S05E98 Navigating the Complexities Between Fillers and Facelifts: The Good, The Bad, The Ugly

Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic discuss the nuanced relationships between soft tissue fillers and facelifts.

They delve into the challenges of managing fillers during and after facelifts, based on a 2023 Aesthetic Surgery Journal article reporting that 52% of surgeons find fillers complicated post-facelift.

The surgeons address the appropriate use of fillers and fat augmentation, the potential pitfalls of overuse, and offer practical advice for both patients and providers. They emphasize the importance of individualized treatment plans, caution against excessive filler use, and highlight the need for skilled injectors. The episode concludes with guidance on recognizing the need for surgical intervention versus fillers and ensuring safe, effective aesthetic outcomes.

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S05E98 Navigating the Complexities Between Fillers and Facelifts: The Good, The Bad, The Ugly

TRANSCRIPT

Dr. Sam Rhee: Hello, welcome to another edition of Three Plastic Surgeons in a Fourth. I have three esteemed colleagues as always, Dr. Salvatore Pacella from La Jolla, California at San Diego Plastic Surgeon, Dr. Sam Jejurikar from Dallas, Texas at Sam Jejurikar, and Dr. Lawrence Tong from Toronto, Cal, uh, sorry, Toronto, Canada.

And his Instagram handle is at Yorkville Plastic Surgery. Today we're going to talk about fillers and facelifts. Usually fillers are awesome, facelifts are awesome, but fillers and facelifts may not always be so awesome. So, let's talk about the interplay between soft tissue fillers in the face and facelifts as well.

But first, let's get started.

Dr. Sam Jejurikar: someone

Dr. Sam Rhee: Disclaimer by Dr. Tong.

Dr. Sam Jejurikar: A person, a

Dr. Lawrence Tong: All right. So, uh, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. [00:01:00] Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something on this show. Yeah,

Dr. Sam Rhee: So, this is based out of an article that was written in a 2023 issue of Aesthetic Surgery Journal Open Forum, which was also reported in PlasticSurgeryPractice. com, where 52 percent of surgeons found soft tissue fillers challenging when Performing facelifts after the filler treatment had been done.

Uh, fillers are, uh, typically, um, injections that we all do. Many, um, Metaspas and dermatologists also do them. Uh, talk to me guys about what you think about fillers, how often you use them, indications, and. And what [00:02:00] you guys, uh, like to use them for.

Dr. Salvatore Pacella: So, um, so it's interesting that, you know, I would say that there is a, uh, a very, um, interesting perception for patients out there when they're talking about facial rejuvenation,

that many see it as an all or none phenomenon, right? Or it's like, hey, you know, I don't want a facelift, so I'm just going to get some fillers, like as an, as if they're one for one, right?

And to some extent, um, you know, fillers, I would say, are much better for patients that are younger, that have very good skin, that have minimal sun damage, and have minimal deformity, right? I tend to see a lot of older patients in their 70s, 80s sometimes that come in for facial rejuvenation and they say, well, I don't want a facelift.

I just want fillers. And they come in and their skin is leathery and it's deflated. And, and I, I honestly just tell them, Hey, look, [00:03:00] I don't want to waste your money. This is not, you're, you're, the fillers are not going to do much. Right. And so, so the problem is, is many providers are not that honest. Right.

So they'll just kind of pump patients up with fillers. Right. And, you know, when you think about who does fillers, right, it's not necessarily plastic surgeons or dermatologists out there. It's a whole population of aesthetic providers. You can be a family med doctor, you can be a nurse, you can be a PA, etc.

So, so this, this problem is sort of permeant out there. And I think from a technical standpoint, it does get challenging. Um, you know, fillers oftentimes create lumps, they create bumps, and there's a tendency in a filler injector to, to put a lot in, so multiple syringes per side. And, you know, sometimes it doesn't go away despite the fact that it may be a, a dissolve a, uh, something that is, uh, consumable.

Okay? And, and that can absolutely affect the quality of the skin afterwards. And it can absolutely affect the deeper structure of the skin, what we're, we're, what we call [00:04:00] the sma, the, uh, the Musculo, a neurotic system, that's a deeper foundation of the face that we're using to support.

Dr. Lawrence Tong: just made a very, uh, important distinction that a lot of patients may not be perfectly clear on, and I try to make it very clear when I speak to my patients. If you need a facelift, meaning something is sagging on your face, then you're going to generally need surgery, something to, uh, re drape the skin, maybe remove extra skin, um, you know, make internal changes, uh, to the, uh, the facial soft tissue architecture.

