Bella Fill and Other Nose Enhancements: What You Need to Know, featuring Dr. Alexander Rivkin and Dr. Brandyn Dunn

Trina Renea  0:07  

Hey everyone, welcome back to Facially Conscious with myself, Trina Renea – Esthetician, Dr. Vicki Rapaport – Dermatologist, Rebecca Gadberry – the Cosmetic Ingredient Guru, and our Fabulous Overly Educated Consumer - Julie Falls. We are gathered here together with you to talk about this crazy world of Esthetics. It's confusing out there in this big wide world. That's why we're here to help explain it to you all, subject by subject. We will be your go-to-girls and from our perspective without giving medical advice, we will keep things Facially Conscious. Let's get started.

Dr. Vicki Rapaport  0:59  

Good morning to everybody. How is everybody this morning? 

Trina Renea  1:02  

Good morning. 

Dr. Vicki Rapaport  1:07  

So excited today. We are the women of Facially Conscious and we have a very exciting program for you today. I'm going to introduce two of our special guests and the special important topic today which is Cosmetics of the Nose. So, our very wonderful first guest is Dr. Alexander Rivkin and he is a Cosmetic Surgeon with a very incredible background. He was trained at Yale Medical School and then he did his residency in ENT at UCSD. He is really the pioneer of Non-Surgical Rhinoplasty which is basically non-surgical nose surgery. He is an Assistant Clinical Professor at the UCLA School of Medicine and has published a number of papers and textbook chapters. And he's also a Lead Investigator on many of the FDA and NIH clinical trials. He actually practices close to me in West LA. And we'll be talking to him about one of his specialties and really, he's an expert in the field. So welcome Dr. Rivkin.

Dr. Rivkin  2:11  

Thank you so much.

Trina Renea  2:13  

We're so happy to have you on this show, finally.

Dr. Vicki Rapaport  2:16  

You guys have no idea how hard it is to get this man around for this amount of time. So please tune in. And then joining us today as well as Dr. Brandon Dunn, who we love as well. He is also a Facial Plastic Reconstructive Surgeon; he practices in Newport Beach.

Julie Falls  2:33  

He's a regular now.

Dr. Vicki Rapaport  2:34  

He's our regular crew.

Rebecca Gadberry  2:36  

Yes, meaning he's been on twice now.

Dr. Vicki Rapaport  2:41  

He grew up in Hawaii, where he actually received a Master's in public health. And he went to medical school at the University of Hawaii. Of course, everybody is drawn to Southern California. So, after medical school, he came to Southern California and completed his residency in head and neck surgery which is EMT at the University of California Irvine a very difficult school to get into. He then did his fellowship in Plastic Surgery, Plastic and Reconstructive Surgery in Kansas. And then I imagine quickly took the next plane back to California, because nobody's going to stay out of California for too long, especially in his field. So, he does also have an amazing expertise and passion for Rhinoplasty and aging face surgery. Welcome, Dr. Dunn.

Trina Renea  3:29  

Hi, Dr. Dunn. Welcome back.

Dr. Dunn  3:31  

Hello, thank you so much for having me.

Rebecca Gadberry  3:35  

We're now on first name terms. So hello, Brandon.

Dr. Vicki Rapaport  3:41  

Part of the reason we decided to do this topic is because Trina had asked me about Nose Fillers years ago not for herself, but just for her own clients and one of the things I quickly blurred out was – oh my goodness, nose fillers soak so dangerous, so risky. I personally never do it. And then you know, she's such an educated human, she wants to deeper dive for herself. She's not going to just take that as an answer. And part of the reason you know why we have this is because there's another side of that story, and you men are experts in this. So, we are going to go deep into the complications, but also the improvements and the beautiful results you can get with non-surgical nose surgery. So, you know, Trina, do you want to ask a little bit about coming from the esthetician’s perspective and go from there?

Trina Renea  4:39  

Yes. So, I used to a long time ago worship, I still worship Dr. Rivkin. I used to go and observe in his office when I could once a month and follow him around and just watch what he did so that I could send patients to him and to have better knowledge for myself. And so, I've always been following him and sending him clients, but he works with a filler. That is a permanent filler. Do you still work with that Dr. Rivkin?

Dr. Rivkin  5:12  

Yeah, it's gone through a couple of name changes, but the filler is the same. I've been working. It's called BellaFill now, yes. It used to be called ArteFill. And I've been working with that for about, gosh, about 13 years or so.

