Latest / Skin Anarchy / Structural Skin Tightening: Understanding XERF with Dr. Jacquiline Hakim

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Structural Skin Tightening: Understanding XERF with Dr. Jacquiline Hakim · Skin Anarchy

• 0:00
  SPEAKER_01: Hey guys, welcome back to Skin Anarchy.
• 0:02
  SPEAKER_01: Today is a very, very informative episode.
• 0:04
  SPEAKER_01: We're gonna learn a lot today, and I'm super excited because we're joined today by Dr.
• 0:08
  SPEAKER_01: Jaclyn Hakeem, who is a double board certified dermatologist and cosmetic specialist.
• 0:13
  SPEAKER_01: And she's also the CEO and founder of Divina Dermatology and Cosmetics Center of Beverly Hills.
• 0:18
  SPEAKER_01: So Dr.
• 0:18
  SPEAKER_01: Hakeem is truly an expert in the field of aesthetics, regenerative aesthetics, restorative aesthetics.
• 0:23
  SPEAKER_01: And so I'm so excited to chat with you, Dr.
• 0:25
  SPEAKER_01: Hakeem, today about everything that has to do with beauty.
• 0:28
  SPEAKER_01: Welcome.
• 0:29
  SPEAKER_00: Yeah, thank you so much for having me.
• 0:30
  SPEAKER_00: I'm excited for this coming back.
• 0:32
  SPEAKER_01: No, I'm very excited, and I know there's a lot to unpack.
• 0:35
  SPEAKER_01: You have a phenomenal background, very, very impressive.
• 0:38
  SPEAKER_01: I mean, you are truly immersed in the world of science.
• 0:40
  SPEAKER_01: And I think for our listeners, that's what we want to like really understand.
• 0:43
  SPEAKER_01: But to get us started, walk us down every lane.
• 0:46
  SPEAKER_01: What got you into medicine to begin with?
• 0:49
  SPEAKER_00: Sure.
• 0:49
  SPEAKER_00: 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.
• 0:56
  SPEAKER_00: And the art and science of dermatology really was an attraction to me.
• 1:01
  SPEAKER_00: 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.
• 1:07
  SPEAKER_00: I worked at a germ office in between college and medical school, fell more in love with it and knew that I didn't see myself doing anything else.
• 1:17
  SPEAKER_00: 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.
• 1:24
  SPEAKER_00: And it's such a cool field because it's always evolving.
• 1:27
  SPEAKER_00: And so there's always constant learning, constant growth, which is really exciting.
• 1:32
  SPEAKER_01: Yeah, absolutely.
• 1:33
  SPEAKER_01: No, this is I, you know, I've said this a lot of times as well to our listeners.
• 1:37
  SPEAKER_01: 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 discipline.
• 1:46
  SPEAKER_01: So lots to absolutely.
• 1:48
  SPEAKER_00: And aesthetics is a medicine.
• 1:50
  SPEAKER_00: 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.
• 1:58
  SPEAKER_00: But at the end of the day, it's still medicine.
• 2:00
  SPEAKER_00: And I think that's such an important factor to hone in on.
• 2:03
  SPEAKER_01: Absolutely.
• 2:04
  SPEAKER_01: No, 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, uh topics.
• 2:13
  SPEAKER_01: You know, and I would I would love for you to really kind of dive into this with us in terms of understanding the structural aging.
• 2:21
  SPEAKER_01: Like, what is the skin's structure and what is it that's making us age?
• 2:25
  SPEAKER_01: Like, if you were to explain.
• 2:28
  SPEAKER_00: Yeah, and it's it's even great that you say that because I think that's part of the somewhat misunderstanding.
• 2:34
  SPEAKER_00: When we say skin, I think people hone in on just skin because it's what they see.
• 2:38
  SPEAKER_00: And truly, aging starts all the way down to the bone.
• 2:41
  SPEAKER_00: And I think that's the most important thing is to realize that the aging process is happening in multiple planes of tissue.
• 2:48
  SPEAKER_00: People 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.
• 2:55
  SPEAKER_00: And we know that that naturally starts occurring in patients in their 30s.
• 2:59
  SPEAKER_00: 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.
• 3:11
  SPEAKER_00: 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.
• 3:20
  SPEAKER_00: And so obviously we have the epidermis to dermis, and that's the generalization in short, but they're made up of proteins.
• 3:28
  SPEAKER_00: Everyone knows collagen, everyone knows elastin.
• 3:31
  SPEAKER_00: And when we're younger, we're born with so much and it, you know, continues to stimulate.
• 3:35
  SPEAKER_00: But we do know that we lose collagen at about 1% a year, starting in our mid-20s.
• 3:41
  SPEAKER_00: And so, you know, with 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.
• 3:56
  SPEAKER_00: And I think that's an important concept for women, especially as well.
• 3:59
  SPEAKER_00: We lose up to 30 to 40 percent of our collagen into perimenopause.
• 4:04
  SPEAKER_00: And so it's not like a slow, gradual slope.
• 4:06
  SPEAKER_00: There's some peaks where there's drop-offs, and we call them the pillars of aging.
• 4:10
  SPEAKER_00: 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.
• 4:18
  SPEAKER_00: So a lot of that is driven by multiple factors.
• 4:21
  SPEAKER_00: 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.
• 4:35
  SPEAKER_01: Absolutely.
• 4:35
  SPEAKER_01: No, I mean, I love what you said, and I love how you explained it.
• 4:38
  SPEAKER_01: Thank you for that.
• 4:38
  SPEAKER_01: Because I think we hear a lot about things like collagen loss.
• 4:41
  SPEAKER_01: You know, that's a huge, huge topic.
• 4:44
  SPEAKER_01: But the percentages no one understands.
