them over there. So this thing is good. So go over laser just the basics, like wavelengths like what does a wavelength mean – you hear different things about it and that they do different things, but for the lay person what is a wavelength?

Dr. Lloyd: Wavelength is basically like one portion of the light spectrum so you know you have this light spectrum where you see red orange yellow green blue and then you can go outside of it – either in to the UV rays and then you have x-rays, microwaves and the length of – the weight of light is a bit wavy so it is like a wave, and the length is the distance between the two peaks so that is not the technical definition but more importantly with regards to laser is the wavelength that targets one well tis i only one wavelength that the laser works whereas if you treat with light you are treating with a bunch of wavelengths a bunch of different ones – does that makes sense?

Host: So the laser has one wavelength but you dial it?

Dr. Lloyd: Yes so it is the 15mp or the 532 or 585, it is only one whereas if you are treating like an IPL or a light based device like broad band light, it is light. So it is you know 40 – 700 nanometers where you put a filter in and it is 515 to 700 nanometers or something like that.

Host: So you basically have to know the wavelength and then that wavelength that reacts differently with different tissues and different tissues absorb that wave length.

Dr. Lloyd: Right

Host: Typically?

Dr. Lloyd: Exactly –

Host: So that is how you damage it?

Dr. Lloyd: That is how you help it or hurt it. So there are 3 different things in the skin that absorbs light. There is water, which build collagen, there is the hemoglobin – oxyhemoglobin which absorbs or is in the red blood cells and then there is the melanin which is in the brown kind of spots.

Host: Okay – so let’s start with water in collagen.

Dr. Lloyd: Yeah

Host: Actually before we do that – what I just heard was you have 3 different types of tissue – which you are targeting with your lasers to cause 3 different reactions?

Dr. Lloyd: Right 3 things in the tissue

Host: So when you use a wavelength which attracts water, you build collagen – how does that work? How do you zap water and make collagen?

Dr. Lloyd: So I know it sounds great – you put some water in the microwave and then collagen come out! So we know that when you add the heat, so when you are – the water is basically absorbing the energy from the laser which is creating heat and when you heat the water in the skin, you captivate these things called tyro blasts – which are what generate more collagen so you are basically stimulating your fiber blasts to make more of your own natural collagen – so I have a lot of people that come to me and say, I don’t want any fillers I don’t want any Botox I just want something natural, and there are few kind of natural fillers, like Sculptra that is a lattice and it stimulates its body to make its own in a similar way. It is stimulating the fiber blasts but a laser you are not injecting anything you are just putting light you know one wave length of light into the skin and that is heating the skin which is stimulating the fiber blasts to make more collagen.

Host: Okay very good explanation, thank you. And what can you do – with these lasers regarding red skin?

Dr. Lloyd: Red – so red usually comes in 2 or 3 varieties if you include blue. So red is either like a diffused redness in a rosacea patent then we also get little like squiggly lines on our faces which are just from the sun or our genetics, and then we have these kind of blue or vermicular veins you see people get on their noses here – or you will see the old ladies or men who get the blue veins going up their forehead, those are sorting that you can also treat. So anything, basically anything that has blood in it – you can get rid of.

Host: So the little streaks of vessels, very tiny ones can you also treat the rosacea –

Dr. Lloyd: Yeah

Host: Right so that is the wavelength that is, last week you told me was 532

Dr. Lloyd: Yeah 532 – so each, the chromophore is that thing we are targeting. Water oxy-hemoglobin, or the melanin and each one of those have a different absorption spectrum so they absorb really well at some wavelengths and absorb terribly at others. So they don’t absorb 300 nanometers at all, but they absorb 500 nm. So you have to be at the right wavelength in order of the target to absorb the energy to have the desiring effect.

Host: Great ok, and then the 3rd – the brown spots where you target melanin. Tell us about that.

Dr. Lloyd: So melanin is kind of what gets to, melanin is made by your melanocytes that is made by your cells in your skin that make you pigment and they can get kind of excited by the sun and over produce which is going to make those brown spots that nobody likes and that brown – those are called solar antigens, and the brown is kind of deposited at the bottom layer and the top layer of the skin. And the light goes there so when you are using – the wavelength goes there – so when you are using a laser targeting one specific thing you need to make sure that you are targeting the right thing and that you get it to the right deck. Because if you are targeting brown and you use something or you have your pulse duration for too long so if your target is here and you turn the laser on and you go all the way here you missed it.

Host: Right

Dr. Lloyd: So you have to makes sure you are going to the right depth and targeting the right thing

Host: Right and how do you know if you are targeting the right depth?

