So Many New Fillers, So Little Time w/ Dr. Michael Gold

Doreen Wu (00:01):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost Doreen Wu. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. Our guest expert today is dermatologist Dr. Michael Gold hailing from Nashville, Tennessee. The title of today's episode is "So Many Fillers, So Little Time." gone are the days when injectables like Botox and fillers were considered a shocking topic for living room discussion, whether it's adding filler to the undereyes to fill in the tear drop hollows, or restoring volume to the areas of the midface that have lost the collagen or reserves of their youth, injectable fillers have become increasingly commonplace and to take society. Dr. Bass, can you give us the history of fillers in the US? How did we get to where we are today with the vast number and variety of fillers on the market?

Dr. Lawrence Bass (01:01):
Fillers in the modern era really started with the FDA approval for Restylane and Juvederm back around 2004. And that was the beginning of a new set of indications and a new focus compared to what had happened previously with collagen injection, which was a more superficial injection and, and really corrected features in a softer fashion. So we were able to do different things with these new fillers Restylane in Juvederm that led us fill it, the nasolabial folds the marionette lines and increasingly work on other areas of the face. Now we're continuing to evolve into a couple of later generations of fillers, and I'm going to ask our guest today, Dr. Gold, to discuss that. Why do we have a dermatologist on the, the park avenue, plastic surgery class? Well, first of all, what dermatologists do and what plastic surgeons do in the aesthetic arena is becoming increasingly aligned.

Dr. Lawrence Bass (02:15):
We're doing more and more of the same things for the same reasons. Dr. Gold is a particularly good guest because he is really an expert in almost all aesthetic things. He has an encyclopedic knowledge of aesthetic fillers, energy based devices, the whole range of aesthetic treatments. And he has shared that knowledge in multiple medical education courses and training courses that are presented worldwide. So I'm very proud and happy to welcome him as a guest and, uh, Dr. Gold, if you would share with us where fillers have gone from that first generation of Restylane and Juvederm.

Dr. Michael Gold (02:59):
Sure. So first of all, thank you for having me. Um, I think one of the things that you said Dr. Bass or Larry, I'm going to call you is, you know, we dermatologists and plastic surgeons today. Um, we work together, um, and, and, and that's been one of the biggest changes in medicine over the last 25 years, um, that I've noticed. Um, and, and in a very good way, um, we all sort of, at least I know my boundaries and I know what I don't want to ever do. And that's why we have people like Dr. Bass. And, and there are certain procedures that I may do that the plastics don't do. And, you know, they do that. And obviously we do the medical dermatology too, which he doesn't want to do <laugh>. And, um, and so I think we've, you know, we we've shared our knowledge and our best practices.

Dr. Michael Gold (03:53):
We have learned tons from the plastics over the, over the years. And so again, thank you for having me. The fillers are a fascinating group of compounds and, and, um, you know, yeah, I think you you're right. What we, we started with collagens and, um, and they worked, um, for what they were meant to do, which was to fill with, you know, these more superficial places. And then we got a deeper collagen that really didn't do much, but, um, but it was our entry into putting things into the skin to try to make lines and wrinkles better and so forth. And then as Larry said, uh, um, Restylane was one of the first what we call hyaluronic acid fillers, which are, um, products that are, they absorb water. And then over time they actually turn into collagen. So, um, so we, we've learned a lot from the early days of, of what Restylane, which is a particle filler to more to gel fillers, all in this hyaluronic acid category.

Dr. Michael Gold (05:00):
And there's been an explosion. Um, there are lots of these, whether it's the Restylane family, the Juvederm family, the Prollenium family, um, the Belotero family, um, those are the main. Now we have the RHA family. Those are the US fillers that we have hyaluronic acid. And they're all sort of tricks and tweaks on what we, what has come before it. So some are more malleable in certain areas. Some are better for deeper volume deficits. Um, some are better. We're going to see a whole explosion of some products for some very superficial lines coming up. Um, and it has to do with the cross-linking of the hyaluronic acid and the amount of particles per milliliter of that hyaluronic acid itself. So there's a lot of factors that go into making these, um, and each company has their own proprietary way to do this.