• 4:46
  SPEAKER_01: And also, you know what I've heard a lot of, and I'd love for you to kind of clear this up.
• 4:49
  SPEAKER_01: People say, you know, when you're 40, everything still looks fine.
• 4:53
  SPEAKER_01: But then when you get into that 45 range, it's like your face starts to change.
• 4:57
  SPEAKER_01: And you almost like a lot of women have said you look in the mirror and you almost don't recognize yourself anymore.
• 5:02
  SPEAKER_01: I mean, what do you get?
• 5:04
  SPEAKER_01: Is that what you were explaining?
• 5:05
  SPEAKER_01: Like the collagen loss?
• 5:06
  SPEAKER_01: Like, what is that?
• 5:07
  SPEAKER_00: Absolutely.
• 5:08
  SPEAKER_00: In in our early 40s, as women, we have an estrogen drop-off.
• 5:12
  SPEAKER_00: And so that's within the perimetopausal phase, there's a hormone shift, and one of the biggest shifts is estrogen loss.
• 5:19
  SPEAKER_00: We have estrogen receptors in our skin that are responsible for helping stimulate and upkeep collagen.
• 5:24
  SPEAKER_00: And so when you have a decrease in estrogen, much of that is decreased.
• 5:29
  SPEAKER_00: 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.
• 5:39
  SPEAKER_00: Um as we enter in our like early 40s is generalized time for that.
• 5:45
  SPEAKER_01: Yeah, no, that's what I've I keep hearing that and I'm I'm approaching 40.
• 5:49
  SPEAKER_00: So I'm like, Yeah, she's like, what do I gotta do?
• 5:53
  SPEAKER_00: So absolutely.
• 5:54
  SPEAKER_00: Well, there's so many things, and we, you know, that's like the concept of collagen banking.
• 5:58
  SPEAKER_00: I know that's kind of a trendy term, but you want to kind of maximize on your body's capabilities.
• 6:05
  SPEAKER_00: 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.
• 6:17
  SPEAKER_00: And so we call them collagen banking to store up as much.
• 6:20
  SPEAKER_00: So those shifts aren't so drastic.
• 6:22
  SPEAKER_01: Yeah.
• 6:23
  SPEAKER_01: No, that makes a lot of sense.
• 6:24
  SPEAKER_01: And you know, I know that in the last, you know, 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.
• 6:34
  SPEAKER_01: You know, a lot more people are opting in for injectables.
• 6:36
  SPEAKER_01: There's a lot more people that are open to procedures now.
• 6:39
  SPEAKER_01: And that's I mean, that's its own group.
• 6:42
  SPEAKER_01: But I mean, I would love for you to talk about like where is it that we're we might be missing the mark when it comes to understanding the true role of injectables versus something that might not be invasive, um, but still give us results.
• 6:54
  SPEAKER_00: Yeah.
• 6:55
  SPEAKER_00: 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.
• 7:05
  SPEAKER_00: And it's such a great time to be in this space and a patient in this space because there's so many options.
• 7:11
  SPEAKER_00: 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.
• 7:32
  SPEAKER_00: And in the world of injectables, there's truly still a place, and I know there's some back and forth on social media.
• 7:38
  SPEAKER_00: Um, there's some fear mongering, there's people that support it.
• 7:41
  SPEAKER_00: And, you know, we have so much scientific data and research with safety, efficacy, and correction.
• 7:47
  SPEAKER_00: And sometimes that's the best solution for patients.
• 7:50
  SPEAKER_00: There's true volume loss with our fat pads decreasing, and we see a lot of that now too, with the GLP1 wave of everyone really losing weight.
• 8:00
  SPEAKER_00: They're calling it ozembic phase, and that's very different from natural aging, which happens in different phases because all of it's happening together.
• 8:08
  SPEAKER_00: And so the speed of aging is actually accelerated.
• 8:10
  SPEAKER_00: 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.
• 8:25
  SPEAKER_00: And so there's a place for everything, and it truly comes down to every specific patient.
• 8:32
  SPEAKER_00: But the great thing is we 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.
• 8:45
  SPEAKER_01: Yeah, no, that that makes a lot of sense.
• 8:47
  SPEAKER_01: And I think, yeah, you're right.
• 8:48
  SPEAKER_01: There's a lot of fear-mongering actually on social media.
• 8:50
  SPEAKER_01: It's, you know, for me personally, I I mean, I never was interested in getting fillers or Botox or anything for a long time.
• 8:57
  SPEAKER_01: And I I remember going on social media, it was before my podcast, and I was just terrified.
• 9:02
  SPEAKER_01: Like it terrified me, you know.
• 9:04
  SPEAKER_01: 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, you know.
• 9:12
  SPEAKER_00: And so yeah, it's a very absolutely and you know, good work.
• 9:15
  SPEAKER_00: I always say good work is not noticeable work, like you shouldn't walk around and people should say, Oh my gosh, she had X and Y done.
• 9:22
  SPEAKER_00: And it's 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.
• 9:37
  SPEAKER_00: And so I think there's it's like a two-edged store sword with all this information.
• 9:42
  SPEAKER_01: No, I I completely agree.
• 9:43
  SPEAKER_01: And I think it it really matters because you know, right now we're in the the era of like real technology emerging, I think, in this field.
• 9:51
  SPEAKER_01: Absolutely.
• 9:52
  SPEAKER_01: One of the first ones that comes to mind is radio frequency for me.
• 9:55
  SPEAKER_01: Um I 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.
• 10:02
  SPEAKER_01: I'd love for you to walk us through that and kind of explain like what is what is the true like impact that this type of technology has for skin and the tissues underneath.
• 10:12
  SPEAKER_00: Absolutely.
• 10:13
  SPEAKER_00: So radio frequency has been around forever, maybe 40, 50 plus years.
