Intro

Dr. Cameron Chesnut 0:00

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.

Today's Case Setup

Dr. Cameron Chesnut 0:12

Welcome to today's OR diary. Today is one I'm really excited to talk about because I learned a lot and I touch on some controversial topics in here. Controversial in ways that we see things happening and we don't have evidence to support exactly why they're happening. So there's a lot of curious observations happening here. And just to get to the point, it's a very unique situation

Meet the Patient

Dr. Cameron Chesnut 0:31

for me. My patient today was somebody that I had been seeing for 10 years. This is very rare for me because all of my patients are traveling to see me, but this is somebody that I've actually have a history with, 10 years of history with this person. And back when I first started seeing her, we did some filler in her lower lids and her midface. And she was about 40 years old then. Now we flash forward to 49 exactly. And we did a full rejuvenation procedure today. That was upper lids, lower lids, um, forehead, to sus, uh, midface. I did an invisible access along her jawline, all the things, right? So

A Decade of Photos

Dr. Cameron Chesnut 1:03

it's really interesting for me because as I always do when I was preparing for her, I went back and looked at the photos that I had. Normally I'm getting historical photos sent to me by my patients, but with her, I had 10 years, over 20 sets of really good high-quality photos that I took. So I got to see her natural progression from where she was at 40 years old to 49 years old, including when filler came into the picture and what changed afterwards. And so this is where I learned so, so much.

Filler Made Her Look Better

Dr. Cameron Chesnut 1:31

She looked better after having had filler. So for all of my filler zealots out there, she looked better after filler, no question about it. I did it myself, did a great job. She looked really good for many years after getting her filler, actually. And I can honestly say that when I see her at 49 now, she looks better still today at 49 than she did at 40. And that was with one time, a decade ago, doing filler in her lower lids in her midface, and then a couple of just little laser procedures around her eyes for skin changes after that. So full disclosure, she looks better at 49 than she did at 40 with those types of things. So okay,

Still Wanted Surgery

Dr. Cameron Chesnut 2:07

great. That's really awesome. That being said, she was still seeking a surgical procedure for a more robust rejuvenation. Uh, so that says something about this, right? Because when I go back and look at these series of photos, I can watch the progression of things happen

Watching the Filler Signature Emerge

Dr. Cameron Chesnut 2:20

over time. And I had not done that with her until I was getting ready for her surgical procedure. I got to see her at 40, 40 and a half, 41, 41 and a half, like all the way down the line. And I could see where filler came in the picture and I could see what happened to that filler over time. And this is where things get really, really interesting, I would say, is that the filler went in and it looked good. And there was a period of time where it just kind of kept looking good, like years, five, six years. But then some changes started to happen that were more than just normal aging changes in her. When I look at the photos of the area where the filler was, things in those areas started to change and give these filler signatures. These are things I can spot literally a mile away when somebody walks into me is like, oh, you've had filler in your lower lids. Um I think the assumption is always like, oh, that was poorly placed filler. It was placed in the wrong place. A lot of injectors say that, oh, that's because the person didn't know what they were doing. Well, here's an example of that's very much not true.

Debunking "Poor Placement"

Dr. Cameron Chesnut 3:16

Um I did it myself. I when I did injections like that, I was, you know, objectively really, really good at those things. My results were uh very solid and they were very solid for a long time. And so we have we know it was placed in the right place, I know exactly where it was put, I know what product it was, I know how much was placed there, and I know how long it looked really good until things started changing. This is a controversial topic because uh my injector colleagues will scream we have no evidence to show that the behavior of the filler changes over time, that the physical properties of that filler change as the filler breaks down over time. Great. We do have a situation, a case like this. And I see this type of thing all the time where I watched the filler for years and years and years do really great, actually. Uh I then start to change down the road. And there's a bunch of data points that come into this. There's just what I you can see in front of your eyes. Like I said, these are things I can spot literally a mile away as they walk in. Um, and I could see it happen in the time frame with which it happened because I had such great, detailed, very uh regimented, standardized photos at very strict time points. So I knew exactly when things started changing. And I knew what had happened in the interim, which was nothing, just normal time in life. And so I could start to see these signature filler changes in her lower lid midface area, which is a little bit more puffiness than there should be, specifically in the orbicularis muscle, the very superficial muscle around her eye. It has the look of puffiness, the look of filler, a little bit of blue, a little bit of that abnormal swelling type of look to it, which it didn't have for many years after the filler. It started happening with time.

