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.

What I Wish Everyone Knew About Filler

Dr. Cameron Chesnut 0:12

These are the things that I wish everybody knew about filler, and specifically my future patients knew about filler. This is going to be our deep focus today on the Five Codes podcast. Filler is something I've talked a lot about in the past. And just to be specific here, we're going to be talking about mostly hyaluronic acid fillers. These are the gel fillers that are so popular and have become so popular over the past, well, couple of decades really. It's something I have talked a lot about, but

The Debate That Sparked This

Dr. Cameron Chesnut 0:38

this discussion today piggybacks off of a really fun and interesting debate that I just did with Dr. Christian Subio, where he moderated a debate between myself and an injector who's been injecting since the very beginning of these hyaluronic acid fillers in the United States, 20 plus years of injecting. And it was a really interesting setup because this was me going into the viper pit or into the lion's den. I went into the filler space amongst a bunch of injectors and talked about things that in reality I've been talking about for about a decade with a lot of friction, a lot of resistance, a lot of personal attacks. Interestingly, including the person that I was debating against, has been part of this part of this think tank and this echo that I have been sort of trying to educate or infiltrate, or at least honestly just tell them what I see. This is what I see in the face every single day. And so it's been a really interesting evolution over time of the things that I have talked about where filler has been practiced with a lot of assumptions since the very beginning.

Filler's Rise and the Assumptions We Built

Dr. Cameron Chesnut 1:39

Filler, like I said, first came on the market in the United States with Restalin in 2003. And for about its first 10-ish years of existence, it was building, but relatively relatively uncommon overall. It was new, it wasn't that proven. And if you look at the curve of its use, it was pretty flat until about 2015 or 14, which is interestingly when some new products came on the market. And that is when I came out of fellowship and started practicing. So I was very exposed to these products in my training. But then the second that I hit real practice, they took off. And when I mean took off, that curve was straight up and got steeper during COVID in the 2020 timeframe. So there was a lot going on, a lot of use, and the filler world exploded right around when I started practicing. So I kind of like grew up with filler. My practice grew up with filler. My surgical practice has co-evolved right alongside filler as it's exploded in the world. And that led to a lot of unique things that I was seeing that had been previously undescribed. I was so convinced about seeing these because I was seeing them frequently, I was seeing them repeatedly, I was seeing them consistently. And I started talking about it. And that was really disruptive in the filler world. Not a real popular person in that space, even though things that I was saying were true. A critique that I would commonly get from them is that, oh, you're saying as though you know these things to be true. And I'm like, well, I know what I see in front of my face. So the interesting thing is on the other, the flip side of this is we are functioning off of assumptions with filler. And just at a baseline, those assumptions about filler were that it was temporary, lasted six to 12 months. It was inert, meaning it went in and it was just like our native hyaluronic acid. Our body didn't recognize it, totally inert. None of those are true. Um, that it was easily reversible if we didn't like it. If you don't like it, we'll just dissolve it and get rid of it. This is something that I explicitly mentioned in the debate that every single person who injected filler said that. And we now know that that's not true. Uh also that it didn't move. It was stable. Wherever it put, it stayed, which is also, we now know, not true. Um, and then that essentially once the filler went away, that everything was back to baseline, back to normal. Nothing had really changed afterwards. No harm, no foul. All of those things need qualification

Assumption One: It's Only Temporary

Dr. Cameron Chesnut 3:58

now. Um, and these are the things that I have been saying, kind of in that order. The first thing I was talking about is filler's lasting a lot longer than we thought it was. And, you know, when I was starting my practice, I was seeing people who'd had filler in the past, but there weren't that many of them who got it a long time ago. Now that we're a decade down the road from when it exploded, we have a lot more people who've had filler in their face for more than 10 years. And we know without question that the six or 12 months is so far gone that it's likely decades plus. Is it permanent or semi-permanent? Who knows? Probably depends on when you get it. If you get filler when you're 80 years old, we may as well consider it permanent. You're gonna have it forever. And if you get it when you're 20, we don't know the answer to that long term, but we do know that it stays around for a long, long, long, long, long, long time. When we do these MRI studies that look at the duration of filler, everybody that had filler in the past still has it now, whether it was two years ago or 15 years ago, it's still present in the face. And those first studies that were coming out about filler and its duration were, you know, they were small. It was like one at a time, these very minor studies. Oh, a few years passed when it should have been gone from a histology study during a skin cancer surgery, or ultrasound studies, or MRI studies. And now it is so well known how long filler is staying around. If we look at even just the last three years of published papers on this, we know a lot of the information I'll talk about today is very recent. Uh, 2026, 25, 24, some in 23. A lot of these things have really come into light in the last few years, yet they're things that I've been talking about for a long, long time. Our debate was structured around kind of four key questions. Um, one of them is that the filler is permanent or semi-permanent, the duration of filler essentially, um, whether it goes away or doesn't go away with dissolution, that was the second kind of debate point. Uh, the third one was that it stays in its the place it was put or that it moves. And then we got a little bit into the inflammation part of filler, which is maybe getting into the more controversial part of things, then we kind of ended with has filler been good, good for the world overall? Is filler a good thing or a bad thing? Um and then I pushed into the boundaries a little bit of where I think the frontier of this is going, which is into things that we just can't study or know yet. And that is simply that we don't know the behavior of filler decades later. We we can look at these snapshots in time early on, but what does happen 10 years down the road, 20 years down the road? Because I've seen this in my practice where somebody had filler and it looked really great, even, you know, sometimes it's bad from the get-go, sometimes it's great. And then down the road, maybe eight years later, 10 years later, it starts to look bad. Things change. We don't know what's happening there. And there's no evidence to support that filler changes over time. This is what I get from injectors a lot. But there's also no evidence to show that it doesn't. And we see it happening in clinical practice. And there are plausible biologic mechanisms to know how filler breaks down, what the enzyme that dissolves filler called hyaluronidase does to filler, how it changes it, what the smaller particles versus larger particles of filler do, how inflammatory they are, how things change. And we have MRI studies that are very interesting showing, well, this person had 20 syringes of filler in their lifetime, but when we look at it on MRI, there's like 38 milliliters of volume present in their face around the filler. It's attracting water. Things are changing. Um, and so there's a lot that we don't know coming down the road. I also think that it changes the way that muscles move. We actually know for sure that filler changes the way that muscles move and contract. We've a filler company did that study to show that it can change it. Of course, they showed a positive outcome that improved muscular function. But if we just look at it as a whole, we know that in general, filler can change muscular function. And it's naive to think that it does it positively every time, uh,

"I've Had Tons and I Look Great"

