Doing It Right the First Time

Dr. Cameron Chesnut 0:00

Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level through optimizing the way you look, move, perform, feel, and connect. Today's OR diary highlights a theme that I see often in the operating room about doing things right the first time. And it also exposes something that I am even a little bit guilty of talking about myself, which is having a procedure at a slightly earlier age

The Budget Surgery Decision

Dr. Cameron Chesnut 0:30

does not inhibit you from having future procedures, which I hold to being true, unless that initial procedure that's done is done really poorly. And that was my situation in the operating room today with somebody who's 53 years old and had a procedure at 51 years old, sort of earlier on in the process, and went into it, admittedly, this was, these were her words, with this mindset that she was early on, she didn't need as much done. So she thought that she could kind of get away with a cheaper option, doing less. So she chose a surgeon that costs less. And she knew it wasn't going to be quite the same, but she just thought, well, I don't need that much anyway. So this should be fine. This should get the job done. Um, and also then kind of skimped on some of the parts. And that's where I fought the surgeon a little bit here, because some of the things that were skipped were very, very, very, very, very key and were not performed in an attempt to honestly, probably from the surgeon's perspective, just to get her to do surgery, like get her to say yes, like, oh, what do you want? Yeah, I'll do that, versus actually, this is probably what's best for you. And skipping this is a key element. And it should just be a non-starter without it. And that probably should have been the conversation that wasn't it. So

When Surgery Creates New Problems

Dr. Cameron Chesnut 1:45

has her procedure done, um, does not go well and doesn't go terribly poor, not like, oh my gosh, everything was terrible. That's not the case. It just wasn't what it could have been. And in the process, created some other issues that weren't there prior, which is, I think, one of the nightmares of surgery, right? Um, well, this wasn't there before and now it is. That happens to some degree in subtle little nuanced ways. Um, so that can happen. But when it's a big, glaring type of situation, like I now have a dent across my cheek, or I now have eyes that are two different sizes, which was one of her things. Um, or I now have like this asymmetry that grossly that didn't exist before, um, all kinds of things like that can happen afterwards. And so, you know, we we kind of like almost like hug it out a little bit, this uh this patient and I, again, 53 years old. I had talked to her originally before her first procedure, and you know, it was a cost-based thing, ended up choosing somebody else, which I I do understand. Um, but with that, you run into the, you know, you you you're getting what you get at that other price point, and had her thing done, didn't go well, tried to be at peace with it, lived with it for a couple of years, and then here we are, um, going through a a revision of that procedure. Now, again, this gets to this thing that I said it exposes, you know, the idea of that I didn't need that much, it's no big deal. Um, you know, oh, I'm just gonna have an eyelid surgery when I really needed a few other things that were way more important than just the eyelid surgery. I talk about that all the time. It's actually like the fourth thing on the priority list, in my opinion. Um, skipping the first three and going right to that that caused her a problem. Um, a lot of

Why I Plan Procedures in Decades

Dr. Cameron Chesnut 3:30

things that I talk about often, sort of the budget option, just didn't work out for her. But I also talk about, well, if you had if she had a procedure at 51, like let's say she had it with me at 51 years old, you know, let's say she's now 63 years old instead of 53 years old, and she wants to have another procedure. My goal within that is to be like, yep, free reign, do it. Like, no issues whatsoever. That we were in the right tissue planes, you're still gonna be in a better spot at 63 than you would have been without doing the procedure at 51. Like everything is green light, you know, do what you want again and go for it. And that's that's the way that I work. I think ahead of on my procedures in decades. I work in the right tissue planes. I'm really focused on the regenerative components of what I'm doing to make things strong and durable. And so I do largely adhere to that, that having a procedure younger does not, you know, stop you or inhibit having a procedure later down the road, should you decide that you want it. But then I, of course, like get smacked in the face with this situation where that's not always true, especially

Tissue Planes, Scar Tissue, and Lost Blood Supply

Dr. Cameron Chesnut 4:30

if the first procedure is done in a way that is subpar, suboptimal, poor, whatever you want to say, which was our case today. And this can happen in a lot of different ways. Um, but some of the most common ways that I see it are the plane chosen for the facelifting procedure, a superficial subcutaneous smash lift type of plane causes issues with the skin, issues with the subcutaneous fat, or just loss of subcutaneous fat in this sort of situation and weakens the inevitable structure of those. You know, people, this is like the idea with tightening devices and things too. Oh, if you heat this layer and create collagen. Well, I'll tell you today, uh, my patient had a lot of collagen in that layer from a previous surgery that was not the layer to put it in in the superficial subcutaneous plane, and it caused a lot of weakness of her tissue because her skin ultimately was not getting the same type of blood flow, which flows through that subcutaneous tissue as it would without it. So this is like this gets on a tangent into devices and things like that. Well, you have to be really careful with those. But admittedly, poor surgery or poor surgical planes can create this too. She had areas of scarring where she had been, she had lost a blood supply, um, had hypoxic, we call it ischemia, like low oxygen there that basically killed some of her tissue and created this matted-down scar tissue in certain areas. And again, a lot of this is the result of just poor technique, poor understanding, poor execution, poor choice of tissue planes, whatever it may be, and it created a really challenging, not impossible, but a really