Trina Renea  5:29  

Yes. So you know, most doctors don't work with that because they're afraid. And you are extremely professional with using it. And so, when people do have nose issues, I send them your way, because people would rather do that than get a surgery. So, when Dr. Vicki said, you know, I don't touch noses. It's so dangerous. I said, well, we need Dr. Rivkin on here because he does BellaFill And then I want Dr. Dunn on here too, because Dr. Dunn is a surgeon who does nose jobs and he also works with filler in the nose, but he does not work with BellaFill. So, I want to know why Dr. Dunn doesn't work with it. And also I want to educate everybody out there to be super careful when working with doctors who work on your nose. And so, I wanted to first ask Dr. Rivkin. What made you decide to focus on these nose fillers in over surgery like and why do you choose the fillers that you choose?

Dr. Rivkin  6:38  

So, it's interesting question. So, this is that that the answer that question goes back about 20 years, when I first kind of came into practice in these fillers, I mean, the world we live in now, in terms of fillers and toxins, and all this kind of stuff didn't exist 20 years ago, there was not very much that was FDA approved. And when I started my practice, it's just the beginning of all these things, suddenly Reslin was FDA approved. And there is this, you know, there's Botox, and now there was collagen that was it, there was not much else. And then there is radius that was being used for on label is being used for the vocal cords. And off label, there was some like crazy people using it to inject for cosmetic purposes. And that was that was the entire field. And I came, I mean, I had done some surgical rhinoplasty and training and I came in to I started the practice and all these, it felt very clear to me that there was a new field being born, as you know, in front of my eyes. And so, I really wanted to be part of that. And I thought it was so interesting to see how can I use these new tools more of which were clearly going to be coming out? How can I use these new tools to do the things that we could do surgically? How could I use them to do things non-surgically. And the first thing that came to mind was the knows that the time again, 20 years ago, nobody had done this. Nobody was injecting noses. I looked in the literature I looked at you know, there's no mention of using fillers to inject a nose. And I thought this would be a really, I thought a paradigm changing kind of procedure. And so, I started doing it and when you know called up some news stations, media, I'm like – Hey, I'm doing this, look at me… And they're like, Yeah, we want to look at you, we're going to get some. So, we went on, like I'm like on today's show, we went on a bunch of shows. And they're like, were like, we've never heard of this. This is crazy. The hell are you doing? I’m like look, you know, in front of your eyes, press their chain joke, person goes from bumpy nose to straight nose. It's amazing, isn't it? They're like, whoa, pull a rabbit out of your hat, you are a magician. So that was great. So then since then it's only become… and at the time… So, I started doing it, I realized that here was a reversible temporary way to correct the aesthetics of someone's nose because you just, I mean, these aesthetic issues that people have when they're small for the most part. I mean, there's certain and we can get into who's a client for the for non-surgical rhinoplasty and who's not and there's a significant portion of people with nasal aesthetic concerns that are not clients. They're not good candidates for this procedure. But if you're a good candidate, it's just I mean it takes five minutes. You know, I do it on stage at conferences all over the world. It's like, no big deal. So, that was great. I mean, and since then it's just only become more and more popular. But first of course, it was, you know, so here's the Dr. Dunn has a surgeon that does this procedure, let me just tell you that 18 years ago was, you know, 16 years ago, there is no surgeon that would have ever admitted to actually doing this kind of this procedure because they're at this was considered to be like, just I mean, this is what's the word? What's the word religious when it goes against religion? Sacrilege? … It is considered to be absolute sacrilege.

Dr. Vicki Rapaport  10:52  

You're a heretic. 

Dr. Rivkin  10:55  

Yes, I was proud to wear, you know, the big H on my head. It was a mark of pride.

Dr. Vicki Rapaport  11:03  

Are you saying that because it was not as prestigious as surgery, or you think was it was dangerous and the complications were manifesting?

Dr. Rivkin  11:14  

Well, I think it was a new ... I mean, it was a new procedure. People didn't know what were the long-term kind of consequences to it. And which is logical, but, you know, we know what the long-term consequence of filler in the faces in general, why would the nose be any different. And also, I think that you know, there's also, it's a challenge. It is a challenge to the finances, frankly, of, you know, of a lot of surgeons and they thought it to be challenged to like that here is like, suddenly…because to them, I think, and this is I don't think… this is not illogical. To them, they're like, okay, these products are coming out here these Yahoo's running around on TV and jacking noses all over the place. And if those Yahoo's are going to be doing it, then all sorts of Yahoo's are going to be doing it and God knows what kind of complications we're now going to have to deal with. Because all sorts of like, you know, people who don't have enough knowledge of the anatomy, don't have enough knowledge of what it takes to really have a good aesthetic result for the nose are going to be going around injecting noses, are going to have problems. And, you know, I mean, that's kind of have a little bit.

Julie Falls  12:46  

Were lots of plastic surgeons worried about their rhinoplasty business that they're going to…

Dr. Vicki Rapaport  12:51  

I think that’s what he means by our challenge. Financially. Heretic that speaks in euphemisms.

Trina Renea  13:00  

So, why is it so dangerous to inject the nose? And why do you have to be careful who you go to?