Dr. Cameron Chesnut 7:39

especially since that was like injected and immediately looked at. What's happening 10 years later? And this is where I would argue I hear a lot of injectors say, oh, I've had this much filler in my face and I look great. And I'm like, yeah, but your upper lip moves a little bit funny. Uh, or and these are things that our brain can pick up if we get into the neuroanatomy of things a bit, which I also think is really interesting because in my head, this is where surgery is going as well. We're thinking about the impact of our surgical results on movement and on emoting and on our communication and how we basically interface with the world, we have to think about how things move afterwards. It's not just about before and after pictures, it's about how we're actually functioning in the world. This filler hasn't gotten there yet to the same way, and surgery hasn't either, but we're progressing in those directions. And that was my sort of spoiler alert to where I think things are going in the future. And I do see this, and whether we like can really pinpoint it or not, when you see somebody who's had filler in their face for decades and they've had this many syringes and they they look great, they don't move normally. Um, and this is, I don't mean to be universal that every person that gets filler this happens to. But what I want people to know, this is what let's really get into the meat of this. What I want people to know is that these things can and do happen and they probably exist on a spectrum. Some people get filler and may have no issue through their whole life. Others get filler and have disastrous outcomes from it. And then most people live in the middle of that, honestly. So you're very unlikely to have no issues whatsoever at any time point if we really get detailed with the microscope that we're looking at things with. Like, yeah, maybe your lip filler looks great in your 20s, but someday you'll be 60 and maybe your lip doesn't move normally. Is that we don't know that answer, but we do know that it can happen. And so I think that the structure of this, if we really get into it, I'm gonna go into the evidence of these things. We're gonna get really nerdy about this. Um, and we're gonna start kind of through that progression of these are parts of the debate and these are things that I have felt friction with in the past. Some of them I don't anymore. And what I mean by that is I talked about these, I got attacked, you know. Dr. Subio, very, I think, cutely in the introduction, even said, you know, Dr. Chestnut's a world-renowned plastic surgeon, you know, proofs in the pudding basically look at results. He's like, Pardon my French, I don't give a shit the circuitous route he took to get there. What he was talking about was through dermatology into the facial plastic surgery world. Um he's like, you can't argue with the expertise in the results, basically, um, which has been a really common attack point from the filler world. Uh, you're not a board certified general plastic surgeon or whatever it may be. It's like, okay, great. Um, I'm not. I have the training in that space, I work in that space, I live in that space, and I clearly know what I'm doing there. Um, it's it's an interesting way to instead of attacking the argument or the facts or the truth about it, they go after, you know, the messenger, basically. So it's it's been a very interesting thing, and that's um been a really common theme. But the duration of filler was one of these first things that uh that I've caught in all this heat and friction for. And if we go really back and look at it, I was screaming from the hilltops essentially that filler's lasting decades. We know this. We know this to be true. I see it all the time. For sure, this patient has not had filler for 15 years, and I'm finding it in their face in surgery, and I can almost tell what type of filler it is at this point. I, you know, I would say 90 plus percent of my patients that I see have had prior filler. So I'm working with it all the time. And in the that 90%, for some of them, it's problematic and it's part of the seeking of surgery with me in the first place. Nobody talks about this, that filler can actually make things worse down the road and may lead you to seek surgery that you might not have otherwise gotten. And I think that's an important argument. This happens in my practice, this is real, and I think that's an important thing to talk about because a lot of injectors say, oh, my patients are getting filler because they're never gonna be ready for surgery. Well, I think that comes with a lot of misunderstanding and a lot of projection from the injectors that, oh, you don't want to have surgery. It's so invasive, it's so this, it's so that. You don't, you don't want to do that. This is simple and easy and it's temporary. And if you don't like it, we can get rid of it and it doesn't last that long. All of these things that go into that, that these are the these are the assumptions that filler has been sold by and functioning under that we have to qualify. We have to talk about the real truth of those. And, you know, even the person I was debating last night said, you know, the injectors are frustrated because people hear my messaging or my content and then they get scared and they go talk to their injector, and their injector has to spend extra time with them educating them about filler. And I'm like, is that a bad thing? You know, I'm nothing that I'm saying is untrue. Nothing that I'm saying is untrue. And things that I'm saying I have seen. So they can happen. Is it bad that we need to talk to patients about what can happen? I thought it was also interesting that I told this person, well, your surgical colleagues are spending more time in the operating room because of what you do. So kind of there's a little balance to it as well. Um, not that it's impossible or difficult to do surgery afterwards, but it does take more time sometimes because tissues change. That's something we'll talk about down the road. But into this duration part of things, um, you know, it was functioning under the six to 12 months, and there was actually nothing looking at the actual duration of filler, nothing at all. It was looking at a correction for an FDA study of endpoints. That was what everybody was basing duration off of. Correction time, not presence of filler in the face. So, how did the burden of proof fall on me or whoever it was saying, like, I'm seeing this in the face, everybody's like, no, it's not, that's not true. It will last six to 12 months. And, you know, my initial kind of like call out was that this is disrupting a huge revenue model, right? The revenue model is you get filler, it's gone in six or 12 months, you get filler again, it's gone in six, you keep coming back for it. And if all of a sudden we realize that you don't need to keep topping it off because it's still present from before, or God forbid you start accumulating it and looking overfilled, that really disrupts the revenue model of how filler fits into things. And so that was unquestionably friction early on in this. And so there was early studies looking at histology, meaning like a biopsy, finding filler, past when it should have been there. Then we got into MRI studies that showed, oh, yep, this is lasting a long time. Then we got into ultrasound studies, and now this is literally unquestionable. The evidence behind it is so strong to know it. Big series with ultrasound and with MRI to show that filler is lasting a long, long time. So, do we know the duration of it? We still do not know the duration of it. And it's probably variable from person to person, probably depends on the filler, and it probably depends on what part of the face it's put in. So there's a lot of variables that go in this. And the answer is it lasts a lot longer than we thought it did. So, how do we function in the world? How do we being injectors, how do injectors function in the world knowing that you can't keep doing it every six or 12 months in the lips or something like that, which is so common to do, right? Um, and because that gets into

