Lisette Hilton

A panel of dermatologists experienced in muscle toning and strength technologies shared their knowledge at the Controversies and Conversations in Laser and Cosmetic Surgery Virtual Meeting 2021, which featured a range of hot topics discussed by more than 50 experts.

Bioelectrical stimulation isn’t new. In ancient times, Egyptians and Romans managed pain using electrical charges from fish. Russians employed direct electrical stimulation to prevent muscle wasting under zero gravy in their 1960s space program. The technology was modified in 2018 for aesthetic use with high-intensity focused electromagnetic technology, or HIFEM (Emsculpt; BTL), according to panel member Anne M. Chapas, MD, dermatologist and medical director at Union Square Laser Dermatology in New York, New York.

Today, these technologies also include magnetic muscle stimulation (CoolTone; Allergan Aesthetics), multidirectional stimulation (truSculpt Flex; Cutera), and bioelectric muscle activation (Accufit; Lutronic).

Chapas combed the literature before incorporating muscle toning and strength into her practice. “Most studies suggest we should only be treating people with 25 BMI [body mass index] or lower,” she said. “But there are studies that suggest this works on visceral fat.”

Although investigators tend to recommend using 4 treatments over 2 weeks, Chapas said the ideal treatment and follow-up regimens remain to be determined. HIFEM study results show longevity for a duration of 6 to 12 months. However, patient satisfaction scores on abdominal use vary from 54.8% in a study by Fabi et al using CoolTone to 92% at 12 weeks in a study by Jacob et al.

Another consideration is that not everyone is a responder to muscle toning and strength treatment in the aesthetic practice, Chapas said. Anecdotally, she has reported positive outcomes in a wide range of patients, including those who are fit, have skin laxity, have BMIs over 25, and are 50 or older. “It gets harder to build muscle over the age of 50 and after menopause,” she said. “These are people that need more muscle mass to prevent injuries, to prevent falls, and to just maintain mobility.”

Technologies to tone and strengthen muscle can be used on the bi- ceps, abdomen, thighs, triceps, flanks, and buttocks, but not all devices are FDA approved to treat all areas, according to panelist Suzanne L. Kilmer, MD, clinical professor of dermatology at UC Davis Medical Center in Sacramento, California.

Study results suggest that treating patients with one of these technologies can reduce volumetric fat, improve aesthetics, and thicken muscle. She cited findings by Kinney et al, which show a simultaneous muscle and fat effect from HIFEM.

At 2 months, the 22 patients studied had an average circumferential reduction of 3.6 cm, a fat reduction of 18.6%, a muscle mass increase of 15.4%, and a diastasis recti reduction of 10.4%.

But there is more, according to Kilmer: After treatment, patients sit up straighter, feel better, and improve in sports. “There have been so many unsolicited comments from my patients, my friends, myself, that support this,” Kilmer said. “Backs don’t hurt as much. Posture is better. They can hold a plank longer. They are much better at yoga and Pilates. They have stronger tennis serves.”

Panelist Leah Spring, DO, US Navy commander, of Naval Medical Center Portsmouth in Virginia, described a study that found that treating athletes after anterior cruciate ligament (ACL) tear and reconstruction with exercise and neuromuscular electrical stimulation (NMES) strengthened quadriceps more than exercise alone.

Another sports medicine study looked at 25 patients with acute ACL rupture who received NMES or a sham treatment.

 Investigators measured muscle fiber size and contractility. “The authors found that ACL tear and subsequent reconstruction reduced muscle fiber size and contractility across all fiber types by 26%, the most marked of which was in fast-twitch type II fibers,” Spring said. “[NMES not only] reduced muscle fiber atrophy through effects on fast-twitch type II fibers but also preserved contractility in slow-twitch type I fibers.”

Spring was the lead author of a study that investigated functional outcomes using a commercially available NMES device marketed for aesthetic improvement. Although treated participants’ waist circumference decreased and thigh circumference increased, Spring said she was most impressed by the improvements she saw in strength and endurance performance.

For example, participants who received 4 NMES treatments using the strength protocol increased the time they could hold a single-leg wall sit 25% at 2 weeks and 119% at 4 weeks post treatment. Those given the endurance protocol increased performance by 50% at 2 weeks and 76% at 4 weeks post treatment. Treated participants also improved in static abdominal muscle endurance (a held abdominal crunch) and dynamic abdominal muscle endurance (standard crunches).

“We concluded that four 45-minute treatments with an NMES device led to significant improvement in abdominal and quadriceps strength and endurance. Results were sustained through 4 weeks post treatment. There was high patient satisfaction and no unanticipated adverse events,” Spring said.

