Sharp Tips on Botox, Fillers, and More with Dr. Steve Fagien

Now there's Barbie-tox, just to jab into the trap, and you've got the neck of Barbie? Well, maybe Margot Robbie. So what tox should you use? Botox came first and it's as famous as royalty. Then Dysport and Xeomin needled their way to the throne. Now Daxify is taking a stab with a toxin that lasts longer, or does it? Welcome to Skintuition. I'm Heather Furnas.

And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for, when you're ready to hit refresh.

It's a real honor to introduce our guest, Dr. Steve Fagien. Dr. Fagien is an oculoplastic surgeon in Boca Raton, Florida and internationally known for his expertise in aesthetic eyelid surgery and uses of neurotoxins and dermal fillers. He advises most major biopharma companies and he publishes like a bestselling author in the scientific arena. He also lectures around the world. Welcome, Steve.

Thank you, Heather. Thank you. And nice to see you Josh as well.

So Steve, you have decades of experience, not to mention even doing even the clinical trials for many fillers and neurotoxins on the market today. So help us out here. What's the difference between Botox and its competitors? Are they different from each other or is it really like Coke and Pepsi?

That's a great question, Josh, and there's no simple answer. In many ways, they are like Coke and Pepsi. It becomes a physician preference, a patient preference. But there are differences in the neurotoxins, the Botox, Dysport, Xeomin, Jeuveau, Daxify, the new one. And it all boils down to the fact that the core active protein of all of these products is nearly identical. The difference is what surrounds them and basically what that means to the injector or the patient is how the drug gets to the target, which is the muscle. They're all used to relax the muscle and they all have their own little personalities based on manufacturing. And the manufacturing does dictate performance. Now when again, the active part of any of these products gets to the target, which is the muscle, they all work the same, but how they get there and how long it takes for them to get there is different. So there is claims that one works quicker, lasts longer, and that may be true, but it is very much dependent on technique. And I think most of these products you could make work very similarly if not identically.

So I hear you saying it's really dose dependent and technique dependent. So can you tell us a little bit about that? Can you inject too much what'll happen? What are the different techniques you're talking about?

Sure. Yes, they are dose dependent. Heather, you're exactly right. And a lot of the claims that are made by the companies as well as the competitors', rebuttal against those claims are somewhat of a bias based on what that company and product wants to display to the public and to the injectors and to their customers. So again, assuming equal dosing to a muscle with any of these drugs, you probably get the same cosmetic effect. Now, some drugs, and there's a spectrum of all of these, with Botox being the most well known as you said very well, and it's been around the longest and has a name like Kleenex. So when people talk about neurotoxins, they talk about Botox, but they may be getting another neurotoxin, they may be getting Dysport, Jeuveau, Xeomin or Daxify. And what happens is there's a field of effect, and I did the initial studies on this where we realize that some of the drugs, if you inject the same volume and the same amount in an area, seem to spread a bit more distant from the point of injection.

(04:43)
And that's called field of effect. Botox was the gold standard. It's been around the longest, it's been studied more than any other neurotoxin in the world, and we got very comfortable with that. It's like anything else, the same thing happened with fillers. You get comfortable with a product, you know how to inject it, you know what that field of effect is, what kind of positive effect is and what potential negative effects you may get because of that field. Then comes along the second neurotoxin in the US called Dysport, and it's a very good drug, works very similarly, but we soon realize that the field of effect, meaning how it, and it's a bad word to use, spread because everybody thinks spread is bad. It's not necessarily bad, but it seemed to go a little more distant from the point of injection assuming equal volumes of injection. And then comes along the other drugs which seem to again have their own personality.

(05:37)
Jeuveau interestingly, and I started to mention this earlier, has a very tight field of effect and some people will use that as a marketing strategy that it's more precise. When you inject it, the field of effect seems to be a little tighter than Botox cosmetic. So there's a competitive advantage there. With precision, there's a competitive advantage with is you can get fewer injections and get a similar result. And basically the injector, not the patient, needs to understand these differences and these different personalities of each of the drugs to get the best cosmetic effect and reduce the chance of a side effect, which is basically the side effect mostly, which is what people fear an unwanted effect or an unanticipated effect from what you were trying to accomplish with the cosmetic use. The biggest fear complication for most of our patients is, oh, I don't want to get that droopy eyelid that I saw my friend had when they had, and they'll use the word Botox and it may not have been Botox, but that's what it is.