Whereas fillers is mostly just for volumizing. And this, um, notion that you can get lifting from fillers, I think is totally BS because Yeah, I mean, you could do it. You want to put 10 syringes in somebody's cheek. Maybe they'll, they'll lift a little bit up here because the most common thing, I'm sure you guys see it, patients will come in, I'll put a little bit of filler right here.

So it's going to [00:05:00] lift like this. And right when they, right when they say that, I just make it, you know, very clear to them that it's not going to happen unless you want to, You know, more filler in the face than would, um, than would look normal. So it is an important distinction to make.

Dr. Sam Rhee: me. I'm getting angry.

Dr. Sam Jejurikar: are awesome points because I think, I think we would all agree that fillers do have a role in our aesthetic patients. Um, we're not saying that fillers are a bad thing. I think what we're saying is that too much filler can be a bad thing, and trying to use filler to do things that's not meant to do can be a bad thing.

So, just to be clear, I think a moderate amount of filler used to fill certain lines in the face, whether it's marionette lines, A little bit of filler to use for lips, even a little bit of filler for volume augmentation, cheeks, temples, things like that are things that we all get behind. But we all have patients that come to our practice that look like they have gotten a lot of filler.

And this was really sort of, um, you know, to kind [00:06:00] of build on something that Sal was saying. The majority of people that are injecting fillers Not only are not plastic surgeons or dermatologists, they're not doctors. Um, the majority of people doing it are physician extenders, whether it's nurses, nurse practitioners, physician's assistants, and this was kind of illustrated to me recently.

Cause in my practice, the majority of people, the person doing the most amount of filler is actually not me. It's a physician assistant who is in my practice. Who's an amazing injector, by the way. But when she was getting trained by one of these sort of master injectors that the companies send out. You know, the person who was training her was either a nurse practitioner or a PA who has a multi million dollar injectable practice, who is basically telling her that to treat marionette lines, the number one thing to do was to put multiple volumes of syringes into the cheek to try to fix that area.

And you know, if, if you are making your entire practice and your only tool is filler, you You put a lot of it [00:07:00] in because you know, the more you put in, you know, the more distortion of the soft tissue you can accomplish. And what we're seeing is in patients that then later on realize, Hey, I may look youthful, but I also look like an alien.

I don't want to look like a youthful alien. I want to look like a youthful human. These patients that are subsequently coming in to get their facelift, we're finding more scarring in that soft tissue. We're finding distortion of the soft, deeper soft tissue anatomy, the smash that these guys were talking about.

Um, I don't know about you guys, but I've done facelifts on patients and I've actually seen soft tissue, Filler, whether it's hyaluronic acid, or radiesse, other, other sorts of things sort of spilling out of the soft tissue when you're doing it, and there's a lot of scarring that's associated with it.

Dr. Salvatore Pacella: and, you know, it's like,

Dr. Sam Jejurikar: but, you

Dr. Salvatore Pacella: phrase comes to mind, when you're a hammer, the whole world's a nail, right? That's the only arrow in the quiver, right? So, like, of course that's the one that's going to be used, right? So, whereas,

Dr. Sam Jejurikar: know, and not to interrupt you, but what these guys also say is, life is a game. You, you, you just gotta [00:08:00] play it. Like, like, like,

Dr. Lawrence Tong: I hate people who say that.

Dr. Salvatore Pacella: That is

Dr. Sam Jejurikar: exactly, it counts.

Dr. Salvatore Pacella: Sage words from the

Dr. Sam Jejurikar: exactly.

Dr. Salvatore Pacella: Uh, the, um, it's too funny. Um, so, you know, what I was gonna say, one of the beauties of plastic surgery is the, the ability for us to use multiple tools to accomplish our goals, right? And we've, we've had the training and the expertise. Um, I would say that, you know, The, the single most problematic anatomic area in my practice that I see fillers utilized is guess where?

Dr. Sam Jejurikar: The lower eyelid.

Dr. Salvatore Pacella: Lower eyelid. Yeah, absolutely. It is a huge, huge, huge challenge. And you know, for our, our listeners out there that, you know, there's a little bit of anatomy I think we have to understand here, right? And so what I want to [00:09:00] specifically talk about is two anatomic areas. There's this area here called the tear trough.

