Fill'er Up: Injectable Fillers in Plastic Surgery

Nipped and Toxxed Episode Take 2, Episode IV Fillers - Now streaming on Spotify, Apple, and Google Playlists

Katie: Welcome to nipped and Toxxed. Which episode is this?

Ashley: Four!

Katie: Episode four. It's all about fillers -fill 'er up. 

Ashley: Hi, I'm Dr. Ashley Robey. I am a quadruple board certified plastic surgeon certified in plastic surgery, facial plastic surgery, otolaryngology, and anti-aging medicine. And with me is Katie Reichart. 

Katie: And I am a CPCP and a permanent makeup artist. I think the last episode I was too nervous. I was like, I'm a makeup artist. I'm like, no, not I'm a permanent makeup artist. 

Ashley: Permanent. It's something different. 

Katie: I tattoo people's faces. 

Ashley: Well, you were saying that there are only how many CPCPs in Indiana?

Katie: There are only three. 

Ashley: Yeah, that's pretty cool. 

Katie: I know. Right. 

Ashley: And I think I'm the only one in the world with my certifications.

Katie: I had never even heard of anyone having a quadruple certification. Having three is pretty amazing, but having four...

Ashley: When I had three, I was one of 13 in the world. Now, I think I'm one of one.

Katie: I think that's pretty amazing.

Ashley: So today we're talking...

Katie: let's talk about filler fillers. So really what is a filler? 

Ashley: Fillers are things that you use classically to add volume to something. So we're talking about fillers in the realm of aesthetic medicine, and they can be either permanent or temporary. And they're injected.

Katie: So where's the most common place to have filler. I personally love filler. I'm all about filler.

Ashley: Well, definitely the face. I mean, you can put fillers most places, but the face by far and away is the most popular location. The most common, temporary filler I use falls into that HA or hyaluronic acid filler category, but I'll also use things like Radiesse or Sculptra. And then for permanent fillers, fat. That's my go-to permanent filler. 

Katie: So with HA fillers, since it's not permanent, what does that mean? I know you can dissolve it. 

Ashley: That means that your body will degrade them. So whether it's the HA filler or the Radiesse or the Sculptra, they're all temporary. And so your body will break them down and absorb them. And depending upon which filler it is, that timeframe is a variable. Some of the ha fillers, especially in some really mobile areas could take as little as six months to go away. But others, it's closer to two years. 

Katie: So is it about viscosity? Is it about how hard the fill is? Cause I know like you use softer fills for your lips, use harder for your cheeks. 

Ashley: You mean as far as duration?

Katie: How long it takes to break down

Ashley: A lot of it can have to do with, for the HA fillers, the degree of crosslinking and how long it would take your body to break down that product.

Katie: So depending on the person. What's crosslinking?

Ashley: So just the way that the chemical is actually synthesized. 

Katie: Okay. 

Ashley: How many crosslinked bonds are placed within it. But yeah, the other variables that you're talking about with regards to pliability and viscosity and how much strength is in the product, those are definitely characteristics that come into play when you're thinking about where do I want to put this product? For example, in the cheeks, you may want something that has the ability to add a lot of height. 

Katie: Right. 

Ashley: And maybe it's a little more firm because you want that kind of bone cheek volume, but you wouldn't want that same kind of thing in your lips.

Katie: Right.

Ashley: So the cool thing about the hyaluronic acids is that most of the companies that make them have a portfolio of products so that you can tailor exactly what product fits which location best. 

Katie: So I love a good cheek filler. 

Ashley: Yeah. 

Katie: And so I usually get it every, I'd say two years to 18 months, so it's probably been probably two years. Am I safe to say that it's completely gone or can you go up to somebody and you can feel it's still there?

Ashley: Probably most of it is gone, but I would say in my experience, sometimes there are smaller amounts that linger beyond that timeframe. And I'll notice it in some areas where you'll have a really obvious bump, like let's say, in a liquid rhinoplasty where you'll see someone's cartilage curling, and you'll see a really defined transition at a certain location where like, wow, look at that shadow. Look at that protruding cartilage. I've seen adding some of the HA fillers to those locations that even beyond the two years, although it may not be as good as it once was, it seems like it's not quite as bad as baseline. 

Katie: Right. 

Ashley: But yeah, around two years.

Katie: And does it depends on the person's metabolism, so people metabolize it better than others I mean faster.

Ashley: Faster, which would probably be worse. Right? Like you don't wanna be a fast...

Katie: I wouldn't wanna a metabolizer. I think I'm a slow metabolizer. 

Ashley: I burn through a Botox pretty fast.

