Structural Skin Tightening: Understanding XERF with Dr. Jacquiline Hakim

0:00Dr. Jacquiline Hakim:Hey guys, welcome back to Skin Anarchy. Today is a very, very informative episode. We're going to learn a lot today and I'm super excited because we're joined today by Dr. Jacqueline Hakim, who is a double board certified dermatologist and cosmetic specialist. And she's also the CEO and founder of Davina Dermatology and Cosmetic Center of Beverly Hills. So Dr. Hakim is truly an expert in the field of aesthetics, regenerative aesthetics, restorative aesthetics. And so I'm so excited to chat with you, Dr. Hakim, today about everything that has to do with beauty. Welcome. Yeah, thank you so much for having me.

0:31I'm excited for this convo.

0:32Dr. Jacquiline Hakim:No, I'm very excited. And I know there's a lot to unpack. You have a phenomenal background, very, very impressive. I mean, you are truly immersed in the world of science. And I think for our listeners, that's what we want to really understand. But to get us started, walk us down memory lane. What got you into medicine to begin with? Sure. I mean, ever since I was a young kid, I think I've always wanted to be a doctor and I wanted to be in a place of service to others. And the art and science of dermatology really was an attraction to me. I was a patient from a young age and it kind of honed in on my two strengths and I loved it ever since I've had exposure.

1:07I worked at a derm office in between college and medical school, fell more in love with it and knew that I didn't see myself doing anything else. And so that's how I got into the field and I've been blessed to be a part of the field. and continue to grow. And it's such a cool field because it's always evolving. And so there's always constant learning, constant growth, which is really exciting.

1:32Dr. Jacquiline Hakim:Yeah, absolutely. No, this is, I, you know, I've said this a lot of times as well to our listeners. Like I feel like aesthetics and skincare and skin health is one of the only fields in medicine that is so, it touches so much, you know, with, with two disciplines. So lots to unpack. Absolutely. And aesthetics is a medicine. And I know it feels very glamorous and it trends and it's, you know, a lot of people are exposed and it's a strong interest, which is amazing. But at the end of the day, it's still medicine. And I think that's such an important factor to hone in on. Absolutely. You know, I want to start with actually understanding the skin because I think this is one of the most, it's one of the most complicated and also oversimplified, I think.

2:12Dr. Jacquiline Hakim:topics, you know, and I would love for you to really kind of dive into this with us in terms of understanding the biology of structural aging. Like what is the skin's structure and what is it that's making us age? Like if you were to explain. Yeah. And it's, it's even great that you say that because I think that's part of the somewhat misunderstanding when we say skin, I think people hone in on just skin because it's what they see and truly aging starts all the way down to the bone. And I think that's the most important thing is to realize that the aging process is happening in multiple planes of tissue.

2:48People look in the mirror and see their skin, and they might not see like the bone loss that's happening, which is the scaffolding that's holding everything up. And we know that that naturally starts occurring in patients in their 30s. And then overall, there's structures from bone up to skin that are also changing, including connective tissue, fibrous septate, the SMAS, fat pads are changing and not at the same time. And then we get to the skin, which is truly what people are seeing and really show a lot of the signs of aging with everything going on below. And so obviously we have the epidermis to dermis and that's the generalization in short, but they're made up of proteins.

3:28Everyone knows collagen, everyone knows elastin. And when we're younger, we're born with so much and it, you know, continues to stimulate. But we do know that we lose collagen at about 1 % a year, starting in our mid-20s. And so, you know, within the world of aesthetics and aging gracefully, it's always important to realize what's happening below to be preventative so that you can take small steps to look your best at any age and to look natural and not overdone. And I think that's an important concept for women especially as well. We lose up to 30 to 40 % of our collagen into perimenopause. And so it's not like a slow, gradual slope.

4:06There's some peaks where there's drop-offs and we call them the pillars of aging. And there's a few studies around that. But we see that starting in our mid-20s and again in our 40s, later in our 60s and so forth. So a lot of that is driven by multiple factors. And I know that's kind of a loaded answer, but there's so much that goes into it, which is important to understand because that's how you can give patients very personalized results when you understand the whole picture and you can see what's going on.

4:35Dr. Jacquiline Hakim:Absolutely. No, I mean, I love what you said and I love how you explained it. Thank you for that because I think we hear a lot about things like collagen loss. You know, that's a huge, huge topic. But the percentages, no one understands. And also, you know what I've heard a lot of, and I'd love for you to kind of clear this up. People say, you know, when you're 40, everything still looks fine. But when you get into that 45 range, it's like your face starts to change. And you almost like a lot of women have said, you look in the mirror and you almost don't recognize yourself anymore. I mean, what do you do?