(06:35)
So back to your question, can you have too much? Yes you can. So if you push the drug, because dosing does give that effect, it also dosing affects onset, higher doses seem to work quicker, they also seem to affect longevity. Higher doses seem to last longer. So if you try to push the drug to an untested, unknown level, you may start to get drug that spreads into the areas that you don't because you're using much more of the drug. So you'll cause that increased field of effect by just using too much of the drug. So again, the advantages of some of the drugs are small field of effect, large field of effect, control the field of effect, and you can control that with technique and volume. So the latest introduction to the neurotoxin world has been Daxify and their claim was it had a six month duration.

(07:36)
And I was involved as I was with most of the neurotoxin, FDA phase two and phase three clinical trials. It seemed to in the glabella, the frown line area seemed to last longer, we thought. And the presumption was that it was an equal dosing as Botox cosmetic, and I don't know if you read most of the papers, but the competitor AbbVie, Allergan would say, wait a minute, you're using 40 units instead of 20 units in the glabella, which is the on-label for Botox cosmetic. So of course you're using much and Revance who owns Daxify said no, no, 40 units has the same nanograms of effective protein as 20 units of Botox. Again, not necessarily substantiated, but again, back to dosing. We know that you can get longer lasting results when you increase the dose. So you need to be careful of that. And then there's cost understanding that your physician should know the differences between the drugs and when he recommends or she recommends a drug to you, they understand the differences as well as the cost because there's a cost difference in all of these, what basically the provider pays to the pharmaceutical company.

(08:51)
So there's so many moving parts and I think it behooves the consumer to find a very knowledgeable injector, and that may be from any of the specialties, but someone who's known in your community as a very good quality injector with good results.

That's really good to hear because I've always said to patients, the most important thing about the filler is the filler, but not the stuff the person who's doing it. So if you put it near the eyelids, for example, the lower eyelids, if you put too much neurotoxin in there, can you lower eyelids get pulled down? Can it actually make you look more like a bulldog?

Sure. Unwanted cosmetic effects, unfortunately not a dangerous adverse event, but certainly an unsightly and a not cosmetic adverse event can happen with too much drug anywhere. So the article I wrote in PRS many years ago about eyelid position,

That's plastic and reconstructive surgery journal, which is the biggest plastic surgery journal in the world.

And excellent, and Heather's been involved with the journal as I have been for years. So in that journal I wrote an article about affecting eyelid position and dosing and how you can do that. And interestingly, Josh, you bring up lower eyelid. I actually treat upper eyelid mild degrees of eyelid ptosis or a droopy eyelid, much like people use the new drug upniq for to reduce ptosis. And I could do it with small doses above the eyelashes and resolve ptosis, but you can overdose there as well. But your point is well taken. If you use too much drug, you can get that lower eyelid to drop and look almost paralyzed. So that's not the result you want. If you want to change, what is that? Sometimes very thick roll underneath the lashes when people smile. You can reduce that with very low doses or some lower eyelid wrinkles by very low doses. And when I made low doses, we're using at least half of what you would normally inject in other areas. So let's say we are treating crow's feet around the outside corner of the eye, you might use 12 units total in that whole area. For eyelid areas, it's one half to one unit per injection point. So literally more than 10 times the reduction in concentration of that drug. So you get the effect without that look that you described, which is unsightly.

So let's move on to fillers. You have some novel approaches on how to inject fillers. Can you fill us in so to speak?

Well, sure. So the problem with fillers is there's a lot of everything else confusion. So early on they were all categorized as dermal fillers. So anything the Restylane, the Juvederms, even up to the RHAs and all the others, teoxane, they were all categorized as dermal fillers because the F D A trials basically led to a protocol that was an intradermal injection we thought, and that's the way it should have been done. And yet then we became volume fillers. So if you're doing volume to the face, you're not injecting intradermal. It's not a dermal filler anymore, it's a subcutaneous filler, much like autologous fat. So the problem with using these products as subcutaneous fillers for volume is if patients come in with a lot of lines trying to remove their lines with volume is like trying to take the tread out of a tire by inflating it with air. It just doesn't work until it explodes. So the volume fillers, which there are many good ones, are essential for a component of facial aging volume depletion, but they ignore a very significant component of aging, which is wrinkles.