Iatrogenic Aging

Dr. Cameron Chesnut 6:10

challenging situation to work through. The hardest part of it is just the weakening of her previous tissue structure, because ultimately that almost creates creates like an additional type of aging on top of her other procedure because we know that as we age, our tissue gets weaker. And if we're, we'd say the word is iatrogenic in medicine. Iatrogenic means created by a treatment or created by us. Uh, if we're iatrogenically aging our patients with surgery, we're doing them a disservice, right? And that's what had happened in this situation. So, you know, some parts were okay and like improved, quote unquote improved, but overall it was a poor outcome. And now she had weaker tissue in a lot of areas, which makes her subsequent procedure more challenging uh to perform, which is where I have to eat my words a little bit, saying that, oh, it doesn't, you know, it doesn't, you know, have any issue with a future procedure.

What Went Wrong in the Eyes and Neck

Dr. Cameron Chesnut 7:00

Well, if the first one's not done well, it certainly can. Um and, you know, this was not unique to just her face. This had happened in her eyes as well, or like I said, uh, this person went right to what's the fourth thing on my hierarchy of making good-looking eyes. Um, and good looking is the wrong term in my world. Actually, I'm thinking of highly functional, emotive, expressive, communicative eyes. Um, it's not just better looking. Better looking comes as a, you know, a benefit to the that function of all those things I just mentioned being better. When you move better, communicate better, emote better, your eyes are going to look better. And just taking skin out is like the fourth thing, especially at age 51. Um, all of these other things were missed and made worse, actually, because the person didn't just take out skin, but they took out some fat pads and removed a little muscle and tried to like create a scar to create a sharp crease and things like this. And it just was a disaster. And her upper lids made them look worse, made them, made her look aged, um, it exposed an asymmetry that was actually there the whole time, but just was at least shadowed by a natural, uh, a natural milieu or a natural environment and look of her upper lids. And once that looked unnatural, then the asymmetry really stood out. Um, and now I've got a bunch of scar tissue and a lack of fat to work with and all the things that I need to make that better. So poor tissue quality, lack of fat pads or tissue in this case. Um, and the same thing had happened in her neck with just a removal of a bunch of fat in that area. You know, the surgeon was he got to the area they needed to go, then did a bunch of liposuction in her neck, which is just so misunderstanding what's actually happening there and weakening everything that I need to work on. And um just again, this it made me eat my words a little bit and the oh, having a procedure now doesn't affect a future procedure. That's not always true. I have to admit that. Um, I'm saying that under the assumption,

The "I Don't Need Much" Mindset

Dr. Cameron Chesnut 8:50

which of course you never assume, but I'm saying that under the assumption that the original procedure was done well. Um, and then the other, I think this highlight of like uh this this really common mindset of I just don't need much. Um it seems silly to spend that much money when I'm this early on in the process. And I understand that. Like uh the idea that you know, you're that well, I'm only 51 instead of 55. So my, you know, where I'm gonna be more advanced aging, so my procedure should cost less. It's actually not always the case. Sometimes it's very similar to a procedure that would be more advanced. Not always. There's often a little bit less time and and nuance and complication involved to do uh to do you a little bit earlier on. So it does cost less, but it's not some exponential change to that, or not even linear necessarily. So um that can drive people at those earlier stages who really want to clearly really want to have a procedure done so bad that they'll kind of bargain hunt a little bit. Um, but just because you're 51 and early in your aging process doesn't mean that you know you should spend a tenth on your procedure or something like that. Um, it's going to, you know, in this circumstance, um, cause a big issue. And the ironic

Why Revisions Are Harder (and Why Filler Isn't the Fix)

Dr. Cameron Chesnut 10:00

part of that is ultimately your revision becomes significantly more complicated than the primary surgery would have been in the first place. You know, had we just kind of done the initial, it would have been, you know, less expensive, less trauma, better end result, of course. Like now we don't have the tissue weakening and changes, um, getting there faster, not having to do two recoveries because your recovery from the second surgery is often a little bit more involved than the first, because there's more scar tissue and more lymphatic, you know, drainage issues, things like that. This person also had a lot had a lot of filler, which is a whole other side note. Um, the filler was done in an attempt to make up for the poor surgery. Uh, the poor surgery, surgical results. Oh, well, let's give you some filler to like fix some of these things. Like, I just want to cover my face and run for that person in that case, but these things happen often. Um, you know, a device or a filler or something to make up for a poor surgical result is is not your answer. Um, and so all's well that ends well. And so here we are revising her surgery, getting her to a better place, um, and me eating my words a little bit about uh a surgery not having any issues down the road. If you decide to do a set a second surgery, I think I need to qualify that by saying, let's assume that that first surgery is done well, um, and then just sort of honestly a hard lesson for my patient to learn a little bit. And you know, she's a happy, lovely, wonderful person who just made a uh, you know, made a poor decision, basically, um and kind of knew she was making a poor decision, I think, um, but was so um locked into this, like, I'm early on, I don't need all these things, you know. And I I understand that. Um, it wasn't all these things that she needed, it was just a more comprehensive approach than she got. And when she got a more cut-down approach, um, she left out the other side of it, you know, in a bad, bad spot. I can just say that frankly, in a bad spot, not even