• 10:18
  SPEAKER_00: And the cool thing in being in this industry, again, is that it's evolved and evolved and evolved.
• 10:23
  SPEAKER_00: So I think when patients hear radio frequency, some people freak out, some people get excited, but it really has so many layers.
• 10:30
  SPEAKER_00: To the like most simplest form, radio frequency is the deliverance of a heat base energy that uses your tissue resistance to create impact.
• 10:39
  SPEAKER_00: And that can be like controlled wound um healing or triggering to create collagen.
• 10:45
  SPEAKER_00: 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.
• 10:54
  SPEAKER_00: There's also concepts of contraction under the tissue and at certain tissue depths to also help with tightening.
• 11:00
  SPEAKER_00: And it's one form of energy to do that.
• 11:03
  SPEAKER_00: Now, the delivery of radio frequency has evolved the most over the years.
• 11:08
  SPEAKER_00: And, you know, 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.
• 11:23
  SPEAKER_00: At the end of the day, it's very provider dependent.
• 11:26
  SPEAKER_00: But when you have so much uncontrol over certain settings or certain tissue depths, you can see certain side effects.
• 11:33
  SPEAKER_00: And 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.
• 11:48
  SPEAKER_00: And they've made tissue response even more comfortable than the past.
• 11:51
  SPEAKER_00: Because it used to be something that people were so scared of because it was so painful or uncomfortable.
• 11:57
  SPEAKER_00: Even in other types of technology in the tightening space, that was a concept that was constantly being discussed.
• 12:04
  SPEAKER_00: Patients were going under anesthesia for tightening devices because they said they were so painful.
• 12:08
  SPEAKER_00: And if patients can't get themselves to do treatments, that's also not a great thing, as well.
• 12:14
  SPEAKER_00: So, 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.
• 12:30
  SPEAKER_01: That's really interesting because when you talk about like tissue depth and like, you know, controlling things like the first thing honestly that comes to my mind is like uh skin of color, because there's so much debate, like you know what I mean?
• 12:42
  SPEAKER_01: 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 uh radio frequency and skin of color and melanin?
• 12:54
  SPEAKER_01: I mean, I'm just curious.
• 12:56
  SPEAKER_00: Yeah, that's a great question.
• 12:57
  SPEAKER_00: You know, I think I've I've I've touched on this, but it's such an important point that uh there are so many lasers and devices, but it really comes down to the provider and understanding skin and tissue.
• 13:08
  SPEAKER_00: Um, and that's the biggest factor, as long as the provider has been well trained, is able to understand tissue, medical tissue response.
• 13:17
  SPEAKER_00: Devices are very safe in all skin colors.
• 13:20
  SPEAKER_00: There's some that are better than others, but in the realm of radio frequency, it's always been considered safe in the right hands.
• 13:25
  SPEAKER_00: But the devices have gotten more advanced to be safer for that fact.
• 13:31
  SPEAKER_00: 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.
• 13:42
  SPEAKER_00: 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.
• 13:50
  SPEAKER_00: But now the delivery systems are also enhanced.
• 13:53
  SPEAKER_00: Whereas some of the old radio frequency delivery systems were through microneedling, you can easily go too superficial.
• 14:00
  SPEAKER_00: If it's done incorrectly, there were some problems with that, but that again is very provider dependent.
• 14:06
  SPEAKER_00: 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.
• 14:16
  SPEAKER_00: And we say it's even like a colorblind treatment.
• 14:19
  SPEAKER_00: It's safe for everyone.
• 14:21
  SPEAKER_00: And the the progress of those updates have made such a big difference.
• 14:26
  SPEAKER_01: That's huge.
• 14:27
  SPEAKER_01: That's really huge.
• 14:28
  SPEAKER_01: I mean, I think that's where a lot of people get confused.
• 14:31
  SPEAKER_01: And, you know, I won't lie to you.
• 14:33
  SPEAKER_01: I mean, there's a there's a big gray box right now for a lot of consumers, 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.
• 14:43
  SPEAKER_01: But everything you're explaining actually makes a lot of sense.
• 14:45
  SPEAKER_01: Like it really comes down to understanding the structural biology of it.
• 14:48
  SPEAKER_01: And absolutely.
• 14:50
  SPEAKER_01: Um, so I want to talk about Zerf.
• 14:52
  SPEAKER_01: You know, I really want to ask Zerf.
• 14:54
  SPEAKER_01: Um, the treatment from uh Sinusher or Lunatonic.
• 14:58
  SPEAKER_01: I mean, explain to us like what is Zerf and like what can we realistically expect from this uh modality?
• 15:05
  SPEAKER_00: Yeah, I think Zerf is really exciting technology in my practice.
• 15:09
  SPEAKER_00: I've had Zerf as one of the first offices in the US to have it.
• 15:13
  SPEAKER_00: I was personally really excited because of all the updates.
• 15:16
  SPEAKER_00: 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.
• 15:23
  SPEAKER_00: Um but when Zerf came out, it is a radio frequency device.
• 15:27
  SPEAKER_00: It's specifically a monopolar radio frequency device, but it does deliver that radio frequency very precisely to multiple tissue depths at the same time.
• 15:37
  SPEAKER_00: That 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.
• 15:48
  SPEAKER_00: And so that was a huge shift in the device itself.
• 15:52
  SPEAKER_00: Secondarily, and like we mentioned, heat and pain and possible risk of pigmentation, that's not a factor reserve.
• 15:59
  SPEAKER_00: There's a cooling system that's built into the technology.
• 16:03
  SPEAKER_00: So with every pulse, there's cooling that goes to the epidermis.
• 16:07
  SPEAKER_00: So a couple of things is that that makes it safer for patients of all skin types, which is amazing.
• 16:12
  SPEAKER_00: Secondly, it makes it comfortable.