Dr. Lloyd: The depth is determined by the pulse duration so the how long the fact – the pulse is fired,

Host: Okay alright .very good- is that, I imagine that is not automatically done.

Dr. Lloyd: The user of the laser fixes it.

Host: The user fixes it on the laser?

Dr. Lloyd: Yeah

Host: And how often do you calibrate those?

Dr. Lloyd: Well they do like annual service maintenance but every skin, every body’s skin and lesions are different so sometimes a pulse of 10 set 10 seconds is better, sometimes there is 12 Nano seconds so there’s kind of – it depends on where it is because not every body’s vessels is in the exact same place jut like when you are doing Botox. The label comes with a template that you are supposed to follow. I don’t know anyone that is actually good at injecting that follows that template because nobody’s anatomy is exactly the same.

Host: Right. So of these 3 different problems, which ones have the best results –

Dr. Lloyd: Well they all do, it depends on what your problem is. So for me I am light eyed and light haired. I get red. I hate the red, I get wrinkles too but the redness is something that really happens frequently on my skin so I use the red laser or a laser that treats redness more frequently than I do something brown and you know 5 6 brown spots, whereas other people that have maybe a little bit more pigment in their skin, at baseline have more brown but don’t have very much red – so they would want one that is going to target more brown. Then there are people who have both that you can do kind of a combination of the 2 and then everybody you know likes collagen so that is good for anyone. So it kind of depends when you look in the mirror, what bothers you.

Host: Right, well I know it bothers me but we want people to know what has really good results. I think last time we spoke you said that the brown spots were the ones that had the highest success rate.

Dr. Lloyd: I mean yeah they are all successful at treating their one thing as long as you are targeting right and put it to the right depth.

Host: Ok, alright and there is this positive comment about clean, thank you Lauri-anna Arthur. Okay lovely so when you are treating people do you identify one area of problem like hey today I am going to work on the brown spots, and do you work on collagen or do you-

Dr. Lloyd: Yeah so some lasers like the Fraxel do what is called the dual because it has 2 wavelengths so brown and 1927 and so for brown it has a 1554 or water, and so you can do in one human session you can use both of those what makes to kind of help to build the brown and some collagen. So that is something that I do – I use that one very often. There are different varieties. Halo is another one, that does collagen uses pink brown there is a bunch of different lasers out there, and as a patient or a consumer looking for a laser procedure you really don’t need to figure out what laser is best for you need to find what physician is best for you. What physician knows what they are doing and you know uses lasers frequently enough to know how to use a loser, because everybody uses the laser a little bit differently because your physician is the one that programs the laser it is not like you turn it on and there is one setting for everybody and everybody is a little bit different. So having a physician know how to use a laser really well is really important.

Host: So how does a patient know if a physician knows what they are doing, or are really well experienced?

Lloyd: So there is a society called the American Society for Laser surgery and medicine and so they do a lot of publications and so if the physician is a member of that group you can think that they are or led to believe that they know something or at least a little bit about lasers so you have to apply to be a member and they accept you based on certain criteria as the person should preferably be a board certified dermatologist. There is some you know plastic surgeon and people out there using lasers, although I don’t – since I am not them, I don’t know how much training exactly they have but you want to make sure that the person has done more than a weekend course in lasers and so even just calling the office of someone you want to go to and asking what experience the person in that position has with lasers. Making sure that they are board certified is really important, because there are people that have masqueraded as various things out there and you want to make sure that you go somewhere, where your skin is safe. If it is programmed incorrectly you can have a burn or scar or hyperpigmentation or something that is not so fantastic.

Host: Right, so it is totally legit for a patient to ask right?

Dr. Lloyd: Yeah totally

Host: Absolutely yeah, I mean I have run into situations where patients don’t want to ask the experience level of a cardiologist and we do know that the more cases you do and the more continuing education that you do the better you are going to be.

Dr. Lloyd: Totally

Host: Very good so repeat the name of that society one more time slowly?

Dr. Lloyd: So it is the American Society for Laser Surgery and Medicine – so ASLMS is what most call it because it is so long.

Host: ASLMS okay – American Society of Laser surgery and medicine?

Dr. Lloyd: Mhmm

Host: Ok and they have all the people that are certified with them?

Dr. Lloyd: Yes it is another society like the American Board of Dermatology, or the American Academy of Dermatology that you can be a member of. But if you are a member of it you are probably interested in lasers or have some experience in lasers, they put on annual meetings, it is all about lasers and new lasers and what is up and coming and how to treat new things with old lasers and so they really kind of keep you informed on what is happening in lasers and they have their own publication. Laser surgery and medicine which is a journal which has lots of articles on different lasers.

