Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level, through optimizing the way you look, move, perform, feel, and connect. This week's OR Diary is two different things from two different patients, one of which is something very interesting that I found and saw, which is kind of unique in novel. And the other one is just an idea worth mentioning. The story of the thing that I saw that is very unique in novel is today, this was today, working through the neck of somebody doing a neck revision, and I found a bunch of filler. Highly eronic acid filler in this patient's neck down the muscles of the neck, which is not something that I see all the time. I certainly know and see all the time where filler migrates, moves, whatever you want to call it, which is sometimes vehemently denied by the injection community. Oh, it was placed there, it was on purpose, it was put in the wrong spot. This is just a straight up situation of the person who had lower face filler, chin filler, things like that, and it had quite literally migrated down the muscles of her neck. We were seeing it way down in the musculature of the neck. So anybody who denies the filler moves, if it's placed in the right, it's just crazy when you see it in real life. There's no way that this person had filler placed in her neck, which is quite interesting. And she had had a previous procedure on her neck that wasn't, it was non-surgical in the sense of she'd had neck liposuction done in the front part of her neck when she was a little bit younger, which left her feeling hollow. It was the wrong procedure for her to have in the first place. I often say that. She just had some laxity forming in her neck and instead of doing the thing that needed to be done, which is lifting and tightening the floor of her mouth and actually elevating the things that had sunk, she'd had liposuction. So when I'm in her neck, now I'm looking at filler and the musculature of her neck, like inside of it, these like globs, these little gems, diamonds of filler stuck everywhere. I'm also seeing the muscle of her neck that's stuck to the skin above. Because if we think of the purpose of the subcutaneous fat in our neck, meaning this fat that's right under our skin, it's a good thing. That is the insulating layer that allows the musculature of our neck to move in its glide plane and have the skin not move over the top, be able to glide. That's a natural cleavage plane that's supposed to be there and that fat is insulating. It kind of takes some of the deep neck contours and makes everything in the neck look soft and youthful. We want the right angles, but we also don't want it to look overly harsh. Removing that fat is misguided because it's usually not what's actually overabundant. It's that other things have sunk in unless somebody's really heavy with a high body hapedist and it's usually part of the equation, not the whole thing. This is why injectable things like kaibella that are aimed at that fat have flopped and failed. It's why liposuction is often a bad treatment. For this particular patient, she had such aggressive, normal, but often liposuction is very aggressive trying to get rid of it, that the fat had been removed between the muscle and the skin. There was no more glide plane and the skin and the muscle were getting stuck together. Literally stuck, fibiotic scarred together, if you will, which creates planes that don't move normally and creates unnatural looks and hollowness and contour irregularities. As I'm going to remove the filler and normalize this patient's neck, her, the muscle is looking a little bit like Swiss cheese from her previous procedure. I'm fixing all these defects in the muscle. I am detaching the muscle from the skin, trying to make everything look normal. In addition to the filler, I guess, which was a very interesting thing to see, migrated filler, unquestionably migrated filler. It was also quite a bit of revision work to do from a air quoting here, non-surgical procedure in her neck that she had tried to improve her neck that was misguided and it failed her. Ultimately, let her probably have surgery in a more urgent fashion than she would have otherwise. That was very unique. This patient really illustrated was interesting and unique to me. It was the difference between buckle fat and perioral mounds. If I break down what both of those things are, buckle fat is a fat pad. I'm pointing at my cheek here that lives inside of our cheek around where our teeth are at. If you were to poke yourself in the cheek and you can poke in between where your teeth meet as you open your teeth, that's the area where this very specific, deep, very unique, very cool and beautiful fat pad lives called the buckle fat. That buckle fat is deep. When you bite the inside of your cheek, you're biting the housing, the membrane that there's a muscle actually that is the inside lining of where your buckle fat sticks in your cheek. Babies have big, beautiful buckle fat pads, but that buckle fat pad extends all the way up into your temple and around some of the muscles that we use to chew and move our jaw. Over time, because the buckle fat pad is very unique and very deep and it has a different structure to it, it tends to sag, sink and can cause some bunching around the corner of the mouth, leaving some hollowness back behind where it came from, kind of like a glacier, leaving a valley behind it as it moves slowly over time. A lot of people like to go cut that buckle fat pad out. They'll