Assumption Two: It Doesn't Move

Dr. Cameron Chesnut 14:33

the next part of it is movement or migration. Well, it's always been thought that, you know, filler goes in, it doesn't move or migrate. People argued with me so hard over that. Oh, if it does, it's poor injection technique. That was the long-said thing. Oh, what because once we started seeing, yes, this is absolutely migrating. Filler was not put in the neck, and you know, it's put in the chin, and I'm finding it in the neck. This is a common thing. Or it wasn't put in this part of the eye, it was put in the cheek and it went up to the what it happens or in the temporal fat pads. Filler was not put in the temporal fat pads, it was put in the cheek and it's ending up there. Well, is that bad? Is that undesirable? Is it well, those are all subjective questions, right? If you're getting filler in your cheek, do you want it in your temporal fat pad? Maybe that doesn't matter, maybe it does, who knows? But it's not where it was intended to be injected. And so the original friction with that was it doesn't move. And then it was, well, if it does move, it's from poor injection techniques. And then that was spun to, well, now we're understanding how it moves, and it's a good thing that filler redistributes, because we don't call it migration, it's called movement or redistribution or whatever we want to call it now. But we know that filler doesn't stay where it was put. Uh, and there's mechanisms to outline this. Now, this is more recent literature talking about yes, if you put too much filler in one place with too much pressure and you aggressively massage it or any of those things happen, it can end up where you didn't intend it to be. So let's call that poor injection technique. But filler can follow paths of least resistance. It can follow the path of the needle or the cannula that placed it there in the first place. It can follow along blood vessels or lymphatics. Muscular movement over time causes it to move. Uh, even just like an adjacent open space, it will redistribute into that space. That makes sense. Pressure on the face, movement, time, all of those things, just straight up time will cause filler to move, migrate, redistribute, whatever we want to call it. So it was really interesting in the bait because I knew where this was gonna go on the other end because it went from no migration to, well, it's only bad injection techniques, and now we've swung the pendulum as everybody's sort of like, oh, yep, it does migrate. How are we gonna deal with this now? Well, now we're starting to look at how it migrates. We're doing studies to look at the retinacular fibers because there's ultrasound studies showing filler placed in the nasolabial folds, migrating up the cheek, like along the this part of our anatomy called the SMAS. We know that it's moving. Um we're finding it in different parts of the lip where it wasn't placed. And so now it's starting to be like, well, let's understand how it moves, and we can look at the direction of the fibers and the retinacular cutis, and we can follow these along. And, you know, uh, that's great. That's advancing, that's progressing, that's using ultrasound, a new tool introduced that's relatively um, you know, some great injectors are using ultrasound with good results, but most aren't. And it's a really challenging tool to use. And it's not as great at delineating tissue and directions and fibers as everybody thinks that it that it is. You know, in my clinic uh with Dr. Meadows, who does a lot

Ultrasound, MRI, and the Limits of Imaging

Dr. Cameron Chesnut 17:32

of ultrasound, this guy's a wizard with an ultrasound. I'm very facile, but he's incredible. Even with that, you the anatomy is not what we would dream it would be with the best ultrasound on the market, right? So to try to do apply that to a face during an injection, it's not as ideal as we would like to make it out to be. And but kudos for the progression in the right direction of understanding, oh, if I place it here, it's going to migrate up the face. And well, the question is, how far? And we know that only some areas migrate more than others. Like there's studies showing MRI in the lateral face, a really great radiologist who does cosmetics. Uh, Dr. Master has ultrasound at his own filler, um, or excuse me, his MRI at his own filler to see how it has distributed. And it, you know, kind of like stays in the area that it is and redistributes, but that's in the lateral face versus what's happening in other parts of more moving around around your mouth, around your eyes. We don't know all the answers yet, is the point to this. And ultrasound is maybe a step in the right direction, but it's not perfect either. And so that was sort of the back and forth on this debate as I

The Next Frontier: Migration Over Time

Dr. Cameron Chesnut 18:31

turned it over. Well, this is what I think. What do you think? The interesting part of this is I think the next frontier, which is okay, now what's going to happen with that filler 10 years later as it migrates? I see filler with my own two eyes. I would call it like percolating upwards. Now we're not talking about spread through anatomic planes. We're talking about spreading across anatomic planes from the deep cheek up through the cheek fat pads into the muscle around the eye. Maybe it was placed there initially and it just changed dramatically. Maybe it was never placed there at all and it has moved there over time. But we do know that for a period of years and years and years, things looked fine. And now all of a sudden they're changing. They're puffy, they're blue, there's edema, they're swelling, does not look normal. And that happens years and years and years down the road, which I think is really important to talk about. And that's the next frontier that's hard to get into because now we know that filler lasts a long time. We know that it moves, and we're trying to understand how it moves so that we can maybe take advantage of that. But is everybody able to do that? How good are we at really judging? We're relying on ultrasound, which is imperfect, relying on injectors, which are imperfect, we're relying on different products, which probably migrate or move with different properties, and we're relying on what's happening years or decades down the road afterwards.