Host: So is there a board certification for lasers?

Dr. Lloyd: No

Host: Ok, and during training how much laser experience do residents get?

Dr. Lloyd: It depends on the training programme. The amount of lasers and cosmetics in any one programme is highly variable. There are programs out there that have almost none, and there are programs out there that have a fairly good amount. In Dallas we had a pretty good amount of lasers and a variety of things, but I know there are other areas where it is just not something that that program does and so it is kind of dependent on your location and that pregame and their director and how they set up their program.

Host: Great.

Dr. Lloyd: There are fellowships that you can do after residency that have lasers. There are 2 different kinds, there is the procedural dermatology or the oncology and micrographic surgery is what is called now it has changed now but basically it has the most fellowships that you can do – which a lot of times the most fellowships have a significant laser portion mixed in so that is what I did. I did a Mohs surgery which was half surgery and half laser surgeries so I got a lot of laser experience but then the American Society of Dermatologic surgery came up with their own kind of quote unquote cosmetic fellowship which is called the cosmetic it has changed names too but it is a cosmetic fellowship where you don’t focus much on Mohs but you do mostly cosmetics and lasers and then there is a bunch of programs out there too. So if you feel, or if the dermatologist feel like they didn’t get enough in residency there is an opportunity for one extra year of training and so when you are a patient looking to go see a doctor, you probably want to pick one that has been fellowship trained in either Mohs or cosmetic – the ASDS cosmetic fellowship because then at least you know they have had an extra year of information about lasers and cosmetics specifically.

Host: Right, good – so let’s talk about the complications of lasers – what are like some major potential complications that people need to be aware of?

Dr. Lloyd: So scarring is the main one, scarring is bad – generally speaking depending on the type of scarring you get. You know there is in the beginning of lasers there is, people were doing the ablative lasers and they were going down on the neck we kind of talked about this last week but the neck skin and the face skin are not the same, and there was a lot of significant scarring on the neck and you can also get hypo pigmentations, so if you are little bit too wild with targeting those wild spots you can get rid of all the melanin – and up with deep pigmentation or hypo pigmentation which is like a lightening colour of your skin – you can end up with hyperpigmentation or increased brown just kind of depending on what happened.

Host: Right so scarring, especially the neck but other areas –

Dr. Lloyd: yeah I mean you can get scarring on the face too – even if you stack a bunch of pulses on top of each other you can problem get necrosis of the skin, when you are treating those vessels along the nose – if the pulses are stacked or you use too much energy you can get little pits or essentially a scar but it is like a dent in the nose from to much energy basically shrinking the skin.

Host: Got it ok – so what about the neck. You mentioned to use lasers on the neck

Dr. Lloyd: Yeah all the time.

Host: For collagen, or –

Dr. Lloyd: Everything! Collagen brown and red. Ok so a very common problem that people have is called Poikiloderma which is from the sun and it basically is like that miss match of colors it is like a little bit of red brown and white and lasers are great for Poikiloderma because that kind of you might have to use more than on and I tell my patients pick what bothers you the most and so I will look at a little bit of neck, a chest or a face and say ok look you have more brown than red so we are going to start off with brown and collagen and then if you now afterwards only see the red because that very often happens – we get rid of some of the noise that was more annoying and then you see the little things you didn’t notice before because now you are looking. Then we will use the laser for the red

Host: Right

Dr. Lloyd: Occasionally people think red looks better after we treat brown and collagen and that is probably because you have a little bit more collagen holding hose blood vessels but you kind of need to use – you usually need more than one but it depends on your skin because if you are super sun damage you will need more but if you are doing something just for skin maintenance you know it is just kind up to you and what bothers you

Host: So can you use the lasers prolactin before you start getting the wrinkles?

Dr. Lloyd: Definitely I mean you are always getting older which is good, but your skin is always – every day you are damaging your collagen and as much as you are wearing your sunscreen and taking care of your skin you are still having breakdowns on your skin is – so there are lasers that have almost no downtime like the clear and brilliant or the laser genesis and they are great maintenance lasers and instead of getting a facial or having an extraction or whatever you know a chemical peel or you – might as well save your money and have a laser very quarter and clear up every quarter that is going to add energy, heat the skin and stimulate those fiber blasts and build your collagen just to kind of maintain your skin's health –

Host: Ok ok very good, and at what age should people start getting maintenance –

Dr. Lloyd: I mean it is up to you – I mean when should people start having Botox, you know or neuromodulator or filler – it kind of depends on the person and how you know they take care of their skin some people are going to age better than others, so it is kind of up to the person.

