The Great Deflate: Is Filler Over?

Dr. Chang (00:00):
Sometimes people just say, "Well, how bad could it be?" And they don't have any idea that it could be really bad.

Jackie (00:05):
Really bad.

Dr. Chang (00:10):
You are listening to Secret Services where we discuss the procedures nobody admits to, but everyone's curious about. I'm your host, Dr. Christopher Chang. I was just saying goodbye to the patient upstairs and she was sort of saying, "Oh, I had this crazy dream." And she's trying to interpret her dreams and couldn't remember anything.

Jackie (00:29):
I heard all about it.

Dr. Chang (00:30):
Oh, you did already?

Jackie (00:30):
Yeah.

Dr. Chang (00:32):
I was like, "Wow." Well, that's similar to the other patient last week who had all sorts of weird reactions.

Jackie (00:38):
As soon as she came to, she remembered her whole dream.

Dr. Chang (00:43):
Oh, really?

Jackie (00:43):
So she was telling us all what she was dreaming about.

Dr. Chang (00:45):
Oh. It sounded like she was dreaming about girl drama with one of her friends.

Jackie (00:49):
Yes. She was fighting a friend.

Dr. Chang (00:52):
All right. Well, you're here for the drama. Welcome to another episode of Secret Services where we talk about all things in plastic surgery, aesthetic and cosmetic industry, and maybe a little bit of medical information as well to make sure you guys get all the right information. I'm Dr. Chang.

Jackie (01:08):
I'm Jackie.

Dr. Chang (01:09):
So Jackie, what are we going to get into today?

Jackie (01:12):
Oh boy. All right. So there's a New York nurse, her patients are now asking her to inject 0.4 of a syringe and throw the rest away. A Beverly Hills surgeon down the street has moved his facelift patients off filler entirely and onto their own body fat. And at the far end of the spectrum, a South Korean woman named Hang Mioku ran out of syringes and started injecting cooking oil into her own face. This is what a decade of filler looks like on the way out and what has to happen before a facelift can even start. Stay with us. That's a lot to take in.

Dr. Chang (01:51):
Yeah. Yeah. There's been a lot of changes in the injectable landscape lately, so let's get into it.

Jackie (01:57):
So how does a facelift consult actually change when a patient walks in with years of layered filler that nobody's really kept a record of?

Dr. Chang (02:06):
Sometimes it matters and sometimes it doesn't matter, I guess is the short answer. You don't have to have a record of everything, but you have to kind of look at the patient, analyze their face and see what needs to be done to achieve their goals. So that could be dissolving filler in certain areas, that could be thinking about the things that they've most recently done. A lot of patients do have an idea, oh, what have I done in the last year? But if you've been doing aesthetic treatments for five, 10, 15 years, you're not going to remember everything. And frankly, it may not matter. At least in this country, generally the FDA approved things are relatively safe and it's not going to be super mysterious.

Jackie (02:44):
So if a patient comes in for a facelift consult, is that even one of the questions that you guys ask, "Have you ever had filler and where?"

Dr. Chang (02:51):
Well, just like with any situation, we're always thinking about what's your medical history? So have you had surgery before at all? Have you had anesthesia before at all? Any cosmetic treatments does come up a little bit because we are trying to think about what the history is, what they're trying to achieve and what their skin or tissue quality might be like. I think that it's not as detailed and nitty-gritty. We think of a lot of those treatments as temporary. We don't think of them as permanent changes like surgery. So if you've had, I don't know, jaw surgery or brain surgery or something, that feels a little more important.

Jackie (03:26):
Well, one thing that comes to mind, some patients come in and they get a liquid rhinoplasty, and then after a while they finally want to just go forward and do -

Dr. Chang (03:36):
A surgical rhinoplasty.

Jackie (03:37):
Surgical rhinoplasty. Yes. So how does the filler for that affect your game plan for the rhino?