Dr. Michael Gold (06:01):
So I think the hyaluronic acid fillers and the nice other thing about hyaluronic acid, they're reversible, um, which is also really important, um, if something, you know, goes wrong for the most part, unless you're in a blood vessel, um, we can reverse that. And even if we're in a blood vessel outside of the eye, we can reverse that. Um, so I think, you know, this, the fillers are best used by those that understand anatomy. Um, they understand where to put the filler and where not to put the filler. They understand if something goes wrong, how to take care of it. Those are the things that I, you know, always preach to people about how we do things. And I think you gotta know how to do it, but you gotta know how to take care of somebody if it goes wrong. So the HAs or the hyaluronic acids are a great group of fillers.

Dr. Michael Gold (06:52):
Um, but we ask, we also have other fillers out there that we call biostimulatory fillers, and I don't know how much you want to get into them, but they're, those are, we call them sculpture radius, and Bellafill and they're little takes on this. They're longer lasting. They, again, produce more collagen over time. Um, and they are very useful for their, the proper indications that we have for them. Um, and again, I think it's up to the healthcare provider to learn how to properly pick which one to use where, um, because again, I don't think, you know, the average person is going to be an expert on everything, right. But also, we have a whole host of fillers coming. So part of my world and Larry's world is we get to play with some of the new products, um, you know, over time and, and so forth. But there's a, there's a whole slew of products that are coming from Europe and from Korea and other places that we're going to have to figure out where they play a role here in the us.

Doreen Wu (07:58):
I want to go back to, uh, the fillers of the past and kind of talk about some of the indications that they were used for

Dr. Michael Gold (08:05):
Sure. So the, the first products were col were called collagen. I mean, it was called the collagen corporation and they had two, they had two fillers at the beginning, Zyderm 1 and Zyderm 2. Um, and they came from a, a cows hide collagen. So not like the cows you see in the field, this was a very select herd that was, um, kept in very strict conditions. And their collagen was taken away. The, the hide was taken, the collagen was extracted, gone through all the testing to make sure he had no out there was no, uh, potential allergens, but patients actually got skin tested to make sure they weren't allergic. Um, and then we, so obviously Zyderm 1 was the most superficial collagen. So if you had a very fine line, whether it was lips or around your eyes, or even your glabella, the, the frown lines we used to inject Zyplast, Zyderm into those, um, Zyderm 2 was for a little bit deeper, and then they realized they needed some volume collagen, and that became Zyplast, um, that, that transferred into something called Cosmoplasty, Cosmoplast took away the cow part of it.

Dr. Michael Gold (09:18):
So it was natural derived collagen that we then put into people's skin. Yeah, those were great products in the, you know, this was in the late eighties, early 1990s. Um, and that's all we had. So if people needed it or wanted fillers, um, there were no ionic acid. And then Restylane came out, you know, around in Europe, in the mid to late nineties. And, and it came here, I think it was 2003 or four, like you said, Larry. And so that was our first foray into, Hey, we have this wonderful, you know, clear filler that acts as you know, it's hyaluronic acid absorbs water, and then, you know, it takes away lines and wrinkles. And that was, again, something unique to that line of fillers.

Dr. Lawrence Bass (10:09):
And, and that was kind of the initial indication. Uh the Restylane, Juvaderm first approvals were things like moderate to severe facial folds increases. So not so much fine wrinkles, but things like nasolabial fold. And, and that's what people started realizing that these needed to be injected differently, that they produced a little different effect than the lighter collagen fillers, because they were heavier. And that water absorbing property you mentioned was really important because as the filler degrades it embibes or absorbs more and maintains closer to its initial volume than something like a collagen fill, just degrades linear.

Dr. Michael Gold (11:04):
And, and when these products all came to the US, the FDA sort of said, okay, you want to introduce a filler into the United States. Well, how do you prove it works? So again, the rest in trials. And so being able to look at your nasolabial folds, you can compare right to left. And so the original studies were Restylane collagen, um, because that's what we had to study. And obviously Restylane did better than collagen, but so you had, and we had scales that had to be created and then vetted so that through the FDA. And so the easiest scales on the face to do at the beginning were the nasolabial folds. It's easy. Um, now we have scales for the nasolabial folds, the cheeks, the lips crow's feet the frown lines. I mean, there's forehead. We have scales for everything now, but back in the early 2000s, we only had nasolabial folds. So every filler that came to the US, even if they were not really for the nasolabial folds, the entryway was the easiest path to get in, was to study the nasolabial folds.