And then there's this area here called the pre zygomatic space, okay? And so the tear trough, super thin, right? And so the tendency is, like many injectors do, is they inject multiple, multiple syringes into these areas, and they don't dissolve. It often comes out looking bumpy, lumpy, and people have this unnatural looking fullness in the tear trough.

And trying to, to get rid of that surgically is, is exceptionally challenging. The second issue is this area right here, what, what we call the pre zygomatic space, okay? The interesting thing about this area here is it, it's almost like a box, right? There's ligaments up top, ligaments down below, and a ligament up front.

And injectors do a lot of injection into this area. And instead of having it distribute throughout, it creates these little mounds of tissue right here. And so people have these big mailer bags. That often times filler injections can make that worse. [00:10:00] And cosmetically when, when I treat that, when I treat malar bags, it's a pretty large dissection, it has to go all the way into the midface here.

And you imagine this kind of, you're going into deep areas and superficial areas of this area of the face, the midface. And just as you said Samir, the, the stuff is just oozing out like toothpaste, it's uh, it's quite gross. Um,

Dr. Sam Rhee: If I was a, if I was a listen, if I was a listener and I was a patient, I'm listening to you guys, and, uh, which is all true, absolutely. And now I'm scared, and I say, well, you know, I have an ejector, I have someone I go to, how do I know how much to inject? What is too much? You know, what kind of guidelines are you guys going to give me here so that I know what the right amount is where?

Dr. Lawrence Tong: I think it's, it's individualized. That's, that's the first thing because it depends on, you know, what, what your volume deficit is and, and where, where the area is. But, um, one [00:11:00] thing to realize is that if you start. To look sort of strange or weird, then for sure, uh, that's too much. And generally, I don't, I don't recommend that, that you do a whole bunch of filler.

All at once, uh, for listeners out there. Um, maybe take it slow, start in an area,

Dr. Salvatore Pacella: Excellent point, excellent

Dr. Lawrence Tong: put too much in. And if you need more, you can always come back. The problem is if you, if you put in a lot of filler, um, sometimes you don't really see those effects, um, of the distortion maybe, uh, until a little while longer, and then you have to deal with it.

Now, fortunately, there is a, there is a way to, to deal with it. There is a, there's an enzyme that you can use. So. Um, to melt hyaluronic acid. Hyaluronic acid is the most common type of, uh, filler that's used on the market these days. So there is a, a solution, but then if

Dr. Salvatore Pacella: can be incomplete though.

Dr. Lawrence Tong: that's, that

is correct. Yeah.

I

Dr. Sam Jejurikar: Yeah. Particularly some of these [00:12:00] newer, um, higher cross lengths, uh, hyaluronic acid fillers, like. I dunno if you guys have any experience with ux, for instance, this one, for the jawline. I find that incredibly hard to dissolve, uh, with hyaluronidase, even though it's a hyaluronic acid cell.

Dr. Sam Rhee: What do you guys think of, uh, jawline correction with filler? What's your experience with that?

Dr. Lawrence Tong: think

Dr. Sam Rhee: Mewing?

Dr. Lawrence Tong: I've used, I've used the Volux before. It, it's actually, uh, not a bad product. I typically I'll use it at the angle of the mandible, which is this area right here. When, when a patient wants a little bit more definition, I don't advocate putting a whole, a whole bunch of filler all, all down the. I don't think that ever looks good.

I don't think it ever, ever looks natural and I don't think it, it actually lasts. So, um, in, in normal sort of conservative, uh, doses, I think it's pretty good. Um, but otherwise I don't recommend that you put a lot of filler along the jawline.[00:13:00]

Dr. Sam Jejurikar: I totally agree with Larry. I, I like it for chin augmentation too along the jawline. I think it's nice for, for that, but um, I've tried to dissolve it in a couple of patients who had had too much put in. Um, um, and, uh, it was really hard, really hard to get rid of. Uh,

I mean, I

Dr. Sam Rhee: like UI don't like using it for jowling correction on the jawline. So like sometimes you'll have this jowl that kind of comes down, and then you have this fullness along the jawline because of that. And, uh, I've seen attempts to try to smooth that jawline by injecting it, like adjacent to that jowling and to me, the results that, uh, the companies always show off.

Look. So Jay Lenoi, like that jawline just looks so prominent and I, I, I can't stand that look. It looks, it looks so artificial.

