Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person because you're making a life-changing decision and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There is no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Today on Meet the Doctor, my guest is Sheila Barbarino. She's one of my favorites. She's a facial plastic surgeon and cosmetic surgeon in Austin, Texas, right down the street from me, and I drive past her office every day and I wave, but she doesn't see me. Welcome, Dr. Barbarino.

Dr. Barbarino (00:49):
Thank you for having me. You are one of my favorites too. As you know. I feel like I've gotten to know Austin with you and kind of built my practice here in Austin knowing you, which is, I think it's so funny. I think, how many years have we known each other now?

Eva Sheie (01:05):
Five, six.

Dr. Barbarino (01:07):
Isn't that crazy?

Eva Sheie (01:08):
Yeah.

Dr. Barbarino (01:09):
It seems like yesterday.

Eva Sheie (01:12):
So what year did you open your own practice? I know you kind of got to know Austin by moving around a little bit, but you went out on your own and got a beautiful space. What year was that?

Dr. Barbarino (01:24):
I went out on my own technically 2018, and I was running space out of another person's office, and then I actually ended up building out during that time and finding space because you remember that was right before Covid and it was really hard to find space. And then once Covid hit, then it was even harder to find space. And then once I acquired a space, it took forever to build out because you couldn't find people to work or build out things. And remember, you couldn't get doors, you couldn't get cupboards, you couldn't get anything handles.

Eva Sheie (02:03):
Yeah, that was a weird time.

Dr. Barbarino (02:04):
It was a weird time. So officially, I think we opened, I think 2020 at the end of it, so I think it took us probably about a year to build out. You think that's about right?

Eva Sheie (02:13):
Yeah. I feel like I was coming to your office with a mask on and then we would go in the back and take it off.

Dr. Barbarino (02:21):
It was just for show except that we were both healthy, so that was what mattered. Right,

Eva Sheie (02:26):
Right. It was that period of time where we were still following the rules, I think.

Dr. Barbarino (02:33):
Yeah. Yeah. I mean, we get vaccinated and we all got sick and it was so silly. Now that looking back on it, we were all so freaked out.

Eva Sheie (02:43):
Yeah,

Dr. Barbarino (02:43):
Now everybody has it. Everyone has that. Everyone has RSV and the flu and nobody cares anymore. So weird.

Eva Sheie (02:51):
Yeah, it's stuff I think we should probably just leave in the past,

Dr. Barbarino (02:57):
Right?

Eva Sheie (02:59):
So catch us up. How are things going now?

Dr. Barbarino (03:03):
Things are good. Things are busy. Things are, we're firing on all cylinders, which is, I couldn't be happier. Oh, I don't think you even know this breaking news. We just hired a new nurse practitioner to inject and my practice we're expanding in this location and it's very exciting.

Eva Sheie (03:24):
So one thing I know about you that I absolutely love is that you're really passionate about experimenting with and trying new products and developing them and helping the companies bring things to the next level and then teaching others from your own learning. So what are you doing these days in terms of research or education with the companies?

Dr. Barbarino (03:49):
So I think the number one thing that I really love best about being in aesthetics is being on the cutting edge. And I think that's probably why you love it too. I certainly think you're interested in all the latest and greatest, and I think it's probably one of the few areas in medicine that we always have something and they're always trying to develop something that's better, that works better, works faster with less downtime. I don't think there's any other field that can compete with how rapidly changing this field is. So obviously one of the things that I really do love to do is, yes, I am close to a lot of the companies for many reasons because people used to think that the big bad pharmaceutical companies and stuff like that, but I don't think of them like that. Certainly not in aesthetics. The ones in aesthetics really, you work together as partners with the physicians to bring products that we like to use and we enjoy and they want our opinions about their new products that are coming to the market.

(04:51):
So I think that having relationships with these companies really helped me as well as help them because I get to try their new product first to see if I like it. I don't think there's anything that I hate more than not having the latest and greatest thing to offer my patients in the practice that works, that works well and has great scientific clinical evidence behind it. So I think that I want every single patient that I see to know that there's not one thing out there that I haven't tried, that I haven't tested myself, that I like, don't like I have opinion about and that I should be offering and I can't because oftentimes the early release products, a lot of the companies don't let their non KOLs, key opinion leaders, to release them before. So the general physicians that don't have relationships with them don't get the products until their KOLs get them first. So like you said, I think that's kind of what I'm known for and that's what I love about aesthetics is to offer all these new products. So what's on the horizon for aesthetics in 2024?