Dr. Lawrence Bass (12:24):
But it it's really expanded out from there because doctors were very smart about figuring other indications, what we call off-label indications that were not the exact FDA approval. And then the manufacturer circled back and actually did clinical studies on those. And this is something that, that I love to do. And I know Dr. Gold loves to do it's fun to be able to play with new materials, but also to actually look very critically generate data, look very critically at the outcomes for very specific indications and understand and really wring out how these products work and perform

Dr. Michael Gold (13:06):
It's also, it's also nice when they, after the approval, when the patients come in and they go, well, I heard about this product X, have you ever used it? Well, I had, you know, put 50 people on this clinical trial for the FDA. I did 150, 200 injections over the last two or three years with people, um, using this product. And we know everything about this product that we've learned over these two or three years, instead of somebody going well, the rep came in and gave, you know, I have a syringe of something brand new. I've never tried before. So by the time these products come to market, again, it, you gotta learn them, but we are fortunate that by the time they come to market, we know all about them.

Dr. Lawrence Bass (13:50):
So, so Dr. Gold, where, where have they gone on formal indications since those initial nasolabial fold studies?

Dr. Michael Gold (13:58):
So, uh, I mean, we have fillers now that have approvals for the nasolabial folds for volumizing the cheeks. Um, we have fillers that are approved for the lips. Um, that's really the main indications that people have gotten approvals for off label. They're still being used all over the place. And I think clinical trials are going on with certain products, like radius is looking at jawline definition. Um, some other fillers are looking at temple hollows. Um, so there are places that people are still looking at it, there's this, um, concept of hyper, we call it hyper dilute, but dilutes a really bad word. So we like the word blended or blended, um, radius or sculpture in the neck, in the decollete. And, and I think we're, we're going to get to the point where they're going to be studying that to improve the, the way the appearance of the neck and the decollete area.

Dr. Michael Gold (15:05):
I think that's nice, um, for those patients that want that. Um, and so you there, the indications are there that I, I know that, you know, Radiesse has an indication and Sculptra as well, I think for the hands and for rejuvenating the hands, um, um, I know Radiesse does, um, I know Sculptra's working on it. Um, I'm not sure they've gotten it yet, but they're probably there. And so I think, you know, you have to look at the class of filler, what the fillers penetration depth is, as far as where you're injecting this and figure out where, where we're going to use it. Now, some of the new fillers are going to come out for very superficial lines and wrinkles, um, and they're coming. Um, and then we're going to have a whole class of fillers eventually that are, um, going to come out what, outside the US, they're known as skin boosters, where they really are just sugars. Um, so the, the amount of ionic acid in there, there's no, there's very little of any crosslink and they really just contain a lot of sugar. So they improve the quality and surface structure of the skin. They don't make wrinkles disappear. So that's a whole new class that exists in Europe. Yeah,

Dr. Lawrence Bass (16:28):
That's really interesting. But my question hearing that is how do the, you know, the way we keep the hyaluronic acid from degrading is with cross-linking mm-hmm <affirmative> and size of the molecule. It's a polymer, basically, it's, it's like a sugar that's polymerized, a really long chain of sugar. So how do they get durability with those, with those, uh, skin quality injections?

Dr. Michael Gold (16:55):
So a lot of, so again, they're very superficial injections, so they're really, you know, right in the superficial part of the dermis, um, and the clinical work outta Europe is that, you know, people get six to nine months duration.

Dr. Lawrence Bass (17:11):
Wow, that's pretty good.

Dr. Michael Gold (17:13):
So, so that, you know, we'll have to see how I always say it. We have to see how that translates when the US gets it. Um, then we'll have, you know, our data and then we'll be able to decide, um, what, but if you can inject and there's some that do it by free hand injections. And there are some devices out there that exist, um, that are, that are skin booster devices. So you just sort of put it on the machine, does the work, you, you guide the machine. So the needle depth is always the same and so forth and so on. So there's a lot out there outside the US. Um, and again, we have to see how fast and how much of that will come to the US, but I know there's several coming.