Katie: I'm pretty good on Botox. I'm like four months.

Ashley: I'm like 89 days. 

Katie: I just need to come in here and just get shot up everywhere. 

Ashley: Yeah. So filler the face is the most common location, but within the face, I would say cheeks and lips are the most popular. but really you can add it to a lot of locations. I like adding it to the tear troughs, which is that area where you're seeing the dark circle under your eye.

Katie: Wonders under the eye. How do you know if you're a good candidate for that or not? Because some people are not good candidates for tear trough filler and some are. How do you know when you look at somebody, whether or not that's gonna work for them?

Ashley: Well, if you have an area that looks like a volumetric depression, if you're seeing some fullness above a line and some fullness below and then a depression in between mm-hmm then adding volume to that depression can look really good. 

Katie: Oh, definitely. I'd love the before and afters on the eyes. 

Ashley: Yeah. 

Katie: And how do you know if you are a person that needs surgery and that, you know, filler's not gonna be enough?

Ashley: Filler is good at volume replacement, right? And if you have some degree of loose skin, sometimes replacing that volume can fill that skin out a little bit, but if you have a substantial amount of loose skin, then there's probably not enough filler to re drape that skin.

Katie: Mm-hmm . 

Ashley: That doesn't mean that you're not a candidate for filler. It's just, it comes down to. Meeting patient's expectations. If you're saying, Hey, there's no way I would ever want to have surgery. What's my next best option?

Katie: Right. 

Ashley: Then I think it would be reasonable to do things like filler. But for some people that's all they need. So it can be really patient dependent.

Katie: So let's talk about lips. 

Ashley: Sure. 

Katie: What is your favorite product to use on lips? Cause there's all these things out there. There's Restylane Kysse there's Voluma or Vollure?

Ashley: I use both the Restylane line in the Juvederm line .

Katie: Uhhuh 

Ashley: so the Restylane Kysse is pretty popular in the lips, and then we use a fair amount of Vollure in the Juvederm lines.

Katie: is that basically the same thing? Just different brands?

Ashley: I know that they would say no. There are differences other than just the name, just like Pepsi and Coke or different other than the name, like they have different whatever ingredients, et cetera. So there are differences, but there are certainly things that are overlapping with regards to where you can apply that product. 

Katie: So I've also seen that the products for lips have lidocaine in?

Ashley: Yeah.

Katie: Is that true of all of them? 

Ashley: That seems to be the trend. When they first came out, it was almost an exception for the product to have lidocaine added, and now I think it's more of an exception for it to not be there.

Katie: Right. 

Ashley: So yeah, people like it to be numb. 

Katie: I had a client that has a lidocaine allergy. Okay. And so I was tattooing her lips and I was asking her about when she had a lip filler and she said well, it cost me more money to get the lip filler without the lidocaine. And I'm like, really? That's so interesting. I actually gave her number. I'm like, go see my friend.

Ashley: I'd have to look and see because I feel like we almost universally stock the stuff with lidocaine. 

Katie: It's not like it's hard get right? 

Ashley: No, you can get it just that you'd have to know beforehand.

Katie: You're gonna numb the lips with a topical all over anyways. Why would you need the lidocaine inside?

Ashley: It helps. it makes a difference

Katie: I guess I've never had it without, so I don't really...

Ashley: okay. 

Katie: Yeah, but I've always been numbed. 

Ashley: Sure. That's unfortunate. That's a rare thing.

Katie: Right? 

Ashley: Mm-hmm 

Katie: I feel bad for her. 

Ashley: Yeah. 

Katie: I had to do her whole tattoo of her lips with no numbing but it looked really nice.

Ashley: The lips would be more sensitive than other body parts, certainly. Most people that get tattoos don't get numbing. 

Katie: Well, that's also about different locations in the body different pain, but also it's about how much it costs. A lot of tattoo artists don't wanna do it cause its costs a lot of money. 

Ashley: Oh sure.

Katie: It's like $50 for two ounces, so imagine you're doing a big area. 

Ashley: you can go to CVS or Walgreens and get those lidoderm patches, right? 

Katie: Who wants to be in pain? 

Ashley: Like maybe a few like sadistic people?

Katie: Right. 

Ashley: Or that would be masochistic. I'm sorry. 

Katie: You're right. 

Ashley: Yeah. I'm confusing my S and M terminology.

Katie: We'll get into that later. 

Ashley: Yeah. That's episode five. 

Katie: I dunno about that. That has nothing to do with Nipped and Toxxed. 

Ashley: No, it doesn't. 

Katie: Okay. So as far as lips go, there's lots of different trends with lips. So you see like Russian style...