Eva Sheie (06:00):
That was my next question.

Dr. Barbarino (06:01):
Oh good. I love that.

Eva Sheie (06:03):
I bet you have some secret things in your pipeline over there. What do you got?

Dr. Barbarino (06:07):
I have to tell you, I felt like it was getting a little stale the last couple of years. And again, I think that might've been due to covid. It might've been due to yes, everybody kind of getting behind the eight ball and not being in the office.

Eva Sheie (06:22):
I never thought about that. Do you think R and D just sort of went on hold for a while?

Dr. Barbarino (06:28):
I don't know. I saw a lot of change within R and D. Good, bad. I don't know, maybe working from home slowed them down. Maybe they couldn't be in the labs or forward facing with the doctors. I don't know what it was, but we definitely saw, did you see anything really new and different that came out during the last two years that anyone was super excited about.

Eva Sheie (06:49):
Virtual consultations?

Dr. Barbarino (06:52):
That is exciting. I can honestly say I've never really in the past thought of that as a real thing and I've become more and more, I guess I'm more open to doing that because I understand now that people, so a couple of things that we saw through Covid is that patients are willing to travel now more than ever because it just became a smaller place and people will travel to you to get a facelift. People will travel to you to get a treatment. People will travel to you because you're the best in the world, whatever the case is. So where you live in the world isn't really an issue anymore, which I think is awesome. I think that it also, covid showed us that a lot of us kind of let ourselves go during that time of covid that we weren't allowed to get the patients in here and we weren't allowed to treat them and everyone was sick and everyone kept getting sick.

(07:42):
And then we saw the robust return of aesthetics once everybody kind of got back to business as usual. And I thought that was really an exciting time. But we also saw the other side of that where people were overfilled and that's where we started seeing feel of fatigue and we started seeing all these other crazy things that we had never seen before, complications that we hadn't seen before. We saw injectors that came out of nowhere that, oh, I'm a grain injector. I now have a training institute. You've been injecting for how long? Oh, a year. That's crazy. We saw certifications come out of nowhere. So I think what we're seeing is really a different time in aesthetics business wise. If you want to talk about that, we can talk about that too. As you know, I've changed my business practice a little bit as well, but I also think patient facing, it's been different. Like I said, we saw filler fatigue, which we didn't in the past. We're seeing that 30% of filler sales are down. I don't think it's because filler. So the question is, is our sales really 30% down from before or did we just see such a high increase of filler sales once we got back to business as usual because people had let their fillers go for so long without getting refilled that we saw such a resurgence of fillers when we got back to business.

Eva Sheie (09:01):
This is really interesting question. I have had a hypothesis.

Dr. Barbarino (09:07):
Yeah, tell me.

Eva Sheie (09:09):
I think people, you're saying filler fatigue. I also have seen a lot of people starting to notice or worry that filler is not actually leaving your face as promised.

Dr. Barbarino (09:21):
Right. So like you said, it's a very interesting discussion. So do we know the answer to that? I do think that some fillers stay quite a long time, especially depending on whether it's in certain areas. I think that depends on the person's metabolism. I think it depends on the area that the patient moves their face. I think that it's the product that's injected that could stay longer or shorter periods of time. We just don't know. And I think it's great. Now we have ultrasound and we have all these other modalities to actually see if the patient still has product inside their face. I mean, I've certainly seen it with under eyes. Patients come back two years later after being injected in their tear trough for eyelid surgery, and I look at them and they're like, oh look, I have this underneath the eye. It looks bulky. It looks like I used to have to get filler in here and now I want to get rid of the fat. And then when I palpate and feel the filler, I'm like, oh my gosh, it's filler. And they're like, well, I haven't had that place injected in like three years, four years, and then I can use hyalanex and get rid of their filler that easy. So it's interesting.

Eva Sheie (10:28):
I think we forget also that a lot of filler is reversible, but what is really involved in reversing it?