Dissolving and Post-Hyaluronidase Syndrome

Dr. Cameron Chesnut 19:46

And so that gets to the next part of the discussion, which is dissolving, dissolution. There's this idea of post-hyliaronidase syndrome. That's the enzyme that dissolves it. This is a really hot topic. And this is a hard one with patients because some psychology gets involved with this as well in full transparency. And I think that we're understanding this better over time. But um, the question is well, filler is reversible. And for years, I'm not, I'm anybody who who's in this knows it was, oh, filler is reversible. If you don't like it, you just get rid of it. That is so far from the truth. A very recent paper came out from uh, these are both really great uh aesthetic injectors, great with ultrasound. I call them the Steves, Steve Harris and Steve Weiner published a really great paper about changing the terminology from dissolving to modifying filler, because that actually probably represents better what's happening when we put this enzyme around fillers. It doesn't just make them go away, but it does maybe modify them, it does change them, it does cleave them, make them smaller, make them not project as much. But we don't really exactly know what's happening. We do know that things change after dissolution, but I can tell you, and this is another thing that I've screamed from the hilltops for years and years and years, I'd have patients that had filler in their midface, they had problems, and they had 10 rounds of dissolution, like a lot of dissolving. And I would see them for surgery and I would still find filler in their face. No question about it. Their lymphatics had changed. There was a lot of, and we we know there's evidence to support lymphatic compression or lymphatic drainage issues. I that's gonna be a whole new thing that comes out too, as we're starting to use fluorescence imaging to look at the lymphatics themselves. That's we're gonna find out that filler disrupts lymphatics, whether it's mechanically from compressing it, whether it's from filler being in the lymphatics, whether it's from scarring and fibrosing lymphatics, whatever that mechanism ends up being, filler changes lymphatics. And so I would find this in people's faces after round after round after round after round of dissolution. I'm saying, guys, this isn't working. It's not getting rid of it. It might change it, it might alter it, it might think make things better, but it's not getting rid of it all the way. And that was a bunch of friction there, a lot of arguments. That's not true. There's no proof to show that. It's like, well, I see it every day. Proof's in the pudding a little bit, right? Now we know that that is um that is that's what's Happening. It's not easily dissolved. It may never go all the way away with dissolution. It's interesting. If you look at the actual dissolution studies, it's, you know, it really works quickly if it's applied right away within minutes. And so there's a study showing like serial every five-minute injections is probably one of the best ways to do it. Yeah, uh, that's probably not going to happen. There's also this idea of using ultrasound to do it. I knew that's where this debate was going to go. And in the ultrasound literature around it, it's like, it's great. Ultrasound improve improves the precision of getting the hyaluronidase around the filler. No question about that. But the harsh truth here is that ultrasound can't tell exactly where sometimes old filler is. It's when the filler's encapsulated, which is a subtopic of inflammation, when filler gets encapsulated, you can see the ball of filler. But old filler kind of looks just like is the swelling, you know, we'd call it anechoic and hypochoic and and hyperochoic, like it changes with time. Like the filler changes with time, and it can be hard to tell if you can even see if this filler is the swelling around. I don't even know. But you can put a hyaluronidase enzyme there and see what happens. So there was a study in like, you know, chicken breasts where they did an immediate bolus of filler. Then they took ultrasound guidance to it, which is better than nothing, but it's not a human face. And it showed, oh yeah, ultrasound can help the guidance of hyaluronidase to the source. Okay, great. That makes sense actually. But what we the interface of the hyaluronidase with the filler is what we don't really understand all the way. There's a study showing that if you put, you know, a filler in a tube and then put hyaluronidase on top of it and let it sit there, kind of like there's some change at the interface, but it doesn't all go away. If you centrifuge it and basically mix it up, now there's some meaningful change that happens there. So different fillers have different properties. We know that they are very some, some in particular are very resistant to enzyme, no matter how you apply it to it. If you're rubbing it together in your hands, you're gonna have a hard time getting the hyaluronidase to dissolve the filler. So imagine trying to do that in the face. Now what happens if it's two days after injections or 20 years after filler injection? There's gonna be a difference there too. So we don't really know what happens, but we do know that it can modify the filler. I find in my practice that older filler gets modified more by hyaluronidase than young filler does. And that kind of makes sense. It's probably slightly more broken down by our native breakdown. It's probably slightly more exposed. It's attracted more water around it, whatever it may be. It's kind of like the crosslinks have opened up to allow that because filler is crosslinked, it's opened up to allow the enzyme to get more surface touch, you know, more surface area, more effective area. And I mean, there's no evidence to show that necessarily in that fashion, but this is what I see, and it biologically is plausible and it makes sense. So ultrasound, again, is not the panacea to correct, like, oh, now that we have ultrasound, filler's easily reversible again. That's not true. And we don't exactly know what happens here. So the enzyme to dissolve it, hyaluronidase is very valuable, especially in emergency situations. I do believe it's helpful in situations where the filler is not great and we want to get rid of it, but in the end, it's not getting rid of all the filler. It just hasn't panned out to be that way. And honestly, we're not following, we're not doing those studies to follow along for complete resolution. We're following along like something's bad here, which is why we're using it in the first place. And what happens afterwards? And a really interesting study of oculoplastic patients, so all uh filler injected around the eye, I think it was like 159 eyes that they looked at who that had had filler, and they were looking, okay, what happens when we inject hyaluronidase in these areas? And this is the kind of the spoiler alert is that like just over half the time, the it was good. It like there's a reason they were getting

Why Hyaluronidase Doesn't Fully Work

Dr. Cameron Chesnut 25:50

in the first place. Things were not great. They did the hyaluronidase enzyme, and 50 some percent of the time, it was like, okay, that's a satisfactory outcome, which means just under half the time it was not a satisfactory outcome. It required repeat injections. Things did not go well. And a subset of these felt like things look worse after the filler is dissolved. That is this post-hyalyuronidase syndrome. And this is a really hot topic. We actually didn't really get into this in the debate when I mentioned it. There was a lot of eye rolls because people don't think that there can be changes. And the real truth is we don't know if the hyaluronic acid that's native in our face, when it gets exposed to this hyaluronidase, the enzyme, which is not FDA approved to do this, by the way, the enzyme is not FDA approved to break down filler, but it is used for that purpose often. When it gets applied to our face, we don't exactly know how our native HA reacts to it. There's some studies looking at the different cleavage points and how things react. And everybody's always said, oh, our face turns over its own HA anyway. Uh we don't know all these things to be true, but we do know that filler, this is a spoiler alert, filler does change the tissue that it's injected into. We know this to be true. Injectors may still argue with this, but we have studies showing like septal thickening. The septum is the area under the eye that gets thicker because filler was present there. We know that tissues change. We see it in surgery all the time. This is why your surgical colleagues are spending more time in the tissue when there's surgery present. I see it every case that I do. There's there's changes around the filler. Um, a good friend of mine, Dr. Guy Mastery, oculoplastic surgeon, you know, I've heard him say, like, the eye is never the same once filler is injected into it. That doesn't mean you shouldn't do it, but we should understand that going into it, right? And so because there's these tissue changes in the areas where the filler was present, getting rid of all that or dissolving or modifying the filler that was there, and plus the enzyme could lead to, well, maybe there was a tissue expander effect from the filler over time, and that changed the tissue that's now left behind. Maybe the enzyme did something. Um, maybe there was just additional aging changes on top of the time that the filler was present there for eight years. And it's probably some combination of all those things in reality, because we know one of the initial assumptions that filler functioned under is that when the filler went away, everything was back to normal. That is not true. We know that's not true. Um, and and this is what people need to know before they get filler injected. It's like it's it'll never, it's like guy said, it will never be the same again once filler is injected in that space. And so how do we manage that? Well, there's a lot of expert consensus on what to do with filler before surgery. Uh, Dr. Cammy Parsa is a great uh oculoplastic surgeon. He has a method that he does that's a little bit different than mine, actually. And we both have relatively travel-based practices where all my patients are coming to see me from afar. I prefer to remove things manually, partially because I've long been a believer and talking about the fact that hyaluronidase doesn't work that well anyway. It doesn't just get rid of the filler. So if somebody comes to me and the filler's not like a major problem, it's just kind of like maybe part of our objective of a multi-you know, let's say we're doing a full face rejuvenation, you know, scalp through forehead through face-neck. The filler is only maybe part of that whole equation. And so I'm usually choosing to remove what I can manually because then I have a direct, I know how much is coming out. I know what's coming out of there. Um, I get to see it come out, I get to see the plane that it's in. And I also get to see the planes that it's in that I can't touch. And this is why I would say that I really have this strong feeling and curiosity about where the filler's going years and years and years and years and years down the road from a movement migration or redistribution standpoint, because I see it and like I can't believe that the filler was placed in this space. I've seen it with patients where I did their filler 14 years ago or whatever it was, and then I'm doing their surgery way down the road. And I'm like, I know that it wasn't placed here, and the filler's here now, right? Um, and so I'm learning how to manage that still. And I would say that this is one of the biggest uh factors for any of my patients who are considering having eyelid surgery and have had prior filler. This is a big discussion point with everybody. I talk to everybody about this. The most likely thing that we will be talking about after your eyelid surgery is your old filler. That's an important point to understand. I know what I can do from an anatomy standpoint: rearranging, putting fat pads back, lifting midface. I can I can make magic happen with no incision points, with a scarless approach to your lower eyelids and midface. But there's something there that neither of us can control that was placed recently or years ago. It doesn't matter, that will change over time. And so sometimes it's the rearrangement of everything in the surgery themselves. And then afterwards, kind of immediately afterwards, I've removed everything I can manually, I've done what I think is an appropriate amount of dissolution. And then the first thing we start talking about in the post-operative period is our next steps to manage the old filler. That's a challenging situation because just like the study I just referenced, just under half the time, that's not a satisfactory outcome with a round of dissolution. It needs more. And so, shoot, now we did surgery, ironically, and we're managing your old filler afterwards. Any dissatisfaction that's left in your midface is from your old filler. This is a really important message, really important message. There's other situations. I'm talking with somebody in Southern California right now who had surgery with me three years ago. Everything's great after surgery, things are going really great. We knew that this person had prior filler. That was one of our sub-topics of management in that process. Now we're still managing the old filler years and years and later. We're not even talking about surgery anymore. We're talking about managing the changes in her mid face and under her eyes that are related to progressive puffiness years later after the filler. This is a really, really, really important topic because I'm essentially inheriting this the issues of the past into the future the second that we undergo any procedure in your midface or under your eyes. I talk about that area specifically because those areas are more prone to movement, migration, puffiness, edema, things like that. This has been well described in this area. And so I really want people to know that in this area under the eye, that it's not as though you have, you know, this issue under your eyes from old filler, and we I call it the magic wand. We put the magic wand of dissolution on it and it all goes away and we have a fresh start. Even if it all did go away, we'd have tissue that's changed from the previous filler afterwards, and it doesn't all go away. So we're working on removing it manually and we're dealing with a moving target over time, which is what we're talking about with my patient who had surgery three years ago. We know that what is there now will not be static over time. This is why I want to get as much of that filler out manually during surgery as I can. It's my most sure way to ensure a good, healthy long-term future is by taking that highly variable, misunderstood or poorly understood variable out of it. We want to get rid of that. I don't want to know, we want to eliminate that part of the equation, which is filler into the face. This is part of the like, this is what I wish everybody knew going into surgery. Really important with eyelid surgery, more common in the lower eye and mid face than it is in the upper lid. But this is applicable to the upper eyelid as well. It's applicable to the temple, it's applicable to the jawline, the chin, uh, even the lateral parts of the face, where we, and I mean it's near universal, but in a facelift, I'm finding filler in the lateral parts of the face because people are trying to tack it up, which does not work. Spoiler alert, like we just eliminate that. It doesn't work. Even in our debates, nobody's like, oh, tacking works. It doesn't work. This is like this crazy subset of people doing filler who, you know, think that these things, this magical thinking that it's not, that it's gonna work. And so that, you know, really covers like the duration, the migration. It covers the dissolution. And then we get into the inflammatory part of things. This is, I think, a little bit more. Now we're getting into things that I talk about still actively, and I catch some heat and some friction on. So I loved the Dr. Subio at the very beginning of the debate, said, There is no implant that goes in our face that does not cause an inflammatory reaction. Filler being included like in that. It's a biomaterial injected into our face. Every single implant in our face, or in any other part of our body for that matter, causes an inflammatory reaction. If we put a pin in that, this is a quick little subnote. This is why I don't use permanent sutures for any parts of my procedure in the face. I do not want you having polypropylene, plastics, nylon, anything like that in your face long-term afterwards. I don't care if it's a mini suture. I don't want anything permanent in the face because it causes an inflammatory reaction. We can pull the pin out of that and go back to the other part of the conversation about filler, because filler is a biomaterial injected. The biomaterial, the biomaterial science, the literature is very clear that there's an inflammatory reaction when anything is implanted in our face. So that has been super argued with.