Historically, it was not safe to combine HIFEM and radiofrequency (RF) in 1 device, according to panelist David J. Goldberg, MD, JD, director of Skin Laser and Surgery Specialists of New York and New Jersey; past director of Mohs and Laser Research, Icahn School of Medicine at Mount Sinai in New York, New York; adjunct professor of law at Fordham University School of Law in New York; and an editorial advisory board member for 

“RF electrodes are made of metal for good electrical conductivity,” he said. “Metal objects are contraindicated to HIFEM because they rapidly heat up when exposed to the electromagnetic field.” That changed with BTL’s Emsculpt Neo, a device that safely combines HIFEM and RF in a synchronized applicator, according to Goldberg, who studied the combined technology.

He reported on 5 patients who had three 30-minute abdominal treatments once a week for 3 weeks. Four participants were treated with HIFEM and RF and 1 received a sham treatment. He looked at histology, fatty tissue changes, in vivo temperature measurement, waist circumference, and patient comfort and satisfaction.

One week and 1-month post treatment, results showed ruptured membranes and alterations of adipocytes, as well as pyknotic nuclei, a sign of apoptosis. “We saw a statistically significant decrease in adipocyte area in the treated group. The sham subject showed no change. Digital photographs of a typical patient showed improved body contour, both in fat and muscle tone, after 1 month,” Goldberg said. “We expanded on that study last year, looking at ultrasound and MRI. If you look at ultrasound and MRI at 3 months, you can see a fat reduction as well as a muscle increase.”

In a 65-year-old female patient with a BMI of 20.1 kg/m

, there was an average fat reduction of 32% and an average muscle increase of almost 21%. Three months after treatment, MRI showed a decrease in the fatty layer and increase in muscle size, according to Goldberg.

He concluded that the histology showed apoptotic elimination of adipocytes, reduced fat cell size, and no necrosis; the therapy reaches effective temperatures for apoptosis; and the procedure is safe and comfortable, with high patient satisfaction.

Aesthetic practices might have viewed muscle toning and strength as treatment for a narrow patient population—people of or very near ideal body weight, according to Spring. “But I think so many different patient populations are good candidates for this,” Spring said.

These patients include many who could benefit from improvements in function, such as those who want to optimize strength and endurance, decrease pain, and return to sports after inactivity or injury, as well as older patients, according to Spring.

Kilmer serves on medical advisory boards for Dominion Aesthetic Technologies, Lumenis, and Solta/Valeant; serves on medical advisory boards of and does research support for Aesthetics Biomedical, Alastin Skincare, Allergan Aesthetics, Cytrellis, Lutronic, Merz Aesthetics, Miramar, Pulse Biosciences, Sciton, Sienna Labs, and Syneron Candela; and does research support for BTL Industries, Cutera, Cynosure, Galderma, and R2 Dermatology.

Goldberg does research for BTL and is a speaker for Allergan Aesthetics, Merz Aesthetics, and Revance. Chapas is a trainer for Allergan Aesthetics and a researcher and speaker for Lutronic.

Controversies and Conversations in Laser and Cosmetic Surgery Virtual Meeting 2021. Controversies Virtual Meeting. Accessed November 9, 2021. https://controversiesvirtualmeeting.com

Fabi S, Dover JS, Tanzi E, Bowes LE, Tsai Fu F, Odusan A. A 12-week, prospective, non-comparative, non-randomized study of magnetic muscle stimulation for improvement of body satisfaction with the abdomen and buttocks. LasersSurgMed. 2021;53(1):79-88. doi:10.1002/lsm.23348

Jacob CI, Paskova K. Safety and efficacy of a novel high-intensity focused electromagnetic technology device for noninvasive abdominal body shaping. JCosmetDermatol. 2018;17(5):783-787. doi:10.1111/jocd.12779

Kinney BM, Lozanova P. High intensity focused electromagnetic therapy evaluated by magnetic resonance imaging: safety and efficacy study of a dual tissue effect based non-invasive abdominal body shaping. LasersSurgMed. 2019;51(1):40-46. doi:10.1002/lsm.23024

Taradaj J, Halski T, Kucharzewski M, et al. The effect of neuromuscular electrical stimulation on quadriceps strength and knee function in professional soccer players: return to sport after ACL reconstruction. BioMedResInt. 2013;2013:802534. doi:10.1155/2013/802534

Toth MJ, Tourville TW, Voigt TB, et al. Utility of neuromuscular electrical stimulation to preserve quadriceps muscle fiber size and contractility after anterior cruciate ligament injuries and reconstruction: a randomized, sham-controlled, blinded trial. AmJSportsMed. 2020;48(10):2429-2437. doi:10.1177/0363546520933622

Goldberg DJ. Deletion of adipocytes induced by a novel device simultaneously delivering synchronized radiofrequency and hifem: human histological study. JCosmetDermatol. 2021;20(4):1104-1109. doi:10.1111/jocd.13970

Articles

Toning and strength technologies work, according to investigators, but many in cosmetic medicine question the procedures' efficacy in their field.

 Muscle Toning and Strength

The World Health Organization and United Nations characterized the unprecedented spread of news, public health guidance, fact sheets, infographics, research, opinions, rumors, myths, falsehoods, and more during the pandemic as an “infodemic.”

