female patient getting cheek fillers

Aesthetic medicine today is witnessing a significant shift in full-face beautification. In 2024, the focus has moved from removing tissue (for example, buccal fat removal) to restoring lost volume. This shift stems from a deeper understanding of how aging affects facial features. Volume loss and sagging skin contribute to a tired appearance. While surgery still holds a place, volume restoration with dermal fillers is at the forefront. 

However, just like any cosmetic procedure, there are potential risks involved. One of the most common concerns with fillers is adding too much filler in the face or overfilling, which can lead to unnatural-looking results and psychological distress to the patient. Social media is often flooded with news of celebrities like Kylie Jenner with a ‘pillow face’. 

Approaching aesthetic full-face beautification from a holistic perspective involves viewing the face as a dynamic whole rather than focusing solely on isolated features. A skilled practitioner will prioritize a conservative approach and focus on enhancing one’s natural features rather than altering them beyond recognition.

Key Takeaways

  • Consultation is Key: Ensure a thorough consultation with the patient to understand their expectations and desired outcomes before proceeding with filler injections.
  • Individualized Approach: Tailor the treatment plan according to the patient’s facial anatomy, aging pattern, and specific concerns to avoid adding too much face fillers. 
  • Less is More: Adopt a conservative approach by starting with a smaller amount of filler and gradually adding more if necessary.
  • Layering Technique: Use layering to evenly spread filler across the face to target volume loss and wrinkles while preserving natural proportions.
  • Patient Education: Explain to patients the risks and limits of filler treatments, and stressing on realistic goals and gradual progress.

The Causes of Facial Overfilled Syndrome

While full-face fillers offer a range of cosmetic benefits, achieving a natural-looking and balanced result requires careful planning and proper technique. 

Unfortunately, several factors can contribute to the development of facial overfilled syndrome:

1. Treatment Misconceptions

  • Overly Aggressive Goals: Focusing solely on achieving dramatic lifting effects with fillers can lead to overcorrection and unnatural volume.
  • Profit Over Artistry: Prioritizing profit over artistic considerations and inadequate understanding of facial aging processes.

2. Treatment Practices

  • Incorrect Assessment: An inaccurate initial assessment of facial structure and needs can lead to incorrect filler selection and placement.
  • Inappropriate Filler Choice: Using the wrong type of filler for specific areas can contribute to undesirable outcomes.
  • Injection Techniques: Injecting large filler amounts in single deposits (bolus injections) can overwhelm the tissues. Placing filler too close to the skin’s surface can create unnatural bumps and distortions. Using Gun-Shot Technique: This injection method using sharp needles on the bone can damage tissues and increase risks.

3. Patient Factors

  • Facial Anatomy: Some facial structures, like those commonly found in Asian patients, might be more prone to overfilling with even smaller filler volumes.

4. Filler Characteristics

  • Multiple filler treatments can lead to a gradual buildup of filler material.
  • Over time, filler can migrate from the injection site.
  • Filler injections can sometimes trigger the formation of biofilms (bacterial communities) or granulomas (inflammatory masses).
  • Delayed allergic reactions to filler materials may result in inflammation and swelling, which can mimic overfilling.
  • Non-biodegradable fillers can persist for longer periods and potentially contribute to developing more pronounced granulomas if overused.

What Does Too Much Filler Look Like?

In some cases, patients may present with signs of overcorrection, which can impact aesthetics and potentially lead to complications. Here are just some factors to consider when evaluating potential overcorrection:

Criteria for Identification

A diagnosis of facial overfilled syndrome may be considered if a patient meets the following criteria:

  • Multiple Filler Treatments: The patient has received multiple filler injection procedures.
  • High Filler Volume per Injection: Each injection point received more than 0.5cc of filler per bolus.
  • Presence of Characteristic Features: The patient exhibits one or more of the following:
    • Loss of natural definition in the medial infraorbital area (below the eye)
    • Overly full lower mid-face
    • Unbalanced appearance with prominent cheekbones and sunken temples
    • Pointed chin
    • Unnaturally full lips
    • Downward turn of the mouth corners
    • “Setting sun” eyes (sclera visible below the iris)
    • The widened appearance of the nose
    • Excessive forehead projection
    • Postinjection nodules and lumps. 

Identifying Borderline Cases

While severe overcorrection is readily visible due to significant facial distortion, borderline cases can be more challenging to diagnose. 

In such scenarios, healthcare professionals may utilize simple techniques such as gently feeling the suspected area with the thumb and index finger to assess the consistency of the material beneath the skin. A soft, fluid-like feeling, especially in the thin-skinned medial infraorbital area, can indicate overfilling. In addition, virtual assessment using photographs and facial animation can reveal visible lumps

male patient getting forehead fillers

Selecting the Right Filler

Dermal fillers offer a variety of solutions for those seeking to enhance their facial aesthetics. Here’s a breakdown of some routinely used types:

Hyaluronic Acid (HA)

Poly-L-lactic Acid (PLLA)

  • Trade Name: SCULPTRA®
  • Length of Action: Long-lasting (up to 2 years)
  • Purpose: Stimulates collagen production to restore facial volume loss due to aging or weight loss. Effective for moderate to severe wrinkles (marionette lines, nasolabial folds) and facial lipoatrophy (associated with HIV/AIDS).
  • Advantages: FDA-approved for specific facial concerns, long-lasting results.
  • Disadvantages: Time is needed to see the effects, multiple initial injections are required, and it is not suitable for all areas.