Ashley: Yeah, you were talking about that.

Katie: You see you know, different ways of injecting lips.

Ashley: Mm-hmm, , there's definitely different techniques. 

Katie: Yeah. What do you say about all of that? 

Ashley: There are some universal techniques that we utilize. To some extent, you're kind of working with what you have.

Katie: Or you're building?

Ashley: Right. 

Katie: Somebody comes in, you're like, okay, we're gonna start with this. If you're come back, we'll add more.

Ashley: If you're starting off with a certain look, you could only push it so far in a different direction, especially at one time but, depending upon what the patient's starting with, it's volume addition and adding height, adding width. Mm-hmm just depends. 

Katie: So let's talk about volume loss. How much volume are we losing in our faces year to year? Because, I keep telling all of my friends I'm like, you look, you are going to need filler. You are losing volume in your face. They always look at me and they're like, you don't look overfilled. I'm like, yeah, I know. Cause I'm just putting back what I've lost. 

Ashley: So every decade we age, we lose about six to seven CCS of facial fat volume. So that really starts adding up, especially if you've never had anything done. So replacing volume is really helpful to restore that young look. The other thing, apart from the HA fillers is Sculptra.

Katie: So, I'm super interested in Sculptra.

Ashley: So Sculptra is a collagen bio stimulator. So you inject this absorbable polymer that your body degrades and gets rid of, but in that process, your body lays down more collagen. 

Katie: Right.

Ashley: So after the...

Katie: so it's kind of like a really natural approach?

Ashley: I mean, you don't have, you don't have polymers in your face transiently, right?

Katie: Right. But that goes away in the left with the collagen, right?

Ashley: Absolutely. The goal is to restore the collagen levels toward a more youthful level. So by the age of 40, you've lost about 25% of your collagen. 

Katie: Wow. 

Ashley: I know.

Katie: That's wild. 

Ashley: So a lot of people will mix those together. They'll add the Sculptra not only for volume, but for stimulating their own collagen levels, and then they'll come back later and add the HA filler to specific areas where they really want to target and enhance the volume depletion. 

Katie: So I saw Sculptra being used in the nasal labinoidal folds. 

Ashley: Labial. 

Katie: Whatever. Whenever we go labial, I'm thinking of our first episode. 

Ashley: They're lips. It's like oral lips, vaginal lips.

Katie: So I feel like this is a big aging spot on a lot of people, you know, so I saw it being used there. And I thought that is really interesting because I like getting fuller there. But a lot of doctors are scared because of that major vein right there.

Ashley: You have to be thoughtful and considerate about anatomy. Absolutely.

Katie: And you definitely wanna go to someone that knows what they're doing.

Ashley: I should think so.

Katie: Right. 

Ashley: Don't go to someone's garage.

Katie: What are your ideal places to use it, anywhere? 

Ashley: Sculptra? 

Katie: Uhhuh?

Ashley: So it's supposed to be injected in a subdermal plane, so underneath the dermis

Katie: You're getting down pretty low...

Ashley: but some products like Voluma, you're injecting it supraperiostial. So just on top of the bone, so this is gonna be. A little more superficial than some of those types of injections.

Katie: Okay. 

Ashley: Because you are trying to stimulate collagen growth, which is going to be in the dermal layer. 

Katie: Right. 

Ashley: To restore collagen levels and to try to improve tone and, and volume associated with aging. So are there different firmness of Sculptra or is it all one?

Katie: It's one. 

Ashley: So the interesting thing about Sculptra, and I think that anyone that's going have a Sculptra injection needs to be well aware of is that you're injecting poly-L-lactic acid microparticles. Your body will break them down and in the process of doing so induces an inflammatory response and creates more collagen. The Sculptra is mixed with sterile water at the time of your procedure. And so that water is a carrier, meaning the water component, your body's gonna absorb it. It's gonna go away in the first couple of days. So you'll see an initial volume improvement, but that's because you've just injected your face with a bunch of water. Okay. So let's say you're doing two vials of Sculptra, so 18 CCS of water. That's a lot of volume to add to someone's face, but ...

Katie: But then the water goes away.

Ashley: It's absorbed. 

Katie: So how do you equate that to how much volume it will add to your face? 

Ashley: Classically, for Sculptra ,they talk about percent increase in collagen, so the net volume is going be a function of where you're starting from. 

Katie: Okay. Yeah. So how deficient you are.

Ashley: It's interesting because for the HA filler, you add two CCS of HA filler, you get two CCS of volume. 

Katie: So, if you're looking for the after effects of Sculptra, how far out do you need to be injected to then see the...