This infodemic has set the stage to be exposed to not only accurate, helpful health information but also health misinformation, which is false, inaccurate, or misleading based on the best available evidence at the time, according to the recently released “Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 2021.”

On a practice level, misinformation has consequences for quality of care and the doctor-patient relationship, according to Brian T. Kelly, MD, of Midwest Allergy and Asthma Clinic in Omaha, Nebraska.

“Misinformation can result in detrimental decisions throughout the field of medicine. Unfortunately, misinformation is readily available and can appear as fact on many different platforms. I suspect that virtually every physician in the USA has conversations with patients each day surrounding some form of misinformation a patient has heard,” said Kelly, who moderated the panel “Combatting Misinformation in Medicine” at the American College of Asthma, Allergy & Immunology (ACAAI) 2021 annual scientific meeting held November 4 through 8 in New Orleans, Louisiana.

 “Combatting this trend through facts and empathy are extremely important to maintain our patients’, communities, and global health.”

Impacting Dermatology and Other Practices

The rise of misinformation has resulted in many problems, according to Kelly.

“The COVID-19 pandemic and social media have resulted in extreme levels of misinformation,” Kelly said. “Two of these issues include reduced levels of care, [such as] patients not getting necessary care or procedures like a skin biopsy for possible skin cancer, and an unfortunate distrust in medical providers. It is imperative for physicians to engage and provide factual and rational rebuttals to misinformation as doing so will only benefit patients.”

The pandemic has highlighted the pervasive nature of health-related misinformation and how it can negatively impact medical decision making, according to David Stukus, MD, a pediatric allergist at Nationwide Children’s Hospital and participant on the Combatting Medical Misinformation panel at ACAAI.

“Patients often seek medical information online and unfortunately the social media algorithms emphasize emotion generating headlines, which frequently dilutes out evidence-based facts in favor of inaccurate anecdotes or testimonials,” Stukus said. “All health care professionals need to be aware of the influence misinformation has on their patients. Unfortunately, misinformation was a rampant problem prior to COVID-19 and will persist even after the pandemic is over.”

Dermatology is not immune to social media generated misinformation.

Researchers evaluating 49 YouTube videos with a total of 28.2 million views on vitiligo health education found more than half, or 27, were from health care sources, and 22 were from nonhealthcare sources.

Videos from health care sources had significantly higher accuracy scores and significantly fewer views, according to the study.

“Misinformation can lead to potentially harmful interventions and delay in seeking evidence-based care,” the authors concluded.

In another study, researchers assessed 39 YouTube videos about rosacea for accuracy and, again, found that videos by non-health care sources were less accurate and of lower quality but received greater viewer engagement than those produced by health care sources.

“The inaccuracies found were centered around the ability of interventions to ‘cure’ rosacea…,” the authors wrote. “For example, one popular suggestion among the videos included using apple cider vinegar to cure rosacea in addition to treating other conditions such as diarrhea and hypertension.”

There are some practical steps every physician and health care professional can take to help combat misinformation, according to Stukus, who offers these 5 tips derived from sources such as the US Surgeon General's report, as well as the growing peer-reviewed publications surrounding this topic.

Each health care professional should spend time online using common search engines to learn about the types of information and sites that appear as they input common questions they receive from patients.

After learning about the various sources of misinformation, health care professionals should learn what the evidence-based resources demonstrate regarding that topic, particularly regarding the discrepancies that appear.

Every encounter with a patient is an opportunity to actively address common sources of misinformation in a non-threatening manner. Health care professionals should always remain non-judgmental and spend time actively listening to their patients. It is important to recognize the influences each patient has in their life.

It is important to have talking points and resources ready to share with patients. These should be concise, clear, and delivered in a manner that is non-judgmental.

It would be great for more health care professionals to engage with social media to provide evidence-based information and fill the void where expertise is often lost online.

Health care providers also can fall victim to misinformation, according to ACAAI panelist Anne K. Ellis, MD, MSc, professor and chair of the Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario.

“It is really important to do you own research. Taking at face value what gets reported in the lay press or on social media can be tempting to make you do or recommend something that may actually be inaccurate,” Ellis said. “Throughout the pandemic I have trusted the Chair of the Division of Infectious Diseases to give the best knowledge ‘as of today’ that I can pass on to my patients and guide my practice. [Remember, it is] important to stay strong and don’t let patients bully you into practicing differently than what you know yourself to be best practice.”

Murthy VH. Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment 2021. U.S. Surgeon General Advisory. June 15, 2021. Accessed October 29, 2021. 

Confronting Health Misinformation (hhs.gov)

Confronting Health Misinformation. U.S. Surgeon General. Accessed November 4, 2021. 

https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf

Kelly B, Stukus D, Ellis A. Combating misinformation in medicine. Presented at: ACAAI 2021 Annual Scientific Meeting; November 4-8, 2021; in New Orleans, LA, and virtual.

