The Discovery That Changed Aesthetic Medicine with Dr. Jean Carruthers

0:00Hi guys, welcome back to Skin Anarchy. Today's episode is very, very special to me. This is literally my dream guest for the show and I am so incredibly honored and humbled to have her here with us today. So without further ado, please welcome Dr. Jean Carruthers, who many of you might recognize from her revolutionary work in aesthetics that has really framed modern aesthetics as we know today. And the discovery continues to frame so many conversations, so many discoveries that are still coming out. So without further ado, please welcome Dr. Crothers. I'm so honored to host you. Well, thank you so much.

0:35I'm honored to be on your famous podcast. It's a thrill for me too. Thank you so much. I really would love to start, you know, from the beginning. I know that yourself and Dr. Elster Crothers, you both really collaborated, you know, to bring this discovery forward. And I would love if you could walk us down memory lane and talk about that moment where you realize that your neurotoxin could be that next frontier for aesthetics. Oh, thank you. You know, I was very blessed to have such an intelligent and thoughtful and open-minded husband. And it was really when the aha moment was actually when one of my blepharospasm patients got angry at me.

1:22Now, I have to frame this, and I use your word frame, because all the blepharospasm patients were given back their life with botulinum toxin injections. They couldn't open their eyes to cross the street or earn a living or drive a car, and suddenly they were back being normal people again. So when one of them got angry, that was a big flag. So I really listened. And she said, you didn't inject me here, pointing to her medial brows. And it just so happened with Alistair being a dermatologist, he had been trying to treat frown lines for his cosmetic patients using collagen, fibril, and autologous fat, none of which gave a nice result when the face was in motion, only when it was relaxed.

2:20So I apologize to that patient for not injecting her in that area. And, you know, I owe her a big vote of thanks for educating me because I hadn't really seen that as an issue before. Because in those days, I was not an aesthetic physician. I was a strabismus surgeon, ophthalmologist, functional. So I went home that night, and we have three sons. and over dinner and the chaos, I said, you know, we should really talk about using my botulinum toxin. I was doing the study with Alan Scott on your wrinkle patients because there could be a great synergy. And instead of saying, oh, don't be silly, you've got that terrible poison, he said, oh, that's a great idea.

3:10And so that's how we started working together. And until that time, we'd always been husband and wife and parents together. But this was the start of a whole new world. That's so fascinating. And, you know, this, I mean, the whole discovery and the story, you know, behind it really reminds me so much about what we, I think, are taught, even in school, right, about science, how it can translate. And we can discover something in one area, and it will really revolutionize so many different areas of medicine and science. And I would love to get your, you know, just your take on this and the idea of true discovery in science.

3:49You know, like, what are your thoughts around that whole philosophical concept? I think we have to use the parachute analogy, that a mind is like a parachute. It doesn't work unless it's open. Yeah. So I think that we have to be humble and we have to be listening to our patients and to our colleagues. Because I think if you think you know everything, you're never going to have a discovery. But if you stay humble and you work hard, things will fall into your lap that you never thought of. So I think it's an attitude thing, the science and discovery thing that I think people who discover, like, for example, the discovery of microwaves being for cooking.

4:45You know, it was an accident. But the gentleman had an open mind and could see, oh, if we can pop corn, what else can we do? So I think it's an attitude thing. I think there was a study done in the eastern states. I think it was an insurance study. And they did everybody's IQ. And then they taught them. And then they examined them. And the other thing they did ahead of time was to check on their attitudes. And the correlation at the end was the people who were arrogant got the worst marks. Wow. People who were humble had the best marks. because they were allowing their minds to be open. Yeah. Wow.

5:33No, that's really, it makes you think. I mean, no one ever speaks about that, the humility component in science. I think right now, the way that academia has evolved over the years, at least in my understanding, it's like everybody's got such a big ego these days. So it's hard to get through that sometimes. But yeah, when I look at discoveries such as yours across the board, I see what you mean. There is a level of humility in every scientist there that's done it. So it's very fascinating. I want to ask you though, because I mean, obviously Botox has now been applied across the board. There are so many areas that have benefited, right?