Dr. Rivkin  13:06  

I think you have to be really careful. Okay. So, it used to be that I that I would write about, and I wrote articles about this procedure. And it used to be I wrote articles about how great this procedure was, and how you can really achieve so much with it, and how happy people were with the results. And that was all true, and it still remains true. But now what I write about always is the safety aspects of the procedure and how to avoid complications, because now, a lot of people are doing this procedure all over the world. And the problem is, is that we're seeing now, side effects, we're seeing adverse events that are very rare. So, we're seeing the adverse effect, we're seeing different kinds of adverse events. In the nose, we're seeing, fairly, you know, bruising, redness, tenderness, no big deal kinds of things that happen, you know, more that happened more often. But very rarely, we see very bad adverse events like ischemia, necrosis, and unfortunately, blindness. And now, we're seeing again, as this procedure becomes even more and more widespread, we're seeing cases reported of stroke as well and death. 

Trina Renea  14:30  

Death from a nose filler?

Dr. Rivkin  14:33  

Correct. And most of these cases are have happened in Asia. And I want to say that most of these cases have happened in places where the regulations for who can and who can't inject are very lacks. And, you know, it's a lot of these kinds of nail shop injections or barbershop injections kind of thing in Asia and you know, in other places, but nevertheless, there certainly been cases of blindness in the States, there's certainly been cases of blindness in Los Angeles. And the UCLA Eye Center has dealt with a number of those. And I know that I've seen those case counts. So, I think the thing about the nose is that it's a procedure that looks very easy and straightforward. And it is fairly easy and straightforward, until you know, 999 times out of 1000. It is, but that one time, out of 1000 can be really devastating. And you want to make sure that you're taking all the precautions you can and that you have knowledge to do to A) Avoid complications, and minimize the risk of complications. B) Be able to recognize complications that they do happen, and C) Be able to treat those complications effectively and in time, because if something happens, time is of the essence. And that's the difference between somebody who knows what they're doing. And somebody who doesn't, is that that person knows what they're doing knows all three of those things done.

Julie Falls  16:18  

Dr. Dunn, you've been doing the same type of procedure for how long? And can you tell us a little bit about how you got into it an your journey.

Dr. Dunn  16:32  

Yeah, of course. So, I would say, you know, first of all, Dr. Rivkin is a pioneer in this. And so, I'd say a lot of what I know about nasal filler has all started from him. So, it really is an honor and a privilege to be talking with you as well today, so appreciate it.

Dr. Vicki Rapaport  16:48  

That is so cool. Thank you for saying that. I mean, to him. Thank you.

Dr. Dunn  16:53  

Well, I figured he deserves it. He's kind of made this a very popular and very common procedure that I think a lot of surgeons are doing now, because it makes sense. So, I'd say all of my experience initially was rhinoplasty surgery, and everything that I did was surgical. And the people that I trained under were exceptional surgeons. And they were really, really afraid of liquid rhinoplasty and non-surgical rhinoplasty. So, my early exposure was to fear it, and to not even think about it and kind of stray away from it. And so, as I started to kind of become more comfortable with the anatomy and my experience and do more surgeries, I saw and become more comfortable with filler, I started to explore it. And so, over the years, I've kind of started to explore non-surgical rhinoplasty. And I'd say I'm definitely much earlier in my career as far as feeling comfortable and doing non-surgical rhinoplasty, but I find it to be a really useful tool to be maybe a stepping stone for many patients.

Dr. Rivkin  18:02  

Yeah.

Dr. Dunn  18:05  

And so, a lot of people come to me, you know, and I will talk about, you know, who's a good candidate and who's bad candidate for liquid rhinoplasty. But, you know, a lot of people will say – hey, I want to see what this is going to potentially look like. And we can use this as a tool to kind of show them and give them a little bit of a exposure to them. And so, I really liked that. And I find that to be extremely useful in my practice. And then, you know, the one thing that I've learned as far as liquid rhinoplasty is obviously it's extremely, there are many cases out there that go extremely well. And there are those few cases that happen where there are devastating consequences, but it is extremely rare. And I was exposed to someone during my training where there was blindness after rhinoplasty and I think it really is just being comfortable with the injection technique and comfortable with the anatomy that will keep you safe.

Julie Falls  19:05  

Blindness after a liquid rhinoplasty.

Dr. Dunn  19:09  

Liquid rhinoplasty.

Julie Falls  19:10  

Trina was going to like run with this now.

Dr. Vicki Rapaport  19:12  

Dr. Dunn, can you just explain to us, you know, just its vascular problem, but can you explain to us and also our listeners exactly why there's the ischemia. God forbid the stroke, god forbid the death, god forbid the blindness just briefly for a lay person?