5:04Dr. Jacquiline Hakim:Is that what you were explaining? Like the collagen loss? Like, what is that? Absolutely. In our early 40s as women, we have an estrogen drop-off. And so that's within the perimenopausal phase. There's a hormone shift. And one of the biggest shifts is estrogen loss. We have estrogen receptors in our skin that are responsible for helping stimulate and upkeep collagen. And so when you have a decrease in estrogen, much of that is decreased. And so that's when you start hearing patients and people complain of like, I woke up one day and all of a sudden I saw this. And it can be that drastic as we enter in our like early 40s is generalized time for that.

5:45Dr. Jacquiline Hakim:Yeah, no, that's what I keep hearing that. And I'm approaching 40s. Yeah, she's like, what am I going to do? No, absolutely. Well, there's so many things. And we, you know, that's like the concept of collagen banking. I know that's kind of a trendy term, but you want to kind of maximize on your body's capabilities and prior to the age of 40, a lot of men and women do treatments to stimulate collagen, which we have proven fact that they can, whether it's lasers, energy, injectables. And so we call them collagen banking to store up as much so those shifts aren't so drastic. Yeah, no, that makes a lot of sense.

6:24Dr. Jacquiline Hakim:I know that in the last few years, I would say even like five years at least, we've seen a lot of people go towards aesthetics in a more, I guess, rigorous way. A lot more people are opting in for injectables. There's a lot more people that are open to procedures now. And that's, I mean, that's its own group. But I mean, I would love for you to talk about like, where is it that we might be missing the mark when it comes to understanding the true role of injectables versus something that might not be invasive, but still give us results? Yeah. You know, there's so much out there. And that goes to what we were saying earlier about the aesthetic world of medicine is constantly evolving and constantly getting better.

7:05And it's such a great time to be in this space and a patient in this space because there's so many options. And I think it truly like to break it down, it truly comes down to finding a specialist that understands all those layers of aging that we kind of briefly talked about to truly understand your goals and to come up with a very personalized plan to maximize on your overall skin health, collagen stimulation, and just the goal of aging gracefully as you continue to age. And in the world of injectables, there's truly still a place, and I know there's some back and forth on social media. There's some fear-mongering.

7:40There's people that support it. And we have so much scientific data and research with safety, efficacy, and correction. And sometimes that's the best solution for patients. There's true volume loss with our fat pads decreasing. And we see a lot of that now too with the GLP-1 wave of everyone really losing weight. They're calling it Ozumbic phase. And that's very different from natural aging, which happens in different phases because all of it's happening together. And so the speed of aging is actually accelerated. And there's such a great place for volume replenishment with injectables, whether it's fillers, but then there's also the biostimulatory types of injections, which are not the gel type of fillers, but they stimulate your body to stimulate collagen.

8:24And so there's a place for everything and it truly comes down to every specific patient. But the great thing is we have probably the most safety data at this point because it's been around for so long and we have such amazing technology that's advancing over the last 40, 50 years and it's getting better and better and better.

8:45Dr. Jacquiline Hakim:Yeah, that makes a lot of sense. And I think, yeah, you're right. There's a lot of fear mongering actually on social media. It's, you know, for me, I mean, I never was interested in getting fillers or Botox or anything for a long time. And I remember going on social media, it was before my podcast, and I was just terrified. Like, it terrified me, you know. And I think it was a lot of the things that are kind of sold to us, you know, how everything is a bot job. And, like, there's just so much conversation. And so, yeah, it's a very— Absolutely. And, you know, good work—I always say good work is not noticeable work.

9:17Like you shouldn't walk around and people should say, oh my gosh, she had X and Y done. And it's an unfortunate, like we're blessed at a time where there's so much information. But the other side of that is that a lot of it is misinformation and there is true science and safety. And you have to find the right provider to give you that result. And so I think there's, it's like a two-edged sword with all this information.

9:42Dr. Jacquiline Hakim:Oh, I completely agree. And I think it really matters because, you know, right now we're in the era of like real technology emerging, I think, in this field. One of the first ones that comes to mind is radio frequency for me. I know a lot of us, you know, in the audience, a lot of us don't understand the true science of radio frequency and what it really does for the skin. I'd love for you to walk us through that and kind of explain like what is the true like impact that this type of technology has for skin and the tissues underneath. Absolutely. So radiofrequency has been around forever, maybe 40, 50 plus years.

10:18And the cool thing in being in this industry, again, is that it's evolved and evolved and evolved. So I think when patients hear radiofrequency, some people freak out, some people get excited, but it really has so many layers. To the like most simplest form, radiofrequency is the deliverance of a heat-based energy that uses your tissue resistance to create impact. And that can be like controlled wound healing or triggering to create collagen. At the end of the day, with any energy that's delivered to the skin or layers below the skin, you're creating a cascade that stimulates collagen and elastin.