Dr. Chang (03:44):
Oh yeah, that's definitely... So a liquid rhinoplasty is a change in the nose using a filler, which is intended to create volume and change the shape of the overlying skin. So instead of changing the structure under the skin, you're sort of distorting or inflating the skin above. And distorting doesn't have to be a bad thing. It can be to make certain features less noticeable and more subtle. I think of liquid rhinoplasty as a camouflage. So it's a sort of camouflage the hump that you have or camouflage the tip drooping that may bother you. But the problem is then if you're going to get into surgery, you have to think about, well, what is the bony structure, the anatomical structure that you're going to fix, cartilage, bone and structure underneath the skin? And you may not be able to fully determine that or fully appreciate that if you are looking at a mask of filler.

(04:41):
So in my practice, we like to make sure we dissolve everything that we can so that we can really get a good look and analyze what has to be done surgically so we have a plan going forward. And I have in my mind where I see this surgery going. So it's a very good example, very, very good example to bring up about when the filler history or the injectable history does affect the surgical plan.

Jackie (05:04):
So we have an anonymous question. They say, "I've been getting lip and cheek filler on and off for six years, a syringe here, half a syringe there, a few different injectors. I never kept a spreadsheet. I'm 44 and I finally went in to talk to a plastic surgeon about a facelift and he told me before we could even schedule anything, I need to come in for a hyaluronidase appointment and let my face settle for a few months." Is he padding the bill or is that actually the standard now?

Dr. Chang (05:32):
I think that it sort of depends. There are people that are patting the bill and trying to maybe get a little bit more treatment out of you, but I think that just as we were discussing before with the liquid rhinoplasty, the surgeon wants to see what is the true anatomy, what is the true deficit that they're being tasked to repair or to focus on. So it's going to be easier for them to determine that if they can remove all the artificial or even temporary artifact.

Jackie (06:03):
When I read this question, I'm envisioning, does this surgeon -

Dr. Chang (06:08):
I'm envisioning somebody for the office actually, one of our staff members.

Jackie (06:12):
I was envisioning Laura Loomer.

Dr. Chang (06:15):
Oh, okay.

Jackie (06:17):
I'm wondering, does this plastic surgeon do this for every patient or did she send in a picture and they're like, "Wow, she is heavily filled." So maybe that's why it's like a case by case basis, not necessarily he does this for every single facelift consult.

Dr. Chang (06:35):
If you've distorted the face of the tissues and it's hard to see what's there, yeah, I guess that's probably normal.

Jackie (06:42):
I'm laughing because at first I thought you meant from The Office.

Dr. Chang (06:46):
Oh, you mean the TV show?

Jackie (06:49):
But now I know it.

Dr. Chang (06:49):
No, from our office, which could be the next sequel for The Office.

Jackie (06:54):
Oh my gosh.

Dr. Chang (06:55):
But yeah, I think that dissolving is probably somebody who's really distorted.

Jackie (07:00):
Yeah. It's got to be. I don't think it's just like, "Oh, I've had filler three times and he's like, let's dissolve everything."

Dr. Chang (07:07):
Right.

Jackie (07:08):
So hyaluronidase, how does it work? How much does one appointment cover? And is it usually painful?

Dr. Chang (07:14):
Right. So the active ingredient in a lot of fillers, Juvederm, Restylane, all those fillers that do lip filler, cheek filler, those are the hyaluronic acid fillers. Hyaluronic acid is a molecule that's in your connective tissue and skin and tissues throughout the body and you naturally make it, but this is a synthetically created version to inject into the tissue. It works by drawing water and it's hydrophilic into the area, so that creates a little more volume and fullness and hydrates the area so that any area that seems deflated can be plumped up. So hyaluronidase is the enzyme that dissolves that. So you generally don't need a very large amount to dissolve the filler. You just use a little bit of it and the enzyme gets to work and breaks it down. However, some of the newer fillers have formulas that are made to be longer lasting, and there's a lot of chemistry behind how the sulfide bonds within the molecules link together and create stability, but that also makes it a little harder to break down.