Dr. Lawrence Bass (17:56):
Okay. That's really interesting. Yeah. We, we know that development is not going to stop and a lot of growth is expected in injectables, um, with all the different products that are out there now, how do you pick what you stock in the office? How do you pick what you give for patients? What's the decision making process like for you? Because that's something I've always puzzled over. I, you know, I don't know that I want to stock 40 products like the Europeans typically do mm-hmm

Dr. Michael Gold (18:27):
<affirmative> well, I think again, in Europe, it's a lot easier because the average cost is much less, you know, here, here in the us, this is the holy grail and, and, you know, all medicines are more so, um, and that goes to all the cosmetic medicines versus what you can get in Europe, but you can't bring 'em back from Europe. So don't go over there when you go and buy products and try to bring back. That's not allowed. Um, but I think, you know, it, it, I think the average that not the average, I think if you're a good injector, you have learned your skill set on a group of products. Again, it could be one from column A and one from column B, but it all, it doesn't have to necessarily be in one family. Um, but you know, if you're, if you're a Restylane person, you're going to learn the seven or eight Restylane products that exist, and you're going to learn every bit of them and how do it what's makes one different than the other, and where do I use one versus the other?

Dr. Michael Gold (19:29):
And then you may say, you know, I don't need all eight. I need three, and those are going to be my three go to products. And I'm going to know everything that can be known, be learned about those three products. Or you may say I I'm a Juvederm person, and I really want to use the, you know, the Voluma vol, you know, all the, the vols out there that exist. And some of the new things that are coming in the Juvederm family, and then you might be a person that says, you know, price is really important to me. And Prollenium makes really good, um, you know, fillers in the Versa family for the, for that work really well. And I like that. And you may be a Merz person and say, I want to use Belotero, which we only have one in the US and there's five or six outside the US.

Dr. Michael Gold (20:17):
Um, but you know, I don't think you can be an expert in every filler out there. Um, I like to think those of us that do the clinical trials know more about it. Um, and you know, if you're going to play in this sandbox, you gotta pick which sandbox you want to go to. And if you want to play in all the sandboxes, you know, that's great. Um, I play in everybody's sandbox, um, because I work with every one of these companies and I, and I, you know, um, but as far as choosing which ones on a specific patient, I sort of use my clinical judgment that I think this one is going to work better for you. Um, you've had X before, you're going to stick with X, if you did well. Um, and I try to, I try to always match the filler to the indication, not the group of fillers. So the name filler, but I know that I have these three volumizing fillers here. Um, you know, first thing is, are we doing a special on one, you know, buy one, get one at half price, or, you know, what did the company do for me this month that we wanna do? Um, or are we not doing anything? And they're going to, you know, this is the cost. And so I cost is very important, um, as much here as it is everywhere. Um, and so I take all that into consideration, but it's not easy.

Doreen Wu (21:54):
Now, let me ask about it from the patient's perspective. Let's say you have a new patient who comes into your office for a consultation. Um, they want to look more rejuvenated, but they've never had any fillers done before and are interested. Um, what are some tips for how to pick a filler?

Dr. Michael Gold (22:11):
So I think, you know, the first thing that we all do, I think if you're going to be a good cosmetic person, first of all, like Dr. Bass is the most calm person I've ever met. All right. And so, you know, even when we're in discussions in meetings, he never gets upset. So I think that having the demeanor of being a good listener is really important. Um, and dermatologists are very quick, so we don't always listen like we should, but the first question is always the same to all my people. What is bothering you? It it's it, you know, here's the mirror, show me what is your concern today? Because they may have a line on their face or wrinkle that they means nothing to them now. And it may, and it may be the only thing I focus on. So you've gotta sort of, I, I let the patients guide me on the, what bothers them scenario, but as it always does, or 99% of the time the patients say, this is what bothers me, but you have to tell me what, you know, what can you do to make me look better?