So Steve with a volumizing, just tell us what layer these fillers are being injected into.

So typically the volumizer, and they vary just like the neurotoxins, in fact very much more than neurotoxins. Typically you're putting it anywhere very deep up against bone to anywhere is superficial to just underneath the skin layer. And that's a lot of stuff between those two. There's subcutaneous fat, there's muscle, there's pre periosteum, there's the periosteum, and then there's the skin

And the periosteum is the lining of the bone.

Exactly. Any of those are fair game depending on the products that you choose and the effects that you want to achieve. The problem is most of us in error thought we can inject it just like fat and fat usually goes anywhere in that area from right on top of the bone, the pre periostial area to under the skin depending on the effect that you want to get and the area that you're injecting. So again, it works very well for volume filling in those areas, but ignores what in many of our patients, what they complain of is the texture of the skin, the wrinkles of the skin, the laxity of the skin. So a long time ago, collagen, and you may remember those days was the only filler, in fact a very interesting association between your training and my training because there was a plastic surgeon, Terry Knapp.

(14:25)
Terry Knapp went to the University of Florida undergraduate just like I did and then went to Stanford for plastic surgery. Terry patented and devised how to procure injectable bovine collagen. Everybody talks about Botox being the first injectable that led us into the non-surgical era for cosmetic rejuvenation. It was actually Terry Knapp when he basically formed Collagen corporation and had bovine collagen, which was a true dermal filler. It was meant to augment the dermis, but he was the introduction to non-surgical facial rejuvenation. The collagen, the problem with it, and we can get into all the other new fillers that are out, was a bio stimulator. The reason it worked, it caused an inflammatory reaction because it was xenogenic collagen, it was animal protein that caused an allergic response, made the skin swollen just like a sunburn does. Wrinkles went away. And why I mention all of this is because several companies had collagen in their armamentarium and then the companies realized when hyaluronic acid came out that the cost of creating and making collagen was 10 times more than making hyaluronic acid, which they can make in a lab.

(15:49)
Collagen needed to be harvested from animals essentially. So everybody stopped making collagen, including Allergan at the time who had bought the patents from Innermed, which owned Collagen Corporation. They bought the patents from Collagen Corporation. Again, a convoluted story, but we knew that collagen had a place in skin rejuvenation. But Alistair Carruthers, the co-founder of Botox with his wife Jean, we went to Allergan and said, you're missing out not having a collagen like product. And I personally said, I think I can take the existing hyaluronic acid product that you have Juvederm and reconstitute it, meaning dilute it because it's too thick to put in the skin. Again, most of these were dermal or subdermal fillers and maybe use it as a collagen replacement. And they said, well, why don't you do an investigator initiated study and try that? And I did, did a split face between collagen and the other side of the face with reconstituted diluted Juvederm Ultra to my surprise, which I wasn't too surprised, but I think they were, the results were as good or better than collagen and they lasted three or four times as long. The problem we had with collagen that lasted max two to three months if we were lucky. And once you got an inflammatory response, you basically digested that protein and it was gone.

There was also that other problem that you needed a skin test with collagen that you didn't with hyaluronic acid.

Absolutely correct. So the fact that hyaluronic acid was cheaper to make, there's more profitability for companies, the fact that you didn't need the skin test, hyaluronic acid took over. And then we got very good with hyaluronic acid. So as you mentioned, I started and I wrote an article again in p r s about the Journal of Plastic and Reconstructive Surgery, about how you variably reconstitute our existing hyaluronic acid products to be appropriate for the target tissue, mostly skin that you wanted to achieve a result with. And so it's a very superficial injection. It's very tedious. It takes a lot of time. There's a lot of planning and marking, but the results are, they speak for themselves. So to prove my thesis, I also did another study with Allergan at the time to try to see what was happening. The problem that we have in cosmetic medicine is people make a lot of claims without a lot of proof. There's no data or science to support their claims. So I said, let's not do that and go there. Let's do an animal study and really look at the tissue that we inject and see what happens to it. And to many surprise, there was a fascinating upregulation and many of the youthful skin components