• 16:14
  SPEAKER_00: Patients are able to tolerate it.
• 16:16
  SPEAKER_00: I personally have patients that have fallen asleep through treatment.
• 16:19
  SPEAKER_00: I've done the treatment on myself a handful of times.
• 16:22
  SPEAKER_00: I absolutely love it.
• 16:23
  SPEAKER_00: If I can do it on myself and I think I'm a baby, then I'm like, everyone can do this.
• 16:27
  SPEAKER_00: Yeah.
• 16:28
  SPEAKER_00: Um, but it it's great.
• 16:30
  SPEAKER_00: It's one of the safest that's currently on the market.
• 16:33
  SPEAKER_00: It's the most advanced now, doing multiple depths at the same time.
• 16:36
  SPEAKER_01: No, that sounds, I mean, that sounds awesome.
• 16:38
  SPEAKER_01: Like I didn't know that it does the the, you know, like the dual thing where it has the cooling effect and all of that.
• 16:45
  SPEAKER_01: I mean, it's interesting because you know, when you're delivering like energy, understanding what that does, like in the time frame, right?
• 16:53
  SPEAKER_01: That's something that I think we don't really talk about.
• 16:55
  SPEAKER_01: That's a lot of biophysics, I in in my understanding, like understanding like absolutely your tissue, like how does because you know, you I'm sure you saw it, everybody got behind the whole like cryo hype, and like everything your skin needs to be cooled down to start seeing like you know, reversal kind of benefits.
• 17:13
  SPEAKER_01: So talk to us a little bit more about that, if you don't mind, in terms of like what does like cool cooling do and what does heating do to tissue?
• 17:21
  SPEAKER_01: Because I think that's important to kind of differentiate.
• 17:24
  SPEAKER_00: Yeah, I mean, the cooling space is like very broad in the sense of like people doing it post-workouts, as like muscular recovery.
• 17:32
  SPEAKER_00: Um, in the world of skin specifically, and in dermatology and aesthetics, we use cooling for a couple of reasons.
• 17:40
  SPEAKER_00: Um, 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.
• 17:50
  SPEAKER_00: And so that's always been an aspect where that's incorporated with different devices, usually not connected to the same device, um, which SURF now has, as it cools the skin while the energy is being delivered through this single handpiece.
• 18:03
  SPEAKER_00: It's not like a completely different system.
• 18:06
  SPEAKER_00: But one for safety, of course, for the pigmentation, and secondly for patient comfort, comfort.
• 18:11
  SPEAKER_00: And that's like in the aesthetic space, specifically with lasers and energy.
• 18:16
  SPEAKER_00: We use cryo and dermatology, of course, in more powerful ways to treat growths and other things.
• 18:22
  SPEAKER_00: And then there's the generalized like cryotherapy for like muscle recovery, overall anti-inflammatory benefits, but that's kind of a different space than the aesthetic medicine world.
• 18:35
  SPEAKER_00: And 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.
• 18:42
  SPEAKER_00: But to go back to like radio frequency specifically, that's a specific heat that's delivered to tissues to stimulate that collagen cascade.
• 18:50
  SPEAKER_00: And we kind of touched on that earlier of how we're losing collagen since we're in our mid-20s and so forth, and in bigger jumps as we age, especially with hormonal changes as women.
• 19:01
  SPEAKER_00: But it stimulates that collagen cascade.
• 19:04
  SPEAKER_00: 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.
• 19:16
  SPEAKER_00: So in that timeline, your treatments have honeymoon periods, I call them, but it takes a true two months to see your actual endpoint.
• 19:24
  SPEAKER_01: Oh, okay.
• 19:25
  SPEAKER_01: So, okay, so two months.
• 19:27
  SPEAKER_01: So how many?
• 19:27
  SPEAKER_01: Yeah.
• 19:27
  SPEAKER_01: So what what do you recommend in terms of frequency of like uh like treatments done for the average patient?
• 19:34
  SPEAKER_00: Yeah, so the studies reserved all were for mild to moderate skin laxity.
• 19:39
  SPEAKER_00: 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.
• 19:48
  SPEAKER_00: But I always start my patients with a minimum of two sessions.
• 19:51
  SPEAKER_00: Some patients with a bit more skin laxity might need a third or so forth.
• 19:55
  SPEAKER_00: Um, and so we like to do two sessions to maximize on that proper stimulation of collagen.
• 20:02
  SPEAKER_00: So 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.
• 20:10
  SPEAKER_00: 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.
• 20:20
  SPEAKER_00: But I call it the honeymoon, and I honestly our results are better than the honeymoon period, but I call it the preview.
• 20:26
  SPEAKER_00: And then your body kind of slowly comes back to baseline after that first session as the collagen is slowly stimulating.
• 20:33
  SPEAKER_00: 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.
• 20:42
  SPEAKER_00: And results peak at two months for patients and then can still be stimulated up to six months.
• 20:47
  SPEAKER_01: Well, so like in terms of like where it works the best, right?
• 20:50
  SPEAKER_01: Like on the body.
• 20:51
  SPEAKER_01: Like I know for me, like I'm starting to see signs of aging on my neck.
• 20:54
  SPEAKER_01: This is one of my concerns personally.
• 20:56
  SPEAKER_01: And I know a lot of women, like we see it early, you know, on the neck area.
• 21:00
  SPEAKER_01: Absolutely.
• 21:00
  SPEAKER_01: I mean, is this safe for like all areas or is it more efficacious on, say, like facial skin versus other areas?
• 21:07
  SPEAKER_00: Yeah, most of the studies are for the face and neck, and that tends to be the most popular areas in office as well.
• 21:13
  SPEAKER_00: We've done thousands of cases and face and neck are the majority.
• 21:17
  SPEAKER_00: 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.
• 21:25
  SPEAKER_00: And 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 they kind of neglect the rest of the body, and that's so common.