Dr. Barbarino (10:37):
It's great. We have Vitrace, we have hyalanex, hyaluronidase dissolves hyaluronic acid fillers, so any hyaluronic acid filler can be easily dissolved. Well, the cross-linking does complicate things. The higher cross-linked the filler is the more hyaluronic acid you need, the hyalanex that you need. So it just depends on the amount that they used, how much cross-linking the particular filler properties that each filler that's injected has to see how long it dissolves. But most of them you can get easily dissolve in a matter of five minutes or maybe several rounds of hyalanex or Vitrace.

Eva Sheie (11:21):
Are there parts of the face that are harder to dissolve than others? If you have too much in your lips and you need your lips dissolved, what happens to your lips afterward?

Dr. Barbarino (11:30):
Oh, you're so funny. That's an interesting question. So

Eva Sheie (11:34):
You can count on me.

Dr. Barbarino (11:35):
It depends really. That's the reason why I think I fell in love with you initially because you ask the right questions and you really understand the science, which a lot of people that don't do this on a daily basis. I know that you have worked for all the companies and all of these things, but you yourself don't inject. So I think it's a very hard position to be asking these questions, but you really understand it and you really understand the science behind it.

Eva Sheie (12:00):
I'm trying to carry the fears that people have that I see. I read so much online and I see what people are afraid of and I always try to get the answers to those questions and connect the dots back. People are worried and the more they know, the more confident they're going to be in the person that they're going to see.

Dr. Barbarino (12:18):
Well, I love an educated patient, so if I have a patient that comes, I know a lot of doctors are like, oh, stay off the internet. I think it actually helps me get through the realistic No, don't, not realistic. Yeah, exactly. It's not realistic, number one. Number two, it also helps me kind of answer kind of the easy questions because some of those easy questions can be easily answered by reading the basics online. But going back to your question, so originally when you started the question, it usually depends on the filler that was used for the amount that you need to dissolve it with the Hyalanex or the Vitrace hyaluronidase, but what happens to the tissue after you dissolve it? So that's an interesting question. So a lot of people initially thought Hyaluronidase actually broke down your own hyaluronic acid in your skin because the reason why HA is such a wonderful filler is because we naturally have it in our skin and when we use a hyaluronidase to dissolve HA, originally a lot of people and a lot of physicians were concerned that it would break down the natural in the body and not be able to discern that between that and the filler that was injected.

(13:33):
But we do know that initially we can see a little bit of depression of the hyaluronic acid in that area, but in a month or two, we often see it come back. The natural hyaluronic acid that was there with no permanent damages per se. However, there are some studies that say that if you use a ton, I think the number was upwards of four or five aisles in a certain area, that it can permanently break down the hyaluronic acid in the skin that you have. I haven't really seen that. I've dealt with a lot of people's complications. I oftentimes have calls from the companies, I have calls from other physicians that call me to help them out, and we end up using quite a bit of hyaluronidase to dissolve the filler that was put in there, whether it's a vascular occlusion or too much filler or whatever's going on. And I have not seen any permanent damage.

Eva Sheie (14:32):
Your expertise on the non-surgical side is far and wide deep and wide is what I wanted to say, but your equally, if not more experienced on the surgical side, especially with the face.

Dr. Barbarino (14:46):
Thank you. I love a good operating room. I love puss and guts and I love blood, and I think it's transformative, right? It's the ultimate makeover. I think it's making everyone look better, feel better about themselves. There's nothing more rewarding because you just see people live their lives to their fullest when they feel good and they look good.

Eva Sheie (15:13):
One thing I think younger patients may not recognize because they're young and they don't have the same issues as those of us who are,

Dr. Barbarino (15:22):
I'm with you. I'm with you. We're older than we look.

Eva Sheie (15:25):
Yeah, there's a real beauty and benefit to having a person be your partner as you get older, help you figure out what needs to happen at what age. And that isn't really that important when you're 25, but it is when you're 35 or 45 or more than that. I'm not there yet, but I have recently reached the point where I don't want to see someone who's not a surgeon handling my face for lots of reasons, but mostly because I think that surgeons know what's going on under the surface way better than anyone else. So what is my question?