(08:23):
So depending on the type of filler, some of those more sophisticated fillers are sophisticated because they have more complex chemical structure that also makes it a little harder to break it down, but it still breaks down over time. It just might take one or two or three treatments.

Jackie (08:37):
What are the ones that are harder to break down?

Dr. Chang (08:40):
The technology that's really popular is called Vycross. That's an Allergan line, and they generally begin with a letter V, so Vobella, Voluma, Velour. And those are meant to be a little smoother and they last a little longer. So people who are like, "Wow, this lasts a little longer or smoother." All those things I mentioned, those seem great on the front end of, "Yeah, let me get that a little more bang for my buck." And a lot of the injectors love those products and they're great. They're great products. I mean, we use them in our practice all the time.

Jackie (09:15):
Oh yeah. I have them in my lips.

Dr. Chang (09:17):
Sometimes I'm looking right at you. But then I'm thinking when you break them down, you just have to tell the patients, "Well, we got to dissolve that for surgical prep. Might take one or two visits or two or three visits."

Jackie (09:32):
Say I'm getting a facelift and we're adding on a little fat grafting to the lips, would we just keep the filler in the lips and then just add fat on top of it? Or is that another instance where you may consider?

Dr. Chang (09:44):
That sort of depends. Some people say, "Well, I'm very fearful of my lips looking too big." And for that patient, I would say, "Okay, let's take everything out that's filler. And when you're in surgery, we're going to do the surgical part of the filler, which would be with biological material like your fat. And if you want, then we can always add in the office later. That's easy to add a little bit, but I'd rather control that situation because with the swelling of surgery and the hydrophilic nature of the filler, I don't want to have a lot of variables if you're nervous. Now there are other patients who say, No, I want big full lips. And that's not their concern. Their concern is being underwhelmed. So if they're concerned is being underwhelmed, then just go for it.

Jackie (10:29):
Just let it ride.

Dr. Chang (10:30):
Yeah. So it depends on the person. Some people are a little bit more gun shy or scared of it, and some people are a little bit more like, oh, that's not enough.

Jackie (10:38):
That makes sense. So there's also fillers that aren't hyaluronic acid, Sculptra, Radiesse, Bellafill. What happens to those when you need to do a facelift and can you dissolve any of those?

Dr. Chang (10:49):
So let's just get into it. So Sculptra is a different type of filler. It's called polyalactic acid, is the active molecule. It works by creating a little bit of an inflammatory response that stimulates collagen production. So that is a different strategy to create volume. It is not dissolvable, but it does get reabsorbed over time and the body breaks it down. Radiesse is a calcium hydroxyapatite particle that is calcium based. So it has to be done very carefully. And some people will do a diluted version of this so that it's nice and thin. It's very powerful to lift the skin and tissues, but it's also not dissolvable. It just breaks down over time. And then Bellafill is a collagen product that is a little bit more, you might say biological in terms of the molecule, but also is not dissolvable in the same way. So the hyaluronic acid one is very, very easy to dissolve, but they all have their own places in terms of what kind of effect they have.

(11:53):
So I would say that the hyaluronic acid fillers are the easiest to control theoretically with the sort of dissolving -

Jackie (12:00):
With the ability to dissolve in the future if you change your mind.

Dr. Chang (12:04):
But some people say, oh yeah, but the sculpture works way better. The Radiesse lifts way more, or something like that. So if you're thinking about it from the efficacy standpoint, it could be the injector's preference as to what they think the problem is and they're treating that problem at the time. They're not thinking about -

Jackie (12:21):
Later down the road.

Dr. Chang (12:23):
Exactly. Exactly.