Ashley: it's about two months before you're seeing what you got out of about treatment.

Katie: So if I might got an event, I wanna wait two months, two months before. My birthday's coming up.

Ashley: To see the full impact of it. Right?

Katie: Right.

Ashley: But that doesn't mean you can't go to an event prior to that you just won't see the full results. So more for your event is, are you ridiculously swollen or bruised? And that probably, I would say a couple weeks just in case

Katie: do people mostly bruise with this? 

Ashley: No, there's always that oddball that gets really bad bruising. Yeah. 

Katie: It's like any other injection, right? 

Ashley: Sure. 

Katie: Okay. So let's talk about Radiesse. 

Ashley: Oh, sure. Calcium hydroxy appetite. 

Katie: Yes. I've seen radius use a lot on bony structures when you wanna create a really nice angular cheek bone or jaw lines.

Ashley: You're trying to recreate bony support or restore some of the bony loss that actually can occur with aging as well. Those are popular areas that people add Radiesse. I don't do a ton of Radiesse in my practice. 

Katie: why is that? 

Ashley: there are so many options and from an end result perspective, I think you can get just as good a result with other products. 

Katie: Gotcha. And you can't dissolve radius, right?

Ashley: That's one downside. But Radiesse can last up to two years, which is appealing.

Katie: I like that. I have noticed I had Radiesse one time. I did notice. I felt like it attracted more water. So I felt a little more swollen, and I didn't like that look because when I had it in my cheeks, it kind of made my eyes feel swollen. So I didn't love that. 

Ashley: long term or just transiently?

Katie: It was a couple months after. 

Ashley: oh. Huh.

Katie: So from then on I went to Voluma. And, I think that a lot of people like to use HA fillers in general because they can dissolve them if there's any complications, right? 

Ashley: Yes. There is a hyaluronidase, which is an enzyme that can be used to degrade fillers. And interestingly, I have been working with a neuro interventionist to develop a protocol for emergencies associated with filler maladventures I have never, myself, had a serious complication, but it's certainly been reported in the literature. Mm-hmm 

 So if you inject a filler into a vessel, instead of blood flowing through the vessel, you have filler occluding it, there can definitely be problems.

Katie: Right.

Ashley: So if that vessel is feeding your eyeball, it can result in vision loss. If that vessel is feeding, let's say the skin of your nose, you could have skin loss.

Katie: Which is why it's also so important to find an injector that knows what they're doing.

Ashley: I think so. Yes, absolutely. That's certainly eyeopening, right. When you're talking about consent and weighing out the pros and cons of fillers, when you throw that out there to patients, oh, well there's a small chance you gonna go blind. That's pretty disturbing. So whereas it's extremely rare. So current protocols are, let's just say someone does that... They inject filler into a vessel that's feeding the eye and, and the patient has vision loss. The recommendations are to inject a bunch of hyaluronidase, which again is the enzyme that can break down the filler, right around the vessel. And my thought is, let's get it into the vessel.

Katie: Right. 

Ashley: So doing an interventional radiology procedure where you can cannulate that vessel and get the degrading enzyme exactly where you need it. 

Katie: So would it be you go to the emergency room and they would have that? 

Ashley: Yeah, you would go to the ER and we would have to get that whole process going expeditiously. You have basically have like 90 minute. 

Katie: Oh, wow. For the eye area. Cause I know I've seen on the internet where some people might get it, you know, around the nose and 

Ashley: it's a true emergency. 

Katie: They might leave though. And they don't know that they have an emergency, but then they start to have necrosis and start to have issues. And if the injector you went to is not prepared, does not have the solution to like dissolve it, whatever. Then you're in a really tough spot. 

Ashley: I'm not sure that everyone keeps hyaluronidase. I would hope so, but I certainly would not assume that .

Katie: No, I wouldn't assume that either, which is why, again, you wanna I'm neurotic, and I always go to a plastic surgeon because I wanna make sure someone has got things ...

Ashley: knows what's going on. 

Katie: And you know, a quadruple board surgeon, plastic surgeon I know is going to so I think that's one of the things though that people need to be aware of. And also when looking for an injector, a lot of people have, you know, as, as do. befores and afters mm-hmm, where you can really look at what someone's work looks like instead of just...

Ashley: what's the cheapest price per vial. 

Katie: Exactly. Don't look for the cheapest price. I mean, of all, for anything plastic surgery...

Ashley: people do though.

Katie: I know, but it's then you're gonna pay more to have it corrected. It's just like a bad tattoo. You're gonna pay more to get it fixed. 

Ashley: I know. 