Dr. Barbarino (16:04):
I love that. I can honestly say the general population probably doesn't feel that way, which is interesting. Post covid, there's also been the shift away from the specialist and the expert surgeon. It's an interesting time. There are lots of experts that aren't surgeons and there are lots of people that certainly know their way around just as much as I do, if not better. But I do think that credentialing and board certification does matter, and I think that it's mattered less and less, especially with younger generations today. I think the one thing that, the biggest thing that I've seen, which I think is crazy, is I'll ask someone that came in that's unhappy with the result and I'll say, oh, how did you find that provider that you unfortunately had this experience with? And they'll say, oh, TikTok or Instagram, I hope my clients aren't finding me through Instagram and TikTok because I think my Instagram and my TikTok are more fun and jovial and it really doesn't show what my clinical experiences and my credentialing and I think even the feedback from my social media team that before and afters really no one really cares to look at is what they're telling me on my social media, which is interesting.

(17:27):
I think before and afters, anytime you get a consult with anyone, if you can't see any before and afters, you should leave because you should leave if they don't have before and afters. That's a testament to their experience, and you're not going to be able to see what your result is going to look like or envision what could happen when you have a procedure with that person.

Eva Sheie (17:52):
I'm actually pretty worried about the future with social media and I'm doing what I can to take podcasting and take the expertise of the people who do know and put it over there. Even if doctors themselves can't do it, we can certainly figure out how to take the very best and put it there. So at least there's something countering that. There was a girl who we interviewed earlier this year who had a skinny BBL in California, and she had made an entire Instagram to chronicle her skinny BBL, and we said, what made you decide to do that? And she said, well, I went on TikTok to find out who else had done this and there wasn't anybody, so I decided to do it myself. You went on just like you could knock me over with a feather. You went on TikTok to find credible information about what was going to happen to you.

Dr. Barbarino (18:46):
That crazy. Well, think about it. It also takes a certain type of person also that wants to chronicle their butt on social media.

Eva Sheie (18:56):
You're so right.

Dr. Barbarino (19:00):
I mean, let's be honest. I drink the Kool-Aid, I sell the Kool-Aid. I want to have a great butt just as much as everyone else. Do I walk around at a G-string? No, not that I wouldn't, but I certainly don't want anyone taking pictures of it if I did. It's a really crazy time. I've never seen anything like it, but things that are coming out, aesthetics, there are lots of exciting things on the horizon. So one thing that everyone's really focusing on right now are the skin boosters, which I think are very interesting.

Eva Sheie (19:32):
Who's making those? Is that a category or a product line from somebody?

Dr. Barbarino (19:36):
I mean, it's all the rage. So believe it or not, the last couple years there's been this regenerative medicine category that has been showing up in our practices. It's been showing up in our medical meetings, it's been showing up in our webinars, and all of us are kind of like

Eva Sheie (19:55):
Is exosomes or something different?

Dr. Barbarino (19:57):
It's exosomes, it's peptides, it's glutathione, all the antioxidants. The Allergan came out with skin Vive. Galderma is coming out with one. Basically the biostimulators have been doing better than they ever have. Sculptra ,Radiesse, all of those using Botox on the surface level versus just injecting into the muscle for pore size texture for rosacea, for redness, for flushing, acne, for sweating, all of these things. It's a whole new world.

Eva Sheie (20:32):
You can always count on Allergan to find more ways to use Botox.

Dr. Barbarino (20:37):
You're absolutely right, but I think that other companies are also upping their game. So as we saw with Xeomin, it's a purified toxin, so now we it more and more that's their neuromodulator. Galderma is actually, we saw with a couple of studies that there was more concentration of neuromodulator in Dysport and now they're actually coming out with relobotuline toxin. Galderma is, that's the already pre-hydrated.

Eva Sheie (21:05):
Does it have a name yet?

Dr. Barbarino (21:07):
That's relobotuline toxin. So it's going to be already ready to go.

Eva Sheie (21:12):
Yeah. Okay. You're connecting a dot for me. So when the injector says I'm going to go mix and I'll be right back, that's what they're doing is reconstituting the Dysport into what is the injectable form, but it'll just be in a vial now?

Dr. Barbarino (21:25):
Reconstituting, Juveau, Dysport, Xeomin, Botox, all of them, every other neuromodulator on the market. So this is kind of a game changer. So it's going to eliminate one step. Is that going to make a big difference for a lot of practitioners? I don't know.

Eva Sheie (21:38):
But it also make it less risky in the sense that you can't make mistakes with it.