• 21:37
  SPEAKER_00: But it's an area that should always be included with your skincare, with other treatments.
• 21:42
  SPEAKER_00: And so, like you touched on, it is a very popular place to receive treatments like Zerf and lasers and anything else.
• 21:49
  SPEAKER_00: But you want, you know, face and neck is the most common combination we do in office for sure.
• 21:56
  SPEAKER_01: That's you know, that's really fascinating to me because I get so many questions about like.
• 22:00
  SPEAKER_01: Neck treatment with skincare.
• 22:02
  SPEAKER_01: And I'm like, guys, I don't know.
• 22:03
  SPEAKER_01: Because there's not a lot of there's not a lot of products that are efficacious.
• 22:06
  SPEAKER_01: Yeah.
• 22:08
  SPEAKER_01: And it just makes me wonder like, what is it about the next tissue that's so hard, you know, to like really get in there and treat.
• 22:15
  SPEAKER_01: And and so, I mean, sure.
• 22:17
  SPEAKER_01: Yeah.
• 22:17
  SPEAKER_01: If somebody was, I mean, I'd love for you to offer this advice, right?
• 22:20
  SPEAKER_01: Because like a lot of frustration in this category specifically in aesthetics.
• 22:25
  SPEAKER_01: It's like, I'm doing everything for my face, but my neck skin never improves.
• 22:30
  SPEAKER_01: I mean, what would you recommend to a patient like that?
• 22:32
  SPEAKER_00: Well, it's a great point.
• 22:34
  SPEAKER_00: And I say I have this discussion daily in clinic.
• 22:37
  SPEAKER_00: One, this difference from a like a biological standpoint is we have more sebaceous or oil glands on our face.
• 22:43
  SPEAKER_00: And that diminishes as we go down from our face to our neck and the rest of our body, but our neck doesn't have as much oil or moisture naturally.
• 22:52
  SPEAKER_00: And so some products can be more irritating because of that, that technically are more absorbed and well absorbed on the face.
• 23:00
  SPEAKER_00: And so, really, for my patients, everything you do for your face, you can do for your neck.
• 23:05
  SPEAKER_00: And I think that as a baseline is super important to understand.
• 23:08
  SPEAKER_00: So your skincare that you are doing for your face should continue down your neck.
• 23:12
  SPEAKER_00: If you can't tolerate, maybe find a product that's best suited for you and get the direction of your, you know, your board certified dermatologist or provider that can help you choose those best products, but you should have a neck routine just as your face.
• 23:25
  SPEAKER_00: And it doesn't have to be different.
• 23:26
  SPEAKER_00: You can use the same products as long as you're tolerating it and have that routine.
• 23:30
  SPEAKER_00: Of course, sun protection is super important because we know UV rays break down collagen.
• 23:35
  SPEAKER_00: We want to be preventative and you want you don't want to just stop at your face when you're also in your protective phase.
• 23:42
  SPEAKER_00: And then when it comes to in-office treatments, the same concept, whether it's ZERF or any other technologies, you want to include your neck in treatments that you're doing for upkeep and for prevention and for overall treatment, because that is a full cosmetic unit.
• 23:57
  SPEAKER_00: And so when one part looks, you know, perfectly kept and another doesn't, that's obviously a telling sign of your overall skin health below the face and for people their age.
• 24:08
  SPEAKER_01: Yeah, no, that makes it makes a lot of sense.
• 24:11
  SPEAKER_01: Thank you for the clarity because I mean, of course it's really difficult because you and you mentioned hands.
• 24:16
  SPEAKER_01: Like I know for me, I was using hand cream because my mother told me that when I was growing up.
• 24:21
  SPEAKER_01: Like, make sure that you know, and I'd be watching growing up.
• 24:25
  SPEAKER_01: And so hand cream for me is like natural, but neck care is like I gotta like force myself, you know.
• 24:31
  SPEAKER_00: I love that for you because hand cream is also not very common.
• 24:35
  SPEAKER_00: And I always tell people to like little tricks of the trade when you're doing your facial routine, hopefully taking it down to your neck, you can put your products on the top of your hand as a way to apply, and then you have those same rejuvenating, revitalizing products on your hands.
• 24:51
  SPEAKER_00: That can also help.
• 24:52
  SPEAKER_00: So don't look at hands and neck.
• 24:54
  SPEAKER_01: I love that.
• 24:55
  SPEAKER_01: I hope you guys are listening.
• 24:56
  SPEAKER_01: That's really good.
• 24:58
  SPEAKER_01: No, no, going back to Zerf, like I really want to talk about some adjacent treatments that we can do with this.
• 25:04
  SPEAKER_01: Um, you know, with this because I know that a lot of people do.
• 25:06
  SPEAKER_01: I mean, I'm sure you've seen the Korean clinics where people are getting like 12 treatments at a time, which I personally is kind of wild, you know.
• 25:14
  SPEAKER_01: But um, you know, for the rest of us who want maybe one or two other things simultaneously, I mean, is it safe to do with things like Botox?
• 25:21
  SPEAKER_01: Is it safe to do with fillers alongside?
• 25:23
  SPEAKER_01: I mean, what is your recommendation there?
• 25:26
  SPEAKER_00: Yeah, absolutely.
• 25:27
  SPEAKER_00: You know, treatment stacking is very popular in Korea, but it is just as popular in the US.
• 25:32
  SPEAKER_00: And I feel like a lot of patients that fly in from other countries or other states have limited time.
• 25:38
  SPEAKER_00: So we do want to maximize treatments.
• 25:40
  SPEAKER_00: And as long as you're treating in different planes and you know, you're not overheating the skin and there's a science to it, you can stack multiple treatments at the same time to address different concerns.