Katie: but you know, I think that it's big to do your research. A lot of people have Instagram pages. You can see there before and afters. But also check out the person's credentials and make sure they are who sure. the other thing I was gonna say about Radiesse is I've seen it used hyper diluted sure. In like neck lines. Okay. And in hands mm-hmm and things like that. And I thought that looked kind of neat.

Ashley: You could do the same thing for all the fillers. And I've used HA fillers in both neck lines and hands and, and you could do it for Radiesse. 

Katie: So there wasn't a reason that they used radius hyper diluted? I don't know.

Ashley: If they wanted hyper diluted, maybe they just wanted better dispersion.

Katie: Okay. So another popular filler I'm saying is the jaw line. 

Ashley: Sure 

Katie: Because it's all about the snatched jaw. 

Ashley: I know -everything's snatched. 

Katie: Everything's snatched these days

Ashley: snatched waste is still in, but ...

Katie: exactly everything snatched up, but as far as jaw lines go, what's your favorite kind of filler and how many syringes is someone really gonna need? I mean, it's not just like a one syringe deal. 

Ashley: Probably not, but I suspect you could probably see results with a couple syringes. So the most common thing that people will do for that jaw line would be, so people have jowls, which is that little hanging thing, right. Just below the corner gel.

Katie: And you're starting to sag a little.

Ashley: Yeah. If you have that little bit of fullness or even hints of it, you are adding some volume just in front of and behind it to smooth it out and define that nice jaw or mandibular border. 

Katie: And what about where you take it all the way back by the ear and create you a nice little angle?

Ashley: So to build up the ramus and angle of the mandible. 

Katie: Yeah. Or even the chin... more chin projection. I don't know what it is, but I feel like my chin is recessing. Is that normal? Maybe I'm just not 20 anymore, but a little bit of chin projection changes your whole look. And aesthetically you're looking at someone you're looking at, okay, what do we need to do to balance out their face? If someone comes in and they never had filler, how do you address looking at their face and everything?

Ashley: Prior to any filler treatment, you're going do a comprehensive facial assessment. That starts off with examining the patient's face, looking at symmetry, looking at areas of relative volume deficiency, relative volume excess. There are some aesthetic norms and ideals that are considered when you're evaluating someone's face. And then you'll think about those things as you're trying to figure out what can I do to make this person look better? 

Katie: I notice a lot when I'm looking at people's faces, one side is flatter than the other and a lot of times I ask them, do you sleep on this side? 

Ashley: You told me this. 

Katie: For example, I sleep on my left. So my left side is a little bit flatter. So whenever I go get filler, I'm like, Hey, fill up the left a little more, puff me up a little more. And then now I've tried to rotate. Now I try to sleep on both sides.

Ashley: Try to sleep on the back of your head. 

Katie: I can't do that. 

Ashley: You can't? 

Katie: No. 

Ashley: Maybe get one of those special pillows that don't let you roll.

Katie: I'll probably snore ...my husband will probably...

Ashley: he wouldn't like that smack. I think if you sleep on the side of your face, you're gonna get more wrinkles on that side of your face.

Katie: And volume. 

Ashley: maybe.

Katie: But everyone's born asymmetrical anyways.

Ashley: There's usually one side of your face that's a little bit shorter and wider and one that's a little bit taller and skinnier. Like pretty much universally, even, even super models. 

Katie: Oh yeah. 

Ashley: They probably have a little bit less of that.

Katie: Well, and they're getting some things done. Well, let's be real. Most of them. Probably they like go to Egypt or something and they're airbrushed 

Ashley: Why are you go to Egypt?

Katie: Because Egypt, this is why I say this. So you're talking, you were talking about, so Elle yes. Was caught. She got some plastic surgery on her face. She was caught. Is it ACA the thing that like mm-hmm covers your face? Right. And they caught her, they figured out it was her by her shoes. She was with her sister's like Giselle. It was someplace overseas.

And if you look at Tom Brady, he's had work done too. 

Ashley: Think so?

Katie: Yeah. His before and after, when he graduated. He's been worked on for sure. 

Ashley: I don't know why you wouldn't. I mean, you have the resources 

Katie: And why wouldn't you wanna look like the best version of yourself? 

Ashley: Well, that's a good question. 

Katie: But the, I think the question is finding the right person that's going to make you look like the best version of yourself and not overdo it. 

Ashley: Absolutely. 

Katie: And not make you look crazy. Cuz that's where a lot of our friends get a little bit weary about anything plastic surgery. They're afraid I'm gonna look like I have duck lips or I'm gonna look overfilled and it's like, you would have to get so much, so many syringes to look overdone. I don't think that that people really understand how much you'd have to get to look that overfilled. 