Dr. Michael Gold (23:31):
What, what should I do? Um, and then you sort of put together a game plan and the game plan doesn't have to be everything in one day. And, and again, when we're, especially when we're talking about and toxins and devices and skincare, um, and that's not even your surgical world that you, that you still live in, that is not a one day process. So you may get a toxin today, and we've just discussed about the skincare. I mean, just about the fillers, or you may get a filler, an toxin, and then next time you come, we're going to introduce devices or some other thing into what we do. So it's always about listening and then finding out their biggest concern. And then once I learn their biggest concern, sort of mapping out a strategy that will get them from a to B in, within a price point that I know will, will be within their budgets too, because the worst thing that you can say to somebody is, wow, uh, you've got, you know, you've got all this stuff and you're going to take eight syringes of filler at, you know, a thousand dollars a piece. And, and it's going to be $8,000. And then we're going to have to repeat this in about a month and half, because you're going to need more, you know, and if that's the case, they need a facelift or they need, you know, they need something beyond what I'm going to be able to give them.

Dr. Lawrence Bass (24:59):
Yeah. And I think your whole point about, uh, you know, you don't have to do it all at once is really important. I mean, you didn't age in a month, you aged in decades and we're going to rebuild and you rebuild a little bit here in a little bit. There, you want to see a meaningful improvement. I mean you want to see something is happening that that's important for patients, but we don't have to change everything overnight. We just need to be getting younger, looking better, looking enhanced rather than letting the aging progress we need to, you know, prevent, maintain, and restore which is a big part of

Dr. Michael Gold (25:40):
It. And even, you know, a little bit sometimes goes a long way.

Dr. Lawrence Bass (25:44):
Oh, absolutely. I, I, I think, you know, we're Americans and we have this mistaken notion more is always better and it's not, it's not always true. You know, we, we want to accent your appearance and little changes sometimes really, really make an impressive change. Why is Botox one of the most popular treatments of any aesthetic treatment in the history of humankind? And we're just treating for starters, those little elevens between the eyebrows. It seems like such a small thing, but people feel so happy when they see how they look after Botox, that they never want to stop doing it.

Dr. Michael Gold (26:27):
And they want to know how much, what else Botox or any of the botulinum toxins will do for them. Right. Right. You did, you did the little lines here and they're like, that's unbelievable. Um, so yeah, I think sometimes it's, it's, it's under, as I said, understanding what the patient wants and that doing it over, doing it as Dr. Bass said, slowly and, and, you know, you don't need, you want the wow, right. We all want the wow effect for our patients, but we don't want them to look weird,

Dr. Lawrence Bass (27:02):
Really important, really, really

Dr. Michael Gold (27:04):
Important, you know, and all you have to do is, you know, look on the internet and look at all these chats and all this stuff, which I never do, but there are weird people saying weird things and we've gotta maintain our strict code of do no harm, do be, be, you know, put yourself in their shoes and make sure that what you're doing to them, you would do have somebody do to you. Because again, we know what the good and bad is. And so we only, we don't want to create the bad. We really just want to create the good,

Dr. Lawrence Bass (27:40):
And that's an important point. You know, if I make my living doing this, and if I'm telling you not to do something or to meter the amount you're doing, that, that doesn't work to my advantage. If I'm telling you that it's solely for your benefit, because I want you to look natural and, and beautiful. Uh, and, and beauty is a process. It's not an event. And that's really what you've spent your whole career doing. Right. Right. Uh,

Dr. Michael Gold (28:07):
And, and you want the patient to look, you want the patients to look natural, you know, so even if you're treating somebody's glabella for the, you know, the, the forehead lines or whatever, it's okay to have a little bit of movement, you know, 20 years ago we wanted everybody to be frozen. All right. And now having a little bit is okay. And if they don't, if they don't want that, you can put a little more in, but you, it, you gotta sort of understand the, the aging process, the natural look. And we want everybody to look natural.

Doreen Wu (28:46):
I want to go back to the earlier discussion about fillers abroad and in the global market. Mm, Dr. Gold, how does the international filler market differ from what we have here in the US?

