EP 17: Maintaining Eye Character | OR DIARIES

In this episode, I explore a question that sits at the heart of aesthetic medicine: what makes someone look like themselves? Using a fascinating patient case involving a former model and actress, I break down why some features commonly labeled as "flaws" are actually defining characteristics that create identity, attractiveness, and recognition.

We dive into facial aging, eye aesthetics, ptosis, scleral show, eyelid surgery, volume loss, and the difference between rejuvenation and transformation. I also discuss the cognitive traps that can lead practitioners to overcorrect natural features, why preserving character matters more than chasing perfection, and how the most successful aesthetic outcomes often come from restoring what was there rather than creating something new. A fascinating look at facial identity, beauty, aging, and the art of natural facial rejuvenation.

CONNECT WITH HOST 
Website: https://clinic5c.com/ 
Instagram: https://www.instagram.com/chesnut.md/ 
YouTube: https://www.youtube.com/@chesnutMD 
LinkedIn: https://www.linkedin.com/in/cameron-chesnut-a6910baa/ 

WAYS TO WATCH/LISTEN 
YouTube: https://www.youtube.com/@5CodesPodcast 
Spotify: https://open.spotify.com/show/1FZ7vpmq21iA1noPcFhixb?si=992ef6c8d859463f 
Apple: https://podcasts.apple.com/us/podcast/5-codes-podcast/id1866214238 
Instagram: https://www.instagram.com/5codespodcast/
 
TIMESTAMPS 
00:00 - Intro
00:45 - Patient Story
01:38 - Sydney Sweeney's Eyes Explained
02:35 - Why I'm Not Trying to "Fix" Her Eyes
05:47 - Another Patient Example
07:46 - My Approach to Aesthetic Assessment
09:12 - Nasolabial Fold Example
10:56 - Outro

ABOUT HOST 
Dr. Cameron Chesnut is the host of the Five Codes podcast and the founder of Clinic 5C, where he leads a team dedicated to integrative cosmetic surgery, regenerative medicine, and functional health. An internationally recognized facial plastic surgeon, Dr. Chesnut is known for producing natural, refined results that enhance rather than alter one’s appearance. His approach blends surgical precision with biological optimization and disciplined restraint, drawing patients from around the world who value excellence, longevity, and holistic care. On Five Codes, Dr. Chesnut uncovers the mindsets and evidence-backed strategies he lives by, helping high performers perform better, recover smarter, and feel their best in every area of life. 

DISCLAIMER 
The views shared on this podcast are my own and are not associated with, affiliated with, or representative of my clinical teaching role at the University of Washington School of Medicine. This content is for general educational purposes only and should not be considered individualized medical advice.

Transcript

Intro

SPEAKER_00 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. Welcome to today's OR diary. These are really fun and special episodes for me. The idea with these is that at the end of my surgical week, when I'm kind of winding down, just step out of the operating room after my last surgery, I get to come sit down and download with you, basically. So these are fun. Sometimes it's a bunch of surgeries, sometimes it's a few. I try to keep my life very compact with the surgeries that I'm doing. I only do one surgery a day. It's very focused. But you get to hear all the things that were going through my head this week. And there was definitely a theme that popped up this week, and it was about maintaining eye character. I had this

Patient Story

SPEAKER_00 0:45

really interesting patient. I hope that we can put it on here so you can see it. This really interesting patient who had been a model and an actress in her younger years and had some very distinct eye characteristics. That would be to that would be labeled as things to fix. And I'm saying when she was like in her 20s, beautiful, had these changes in her eyes. One of them is tosis, sinking of her upper eyelids, kind of like a uh, you know, hooded look to her upper lids at a young age. And then the other one is called scleral show, and that's where the lower eyelid is pulled down a little bit, and you can see some white between the iris and the lower eyelid margin. Those are typically considered things that are aging related, that we need to go fix, that come with time. Um, there are sort of these big bright signals that go off in our head as to, okay, this is a, these are my targets to correct. Her situation

Sydney Sweeney's Eyes Explained

SPEAKER_00 1:38

was actually very similar to somebody like Sydney Sweeney. And I only bring that up because all the time people reach out to me, oh, she has tosis. You could fix her tosis because for some reason, uh, the first time someone learns about tosis, they associate it with her, which is correct. Sydney Sweeney is clearly not having any aging changes that have to do with her eyes. Her eyes are her. Her eyes are distinct. They are very beautiful, they're part of her, they're her signature. It's not something to change about her, right? And this particular patient has something very, very similar happening to her uh over time. Those will be a disposition to how things age. And that's maybe when somebody seeks out having a rejuvenation, going back to who they were, not transforming into something that they never were. That's really important, and that's illustrated very well here. Uh, where I'm not trying to change her to something she wasn't. I would never try to change Sydney Sweeney into something that she isn't. Uh, but over time there will be aging changes on top of that baseline that may lead somebody to seek it out. So it