Dr. Barbarino (21:45):
So I am one of those practitioners that has been injecting Botox in Neuromodulators for years and years and years. I did it before it was FDA approved for cosmetic use because I'm ocular facial plastics and we do it for blepharospasm and hand facial spasm. So I've been using neuromodulators forever and I like to play with my dilution. So it just depends on what you're looking for in a neuromodulator. But yes, for those newer injectors or if I'm feeling lazy on a day or if I decide that it's just easier for me to just use their premixed one, I think that is anything to save a little bit of time. It does help, but you're right, it adds up. It does add up, and you have to get out the syringe and you have to drop and you have to mix and all of these things, and it does standardize.

(22:39):
So like I said, I've now brought on a new injector and when I've shared offices or anything in the past with other injectors, my dilution is different than their dilution. And so it kind of makes one dilution for everybody. And it's interesting. Like I said, I personally haven't used it yet. I don't think anyone has other than the clinical trials that were done for the FDA, but I do think that it's interesting in the sense that the results from the clinical trials have been so positive and strong from all the sites that did inject it for the clinical trials.

Eva Sheie (23:12):
Well, we heard it here first.

Dr. Barbarino (23:14):
Yeah. You know what they're also coming out with, I think there's going to be more emphasis on these Bio regenerative and bio stimulator in the future. Like you said, exosomes and PRF and all of these things are going to be even more of a player than they have been so far. I know that sculptura's coming out with a pre mixed sculptura as well, and I think it is Allergan that's coming out with a calcium hydroxy appetite HA syringe. That's kind of a mix of the two, which until now, we've only had really Radiesse, which is one of the main reasons why I love, I mean I love the whole Merz portfolio, but Calcium Hydroxy appetite has been a standalone product for years and nothing has ever broken the market and competed with it per se, and now there's going to be another company that's coming in with a calcium hydroxy appetite.

Eva Sheie (24:11):
There's so much that we can pick up from you, and I'm actually sad that I'm running out of time because I think we need to come back and do more. So let's figure out when we can do that.

Dr. Barbarino (24:23):
Yeah, anytime. I love talking to you. I feel like, like I said, you really understand the market, you understand what's going on, and I love to hear your insight of what you've been seeing because you just have such a different take as opposed to the practitioner.

Eva Sheie (24:39):
That's true. I hear a lot of weird stuff and I love to share it and pass it along because it's a lot to carry by myself.

Dr. Barbarino (24:46):
I love it. It keeps me on my toes when you say these things. It makes me think of what I should be doing and what I should be thinking about. And I think you and I were a couple of years ago, the ones having the conversation about how the single practitioner is going to have a really tough time moving forward in aesthetics because all of these big companies were really bringing doctors together, surgeons together, injectors together, and as a standalone, it's going to be very hard to compete with that market. And that's what made me really look at my practice and that's what made me change quite a few things and my personal journey and my personal and professional goals.

Eva Sheie (25:27):
There's a lot of people out there who want to work with a doctor like you, and so I am not afraid of you being on your own at all.

Dr. Barbarino (25:35):
I love you.

Eva Sheie (25:36):
Before we go, if someone's listening and they want to come see you, where should they look for you online.

Dr. Barbarino (25:43):
www Barbarino Surgical Arts. It's B-A-R-B-A-R-I-N-O, surgical arts.com. I would love to see you. I'd love to meet you in person. And as you know Eva, I want to warn them I am not for the faint of heart. If you come in, honesty is the best policy, and I think that when patients are always surprised when they come in, they're like, oh, you seem so nice on social media and in your interviews, and I am nice, but I don't think you come to see me, for me to say, oh, you look great. You don't need anything. I don't think that that's why you're coming to see me. If you're coming to see me, I'm going to tell you that there are certain things that we can improve upon, and even though someone might be a 10 out of 10 and they might be perfect, if there's something bothering them, then I'm here to listen to them and get to them their personal goal, whatever that is.

Eva Sheie (26:36):
Yep. A hundred percent honest. That's what we love about you.

Dr. Barbarino (26:40):
Honesty is the best policy.

Eva Sheie (26:41):
Thank you so much, Dr. B. So good to see you.

Dr. Barbarino (26:44):
Thanks for having me. This was so fun.

Eva Sheie (26:51):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the Doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, THE AXIS.io.