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I’m back after a short hiatus due to a “zoom boom” in the industry, and for a few episodes, instead of chatting with a guest, I’m going to take some time to discuss cosmetic surgery and cosmetic medicine so that prospective patients can learn a little bit about it. In this episode, I’m dispelling the myths of facial fillers and answering some common questions that I receive about them.
Highlights:
Check out past episodes!
Join us on our website for more information.
Download Podcast transcript
I’m back after a short hiatus due to a “zoom boom” in the industry, and for a few episodes, instead of chatting with a guest, I’m going to take some time to discuss cosmetic surgery and cosmetic medicine so that prospective patients can learn a little bit about it. In this episode, I’m dispelling the myths of facial fillers and answering some common questions that I receive about them.
Highlights:
Check out past episodes!
Join us on our website for more information.
Dr. Torkian 0:01
This is Dr. Behrooz Torkian, and I'm a board-certified facial plastic surgeon in Beverly Hills.
Dr. Torkian 0:06
Join me as I share the secrets in plastic surgeons and beauty professionals alike on achieving beauty for your face. Hi, this is Dr. Torkian with beauty in progress. And as you have noticed, I have not recorded a whole lot recently, because we just got super duper busy with a phenomenon that has become known in our industry as the zoom boom, a number of reasons for it. But we think a couple of them are the fact that people using zoom are more likely to look at themselves in a more critical way. And of course, as you may have noticed some of you when you are looking at yourself in a mirror, or if you see a flipped mirror image of yourself when you didn't expect it to be flipped. So for example, if you take a digital picture and then flip it around so that it's a mirror image of the digital picture. Sometimes it just looks real weird too. So people are starting to notice things in their faces that they didn't notice before. And of course, a lot of people's cameras are coming from their laptop, and it's sitting like on the lower desk. And so sometimes they're catching a video of themselves from a little bit of an angle below what they're normally used to seeing in the mirror, which is either I and occasionally their heads tilted down. So people are coming in for all different kinds of aging-related stuff, which is a really nice segue into what our topic is today. So the agent-related stuff that we've been seeing in this so-called zoom boom, we've been doing a lot of facelifts has been busy surgically. From that perspective, the nose surgeries have also been really busy. I think maybe because people just have more time to recover. And so I'll be doing some specials in the next several upcoming months. Instead of meeting with a different person such as a guest, I will just be talking about some of the things that are happening around here. And some things that are really interesting learning points for patients, prospective patients, or anybody interested in beauty and or in the cosmetic surgery and cosmetic medicine industry so that we can all pick up pearls from each other, we do have some really good guests lined up a few of them are going to be recording with me within the next couple of weeks. And so we'll have hopefully a return back to our normal weekly schedule of having a show and a podcast for you to listen to approximately every week. So hopefully, we'll be back on track with that. It's a promise that I have to make to everybody, including myself, it's really hard to make the time to make these things, but it's working out pretty well. Some of these will also be accompanied with video. And sometimes you can see that video on an Instagram TV or Instagram igtv posts on my Instagram. Of course that is d r t o r k i a n. That's @drtorkian on Instagram. And you can also see those on Facebook as well. So let's just kind of jump in today's topic. I had a patient last week who came in and she had some filler at a med spa that I'm like a medical liaison for. and that word is kind of tricky. There is medical director, there's medical liaison, and of course all Medi spas need a medical director. But in California, we're getting more and more autonomy with nurse practitioners and physician assistants. And so as they gain more autonomy, the medical director will not so much be a director so much anymore, but more of like a peripheral guidance and or a helper of problems. And so as this type of relationship gets worked out, or gets used, what ends up happening is that patients who have been to an injector in a Medi spa somewhere who have a problem when they have the problem first, the nurse practitioners, physician assistants and the RNs working under them initially begin to try to work out these problems for the patient. And if that doesn't work, or if they feel like they've lost the trust of the patient, and they need to bump it up one level or one notch, then they send them to their medical director, which would be me in this case.