Dr. Michael Gold (28:57):
There are hundreds of them. We, we, I think I don't even, I stopped counting what we have here. We probably have, and Larry correct me. We have like 20 fillers.

Dr. Lawrence Bass (29:06):
Yeah. That's about right.

Dr. Michael Gold (29:08):
Okay. There are hundreds, hundreds of fillers in Europe. Now having said that, and the reason was that be, was, it was easy to get approval. You, you basically just had to say, well, we're just like that. And so they, they had to prove that they worked, and that was really it in 2018, the rules changed in the European union. Um, that said that if you're a filler company and you wanna introduce a filler, or if you have had fillers, you have to do two things. You have to do a study on those with HIV lipoatrophy. First second, you had to do a safety and efficacy study. So in the US, we don't care if it works, they they're not coming here. If they don't work, we're just going to prove they work. We wanna prove their safety or, and their efficacy. That's the most important thing when we do clinical studies is looking at the safety profile.

Dr. Michael Gold (30:16):
And so that's why we do what we do in Europe. Now, since 2018, any new filler has to do exactly what we do and that didn't exist before then. And if you wanted to maintain yourself on the market, you had to go back and do those safety. And these studies on a significant number of patients. So you could have come out with a filler with like, I, you know, they did a 10 patient study, but it worked. Um, and so they got approval EU approval. Now they can't do that. So I think the numbers are dropping. Um, but those that we're seeing in Europe that haven't gotten here yet, have all gone through this safety and efficacy study, um, that they've had it go through. And it was amazing a couple years ago, right before the, in the 2018 19 realm. Cause I go to a lot of meetings in Europe.

Dr. Michael Gold (31:08):
Um, I had every company wanting to talk to me about, you know, what I would, I help, you know, consult with them on, on making sure that they were doing it right and so forth and so on. Which for me was great because now those companies are coming to the US and, and you know, we're helping them. So, um, but yeah, the, yeah, you want to make sure that the, these things are safe and I'll give you one, for instance, um, there was a filler, it worked incredibly well in Europe. At least it looked like it did. It looked like it was going to last about a year to 18 months. And sort of, as soon as they got their European approval, they started their US FDA clinical trials. And about six months after the filler injections, people started getting what are called grans, um, which really hadn't been seen in the European stuff because they hadn't been studied out that long, or they didn't do a lot of injections.

Dr. Michael Gold (32:15):
And, you know, there was a class action lawsuit against the company. The doctors were in trouble. I mean, I had nothing to do with this trial, but again, it's why we do clinical trials. Um, because we want to make sure before we take it to the masses, we're studying it again with the right doctors that know what to do and know how to handle problems. Um, you know, and so those scenarios are not going to happen very often here in the US because the companies have to go through so much today to get a filler into the country, into the US. So we can be very comfortable that if they've made it into their quote unquote pivotal trial, that we know it's going to work and we are comfortable that we're going to study their safety through at least a year, if not longer.

Dr. Lawrence Bass (33:08):
So I think part of this is about how FDA has dealt with fillers compared to European regulatory agencies. And basically, you know, FDA did the job, right? We have a relatively small number of fillers with a great deal of data, with a great deal of experience, uh, and study demonstrating that they're efficacious, that there are specific indications where there's really solid proof, they're efficacious. And as Dr. Gold said a hundred percent, most important that they're safe, uh, and that's critical, uh, the ability to then vary and customize the fillers a little bit or blend as Dr. Gold said gives you some control as a, as a provider. Uh, but basically it's that knowing you're starting with a safe material that's biologically compatible and that has a track record is, is really the difference. And then the qualifications of the provider injecting, which varies a lot in the European markets, uh, from country to country who is legally qualified to inject. And here that's much more uniform and standard, at least when it comes to injecting fillers,

Doreen Wu (34:36):
Before we end Dr. Gold, can you share any important points for our listeners to keep in mind about fillers?