Dr. Sam Jejurikar: Pacella,

Dr. Salvatore Pacella: my, my impression of, um, you know, fillers along the jawline are exactly, um, the response that my wife gets when she gets a, When she orders something at a restaurant and the waiter delivers it over and, and the [00:14:00] waiter asks, did you like this? And she says,

Dr. Sam Jejurikar: next

Dr. Salvatore Pacella: didn't love this. That's exactly how I feel. Um, it just, it just doesn't do it.

Right. It doesn't do it. And you know, what I, what I oftentimes tell patients to is, um, you know, it's pretty easy to just go off the shelf and take a syringe and inject it into the face. You have a, basically, a bowelless, uh, massive supply of soft tissue filler that your body carries around with you, and that's fat.

And that, and the beauty of fat augmentation done in the office setting is, is phenomenal. I mean, the beauty of fat is it can be big, it can be small, you can use nano fat, you can use thin areas of fat, you can pare it down. And, you know, it's, it's organic and it takes and it's, it's wonderfully predictable in the correct hands.

And, you know, that's something you're not going to find from a, from a nurse practitioner, PA, [00:15:00] or some sort of non plastic surgery

Dr. Sam Rhee: when do you lead patients from a soft, like how do you help them navigate the soft tissue filler versus fat transfer? Um, sort of,

Dr. Salvatore Pacella: Well, I, I'm honest with them. I say, you know, this is a,

Dr. Sam Jejurikar: C., R. K.

Dr. Salvatore Pacella: transfer is a surgery, and it's not as easy as a filler because the recovery is not that easy. Do you want something that's reliable? Like anything in life, you have to invest the time and invest the energy to get the reward. And I think the reward is so much better, but they definitely have to take the time off.

They have to be willing to undergo surgery, albeit under local anesthesia. And, you know, it's oftentimes a situation where we can't add a little bit. We want to do as much as we can in one sitting. Right. So it is a recovery. And, and, you know, Samir, you may agree, you know, many patients are not willing to take that.

They want a lunchtime fix, right?

Dr. Sam Jejurikar: Yeah. I mean, it's, it's a very different recovery from a fat grafting procedure to the face. It's multiple weeks of swelling and bruising that go along with it. So it's [00:16:00] surgery. Whereas I do like filler. I'm not saying there's no real filler at all. I like filler quite a bit. If done judiciously and for the right, for the right reason, recovery is quick.

You can get it and go right back to work and with a little bit of ice, you know, there's almost no sign that you had it done.

Dr. Lawrence Tong: Yeah, I agree with all your, your comments. Um, you know, fat and filler, I think are, are actually fairly different. They both act to volumize, but they both have their pros and cons. I would say is, is less predictable. Um, at least if you're just doing it once. So if a patient wants predictability, I would say Then filler is generally better.

Fat, I think, is better for large volumes. So if you come in with a patient, if a patient comes in, their face is very thin and they need a lot of volumization, it's sometimes not practical to use filler, um, because you're going to be using a lot of it. Uh, and in that case, fat is a better option. The other thing is [00:17:00] maintenance.

So, you know, if you get a successful fat transfer, You might not have to, um, worry about topping up for several years and, uh, that is not true, uh, for filler. And then what, uh, Dr. Jejurikar said about the, the recovery. So surgery takes longer to recover, that's, that's a fat transfer, there's bruising and things like that.

With filler, you just come in, get it done at your lunch hour and you go. So they're different, but they have their, uh, their roles. They're not always, um. So different that you can only use one or the other. Oftentimes there's, there's overlap, but there are some, you know, notable differences in, in what they can do and, and, uh, the pro, their pros and cons with their application.

Dr. Sam Rhee: I love using fat for adjunctive procedures for facelifts. I, I almost never will do a facelift or a neck lift without doing some fat. in addition to, but that's because the recovery is long with that. Um, I'm like you guys. I love doing [00:18:00] filler. Um, I'm very judicious with it. I'm seeing more ozempic or, you know, weight loss patients, and for a lot of them, just adding a little bit of volume with a soft tissue filler can be super helpful.

Um, and, uh, and I do like the fact that it is quick, but that, like you said, in the wrong hands can cause problems. So if you see a patient now who has a lot A filler, but they need a, they need some sort of surgical pre procedure, a facelift, neck facelift, whatever. Um, what do you do with those high volume soft tissue filler patients prior to surgery?