Read C, Wu KK, Young PM, Armstrong AW. Vitiligo Health Education: A Study of Accuracy and Engagement of Online Educational Materials. J Drugs Dermatol. 2021;20(6):623-629. doi:10.36849/JDD.2021.5835

Chen AY, Azizi B, Borba AJ, Armstrong AW. Rosacea videos on social media: A comparison of accuracy, quality, and viewer engagement. Dermatol Online J. 2021;27(2):13030/qt55c0g9wz. Published 2021 Feb 15.

Experts discuss the impact of misinformation in medicine at the current ACAAI annual scientific meeting.

Misinformation in Medicine: Scope, Impact, Consequences

Dermatologists and aesthetic physicians are using the social media platform TikTok to educate and market their practices. And it’s working.

“…TikTok holds great potential as a platform for disseminating educational information,” wrote authors of a 2021 article published in the 

Journal of the American Academy of Dermatology

And TikTok’s influence is only growing. For example, views for #acne on TikTok more than doubled from 3 billion to 6.7 billion from September 2020 to February 2021, according to the article.

Brooklyn, New York, dermatologist Angelo Landriscina, MD, started using TikTok regularly when the pandemic began. The platform in turn helped him build his dermatology practice, which he started in December 2020. Using the handle @Dermangelo and with more than 258,000 TikTok followers, Landriscina tackles topics such as skincare. He also busts social media-inspired “hacks” such as why people should not apply vodka to their faces.

“At the time, I was already active on social media, mostly on Instagram,” Landriscina says. “While my primary goal is to produce educational content for the public, many patients have found me via TikTok. Having a presence on social media has been very helpful in building my patient base.”

New York City-based celebrity cosmetic dermatologist Paul Jarrod Frank, MD, uses the handle @drpauljarrodfrank on TikTok. He capitalizes on social media platforms to drive traffic to his PFRANKMD aesthetic health care brand.

“At the end of the day, everything we do on social media is educational and leads back to the [return on investment] of bringing in new patients and building brand awareness,” Frank says. “TikTok is a platform where content needs to be quick and digestible, and it allows us to take our creativity to the next level, while still providing educational content.”

Frank discovered TikTok’s power when he contracted COVID-19.

“It was a very scary time, and I wanted to openly share my experience to educate others who may have been going through the same thing,” Frank says. “As one of the first people to document my COVID-19 journey, my videos began to go viral and started important conversations. My educational COVID-19 videos got over 4000 comments and reached over 3 million people all over the world. Our treatment videos also go viral as they show eye-catching procedures and results that followers may have never seen before.”

Despite being banned in some countries, TikTok is the seventh most-used social network with 689 million active users worldwide as of January 2021. The majority of TikTok users in the US are younger than 30, according to Hootsuite.com.

“Social media platforms such as TikTok are changing the way we connect and interact,” Szeto et al wrote in an article published in April 2021 in the 

TikTok offers a constant, addictive stream of short, catchy videos curated for users, with the potential for cross-generational appeal. It is user-friendly and shows viewers videos based on their interests, according to an email to

™ from 2 of the article’s authors, Colby Presley, DO, a practitioner in the Department of Dermatology at Lehigh Valley Health Network in Allentown, Pennsylvania; and Mindy Szeto, MS, Department of Dermatology at the University of Colorado in Aurora.

“Typically, TikTok users post and seek out content they enjoy, things they’re passionate about,” they wrote. “They can also ‘duet’ to build on existing videos and communicate with people around the world in real time, so it becomes easy to make and develop those human connections. Our published study also highlighted how TikTok videos are unique because they can be posted to Instagram as Reels. With this capability, TikTok can make its videos available on both their application and Instagram, presently the largest social media application by follower numbers. [Although] TikTok is currently used heavily in the younger generation, Instagram has a wider age range of users and those Instagram users can see TikTok videos.”

Providers can leverage the fact that consumers and patients are using TikTok to discover and discuss medical information to directly connect with the public, as well as promote their brand and practice, Presley and Szeto wrote.

“Interactive ‘duets’ are very popular on highly viewed skin care videos, and we encourage providers to use this feature to be a presence and provide guidance on what medical advice videos say and do,” the authors wrote. “However, it’s also very important, and we recommend, that providers conduct themselves ethically, being aware of privacy and confidentiality, explicitly disclosing conflicts of interest, and maintaining professional boundaries, among other social media best practices. Furthermore, the amount of inaccurate or misleading health care information being shared on these platforms is high. We hope that greater provider presence on social media can help dispel some of the health care myths.”

TikTok, as with most social media sites, does not verify users’ credentials. So anyone can say they are a medical professional and provide medical advice, according to Presley and Szeto.

Frank says TikTok gives him the opportunity to set the record straight on important safety measures such as the use of at-home hyaluronic lip fillers.

Some dermatology and aesthetic topics or themes really seem to strike a chord with TikTok users.