Explain

Is first of all, the body is an amazing constellation of organs that do things that took millions of years to evolve to. So we have protective mechanisms that your body protects you from infection disease, and there are ways that we can manipulate that with drugs and even injectable agents. So with time what happens in part with aging, because aging is so complicated, we lose our ability to repair. So all the collagen that is lost and turned over, meaning that you make collagen, your body breaks it down, you make new collagen that seems to fail. And with time and age, elastin is the same thing. And with people, interestingly, to just take a step back when they talk about when resurfacing with lasers, the problem with lasers is that they replenish collagen at the cost of depletion of elastin, which is very important and very significant.

(19:49)
So I said, boy, if we can prove we up-regulate and the point of upregulation means that we can make your body now start to produce these things again, boy, that would be amazing. And that's what we found. There was a significant replenishment or upregulation of many of the youthful components of skin, including the ground substance, which is the material between the collagen and elastin, the soft spongy tissue upregulation of collagen, upregulation of elastin acid, mucopolysaccharide, which is the ground substance glycosaminoglycan, and some people call them, but I was fascinated by that and we proved that it did it, and I see it in my clinical practice. You look at these patients that have significant static forehead lines and you treat them a couple of times over a year, those lines never come back to the way they were before you treated them. So something's happening at a cellular level, which I think in part we proved it.

(20:47)
I think there's more to be done because upregulation, by the way, is also transient. When you start to reproduce things, it doesn't reproduce it forever. And that may be good because that's what a keloid is, an uncontrolled. When people talk about keloid scars, that's an uncontrolled production of collagen. It's kind of nice that it doesn't do it forever and continuously do it, but it requires maintenance therapy then. But that was the premise of the reconstituted hyaluronic acid. And I believe it works. And the problem is, and I have a lot of surgeons and dermatologists that come and visit to watch me do my technique, it takes a lot of time and I tell 'em all this is not a race. This is about getting the best result for your patients to give them what they want and need. And it's sustainable, it lasts and you don't give 'em a problem. So that's what reconstituted is

Because you're not just going to one point to act on an area, you are really doing these micro injections along really to change the skin, the entire area of that skin.

Exactly right. Usually I will, for instance, from a technical standpoint, I'll thread underneath the wrinkle. I'll do other areas as well, but I concentrate on where the deficiency is because the other non wrinkled areas seem to be reasonably okay. And then they tend to blend into each other. And then you have what was originally a very wrinkled forehead to a rather smooth forehead. And it's very technique dependent, and it's not easy to do, I admit, and when I see three or four patients in an afternoon that I have to do a full face reconstituted hyaluronic acid, I know I'm in there for a while. But again, the patients really don't mind the time at all. They want the result.

Yeah, I think, well, I think that's a big point that fillers, we're trying to learn how to use them precisely to make people look refreshed rather than look like the Pillsbury Doughboy. I think one of the problems that goes on way too much is that there's just too much volume just put in. So the question is how would you advise both patient and practitioner? Obviously it takes more time, but the patients don't mind it from a cost standpoint, that obviously has to be a more expensive to the patient. And if the product lasts, what are we saying, six to nine months in many instances or maybe longer? You tell me, what would you recommend?

Well, your last comment is true. We're all biologic variants. We have patients where we'll get 12 to 18 months, and I have patients that last three to four months, it's the same patient that tells you, my neurotoxin only lasts two months and her friend that lasts eight months. Why we're all different drugs affect us differently and people don't want to admit that, but it's true. So we need to realize, one, there's a biologic variant two, one of the things about reconstituted Juvederm that's great is I could take a syringe of Juvederm and reconstitute it 50 50. So if I add half of a syringe of local or saline or whatever, you blend it or dilute it with, now I've got two syringes. So it goes a long way. Number one, two, skin rejuvenation is just part of it. So when a patient wants to be comprehensively rejuvenated, it's more than just volume.