10:54There's also concepts of contraction under the tissue and at certain tissue depths to also help with tightening. And it's one form of energy to do that. Now, the delivery of radiofrequency has evolved the most over the years. And initially, they're like, yeah, you just need to put heat. You want to get it into this tissue and we can see tightening. But it is fine-tuned so much where in the past, we might have seen issues with fat loss. We might have seen issues with scarring. At the end of the day, it's very provider dependent. But when you have so much uncontroll over certain settings or certain tissue depths, you can see certain side effects.

11:33and technology as it's evolved has become really amazing at not just the concept of bulk heating tissue but truly like precise heating of specific layers without causing scarring without causing fat loss and they've made tissue response even more comfortable than the past because it used to be something that people were so scared of because it was so painful or uncomfortable even in other types of technology in the tightening space that was a concept that was constantly being discussed. Patients were going under anesthesia for tightening devices because they said they were so painful. And if patients can't get themselves to do treatments, that's also not a great thing as well.

12:13So, I mean, we've evolved so much at the end of the day of how energy is being delivered, the comfort level, the precision of depth that the heat is going in and creating a tissue response where it was kind of more generalized in the past. It's become a lot more specific now.

12:30Dr. Jacquiline Hakim:That's really interesting because when you talk about like tissue depth and like, you know, controlling things, the first thing honestly that comes to my mind is like skin of color because there's so much debate, like, you know what I mean? And I know with lasers, it's a pretty clear debate and we've talked a lot about it, like in the industry about lasers, but like, I mean, do you think there's something that we should know about, you know, like radio frequency and skin of color and melanin? I mean, I'm just curious. Yeah, that's a great question. You know, I think I've touched on this, but it's such an important point that there are so many lasers and devices, but it really comes down to the provider and understanding skin and tissue.

13:09And that's the biggest factor. As long as the provider has been well-trained, is able to understand tissue, medical tissue response, devices are very safe in all skin colors. There's some that are better than others. But in the realm of radiofrequency, it's always been considered safe in the right hands. But the devices have gotten more advanced to be safer for that fact. And so the concept with melanin that we always want to be aware of is that if it's overheated or stimulated, there can be something that results in post-inflammatory hyperpigmentation is what we call it. And so we want to be cautious as a provider to make sure you're not stimulating at the wrong layer that might stimulate that.

13:50But now the delivery systems are also enhanced. Whereas some of the old radio frequency delivery systems were through microneedling. You can easily go too superficial. If it's done incorrectly, there were some problems with that. But that, again, is very provider dependent. Whereas now the technology has evolved and there's cooling systems that are cooling that top layer where you want to be cautious so that energy going in is not even affecting that pigment. And we say it's even like a colorblind treatment. It's safe for everyone. And the progress of those updates have made such a big difference.

14:26Dr. Jacquiline Hakim:That's huge. That's really huge. I mean, I think that's where a lot of people get confused. And, you know, I won't lie to you. I mean, there's a big gray box right now for a lot of patients, a lot of patients, because we are constantly being told, like, when you apply heat, when you apply any energy, like, there is a huge shift that's happening. But everything you're explaining actually makes a lot of sense. Like, it really comes down to understanding the structural biology of it. Absolutely. So I want to talk about ZERF. I really want to ask you about ZERF, the treatment from Sinusure or Lunatonic.

14:58Dr. Jacquiline Hakim:I mean, explain to us what is ZERF and what can we realistically expect from this modality? Yeah, I think ZERF is really exciting technology. In my practice, I've had ZERF as one of the first offices in the U.S. to have it. I was personally really excited because of all the updates. I historically didn't bring on a skin tightening device because I wasn't absolutely in love with one that I had tried or had patients try. But when Zerv came out, it is a radiofrequency device. It's specifically a monopolar radiofrequency device, but it does deliver that radiofrequency very precisely to multiple tissue depths at the same time.

15:37That was one of the advancements is that it has two frequencies that it works with, and it can precisely go to multiple levels where historic treatments were just at one level. And so that was a huge shift in the device itself. Secondarily, and like we mentioned, heat and pain and possible risk of pigmentation, that's not a factor reserved. There's a cooling system that's built into the technology. So with every pulse, there's cooling that goes to the epidermis. So a couple of things is that that makes it safer for patients of all skin types, which is amazing. Secondly, it makes it comfortable.