Ashley: You're probably right. 

Katie: You know, I mean, if, if it have to be upwards of five to six syringes.

Ashley: It would be a lot, but sometimes what people will do is they'll get a vial in their lips and they like it. But then they like how the first couple days it was really swollen. 

Katie: Right. 

Ashley: And then it goes down because it was swollen, then they're like, oh, I liked it. And then they come back, get another. And then they're like, oh, I liked it when it was swollen with that time and went down, right. 

Katie: They come back and it becomes addictive, but that's, that's someone turns him down and says, I think that's pretty rare.

Ashley: Even porn's addictive. 

Katie: Everything's addictive. So as far as filler goes, how much is a syringe? 

Ashley: It depends on which product, but I would say around 700 to $800. 

Katie: No, as far as a volume. 

Ashley: Oh, sorry. Classically one ML. They make one that's at like 0.65 MLS. 

Katie: Which is like, when you look at a teaspoon, I mean, a third of a teaspoon? 

Ashley: Teaspoon is five MLS. 

Katie: So how much is ? 

Ashley: A fifth of a teaspoon. 

Katie: A fifth of a teaspoon? When you look at how much volume it is, it's not really that much. 

Ashley: It's not a lot. People that are banking, one MLS. I'm like, no, man, just use it. It's one ML and there's always, definitely somewhere put 

Katie: there's always someplace else you can put it.

Ashley: For sure. One ML is not a huge amount of volume. 

Katie: Just use that whole thing.

Ashley: You can put it in your earlobe

. 

Katie: I never even thought that.

Ashley: When I do facelifts, I always put fat in people's ear lobes. 

Katie: Oh, nice. You know what? We haven't talked about fat: the ultimate filler. 

Ashley: it is a great filler. 

Katie: So tell us about using fat. Where are you getting this fat? 

Ashley: so a very common question that people will ask me is, or usually it's the friend or spouse of whomever the patient is.. Mm-hmm is, can I give her my fat? No, you can't.

Katie: Right. 

Ashley: You can't. Has to be, right, same person. So classically to do fat as a filler, you have to first harvest the fat and that's done...

Katie: lipo back to episode three.

Ashley: I know, liposuction. And, usually for the amount of fat that's required for, let's just say the face, let's say we're adding fat to the entire face. Uhhuh, usually it's depending on the age, but somewhere in the 30 ML range. 

Katie: Okay. 

Ashley: 30 something ML range. 

Katie: And there's some atrophy, right?

Ashley: So not every single fat cell survive. Adding fat to the face is called free fat transfer. And that means the fat is separated from its donor site blood supply. You've disconnected it from the blood supply where it was ...

Katie: uhhuh. 

Ashley: So let's say in your abdomen it had a blood supply there. You've removed it. So it it's free from its blood supply.

Katie: Okay. 

Ashley: And then you add it to the new location. When you add those fat cells to the new location, not every single fat cell will establish a new blood supply. 

Katie: Okay. 

Ashley: So those fat cells that do not, will not survive .

Katie: They'll just be absorbed.

Ashley: And the expected fat survival rate is about 50 to 70%.

Katie: Okay. 

Ashley: That's pretty good. 

Katie: so you go a little bit up, but come a little bit down. 

Ashley: Yeah, I don't try to overfill a lot because you don't know really within that range, how much is going to survive. 

Katie: You do it til it looks good? 

Ashley: Yeah, my end point is looking good and I know I'm gonna lose a little bit. And then either we can come back with some more fat or we can add just a little dollop of HA filler or whatever. 

Katie: Right. When you do the postop 

Ashley: mm-hmm . 

Katie: So, if you're doing some fat transfer with you know, with fat your face , there's the same risk of bruising? All that stuff, right?

Ashley: Sure. 

Katie: Are you just gonna look pretty normal when you're injecting the fat or is there any other thing that's different when you're injecting fat in the face? 

Ashley: So when you're injecting fat, usually you're getting an anesthetic. I mean, not always.

Katie: Well, if you're harvesting, you probably got that anesthetic anyways. 

Ashley: That's what I'm saying. It's a bigger production. You have to prep the donor area, numb it up. So whether you're getting numbed up with some anesthetic or you're just doing local injections or whatever, and then you're harvesting it, then you're preparing it, then you're reinjecting it. 

Katie: Right. 

Ashley: So yeah, it's different. But, the cool thing with fat transfer is that whatever fat cells survive, and like I said, it's about 50 to 70% of the fat that's added, that is a permanent filler. So it it's appealing, especially if you have a substantial amount of volume loss to add fat that you don't have to keep adding every one to two years.

