The Filler Files, Part II: Pump Up The Volume

Dermal fillers are a great anti-ageing treatment
Dermal fillers are a great anti-ageing treatment - in the right hands.

Fillers are pretty amazing. They stimulate collagen, they make pores smaller, they’re great for treating acne scars and hydrating skin, in fact they’re a valuable and viable solution for anything to do with ageing where the root cause is a loss of collagen. However, they are not miracle workers. There are limitations and, as the saying goes, you can have too much of a good thing.

Migration, Migration, Migration

There’s a lot of talk right now about migration, but filler doesn’t migrate. That’s the truth. So, what’s happening?

In the past, filler was injected with a bolus and it caused major problems, the reason being that the bolus injection would have caused a cyst to form around the filler, encapsulating it and rendering the filler unable to fully disappear. The result of this is we have faces left with small islands of filler.

Now, as many will know, fillers can be dissolved, but in the relentless pursuit of wanting more for less, the structure gets altered and then altered again, making a relatively easy procedure ever more complicated.

To paint the bigger picture here, filler is basically a hydrogel – a long chain sugar molecule that holds a lot of water. When it dissolves, it literally falls apart, turning into water and sugar. What isn’t so dissolvable is the preservative and thickening agent in fillers.

Take Profhilo, a very popular treatment at the moment. Because it is a non-stable hyaluronic acid, it disappears very quickly, and filler would do the same if it wasn’t for crosslinking agents.

Cooking Up Problems

Many years ago, I worked with a prominent scientist in research labs. He described crosslinking like this: you have a bowl of spaghetti and each individual spaghetti strand in that bowl is an individual hyaluronic acid. Now, if you somehow glue two strands of this spaghetti together, you create a ladder between them, which creates a more stable structure. Do that with a lot of spaghetti and you can actually take it, like a rope, and twist it, crosslinking it more and more until it becomes a sphere. Once it’s a sphere, it can transform into anything. You can make a big shape out of a single molecule, and because it’s more stable, it will last longer.

Now, if you create this sphere, or huge blob of hyaluronic acid, it is no longer easily dissolvable because there’s no way to attack the structure through the usual channels of immune activity. And so out of frustration, or self-preservation, skin forms a capsule around this alien substance. The capsule is inert and it stays where it is. All of which is bad.

The Good News

Clearly, an application of thick, crosslinked filler in a large bolus, is not the ideal way to do filler. And if people do have filler in this fashion, it could well be that they feel it has migrated or broken up into pieces and travelled elsewhere.

Thankfully, things have changed in recent years, with the big difference being in application. The good guys use cannulas and they inject in layers.

Filler also lasts longer than previously thought, or we were led to believe, and six to nine months is definitely not the lifespan of a hyaluronic acid molecule. Indeed, it could be much longer, but there is other magic afoot because filler doesn’t merely plump up wrinkles.

As the filler becomes degraded, it is during the degrading process that the skin produces more collagen, out of irritation and not dissimilar to an oyster creating a pearl out of sand.

This is why fillers are an anti-ageing agent because they stimulate the holy grail of eternal youth, otherwise known as collagen. The fact is, the visible signs of ageing are partly due to a loss of collagen, and this is something you can treat with small amounts of hyaluronic acid. You don’t need to inject product the size of a golf ball into your cheeks. Which brings me on to…

Pillow Face

I know what you’re thinking, if fillers are so great why are there so many problems? The answer is ‘application.’ This is how we ended up with ‘pillow face.’

Pillow face is a term used to describe an overfilled or unnatural facial appearance due to the excessive use of dermal fillers. This can result in a swollen, puffy, or overly-rounded face, particularly in the cheeks, lips, or under the eyes.

Several factors contribute to pillow face:

Overfilling: injecting too much filler or using a filler with a high viscosity that can lead to an exaggerated and unnatural look;

Poor injection technique: inexperienced or unskilled injectors may not distribute the filler evenly or may inject it too deeply, causing lumps, bumps, or an uneven appearance;

Wrong choice of filler: different fillers have varying consistencies and are suitable for different areas of the face. Get this wrong and you can contribute to an unnatural result.

And the easiest way to avoid pillow face and achieve a natural-looking result?

Go to a skilled and experienced practitioner who is an expert in facial anatomy and understands aesthetics.

Filler Limitations

Generally, a large amount of hyaluronic acid in a bolus is a problem, and migration can possibly be a result of that. However, this is not something that filler automatically does unless it’s an under eye or upper lip procedure; places where the skin is so thin it doesn’t easily absorb or dispose of filler. That’s why the tear trough area is tricky. It tends to look okay for the first two weeks and then after three months it looks too fat. Same with the upper lip.

Elsewhere, there are other limitations. Take a neck lift, for instance. As we age, we lose bone or bone density and we effectively try to replace this loss with a gel. That in itself is obviously tricky.

If we could actually go down to the bone and somehow cement something onto it, and make the face bigger like that, we would, and it would be great. Of course, it would also necessitate surgery. With the filler, we can fake it. To a certain extent.

In the case of a neck lift, we are dealing with loose skin and that can be down to an array of potential causes, such as a loss of muscle tone or a shortening of tendons due to bad posture. There is also a shrinking of the upper parts of the face, which leads to a sagging bottom half of the face and the neck. Basically, there is less to hold up these structures – it’s a loss of subcutaneous fat and of structured fat pads that shape a youthful face. As you age, this slowly disappears.

Now, if you try lifting the neck with a filler, which is what some people do, you’d have to inject huge amounts of a gel like substance into the face in the hope of getting it to a size where it starts lifting up the neck. It’s like inflating a hot balloon until it eventually lifts the gondola.

This means that you’d have to over-inflate the upper face to a point that becomes grotesque in order to do something useful for the neck.

Far better to tighten the loose skin on the neck using radiofrequency, or temperature, or dermal needling, or fat dissolving agents such as Aqualyx.

It’s Not Bad, It Just Doesn’t Look Good

Clearly, fillers have their limitations, and pillow face is the result of bad doctors and bad patients who keep wanting more. When you use hyaluronic acid in that amount it’s doubtful that it totally disappears.

The main problem here is perception; once you start looking at your face and you accept what you see as ‘normal’, letting go of that look will always be difficult because as the filler dissolves the signs of ageing will be screamingly apparent. Deflate anything and you know the result.

For me, pillow face is simply a response of people not knowing any better or not being interested in knowing any better. One should be able to avoid it, but there’s also the intention of having it. And I have to say, not all of it looks bad.

Once upon a time, having two golf balls injected into the cheeks would have only ever looked weird, but with better application some of the results are actually OK, with people looking clearly enhanced but not looking bad for it.

So, while huge amounts of filler might have aesthetic consequences or result in it sticking around for far longer than intended, it’s always worth looking at the bigger picture. Is it dangerous? No.