Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level, optimizing the way you look, move, perform, feel, and connect. Just stepped out of the operating room and had a couple of awesome ideas I wanted to bring up for this week's operating room diaries, our OR diaries, one of which is related to something that's terribly misunderstood, the Buckle Fab Pad, and the other one that relates to what is essentially the future of face lifting. She did very well in this one patient who was really awesome, she was so cool. We have, I just love her, she is a super cool person, very high-performing, found a great local surgeon where she lives, had a relatively comprehensive procedure with that local surgeon. Everything we did today was a revision, was sort of updating, I'm not going to say fixing everything, but updating what had happened before. She got this procedure done, it was different, she wasn't sure if it was better, the person she went to had a great reputation, it was awesome. Everybody that she got word of mouth from, but then she realized that probably her standards were just a little bit higher than the people that she got this word of mouth from. She knew that there was something better out there, which is how we met, we created a great relationship, we kind of went through the nuances of things that were better, but missed, things that were just different, but not better, things that were maybe worse than before. Again, some of these really, really key points came out. The interesting one that I was really thinking about as I was operating, I'm literally operating thinking, I'm in my flow state and going through what happened to her and being like, this is the future of facelifting happening right now, which is she had just kind of an old school procedure again, very high reputation, very well regarded surgeon, and kind of instant famous type of thing, and the procedure that she had was just old school. And it tightened the exterior envelope of her skin. And what she told me when we were consulting, she was spot on. She's like, I feel like the surface is tight now, but everything underneath is still sagging, and that's exactly what happened with her. And I see this with old school facelifts, I see this with like tightening devices and things that are just aimed at the wrong thing in the first place, which is everything is sinking all the layers of our face. And so as I was revising her, I was especially focused at tightening the deeper layers. Now this is beyond what we would call just a typical deep plane facelift. That is one thing in and of itself, and that represents an evolution over time where people really focused on first the skin. Then the skin and the fat pads underneath it. And that was like the traditional that stood for a long time. You know, going back to the skin was like over 100 years old and people were just tightening skin. And fortunately, that still happened sometime, so there was the next level of the fat layer underneath. And then we went to the deep plane, and the deep plane has a wide meaning of what's happening there. But when we really get into a good thorough deep plane facelift, now we're getting underneath the fat pads, and we're focused on the whole envelope of the musculature and the fat pads and lifting that up. And that's, I would say, becoming the standard now. People are starting to adopt that. It's not a fat. It is definitely the way to do it. It obeys embryo, embryologic cleavage planes. It's the way to go. But interestingly, there's another level beyond that. And that's what she was experiencing is that there is a deep, fascial floor. Even when we're in the deep plane, there's a deep fascial floor that exists below that. And this is literally the newest, latest and greatest that's happening is like when I'm looking at the floor of this dissection that's already very next level, when I can see some laxity in that, it's like, okay, how do we work on tightening the deepest of deep levels? So it's kind of this evolution that's been happening over time of just continuing to look deeper and deeper now, or quite literally looking at all the layers of the face. And so she just exemplified this prime example, because she nailed it. Her envelope was tight. The deep stuff was lax, and I had to really focus on not necessarily tightening the exterior, but working on the deep structures to match her tight exterior. So as I'm doing this, I'm thinking like, this is the future. It's happening right now, just especially relevant and especially magnified in what was a revision facelift case. So I've been doing this. I've been seeing great results with it, but she's who it's meant for in a revision situation. I'm doing it with everybody, focusing on all of these different layers, but she really exemplified that. Well, the other thing I thought she exemplified as far as just an understanding that exists in the cosmetic community is like this really confusing area around the corner of the mouth down here, which is one of the more challenging areas to address with literally anything, whether it's people are trying to address this with filler all the time, bad option. People are trying to address it with different types of lifts. And what had happened to her, she had had this fullness down on the corner of her mouth, and she had this kind of older school facelift that tightened everything on the envelope, but then it looked like there was more happening in her cheek. Like almost she had like a little, you know, she said it looked like she had nuts stuffed in her cheek and nailed it exactly because it was her buckle fat pad. Even when she saw this surgeon and follow up after her surgery and was asking about this, the surgeon was telling her that it was a perioral mound and wanted to go on the inside of her mouth and cut out some of them, Eucosa, the lining of her mouth, because he said it was a bunch of muscles that was part of her anatomy and it was bunching there, and you'd have to go debulk the muscles and in reality this was just her buckle fat pad. Now some surgeons recognize the buckle fat pad and want to cut it out, take it out, which I think is, it happens and, you know, I just question the long term part of that because that buckle fat pad is wild, be valuable to our facial structure, and it does sync with time. And so that's led to this process of lifting it up. I don't know anybody else that does this. I've trained some of my fellows to do it now. My protegees do this as well, but this is just a different thought paradigm and a different approach to instead of cutting out the fullness that's sitting down here, which can just hollow you out even more, especially as you're dealing with aging changes, right? I just am trying to lift the fat pad back into place, which I do in a scarlet fashion through the inside of the mouth, actually. So the incision is inside your mouth, nothing external to drive that buckle fat pad back up into place, which I was doing for her today as part of her procedure because that was essentially unaddressed and terribly misunderstood, kind of dodged a bullet by not having it sort of cut out, having muscle and things cut out from the inside of her mouth, but it overlaps with this idea of periural mounds, buckle fat, what's happening in the corner of the mouth. Some of it can be superficial, like jowling. It's really a complex area and it takes a deep understanding and the more that I do revisions and the more that I see people coming in for consultations, the more I understand like how poor the understanding of this area is in general. So it's definitely something, it's really common that that's a highly sought after area when you're looking at a lifting procedure, addressing that particular area and I think it's just knowing that there are multiple facets that can contribute from fat pads to muscle, to gravity, to skin, how all those things go together and generally it's just replacing anatomy to where it used to be. That's my philosophy versus just cutting. When things fall they shouldn't be cut out, they should be lifted in my opinion. So a lot of really cool illustrations from there, the future of, what I think is the future of a couple of things, the future of lifting the buckle fat pad, my mission is that this will be adopted and lots of other surgeons will adopt it as well. And what is the next frontier of face lifting, which is really focused on the next level, literally the next level of layers that we can be tightening and optimizing our results in the long term. 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.