“Recent topics that have done well on my page include using benzoyl peroxide for acne, tips for saving money on prescription drugs, and the lack of data behind using rice water for hair growth,” Landriscina says.

To make TikTok work for their practices, clinicians need to spend time on the app. “[TikTok] is not the same as other social media platforms, so you should familiarize yourself with the types of content that people respond to, see what kinds of content end up as trends, and absorb the overall vibe before producing anything yourself,” Landriscina says.

Users may ask clinicians who post on the app for individual medical advice, Landriscina cautions.

“Keep in mind that answering these requests is not considered ethical,” Landriscina says. “A good way to keep people happy is to see what topics people ask about frequently and produce educational videos about [those topics].”

Landriscina says he was successful on TikTok because he went into it without expectations and to produce content that he likes.

“People can tell if you’re enjoying yourself or not,” Landriscina explains.

It is OK to get a little bit personal, according to Frank, who uses his hobbies, including cooking and roller-skating, in his TikTok videos.

“It’s ok to experiment with different forms of content as long as it’s authentic and true to yourself and your brand,” Frank says. “It’s nice to get a glimpse into someone’s personal life.”

1. Kassamali B, Villa-Ruiz C, Mazori DR, Min M, Cobos GA, LaChance AH. Characterizing top educational TikTok videos by dermatologists in response to “TikTok and dermatology: An opportunity for public health engagement.” 

 2021; 85(1):e27-e28. doi:10.1016/j.jaad.2021.02.051

2. Sehl K. 23 important TikTok stats marketers need to know in 2021. Hootsuite. May 5, 2021. Accessed May 18, 2021. 

3. Szeto MD, Presley CL, Pulsipher KJ, et al. Dermatologist influencers on social media: Instagram Reels and TikTok interactive short videos. 

. 2021;85(3):e185-e188. doi:10.1016/j.jaad.2021.04.052

The app helps dermatologists and aesthetic physicians promote their practices, gain new clients, and share information. 

Inside DermTok: Winning TikTok Strategies

Intrinsic and extrinsic causes of hair aging differ among race and ethnicity.

For example, hair graying with age is universal, but its average age of onset varies with race. The average age of graying in Caucasians is in the mid-30s, for Asian people it is in the late-30s and for Black people, the mid-40s.

There also are different presentations among ethnicities of common hair concerns. A Caucasian patient seeking recommendations on what to do about damaged hair is more likely to experience damage at the distal hair shaft. A Black patient with the same complaint would be more likely to present with damage closer to the hair root.

Understanding these differences and why they occur can lead to more informed, culturally sensitive recommendations for treating and managing hair aging concerns, according to a review of studies published earlier this year in 

the Journal of Clinical and Aesthetic Dermatology

Study author Neelam Vashi, MD, founder and director of the Boston University Center for Ethnic Skin, director of the Boston University Cosmetic and Laser Center, and associate professor of dermatology at the Boston University and Boston Medical Center, in Massachusetts, says conducting the review helped to qualify and quantify what she sees in the clinic when Black, Asian, Hispanic or Caucasian patients present with hair aging concerns.

“There is very little published on hair aging in different ethnicities,” she says. “I really wanted to better understand the differences that we visibly see.”

Intrinsic hair aging includes the natural physiological changes that happen with time, according to the authors. “Intrinsic aging is what we are born with,” Vashi says. “It is dependent on the genes that we inherit from our parents, and it is also what we’re made of—our ethnicity and background.”

Hair graying is associated with aging and the decline in melanocytes thought to happen naturally with age. “I have had some patients come in because they felt like they were graying too early,” she says.

Not only is average age of graying onset different among ethnicities, but so is what is considered to be premature graying. “Graying is premature if it occurs at different times in different populations. It is at about age 20 in Caucasians, 25 in Asians, and 30 in African Americans,” Vashi says. “A lot of the differences can be attributed to pigment.”

This is important information to have when managing patient expectations and addressing their concerns, she says.

“If someone is an age where changes such hair loss is premature, then we can be more aggressive possibly in the medications we use and advise them to follow up with us,” she says.

There also are structural differences in hair that can impact how hair ages among ethnicities. The average diameter, or thickness, of Asian hair is from 80 to 120 µm, compared to 65 µm in Caucasian hair and 55 µm in Black hair. The average diameter of Hispanic/Latino hair tends to fall between that of Asian and Caucasian.

Caucasians have the highest hair density among the ethnicities studied. Black people have the lowest. Asian people have hair density that falls somewhere in between. The review authors did not have enough data on Hispanic hair density.

Black people have the lowest growth rate of hair but the highest eumelanin content. Breakage is increased or faster in this hair type. This group also has smaller hair cuticles than other ethnicities.

And while the hair shaft shape in Caucasians is cylindrical, it is ellipsoid or flattened in Black people, circular in Asian and cylindrical and circular in Hispanic populations.