Jackie (12:25):
Well, so ripped from the headlines here, the Wall Street Journal, the fall issue is calling it the Great Deflate, the US facial injectables market where 3.3 billion is contracting for the first time. Quarterly filler spending dropped from about 970 million in 2023 to 850 million in 2025. Juvederm lost its billion dollar status and Beverly Hills surgeons are moving dramatically away from filler toward facial fat grafting instead. At the outer edge of the same culture, that Korean girl, Hang Mioku, former South Korean model who became one of the most documented cases of cosmetic surgery addiction cut off by surgeons, she found a doctor who would sell her syringes and when those ran out, she injected cooking oil into her own face. Both stories are getting recirculated in the same beauty news cycle. So the article in the Wall Street Journal is also saying they're seeing a huge influx of GLP-1 patients with hollowed out faces. Are you seeing this around here too?

Dr. Chang (13:25):
I mean, I think there's a ton of click baits. A lot of bullshit, frankly. People are losing weight and good for them. These GLP-1s are super popular, super effective. I get emails from these sort of medical news outlets that say all this time showing great effects from the weight loss, essentially cardiovascular improvements, blood pressure improvements, longevity improvements, cancer risks decrease.

Jackie (13:52):
Even addiction, aren't they saying people who are drinking less, their spending habits? It's affecting everything.

Dr. Chang (14:00):
Absolutely. So you're seeing a lot of positive articles, research and press, some of it's marketing press or whatever, but people are losing some weight in America and I don't think that that's a bad thing as we were formerly the fattest country in the world. Right. So that's okay. That being said, weight loss, extreme weight loss and rapid weight loss all can have problems, right? You can have energy problems, you can have skin problems, you can have hair thinning, you can have mood or mental health issues. So I think there are real concerns with anything extreme, whether it's filler extreme or GLP-1 extremes. And also everybody likes to write all this stuff about looking older and Ozempic butt and Ozempic face. That being said, when you do lose some weight, yes, your face gets thinner. And I think that yes, just like anybody with aging, you may benefit from a little bit of volume.

(14:57):
And I think that that's okay. It's a reasonable thing to do. As long as you do it controlled, I think it's great.

Jackie (15:03):
I just think the trends just ebb and flow so much. It always goes back to the Kardashians. It was Kylie Jenner lips, and then she clearly got thinner and then she deflated a little bit of her lips. They still look good. They're still full lips, but they're not as large. So I feel like it just comes and goes. And then in probably two years, her lips will be huge again.

Dr. Chang (15:26):
Yeah. When they're like, oh, well now they're dissolving everybody's filler and faces. Yeah, I think there's an ebb and flow to the style.

Jackie (15:33):
And I think they're dissolving, but I wouldn't say that these celebrities aren't using filler at all. I think they're just using smaller amounts. So the average person might be like, oh, they're filler free, but I don't think that's the real truth. Maybe just a little less.

Dr. Chang (15:48):
I always say this to everybody who's thinking about surgery or asking me, well, what can I have besides facelift or can I have more injections? Injectables are a tool. They're a tool in your cosmetic plan and you can just have one tool and try to build your face with just the injections, but there's a place for them. If you have injectables and Botox and lasers and facials and surgery, it blends together much more nicely because each tool can do something different. And so I try to educate patients that, yeah, just because you've had surgery doesn't mean you're never going to need injectables, you're never going to need facial, you're never going to need those things because those little, it's sort of like you've bought a new car, but you have to be able to get the car washed and polished.

Jackie (16:32):
Got to maintain it.

Dr. Chang (16:34):
Yeah. If you don't have it looking good and shiny, it's not going to be impressive. It's going to be an old rusty sports car or whatever.

Jackie (16:40):
So the American Society of Plastic Surgeons reported that facial fat grafting is up 39% over last year and 82% of member surgeons are getting GLP-1 consults. Does that match what we're seeing here?

Dr. Chang (16:53):
I do think that our facial fat grafting is up a lot. I think that's very, very popular. We're doing a lot of it and we've seen some good effects.

