The New Era of Deep Plane Facelifting

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. In today's episode, we are going to discuss the new era of the deep plane facelift and necklift. We're going to discuss what's changed and where we're going. And this is a really important topic because there has been a great evolution in the term deep plane facelifting over the past 10 plus years. And it's a really confusing topic if you are a patient seeking a procedure like this, trying to understand all of the different nomenclature and keeping up with the evolution of changes. And I will tell you, spoiler alert, that not all deep plane facelifts are created equal. This is also a great resource for surgeons in the facelift space who want to understand what's happening at the highest level, what's changed, where we're going, what the nuances are, and what the state of the art is, if you will. So that's the intended audience here. My audience is high performers, athletes, people at the peak of their field who care about their longevity, want the best for them. They're pulling all the levers. That's the level that this is going to be at. I'm going to discuss technique. I'm going to discuss how the techniques have evolved. I'm even going to

Who This Episode Is For (and Pricing Preview)

Dr. Cameron Chesnut 1:18

discuss pricing in this, which is a really common question and a hot topic. Again, so this is very much meant for people at a bit of a higher level who want this deeper dive beyond just the term, quote, deep plane facelift and necklift, ending that quote. So when we really think

A Quick Evolution of the Facelift

Dr. Cameron Chesnut 1:36

about the 10 last 10 years of evolving deep plane facelifts, the big acceleration has really come in the last four or five years. It started picking up, but really, even over the past two or three years, and even within the last year, tons of evolution in the space. If we were to kind of look at this line of where the evolutions happened, it was relatively flat, started ticking up, and now it's quite vertical and how things are changing. And there's a lot of reasons for this, but most of this is driven by results. And there's some important nuances in this when I say that not all deep plane facelifts are created equal, because we're a little bit beyond the argument about deep plane facelifts being superior to other types of facelifts like SMAS facelifts. And if we were to really just dive into a quick evolution of facelifts, um, when we talk about the face as surgeons, we have names for structures, but we also talk about levels or layers

Skin Only Lifts to the SMAS Lift

Dr. Cameron Chesnut 2:32

of the face, layer one, layer two, layer three, layer four. Um, and those are important to know because the original facelifts were skin-only facelifts. That was just elevating the skin, actually separating between layer one and layer two, and taking all the blood supply out of the skin, because that's where all the blood vessels go in the subcutaneous fat, which is layer two, and just trying to pull the skin. And those were the first attempts. And, you know, those go back well over a century. Um, one of the first people doing those, the one who really popularized them was a dermatologist named Suzanne Noel, a female dermatologist who really got into these skin-based facelifts and had the elite clientele of the time happening. Um, then it evolved to the next level down, which is making the same plane of dissection through layer two, uh, lifting up layer one, the skin off of the fat, and then getting to the top of layer three and pulling it. And that's called a SMAS lift, SMAS. SMAS is layer three of the face, or there's different types. We'll really get into this, but layer three of the face, pulling on it from above, uh, the superficial musculoapineurotic system is what the acronym SMAS stands for. And that was slightly better, but still not great and not addressing the right layer, not addressing what was actually happening in an aging face, but that still is performed today. And that was been an argument over is that any better than deep plane facelift? But D-plane facelifts were the first one to kind of go underneath the SMAS into the areas below layer three, into layer four, where our actual aging is happening more and more. In layer two, instead of having gravitational descent and the fat pads, we were losing fat, losing volume in those areas, which is where something like my stem cell rich fat transfer becomes such an important adjunct to a facelift, because now we're talking about basically aging happening in different layers or different levels of our