The "Stimulates Collagen" Myth

Dr. Cameron Chesnut 34:41

But at the same time, filler companies have long known that filler, quote, stimulates collagen. It's been a spun as a positive thing. You put filler in your face and you build collagen, this little local reaction. And they used to call it like uh infiltrating or kind of like the filler getting fixed in place. That's maybe not actually what's happening. But nonetheless, there's no way you can create collagen without an inflammatory response. Surgery creates an inflammatory response. My whole post-pre, well, pre- and post-surgical world is about making that inflammatory response as perfect, quick, and efficient as we can get it. I don't want to stop the inflammatory response. I want it to happen because that's where all the building happens. Then we get past it and we move on. Well, filler remains as an implant in our face and our body does things to recognize it. Most of the time, likely most of the time, I'm not saying that everybody has these massive inflammatory reactions after filler. That's not what I'm saying. But the literature would support that everybody that gets filler does have an inflammatory reaction to it. Most of the time we'd call it sub-clinical, below a clinical threshold. It's happening, it's of no consequence directly. This is where I get a little bit, I'm projecting my values now. I don't want something permanent in my face that's going to be recognized by my immune system and causing inflammation. But for all intents and purposes, it's this is a minority of people. It's not everybody. They're getting it. And yeah, their body recognizes it. There's a spectrum that exists maybe from no inflammation, which we know that that's not true, all the way through like bad things happening. These we call them granulomatous responses. Our body recognizes a foreign body and creates a crazy reaction around it. We know that at a baseline, that just the injection of the filler or any implant has an effect on protein adsorption. It has an effect on macrophages and fibroblasts, and our wound healing cascade gets involved in this to like, well, there's something foreign here. What are we going to do with it? It's recognized. When that gets out of hand on the other end, we have these granulomatous reactions. And these are bad. Um, and they're they're really underreported, just being frank, but they're like, they're minorities of a percentage of the time, 0.2 to 0.5% of the time. But I promise you that injectors have seen these and either not recognize what it was or been like, oh shoot, that's a granuloma, and didn't take the 16 hours it takes to publish this, right? That's that's an onerous process to get a peer-reviewed publication, even if it's something simple like that. It's not like, oh, I've just got to call, or, you know, you can report these things, but to do like a formal publication about it is is onerous. So you got to like call and, you know, let everybody know, oh, call the FDA hotline and let them know you people aren't doing that. Is this my point? And so these are ends of the spectrum. But in the middle of the spectrum lives some really interesting phenomenon as well. There is below that, you know, granulomatous reaction, there's encapsulation. And this is something that I have seen, talked about, posted about, posted videos about. Um, and still, even with this, like vit here's a video of encapsulated filler getting a lot of heat and a lot of anger directed towards that. And I've had it multiple times, and I usually find this around the eye. And maybe that's a sampling error from that's where I'm working. When I see it in the lateral face, I don't see it as encapsulated. I found it on the SMAS during facelifts. Um, and a lot of delayed nodules. According to my counterpart in the debate last night, every delayed nodule in one study was found in the SMAS, in the like moving part of the muscles of facial expression. Uh, that's not good. We don't want that. We don't want those delayed nodules there. But I have seen encapsulated filler. And encapsulated filler would be like, imagine, and this there's some really interesting videos that I have about this. I used to post them on Instagram, but they don't love uh those types of like interoperative videos as much. So you get a little hand slap about them, so I don't do them anymore. But you can go back and find it. It's still there, and it's a you know, uh essentially like it looks like a breast implant. It's a ball of encapsulated filler. It's got a fibrous capsule around it. And I took a scalpel and I cut it open, and there's like a, you know, like it's got a casing on it. That's the encapsulation, and then you can squeeze it and the filler comes out of it. And it's it was really satisfying actually, but this is encapsulated filler. I got I dissected the entire capsule out, and then you can incise it and boom, there it comes out. And you see the same thing with breast explants, where the implant itself has another layer around it that your body put there, and you cut that layer open, and then the old implant is inside of there. It's the same phenomenon happening here, right? And so it's causing an inflammatory reaction there. I don't think that everybody gets encapsulation of their filler, but we know that it's being recognized. But here's the one. This is the one that really um uh that I was trying to hammer home in the debate last night, too. There's this idea of these like delayed inflammatory reactions that come after somebody has filler. Talk about being under-recognized and under-reported. We know these happen now. We know they happen, and that is somebody that had filler eight years ago. They get a COVID vaccine. This came out during the there was a case report about this during the COVID vaccine, or this was talked about during the COVID vaccine. They get a cold, a viral infection. They get hay fever, like a seasonal allergy, and that filler that's in their face gets sore, red, warm, swollen, or some combination of all those things. Something happens and that filler gets like, oh my gosh, my filler is sore. One of my colleagues told me recently, like, that's how she knows she's getting a cold. Her filler gets inflamed. That's like her first sign that she's getting a cold. She recognizes that. But if you don't believe or understand that filler can last for decades, then you're gonna miss this, right? If you don't understand, and imagine being a patient, like, are you it's it's it's pretty subtle. Like it happens to them and they're like, oh, my cheek's sore. I don't even know why. I guess I did have filler five years ago, but that's long gone by now. No, it's not. But they don't understand that. Their injector doesn't understand that. And so this gets missed. And it it's just a sign that our immune system is constantly