Dr. Torkian 4:14
And so this patient came in and said, You know, I don't know what happened. But I've been going to these people for a long time. And I've gotten a number of filler injections, and I've gotten Botox, and I have this party coming up, my son is getting married. And as I prepare for this party, you know, going back and forth and it's so hard on me, I don't have a lot of money and I've been back and forth to them a lot. And so now I've wasted all this money and I look worse and we try to hammer out what really looks worse in this patient. So after reviewing some pictures, we noticed that there were some areas of the face specifically the cheeks that will just overfilled and of course as the medical director and or you know medical guidance of this clinic, I got some information from the nurses that injected her and I was able to see Not just pictures, but also, I was able to see a whole bunch of the past history that she had had. And it dawned on me that everything that had been done for her was with not only the best of intentions but the best of skill. And none of the injections were ever too much. Meaning the number of filler syringes, the amount of filler used, the places that the filler was placed, was just never too much from my perspective. But what happened is that the expectation that was set for the patient that the filler is going to melt away in six months to a year was ingrained into her head as it is in all of our heads, even in the injectors, even in the doctors, even in the nurses that we expect when we see the patient the next time if it's been about nine months or so that they're probably going to need some more filler. Now, are they really going to need a whole syringe of filler to replace each syringe of filler that they had in the past? That is up for debate, I think but you may actually think that yeah, I mean, all that filler is gone, right? So you got to you got to fill it back up again, you got to bring up a whole new syringe and fill that thing backup. It was great the first couple months that I had it. And so what ended up happening is that in this patient, what reality was, which is the reality for most patients, if not all patients, especially after multiple injections, maybe not the first timers, but especially after multiple injections that the fillers don't really go away in the time that we prescribed for them to know when they are really melting away within six to nine months like they should or like we expect them to, they aren't really just kind of click of a button disappearing from the face. But what's happening is that they are getting stacked up on so over the course of about seven or eight years, this patient was getting some filler injections. And about every year or so she was getting a little bit more filler on the cheeks. And she expected after a year it's gone. So I'm going to do more. And so the injectors and of course they want to help her, they want to help her see through some of these changes she's seeing with aging and the drooping of the cheeks and the little cheek trough that happens that makes your eyelids look sunken and nasal labial folds look deeper, and so on. And so they ended up adding some more filler, but it ended up stacking up and over the course of about that seven to eight years, she went through a really critical time of aging as well, meaning she had this stuff in her, but she was still aging, it's kind of like if you had a bandage on an area of skin that continue to age underneath that area of skin, that skin is going to look different when you take the bandage off if you left it there for about eight to 10 years, right. So she continued to age and the fillers and Botox treatments and so on that she was doing, were actually trying to keep up with that aging process. While they were stacking up and becoming more and more and more and more and then all of a sudden it reached this critical level where she noticed it by looked at the pictures. I noticed it beforehand, but it wasn't apparent to the patient until it got to a certain level where she just said oh my god, what did she do to me? I can't go back there anymore. I have to get this stuff melted away whatever it was she was thinking she was really bothered by it all sudden, and so by the time I saw her you know all trust is out the window. It is a crying game at this point. It's you know, a lot of tears. How did I let myself get like this? How did they do this to me I've been such a good client to them and so
Dr. Torkian 8:39
on. And of course once I showed her how she actually had been allowing this filler to stack up over time and she had been allowing the filler to be done in the same parts or maybe even asking for it to be down in the same areas. That filler was placed before that hadn't yet gone away. She didn't really understand what was going on. She just thought that somebody did her wrong on the last treatment that she was at this place. Long story short, she had some of it melted away. I plan on melting more of it away. And we started to inject some some melter and we immediately saw some of the improvements that she could get with melter and she was already seeing some of the improvements that she got with melter from the melter that the initial nurse injector had done for her and we started to kind of get her back on the right track. A lot of times people say to me like you know don't put too much because I don't want to look back that cat lady or you know, whoever they don't like the appearance of because there's they feel like there's way too much work or way too much filler done and I always remind them you know, you're gonna love your first few injections. Just remember let's not go overboard on either on any of them after this because what ends up happening is that you like it so much and you start seeing it change whether it's your aging process or whether it is really going away and decreasing in volume, the filler from The original results that we got. And so you start to kind of want more, you know, you almost get hooked on the effect of the filler, or the feeling of that improvement that you got until one day that all of a sudden becomes too much. And it just doesn't