Enter the Deep Plane: Aging Across the Layers

Dr. Cameron Chesnut 4:30

face in there. So now we're finally in the era of the deep plane facelift. And if we look at the superiority of a deep plane facelift to a smash facelift, there were some old studies. When I say old, I'm talking like lifts performed in the 90s, um, where they looked at smash lifts versus deep plane facelifts and determined, oh, there's no superiority. That's just not true. We know that's not true. That's the surgeons performing the procedures, basically. We're so far beyond that now, it shouldn't even be a debate anymore. Um, when I sit on panels talking about D-plane facelifting, and I have colleagues who still perform smash lifts and they show their results. Honestly, it's just not something that I would show, not something that I would want, not something that I would be happy with having or performing for that matter. So um, we just get into the D-plane facelift category here, and now we're getting into the state of the art, what's happening. Um, understanding the different layers of the face. When these layers first were described, it was an advance. It was a way for us to have a nomenclature among surgeons, but if we really get nuanced with it, there's different parts of layer three and different parts of layer four. And we're working in these different layers in different ways, and we're in different parts of the plane. Well, I'm in superficial layer four, deep layer four, or whatever, however, we want to describe this, um, it's so much more nuanced if we really break it down and split it. And that's just an evolution that the techniques have out accelerated, even what the nomenclature is. That's relatively new to describe how we are performing

Deep Neck Work and the Submandibular Glands

Dr. Cameron Chesnut 6:02

these types of facelifts. And so, really, about four or five years ago, the first big advancement, the first big change started coming, which actually has a lot more to do with necklifting. There were a few surgeons performing procedures in the neck that involved addressing the submandibular glands, the glands that sit underneath the neck. Um, so it's not a brand new thing, but the use of it accelerated greatly around four or five years ago. That's kind of when we've people were first talking about it, performing it more regularly. Uh, the those of us that were doing it started lecturing about it more. And all of a sudden we saw this uptick in people utilizing deep neck work, we'll call it, into the submandibular glands, into the digastric muscles, understanding how the hyoid was interacting with these better. So now we're in deep structures of the neck. We're in a whole different sort of universe, if you will, that wasn't really touched by many prior. And that was about four or five years ago. And there has been the pendulum has swung one way to the other versus doing glands on everybody versus nobody versus just some. And now we've kind of settled in a good spot where we understand this much better. So when we look at, you know, a century-old plus procedure, something that has evolved so greatly in four or five years is very, very new. It's the blink of an eye if we really get into it. And it's been made possible by the way that we communicate among surgeons to patients, uh, the way that we can share information via video. There's a lot of reasons that this has happened, but ultimately, again, it's all driven by results. So that's four or five

The Last Three Years: Preservation Style Lifts

Dr. Cameron Chesnut 7:38

years ago. Now we're into the past two or three years, where now we're advancing in the facelifting space itself as well. The first of these advances were different ways to raise the deep plane, different points to enter, and then getting a little bit more progressive with where the best places to enter the deep plane were, how to fixate them, how to pull on the vectors. And now we're in a place that is where exactly do we need to go? What's the safest way to get there? What is the maximum amount of release that we really need to get to our effective end result? Because we could go further in a dissection than is really needed. And in the end, we're causing a lot more trauma. And this gets into my world of causing a surgical trauma, how it leads to inflammation, and what that means to the overall healing process, we want to minimize that as much as we can. Um, these are these molecular pathways that I've discussed in the past. So understanding the exact amount that we need to dissect, how to release it, then now we're in a phase of, okay, now that we're in this space, what can we do? How do we elevate? What are the correct vectors? How do we keep things there as long as possible? And so let's really dive into this. This is this last two or three years of evolution, and people would call this like a preservation style of a deep plane facelift. And again, not all deep plane facelifts are created equal.