6:08And this understanding, it just continues to expand every single day. Did you know that when you first discovered the benefits in the aesthetic field, did you think that this would go beyond and start dealing with things like migraines and all of the different applications we see today? I know. That's an easy answer. It was pretty amazing to find a treatment that worked and you could see on an N of one that it worked. Our very first patient in our study, the one we did together, which we published in the Journal of Derm Surgery, and it was our receptionist. Now you have to imagine what it's like back then in 1987 because I've been treating patients now in Alan Scott's NIH study since 83 when I got approval from Health Canada.

7:12So four years I've been treating all these people for dystonias and strabismus. And the one person in the world who could see that all of these people were happy, well-looked after, healthy, doing well, doing better, was our receptionist. And our receptionist, Kathy, had wonderful frown lines. And so we needed a first person for our study and so we said to Kathy who unique person on the planet because every other one of the eight point whatever billion people on the planet except for Alan Scott and a few other notables in United States and Canada thought of botulinum toxin as the most poisonous poison so to have somebody who was so relaxed about being treated for cosmetic reasons by the most poisonous poison was our receptionist because she'd spent four years seeing all my patients in the research patients.

8:25Unusual because everybody else in when we then were recruiting more patients for the study, Everybody else would say, oh, no, I don't think so. That's a terrible poison. I don't want to be part of that. Yeah. So I've got Alistair to eject me. And then they'd get to the part where it's, oh, no, it's a terrible poison. I don't want. And I'd say, oh, what do you think of this? And I'd show them my photograph from before with my magnificent frown lines, which I used to have. And then I'd say, well, what do you think? And they'd say, oh, do it. Because they could see I was perfectly healthy and I had the brow that they wanted and they could see where I had come from.

9:11And they also could see I was perfectly healthy and engaged with this. So it's a big learning point too in discovery. Maybe you have to do something yourself before other people will believe you. Yeah, that's really fascinating that you say that, you know, because I was going to actually, that was one of my biggest questions. because when you think about it, I mean, it must have been so shocking for everyone involved back then that this is a toxin, you know, how can we bring this forward in a therapeutic way? And I would love your thoughts on like, just what you see now, because I feel like it's happening again, where people are trying to discover something truly novel, right, in aesthetics, like, for example, exosomes are super, you know, on the frontline right now.

9:56But again, you see that same kind of critique coming up where it's like, this is absurd. Like, how could this possibly work? You know, so what were some of the things you had to push through from the scientific side, as well as convincing, you know, your colleagues and the prominent researchers at the time to, no, this is the real deal, you know? Yeah, that's actually the question. And that was the question. And the only way we had to confront the horror of our colleagues. When I I gave the first paper at the American Society for Dermatologic Surgery meeting in 1990.

10:38There was dead silence in the room. And normally after I give a talk, people ask some questions. We have some discussion, you know, like anybody else. But it was dead silence. But they came up afterwards and they said, how could you use that terrible poison on something so frivolous as wrinkles? First of all, it's not a poison if you know what you're doing with it. Paracelsus, the famous Swiss physician, everything is a poison. It's the dose that matters. And so that's one realization. And also, to be fair, they hadn't been involved with Alan Scott's research program for four years. So they hadn't had the experience of using this incredibly new, exciting material in a research way.

11:26So they didn't understand about the fact that it had been used by many other people other than me all through the four years of the study. And the other thing was that was really would never fly today. There is nothing frivolous about a wrinkle. because wrinkles are self-esteem. And the most important thing for people is their self-esteem. So there were so many misconnects in the messaging. So that was really what we had to deal with. But how do you deal with that with people who've got a certain mindset and are not happy to open their minds to another use? So what we had to use was the scientific method because everybody understands the scientific method.

12:22It's cast in stone how you do things to be believed. And so we used that. So that was how. And then gradually we kept, we were so busy. We would do, you know, 17 meetings in a year, you know, trying to get the message out. and then gradually we got invited all over the world to talk about what we did. And gradually they start getting, oh, well, I could do that. I could do my own research projects on that. So pretty soon now you start seeing we've got, I think there's over 6 ,000 peer-reviewed scientific articles in the literature on botulinum toxin and its uses cosmetically. Really amazing. It's probably the best studied of many drugs and studied with great science.