Surgical Journal Entries

Dr. Cameron Chesnut 4:53

Then I get this beautiful data point in surgery. Now I'm going in for surgery, and I get to see with my own eyes, in front of my face, where this filler is at. And sometimes when I go do these surgeries, I'll make these journal entries to myself for those that don't know. Like after my surgery, I document literally every detail about every nuance that I saw, all the decision points that I made, things that were surprising, things I learned, things I want to watch, things I want to learn from. And then later down the road, when I get to go see this person's before and after photos, by the way, you will get to see her before and after photos. When I go see their before and after photos, I get to like go back and look at my journal entry of all those data points of things that I want to learn about. So sometimes I talk about accessing these areas of filler and it's just pouring out lots of filler,

What Surgery Revealed

Dr. Cameron Chesnut 5:37

and that's usually when the filler is newer or when there was too much placed. Well, we know that none of those were true with her because it was a conservative amount, you know, a decade ago. And so I found filler a decade later. She had not had any dissolution or anything leading into this. This was just filler that was very conservative amount placed in a very specific location, the right location, if you will. And I got to see filler still in that right location. And it was like the typical situation: wet sugar kind of removing it, not an egregious copious amount, just like amounts of filler that were appreciable. You could see it right there. I can almost tell what type of filler it is with my eyes now just by looking at it. Uh, and it was very much as I would have expected in that area that it was placed. Still present, still doing its thing. What I was surprised to find out was that the filler was also in different areas where it was not originally placed, including inside of that muscle superficially around the eye. And this is what I observe from a superficial standpoint, looking at somebody's surface anatomy that I see all the time. There is filler inside of that person's muscle. I talk about it all the time, almost every day, almost every consultation when somebody's had a history of filler, I start to get this pattern of like, well, we're gonna probably find filler in that muscle.

A Pattern Across Patients

Dr. Cameron Chesnut 6:52

And again, the pattern is always, or the explanation from injectors has always been, well, it was it was too superficially placed. It was placed in the wrong place. And, you know, we don't have anything to say that that is or is not true necessarily, except when it starts to happen literally every time, are we saying that everybody is getting it placed in the wrong location? Probably not. And then here's an example of I know exactly where it was placed, I know the type of cannula it was placed with, I know the exact plane, and now I'm finding it in the orbicularis muscle. So this starts to explain a lot of things that I see in my other patients as well. If we put a pin in that patient and move on to a normal uh situation where I'm meeting somebody for the first time, we do their procedure, you know, that process takes six months or a year, we get to it, we do the thing, and they had filler maybe three, five years prior to our procedure, and it's still like looking pretty good. So I might find a little and remove a little manually when I'm in their procedure, but it's not a problem. So we just kind of let it be. The procedure gets done, that person is doing great, beautiful, excellent results, doing awesome. And then about three or five years after our procedure, when things have been doing really great for a long time, they start to get these filler signatures showing up again, these like fill this filler look in their lower lids. And it's like, well, have you done anything since our last surgery? And this happens over and over again. No, I haven't done anything since we were done. My eye my lowered lids look so good I didn't need to do anything. And what's happening is in those people, when they start to get out to these like five, seven, eight year time points. And again, these are arbitrary time points, these are observational by me. This is not, you know, citing scientific literature, but it's pretty reliable that around those time frames, I start to see these looks, this signature of HA fillers and around the lids showing up, even when that person is post-stop. So now we're in the situation where they, you know, looked, they had their filler and everybody got filler for a reason, right? If you got filler when you were 40, there was a reason that you got filler then. Uh even if you're now 49, there was a reason back then. And so these, you know, we we eventually do this procedure for the reason that they got filler in the first place, and it looks great. And then we start to get these changes over time that form in my patients post-operatively. And now we're managing an old filler issue in the years post-operative period. So it's something to pay attention to. With my own patient pulling that pin out and going back into the patient that I'm talking about, when I look back at

Candidate for Surgery at 40?