Host: So the talk is that it is being pushed to the 20 year olds

Dr. Lloyd: I mean I had all 3 in my 20s.

Host: Ok yeah alright

Dr. Lloyd: (Laughs) so maybe 23 or 24, you know I mean it is preventative and if you are a smart – 20 something year old you are going to do what you can to prevent looking like a leather purse.

Host: Right yeah that is what I notice a lot in San Diego. Beautiful bodies with leather purse skin.

Dr. Lloyd: Yeah –

Host: It is just incredible how it works. Anyway so let’s get to the others – IPLS and so go with the non-laser general areas that I think you went through some of last time.

Dr. Lloyd: Well the other light device would be an IPL or a broad band light – I guess there is phototherapy but also phototherapy is also there for Vitiligo or Psoriasis, or something along those lines that are more of the inflammatory or autoimmune type things which phototherapy uses UVA or UVB which generally the average public just doesn’t want to get UVA or UVB like a tanning bed – you certainly don’t want to go into because that is negative UVA and that will damage your collagen and it will turn your collagen into mush. It is going to give you brown spots, it is going to give you red spots it is going to give you melanoma and it is going to give you all kinds of bad things – so you certainly don’t want to go pop in a tanning bed but then there is other things that are too like light related, but they are used for quote unquote improving the skin like radio frequency or micro needling or Thermage which is ultra sound, so it kind of depends on which route you kind of want to go.

Host: Right so you have nearly a dozen options so you better get the hands of someone who know is how to use these –

Dr. Lloyd: Yes so the right therapies. Someone asked if you can get scarring from Thermage. I mean you can get scarring from anything so you want to make sure you know who is treating you.

Host: Right. Well great, so I am so glad that we got back together because our connection last week was bad and now we have all this awesome information, and do you have anything else that you want to add as far as aesthetics and you know make some general comments – I know you wanted to talk maybe a little bit about fillers, maybe spend a couple of minutes on that and come back?

Dr. Lloyd: Sounds good.

Host: What about – you want to say a few things about fillers?

Dr. Lloyd: Sure

Host: What are your favorite fillers are?

Dr. Lloyd: My favorite filers – well, fillers I can’t pick one to be honest. It depends, so like what are my favorite places to fill – in the face is the tear drops the area under the eyes because that is an area where people, it really weighs down on people's self-esteem and makes them feel old and tired, even though they don’t look or you know they do look it but they don’t feel like they are old and tired. The look older or more tired than they should – I had a patient recently who lost her son and she was crying a lot and she also had a lot of volume loss under her eyes and so we treated her under eyes and she looked in the mirror and went that she looked a million times better now and I don’t see this you know lady that is old and has been crying all day. It is very rewarding to help people feel better about themselves by improving a relatively small – area on the skin.

Host: Right, right.

Dr. Lloyd: Everybody’s face loses volume a little bit differently so that is why there is a bunch of different fillers, I don’t know how many – there is like 30 plus fillers on the market and they kind of like have the person choosing the laser has to know what they are targeting there and the standard is the person using a filler needs to know the properties of the filer they are using and where they are putting it – so you need to have the amount of volume that the filer provides and the location where it is being place matched so there are some fillers like Filletero or Restylane Sylk or Juvéderm Ultra which are very thin and so they are good or even Restylane so they are good for under the eyes – they are an area that you know you don’t have a lot of skin in this area but you can have significant hollowing that makes you look tired. You can use something fairly thin there to help increase the amount of volume but not have it look like you have caterpillars under your eyes where there is other fillers that are more – structural and more luminesce like Voluma or Lyft or Define which are these other kind of more substantial filers that are better for kind of rebuilding deeper underlying structure like the cheeks or the jaw line so area where the temples, areas where you need more volume where if you put something thin and fluid in the cheek you are not going to notice any difference.

Host: Right

Dr. Lloyd: So very soft malleable thin filler that is going to add some volume but not a ton whereas if you put something like Voluma there you will get something that stands up on itself which you wouldn’t want a huge blob of something stuck under your eye but on your cheek you want it to lift to kind of help improve the nasal labial fold and the wrinkling in the cheeks.

Host: Right very good! Super good reviews, so the bottom line is I hear you saying quote several times – you want to really identify your own problem, what is bothering you go talk to a board certified dermatologist and then make the client know the complications and they will be afraid to ask questions.

Dr. Lloyd: Right

Host: In training – so a lot of great advise I want to thank you for coming on, yeah ok Dr. Lloyd thank you for coming on and being a guest on our show and I will go ahead and end our session now – and no technical problems

Dr. Lloyd: Alright! Thanks you have a great day

Host: You too bye bye.