• 25:50
  SPEAKER_00: I also like to personally stack different lasers.
• 25:53
  SPEAKER_00: So if patients have, let's just say, sun damage, we have a handful of lasers in our practice that can also treat all those sunspots or sun damage while you're also tightening, and that's been very safe to do.
• 26:05
  SPEAKER_00: Or even texture and wrinkles, you can be more precise with like superficial resurfacing while you're doing surf, and it's very safe.
• 26:14
  SPEAKER_00: So there's so many stackable treatments that are possible.
• 26:17
  SPEAKER_00: It just depends on that specific patient's concerns.
• 26:20
  SPEAKER_00: When it comes to like more hyaluronic acid filler, I always tell people to wait post-surf just to see their true endpoint because once you're tightening, and if that's the true issue of what's going on, there's not like distinct volume loss, you may get some correction where you either need less filler or you might not need filler post-tightening.
• 26:40
  SPEAKER_00: So I like to personally wait on that um just to see the true endpoint and then decide what would be best.
• 26:46
  SPEAKER_01: That makes sense.
• 26:46
  SPEAKER_01: Yeah, like see if it's really working for you before you keep going.
• 26:50
  SPEAKER_00: Yeah, that's or if you need the volume once the skin is tightened, because a lot of times when the skin is actually pulled and tightened, some of those volume corrections that you were looking for with filler, you might not need the filler or you might need less, which is great too.
• 27:05
  SPEAKER_01: That's really interesting.
• 27:06
  SPEAKER_01: I mean, I honestly for me, I have never understood because I know a lot of people want to target specific areas for tightening.
• 27:12
  SPEAKER_01: And that's something I'd love for you to speak on because I know that you mentioned early on, you know, that aging is like this whole process that's happening, you know, it's not it's not in one area, it's happening all at once.
• 27:24
  SPEAKER_01: And um, when it comes to treatments that are targeted, like skin tightening, I think there is some sort of a misunderstanding in patients and consumers that, oh, I can just target my jowls or I can just target like, and so what is like give what is your advice on that in terms of like approaching it realistically as a patient rather than, you know, because I'm sure you people love to complain and you know absolutely.
• 27:48
  SPEAKER_00: Absolutely.
• 27:49
  SPEAKER_00: You know, that's a great question.
• 27:51
  SPEAKER_00: And when it comes to skin tightening, you might have those select patients that have like a single problem area that might want to just target like a small area under their chin or something.
• 28:00
  SPEAKER_00: But truly what it does, even like your gel has multiple vectors.
• 28:04
  SPEAKER_00: So if you're only treating like a single vector, you may get results, but they might not be as good as if you actually treated every vector that might pull up on that.
• 28:12
  SPEAKER_00: And so we, you know, it I definitely personalize the treatments.
• 28:17
  SPEAKER_00: It's it's more recommended than not to treat like a whole area because you want the maximum effect.
• 28:23
  SPEAKER_00: So the patients are happy and they get the results they also want as well.
• 28:27
  SPEAKER_00: And sometimes that does include treating, if you're just worried about the jaw, you still need to, you know, treat all the way upwards of the face to get a full vector lift versus like a smaller area where maybe they can get away with it, then I would be happy to do that as well.
• 28:41
  SPEAKER_00: But it's very personalized.
• 28:43
  SPEAKER_00: And so every, you know, it's it's not just memorizing settings and coming in and you can do this for every patient that's concerned with the jaw.
• 28:50
  SPEAKER_00: It's a very personalized treatment plan that we do come up with.
• 28:53
  SPEAKER_00: And every patient's different, every setting is different.
• 28:56
  SPEAKER_00: And to get maximum results, you you got to personally see that patient and everything going on.
• 29:02
  SPEAKER_00: Not just, you know, when they're younger, you can do a little bit less and you'll probably get away with it.
• 29:06
  SPEAKER_00: But when they've accelerated into that collagen loss period and they've aged and have other things going on and multiple tissue planes, you do want to address as much of that as possible.
• 29:16
  SPEAKER_01: Now you mentioned like younger patients, and this is a really, really interesting topic for me, especially because I have always been concerned about where the beauty industry is headed when it comes to, you know, like what we're telling the youth, especially young women in their 20s, you know.
• 29:30
  SPEAKER_01: And I think like my, I mean, my stance, and I I don't know if you agree, my stance has always been I think if you're 20-something years old, you got to get your dermatologist, you got to go find your darm and go and get your advice from them.
• 29:42
  SPEAKER_01: But unfortunately, that's not what's happening, you know?
• 29:45
  SPEAKER_01: And so when it comes to Zerf specifically, is there an age bracket that you're like, okay, this is where I feel comfortable starting my patients?
• 29:53
  SPEAKER_01: Below this, yeah, not, you know, that kind of thing.
• 29:55
  SPEAKER_00: Yeah.
• 29:56
  SPEAKER_00: There's always gonna be an anomaly of ages with genetic variants and different circumstances.
• 30:02
  SPEAKER_00: But that general concept of collagen loss starting in your mid-20s is when I feel like these treatments are beneficial to start, even when there's, you know, like when you're starting to see certain signs or you want to get ahead of the collagen loss.
• 30:14
  SPEAKER_00: And I know I I am trendy saying collagen banking, but it's just an easy term to understand.
• 30:20
  SPEAKER_00: Because you're losing collagen, you want to do something to increase collagen so that this down slope isn't so drastic and you're not like playing catch-up as it continues further and further along in your years.
• 30:31
  SPEAKER_00: But when your body is youthful and you're able to stimulate collagen, there is a benefit.
• 30:35
  SPEAKER_00: And so I feel like that's that pace, that's as early as I would typically start.
• 30:40
  SPEAKER_00: Um, and there's I've done it up to patients in their 80s with great results.