Katie: Well, permanent, but your body continues to lose volume. So then that just becomes part of your volume, right? 

Ashley: You've reset the clock. If you went back two decades as far as volume loss ,unfortunately yes. Time does tick on and surgery doesn't freeze your look. And I say that to patients, they'll ask me, how long does this face lift last? Well, it resets the clock...,

Katie: but you will still age. 

Ashley: You're still going to age. Stop the clock. Exactly. It doesn't stop the clock. So, same thing with. Fat transfer. It's going reset the volume with regards to how much volume was lost, but you're gonna still continue to lose additional volume. 

Katie: So where else can we use filler? We've talked a lot about the face.

Ashley: People will use filler in the dorsum of their hands...

Katie: uhhuh 

Ashley: where you're seeing that tendoness or overly bony top of your hands.

Katie: My kids say that to me.. 

Ashley: Your kids do?

Katie: They're like, you're old; I can see your bones

Ashley: I've always had really skinny bony me hands. So, 

Katie: so I'm like, that's just how I am.

Ashley: I know I'm over it. And then the other thing is like breasts and buttocks. 

Katie: You can put filler in your breast? I guess fat's filler.

Ashley: Yes. Price per volume, it would be tough to do something like Juvederm to your breasts. It could be done. It would be really expensive and it would only last so long, So that wouldn't be appealing. 

Katie: So fat would be the better option for that. 

Ashley: Yeah. Most people would do fat. Absolutely. 

Katie: I've heard of people getting fill in their butt.

Ashley: Mm-hmm, it would be classically Sculptra. They're getting one of the temporary injectable fills. 

Katie: So let's talk about like the Kardashian butts. 

Ashley: Yeah. 

Katie: Do you think those are filler butts or, but implant.

Ashley: Well, I thought Kim got an x-ray or MRI or something

Katie: if she had an X x-ray, but implants would show, but filler wouldn't right. So she could have butt filler. 

Ashley: I don't really care what Kim has in her butt. I guess. I don't really care. 

Katie: Well, and they just say Khloe's butt got smaller. So I'm like maybe her filler either... 

Ashley: Where do you find this stuff? 

Katie: I'm telling you, this is the stuff that I'm interested in. 

Ashley: That you're sucked into? This is the worm hole you go down? 

Katie: This is the stuff that Instagram shows me.

Ashley: Oh, okay. 

Katie: So her, her butt got smaller. I think her audience wants to know.

Ashley: But is she skinnier also? 

Katie: She is skinnier, but it's, it's significant. And actually I'm gonna show you a picture. So what they're saying is either she got her butt implants removed. What else would you create that?

Ashley: What if she just had padding in? She does look way skinnier.

Katie: She is way skinnier, but definitely something happened to that. 

Ashley: The butt ...something's been done.

Katie: Don't you follow plastic surgery on Instagram? 

Ashley: Who's that? 

Katie: They're good. It's just a plastic surgery thing on Instagram. This just shows you different things, which I'm just intrigued. You know, which I sent her a picture the other day of a, of a no implant breast lift. And she's like, why are you sending me pictures of saggy boobs? I'm like, it's a video click on the video, but you're not super into social media. So, you don't really see that stuff. 

Ashley: Well, I just don't watch stuff that I already know. 

Katie: Right.

Ashley: I already know that. I don't want to watch a video about, look, you can save the tissue. And, but what I think an autoaug 

Katie: interesting is just, just to see what other people are doing, just to see, no, I think's what's going on out there.

Ashley: It's important to keep your finger on the pulse of what's going on in the field. And the latest technology are absolutely

Katie: the Kardashians have their butt and implants removed. 

Ashley: I don't think they're gonna tell you.

Katie: Right. They're probably not going to. Yeah. But I think that's all we have on fillers. Is there anything else that we forgot? 

Ashley: For the ha fillers, we talked about how there's so many different types, right? Whether it's.

Juvederm or Volbella or Vollure, Voluma that family or the Restylane Lyft, the Restylane Defyne, Refyne, Restylane contour, and there's the Revanesse, or Belotero . There are other brands, so I don't wanna exclude anyone. As a patient interested in filler, it's important to find someone with experience, and rely on their knowledge to select the appropriate filler for you. 

Katie: One thing you mentioned with another one is some people push what they have. If you go to someone who has a selection of different things, You're going to get a better scope of what's the best thing out there. 

Ashley: I that's true across the board, especially in plastic surgery things like med spas, if let's say, as a med spa provider or owner, all you do is cool sculpting...

Katie: right.