Filler and the Immune System

Dr. Cameron Chesnut 40:48

recognizing this filler. When it gets revved up by something else, it turns on and our filler gets sore because it was already there. It's not like our filler is blind, or our immune system is blind to the filler forever, and then it all of a sudden recognizes it when it gets turned on. It's always aware that it's there and then it gets turned on. I had a patient who's now a great friend, actually. The first time I ever met her, she's from Southern California, was plugged into me by one of my colleagues there. First time I ever met her, her son, she had had filler with my colleague in California. Her son had a strep throat infection, which is interesting because the hyaluronic acid fillers are made by strep bacteria. That's what makes the hyaluronic acid, right? Well, all hyaluronic acid chains are identical across species, and so there's no strep on there, supposedly. But maybe coincidental, maybe not. Her son had a strep infection. She was clearly exposed to it, and all of the filler in her face lit up. It could be because there were strep proteins or something left, antigens, we'd call them. It could be just that it had nothing to do with that, and just her immune system was rubbed up, but her face got hard, red, swell in every area she'd had prior filler. Super interestingly, different types of filler in different areas had different responses to it. But it was happening everywhere, her lips or mid face around her eyes. And so at that time, it's like, well, let's get your inflammation under control. We did some hyaluronidase. All of these things seem to help, right? She still has filler in her face, even after the hyaluronidase. And she's had incidents, now that she's aware of this, she's had other incidents afterwards where she's noticed it happening for other reasons, but it's never been as severe as that first one was. This happens. And in the debate last night, I metaphorically asked everybody who's seen this to raise their hand, which should have literally been everybody watching. If you haven't seen this, you haven't been paying attention. Then I asked, okay, have you ever reported this? And of course, like nobody's reported it. So yes, it's rare, but it's not rare. It's really common, actually. It's just crazy underreported. I'm guilty of that too. I've seen this a ton of times. I've never once reported it. So it's out there, um, it happens, and we'll see this all over medicine. The burden of proof has been placed on, you know, the m'ies of the world, but this is this is happening, and this is happening in real life. And people that recognize it will tell you, that does happen. Like my colleague who said, that's the way that she knows her cold is coming on, right? And so, you know, that the whole inflammatory part of it, you know, changes probably with time. This gets into the next cascade of what changes over time, but we know how hyaluronidase cleaves hyaluronic acid chains. They're crosslinked by this cross-linker called BDDE. And, you know, the hyaluronidase hits the chain of hyaluronic acid and it breaks it into smaller pieces. And we know that smaller, low molecular weight hyaluronic acids are more inflammatory. They stimulate our immune system, inner leukins get released, cytokines get released. We know that there's an inflammatory part of smaller bits of hyaluronic acid. That is real. And we also know that hyaluronidase cleaves hyaluronic acid into smaller pieces. So we know that smaller pieces are more inflammatory. We know that, but there's nothing acting. This is where people will say there's no proof to show that. That its properties change over time. We call the properties of a filler rheology. Well, we do know that the rheology changes over time. We do know that there's inflammatory components of smaller, low molecular weight HA chains. So it would be very plausible, although there's not strong evidence like there is for duration, dissolvability, whatever it may be, and there or moderate evidence for migration and inflammation. We do know that there's a plausible part of this, and I'm seeing it happening. We are all seeing it happening, whether we know it or not. This is happening. It's probably moving through muscle planes. It's probably moving through passive least resistance. This is something that is going on. And that filler, as it moves, is changing properties or it's moving because it changed properties. Something's happening there. So we're going to have to understand this. We're going to have to understand the best way to manage it. And if it sort of can be stopped, if you will, with, you know, knowing that we're not going to stop injecting hyaluronic acid, basically. That's not not this is not going away. It's, you know, maybe for the first time ever, flattening or decreasing a little bit. But it's not going away, right? So how are we going to manage this over time? And guess what? If we look at the number of people treated, we have a lot more people to learn from now than we did 10 years ago. A lot, lot, lot more. And so we're going to, this is going to be elucidated over time. We're going to learn a lot more about how this changes as time goes on. What to do with these smaller chains as they're, you know, changing lymphatics, changing inflammatory states, maybe attracting more water. That it sure looks like that's what's happening, not just observationally, but even based off of some MLR studies. It looks like it's actually more there, more volume there than there is filler. So something is happening in this area. And like I said, I think we're going to get into the myomodulating, into the muscular movement parts of the face. I would have a really hard time understanding that you have, I don't know, 20 milliliters of hyaluronic acid throughout your face and that it's moving fully normally. Do we really think that's happening? Um, or that that if that 20 turns into 28 or 38, like is it, is that really what's going on? It's it's not normal muscle, it's not normal fat. Um, it's a it's a foreign body sitting in our face, and that is really contested, what I just said right there. Um, because for years and years and years, it's been that hyaluronic acid is preserved through all vertebrate species. It doesn't matter if you're a lizard or a human, you have the same hyaluronic acid. This is the same structure. It is inert