Dr. Cameron Chesnut 9:09

her pictures at 40 years old, she was actually a good surgical candidate then. She was very young, admittedly very young. But the changes that she had that we she was seeking filler for would have made her a good surgical candidate then. We could have done a very minimally invasive, essentially scarless, not essentially, like actually scarless procedure for her and accomplished what she was after then. And the question then becomes well, is that the right thing to do? Or do you do the filler that she did have done, which looked really great for six years, maybe? And then things started to change, and then it got to a point where it wasn't so good. Or do you just do the procedure then and kind of let go with it after that? It's a hard answer. Nobody knows the answer to this. If anybody says they know the answer, run away because this is this gets a little bit philosophical. Very curious is, well, what happens then at six years when

The Dissolution Myth

Dr. Cameron Chesnut 10:01

the filler, this is an arbitrary number, but for her, around six, seven years when the filler starts to not look so good, is it easy to manage? And the answer is no. Um, we don't actually even know the right way to manage it, let alone what's happening here. Um, and the reason I say we don't know exactly know either of those is because dissolution, which has long been sold as, oh, you put hyaluronidase on hyaluronic acid fillers and it just melts away. It's magic, it goes away. If you don't like it, you just get rid of it. Well, I've been screaming this from the hilltop for a long time that that is not true. That does not work because many of my patients in the same situation have maybe had 10 rounds of dissolver or dissolution, and I still find filler in their surgery. It doesn't go away. So interestingly, the nomenclature in the filler world, even in the last year as I record this, has started to change a little bit to instead of dissolving filler, we call it modifying filler with hyaluronic acid. Fair enough. Meaning we're acknowledging that it's not going away, but it is changing with it. Just like I think it also changes with time. The properties of the filler change with time. And again, the argument will be that there's no evidence to support this. These are very new thoughts and observations, even going into the dissolution thing that has been for well over a decade, 15 plus years, been like, oh, if you don't like it, you dissolve it. We know that's not true now. So that, you know, that was just spread to everybody was was not the actual case.

Managing Old Filler in Surgery

Dr. Cameron Chesnut 11:22

So when we get to this time frame of things aren't looking so good, it's been six or seven years, it looked good for a while, now it's not looking good. Well, okay, what's the penalty of that? Is that just like simple? We just go remove it. Well, I will tell you this, having done this hundreds of times now, is that I cannot manually remove everything during surgery. Just like the other patients I described where the filler wasn't too bad and I found some during surgery and I kind of removed what I could. Even those people who didn't have an issue and had some of their filler manually removed can still have problems down the road afterwards. When somebody comes, and that's the more rare situation. The more common situation is that somebody comes in, they're already kind of having problems from their previous filler, even if it did look good for a while. They're kind of having problems from it. Now what do we do? Well, I remove as much as I can manually, which is something I directly visualize. Then we go into dissolution, which is meaning like, okay, now I know where it is. That muscle, the muscle that I talked about, that very superficial orbicularis muscle around the eye, is a very delicate flower and very functionally important for us in the long-term health of our eyes and mid-face and things like that. We do not want to mess with that muscle. If it's got a bunch of filler in it, I can't just go cut it out or take it out, or I would risk damaging that muscle and it's not to be compromised. It's very delicate and very important, but it's also very superficial. It sits right under our skin, does not really have a layer of subcutaneous fat to insulate the vision, the visual of it. So if that guy is puffy and has filler in it, you're gonna see it. And you see it all the time. I promise you that you see it all the time, and you'll maybe pay more attention to that now. So we get in the situation, well, I can put some dissolution in it, but as we now know, dissolution doesn't magically erase it, it modifies it, but it doesn't make it all go away. This is the most common thing that we talk about after any midface or lower eyelid surgery when there's filler present. It's not the surgical results, actually. It is what's happening with the previous, the previously existing filler, the prior existing filler that was there before we ever did the surgery. How is it now that we've tried to manage it and mix it in with a normal restoration of underlying anatomy? Uh, that's the challenge of these

Old Filler vs. New Anatomy

Dr. Cameron Chesnut 13:22

procedures. And so I learned so much from this very, this is it's as ideal of a situation as I could ever get to have observationally. I got to see very perfect photos, very regular time frames over a perfect decade when filler came in, what happened, how it did over time, admittedly having an improvement, admittedly still looking better at 49 versus 40, but having problems with the filler now. Um, at what point would the problems have outweighed the benefits and she actually looked worse? Who knows, right? We didn't get to that point. Um, but you learn so much from that and you get to see what's happening in there. Uh, and you know, it it just supports. It was a very controlled example of things that I've been observing and

Does Filler Move Over Time?