13:17Yeah, yeah. I know this, it's really, I mean, it's fascinating what it did for an entire field, you know, and I think this is where the idea of a ripple effect really comes front and center in science is that, you know, and I get very confused by some of the critique I see, right, in the scientific community when somebody is trying to really revolutionize, maybe all of the pieces aren't there yet, but there's enough to where they're like, no, this is something worth talking about, you know? And that's why I asked you that because we see so much of that critique now, you know, before things even, they start blossoming at all, you know?

13:53Yeah. Yeah. Yeah. It's a steep curve. It's really, really hard to make progress. But then once it gets flying speed, look out. I mean, look at how many indications there are around the world. It's in every country. It's a great idea. And I think it's also fueled a whole other thing, that if you feel good, you're going to do better in your life. And so it's created this whole new avenue, as you were pointing out, with exosomes and other approaches to general wellness. Yeah, absolutely. No, it's remarkable what it's done for the field of aesthetic medicine, but also beyond. I mean, this is the kind of stuff that I think when you look at it from the lens of science and creativity, it makes you really think like, yeah, this opens doors to people's minds and how you think and how you interpret the data that we're seeing in a lab.

14:51And it really is the spotlight and truly what translational medicine actually means. And that's why for me personally, as a young person in science, it means so much to watch this work evolve even now. And on that note, I would love to talk about your recent paper. You discussed and showed that drugs like Ozempic and the GLP-1s, they make the neurotoxin wear off faster. Can you talk to us about that and what you're really finding in that realm? We don't really know that. This is computational modeling. And so the FDA has used computational modeling for over 30 years. and it's a great way using mathematics to decide whether it's worthwhile going ahead and putting research subjects through a trial because you can actually, using information that's publicly available and using various algorithms, you can compute whether something is likely to work or not.

15:56And so it's used all the time now in discovery for cancer drugs and starting to be used more for other drugs. And I think, I don't know for sure, but I think with the weight loss drugs, they've probably been using it as well. But the weight loss drugs are a really fantastic new wave because if you look at the United States, it's 12.5%, which is like 44 million people. And I bet you that's an underestimate. of how many people are using. Because it's so good for your mental health, for your inflammation, for your lungs, for your heart, for your kidneys. It's not so great for your skin. I'm just doing a study on that at the moment, looking at a group of women who are on terseptide, 20 of whom are getting treatment with a skin-shrinking device called SoftWave.

16:59It's an ultrasound device. at the beginning when they start their TOS hepatite versus the other group that are going to get it at six months, when they have had their TOS hepatite for six months, asking the question, is it better to think like a millennial? And prevention is better than cure, I suspect, but I don't know until the end of this study. That's very fascinating. I can't wait to see the results of that. I mean, it's really interesting because, and this is what I wanted to ask you really was what was the most interesting like kind of side you know revelation that happened after botulinum toxin really came to the forefront people started studying it more for you personally like wait what was that one like application where you're like oh you know I never even thought that we could use it like this you know it was um I saw the benefit with fillers in because I published on that but what really blew me away was how great it was with energy-based devices for example one study I did was on intense pulse light and I was treating the patients for their crow's feet with with Botox and what staggered me was how much the pigmentation that they had how much better they responded to the IPL in the group that got Botox.

18:23Oh, wow. It's fascinating. Why is that? You know, it obviously has other ramifications that we just don't understand yet. Yeah, yeah. No, that's really, I mean, I think that's what I get very fascinated because so many dermatologists are now educating on this where it really improves the quality of your skin over time as well. And, you know, I would love for you to speak on this because I think recently there has been some fear-mongering, you know, amongst consumers and you know about oh what you know too much Botox like when do you start and like is there such a thing as starting too early what are your thoughts on that in terms of true patient education around the use of Botox for you know your lifetime?

19:06Well that's a great question because I am not a millennial but I think millennials rock because I love their attitude. And I agree. I mean, there's with their attitude that if you can prevent something going down the wrong road, why don't you do that? For example, millennials in their early 30s will notice that they're starting to get frown lines or horizontal forehead lines and start with what's called baby Botox. But, you know, small doses, preventative doses, I think that the question of when should you start is when it starts to bother your self-esteem. Now, given that in society, largely we don't approve of people doing things independently until they're at least of age 18.