The Enigma Lift and How the Brain Reads Faces

Dr. Cameron Chesnut 8:59

I call the procedure that I do an enigma lift. And this goes back to uh what patients told me years ago and that they were having these procedures done, and they felt like everything when they got to the end was just better and improved and looked natural, but you couldn't even really tell how everything fit together what was done. That's the enigmatic part of it. That's the enigma. And honestly, that really gets into first order, second order, and third order thinking about how our brain interprets faces. And for anybody that's tuned in, you know that I'm very, very obsessed with how our brain interprets faces because to me, that's where the rubber meets the road as the end point of these procedures is yes, I'm doing a deep plane facelift or an enigma lift. And I want to, I, the ultimate goal of that though, is I want someone to move through their world, affecting it the best that they can. Form follows function. So I want the communication of their face, whether they're resting or dynamic or speaking or making facial expressions, I want that to be on point with who that person is, the emotion that they're trying to convey, how they're trying to communicate, because ultimately, when that happens as best it can, it will look beautiful, it will look natural, it will look more pleasant, and that is the enigma of it right there. And so this is where we're at in this new era of deep plane facelifting, is that we are trying to best understand how we can ultimately make what I would call the third order thinking of how our brain's interpreting faces better. It goes from just pulling, which is what still many people do. They're like, oh, things have fallen, I'm gonna lift them up. Okay, that's very much like first order thinking. What's the best way to do that? And we get into second order thinking is okay, where are these changes happening that are creating that? And that's that was a big advance, even right there, understanding which layers of the face we need to be be going to to addressing these as best we can. But I would argue that our new third order of thinking, getting into how our brain's interpreting us, okay, now what have those aging changes in that plane meant to how the face is functioning? And this is where we get to what's happening in the deep structures of the face, how the muscles of the face, something that makes us uniquely human, how they're functioning and what they're doing, and how we can optimize that through our facelifting approach. So we are orders of magnitude above when we get into this new era. This is what has changed and where we're going with this, is best understanding this. So now we have this preservation style facelift where we're doing as little, as little separation of the skin from the fat as we can. It's it's so minor now. Sometimes it's very little when all is said and done and things are lifted up. That means faster recoveries, that means healthier skin, and that means that we're going right to the area that the aging changes have happened and skipping over, creating a bunch of unnecessary damage in those other areas. This is a significantly more challenging procedure. It takes more time. You have to know what you're doing better, and this will all play into pricing later on, of course. But this is what's ultimately giving us the best results, creating the least collateral damage in the process and leading to results that are better, more natural, and ultimately end up healing faster when we get there, all said and done. And so what's happening now is we're getting to this place very quickly, getting to the right plane, and now we're understanding what's happening within this plane. And what I mean by this is layer three of the face, the SMAS, and we have the surgical SMAS, and that we can really get into the nuances of that, but understanding what's happening in the SMAS, which is thinking of this, the muscles of our face that move the skin, that cause the skin

Layer Three Failures and the Smile Block

Dr. Cameron Chesnut 12:30

changes. These are our muscles of facial expression. Again, one of the things that make us uniquely human, because that's what our brain is interpreting. We now are understanding what those muscles are doing, what they're anchored to, what they're moving, and we can change what they're anchored to next to the next level, and we can change what they're moving. That was kind of happening just with lifting up before, but now we're understanding the glide planes of the face, what the fat pads are doing, what the volume of those fat pads should be, even better. And layer three has a very deep focus on it now as to here's what we need to do to this plane, here's where it needs to anchor, here's what it's supposed to be doing. And this is important because when I see a lot of deep plane facelift failures, it's lack of understanding of what's happening in layer three here, or how layer three transitions from being largely a fascial plane, an aponeurotic type of thing, we would say in medicine, how it transitions from a fascial plane to a muscular plane. That point where it's transitioning is very, very, very important and where I see a lot of deep plane facelifts fail. I had a patient recently who had a deep plane facelift and had literally a crater running through the space where layer three transitioned from muscular to apineurotic, where the muscles were attaching to their anchored base. It had gotten separated, it had not been reattached, and now this person had a very abnormal smile. We call that like a smile block, couldn't even get the muscles of facial expression to do what they're supposed to do because they're no longer anchored to the appropriate face place, and at rest had a very distinct, hollowed, cavernous area running through her face from the way that this had been separated. And so this is really important for surgeons to understand when we're talking about layer three or the SMAS is where it needs to be lifted and where it needs to be reconnected. A more modern approach, a more new era approach to a deep plane facelift would not have caused this to happen. This is a very old school, um, even deep plane approach, the way that it was done. So they're not all created equal. Once we're in that plane, we want to understand how layer three, for example, is moving, what it's intended to do, and how it's interacting with the layer before it, layer four or layer five, whatever that may be, whatever plane that we're in and different parts of the face, because sometimes in a deep plane facelift, we are truly sub-smashed and underneath it. And other times we are on top of those muscles of facial expression, but in a deeper way, in a deeper layer to get them to function appropriately. The beautiful part of a really nice facelift dissection is we get to see all of the anatomy right in front of us. And what I mean by that is when we are underneath the smash, we get to see the smash in the roof of our dissection. We can see where the muscle is, we can grab it at different points, and we get the floor underneath that. This is one of the new frontiers