Jackie (17:01):
I agree. I do think we're doing a lot more of it. And I can say from my friends, people I know that are not necessarily afraid of getting things done. I think people just in general like the idea of it's my own fat versus a foreign liquid going into my face. So I think people finding out that that's an option, they like that idea more so. Even though the hyaluronic injections are FDA approved and safe, I think people like the idea of their own fat.

Dr. Chang (17:35):
Well, it's all about timing too. It's sort of like it's been demystified a little bit because other people talk about it. It's not as scary of an idea. And also because the fillers had such a boom five years ago or 10 years ago or whatever, and we're very, very popular, we are putting it everywhere, putting it in under eyes, we're putting it in the cheeks, in the lips, in the folds. And I think we've also sort of seen the limitations of some of those things. Again, going back to using the same tool to treat all problems, we've sort of seen, okay, well maybe it's not the best in that particular area. What else could we offer patients that would be better? And I think fat has found a role in that because it does some really great stuff. The downside is you got to find a way to get it out.

(18:19):
It's a little more involved than taking something off the shelf. The other thing that's coming is that cadaver fat is a huge thing.

Jackie (18:26):
Well, that's what I was just thinking about.

Dr. Chang (18:28):
The Alloclae and Dermaclae. So that is bridging the gap between an off-the-shelf product and taking your own fat in the operating room.

Jackie (18:40):
So this patient, the Hang Mioku, she's the extreme case.

Dr. Chang (18:44):
Oh, this poor lady. She sounds struggling.

Jackie (18:45):
But she started somewhere on the same spectrum as every patient walking in. At what point in your career does a good surgeon start to see the telltale signs of this?

Dr. Chang (18:56):
We've had a couple people that we have to kind of try to guide back to the straight line, right? I think that there's -

Jackie (19:05):
I'm just so curious as to why she chose cooking oil.

Dr. Chang (19:11):
I think what happened was that she was starting to get really pushy and no surgeons really wanted to do anything for her. So she started to take things into her own hands because she was like, "Well, if they won't do it, I'll do it myself."

Jackie (19:25):
But why cooking oil? I would love to know.

Dr. Chang (19:29):
That you'll have to ask Hang yourself.

Jackie (19:34):
Hang herself.

Dr. Chang (19:36):
You have to DM her.

Jackie (19:37):
I mean, I just can't even imagine thinking that that's okay. So when you start to see patients go that way, you're just like, "Oh my God, that's honestly..."

Dr. Chang (19:50):
She looks like her face is melting off.

Jackie (19:52):
That's nightmare fuel.

Dr. Chang (19:53):
Yeah. I think that why do people go to a motel room and have some lady who has no credentials inject motor oil in their butt? You've seen those stories, right? Sometimes people just say, "Well, how bad could it be?" And they don't have any idea that it could be really bad.

Jackie (20:11):
Really bad.

Dr. Chang (20:12):
So don't take matters into your hands

Jackie (20:15):
Yeah, don't be Hang. Yeah. We have lots of options. The hyaluronic fillers, the non-hyaluronic acid options, we have some. And then we also do a lot of facial fat grafting. So if you're interested in something like this, don't inject oil into your face. Give us a call.

Dr. Chang (20:34):
Leave the oil for the cooking.

Jackie (20:36):
Yeah. Yeah. Leave the oil in the kitchen and call us and get a consult and we can figure out how to fix you up safely.

Dr. Chang (20:45):
Speaking of which, patients are waiting. We got to go.

Jackie (20:46):
All right. Thanks guys. See you next time.

Dr. Chang (20:49):
All right. See you next time. Thanks for listening to Secret Services, the podcast where we see everything and say nothing except right here. I'm Dr. Christopher Chang, double board certified plastic surgeon located in Tysons, Virginia. Follow us on TikTok @congressionalpsurgery or on Instagram @congressionalplasticsurgery. To send us a classified message or to hear more episodes, go to secretservicespodcast.com. Links to everything we talked about on today's show are available in the show notes. Oops, patient's here. We got to go.