work for you anymore. And then you realize, Oh, my gosh, how did I get myself in this mess? It was one of those days that it really brought everything that I believe in, in my practice together. Number one, do what you need. But don't do more than what you need. That's really important. Number two, you really got to know that you need to inject something, or operate on something or try to make an improvement on something in someone's face before you jump into it. As the surgeon as the provider, there's been plenty of times where people came to me and they said, This bothered me, I looked at him and I said, Well, if it bothers you, I understand I will do what I can to help you through it. And to help you make it so that it doesn't bother you anymore. It looks better to cosmetically aesthetically so that it doesn't bug you anymore. But I really don't think you're ready and I turn them away, or I really don't think surgery is the right thing where I don't think injections can get this, and I let them know that they should just not do anything. Sometimes I tell them you're not ready, or this is too much, or this isn't gonna help. And I try to basically get people to just wrap their head around what they have and what they've been dealt with and be comfortable with it first before try and do anything on that a lot of times I'll see the problem. And I agree with the patient, and I know that I have a fix for it. In those cases, I say, look, this is something that can help you. And I guide them through the process of understanding how it can help them and then we make the decision together whether to do surgery or you know, injection or whatever it is whatever treatment we have for it together. But patients who I have told before you don't need anything, or you don't need anything right now have always come back to me and had a little bit of something done and been happier with it than if I would have just said, Yes. Remember, you came in with your friend at one day and I did fill on her cheeks or I did her nose operation or whatever. And she was so happy, you can have the same thing. It doesn't work that way for everybody it's different for every face is different for every personality, and everyone really needs to have all the right intentions for the treatment that they're about to get into before they get into that treatment to avoid problems. That's kind of how it works. So one of the problems we get with fillers is that it does stack up but it becomes a little too much. And let's talk about some of the other problems that we can get with fillers just since we're on this topic. fillers are essentially exactly what they are named, they just fill up a space, that's all they do, they have sometimes the tendency to induce collagen formation in your body. So a lot of the times when people are advertising a quote-unquote cosmetic filler or dermal filler that can last longer. For example, or Sculptra, or Bella fill, these are both products that can last a little bit longer or that have a little bit more rigidity such as radius, those things actually can have some of their results extend even over longer periods of time for some people because they induce collagen formation in your body. And as you know, the collagen in your own body is going to be a little bit more stable than a foreign substance that has been injected that is meltable. In addition, some of these products do have permanent materials in them, such as Bella Phil bellafill, has permanent pmma or polymethylmethacrylate beads in it. And so it can actually give long term results. So now let's step back a little bit. And remember that patient that I was telling you about a few minutes ago,
Dr. Torkian 13:39
her face continued to age around this filler, right it continued to change around the filler and the fillers were being done on a regular basis in-office visits that the patient had with providers. And there were little adjustments being made to the way that the fillers were done so that they can keep up and camouflage those continual signs of aging that are happening. That process can't really always be performed with a filler that is almost permanent in the body, or has permanent materials mixed into it such as pmma. And so with great care with great, great trepidation, I recommend pmma fillers for certain areas of the face. But usually those areas that I'm filling in with pmma are areas around the bone in the jawline or the bone and the cheek. So what we noticed in patients who age is that their bones slowly thins out in the face. And there's a couple of studies that have shown that the bone changes that occur on the face are the result of pressure on the face from the muscles that are attached to the bone that move the bone of the face somehow or move the skin of the face somehow. For example, muscles that are attached around the eye socket can draw the eye socket outward and make it enlarged because the muscles that are attached to the eye socket and around the eye socket in the upper part of the cheek that help you smile are pulling it in that direction. And so over time, the bone remodels in such a way that it gives way a little bit in the largest or the eye socket and largest as the bone is being remodeled. There's also a change in the angle of the jaw where the angle of the jaw right at the kind of bottom-most angle, just drop down from your low is actually getting smaller over time. And that happens most likely because there's a couple of muscles really strong ones that attached to it that you chew with. And you're constantly chewing or grinding or somehow moving your jaw as I happen to be doing right now as I yap away that's constantly putting pressure on the bone. And that bone is remodeling in response to that pressure in response to that tension that the muscles are exerting on it. And so putting some filler that's going to be a little longer lasting on that bone is actually not really going to hurt anybody in the long term, because they'll probably just need additional in that same area. That makes sense, right. So in cases where I'm using pmma, it's almost exclusively in that fashion, I never recommend injecting it into scars, although it is FDA