The more manageable and controllable hair aging factors are extrinsic, including environmental exposures and physical stress from grooming practices. “Oxidative damage of the hair that can be caused by ultraviolet light and chemicals can change the quality and quantity of our hair,” Vashi says. “Chemicals, like hair dye or products for hair straightening, can cause damage to the hair fiber. Smoking can increase the rate of hair aging.”

In fact, studies have shown that the risk of hair graying is nearly twice as high in smokers vs nonsmokers, according to the review.

“There is a component of extrinsic aging related to different cultural practices. It’s not just how you were born and your genetics, but also your culture and what you do,” she says.

For example, the findings that Asian and Caucasian people present with more distal hair damage at the hair shaft and Black people with damage closer to the hair root is due not only to the structure of hair but also extrinsic factors, like cultural hair care practices, according to Vashi.

“Patients have come to me who say their hair just stopped growing,” Vashi says. “They think there is something wrong with them. There is nothing wrong with them. The hair is growing but when a break happens it is in a different hair. There is one hair that is growing and another that is breaking. If the breakage is happening faster there is a visible perception that there is no hair growth.”

There are things patients cannot avoid as they age, including graying and hair density decreases. But there are general and culturally specific changes and practices that can prevent premature hair aging. Among those strategies that health care providers can recommend are appropriate grooming habits; careful hair styling; better choices for shampoos, conditioners and leave-in products; better hair coloring choices; and medical therapies to treat underlying conditions, according to the study authors.

“If we can practice better hair styling regimens or if we can advise our patients to, then the aspect of breakage may at least improve,” Vashi says. “Then the perception of hair is that it is longer and growing more.”

Some examples of recommendations include telling Caucasian patients with hair damage to avoid hot straighteners. Black people with hair damage should also try to avoid harsh chemicals in hair care products, such as chemical relaxers, and practice healthier hair styling practices.

“Unique hairstyles, such as cornrows, tight hair ties, braiding, and weaves, common in individuals with African hair, create traction on the scalp, yielding traction alopecia,” the authors wrote. “Furthermore, as African hair exhibits tight coiling, everyday washing, combing and grooming practices increases knot formation and leads to a high prevalence of fractures along the hair’s length.”

Interestingly, cosmetic products to bleach, color, perm, or straighten hair can impact hair types differently. For example, Asian hair tends to be more resistant to straightening treatments than Caucasian and Black hair. Asian hair seems to have larger amounts of integral lipids, fatty acids, cholesterol, and wax esters than other hair, which makes Asian hair less susceptible to UV damage, as well, according to the review.

Hair dyes, in general, can cause allergies and damage hair, according to Vashi.

“There are certain components of hair dyes that can act as allergens,” she says. “I don’t tell patients to stop dying their hair, but I advise on safe procedures and to avoid anything that is causing pain, itching or burning on the scalp. We are only born with so many hair follicles. Once a hair follicle scars down or goes away, that’s it.”

Vashi says she offers patients patch testing to determine which hair dye ingredients might be causing the reaction and gives them an alternative recommendation.

Hair dyes are not the only culprits. Some relaxers or hot hair styling treatments can cause burns that permanently damage the hair follicles.

“Hair is such an important aspect of how people and patients perceive themselves,” Vashi says. “Cross culturally, there are certain aspects of the appearance of hair that are considered to be beautiful. We also have a population that is aging but wants to maintain a youthful, vibrant appearance. A lot of what we can do is to counsel, make hair care recommendations, offer treatments, and set expectations in a culturally sensitive way.”

Maymone MBC, Laughter M, Pollock S, et al. Hair Aging in Different Races and Ethnicities. 

A patients’ race and cultural background may be a factor in how the hair ages, according to a study in the Journal of Clinical and Aesthetic Dermatology.

Hair Aging in Different Races and Ethnicities

In his 25 years of treating women with hair loss, Alan J. Bauman, MD, ABHRS, FISHRS, says cosmetic physicians should take postpartum hair loss seriously, not only because of its potential cosmetic toll but also because of the emotional burden that comes with hair loss.

“If women say they are losing their hair, 99% of the time they are right,” says Bauman, who has a hair restoration practice in Boca Raton, Florida. “We take the situation seriously, and we more often than not uncover an underlying tendency toward hereditary hair loss which we can evaluate and treat if she desires.”

Common misconceptions about postpartum hair loss, according to Bauman, are that staying on prenatal vitamins will take care of it, there’s nothing patients can do about it, and shampooing less will help.

Hormones often cause postpartum hair loss, according to Jessica A. Shepherd, MD, MBA, FACOG, a board-certified obstetrician-gynecologist, women’s health expert, minimally invasive surgeon, and founder and CEO of Sanctum Med + Wellness, in Dallas, Texas.

“There is a significant shift in the postpartum phase that can lead to changes in how the hair processes, such as when you go through the actual cycle of hair growth. But that is temporary,” Shepherd says. “Patients usually say that they see more of their hair falling out, particularly in the shower, and when they are washing their hair.”