go access it, which we can do through the inside of the mouth, very, very stealth, essentially scarless to get it, and people will cut it out. I think a little bit differently, and I argue that we don't want to cut that out because that fat is very important structurally, almost like as a three-dimensional buttress to the rest of the structure of our facial fat, that we want to put it backward it came from. I have developed and am always improving on a procedure of lifting the buckle fat pad back into space. This is a theme of my overall practices. I very rarely am cutting things out and throwing them away. I'm usually putting them back where they came from, and the buckle fat pad is no exception to that whatsoever. I am restructuring the space. I'm using the volume that's there to redistribute. I want to recreate things the way that they were. I don't want to transform anything to the way that it wasn't. So buckle fat pad fits very, very much into that. That can be very confusing to some surgeons and especially to patients, into what some of the mounds or contours they have around the corners of their mouth are. Because some of the fullness that can form around the corners of your mouth that are under smile lines, underneath your lip, above your lip, wherever it may be, are not all from the buckle fat pad. They can be mounds that form from books of musculature, from the way things have descended, from how our muscles uniquely pull on our fat pads in our skin. So it really needs to be delineated as to what's actually happening in an area and how we can correct it. And the patient that I am really referring to who sparked the story had had her buckle fat pad removed, which makes me cringe inside because she's in her fifties. And removing her buckle fat pad was not the answer. Even if it was, the culprit should have been lifted, in my opinion. But what she had was a parry or a l amount had nothing to do with her buckle fat pad in the first place. She already was a little bit thin in her buckle fat. Not everybody has excess buckle fat that's mounting around their mouth and causing gravity. A lot of times I'm trying to restore the structure from the buckle space from my fat pad that is actually shrunken away, which I do with my very unique blend of stem cell rich fat transfer. But for this particular patient, not only did she already have a small hollow buckle space that was creating some almost aging and structural regularity in her face, but she had some parry oral mounds that were confused for buckle fats of her. The buckle fat pad she did has have was further removed by a past procedure, which creates a very unique environment with a kind of an updating surgical procedure that we were doing where this became a small but important component of her overall facial rejuvenation because we're trying to number one take care of the parry oral mounds that sought her to lead or that led her to seek treatment in the first place. I'm trying to restore the damage essentially that was done to her buckle space of the subtraction that was done by restoring it. In addition to doing what she needed done in the first place there and restoring her overall facial architecture with the rest of our procedure, this is very common for me. It's not one thing that we're after. It's a full facial rejuvenation, but this became a very important part of it. And it helps me understand the amount of confusion and misunderstanding that exists between what is a parry oral mound and a buckle fat pad, which gets really nerdy and really detailed and really into the weeds, but also helps illustrate how important it is that whoever you are choosing to have this procedure with is digging into the weeds, getting into the esoteric is curious, understands what's happening on a deep, deep level with the buckle fat pad, quite literally the deepest fat pad level of our face and is doing things not just because they can, but because they should with the deep understanding of that. So I love that. I talk to my kids about that all the time just because you can't, doesn't mean you should. What are the levers that we need to pull? What's causing what we're after? That's our best way to maintain harmony and then of course do all that in a way that nobody ever knows that you had something done in the first place. So you can look in the mirror and see that thing that you want to be seeing, erasing that cognitive dissonance. So oftentimes the area around the mouth is big for that and that taps into our neuro and anatomy, neurobiology. We know that the area around the mouth is wildly important for our nonverbal communication and what we're putting out into the world and the buckle fat pad and the parry oral mounds are very, very key parts of that. If you have any questions or topics you would like me to explore further, please leave them in the comments. I read them all and they often help shape the future conversations here. If you would like to learn more about my surgical practice, you can visit clinic5c.com where you will find additional information on my approach to surgery, recovery and performance focus care. I also want to be clear that the views shared on this podcast are my own and are not associated with or representative of my clinical teaching affiliation with the University of Washington School of Medicine, nor should this be taken as individual medical advice. Thank you for spending your time with me. I appreciate you being here and I will see you on the next episode.