• 30:44
  SPEAKER_00: So I don't think there's a max age as well.
• 30:46
  SPEAKER_00: Um, but that's the time period I would start.
• 30:50
  SPEAKER_01: That's awesome.
• 30:51
  SPEAKER_01: Okay, that's really good to know because I know we have a lot of people like in that 20s age group, mid-20s, 30s, you know.
• 30:57
  SPEAKER_01: And honestly, that's how that's most it gets confusing in that age group.
• 31:01
  SPEAKER_01: Right.
• 31:02
  SPEAKER_01: We're like, what do we what do you do?
• 31:04
  SPEAKER_01: Where do you start with aesthetic treatments, you know?
• 31:06
  SPEAKER_00: So yeah, and it's you know, it's not about doing all the things or doing a lot.
• 31:10
  SPEAKER_00: You have to really have someone that you can trust that's gonna be honest with you.
• 31:14
  SPEAKER_00: And that's, you know, what are your goals and what are your goals like long term as well?
• 31:19
  SPEAKER_00: And sometimes that's you know, there's a lot of trends and things come people come in all the time for things that are just not gonna either age well or not suitable for them, and they need someone to also tell them no, they need someone to properly guide them.
• 31:31
  SPEAKER_00: And I think that's huge.
• 31:32
  SPEAKER_00: Again, we talked about social media earlier, and there's just so much misinformation.
• 31:37
  SPEAKER_00: So if we can get that right information and right education to the patients, it makes a big difference for the longevity of how they age.
• 31:44
  SPEAKER_00: Absolutely.
• 31:44
  SPEAKER_01: Yeah, absolutely.
• 31:45
  SPEAKER_01: And I love I love that you stand on that because that's something absolutely.
• 31:49
  SPEAKER_01: I mean, I feel like that's the difference between a board certified dermatologist who can educate you and somebody who might not have as much training.
• 31:56
  SPEAKER_01: And, you know, on this podcast, I I try to get experts like you to just, you know, advocate for this because so many people are spending, I mean, people are spending crazy money right now, you know, in aesthetics.
• 32:07
  SPEAKER_01: And yeah, that's it's fine if you're doing it in a place where you're getting guidance, you know, where you're getting and that's why I asked you so many questions about like what's the age, you know, but they don't get that, and so they end up feeling like aesthetics is failing me, you know, when in reality it's not.
• 32:24
  SPEAKER_01: You just might not be going to the right place.
• 32:26
  SPEAKER_00: So yeah.
• 32:28
  SPEAKER_00: And I think it's always important to know who your provider is.
• 32:31
  SPEAKER_00: And and it's I you know, something I think is not like a big point of education that are a lot of people don't know is in medical school and in residencies, dermatology is specifically the field that gets training and non-invasive aesthetic treatments.
• 32:46
  SPEAKER_00: And it's part of the requirements for our graduation.
• 32:49
  SPEAKER_00: We have our internship and then three years of dedicated time to that, where we see and treat thousands of patients and understand the skin and understand that biology and the aging process so in depth from surgeries and all our journey of learning and educational like programs, but also seeing the skin firsthand, seeing how it ages, being under the skin and really taking that into account as we're learning, doing research on a lot of these devices as well.
• 33:14
  SPEAKER_00: So it's a blessing to get all that exposure, but it's and then we come out into the field and practice and train and continue to learn.
• 33:22
  SPEAKER_00: And so, you know, there's there's a large gap, and I think the industry, and there's amazing people of all levels, but that's something that I think people just don't even know a lot of the times, where it's like a necessity to graduate to become a dermatologist to go through all that, which I think is very important.
• 33:38
  SPEAKER_01: Absolutely.
• 33:38
  SPEAKER_01: No, I'm glad you said that.
• 33:40
  SPEAKER_01: And I think also like dermatology is one of the hardest fields of medicine to get into.
• 33:45
  SPEAKER_01: You guys are starting early, you know, with the over-excelling part.
• 33:49
  SPEAKER_00: So it is, it's still, I think, out of uh we're in 2026, but the last graduating class or the entry class, it was still ranked the most competitive field to get into.
• 34:00
  SPEAKER_01: So it's crazy.
• 34:01
  SPEAKER_01: My brother's going through a match this year.
• 34:03
  SPEAKER_01: He's MD PhD candidate, and he's like, I'm scared to apply to Derm.
• 34:07
  SPEAKER_01: He's like, I don't think, you know.
• 34:09
  SPEAKER_01: And and it is, it's I and it's more important for consumers to know that.
• 34:12
  SPEAKER_01: It's like you it dermatologists don't just start, you know, you get into residency and then it's hard.
• 34:17
  SPEAKER_01: No, it's hard from the beginning.
• 34:19
  SPEAKER_01: Like you have really got that you want to do medicine if you land dermatology.
• 34:23
  SPEAKER_01: So yeah, yeah.
• 34:25
  SPEAKER_00: You know, and it's and for your brother and those applying, you know, it's always something that feels like such an impossible task, but it's so doable.
• 34:33
  SPEAKER_00: And I think it's just important to find something you truly love because you will enjoy it and it it doesn't feel like work.
• 34:39
  SPEAKER_00: And I think that's the biggest blessing in whatever you're doing is to find something you love and truly pursue it.
• 34:45
  SPEAKER_00: Just, you know, whether it takes more than one try, there might be different roads to getting there.
• 34:50
  SPEAKER_00: But if you love it, tell your brother don't quit if he loves it.
• 34:54
  SPEAKER_01: Absolutely.
• 34:55
  SPEAKER_01: I will definitely pause specifically.
• 34:56
  SPEAKER_01: I will say talk to Dr.
• 34:59
  SPEAKER_01: Hakeem, and this is her advice for you.
• 35:01
  SPEAKER_01: Absolutely.