Dr. Dunn  19:37  

Of course. I will say that I don't think we know the exact mechanism. There's a lot of proposed mechanisms that people suspect but one of the more common, and Dr. Rivkin please weigh in if you hear something different, but one of the proposed risks is that you know, in the nose, there are blood vessels or veins that don't have valves. And so, if filler, a small amount of filler gets into one of those veins, then it can travel like a stroke or an embolism back into circulation deeper into the face. And that can be the eye or potentially into the brain. And that can cause basically a clot and stop blood flow. And then when it comes to ischemia, or death of tissue, that's more from potentially a stroke, or an embolism or clot or also pressure putting too much filler into a particular area and causing compression of the blood vessels to that area. So, I think there's two things at play. Do you have anything else to add?

Dr. Rivkin  20:39  

Yeah, I think that's exactly. I'm glad you said this, because you're exactly right. Because we used to, and this is actually a much more nuanced explanation, then you hear at almost any conference that you go to these days, as people are still talking about blindness being caused by retrograde propulsion of filler, you know, back up through the arterial system. And I think that that is probably is a possible mechanism, but it's probably an unlikely mechanism. Most likely, it's, as you say, it's an arterial, arterial venous connection somewhere. And somewhere along line, it just basically, but for the lay people out there, it's basically filler getting into a vessel and going into the wrong place. And sometimes it's something and it's and I think that the reason why it is very, very rare. It's like a plane crash kind of thing. And I think the reason why it's very rare is I think it'd be it depends upon someone having a that kind of malformation within their facial vasculature, which is quite-quite rare. So, I think that that's exactly right.

Trina Renea  21:57  

But couldn’t that happen to any doctor, no matter if you're skilled or not skilled about injecting, if you don't know where the vessels are under there, so how are you… 

Dr. Rivkin  22:08  

But there are measures you can take, right? I mean, there's, measures you can take that keeps you more safe versus less safe, you know.

Julie Falls  22:14  

Are there patients who are, you know, who are clutters that maybe you would stay away from? No, has nothing to do with clotting?

Dr. Rivkin  22:21  

No, I think it's just you have to be careful in terms of how much you're injecting and what kind of pressure you're putting on the plunger, you know, when you're if you're showing a whole bunch of stuff, like material into one place, I think that that's, that's unwise, you know, I mean, so there's, we can get into kind of safety kind of safety maneuvers, that that we both Brandon and I use, but I think like the main thing is, you never know where that tip your needle is, because you can't see under the skin when you're inject. And so, you have to just kind of, you have to take what I call universal injection safety precautions, which means that you just assume that the tip your needles in someplace not good. And so, you never inject a large amount of filler into one place you I always keep moving with my syringe and I inject tiny amounts. I think that's a big portion of what keeps you safe.

Dr. Vicki Rapaport  23:20  

And also, you touched on that before we switched over to Dr. Dunn, you were saying that, if there are complications, not only to recognize them, but time is of the essence and there, you know, these doctors who are very skilled and, you know, surgeons are skilled at not panicking, they know how to manage these complications. And that's a huge proponent of this trying to avoid the problems. Have you ever had a problem that you've had to manage? And did it hopefully go well? Either one, yes, either one.

Dr. Rivkin  23:53  

Brandon, you want to do that?

Dr. Dunn  23:55  

Knock on wood, I have not had any problems at this point. But I imagine you know, you get enough numbers and something is going to happen. And but I have a protocol at the at the office that I'm at, we have a protocol exactly how to treat it, how to identify it. And anytime that I do nasal filler, I always have a very explicit conversation with my patients of what exactly to look out for, the timeline to expect when things could potentially be happening, and to be, for me, you know, I don't do nearly as much as Dr. Rivkin. But, you know, I'm essentially on call for those early periods if they need me they can call the office and get in touch with me and so that's how I generally handle it. I just wanted to ask one question, because one thing that I've started to do and I don't know if you do it, Dr. Rivkin, but do you stage your injections to kind of do it over multiple, you know, a couple of treatments?

Dr. Rivkin  24:53  

Okay, I think you have to with non-surgical rhinoplasty partially for efficacy. But also, it's not like a under treat on the first session, I find that they settle. But no matter you know, you treat them and it looks really good right afterwards and you're like, oh my god, I am Michelangelo of the nose, I’m the DaVinci have schnoz. It's great. But then and for a moment you are but then it there's some every time you put a needle through the skin, there's a little bit of edema that happens, there's a little bit of inflammatory effects, so there's swelling, some that swelling phase and there's some settling of the filler. So, I like to bring them back whenever is possible, like a month, two months, three months later, depending on availability and do a touch up. And that's standard for each of my procedures.

Julie Falls  25:47  

By the way, sorry to interrupt you, I have to say that the shape of her nose is beautiful. I don't know what she looked like beforehand. But even with all of that, you know stuff the shape was gorgeous.