Working the Floor: Micro-Correcting the Deep Anatomy

Dr. Cameron Chesnut 15:23

is understanding what's happening in the floor underneath that, where the muscles of facial expression are meant to be anchored, what's happening in the deep fascia, whether it's around the parotid gland or around the buckle space, we want to know what's happening with that buckle fascia sitting over the top of the buccal capsule. If it's loosened, we want to tighten it. Um, if the muscles that make us smile, let's we call them the zygomaticus complex, if they have lost a little bit of tension and have sunken down, we can now tighten those under direct visualization. When we talk about the fascia up in our temple, the temple parietal fascia and how it interacts with the fascia lower in our face, we can see if there's laxity in there and we can tighten it directly. And so now we get all of this ability to literally go through layer by layer, anatomical zone by anatomical zone, and micro-correct all of these little fascial or muscle laxity issues that we see happening right in front of us. This is very, very new and this is technically challenging. And you have to know your deep anatomy and know where the nerves are and know what's lax and know what's supposed to be attached to what. And not understanding this or failures in the space lead to issues, again, with not all deep plane facelifts being created equal. Even a deep plane facelift can under or inadequately address these and leave something on the table, or sometimes just have poor results overall. So this is very much the next frontier of the space, is getting into that. And the reason that I love this is that because this is pulling the levers that we can with the functional changes that have aged in our face, what the muscles are doing, how they're interacting with the fat pads and the skin, and even the deep structural anchors of those muscles of facial expression. This is leveraging the understanding of our facial interpretation within our brain. What parts of our brain read what? What do they say? What does a downturn corner of the mouth mean to our brain? How do we interpret it? And how do we turn those changes around ultimately? So this is where everything collides, and I get very, very excited about this in this space. Um, the same goes when we think about that. Okay, now we're elevating this and we're moving these vectors

Vectors, and Why the Skin and SMAS Move Together

Dr. Cameron Chesnut 17:29

around. We can pull these layers that we've elevated in different vectors. We really want to have a deep understanding of where things are supposed to go, how they're supposed to move, how our brain interprets certain things, because ultimately, even with a really great facelift dissection, we want to put things back in the proper place. You know, six, seven, eight years ago, we were talking about, you know, the ligaments of the face and things like this, which is we're so far past that now. That is not true anymore. It was all about the release, all about releasing the facial ligaments, the fascial connections. And that was a discussion five years ago that was starting to get out the door of like, there's no ligaments in the face, there's no bone skin connections holding thing. What we're really describing as these fascial condensations of how the different layers interact with one another, which we understand much better now, and we move them much better, but we're so far past that part of the release, and now we're on to the vectors. And I would argue that we're on a little bit to how do we fixate? How are we doing this? Um, you know, with the vectoring part of things, you we want to have that deep understanding of what's happening there. We want to put things back in place and we want to keep them there. A lot of surgeons will use this happens with sutures generally, and when we're fixing and elevating, and once we find the right plane, and again, each surgeon's gonna do this differently, and it shouldn't happen in different vectors. And what I mean is the skin should not go a different direction than the smaths goes. That's crazy, that's asinine. Those are called biplanar lifts or bilamellar lifts, and they're they happen. Um, and I would just say run, don't walk away from something like that. Um, the skin and the and the underlying fat and smaths are not aging in different directions. That's not what's happening, so they shouldn't be corrected in different directions, right? So once we understand what's happening, how layer four is interacting with layer three above it and where the glide planes are, we want to put things back. We want to have that deep understanding of our neuroanatomy, put things back, and then I fixate solely with dissolvable sutures.