Anything? Nothing. What, what is

Dr. Sam Jejurikar: I try to dissolve, I try to dissolve as much of the fillers I can ahead of time because, um, like we talked about, there's gonna be, um, distortion of the soft tissue that occurs from that soft tissue filler. There's gonna be scar tissue. And plus, just like you said, I think all of us here like using fat at the same time that we do a facelift to add additional volume.

We want to actually know what their soft tissue [00:19:00] deficit's gonna be. So I dissolve as much of it as I can beforehand.

Dr. Salvatore Pacella: You know, I, I, uh, I, I do something a little different, Samir. I, I, um, I really try to avoid dissolving, particularly in the periocular region. I think it just leads to a lot of lumps, a lot of problems, and that, that, uh, dissolving agent, the holuronidase, um, I've seen it, you know, damage regular tissue, too.

It's not, it's not benign, um, I'm talking about in the eyelid. Um, I think the face is a little bit more forgiving. Um, so, you know, my strategy is really to massage the hell out of it and to wait, you know,

Dr. Lawrence Tong: We've had, we've had a podcast before talking about the longevity of filler. Sometimes these things stay around for years and years and years. And these are, this is in particular with patients who've had decades of a filler, that stuff is not going to go away. So. Um, it can be a [00:20:00] problem, um, because for me, you want to, you want to see what that patient's face looks like.

Sometimes it looks totally different, and, uh, the planning of your surgery would be different. So, um, I agree with, uh, Sam that, you know, melting as much as, you Uh, melting away as much as you can is very helpful. Yes. In the periocular area, it it is, it is more of a tricky thing. And I think what the issue is, is that the hyaluronidase doesn't work unless it actually contacts the filler.

And that the nature of filler is such that the filler is placed in so many different layers of the face that the hyaluronidase can't necessarily contact. They get contacted and sometimes when patients have very. Very sort of mature and old filler. There might be scar tissue around that, that prevents the, uh, the hyaluronidase from, from, um, from contacting it.

So, you know, one of the cautions for viewers is that yes, fillers are a great tool, they can be very successful, but [00:21:00] just don't go overboard with them.

Dr. Sam Rhee: Uh, I'm, I'm in the SAM camp. I do, uh, reduce it as much as possible. I do realize there can be problems. I've had to go back sometimes two or three times with treatments when there's residual filler that just is super stubborn. And I do know I'm risking, especially as Sal said, if you're in the periorbital area, like, that, that can cause problems.

The other thing is patients hate looking like crap when all that filler's gone. Because at least they look like youthful aliens, not just sagging old aliens, so. Uh, it's, it's a little bit of a challenge. Uh, so to finish, what would your takeaways be? Who should you get, be getting fillers from? When do you know how much is not an, uh, is too much from that, uh, provider?

And then when do you know when to transition into like a surgical type of procedure instead? Yeah,

Dr. Sam Jejurikar: I mean, I think there's great injectors that are not physicians, and I think there are bad injectors that are physicians. So I don't think it's necessarily coming down to [00:22:00] what their specific job title is. It should be someone that, that you trust, someone who's aesthetic matches what yours is, someone that you don't feel like is trying to push a lot of excessive filler on you.

In my opinion, someone who values a natural aesthetic, I mean, we're plastic surgeons, so ultimately, we're trying to. Restore what has been lost as opposed to create a distorted or fake, fake look.

Dr. Lawrence Tong: Yeah. To add to that point, if you go into a practice and you see your injector and their face doesn't look normal, or their staff's face. If you like that look, then go for it, but if you don't, then I would probably think twice.

Dr. Sam Rhee: I agree with Larry. See the people around them, the people that they've managed or treated. And I, I would say also. As Sal said, if you're an injector and you have no other treatments, you're going to have, that's the only hammer you got. So I kind of, and I'm biased obviously, I don't have any, um, practitioners associated with me that do [00:23:00] injections.

Uh, I do them, but I would say work, if you work with someone who is also affiliated with surgeons, someone who has people they can refer to, they have, they know the difference of like what they can treat. For And then they have a resource of someone that they know would be more beneficial for that particular condition.

Then I think that's always great. I think if they're a standalone and they don't do anything but fillers and they have no one around them that does anything else, I think that that can be a little bit problematic. Well, gentlemen, excellent discussion. And, uh, I think it's really helpful for people thinking about fillers.

Uh, as well as the next stages after fillers. Uh, I appreciate that. And, uh, as always, uh, thank you so much and we'll see you on the next episode.