• 35:01
  SPEAKER_00: Don't give up.
• 35:02
  SPEAKER_00: Don't give up, don't give up.
• 35:04
  SPEAKER_00: People will say it all the time.
• 35:05
  SPEAKER_00: Oh, you'll, you know, they just it's there's a lot of naysayers and people that know how competitive it is and are negative about it.
• 35:11
  SPEAKER_00: But you love it, don't give up.
• 35:13
  SPEAKER_00: It'll come.
• 35:14
  SPEAKER_01: Absolutely.
• 35:15
  SPEAKER_01: No, I on that note though, you know, looking into the future of aesthetics, you know, I would love your opinion on this in terms of where the field is evolving into, you know, where are we going with aesthetics?
• 35:26
  SPEAKER_01: Because I personally love this non-invasive wave, you know, of options.
• 35:31
  SPEAKER_01: I think this is amazing.
• 35:32
  SPEAKER_01: And if we could expand on this, I mean imagine how many more people would be comfortable.
• 35:36
  SPEAKER_01: So, what are your thoughts?
• 35:38
  SPEAKER_01: Like, where do you think the field at large is headed?
• 35:41
  SPEAKER_00: You know, it's been amazing to see technologies like Surf come up and you have non-invasive options that are comfortable that are giving people results that they're so happy with and giving them that endpoint, not having to go under the knife.
• 35:55
  SPEAKER_00: And, you know, there's still that option always, but we have so much now leading up to where that's either slowed down or unnecessary for some patients.
• 36:03
  SPEAKER_00: I think the industry as a whole is kind of coming back to the natural aesthetic, which I love.
• 36:08
  SPEAKER_00: I think people are like aiming to look natural, aiming to look themselves and doing more like lower invasive treatments to just maintain looking like their best selves.
• 36:18
  SPEAKER_00: I think there's a regenerative wave coming into the industry of just maximizing your and optimizing your own health.
• 36:24
  SPEAKER_00: And I think that also is a huge part of what's going to influence the aesthetic field as well, which I'm really excited about because that's been my philosophy from the start.
• 36:32
  SPEAKER_00: So you see trends come and go in aesthetics all the time, but that natural aesthetic, the more regenerative, less invasive options, I think are making a huge boom in the industry.
• 36:44
  SPEAKER_01: I love that.
• 36:45
  SPEAKER_01: And I, you know, I just want to ask you as a follow-up, because I really like that you brought up regenerative aesthetics, because I think that's something that a lot of us don't understand.
• 36:54
  SPEAKER_01: Like, what is regenerative aesthetics?
• 36:56
  SPEAKER_01: You know, and I think a lot of the wording is getting mixed up.
• 36:59
  SPEAKER_01: Like, for example, longevity keeps coming into the conversation.
• 37:02
  SPEAKER_01: Longevity is not the same thing as regenerative medicine.
• 37:04
  SPEAKER_01: So it's like, you know, I I'd love for you to kind of like kind of tell us a little bit more about the regenerative side in terms of you talked about Zerf, you talked about the structural biology and all of the, you know, the thermodynamic components.
• 37:16
  SPEAKER_01: But then where do you think this really falls when we try to understand what is truly regenerating tissue?
• 37:22
  SPEAKER_01: Like, where is that intersection?
• 37:25
  SPEAKER_01: Yeah.
• 37:26
  SPEAKER_00: Yeah.
• 37:26
  SPEAKER_00: And I still think it's a very early and evolving field.
• 37:29
  SPEAKER_00: Like, by no means do I feel like we're there and it's it's it's at its peak.
• 37:33
  SPEAKER_00: I think this is just the start.
• 37:35
  SPEAKER_00: But the concept of that regenerative medicine is using your own body to stimulate your own body's collagen.
• 37:41
  SPEAKER_00: And so just in the shortest terms possible, you know.
• 37:45
  SPEAKER_00: So we talked about energy-based devices like ZERF, that's creating heat in your tissue to stimulate your own body to create collagen, to create tightening and contractions below the skin, which is giving patients that natural tightening effect, stimulating collagen, making that skin look firm in the most natural way, not by doing something of injecting something different or using other ways of more invasive types to get to those same endpoints.
• 38:09
  SPEAKER_00: So I think it's like optimizing your overall body's health to stimulate your own collagen and your own elastin to maximize on your overall skin firmness in the realm of tightness, of course.
• 38:21
  SPEAKER_00: And so I think just regeneration is using your own body and re keeping it as youthful as possible.
• 38:26
  SPEAKER_00: So we want our collagen like it was in our 20s and 30s, you know, or mid-20s and 30s for when we're in our 40s and 50s and not trying to look different doing so.
• 38:34
  SPEAKER_00: We just want our body to stay optimized in those ways.
• 38:37
  SPEAKER_00: And I think there's there's work to be had, and there's a lot of studies and there's things coming up in the pipeline, but it it's not there yet.
• 38:47
  SPEAKER_00: And I I think that's where it's going.
• 38:49
  SPEAKER_00: And I'm excited to see all the updates that come about with that.
• 38:53
  SPEAKER_00: Absolutely.
• 38:54
  SPEAKER_00: No, I'm excited as well.
• 38:56
  SPEAKER_01: And you know, thank you so much because I've learned this conversation and I'd love coming back if you're scared.
• 39:02
  SPEAKER_01: I knew you're super busy, but No, I love it.
• 39:04
  SPEAKER_00: It's fun to chat.
• 39:05
  SPEAKER_00: I chat about this all day, so I'm here for it.
• 39:08
  SPEAKER_00: I'm happy to be back anytime, and I appreciate you for having me.
• 39:11
  SPEAKER_00: It's been lovely.
• 39:12
  SPEAKER_01: Oh, it's an honor.
• 39:13
  SPEAKER_01: Thank you so much.