Fixation: Only Dissolvable Sutures, Nothing Permanent

Dr. Cameron Chesnut 19:29

I do not leave anything permanent in your face. This is one of my unique value systems. I do not like implanting foreign objects in the human face, and that even includes the sutures that I use in a facelift. This is not the norm. And most of my surgical colleagues use permanent sutures for this. I do not. Um, and one of the reasons is I use some regenerative fibrin matrices to help things heal in place once I put them there, which doesn't mean that I don't need the permanent sutures. I don't have to leave something permanent in your face, whether it's polypropylene or nylon or something like that. I'm using only dissolvable sutures and I'm relying on your body's ability to keep it in place afterwards. So that is my new era. That's a very unique part of the way that I do things, um, which is definitely adheres to my overall value system, right? Um, and so fixation is different. There's different ways to fixate when we get the vectors updated. And now when we we talk about um ways that we are controlling the tissue planes that we've created so that we don't get little blood collections, which are called hematomas, or collect fluid underneath the skin, we're undermining so much less of the skin. We're creating less of these potential dead spaces, and there's different ways to close them down. You could do nothing, that was old school. Um, you could put a pressure wrap on, which is just using gauze or elasticity to hold dressings in place to kind of keep things adherent. Um, but about, you know, along these same time frames, you know, let's call it five to ten years ago, eight years ago, um, in into our lives started coming

Hemostatic Nets, Drains, and Fibrin Sealants

Dr. Cameron Chesnut 21:04

these hemostatic nets. And you may have seen these if you're paying attention to the space. This is the superficial through the skin, all the way down to the smash and grabbing it, the sutures that you see through the skin surface underneath, it almost looks like a web or a net built along somebody. Those are put over where the skin is separated from the underlying fat because that's not a space that we want to have to separate, but the small amount that we do, we want them to sort of quickly adhere back together, these hemostatic nets, they can be kind of um off-putting or scary looking or a little concerning when you see them because it looks like a bunch of sutures through the face. And the, you know, the concern is like, well, what's that going to look like when it all heals? Well, these are something that are very regularly used in certain circumstances. I tend to be quite minimal with them. I use them when needed. Um, and I'm doing so in as least invasive a way as possible. And I'm leaving them in as short as I can to accomplish the goals that I'm after. So they have largely helped to replace something called a drain. And people may have this again goes back if you look a little bit, if you were to just sort of see the evolution over time, you could see drains kind of come in and everybody talk about them. And then drains start to fade away and nets start to come into the picture. And now nets start to fade a little bit away. And we have the tissue sealants or the fibrin glues coming into the picture, which have also been around for a long time. But we're finding our right cadence and the right rhythm and how to use these things best in facelift surgery because there could be times that you need drains, there could be times that you need netting sutures, and there can be times that a sealant or a glue is an appropriate aspect to do. I try to be quite flexible on what I'm doing in here, but also doing as little as possible. I'm not just netting everything just to net it. I'm not just using drains just to use drains. I've been through the evolution of all of these and I found the sweet spot that works really well for me that gives me an arsenal of different things that I would need for different patients. So honestly, your facelift is going to be as minimally invasive as possible, including in the way that I utilize a net or a glue or even a dressing. But it's going to be different for you than it is for the next person. It's quite customized as we're going along. And so as the current state of the art with drains essentially fading away, they're not all the way gone, but you will see them much, much, much, much, much, much, much less than you would have a few years ago. Nets have come and peaked and are trending down as well. They're still out there, they're still really valuable sometimes, but it's now understanding the right way to use them, when to remove them, what the right places are. And honestly, we need less of them because even since nets came into the picture, we've started undermining so much less in this preservation style that one of their main needs, one of their main targets has been reduced significantly. I'm not going to say eliminated in all cases, but greatly reduced. And that's led to the rise of fibrin glues or sealants that are put underneath the areas of a facelift and then held in place to essentially start a little clot to get that area to adhere together to reduce the fluid load in that area. And sometimes these are used overlapping. So you may use some netting on top of some fibrin glue or a sealant. And so this is one of our current states of how things progress along. It needs to be individualized to each person. And these are no replacements for a good preservation style or proper technique or proper fixation. And again, for me, I'm trying to reduce anything foreign that I use inside of you, whether that is sutures or the type of adhesive that we're using. I really love my fiber matrices because they are autologous. That means they are yours. I get them out of your blood directly. And I process your blood in a certain way to get these beautiful little weld points of a healing scaffold or a matrix to put in the areas where I really want things to heal down and be really strong in their adherence. And that makes it very, very nice in the adherence and healing and durability of your facelift because ultimately that gets into one of our other goals