(24:21)
It's more than just skin rejuvenation. It's more than just neurotoxin. And I know a lot of people have tried to sell global treatments like you need everything in order to get a good result. And there's some truth to that. There's always some lies to truth as well. And the reality is, is not everybody needs everything all at one time. So for a person who's on a budget, they may do volume filling at one treatment, they may do line filling and neurotoxin at another treatment, so you can divide it up if it doesn't match their budget. Or somebody who says, I want to get everything done at the same time, it may require volume filling, reconstituted for line skin improvement, and then neurotoxin. So your point about looking like the Pillsbury Doughboy is that's a person that used volume in an attempt to correct everything and it just doesn't work.

(25:17)
It's like a chef. It's a little bit of everything that makes the final entree. And it goes back to something I know Heather and I have talked about is people get worried about their charges and their costs, and I completely understand that it can be very expensive, but I don't charge by the unit. I don't charge by the syringe. I never have because when you do that, you're basically selling gasoline, you're selling gallons of milk, and yeah, they're all the same. But with this, it requires technique. So again, you need to find a provider that does understand that and gives you actually the least volume, the least amount of products to get the best result. I have seen and watched injectors just waste product using neurotoxins in areas that does absolutely nothing using fillers that are not appropriate for volume filling deep in going through two and three syringes to not get anywhere with the amount of expense that they've charged that patient for. And the key is understanding the product, knowing where it's efficient. So again, understanding the drug, the product, understanding the goals you're trying to achieve, being efficient with your products gets the best results at frankly the best price for the patient.

So that leads into the next question. How do evaluate and determine your technique in nonsurgical facial rejuvenation when you see a patient? And does it vary when they are on a budget?

It does. A lot of our patients will go, look, I'm here. I haven't been here in six months. Do everything you can. And then we have a conversation. And again, one of the other many, many problems is this is medicine, it's cosmetic medicines, but it's medicine. You take a history, you do an assessment, you have a plan that you discuss it with the patient and you see if they're okay with it because they can decide and pick and choose whatever they think is reasonable that also fits their budget. So yes, I assess everyone and I assess them differently, but I most importantly take that chief complaint. I take that subjective in the soap and say, what are you here for? What are your goals and what do you want out of your treatment? And then we lead to everything else. And usually they're pretty happy.

Obviously we all have patients that I guess everybody wants the least expensive best result, least invasive, longest lasting, and we don't have magic wands, but we do the best we can. So as a board certified world's expert, ophthalmologist eye surgeon, let's talk about the tear troughs for a second. Those are those areas in the lower eyelid where essentially I guess the way to think about is people have fat bags that caused from the fat moving forward, and that's somewhat genetic when it happens and all that. And people don't really want surgery, but they don't want too much volume to make it look worse. And they sort of searching all over Google University, what's the right thing to do? And obviously it depends on the person, but tear troughs are a particular point of that. So help us out here and understand what's your approach to kind of figuring that out.

A great and very complicated question. First of all, tear troughs are not due to a hyaluronic acid deficiency. We should get that straight because the fact that we've got something that can improve an area on the face that we don't like doesn't necessarily mean we're correcting the problem. We're making people look better. So there's some validity to tear trough fillers. There's no doubt. The problem is, is they're overfilled and back to anatomy, like you said, most of these dark circles and grooves that are created are mostly created by a contour deficiency and a contour change from a bag as you described, that's above the shadow light, typically coming from above hits the shadow, hits the bag, has illumination on the bag, creates a shadow beneath the bag, it happens everywhere on the face. So with the advent of hyaluronic acid, we said, whoa, let's even out this contour disparity and fill up that groove so the light can hit it fluently and create a uniform reflection that it at least gives the illusion that the groove is gone and may be gone and it looks better.