Dr. Rivkin  25:58  

She actually looked really good. She looked pretty good beforehand. It was a minor stuff, but she was but of importance, okay, but this is actually something I forgot to mention. She had had two previous rhinoplasty, surgical rhinoplasty. Those are the patients I see. Those are the patients where it's clear that there is increased risk. And I wrote a paper looking at my first 2500 cases that I had of this, and clearly of those of the patients that I saw, if you had had a previous surgical rhinoplasty your risk of problems is 50% higher at least.

Julie Falls  26:35  

So, she hadn't had an actual rhinoplasty. She had a liquid…

Dr. Rivkin  26:41  

No, she had surgical rhinoplasty.

Julie Falls  26:42  

Why? What does she want, then? What's happening? What? 

Dr. Rivkin  26:46  

This is really common. I mean, half the people I see have had surgical rhinoplasty because there's not I mean, it's a hard procedure. Rhinoplasty is a super difficult procedure. So you know, I mean, I commend Brandon for being an expert in rhinoplasty, because that is a hard thing to do. You never know how it's going to scar you, you never know what the final result is going to be. And there's always going to be little itty-bits that just kind of you want to smooth over or you want to, you know correct and stuff like that. So, I see, half the patients I see are after rhinoplasty.

Julie Falls  27:19  

Just kind of looking for some kind of perfection that doesn't exist after like to…I mean, I'm curious what that is with all of social media and they're seeing…

Dr. Rivkin  27:32  

For sure. I mean, but fortunately, but this is the thing. I'm glad that this procedure exists, that they're not looking for that perfection under the knife, you know, that's like, Should I do this? Or should I do surgery? I'm like, do not do surgery, do not do a fourth surgical rhinoplasty for this silly little itty-bitty thing that you need to fix, you know that you're obsessed about.

Julie Falls  27:53  

So, I'm sorry, one more question. Dr. Rivkin. Were you saying that if somebody had a surgical rhinoplasty, that the complications were more likely to happen if they go ahead and have the non-surgical after?

Dr. Rivkin  28:07  

Yes. 

Julie Falls  28:08  

Thank you.

Rebecca Gadberry  28:09  

Brandon is, you guys can't see at home, but Brandon is shaking his head or nodding his head, or nodding his head.

Dr. Dunn  28:20  

No, no, he everything he's saying is perfectly. And that's what I mean, again, a lot of the stuff that I'm quoting to my patient is from actually many of his papers. And so, it's true. I mean, you know, the anatomy of the nose is already complex. But then when you have surgery, it becomes so unpredictable, and so much more complex. And so, I suspect that's probably why we end up seeing more complications. You know, we tend to have areas where we know are safer and more dangerous in the nose. But those areas tend to change when you surgically manipulate them. And so, I think that's probably why that happens. 

Dr. Vicki Rapaport  29:00  

And then here's the big scary question. So, Dr. Rivkin you do, do permanent filler. A) Why? And B) If you get a complication, is it just as easy to manage potentially as the semi-permanent filler? Not easy, but you know what, I mean, is it manageable?

Dr. Rivkin  29:19  

I mean, so I think it’s important to explore that. Permanent filler is here. There's a desire for patients to not have to come back every you know, whatever it is two years, one and a half years for a refill of their temporary filler. Number one, number two, every time they come back for refill of their filler, they're going through another round of risk, right? Every time we do injection, it is another round of risk. Small that risk may be, but it's still risk. So, you know, at this point I am doing it because I've worked with the filler for such a long time with and I know it to be safe. I think the issue has been in Europe, there's been a bunch of permanent fillers that were on the market that were not good products, they were not good substances, there's bio-Alchemy, there's all sorts of like hydro-gels that really had a lot of side effects that had issues. The previous iterations of this filler in Europe, which was ArtePlast. There's ArtePlast, ArteCall and ArteFill, and then now BellaFill. ArtePlast and ArteCall in Europe had issues and there is granulomas. And so there was there was problems, they took the filler, and, you know, I have to say I to commend them for this, they took the filler and fixed it. And it made it more safe, there's little things that did these little tiny beads of polymethylmethacrylate, they made the beads more regular, they've made to be smaller and more uniform, and made it into more into a safer filler. And, you know, if I hadn't been using it for 13 years, or more, I wouldn't say this, but I really am very comfortable and confident around this filler. I inject it very superficially. And so, for the most part, don't get into the plane where the vessels are in the nose with this filler because the with hyaluronic acid l injected throughout the plains of the tissue, but with the BellaFill, I’ll Inject relatively superficially, because that's it depends on collagen stimulation to act, it's a filler that stimulates collagen growth. And the lift that you get is based on it building up your own college and the best place to put it in order to build up that college is very superficially. So, frankly, I don't see as many complications with this filler as I do with hyaluronic acid. And it is manageable because we still have even though the, we don't have a reversal enzyme for BellaFill, we do have all the other tools, which is steroids and hyperbaric oxygen, if that was to ever become an issue. But I haven't seen it happen.