Why I'm Not Trying to "Fix" Her Eyes

SPEAKER_00 2:35

was very interesting for me with her that I had these beautiful headshots of her in her 20s that you can see here, uh, that show her with these changes at a young age. So this was not something to quote quote unquote fix. I'm not trying to fix these changes for her, which honestly, she would have been very much in danger of having that done anywhere that she went. Somebody would have just saw this thing and said, Oh, I'm gonna fix that for you. But it would have completely changed her eye character. And this gets into my love of neuroanatomy and how we interpret faces, including our own, that would have quite literally changed her sense of identity when she looked in the mirror. She has had years and years and years of now looking, the decades of that, looking in the mirror and recognizing who she is. And if you change the shape of her eyes, if you change the positioning of those to something that it never was, she's gonna have quite literally an identity crisis, which is a very emotional situation. Interestingly, this is very interesting on the flip side of this, when somebody has a lower eyelid position where they do not have scleral show at baseline, and if they have an old school lower eyelid surgery that cuts to their skin and pulls their eyelid down, they get what we call scleral show or lower eyelid retraction. The same thing happens the opposite direction. They have a massive identity issue that is very, very, very emotional. Um, all of my other experts in eyelid surgery can attest to this. Those patients tend to be really distraught when their lower eyelids get pulled down, and that has changed from their baseline. So it's so interesting for me here that we have a flip of that. We're talking about the other baseline. The eyes are starting down, pulled down with scleral show. They're starting with ptosis. Uh it has changed since she was in her 20s now, and you know, three decades later, it's changed. So we're trying to shoot at this target that is not some, you know, textbook ideal, but is her, basically. Um, and I I just can't wait for you to see these results as it comes out because I worked so, so hard and so intricately and so thoughtfully. I visualized through her for so long before I went in there to do this, to know exactly what I was gonna do, how I was gonna protect her previous look, her identity. Her old photos were gold to me, honestly, um, because they told me everything that I needed to know. There's no interpretation other than this is quite literally what she looked like in her. I had pictures of her in her 20s, 30s, 40s, and 50s, right? So at all of these decades to see how things changed over time. Um, and it was a lot to protect her identity, to protect the shape of her lids, to protect the character, her interface with the world that her eyes gave when she has been an actress and a model. You know, this is known, it's out there. Um, and so there was a lot to that, interestingly, um, and how to correct it to the right degree, how to restore things that were there without taking something to some arbitrary baseline, but just restoring her and her identity. So we'll be really excited for you to see that was very challenging cognitively and from an execution standpoint to know exactly how to get that right. Um, and so definitely something I thrive on is that little test in there. Um, the other, so that that was, you know, my big thoughts around one of those procedures this

Another Patient Example

SPEAKER_00 5:47

week. The other one uh is another eyelid situation, but very different in the sense of was a patient who had very hollow upper eyelids. This is one of my, I guess, unique specialties in our world is restoring upper eyelid hollowness. Um, and I use a lot of different ways to do that. One of them is something that I am sort of working with and pioneering and publishing about using a certain type of fascia in a certain way to sort of add some extra volume to the upper lid, but just take that as part of this is a passionate area of mine, restoring that upper eyelid volume. And interestingly, this particular patient had been suggested to have just an upper eyelid surgery alone, to just like have the skin cut out of the upper lids. And I I you hear me talk about this all the time that almost never, I can't say never because I don't love absolutes, but let's just essentially say almost never is just cutting upper eyelid skin out the actual best answer to an overall upper eyelid situation. And I will have expert eyelid surgeons who disagree with that. Um, but I will challenge that because, okay, show me that person who you think is just an upper eyelid candidate. There's no changes in their lid aperture, there's no changes in their forehead or brow position or the soft tissue sitting above the eyelid, it's just isolated to that one point. Seems very hard for me to understand or fathom or believe, really, that there's no changes around it. That would also be like another small lever that would be important to pull if you're gonna pull the big one of just cutting skin out of the upper lid. With a hollow upper lid, this becomes extra special important because it just illustrates that somebody sees eyelid change or aging and they have a one-thought approach, which is cut skin out of the upper lid. When somebody's really hollow in their upper eyelid, there's not a lot of extra skin there. And in fact, taking that, the skin that is there out can make it worse by decreasing more volume from an area that's already missing volume of the upper lid. There needs to be a much more thorough approach, which