The Bell Curve of Surgical Outcomes

Dr. Cameron Chesnut 11:50

just in a suboptimal spot, because you know, let's be honest about this. Okay, so we have that group that like the patient that I'm talking about that makes for an OR diary. Like, I had a previous surgery, it did not go well. I had it at 51, I was trying to do as little as possible. I didn't think I needed that much, I didn't want to spend that much, I got in a bad spot. Okay, there's that group. That's an outlier. Let's hope. Then you got the other outlier, the 51-year-old. I know I don't need much, but I want to do it right the first time. Comes and sees me, and we get it done, and it's this incredible result. You can't even tell what happened. It's an enigma. It's the enigma lift. It's an enigma. Oh my gosh, it's incredible. Moose moose for the rest of her life, happy, and maybe never does something again. But if she wants to, totally open to do it. That's the ones I talk about, and that you can always do it again later. Maybe that's another outlier. You got those two extremes. And then a lot of people lie in the middle where they had a previous procedure, they added a 51, fill in the blank 47, 49, whatever it is. And, you know, yeah, it's better, it's okay. You know, there's some things that could have been better, like I don't like how this looks or moves, or that wasn't addressed, or this kind of looks a little funny or asymmetric. And, you know, this is this is the majority. This on the bell curve, this is the largest number of people live in that type of space afterwards. And uh good or bad, I don't know. I don't know what the right answer to that is when it's like uh, oh, it's yeah, it's okay, fine, could be better. Nothing's terrible, looks, you know, like wish this was a little bit better or that, this, that, or the other. Um, and you know, I definitely work with the patients who live in the other end of that space where it's like, uh, I don't want to be 52 years old a year after surgery and just be like a little bit better than I was before. Like my patients tend to be of the type who like, I want to look as good as I can, I want to have this the surest thing that I can, I want to get there as efficiently as possible, as reliable as possible, with the best experience possible. Um, that's my world, right? And I think on some level everybody wants that. Um, but you it has to, you know, sort of like click with you or resonate with you enough to sort of like go down that route to be an outlier on the other side a little bit. Um, and it's never a fun situation where being an outlier the other way pushes you into that necessity. I don't want that to ever be the situation. Um, and you know, a lot of people are cruising around with their seven out of ten results and they're happy as a clam, they'd even know there's a 10 out of 10. And, you know, that's kind of more power to them in that situation. Uh, but when that uh level of awareness is there, I will say, um, even that result is dissatisfying to some degree. So um, you know, that's that this is the space I live in. Um sometimes it's a bit of a liminal space. Um, but I, you know, I love it personally. Um I love it when it's a 51-year-old doing their first ever thing with me, and we get to

Two Lessons From the OR

Dr. Cameron Chesnut 14:40

make some magic happen. And I love it when it's a 53-year-old who's in a bad spot from a previous procedure, and we get to make some magic happen there too. Um, so I I love it all. Different challenges to each one. And uh again, this this whole OR diary for me just really highlighted it made me think about my statement of having a surgery at 51 keeps the doors open for a subsequent procedure down the road. I have to qualify that. Add the caveat that assuming that procedure is done really well the first time, then we have no issues down the road. Um, so that was big learning lesson number one. And then number two, this idea of like, and it's more and more common, right? Being earlier on. This this is a definitely an increasing theme in our space of you know, facial plastic surgery is that people are seeking younger procedures. Um, and this mindset becomes more prevalent that like, oh, it should be, it should be, it shouldn't cost that much. It should be like, you know, nothing to do it because I'm 51 and I'm in a good spot. And and that's looking at the whole face of like, okay, yeah, you're only 21% aged, where this other person at 60 is 61% aged. So okay, great. At 21% age doesn't mean that you only do one thing, or it means that we just have to correct everything else a little bit less to get to that end result. And again, with that mindset, you become an outlier on the positive side. They're like, okay, I'm gonna correct the things that need to be corrected to the degree that they need to be corrected. I'm gonna be comprehensive about it and I'm

Final Thoughts

Dr. Cameron Chesnut 16:10

gonna get this beautiful result on the other side. The alternative being some other space in the middle where some things are better and some aren't changed, or things get worse. So um I learned something. I hope you learned something. Um, I'm always grateful to my patients for their trust in me. And this was a really prime one. Um, you know, like that it's a you know, admittedly an awkward situation for her to kind of have the consult choose somebody else, which I understand, and then a couple of years later come back and say, Hey, you know, can you help me again? Um and this is a patient I'll have a relationship for a long, long time. She's lovely, like I said, and and um we're very much linked now, we're forever linked in my opinion, and um I'm looking forward to seeing her results as she heals and gets better and gets back on the track that she wanted to be on in the first place. 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.