(30:06)
And in a perfect situation, in a perfect world and an appropriate patient selection, it's a fantastic alternative to surgery. The problem is fillers around the eyes are not very well tolerated in a significant proportion of patients, and there's a lot of reasons for it. One is that's probably the thinnest skin of the body, the lower eyelid. And two, the distance as we talked about depth between the surface of the skin to the bone is also the shortest distance, probably anywhere in the body where you go from the skin surface to the bone. So it exposes every contour problem that we create, including putting filler there that either winds up being lumpy or bumpy or accumulates fluid. And most of these hyaluronic acid agents are what are called hydrophilic. They absorb and attract water. And sometimes you'll inject somebody with hyaluronic acid filler and they look fantastic when they leave your office and they may even look good, especially first time treated patients for a couple of months and they'll call you six months later and go, I was doing fine and my eyelids are swollen and they don't understand why.

(31:26)
And sometimes the injector doesn't understand why, because what happens when you inject substance, particularly hyaluronic acid, it doesn't evaporate into space in time and go away. Your body is attempting, as we talked about evolutionarily healing and our defense mechanisms and aging is so complicated, but we're trying to get rid of a foreign substance. And when you get rid of hyaluronic acid, you break it down into smaller fragments that interestingly your body. And what I think happens is the second time it's broken down, your body sees it as another injection, essentially, it's a new substance that it now reacts to either with water retention because it's hydrophilic or tracts water or another inflammatory response or even sometimes an allergic response. We don't know exactly why it happens. And fortunately that doesn't happen in everyone. But I will tell you, and again, you mentioned I'm a bit biased.

(32:28)
I have a cosmetic blepharoplasty practice, so I will see three or four or five patients a day who've had hyaluronic acid filler in the past. Sometimes they're here just to have their done and they've got a little swelling along their eyelid where it blends into the cheek called the lid cheek junction. And I'll say, well, did you have filler ever? And they go, no, no, I never had filler. Oh yeah, I had filler four years ago. The filler around the eye, especially when you place it deep, lasts a long time. So the problem with it is we can create potential long-term problems in some patients, not everyone that we need to be aware of. And the misnomer that, oh, if you don't like your filler, I'll just dissolve it with a substance called hyaluronidase, which basically breaks down hyaluronic acid in a similar but not identical way that your body does.

(33:20)
It doesn't get rid of the filler completely. It breaks it down again. So many times when you try to dissolve filler in the office, it doesn't dissolve very well. So I'm a little biased. I do eyelid surgery and I know with minimally invasive surgery I can accomplish a similar result, but there will be those patients who are just not ready for surgery. Sometimes some of these patients just need a small transconjunctival incision and reduce the fat bulge to get a result. And it's long lasting and it's not very invasive, obviously. Sometimes they need more than that. But long answer to your quick question, I think it works for some patients. You need to appropriately pick the fillers, which are all different. Some are more hydrophilic and water retentive than others and appropriate technique. And to Heather's point, less is definitely more for tear filler, the least you use to get a result, the less likely you're going to get into trouble. Don't overfill it. It's never going to work well.

One thing that we see in plastic surgery is people come in wanting a permanent result with a facelift or eyelid surgery, which of course you do, and they consider fillers and neurotoxins a waste of money as if it's an either or. Can you discuss how you discuss this with patients?

I do and I do often because a lot of patients will come to me in consultation and they'll say exactly that. They go, well, I'm coming here to get my eyelids done because I'm tired of getting injections. And they do two different things completely, and you need to think about it that way and it makes sense. Surgery is a surgical long-term effect that hopefully is cosmetically acceptable and will go into that a little bit too. Injectables are typically short term and for people who are not quite ready for surgery back to eyelid surgery, most surgeons, when they do eyelid surgery, they can make people look better. Even if you're an average surgeon, patients come to you and you can make 'em look better with your surgery. The problem I see is, and maybe social media and the internet and everything has fueled it. And fortunately it's made me very busy.

(35:40)
People just don't want to look a little better. They want to look like the fashion magazine models that are 26 years old and have amazing skin, have no bags, no shadows, and they want your surgery to provide for that. And that takes a particular level of expertise. And that doesn't necessarily just involve eyelid surgery. It's anything. My patients, interestingly, I think they're pretty selective. They want to look amazing. It's very difficult to make people look amazing unless just like with fillers, you spend a lot of time with them, and I'm over two hours for an upper and lower blepharoplasty, meaning the upper and lower eyelid, cosmetic, two and a half, sometimes three, because it's not a race. These patients really don't care how long it takes you to do their surgery. They want to look like a fashion model when they're done. Now, you may not be able to achieve that, but that should be your goal.