How Long a Facelift Really Lasts

Dr. Cameron Chesnut 25:06

is okay, well, how long do these facelifts last is when we get into this. And I've talked about this a bunch recently. We have old articles showing differences in SMAS versus D-plane and how long D-plane lasts versus SMAS, you know, getting past the fact that, you know, oh, there's no difference in the outcome. We just know that's not true. Um, you know, a recent article on the duration of these facelifts was from basically one surgeon and showed differences based off of age, differences like basically past the age of 53, a facelift didn't last as long as if that same person had it in that one surgeon's hand at a younger age, which we also kind of intuitively know this, that getting a facelift maybe pre-menopause versus post-menopause could have a different effect based off the tissue quality, could last different lengths of time. And so this is with one surgeon, and that's not talking about the difference of all deep lane facelifts not being equal, and that some of the more durable, bigger, um at least done with greater understanding types of deep plane facelifts are going to not only give more natural, nicer results right off the get-go that we get to faster, but they're also going to last longer because of that. And so we have all of these avenues that go into this modern state of what's happening with a deep plane facelift. And, you know, it plays into this, the ultimate results that you're going to get. It plays into the durability and it plays into does this fit into your value system, even something as simple as the type of sutures that are used, right? Um, and and again, I think that this is really important to talk about from a durability standpoint and from a results standpoint, because lots of people have a quote, deep plane facelift, and they get a result that is improved from where they were before. Um, maybe it's a six or a seven out of ten type of result. And to them, they had a deep plane facelift. That's they were seeking a deep plane facelift. They

Why a Six Out of Ten Isn't the Goal

Dr. Cameron Chesnut 27:00

got a deep plane facelift from their you know local surgeon and it looks better than it did before, and they're thrilled. And so is that a success? That's the question. And yeah, I mean, judge it how you want to. Um, maybe you got a six out of 10, but it's better than it was, and you're happy with it. Is is that okay? Um, and I think this is variable from person to person. And if you're watching this, my guess is you're on the other end of this, where, well, I kind of want the eight, nines, and tens out of this, right? And that's where I say they're not all created equal because you can certainly get your six or seven out of ten result with your deep plane facelift. Um, having no idea or control over the circumstance of what's happening, it's it's about the surgeon performing it, not even just the technique. You'll have somebody who's doing a similar preservation style to somebody else, and they're they're not getting the same results. And there's all these other nuanced reasons why. What are they doing with the tissue planes? How are they fixating? What's the vector there that they're using? What does their pre-uh surgical protocol look like? What does their post-surgical protocol look like? How are they managing uh the dead space? Is are they using drains or are they using that? All of these can make a meaningful difference, not just in your recovery time, but in your end results. And so this is where we really get into these split nuances of not only are they all not all created equal, but there's a rapid evolution happening at the cream at the top that's creating, you know, that there's there's a new 10 out of 10 result that was different than it was a few years ago. And a lot of that has to do with some of these deep structural nuanced techniques that we're doing from a fixation standpoint, from an elevation standpoint, from a vectoring standpoint. Um, and this ultimately plays into the result that you're getting, uh, the mindset of the surgeon that's doing it. Of course, your surgeon is the ultimate determinant of the skill that you're getting, the focus that you're getting put into it, the resilience, the all of the things are gonna go into your ultimate result. And this is gonna carry into pricing as well. And this is a hot topic, and um, you know, facelift pricing has changed dramatically. Um, you know, and it's honestly paralleled changes in the, I'm gonna say, the results that have been delivered and the techniques that have led to those. And so it can be very upsetting to some people who, you know, maybe eight years ago had this sort of idea in their mind as to what they were going to spend on their D-plane facelift, and things have changed. Um, and you know, ultimately the value that you're getting out of this is um is very inter,