Trina Renea  32:43  

How often you use the BellaFill, daily? And do you do that on most of your noses.

Dr. Rivkin  32:51  

Daily. Most of my patients come in for one round of temporary filler and then when they come back for the touch up, I give them a choice. Do you want to stay with temporary or do you want to switch over to permanent? And a lot of them are like well, you know, I like the result. I know what we can achieve. This is good for me. Let's go ahead and switch over. But some of them stayed with temporary because they're like – Well, you know, I'm thinking I may go you know I may do surgical rhinoplasty at some point, because once you do permanent, you're taking surgical rhinoplasty off the table forever. Because once that stuff is at your nose, you really don't want to do surgery. I mean, Brandon, I don't think you want to operate through BellaFill.

Dr. Dunn  33:34

I’m okay.

Dr. Vicki Rapaport  33:36  

But the temporary fillers, no matter how many times somebody has had it before surgical rhinoplasty, obviously, it's a challenge. But it's doable, right?

Julie Falls  33:46  

You can also take it out.

Dr. Dunn  33:48  

Yeah, you oftentimes will see it depending on how early in the process you're operating. But most of the time, I will say, I wait for it to be fully dissolved so I can see how much of a correction I need to ultimately make to achieve the result. So, I will either dissolve it if it's early on and they're really pushing for something or I will wait the full one to two years for it to kind of go back to its original form.

Trina Renea  34:16  

And Dr. Rivkin, do you put BellaFill in other parts of the face? 

Dr. Rivkin  34:23  

I don’t. Occasionally. Not very often. I don't like putting large amount. The nice thing about the nose is I'm using very, very tiny amounts of the BellaFill. I don't like putting large amounts of BellaFill anywhere because I do think that that can cause complications.

Trina Renea  34:39  

So, not chins, chins or temples or anything.

Dr. Rivkin  34:43  

I do. I'll put some and that's where I really stage it. I'll really have people come back like three or four times for something like the chin where I'll put some in and then have them come back and put some more in and put some more than, again, fairly superficially, and, you know, and watching at over time, that kind of projection happens. I don't like I really don't like putting large amounts in. But you know, I mean, and this is the thing is right, right as, as we age, the nose doesn't change that much. But as we age, other areas like the cheeks, they do change. So, I don't like putting a permanent filler into a place that changes over time.

Dr. Dunn  35:31  

Can I add one thing that I think would be really helpful? And, again, I would be interested to hear what Dr. Rivkin has to say about this. But I think the one thing that we maybe didn't touch upon is who's not a good candidate?

Julie Falls  35:43  

Right.

Dr. Dunn  35:44  

So, the two, I mean, I kind of put it in two categories. And obviously, it's much more complex than this. But if we want to simplify things, and I like to simplify things. Number one, I would say is that they have functional issues. So, if people have difficulty breathing out of their nose, if there's a cosmetic component, as well, as a functional component, I think that the efficacy of nasal filler is much less than surgery, when it comes to improving the breathing. That being said, there are studies out there that say, you know, they can do similar things, or they can improve the breathing a little bit. But I personally don't have any experience with that.

Dr. Rivkin  36:26  

I'm really skeptical of that, I think there's a lot of wishful thinking among those studies.

Dr. Dunn  36:32  

Yeah, maybe a little bit of a placebo effect, but that's okay. And then the second is, if you want to make your nose smaller, so generally filler provides it's mostly camouflage. And so, you're filling in areas to help smooth things out and prove contour. But overall, the size of the nose is becoming a little bit larger. And so, if you're wanting to make it smaller, if you wanting to make the nostril smaller, if you wanting to make the whole nose smaller, those patients tend to be a little bit less ideal for nasal filler. But those are the two major candidates. Do you have any other categories?

Dr. Rivkin  37:12  

Yeah, so I agree with that. And with one small caveat, totally, I don't promise people functional improvement, because I think that if it happens, I'm just like, bonus, that's great. But in terms of, the patients that I send to surgery are the ones that need reduction that just have a nose that is disproportionately large the rest of their face, and it needs to be reduced. There are … but the interesting thing is that there are some of those patients that do have a nose, it's disproportion and large, but they still are saying – Look, I'm not going to have surgery no matter what. So is there anything you can do to help and the interesting thing is that, while this procedure does make the nose technically larger, the perception of a straight nose versus the perception of a bumpy nose or nose with a hanging tip, because a bumpy nose or a curved nose attracts visual attention, it looks bigger than a straight nose, which blends into the rest of the face and looks smaller. It's really interesting thing I noticed early on, where if you camouflage and you make things look smooth and straight, it looks magically smaller. And I'm like, I'm making your nose bigger. And they're like, no, you're not, you're making smaller. You're Houdini, oh my god. So, it's really cool that way. So, because we're working with preset what, you know, what actually happens doesn't matter. Because what we're working is with perception. So, those are some, but what I know that the patient needs reduction, then that's not a great patient and when a patient's nose is crooked, is significantly crooked, like twisted from the front, it’s hard to make them look straight with fillers without making those nose look like a potato, you know, you don't want to fight it too much.