It Is Not Inert, and We Have to Stop Saying It

Dr. Cameron Chesnut 46:25

when it's put in our face. It is not, you know, reacted to. We know that's not true. We got to stop saying that. We got to stop telling patients that. Um, I guess getting back to the inflammatory theme, an extreme example of this would be if you have autoimmune disease, um, are we really talking to our patients about that enough? That's like, hey, you have this propensity to have autoimmunity and we're gonna put something in you that's kind of constantly recognized by your immune system, that may not be your best bet. I don't know. What's the right answer there? We don't know, but we do have evidence to support that that may be uh something we should be talking about with our patients more, which is ultimately what my um person on the other end of the debate last night was saying. It's like, we got to talk to our patients about all these things now. Yeah, if your patient has rheumatoid arthritis or lupus or, you know, a a gut, an autoimmune gut condition, you should talk to them about getting filler. This is a good thing. Or if they're, you know, thinking about maybe having surgery 10 years down the road, maybe you should be talking to them about what could potentially change 10 years from now if they decide to have surgery. Um, and so, you know, the end of this sort of debate or discussion was this like, have they been good for the for the world, for the aesthetic field, for the whatever? And, you know, my spoiler alert answer to that was like, well, I don't think that all filler is bad. Um, I use filler, I mean, like maybe a handful of times a year. Um, and I'm using it for very like focal things, like there's a bump or a dent or a whatever. And I'm putting it there and I'm like, great, I want this to last 20 years in this spot and do this thing. Like there's a dent in the cheek or whatever it may be, right? Very minor things, like instead of syringes, it's like a tenth of a syringe type of things. That's my actual real use of it. Um, Aubrey, my wife, who's been on this podcast, sat in the seat next to me before, is a PA who's an injector, right? And so that was another thing. Oh, you know, Dr. Chestnut offers filler in his clinic, and you know, it's like Aubrey is very similar in her approach in that she rarely uses hyaluronic acid filler. She does it in a very appropriate circumstance, but she does it with the knowledge that it's going to be there a long time. It's not easily reversible, it's not gonna stay where she put it, and that there's the potential for it to change over time, especially if you put a lot of it in there, right? When we get into that post-hyaluronidase syndrome where we know that things change, like septal thickening, tissues change after there, the biggest predictor of poor outcomes after hyaluronidase injections is the volume of filler that was placed in the first place and the amount of time that it was there. So if you're using low volumes infrequently and you're not doing it all the time, it you're probably gonna be okay. Does that mean it's like perfect and you'll love it forever? We don't know that answer. We can't say yes. Um, we I do see a trend in the direction of like that should be curious about that. Like you can't tell your patient that this is gonna be good forever, then it just goes away and you're back to baseline. That doesn't appear to be what's happening. And there's evidence to support that too, right? So, you know, and it's funny because Dr. Subio last night said, I actually went to your website, it doesn't say anything about filler on there, which is true. Um, but you know, in the past, that you know, we had that on there. And honestly, it was to create conversations. If you're seeking filler, um, well, let's talk about alternatives to it. Let's talk about real, real talk about it, not like not the standard assumptions that, oh yeah, it's it's easy. If you don't like it, we'll get rid of it. It goes away anyway, blah, blah. Those aren't true. And so part of our practice is doing filler, Aubrey's doing filler, is you know, it's functioning around those assumptions, which I think is really safe and conservative and is sort of this idea of that's what I would want if I were giving filler somebody to talk to me about that. And then this is the spoiler of the conversation is has filler been good for the industry? Well, it's built a whole industry, it's attracted people into cosmetics, it's given a lot of people practices and jobs who depend on frequency, basically. But I'm very neutral about it because yes, it can be good for contours and shapes, but I don't think we know if it's good 20 years down the road. We know that it's probably not all gone, but we also don't know what it's gonna look like. And so it's hard for me to be like, yes, it's really good. But it's also hard for me to say that it's bad for everybody because I don't know that answer either. We don't know what's gonna happen down the road. So I'm very neutral on it. Um, and this is me projecting my values onto my patients now. So all my patients tune into this. Me projecting my values is it doesn't meet the value proposition for me in the sense of what it's gonna provide, what the potential downsides of it are. Like I personally wouldn't want a substance in my face that I know is gonna be present for a long time, that my immune system is recognizing that um that I don't know what the long-term change of it looks like. I mean, uh like I'm talking to you guys about, I don't use permanent sutures, which is very atypical. Most of my colleagues are using permanent sutures somewhere for some reason. I don't do that at all. Is that completely necessary? Is it over the top? Is it too deep? Is it, am I overthinking it? Maybe. Um I have a, you know, exceedingly microplastic free OR. I would, I wouldn't even say reasonably micro, it's like unreasonably microplastic free operating room. And that, you know, same thing. Is there any evidence to support that? Well, kinda. It's plausible. I do know it's not what I would want in my body, right? And so I don't, whether you like it or not, I'm not using my when we do surgery, I'm using a very unreasonably microplastic free OR. It is exceedingly microplastic free, and I'm not going to use any permanent sutures on you. When we look at the end results, that's what we're really after in the end. Proof meeting, you know, proof in the pudding, rubber meeting the road is like, what do the results look like? But I also think it's like, well, what happens 10 or 20 years down the road? And what are we like risking or what do we trade, what are the trade-offs to get those results? And for me personally, this is where filler doesn't line up with that. So do I think it's the worst thing in the world and nobody should ever get it? No, I don't think that. Do I think that it's great and it's been wonderful for where we're at? I think no, there too, you know, and from my biased point of view,