Pricing, Craftsmanship, and Value

Dr. Cameron Chesnut 29:31

it's very individualized. How about that? So some lifts are going to be more expensive than others, and generally I find that um the price that you're paying for a lift has a correlation to who's doing the lift, how experienced they are, the results that they're getting, um, how much time it takes to do that, which is often linked to the results because sometimes good things take time. If we want to do all of the deep floor tightening, sort of anatomical area by anatomical area, very precise in what muscles connected, it just takes quite a bit longer to do that. If we're quite careful with our vectoring and our fixation and the regenerative medicine that we're using under even with something like a fat transfer procedure, it takes a lot more time. Well, that means that things can and should cost more. But ultimately, you're paying for the results that you're getting. And I think also to some degree to the consistency, I kind of say the sure thing. You know, if you come to me and you get a procedure, you know pretty well what you're gonna get out of it. Um, you know, my dispersion is very narrow at this point, and that's not saying that everything's the same and that everything's perfect, or you know, I every procedure that I do, I look at it and say, I want this to be a little bit better, or that could have been a little bit better. There's no such thing as me being perfectly satisfied with every procedure. There's always room for improvement, and that's what drives me. I have an obsession with my results, and that obsession also stems into well, how not it's not just how I'm interpreting these results, it's what's the world interpreting? What's what is that person putting out into the world? Does this align with who they are? There's lots of metrics to this success for me. And so my dispersion is small. I'm consistent and my results are elevated. And so you see, here's what you're gonna get. Pretty sure thing within that. You know what the experience is gonna be like. It's very curated. Um, it's a positive experience. It starts before you ever get here, it continues well after you leave. We're gonna have a positive relationship afterwards. There's all of these types of things that go into it. Yes, the pre and post-operative recovery help you get better faster. So not only do you have this initiation hurdle that's lowered to get to it and through it, uh, but ultimately that makes your results better too. And and, you know, people get upset about pricing for all kinds of different surgeons, as though this is a mandatory thing. Well, everything that we're doing is elective. You know, I'm a luxury item. I'm not a gatekeeper to some life-saving procedure. Um, you know, I'm doing something that is very luxury, very nuanced, very artistic, very high-end, very curated, very thought-through. And you could use analogies for anything from handbags to cars, whatever it is, um, at high, high levels, when there's that level of craftsmanship or thought that goes into it, um, things are going to cost more. But you also have this beautiful product when you're all said and done, that you're very connected to. In this case, it is your face, maybe the most important of all of these things that we could talk about. And you know what's in it, you know how durable it's going to be, you know how functional it's going to be for you. You know what it's going to relieve in you, which is that cognitive dissonance that when I look in the mirror, I'm not seeing what I want to see. That's not me. That's not how I feel like I'm showing up in the world. And so that is where pricing comes into this. You can take a chance and you'll you'll see this. Oh, so-and-so in this location only charges this much for a deep plane facelift. Well, they're not all created equal. We know that. And you may see some results that are really compelling in that situation. But what you want to see is, and this is what I do when I lecture at a meeting, I don't just show my best five results.