Ashley: ...then everyone that comes in that has a body contour concern, that's the only thing you offer. It's the same kind of concept with fillers.

Katie: Which you have everything. So, you're gonna recommend...

Ashley: what I think is best, the best, even if, yeah.

Even if the patient doesn't prefer what I recommend, they still knowand have been educated that I'm recommending, this as my first choice, and this is why this is an alternative, and these would be the pros and cons. I mean, I think that's important and I'm not sure that's the experience you're going to get with potentially

Katie: everyone else. There is one more thing we forgot to mention is cost. 

Ashley: Sure. 

Katie: You know, typically a syringe of filler is gonna be like between six and 800, right? Depending on what it is. 

Ashley: That's fair. Yeah. 

Katie: And typically you're gonna need, I mean, minimum of one, right?

Ashley: You can't buy a half. 

Katie: You can do a half for the lips. 

Ashley: I guess. You can't buy a half a syringe. 

Katie: Oh, you can't? 

Ashley: some of the companies make a 0.65 ML syringe, which would be cheaper than a one ML syringe.

Katie: Uhhuh.

Ashley: But you can't buy half of a one ML syringe. Like you buy the whole syringe mm-hmm 

Katie: so minimum, you've got one syringe.

Ashley: Mm-hmm

Katie: But if you're looking for a total fixer upper situation on the face, obviously depends on the volume loss. 

Ashley: Sure. 

Katie: You know, multiple syringes. So you multiply that out.

Ashley: For sure. 

Katie: You need to be prepared, you know, it's gonna cost more than Botox. And, there is a little bit of downtime you. 

Ashley: Again, when it comes to providing options, okay, we could do five syringes, maybe they'll last one to two years. You're going to need more in two years. At some point, the consideration of what's the cost to add fat as a filler should be part of ...

Katie: what's the difference in cost with fat?

Ashley: Well, fairly substantial. 

Katie: Okay. Well, then I guess you're multiplying that out.

Ashley: It depends on how you do your cost analysis. Right? Right. Are you talking about a two year, window of cost analysis or a 10 year window? 

Katie: Well, in fat harvesting, I mean, that's like a two for one, because you're taking away from an area that you don't want it adding it to another area.

Ashley: I think so. There are very few people that look at their body and say, I wouldn't mind if I had a little less here. 

Katie: So what's the minimum on harvesting some fat?

Ashley: Like ,what would I need? So let's say we were wanting to add 30 CCS of volume to the face. I would need to at least harvest about 60 CCS of lipoaspirate.

Katie: But pricewise, what's the minimum? You can gimme a range. 

Ashley: So, maybe four -5,000. 

Katie: Okay. But you're getting long lasting results. And it's a two for one. You're gonna be skinnier in one area. Plumper in another. 

Ashley: Yep. It's got it's appeal. 

And if you get a few syringes, you're gonna be a couple thousand dollars in. 

 It's good to have options, and for each person, it just depends on how you weigh out the pros and cons of those choices and different people would weigh them differently.

Katie: Right. 

Ashley: And my job is to educate people as to what's available, what would make the most sense for them and to some extent, just putting the ball in their court. I'll provide recommendations. . But that doesn't mean if I think, oh, well you need a facelift and you need a fat transfer that they have to do that.

Katie: Right. 

Ashley: They may say to themselves, well, I don't wanna do that. What else can I do? 

Katie: Right. 

Ashley: And that's okay. 

Katie: I do love how straightforward you are. cause you're gonna really tell somebody like, this is what I think. And I don't think a lot of people are like that. And I love someone just telling me, Hey, this is how it is.

Ashley: Some people might not like it, but I want my patients to be happy. 

Katie: Right. 

Ashley: And I want to be satisfied with the result, and I want them to be satisfied with their investment in how they look at the end. Just telling them what they want to hear will not serve either of us well.

Katie: Okay, one more place. I've heard about getting filler and we talked about this in episode one. 

Ashley: Oh, the vagina?

Katie: I've heard it in the G spot. How would, you know, if you need that?

Ashley: Just like you're losing collagen in your face, you're losing everywhere. Right? so...

Katie: you plump it back up.

Ashley: Plump it back up, fill 'er up. You're trying to restore the volume that's associated with aging and it unfortunately occurs everywhere. 

Katie: Interesting. You can almost fill anything. All right. I think that's all I have on filler. 

Ashley: All right, cool. 

Katie: Tune into the next episode: anti-aging. 



Ashley: Yeah, we'll just do an overview because that topic is so broad and so we're just gonna touch on it, and then we'll delve further into the various aspects of it and break it down. Yeah, I love it. All right. Bye everybody. Bye.