(36:38)
They want to look as good as they can and not look like anything ever happened. And that should happen with injectables as well. They need to look as good as they can without looking like they've had anything done. And that takes a lot of experience and learning and frankly, mistakes. I've fortunately, in my long career, I've never caused anybody harm, but I've learned from situations where I think I could have done better. And if you're not learning, and Tom Baker, one of my mentors till he was 90 years old, he was in the OR watching people saying, I learned every time I'm in the operating room and you need to. And we learned from our mistakes, not from our achievements in many ways, much more. So again, like injectables, like surgery. I'm biased because I think I deliver a high quality product with blepharoplasty, but I put in the time and I make sure that the patients don't look surgical. And sometimes the results are absolutely what they expect. And I get beautiful letters from them saying, you know what? I can't believe I look this good, which is a huge compliment to me, and it keeps me going. And then you get the patients who aren't completely satisfied and you spend a lot of time in anguish and saying, what could I have done better? Their friends think they look great, but it's what the patient sees. And you got to be aware of that.

So what do you think about exosomes? Do you think they play a role in skin rejuvenation? It's a very trendy concept and used for a lot of different things, some on-label with the F D a, some off-label. So since you worked so hard on getting that skin to look amazing, what do you think about exosomes?

Well, it's fascinating. It's a fascinating concept. I've actually worked with a couple of companies that that's their main focus is on how to procure exosomes and make them work the big problem. It's just like stem cells. It's like we just don't know enough. It's not that there's not a huge promise with exosomes. And just so that the audience understands exosomes are substances which are very, very tiny. We call 'em nanoparticles, which are extruded from the cell, and they have certainly a rejuvenative and reparative mechanism. And it's interestingly exosomes in many ways, which relates to all the other things we're talking about. Help cells in our body communicate with each other, which we don't understand at all. There's a communication even when you inject Botox. Again, to digress, our neurotoxins, our muscles communicate. It's one of the reasons we get relapse because if we get skip areas, the muscles talk to each other.

(39:22)
I really believe that. And it's beyond our comprehension. Einstein said, we'll never understand it all, and he's right and there's so much to it that is fascinating, but there's so much that we just don't know. And I think, of course one day we'll figure it out, but people are selling. They did stem cells, they understand it. It's the holy grail. We don't even know necessarily if we can extract exosomes and if they're really viable. We know even with vaccinations, remember we had to keep them super cool during covid. It had to be in the liquid nitrogen because it would degenerate if it wasn't kept at that cold temperature, which may or may not have been true. We don't know the delivery of exosomes on what keeps their viability, and then even when it's a patient's treated with it, the delivery mechanism to get it to the target.

(40:20)
So I think there's a bright future and understanding exosomes, I don't think we're there yet. It doesn't mean we shouldn't keep looking at it. I think there's so many things that, boy, they may be the answer to everything including curing cancer. But again, I think a lot of people that talk about it get their five minutes of fame in a fashion magazine. They read about it right before they are interviewed on Google to figure out what an exosome is. And it's not that they have any direct experience with exosomes. Now, there's some anecdotal evidence, which if you call it evidence where patients are treated with products with exosomes, and they may claim saying they're better and they might be. But as we talked about in this whole session, I'd like to know where the science is to show how we can effectively extract these substances, keep them viable, and know how to best target them to get the results that we want.

Now, there are a lot of established medications and supplements to increase the youth, and we hear about a lot of 'em sometimes from doctor's offices, but also social media and magazines and whatnot. Are any of them worth it? What do you recommend to your patients?

I recommend them to use common sense. I wouldn't spend a fortune on substances that are unproven if they want to take vitamin C, if they want to take omegas, if they want to pre-treatment, use Arnica and Broome. If they want to take multivitamins, fine. A lot of these things are not very well absorbed either, so we don't even know if they're effective. But I would not ignore the placebo effect. I mean, some people just believe, and that belief may be stronger than the substance itself. And I really believe that. And it's like our patients that have a great attitude do very well postoperatively. The ones that have a bad attitude, it's a long course. And there's something about the mind, again that we don't understand that's healing. And if they believe these supplements, even if they don't work, work, take 'em. As long as you're not neglecting your children on meals, in order to buy these expensive supplements, more power to you take all you want as long as then there's some data that there's overdosing of certain substances that you need to be aware of.