Dr. Cameron Chesnut 14:03

seeing. Um, and there's emerging literature on this. We were finding this out as far as people are studying as a lot of this probably has to do with the properties of the filler. Do they change over time? That's the question. I would observationally say it certainly appears that they change over time. It the filler moves from its original location. We're trying not to call it migrating anymore, because that sounds active, but the filler is definitely in a different place than it was before. So, do the properties of the filler change over time? It would appear so to me. Uh, does it move? Absolutely yes. That was another thing that was so vehemently denied, and it's now becoming like very clearly the filler moves from where it's placed, whether it's lips or midface or eyes or anywhere, it's moving around. So that is happening. Um, and then there's the question of like, well, how do you manage it? How do you dissolve it? What's it doing? But this this next big element is like, well, what what are those changes over time entail? What do they look like? What's happening? Is the filler attracting more water? It appears to be, but again, there's nothing to support that actually happening. Is the filler affecting lymphatics? And until very recently, um, we didn't, we knew that that was happening. We I see it post-surgically all the time. If somebody's had previous filler and they have surgery, their lymphatics do not drain normally. There's something going on there. So again, observationally, screaming this from the hilltops for years and years and years, um, everybody saying, oh, there's no evidence to support that. That's not true, that's not true. Well, uh, we don't want to confuse a lack of evidence for a lack of it actually happening, right? Um, and so we are now, we now have some emerging evidence that you, if we're following what's happening in lymphatics post-filler, that there are changes in post-filler lymphatic drainage. So this is this is a thing, and it always has been, and we've observed it. Um, and now we're gonna have some evidence to support what's actually happening there, what we've been seeing for years and years and years. So there's a lot going on here, controversial topics, and I'm admitting that there's not strong evidence to back up all of these observations and these very uh seemingly common things that happen in front of my eye. I am a sampling error because I do surgery, I do a lot of surgery around the eyes, and I almost 90 plus percent of my patients that I'm working on have had prior filler. So I see this a lot and I get to see it. So this beautiful patient of mine, who I'm so grateful for, having had for 10 years, I got to see what happened in her photos. I got to see what happened when I was physically in the area where the filler was placed while I was doing surgery and got to visually directly observe where the filler is. There's so much golden information in there about things that I'd been observing, but I didn't have the sort of runway with. I didn't have the photo documentation with, I didn't know the exact details of their prior filler placements with as much certainty because sometimes it happens more frequently or they go to different places to get it injected and the records aren't as strong. So I learned a whole

Before & After Photos Coming

Dr. Cameron Chesnut 16:52

lot from this. You will get to see her before and after photos. Um they, you know, you'll be those will be trickling out over time. Um, and we'll get to see this whole progress. I'll try to put together her at 40 through 49 plus what looks like afterwards. I think that'll be really interesting for everybody to see. So you can see exactly what I'm talking about here. But definitely got me thinking, definitely a unique situation with a lot of longevity to you know tie these things together. And it really helps explain observations that I've had that have been a little bit um challenging in patients who had prior filler with no issues, had prior filler with issues, how do we best manage this? These are things that we're all still trying to figure out. Um, and this just highlights the curiosity that we have to have. We have to go into these things, um, not thinking that we know everything about it, um, especially when things don't quite click and make sense, like filler just all gets dissolved, it doesn't move. The things that we knew weren't true. Um, we again we don't want to say that just, well, there's no evidence to support that, that does not mean it's not happening, right? And that's what we're seeing right in front of our eyes. So um tune in, pay attention, a lot of change is happening here, and I'm observing this all the time, managing it all the time, and I love the direction that we're going in with starting to accept things as

Closing Thoughts

Dr. Cameron Chesnut 18:07

a field, especially with my injector colleagues, of what's actually going on, because these products aren't bad, nothing's bad. We just need to know how to best use them, and we need to quit denying reality and things that we see in front of us if we want to move in that direction. So prime example, can't wait to show you her photos. But thanks for tuning in. But 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. But 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.