Bad Filler Gets Blamed on Bad Surgery

Dr. Cameron Chesnut 52:17

is I think a lot of things that get blamed for bad plastic surgery are actually bad filler now. So it's giving the whole world a bad name in that sense. And, you know, I get the injectors come at me like, well, you just want to do more facelifts. It's like, number one, I don't need to be doing more facelifts. Um, I grew up with filler, like I was saying, like my practice grew along with filler. It's not like there's been some cannibalization. Let's be honest. Let's be honest, guys. This is a very important fact. People that are coming to see me are not debating between me and filler. It's not like, should I see Dr. Chestnut or should I get filler? That is not 100% not what's happening. Um, it is the sh, I'm gonna have a procedure with Dr. Shesson in the future. I know that's gonna happen. Should I, or with anybody else? It doesn't have to be me. Should I get filler in the interim to fill in this? And this is where my opinion comes into it. And this is why I say I think I'm very neutral. I think the value proposition doesn't line up. I don't think we know the answer to it. I don't think it's a hard yes. I don't think it's a hard no. I'd be projecting my opinion. This is my opinion onto it, that like my preference, whether you're gonna do surgery with me or not, in five years, my preference would be that you don't do the filler in the interim. And it's not just because it makes my surgery harder. Almost every surgery that I do involves filler. That's not it. It's because I want what's best for you. And I said this in the in the debate that sounded almost a little cliche. I'm like, it's we should be doing what's best for our patients, you know. And that sounds in a in a world full of like my colleagues, that's so overplayed, overused. But this is, you know, my wife asking me before I did this, like, why are you doing this? You don't need to do this. This is not, you don't need to go into the viper's pit uh against a bunch of people that attack you. Um but I'm like, yeah, but you know, if even if we just kind of open minds and get people to think a little bit different, this is ultimately what's best for patients. They should be having these conversations with their patients. And if they ultimately decide to do hyaluronic acid afterwards, great, do it. That's fine. Um but you should be having conversations that we don't know what's gonna happen with your muscular function or your lymphatics over time. Yeah, it's gonna make your surgical recovery longer, or it might make things more difficult, or if you we put this in your mid face or your lower lids and you do end up having that the blepheroplasty, which is what you really needed in the first place, um, but we're gonna cover it up with filler, that it's gonna really like make a bumpy, lumpy post-operative course with that, probably. Or, or, you know, as the statistics would show, maybe about half the time, there's a high likelihood that you're not gonna be happy afterwards, almost no matter what happens, right? And so I think those are important conversations. That's ultimately why I decided to do the debate, why I have do a discussion like this. I'm not competing with filler. That's not what's happening here. I'm actually not competing with filler at all. I'm I'm educating. Um, I want people to know this. I do have my own personal values. Yes, I'm microplastic free. Yes, I don't eat seed oils, you know. Yes, I do the same thing with my kids. And but and this fits into that, honestly. Filler would definitely fit into those things. So if those resonate with you, maybe filler fits into that as well. Um and and so, you know, kind of as I close this, I feel like I'm very neutral about it overall. I think in my subset of patients, in my personal life, if I could choose that you didn't do it beforehand, whether it changes you having nobody's getting filler than not having surgery with me in the future because they're so happy with their filler and it took care of the thing they were doing. They don't compete with one another. This is this is another thing, is like filler's not really competing with surgery because filler doesn't lift and tack like everybody wants it to. Somebody who can't do surgery wants filler to lift and tack. And again, people are not choosing between me and filler. If you need a lift, you get a lift. If you need volume, maybe we should be talking more about fat transfer versus filler. Like those are a little bit more applicable to one another, but even those aren't the same. You have a whole biologic regenerative part of fat transfer, which also causes inflammation at a time while it's setting up its new blood supply, but then it kind of that switches off. Or filler, that doesn't change in the quite the same way. So that is actually the conversation here. I'm not competing with filler. I'm not anti-filler because it's stealing surgeries from me. It's so far from that on the other end. My only gripe about filler, if we're really talking from the surgical end, is that I I truly believe this is that it can decrease the quality of the results after surgery. And I will predict to you right now, this is where people will come and be like, well, then you're not that good of a surgeon. You know, that's, you know, all of my my, I'm an injector and my supervising physician is a is a plastic surgeon. And he says he's never had, or she says she's never had an issue with it. It doesn't make anything harder, it doesn't change the results afterwards. And this is where I would say that person is not paying very close attention, or they don't do a lot of procedures on the face. Flat out, you know, putting a stake in the ground, hitting the the hammer or hitting the nail on the head with the hammer there is that's not true. That's flat out not true. It does change the postoperative course after surgery, not for the better necessarily, because we have a variable mixed in there that we don't understand that changes over time. And so, you know, almost by definition, we don't have a stable ground for our surgery afterwards. So that would be my only real actual gripe afterwards. It's not that it makes the surgery more risky necessarily, or even that it makes it take longer. Yes, it takes me longer to manually remove filler versus somebody where I don't have to manually remove it, but that's not what it's all about. It's about what are is the stability of and predictability of the results afterwards? And that is where I think filler introduces a variable that I don't want to be there. So this would be my choice. That's that's very opinion-based on me. And people argue that, oh, you're not a good surgeon.

Why I'd Rather Operate Without Filler Present

Dr. Cameron Chesnut 57:50

If you a good surgeon would just be able to manage filler, that's not true because we know we can't get rid of it all. We you can't. You know you can't manually remove it all, you can't dissolve it. And so by definition, there's a variable there that changes. And anybody who says that it doesn't change their results at all isn't paying close enough attention. Maybe they're not focused on the 0.1% differences or the 1% differences. It's that overall, I achieved every before and after result you see, 90 plus percent of them, I achieved with filler present. So I'm not saying you can't get good results, but when I get into the micro details of those little fine nuances, especially around the eye or especially around the mouth, if I could have it my way, there wouldn't be filler present when we go into those areas. It would make things a lot more predictable in our outcome afterwards. So I guess that's my end summary. That's a long way of getting through. What is what I wish all my people knew. A long, long time from getting from that. I wish you knew this too. That's kind of what it really boils down to in the end, with

Should You Get Yours Dissolved?

Dr. Cameron Chesnut 58:45

a lot of information between this. It was a very deep focus on a very hot, controversial topic. Um, people aren't going to like this, especially in the injectable world. Some patients don't love this either. It can be triggering. If you've made the decision to get filler, you don't need to get it removed. It's not the end of the world. It's not like doomsday. Oh my gosh, I've made a terrible decision. Almost all my patients have made that decision. It's okay. We will manage it. Um, it's not an emergency. I kind of I'll get questions about this in a nutshell. The question is always, well, I had filler three weeks ago or three months ago or three years ago. Should I get it dissolved? The answer is not if it's not causing any problems. We dissolving doesn't work perfectly either, modifying now, not dissolving. So you should not run and get your filler modified because we don't exactly know the end point of that either. There's no good answer to it other than if it's not causing you a problem, let's enjoy the time that you're having it when it's hopefully of a benefit to you. And then you can kind of roll with things down the road and hopefully we learn more as that time comes on. So that's my closing summary.

Closing Thoughts and Disclaimer

Dr. Cameron Chesnut 59:47

I hope you found this very helpful. Please reach out if you have any questions about this, and it'll be really interesting to see where the field goes in the coming years. This is where I'm currently feel like I'm swimming upstream against filler changing over time, myomodulating, changing the way that our face moves, and ultimately changing the way that our neuroanatomy perceives faces. We've all seen it with pillow face, we've all seen it with things that look a little bit off. We're going to know more about that soon, so please stay tuned. 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. 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.