approved for scars and I hear that it can do a nice job. I just don't trust its long-term capability, as the skin thins as the connective tissue thins, and as the fat dwindles down and reduces in the face, most likely that stuff is going to show up in some not-so-nice way. Not that it's a bad part. I love the product, I just don't like it for those particular purposes in my practice. So filler is only fill in a space and or sometimes gray collagen. But if they're just filling in a space, we have to imagine what it is that requires expansion or filling or rehydration or plumping up in that area of the face that we're injecting. So areas of the face that typically tend to have decrease in volume are the middle of the cheek or the mount of the cheek. Some people call it the apple of the cheek, which is where fillers can do a really really nice job filling up and replenishing volume or replacing volume that has kind of decreased because of fat melting away in that area or even bone changes also in the tear trough which is the area just underneath the lower eyelid that shows as kind of a dark circle sometimes it's just a dark shadow pigment being put aside and color changes in that area being put aside it casts a little bit of a shadow that looks like a dark circle under the eye that area as well. So those two areas in my practice are two of the primary areas that I use fillers for. I also use fillers for the nasal labial fold in some cases because the nasal labial fold as the muscle keeps pulling on it and as a connective tissue and skin changes occur with age seems to look a little bit deeper. Now filling the cheek mount the apple of the cheek on some occasions can make the nasal labial fold look less deep. In reality, it's not plumping up the nasal labial fold is not really pulling up the nasal labial fold as you would with your finger. If you were to pull your cheek up towards your ear, all it's really doing is creating a situation in which there doesn't seem to be as much weight or heaviness on the nasal labial fold. And it's kind of hard for me to show unless you're seeing it in a video or in a picture. That's the best I could do with words. And of course, if you're ever in the office here, I'd be happy to show you with my fingers. That area to me is probably the primary place to treat because a lot of people when they come in and they see the signs of aging, the first thing they point to is their nasal labial fold the smile line around the lips.
Dr. Torkian 18:38
The other area that I feel loses volume that people have legitimate volume changes and is the lips and I love doing lip fillers because I feel like you can restore the contour of the nasal labial angle by bringing forward the upper lip. In patients, as they get older, they seem to have like an elongation and a shrinking down of their upper lip, and the upper lip sort of falls backward. And so filler in the upper lip can really help build this back up It can also help get the vermilion border or the lip border to stand back out again. And of course, when you look at like younger photographs of most people, most people both men and women have much stronger vermilion border as they're younger. And they start to get thinner and thinner in their connective tissues and all the movement in that area probably accelerates that process and as that happens then the lips thinned out too. And so it really helps to put a little bit of filler in there. Can the lips get overfilled? Yes, pretty quickly for really the same reasons we were discussing before. Sometimes too much of a good thing sometimes a stacking of filler that we expect has gone away. As a matter of fact, just today I had a patient that came in a young lady who was only 35 years old, and she's been having lip filler for a long time and she had made an appointment with me a year exactly after the last injection I did on her lips. And she said, I feel like it probably should go away by now. Right? And I looked at her and I said, Nope, it looks great. And she said, How long is this stuff supposed to last I said, I probably told you six months. But it's been a year, and it's still there. So we didn't do any, we just touched up a little bit on the lip border, so that you know, the border of the lip or the vermilion border could stand out. And she needed a little bit less lip liner. And that was it. So you know, I hate to turn you away and not give you fuller lips. But when you already have fuller lips, it doesn't make sense to keep adding to it right. Last thing I want is for them to be too much. This is what's happening with the fillers, quote unquote, they're just filling up a space, they don't really pull on any tissues upward or downward migration of the filler is something a topic that is really still to this day, not really fully understood. But we believe that most of the time migration does not happen very easily or automatically. Sometimes the fillers are placed and immediately pressures placed. If that happens immediately afterwards, when the patient goes home, and they're laying down, for example, facedown on someone's massage chair, after I inject them, then yes, they can get some migration, they're filler. And over time with muscle movement, and so on, there might be some migration. But really, in general, we don't expect that to be too much of an issue until the filler start to get almost completely dissolved in the body. And what happens during these times is that the hyaluronic fillers, especially such as Juvederm, wrestlin, teoxane, and any other hyaluronic acid, filler revanesse, any of those that you pick, as they're going away, the hyaluronic acids are getting chewed away by your body and your body starts to allow water or kind of kind of infuse water into the area where the hyaluronic acid was. The reason is that the hyaluronic acid in these fillers, it's kind of like a sponge, it's very hydrophilic, it likes water, so it absorbs the water and sucks it into its own structure. And when it does, as its aging, as it's getting older, and the hyaluronic acids are melting away, it becomes a little bit more hydrophilic. And so sometimes it can puff up a little bit more, and therefore be softer, and