My Approach to Aesthetic Assessment

SPEAKER_00 7:46

is what I took with this particular woman. I replaced and rearranged her fat pads that had been sucked back up into her eye socket. I put them back where they belonged. I fixed her tosis. The drooping of her upper eyelid was causing her brain to send a signal to the muscles to try to pull that upper lid up. And so the muscle that does that's back at the back of our eye and it's trying to pull on her upper eyelid. And as it's pulling, it's also pulling all the fat contents and soft tissue contents up. So she's got hollowness from her tosis. She's got metabolic hollowness there from some of the fat pads just being smaller. She's got volume depletion in the sub brow region of the fat of her, it's actually in her forehead and her sub brow area. Um, it's not a skin excess in that area. And so once I replaced all the fat pads, added some fat transfer back, used my fascia graft, fixed tertosis, we had this beautiful volume contour to her upper lid again. And I'm sitting there interoperatively looking at this and going, okay, now let's look at how much extra skin there actually is. And there was essentially none. There was no extra skin to her upper lid. It just that volume content needed to be filled up again. And so as I was doing this, I was explaining this to my fellow that when somebody's really thin and hollow in their upper eyelid and they have just changes in a fold or something that's there, cutting it out, if we think about, you know, taking that same thought paradigm to other areas of our face.

Nasolabial Fold Example

SPEAKER_00 9:12

And a really common one is this fold that goes from our nose to our mouth, our nasolabial fold. People hate that fold. It's actually naturally an anatomic part of us. My beautiful, you know, eight and 10-year-old daughters have some fold there. They're normal to have a delineation, but as we get hollow in this area and it folds over, or as we get sinking of our cheek fat pads and it folds over, there's a bunch of different reasons that this thing can get more deep. Sometimes it's for movement and from smiling. And we need to look at what's actually happening there because if somebody's really got hollowness and sinking and their cheek skin is folding over onto their upper lip, creating this, we're not going to go cut that fold out. That's that's it's just a restriction point from which everything else above is sinking, just like on our eyelid. The crease of our eyelid is part of a restriction plane, literally, where some of the tissue planes of our forehead and temples and lids and even the base of our nose are sinking, and that's like an adhesion point on which it sinks. And we see that across our nose, our upper lids, and into our temple all the time. Uh, it's where a fusion of a few key layers are, but our upper eyelid crease is one of those layers. So you will notice if you push up and down on your forehead that there's more and less volume on your eyelid crease from those things sinking on top of it. Same thing if we talk about the corner of our mouth. So the idea of just cutting skin out of your upper eyelid is analogous to just cutting out your nasal labial fold if you don't like it, which is clearly not the right answer. The right answer is, well, what's happening with the gravitational status? Does the cheek need to be elevated? What's happening with the volume status in there? What do we need to lift off of that fixation point to take things back to where they were? So I think that just illustrates it really well. Um,

Outro

SPEAKER_00 10:56

and I don't know how many people have reached out to me to essentially say, oh man, you saved me from having this upper eyelid surgery, or my friend was booked for an upper eyelid surgery and I showed her your things and, you know, she pulled out and lost her deposit, or, you know, whatever types of things happened. But, you know, she's so grateful that she didn't go through with this because a lot of them are exactly what this woman experienced when she had, you know, the metaphorical eyebrow raise when her surgeon that she was seeing in consultation in her hometown told her, Oh, yeah, we just need to take some skin out, that'll be good as news. She's like, I feel like there's a lot more going on there, which was very much the case and very true. So thankfully she found me, traveled to me, um, and we got that taken care of. But for her, um, when I looked back at her older photos as well, she had the volume change in her upper eyelids was probably the most noticeable. She had a full facial rejuvenation, but the eyelid volume change was probably the most noticeable change that she had had over the decades from her 20s, 30s, and 40s to get to where she was in her 50s at that point. And so, you know, it was just a great illustration to me of like just a uh how the mindset uh approaching this um, you know, with critical thinking and first order and second order and third order thinking uh are really important with the eyes, maintaining identity, maintaining volume. And I had two very distinct uh versions of that this week um that really sort of piggybacked on one another. You can tell exactly where my head's at this week, which is very much on eyelid identity preservation um and kind of doing the right things for eyelids. Uh, but both of these people illustrated that very well. Um, and so just wanted to share that with you. Cannot wait to show you the photos of um the preservation of this particular person's identity. Uh I could you're gonna get to see her photos. Her name is Kaya. Um, and so I can't wait to show those for you. 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. If you would like to learn more about my surgical practice, you can visit clinic5c.com where you will find additional information on my approach to surgery, recovery, and performance focused care. 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.