Showing the Last Fifty, Not the Best Five

Dr. Cameron Chesnut 33:16

I show these are my last 50, all 50 of them that where I have consent to show them. Like this is every single one of them. There's no selection bias here. It's just this is the last 50, because honestly, those are the most pertinent ones to the lecture that I'm giving. It's not, what did I do 150 cases ago? It's like right now, the last 50 that I've done, this is what's happening in those. And from a patient standpoint, you get to see this when you're following along on my social media feed or on my website. You're seeing people in different stages of the journey. You're seeing everybody who gives me permission to post them. You're seeing videos, you're seeing photos, you're seeing one week, one month, six weeks, you know, all the way through years and years and years later. And so these are the types of things that you're paying for. It's not the one static photo that's an impressive result for this much money. Great. Is that going to be you? You don't know. You the spread could be huge. Um, you know, you're getting a tight spread at these different price points. And so I think people on some level know that. That doesn't mean that it's always a really, you know, a really pleasant conversation because sometimes it just may be out of somebody's budget to do it. Um, and we're usually trying to find solutions to that. Uh, but in general, when we get to pricing, there's a strong link to results. There's a strong link to time things take in the operating room. And I, like I said, those two things are very linked. Um, I'm not priding myself on how fast I am. I'm priding myself on the results that I produce in the end, how long they last, how they work with that patient, and how functional they are, how they're interacting with your brain. Um, and so that's what you end up, you know, sort of paying for. And that's where the nine and 10 out of 10 results come, 9.7s, and they're coming from that type of thinking. And so if that holds value to you, if that resonates with you, that's what you know, these are the types of things that you end up sort of like paying for as part of the overall procedure. So um there's a lot of nuance in there.

Constant Evolution and the One Percent Adjustment

Dr. Cameron Chesnut 35:09

There's a new era of D-plane facelifting, they're not all created equal. That term of a D-plane facelift is variable now, and that spread has gotten greater in the past two or three years. Um, I have a fellow who just started with me right now, and it's very interesting because he at his home, prior to coming uh with me and his other training, was working with another um, you know, uh ear, nose and throat trained facial plastic surgeon and was doing deep plane facelifts there. And in the first deep plane facelift that he did here with me, um, he immediately went into this like, oh my goodness, this is so different than what I was doing before. Um, this is a completely different evolution. And for me, honestly, nothing that I do today, nothing that I do today is the same as it was when I was in my training or in my fellowship, or even when I first started my practice. Everything has evolved and will continue to evolve so much. Everything is in this state of the art. It is new, it is the best. And, you know, I'm making a 1% micro adjustment with every single procedure that I do, and I'm paying very close attention to that in my journaling exercises into what did that slight difference in this area, what what result did that ultimately produce? And then I'm fine-tuning everything that I'm doing in that direction. We really want to continue that story uh with my fellows. The really interesting part is the first procedure that

The Fellow Who Revised His Own Case

Dr. Cameron Chesnut 36:38

he ever did with me was revising a procedure that he had been part of. I'm talking the other side of the country. It was such a coincidental situation where this patient came for me for erosion from the other side of the country. When we first talked and planned this out, I hadn't even interviewed this person as a fellow yet. Um, but he happened to be involved with her primary surgery with the other surgeon he was working with a year and a half prior. And then he saw the same patient with his first procedure with me. Um, and she had the smile block and the cavernous changes in her face. And, you know, this was done with a deep plane facelift from a very reputable, qualified, you know, board-certified facial plastic surgeon. Um, and it just goes to show that the technique has evolved greatly. Not everything is created equal. Um, not all deep plane facelifts are the same. There are nuances to this, there are levels to the game, if you will. Um, and I think you can appreciate that with a lot of results and the consistency and the experience and the process that gets you there. And ultimately, I really hope that you find the right surgeon who resonates with you, who hits with you, who checks the right boxes for you. Um, and ultimately in my world, who is hyper focused on you, only thing they're doing that day, this is my world, um, in my flow state. Um, and everything is about visualizing what's happening with you, making the right decisions for you, for your goals, functionally to restore what you're after. Um, and again, I hope that this is a smooth journey for you. I hope this helps clear up a lot of the nomenclature around what's happened with the D-plane facelift. And for my fellow surgeons out there, I hope this is a nice refresher and some motivation to go seek out some of these more advanced techniques to put them into your practice.

Final Thoughts

Dr. Cameron Chesnut 38:22

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.