Devices, Depth, and Decision-Making in Aesthetics

In this episode of Conversations in Aesthetics, Gary Goldenberg, MD, speaks with dermatologist and professor of dermatology at Howard University, Cheri Frey, MD, about how aesthetic dermatology actually plays out in practice, from the consult through device selection, technique, and outcomes.  Dr Frey frames aesthetics through a clinical lens. Even when the chief complaint is cosmetic, the drivers are often clinical—post-inflammatory erythema, hyperpigmentation, scarring, hair loss. The work sits in that overlap, where aesthetic goals are shaped by underlying disease and biology.  The consult is central. She emphasizes defining endpoints early by discussing “improvement” in practical terms and what it will take to get there. Reduction in erythema, lightening of pigment, softening of scar depth. Many of these patients require multiple sessions, combination approaches, and ongoing maintenance. As she notes, “results may vary,” and setting that expectation upfront matters.  Risk assessment goes beyond what’s visible. Ancestry, treatment history, and timing all factor in, especially with energy-based devices. While hyperpigmentation is common, hypopigmentation is the complication she’s most cautious about, given how difficult it is to reverse.  They move through treatment strategies with that framework in mind. Microneedling remains a foundation, typically paired with PRP or exosomes. Depth is adjusted by anatomic site, with the aim of reaching the dermis without unnecessary injury.  In melasma, she moves past pigment alone. The target includes ectatic vessels, senescent fibroblasts, and dermal changes consistent with solar elastosis. Using pulsed radiofrequency microneedling, she works to address these layers while limiting thermal buildup that can exacerbate pigment.  The conversation ends where the field is heading, on prevention. Less correction, less volume for the sake of volume. More attention to maintaining collagen, elastin, and skin quality over time—so patients look like themselves, just held in place a little longer.  Disclaimer: This podcast is not intended to provide diagnosis, treatment, or medical advice. Content provided in this podcast is for educational purposes only. Please consult with a physician regarding any health-related diagnosis or treatment.