20:04In some jurisdictions, it's 19. But I think that that's the thing. there is a tremendous tie-in between how you feel and how you look. Yeah, no, that's, I, yeah, I couldn't agree more. I mean, even like when I look out into, you know, social media and stuff, I mean, I'm always in the media space. It's always so apparent that, you know, it's not about this like procedure that someone's getting. It's more about like, where was your mind when you went in for that? And where's your mind now after you got it? You So I hear you when you say that about the mindset part. But I really want to know, in your mind, where do you think we're headed as an entire field, like the aesthetic medicine at large?

20:45Do you think it's going to be more device-based going into the future? Or do you think these topical applications are also very viable for real changes? Oh, I think a combination. Because the aging process affects every single tissue layer from our bone out. You could say it affects our brains as well, but we aren't going there except for the emotional side. But I think that if we can find ways that in a non-invasive and safe way we can help people prevent the aging changes and allow them to be productive, happy members of society for longer, why not? Yeah, yeah. That makes sense because I brought up exosomes earlier and that's what I would love to like.

21:33I mean, how do you feel about exosomes and these regenerative ingredients that are kind of popping up now? I don't see. There's a lot of marketing with exosomes. And there's also getting to be much more science. But I think it could be said truly in the last two years, the marketing was ahead of the science. But there is one company in Toronto called Acorn, which pluck 50 hairs from your head. and then use the hair bulbs to grow your own secretosomes. So your own personalized exosomes. And they make the product for you and store it. And then you can use it for facial rejuvenation or hair growth or whatever.

22:20And I can see the point of using your own product on you. That makes so complete sense to me. I'm not so sure about using plant products on us. I'm not so sure about using other people's adipocytes as the exosome source. But there's so many different sources of exosomes. But truly, I think topical exosomes, if they're your own, that's the sweet spot. Yeah, no, that's, I'm glad you brought that up because, yeah, I know about Acorn, actually, very fascinating stuff that they're doing. Yeah, really, really cool company. And, you know, it makes me really wonder, like, about the customization of aesthetic medicine as we go into the future, you know.

23:11So, I mean, what are your thoughts on that and your take on in terms of like bringing dermatology almost like home for people? You know, I always wonder about that aspect because it's the one field of medicine that so many are interacting with. But it's like that part of you that feels like, OK, I can do it at home. Kind of how we do IVF these days where you can do your own injections at home. What are your thoughts around that? I think it's the future. Yeah. Because you live in your skin. And you can buy virtually everything on the internet. I love it, the red light masks, you know, stimulating your mitochondria.

23:49I think that's great. There are people who do their own little microneedling things at home. The one thing I'm scared about with the at-home is self-injecting botulinum toxin. Dr. Andy Pickett, who's a famous researcher in England, sourced five vials from the internet. of so-called Botox. And he analyzed each vial, and he found between zero and 280 units of botulinum toxin in each vial. Wow. So you don't know what that little white powder is, first of all. It could be bleach. You don't know how much, and the units, I mean, how strong is it, what you're injecting. And then there are people who've used sourced neuromodulators on the internet.

24:40A year or so ago in the United States, there was an epidemic, a localized epidemic of essentially clinical botulism. And in Canada, we had two ladies, ditto. This is all totally preventable if you use the approved substance. And I couldn't inject neuromodulator if I didn't know who made it and where it was approved. It's just too dangerous. Yeah. No, thank you for saying that. And I really hope anyone listening out there that has never, you know, actually gotten it done professionally, like you're not planning on experimenting. I'm so glad you said that. And, you know, I actually want to ask you about in terms of because, you know, Botox grew so fast, right?

25:31It became a phenomenon, and that's wonderful, right, to see science grow so quickly and be adapted to so quickly. But were you ever concerned at any point? Like, where is this being taken, and are we going to stay true to the science? I mean, were there ever moments like that for you, watching it grow and expand? Not really, no, because my experience was with other doctors who were cognizant of what this molecule could do if it was, you know, if we didn't use the paracelsus, tame it down with the dose. I didn't have that worry. I do have that worry where people are, I don't know where they're making it, but they're putting the vials out there.