Trina Renea  39:18  

It is amazing how much smaller their nose looks, even though you're adding filler. It is so true when you see the before and after pictures. It does. It's crazy. It's that perception. 

Dr. Rivkin  39:31  

Yeah. It does.

Dr. Dunn  39:34  

Can I say one other thing about the location about injecting filler because I think that's another thing that's important, you know, for people that are injectors and injectors that are listening. So, I'd say staying in the middle is the safest area from the beginning. Straying from the middle is when things become much more complicated. And so, I'd say those are the two things that I would think about if you're interested or thinking about becoming an injector. 

Trina Renea  40:04  

And Dr. Rivkin, do you still teach people how to do nose injections or no?

Dr. Rivkin  40:09  

Oh, yeah, yeah, people come over for preceptorships, where either they observe or they bring patients over and they inject under my tutelage. That's really fun, it's great, because it's really, I know that these are people that are now going to be injecting within a framework of safety. And it's nice to form this kind of community of people that are, you know, kind of that are injecting the nose with full appreciation of how to do it safely, and how to do it really, effectively. And we stay in touch and you know, if they have problems, they're getting, you know, call me and etc.

Trina Renea  40:53  

I like that because that way it can give people confidence. And also, I wish that there could be a list of people that you recommend in the country for people who aren't in Los Angeles, or just you know, what, just take a trip to Los Angeles and come to the people that could do it right. 

Dr. Rivkin  41:13  

Yeah, but I do, I get DMs all the time. But hey, is there anybody in this place that you are committed? And I have, we have a list in the office of people that are like…

Julie Falls  41:22  

Yeah, that's generous.

Trina Renea  41:24  

And can I just say, your Instagram girls are hilarious with humor, I’m dying.

Dr. Rivkin  41:29  

I know, it's so funny, because people meet me at conferences, and they're terribly, terribly disappointed, because I’m not nearly as funny as the Instagram.

Julie Falls  41:42  

You got to work on your comedy doctor.

Trina Renea  41:45  

They bring it out of you. I was like, if he got funnier, maybe it's because he had kids. Or maybe the girls are making them do it. 

Dr. Vicki Rapaport  41:53  

He turns it on for that for the camera.

Trina Renea  41:57  

I love it. I was showing it to my 12-year-old daughter where you were sitting at the table with the two girls and you had to bring in the translator. The Gen Z translator and my daughter is like, I understand everything they're saying. Like she knows it's all Tik Tok.

Julie Falls  42:11  

Dad jokes.

Trina Renea  42:14  

Oh, the girls are hilarious. They talk in these words like you don't know what they're saying. 

Dr. Rivkin  42:23  

No, I love working with them. They're fantastic. They really keep me on my toes. 

Dr. Vicki Rapaport  42:30  

So, should we do a takeaway from this episode? Is there anything else? Are we all good? 

Trina Renea  42:37  

Oh, wait, no, I have that question. A guest question. We have a question from the people. I've wanted to know if either of you can help with this. So, the RF micro needling, which is radiofrequency on the tips of the needles, I'm saying this for guest listeners, is very popular now. And we had a question that they said that they think that the radio frequency causes scars, scarred collagen instead of your normal collagen. And is that true? And doesn't even matter if it's scarred or not? Does microscopic scarring, is it okay for the skin over and over through time?

Dr. Rivkin  43:31  

Brandon, what do you think, do you do much of this that stuff?

Dr. Dunn  43:35  

I don't do a ton of radiofrequency microneedling. But, I mean, I've looked at the studies, and I've talked with a lot of colleagues that do maybe a little bit more. But my I mean, my experience is that it, it's very successful, and it works, it actually works pretty well. And I think it's great for improving skin texture and fine lines and wrinkles and helping to tighten and tighten the skin a little bit. The one thing I will say is that, you know, this is very precise injuries to the skin, and any injury to the skin or any tissue creates collagen and scar tissue. And so, you know, I think what the inventors of this device did is they basically tried to find something that produces controlled scars and contractures and use that to kind of have a positive impact. So, if you cut yourself or you apply a little bit of heat and radiofrequency, you're going to get a similar scar formation and then a scar, immature scar and then a mature scar like we've talked in the previous episode, but so I think all in all, a scar is the same, but it's just a much more controlled scar that leads to a positive result. And so that's my interpretation, and that's what I have seen to be true.