(42:57)
And I think people should be aware of that. But by and large, the over the counter supplements are fine. I think a lot of offices sell these supplements. There's no problem with that. I prefer not to because then I am making a claim that I understand it and I don't. So I think it's fine. They always want to blame the doctor sometimes. And I say, buyer beware, you made that choice. Do your homework before you decide to embark on that journey. And if it makes sense for you and you trust this person and they have supplements that you want to purchase from, great. If you don't, don't do it. So I think patients and the consumer needs to take some responsibility in doing their research, and I don't have a problem with it. I take supplements, by the way, and I don't know if they help, but they make me feel better that I take them.

Yeah, well, it's like an anatomy. Professor of mine told me in medical school, if it helps you find, if not, forget it. So I think that's probably the thought.

I like that.

Yeah. So poets say that the eye is the window to the soul and the human beings. That's one of the big places they age or the eyes as an eye and eyelid expert. Besides what you've said so far, is there anything else you might recommend for people, practitioners, patients, all of us humans, to make those eyelids of ours look amazing, to use your word.

Just like we talked about, the assessment with fillers, appropriately assess your patients. Again, making the right diagnosis usually leads you to a better conclusion. So I spend a lot of time in consultation looking at patients. Sometimes I'm staring at 'em, having 'em look at my finger and looking, just getting a sense to be able to make a good result, a great result. And then the attention to the detail and you both as excellent surgeons, this, everybody thinks upper lid surgery is so easy, you just take a little skin off and you close it, in my opinion. And I've written a lot about my lower lid technique with Retinacular suspension and canthoplasty, but I actually find in many ways upper lid surgery more challenging, not technically, but how to get a phenomenal result. You can always make people look better, but how do you make them look amazing and make 'em look like they didn't have surgery?

(45:22)
And my friends who watch me and know me, and they say, you spend so much time marking, and yes, I do. It's like you measure five times, you cut once. That's a good builder told me that once. So it's paying attention to the detail that is the secret sauce in my opinion. And you have to be willing to put in the time I spend as much time with these patients, preoperatively, consultation wise, intra-operatively, and frankly postoperatively taking care of any issues and hopping on it immediately, you see a problem, fix it. It's not going to go away just because you think it is. So those are the things that I think that have made me pretty successful in cosmetic blepharoplasty. So it's, again, if they've got skin issues taking out fat isn't going to help. They may need energy-based devices, and I don't do lasers.

(46:13)
I'll send 'em to somebody good. That's another thing. I have no problem sending my patients out for procedures that I don't do or I don't do well. So I think sometimes you just got to say, I'm not the best for this. I think you should see so-and-so for laser resurfacing. So if it's a skin wrinkle issue only, blepharoplasty is probably not the way to go surgical blepharoplasty. It's something else. But if it's skin issue, you need to address it. Skin laxity, you need to address it. Typically what happens with aging around the eye, and again, very complicated, people say, well, they always go, why? You just pull the skin up and they think pulling the skin up is what's going to happen. I said, well, that's like in everything we do, whatever you do, whatever action. There's an opposite reaction when I pull your skin up, when I make this tight and you're 55 years old, and I make your eyes 45 years old, now you've got 45 year old skin on a 55 year old tendon that no longer supports 45 year old skin. So that's why I need to basically derivate that I need to tighten your tendon. I need to tighten the muscle. I need to tighten your skin. I need to contour the fat. All those little things takes two and a half hours. So that's why I think paying attention to detail almost always leads you to a better place.

And I think that's true with, as you described, Steve, the nonsurgical approach too. Basically anything in the aesthetic arena. Thank you for listening to this episode of Skintuition. Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves. Thank you so much, Steve, for being our guest. We've truly enjoyed this.

Follow us comment, ask questions, and keep in touch. We'd love to hear from you. And thank you, Dr. Fagien. You were amazing.

Thank you. Thank you guys. Appreciate it.