Women often describe postpartum hair loss as a synchronized shedding phase that starts 6 to 12 weeks after childbirth. They complain of decreased hair volume, decreased coverage, and sometimes recession in the hairline and temples, according to Bauman.

What happens to hair postpartum is much different from during pregnancy.

“During pregnancy, due to the effects of hormones, follicles are held in anagen [growth phase], longer, delaying telogen [resting phase]. Therefore, less daily shedding occurs,” Bauman says.

Hormones return to normal after childbirth, and those follicles that were previously in a prolonged anagen phase begin to turn off and hairs begin to shed—a lot—starting about 6 weeks after childbirth and continuing for at least another 2 months, he says.

“This telogen effluvium after childbirth is sometimes referred to as telogen gravidarum,” he says. “Within a few months after pregnancy, a higher percentage of follicles than normal are in the

telogen phase. Regrowth can be slow and some of our postpartum hair loss patients complain of poor hair quality, dull hair, [and] brittle hair.”

However, hormones do not explain all postpartum hair loss.

“There’s also a multifactorial process occurring that includes emotional stress, physical stress, immune response, a healing response, and likely some nutritional gaps that could make this situation much worse for some, especially those who have preexisting conditions like strong hereditary hair loss in the family or genetic traits such as thin, fine, less dense hair [fewer follicles], or a previous history of telogen effluvium, either chronic or acute,” Bauman says.

It is important to reassure patients that postpartum hair loss generally is normal and temporary, according to Shepherd.

“I tell patients hair usually returns to its usual hair growth cycle between 6 and 12 months after birth,” she says.

Postpartum hair loss can take an emotional toll, especially given the changes and stresses after a baby is born. Patients unaware of the possibility of postpartum hair loss might find it shocking or worrisome, Shepherd says.

“Unfortunately, many doctors shrug off female hair loss in general and don’t understand the emotional connection between a woman’s hair and her well-being,” he says. “This is especially true about postpartum hair loss.”

Bauman starts the patient evaluation by taking a thorough history and doing a physical exam.

 and the new AI [artificial intelligence]-driven HairMetrix

 (Canfield Scientific) for a detailed hair growth analysis so we can establish a baseline and monitor over time. We recommend evaluations every 90 days,” Bauman says.

While there are a few treatment options for postpartum hair loss, Bauman says, it is important not to prescribe medications during pregnancy or nursing.

“Nonchemical, breastfeeding-friendly therapy must support the mom’s body and mind, as well as not affect breast milk or the baby,” he says. “Nutrition, self-care, feeling calm, [and] getting rest are all part of the equation. Taking a multitherapy and holistic approach may be preferred.”

As part of his emphasis on self-care, Bauman’s practice offers scalp makeover treatments, performed by a certified trichologist.

“These became exceptionally popular during the pandemic as a safe and relaxing, mentally transporting experience that also helps maintain healthy hair and scalp by addressing scalp inflammation and cortisol levels. A Keravive

 [HydraFacial] exfoliation combined with a scalp massage is therapeutic but also extremely relaxing,” he says.

Nutritionally, since many women continue their prenatal vitamins in the months immediately following childbirth, Bauman says, he is careful not to overdo nutritional recommendations. He recommends supplements, including Nutrafol Postpartum

(Nutraceutical Wellness Inc), which is breastfeeding-friendly, works with prenatal vitamins and addresses the stress/cortisol component of shedding. He also recommends theanine and shatavari, which are herbs and stress adaptogens to help with stress hormones and relaxation, specifically for female physiology, according to Bauman.

At-home laser therapy devices can help, Bauman says. They are nonchemical, noninvasive, and convenient. Plus, today’s options deliver more energy to larger areas of the scalp in less time, he says.

“Avoid weak, clunky-plastic consumer devices and stick to physician-prescribed devices that have over 300 diodes,” he says. “You get what you pay for on this.”

Platelet-rich plasma (PRP) is among the most aggressive of the minimally invasive treatments, and local anesthesia is not an issue for nursing, according to Bauman, who cites a published report in Stem Cell Investigation.

Shepherd, who is unlikely to recommend treatment for postpartum hair loss for up to 1 year after childbirth, says she might recommend PRP if hair loss continues past that point.

“PRP injections are a good avenue because the treatment does not impact moms who are breastfeeding,” she says.

Most importantly, doctors must leave patients feeling reassured that postpartum hair loss will most likely straighten itself out on its own, and give women the time to revert to a normal hormonal status, Shepherd says.

Bauman and Shepherd report no relevant disclosures.