then dissipate a little bit from the area that it was injected. So it spreads out a little from the area that it was injected. And that can be one form of migration. The other form of migration that some people have mentioned and seen and observed is that occasionally as your body's starting to melt this stuff away, your lymphatics are also trying to carry it away, and get it into the bloodstream, process it and excrete it and get rid of it right, as happens with pretty much everything in your body that is renewable and refreshable such as your own proteins and some of your own connective tissues. And so as this is happening, the sticker material of the hyaluronic acids that has absorbed all this water that happens to get into the lymphatic seems to get clogged up in the lymphatic sometimes. And so the lymphatics being usually downwardly positioned in their orientation, going from the upper part of the face down to the lower part of the face and into the neck for ultimate entry into the bloodstream. They happen to get sometimes a little bit more filling effect in the lower part of the face. And so while there's another theory on how migration can happen, does it happen? And everybody? Probably not? And I would say, most likely, no, it's probably happening at the same time that aging is allowing some drooping in the lower face anyway. And so sometimes it can be confused with that as well. And most likely, is just not happening in patients. Anyway, overall, I think filler stay pretty much where you want to be. And they very, very slowly over time, get dissolved, and they go away. And so that is my thoughts on a number of different topics surrounding fillers. Number one, how do we get over done? Number two? Is it migrating? is it changing? Do I need more on a scheduled basis? Those are pretty much it. I also have been asked very often this is one of the questions that comes up all the time in the office, is this going to make me age faster? If I don't want to do it anymore? And it goes away? Am I going to look older? And I tell them the same concept is what we've been talking about? No, you were just going to be aging underneath the band aid, right? Phil is going to be in you it's going to look great. And then as you age, if it goes away in that time period, then you will notice the aging again. And so you may be at a more advanced stage of aging. Of course if it lasts a year, sometimes when you're in your late 40s or early 50s a year can actually make a big difference in the face. So unfortunately, there is kind of like a acceleration of aging that's happening anyway and it happens around the same time you're using filler. That's why you're looking for it. Number two, can I use this to prevent the aging process? And the answer is no. fillers don't really prevent the aging process but because they do stack up and if they're done properly and if they're done with great care and exercising real caution The amounts that you end up adding up, then the stacking effect. And the effect of increasing without wanting it, if you kind of use it to your advantage can actually have a very beneficial effect on people.
Dr. Torkian 25:11
And so those who get fillers on a regular basis over time will look better than those who are the occasional filler treatment people. That's something we have seen. And there have been some papers published by some of my colleagues in San Francisco area on that topic. And then another topic that comes up is Botox. Can Botox help me prevent aging? In my face? The answer to that is yes. Botox has become more and more common in the younger age group because they're more comfortable knowing that their moms and their older sisters had been getting it in there. Okay. All right, and they're fine. They are more comfortable with it. It doesn't seem like as as much of a taboo I don't think anybody's really that concerned worried about you know, Alzheimers and that kind of weird stuff happening from Botox anymore. I mean, we've had these products FDA approved and use for over two decades now maybe even longer. And we have not been able to show any correlation with any of those neurological diseases and Botox, but we have been able to show a correlation between less wrinkle formation on the forehead and in the crow's feet area with regular use of Botox, and so voila, yes, you do have something that can prevent lines in the face and prevents the appearance of aging skin and aging face of course, the color will continue to change and it'll continue to thin out but at least the lines will be better with continued and repeated use of Botox. So I hope that answers some of the questions that people have about fillers and Botox and dispels a few of the myths here and there. I plan to come back for a dispelling of the myths of facelifts and what it means to have a facelift. And is every facelift created equal? Is every facelift going to make me look stretched and pulled? And my favorite thing of all, I don't want that Beverly Hills look, people tell me now My office is in Beverly Hills. And so I don't really know what that Beverly Hills look means. People who who say that, but I will dispel some of the myths of facelifts which I think can be one of the most satisfying procedures for both physicians and patients alike. I think a lot of people get excellent, excellent results that for a long, long time that can be very happy with and I'm a big proponent of faceless overall. So that'll be our next episode. In the meantime, if anybody has any questions that they want answered in these sessions, where I do not have any guests where it's just me talking, you want to pick my brain you don't want to come in for a consult and you just want me to answer some questions for you. Please feel free to contact me reach out to me on Instagram @drtorkian. And of course, you can reach out to me on Facebook with that same handle. Please don't forget to follow me anywhere you get your podcasts including Apple, Spotify, or Amazon.
Dr. Torkian 27:58
This is Dr. Torkian for beauty in progress signing off. great having you all with me again and I'm glad to be back. We will see you again next week.
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