Trina Renea  44:56  

So, the word she used Scarred Collagen, she thinks that this person thinks it's bad because you're scarring your collagen does that, is that a thing?

Julie Falls  45:07  

I mean, even dermabrasion is going to scar. You know, it's a form of, you know, I think any kind of exfoliation.

Trina Renea  45:18  

But this is needles that are going under the skin not on the surface, and they're burning or heating up the collagen. I guess what I'm getting at is if somebody wants to go and get a surgery of facial surgery, facelift, and their collagen is all scarred from lots of micro needling, RF microneedling, is it going to create any damage that it's going to hurt you later in life.

Dr. Dunn  45:49  

It shouldn't. But first of all, it's a micro needling RF doesn't go deep enough to be able to impact the tissue that we're going to be working in. So, during a facelift, we work in much deeper planes. And it shouldn't disrupt the blood supply. Again. This is on average, I would say most of the time, there shouldn't be any issues with this stuff. And yeah, it shouldn't, it shouldn't influence a facelift in the future.

Trina Renea  46:18  

Okay, do you have anything to say Rivkin?

Dr. Rivkin  46:22  

No, I agree. We do some of that, we do RF micro needling. And I think that it's just the amount of energy that you put in with those treatments, and the amount of heat that's being delivered in the amount of scarring that's being caused is really quite controlled and quite small. And so, it's not, you know, what I mean? It's not a black and white kind of thing. There's a spectrum. And I think this is in terms of what how much injury you're causing, it's quite low on the spectrum and quite superficial. So no, I don't think that it's got causing undue damage or really problems for the skin.

Trina Renea  47:10  

All right. Question answered everybody. Thank you. And so, we're going to have Dr. Vicki, do a takeaway today. And we want to thank you both so much for coming on the show. And we hope we can have you both on again sometime. Talk about another subject. That would be great. And this is such a long overdue subject. There are so many people out there that have issues with their nose. So, thank you for talking about this today.

Dr. Vicki Rapaport  47:44  

Yes, and thank you guys, we're going to definitely have you back. I was very impressed with both of you. And I love the banter between both of you, I think it's important to get multiple perspectives, although your perspectives were very similar, which I love, because you're both so educated and so forthcoming, and I just love the way you take care of your patients. Thank you both.

Julie Falls  48:03  

Will we be posting all their information on our website?

Trina Renea  48:07  

Yes, yes. We will have both of you up on our ‘About’ page with the links of how to find you and get to you. Dr. Brandon is on there.

Julie Falls  48:17  

You're right.

Trina Renea  48:18  

Dr. Rivkin you’ll be there soon.

Dr. Rivkin  48:22  

I look forward to it. I'd be in very, very honorable company. Appreciate it.

Dr. Vicki Rapaport  48:31  

Okay, so my takeaway from today is the following. – Do not I repeat, do not get nose filler from a low-lying provider. Don't go to a med spa. Go to somebody who writes the papers, who does the research who trains the other trainers. I have changed my perspective about nose-filler a little bit after today. I will not be doing that procedure, but I might be recommending it to my patients. So, just go to somebody who really knows the anatomy. God forbid you have a complication, can manage your complication. And my second takeaway would be, as you heard the two plastic surgeons discuss even plastic surgery isn't the end-all be-all. So, I love starting with filler and maybe eventually doing surgery but you know, they put filler in patients who have already had multiple plastic surgeries on the nose, which shows you that even plastic surgery isn't the end-all be-all so please don't have body dysmorphic syndrome. Please go careful with your body and your face. And my last little tidbit that I thought was really cool was when Dr. Rivkin manages complications. I don't know if you guys noticed, but he uses Viagra, which is basically… Yeah, did you not see it on the list? It's part of the it's part of the crash cart. It helps dilate blood vessels. So, I thought that was really cool

Julie Falls  49:53  

Multi-uses. I don't know what the other ones are, just guessing.

Dr. Vicki Rapaport  49:58  

So thank you all very much.

Julie Falls  50:01  

Thank you, doctors. 

Dr. Dunn  50:04  

Thank you for having us.

Dr. Rivkin  50:04  

Such a pleasure. 

Rebecca Gadberry  50:08  

All right, bye, everybody.

Trina Renea  50:12  

This podcast is so needed in the world right now. There's so much information out there that it's hard to know who to believe and if it's right for you. We are very excited to be your guides and bring you Facially Conscious. You can find info we talked about today in our show notes and on Instagram, YouTube and Facebook. Please subscribe, like and review us wherever you listen to podcasts. This helps others find us. And if you have any questions or ideas, please send us an email at info@faciallyconscious.com