16:15Patients are able to tolerate it. I personally have patients that have fallen asleep through treatment. I've done the treatment on myself a handful of times. I absolutely love it. If I can do it on myself and I think I'm a baby, then I'm like, everyone can do this. But it's great. It's one of the safest that's currently on the market. it's the most advanced now doing multiple depths at the same time.

16:37Dr. Jacquiline Hakim:No, that sounds, I mean, that sounds awesome. Like I didn't know that it was the, you know, like the dual thing where it has the cooling effect and all of that. I mean, it's interesting because, you know, when you're delivering like energy, understanding what that does, like in the timeframe, right? That's something that I think we don't really talk about. There's a lot of biophysics in my understanding, like understanding like your issue, like how does, Because, you know, I'm sure you saw it. Everybody got behind the whole like cryo hype. And like your skin needs to be cooled down to start seeing like, you know, reversal kind of benefits.

17:13Dr. Jacquiline Hakim:So talk to us a little bit more about that, if you don't mind, in terms of like what does like cooling do and what does heating do to tissue? Because I think that's important to kind of differentiate. Yeah. I mean, the cooling space is like very broad in the sense of like people doing it post-workouts as like muscular recovery. In the world of skin specifically, in dermatology, in aesthetics, we use cooling for a couple of reasons. When we're doing energy-based devices and it comes down to that epidermal cooling to reduce the risk of side effects like post-inflammatory hyperpigmentation, especially with darker skin tones.

17:50And so that's always been an aspect where that's incorporated with different devices, usually not connected to the same device, which Surf now has as it cools the skin while the energy is being delivered through the single handpiece. It's not like a completely different system. But one for safety, of course, for the pigmentation and secondly, for patient comfort. And that's like in the aesthetic space, specifically with lasers and energy. We use cryo and dermatology, of course, in more powerful ways to treat growths and other things. And then there's the generalized cryotherapy for muscle recovery, overall anti-inflammatory benefits, but that's kind of a different space than the aesthetic medicine world.

18:34And then, of course, heat on the other end is different because the way it's delivered is variable, of course, among so many different technologies. but to go back to like radio frequency specifically, that's a specific heat that's delivered to tissues to stimulate that collagen cascade. And we kind of touched on that earlier of how we're losing collagen since we're in our mid twenties and so forth and in bigger jumps as we age, especially with hormonal changes as women, but it stimulates that collagen cascade. And so no matter where you're getting your collagen stimulation, whether it's from injectables or lasers or energy-based devices, like ZERF, it takes two months for the body to get that collagen stimulated.

19:16So in that timeline, your treatments have honeymoon periods, I call them, but it takes a true two months to see your actual endpoint.

19:24Dr. Jacquiline Hakim:Oh, okay. So, okay. So two months, how many? Yeah. So what do you recommend in terms of frequency of like treatments done for the average patient? Yeah. So the studies with ZERF all were for mild to moderate skin laxity. And so, you know, if they're beyond moderate or severe and they're truly possibly like facelift candidates, they might need more than the minimum that's recommended. But I always start my patients with a minimum of two sessions. Some patients with a bit more skin laxity might need a third or so forth. And so we like to do two sessions to maximize on that proper stimulation of collagen.

20:02So once your collagen is stimulated the first four to six weeks, We try to see those patients back to really build on that first level of collagen stimulation. And with my personal experience, you kind of go through, I call it the honeymoon period, because when you get the treatment that day, there's the heat that's been placed into the tissues. But I call it the honeymoon. And honestly, our results are better than the honeymoon period, but I call it the preview. And then your body kind of slowly comes back to baseline after that first session as the collagen is slowly stimulating. but by the time you do your second session and you've already stimulated collagen, you only continue to see improvements throughout that second month, which is great.

20:42And results peak at two months for patients and then can still be stimulated up to six months.

20:47Dr. Jacquiline Hakim:Wow. So like in terms of like where it works the best, right? Like on the body, like I know for me, like I'm starting to see signs of aging on my neck. This is one of my concerns personally. I know a lot of women, like we see it early, you know, on the neck area. Absolutely. I mean, is this safe for like all areas or is it more efficacious on say like facial skin versus other areas? Yeah. Most of the studies are for the face and neck and that tends to be the most popular areas in office as well. We've done thousands of cases and face and neck are the majority. And it's interesting that you talked about neck, but there are studies that show people see the signs of aging first on their neck and their hands.

21:25And so I think people are cognizant of that because a lot of people sometimes only treat or do like skincare only on their face and may kind of neglect the rest of the body. And that's so common. But it's an area that should always be included with your skincare, with other treatments. And so like you touched on, it is a very popular place to receive treatments like Zurf and lasers and anything else. But face and neck is the most common combination we do in office for sure.