26:20I do worry that people, like just happened in Canada, will have an adverse event, which could be, you know, they could lose, I think the first one I was aware of was 2004 in Florida, where an unfrocked osteopathic physician injected 20 million units of Botox. It wasn't really Botox. It was a research-grade neuromodulator that he bought from a lab in California and injected it into four people, one of whom was himself. And the reason all these people survived was because of the fabulous skills of the intensivists in the hospital in Florida. But that was such a shock that it killed the cosmetic Botox business in Florida a good six months, maybe longer.

27:18I think the public understand that it's safe and effective. And then the question is, if somebody says, well, here's another one, I got it on the internet, it's the same, but it's only, you know, a tenth the price. If something is too good to be true, it probably is not true. Exactly. Yeah. You know, I think we have to have common sense out there too. Yeah. No, that's really, that's interesting. I didn't know about that, that 2014. I mean, that's exactly like what I, like, it really just, it confuses me in aesthetic medicine, because for some reason we see it so much in that field of medicine, you know, it's like, even with you know I know you brought up like the at-home microneedling devices I feel like they've evolved now you know in the recent years but I remember people were just like going crazy with it you know and they had these terrible injuries and for some reason in aesthetic medicine we love to take it into our own hands and say well we can do it you know and you don't need a professional to really guide you which I will never understand.

28:22I know I know it's it's it's amazing. Yeah. No, what is, what excites you the most when you look at the research being done in, you know, in this field now compared to 20 years ago or so? Like, what is the most exciting part nowadays? nowadays? Well, I think that I'm starting to become incredibly excited by the fact that people are getting data. I think we've been very spoiled over the last years because the FDA and other regulatory agencies have approved before and after photographs. and we've been so spoiled but now i can see with ai can you trust those photographs yeah and so what's the truth does this really work are all those photos um are they all shall we say reimagined uh so i think we're going to see the need for more data uh i have just developed with my colleagues have just developed a little cell phone app that you can measure your own elasticity in your skin with data.

29:41It's called the skin elasticity factor. So we're just at the last stages before getting it into the Apple App Store and the Google Store. So that's our feeling that if the AI is going to take away one of those, I mean it's huge to take away the validity of photos that's just enormous that's an enormous blow to our industry yeah so we need to have another way we can validate the photos yeah no that's actually I mean that's a very fascinating take because you're right I mean there are so many now editing apps and so much I mean even before AI I feel like that the face tunes of the, you know, the app world and stuff.

30:28I mean, it's a lot. And these days, I think there was, somebody told me a statistic where you need to see like, I think 12 to 14 before and afters before you get convinced as a consumer to go in for a procedure. And it just makes you wonder, like, is that even applicable anymore? Because that's all we seem to be seeing these days, you know, is people online. So it's a whole new world of evidence. I'm excited by the fact that is going to improve the quality of evidence. Yeah. And maybe somebody can figure out how to tell if a morphed picture is a morphed picture or if it's a real picture. Yeah.

31:06No, I hope we can get there because that would be wonderful. I would love for you to offer some advice, though, some words of wisdom to the current physicians in aesthetic medicine right now and maybe some aspiring ones, you know, about medicine at large and staying true to the science and not letting yourself get, you know, roped into other avenues that maybe dilute those efforts in the scientific side. Yeah, that's a great question. You know, there's a saying that advice isn't worth the paper it's not written on. Yeah, yeah. But I think believe in yourself. That's probably the best thing. When you have an idea, then think through what you have to do to follow up on that idea, to give it the evidence that you can then share with your colleagues.

32:06But I think believe in yourself. Look after yourself. No one else will. I think make sure, and rule two would be surround yourself with positive people. that makes sense i like that i like that a lot no it's really it's amazing um hearing you talk about the psychology aspect of everything because i just feel like we don't hear that enough you know about like like what you were saying earlier about self-esteem and understanding like what all of that really means in the context of like how medicine applies to real life and you know what results you end up seeing at the end of the day and i think it's profound to have that kind of mindset.

32:49But Dr. Carothers, thank you so much. This has been such an honor, and I am so grateful for your time. Thank you so much. Thank you for thinking of me, and I appreciate the good things that you're doing with your podcast. Keep doing it. It's wonderful. Thank you so much. That truly means the world coming from you. Thank you so much, and for everyone listening, thank you for tuning in.