1. Haircheck. Haircheck. Accessed August 9, 2021. http://www.haircheck.com/for-the-trade/ 

2. HairMetrix. Canfield Scientific. Accessed August 9, 2021. https://www.canfieldsci.com/imaging-systems/hairmetrix/

3. The scalp health solution: Hydrafacial Keravive. Hydrafacial. Accessed August 9, 2021. https://hydrafacial.com/keravive/

4. Nutrafol Postpartum. Nutraceutical Wellness Inc. Accessed August 9, 2021. https://nutrafol.com/nutrafol-postpartum-for-women/

5. Garg S, Manchanda S. Platelet-rich plasma-an ‘elixir’ for treatment of alopecia: personal experience on 117 patients with review of literature. Stem Cell Investig. 2017;4:64. Published July 18, 2017. doi:10.21037/sci.2017.06.07

Postpartum hair loss can cause acute emotional burden, according to Alan J. Bauman, MD, ABHRS, FISHRS, and physicians must be aware of the considerations needed for this patient group.

Expert Advice: Don’t Shrug Off Postpartum Hair Loss

Most reported adverse events (AEs) associated with cryolipolysis (CoolSculpting; Allergan) treatment are minimal and transient. But there are a handful of potentially serious complications from the popular noninvasive body contouring option.

The most common and relatively mild AEs of erythema, numbness/paresthesia, bruising, and edema are to be expected from a technology that freezes subcutaneous adipose tissue, according to Bobak Hedayati, MD, dermatology resident at University of California (UC) Irvine and first author of a systematic literature review of cryolipolysis-associated AEs published last year in 

In the review, the less-serious common AEs developed within a week of treatment and resolved spontaneously, according to the authors.

“The meat of our study was to look for those uncommon or rare complications that are possible,” Hedayati says.

In their review of 53 articles and a total 3,312 cryolipolysis patients, Hedayati and colleagues found the more serious AEs (SAEs) associated with cryolipolysis were: dysesthesia—including increased sensitivity, tingling or burning in 59 patients—delayed, severe, or persistent pain in 49; paradoxical adipose hyperplasia in 30; skin blanching in 15; vasovagal reactions in 14; skin hyperpigmentation in 8; and contour irregularities in 3 patients. Nerve injuries also occurred in some patients.

A Closer Look: Paradoxical Adipose Hyperplasia

Less than 1% of cryolipolysis patients develop paradoxical fat hyperplasia, an unexpected increase in the number of fat cells, according to the American Society of Plastic Surgeons website.

Paradoxical fat hyperplasia is three times more common in men than in women and is seen more in those of Hispanic or Latino descent, according to the American Society of Plastic Surgeons.

“This is a serious complication in the sense that it does not go away on its own,” Hedayati says. “It is a benign tumor of the fat cells. All the cases in our review had to be treated with liposuction.”

There is evidence that some patients with paradoxical adipose hyperplasia resolve without treatment, according to a 2018 paper published in 

 Investigators studied 398 patients who each had a session of cryolipolysis, 4 of which presented with voluminous painless swelling in the treated area between 2- and 4-months posttreatment. While 1 patient was treated with liposuction, the other 3 did not receive any additional treatment and their symptoms stabilized after several months, according to the authors

 of nearly 8,700 cycles of cryolipolysis in 2,114 patients, investigators reported paradoxical adipose hyperplasia incidence rates of 0.05% to 0.39%. However, incidence rates fell by more than 75% with new CoolSculpting units, according to the 2021 paper.

 Italian investigators reported that transitioning from the CoolSculpting CoolCore system to the CoolAdvantage applicator system had no impact on safety but led to greater versatility and increased numbers of cycles per treatment.

“There were only 2 significant complications: 1 paradoxical adipose hyperplasia (with CoolCore) and one loss of sensation (with CoolAdvantage),” the authors wrote.

Some suggest paradoxical adipose hyperplasia can result from improper use of the device—not freezing an area long enough or not latching on well enough to the treatment site to achieve adipose tissue apoptosis, according to Hedayati.

Nerve injuries post-cryolipolysis are also more likely to occur with improper or inappropriate use of the CoolSculpting device, says study author Margit Juhász, MD, MSc, a dermatology resident at UC Irvine.

“It’s very rare to have nerve pain or numbness that lasts for more than a week after cryolipolysis,” Juhász says.

study included a case where a patient treated with CoolSculpting on the upper arm developed a radial nerve injury leading to weakness in the wrist and finger extension. The patient’s motor function was restored 6 months later with no additional treatment.

One possible reason for the complication, according to Hedayati, was the patient was thin and might not have had enough adipose tissue on the arm to indicate cryolipolysis.

“The radial nerve runs pretty superficially to the skin, so a skinnier person may have a higher risk of damaging those superficial nerves,” she says.

Additional complications written in the review included separate patients reporting left mandibular nerve injury, throat swelling, and hoarseness after submentum cryolipolysis.

When used incorrectly or inaccurately, cryolipolysis can, in rare cases, result in SAEs including dysesthesia, pain, paradoxical adipose hyperplasia, skin blanching, vasovagal reactions, skin hyperpigmentation, contour irregularities, and nerve injuries.