Dr. Michael Gold (34:43):
Um, to me, yeah. I mean, I think always go to somebody that knows what they're doing. I think, you know, you're in New York City, I'm in Nashville. I think there's somebody that can inject that wants to inject a filler, probably, you know, every 15 yards from where you work. Um, and the reality is they, they don't have your experience and they don't have your knowledge. And, um, again, I don't badmouth anybody. Um, but I think, you know, we've, you've gotta, you've gotta go to somebody to have these procedures done that really understand what they do. And even here in Nashville, um, I sometimes get amazed at somebody putting in the filler where we know they should never put that filler. Um, so an inappropriate filler in an inappropriate location. Um, and so as I do, I know you do, we spend some time actually trying to reverse some bad results that people get.

Dr. Michael Gold (35:48):
And so I think that if people do their homework and go to reputable providers that are really knowledgeable, that's the most important thing for the healthcare worker that does this. This is in point and shoot as is not botulinum toxin. This is a learned skill. Um, and you've gotta know the anatomy. Um, you've gotta know where not to put the needle. You need to know what to do if something goes wrong, um, which is rare and really rare, but that's the, you know, that can define your whole career. So, um, we want to, so the, I it's always patient beware out there for everything they do. Um, you know, I, and, and it doesn't have to be in the cosmetic arena. It's for everything. You know, why are you going to this person to get this done? When you know, there's somebody down the street, that's a real expert.

Dr. Michael Gold (37:01):
Well, they charge more money. Well, they charge more money because their educational level and their skill level and their expertise is worth it to me to go to them. You know, I always say that, why do I, you know, why do I go to who I consider to be the best cardiologist in this city once a year to listen to my heart, I've done it for 30 years. He was my chief resident. When I was an intern at Grady hospital at Emory in Atlanta. He is the, to me, the finest cardiologist I ever met. And once a year, I want him listening to my heart. I have no heart problems, but once a year he tells me I have no heart problems. That's worth every penny that I pay to that visit. And so if somebody wants to come to me, I want them to have that comfort level that I know what I'm doing or come to you. We know, you know what you're doing and not somebody that is just, you know, Hey, they just did a weekend course. And, you know, so and so, and watch somebody inject somebody and, you know, so they just, so it's buyer beware.

Dr. Lawrence Bass (38:16):
I think what Dr. Gold said is exactly right. It's really critical to have expertise, skill, experience, background knowledge, to be able to use fillers safety safely, which again is critically important. And to get great results, make great selections of which filler is appropriate or how the filler should be blended or customized, uh, to address the features that are really bothering the individual patient in the United States. We have the core for the group of four aesthetic providers who as part of their residency training and experience are trained in providing aesthetic treatments. They didn't pick it up in a weekend course or some other way. But this is part of their medical knowledge and training part of their board certification. And those are plastic surgeons, dermatologists, facial, plastic surgeons, and oculoplastic surgeons. So those individuals, you have a baseline assurance that this is a, a part of their specialty that they were trained to perform. And then if they have a great deal of experience doing injectables on top of that then they're particularly qualified to bring you the best result. So that, that really is, is the best way to get what you're looking for with fillers, be safe, be natural, and have someone who will listen and respond to your aesthetic concerns. That's right. That's right. Well, Dr. Gold, I I'd really like to thank you for joining us for this episode of park avenue, plastic surgery class, and bringing your encyclopedic knowledge and wealth of experience.

Dr. Michael Gold (40:09):
Thank you. All right. Take care,

Doreen Wu (40:12):
Everybody. Take care. Thank you. Thank you for joining us.

Dr. Michael Gold (40:15):
Thank you.

Doreen Wu (40:16):
My thanks to Dr. Gold for taking time out of his busy schedule to be here with us and shares expertise. It's always exciting to hear from experts who are at the forefront of their field. And this episode has certainly given me a lot to think about if you have any remaining questions for Dr. Bass and Dr. Gold, or if you think of other exciting trends or developments in plastic surgery that you would like us to discuss in a future episode, please reach out by email or Instagram. We'll see you next time. This is Doreen Wu. Thanking you for joining Dr. Bass, Dr. Gold, and me for this discussion of injectable fillers in the US and abroad and how the industry has evolved over time. Be sure to join us next time to hear about another aspect of this fascinating field, as always, don't forget to subscribe to our podcast. So you don't miss out on any of the exciting content that is coming soon.

Speaker 4 (41:07):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.