Calcium Hydroxyapatite (CaHA)

  • Trade Name: RADIESSE®
  • Length of Action: Semi-permanent (up to 1.5 years)
  • Purpose: Ideal for correcting moderate to severe wrinkles and folds (nasolabial folds, marionette lines). Used for facial contouring, volumizing areas of fat loss, and stimulating collagen production.
  • Advantages: Highly viscous, stimulates collagen, offers long-lasting results.
  • Disadvantages: It can cause nodules and is unsuitable for fine lines or all facial areas.

The Importance of Anatomy and Proper Injection Techniques

Selecting the right filler is just one piece of the puzzle. A masterful injector can transform a good filler choice into a truly transformative treatment. Facial filler injection is more than simply placing a product. It requires a high degree of skill and precision. Mastering injection techniques enables:

  • Targeted filler placement.
  • Natural-looking results with controlled product distribution.
  • Minimizing risks and avoiding complications.

In addition to having a solid knowledge of facial anatomy, understanding various injection techniques allows the injector to tailor the approach. The commonly used means of delivering fillers include:

  • Retrograde and Anterograde Injection
  • Fanning
  • Cross Hatching
  • Bolus
  • Linear/Serial Threading
  • Serial Puncture
  • Micropuncture/Droplet
  • Mantoux Test Injection Technique
  • Sandwich Technique
  • Tower Technique
  • DPS Technique

How Much Filler is Too Much?

The amount of filler required varies depending on individual facial features, filler type, desired outcomes, and the practitioner’s expertise. Opting for a conservative approach initially is often recommended, as it allows for gradual enhancement and adjustments if necessary. Remember, adding more filler than removing excess filler is always easier.

How to Mitigate FOS?

Healthcare professionals can take several measures to prevent and manage Facial 

Overfilled Syndrome (FOS) in patients who have undergone facial filler treatments:

  • Hyaluronidase (LIPORASE®): A natural enzyme that can gently dissolve excess filler in areas with overcorrection, smooth out uneven distribution, and address the Tyndall effect. The dosage for dissolving filler depends on the area: under 2.5mm needs 10-20 units in one injection, 2.5mm to 1cm needs 2-4 injections of 10-20 units each, with repeat injections if needed. The new protocol recommends hourly injections until symptoms resolve, replacing the older method of daily injections for at least four days.
  • Tailored assessment and treatment plans before administering filler injections. This involves assessing muscle activity, observing facial movements during injection, and using ultrasound imaging to evaluate the thickness of superficial and deep fat layers.
  • Proper filler selection and appropriate injection techniques are essential. Understanding the interplay between facial aging and augmentation techniques is crucial in preventing FOS. Attention should be given to filler pressure and migration risks, particularly in areas with elevated pressure.
  • Minimize Filler Use. Alternative approaches, such as energy-based devices for skin treatment or polymer reinforcement of facial ligaments, can reduce reliance on fillers and minimize the risk of FOS.
  • Consider Ethnic and Gender Differences to avoid overcorrection. Understanding the specific facial characteristics of different ethnicities, such as Caucasian patients, African-American patients, East Asian descent, etc., can help in tailoring treatments to each patient’s unique features and reducing the likelihood of FOS.
  • Myomodulation: This technique involves adjusting muscle activity to prevent stiffening of facial expressions due to fillers. This is particularly important in maintaining natural facial movements and expressions post-filler treatment.

Conclusion

When it comes to treating too much filler in the face, achieving natural-looking results with fillers requires a focus on both patient education and meticulous treatment planning. Understanding filler properties, appropriate injection techniques, and the potential for overcorrection is the key to guiding patients toward safe and aesthetically pleasing outcomes.

By prioritizing a “less is more” approach and favoring natural fullness over excessive correction, it is possible to minimize the risk of complications and patient dissatisfaction associated with overfilling.  For some concerns,  non-surgical alternatives like Botox for wrinkles or laser treatments for skin texture improvement might also be suitable options to discuss with your patients.

FAQs

Can fillers make your face fuller?

Yes, facial fillers are designed to add volume to specific areas of your face to enhance lips, cheeks, and other areas, smoothing wrinkles and improving facial contours for a more youthful look.

How can filler be removed if needed?

There are a couple of ways to remove filler, depending on the type used:

  • Dissolving enzymes: This non-surgical option is most effective for hyaluronic acid fillers, the most common type. Certain enzymes can be injected to break down the filler material safely.
  • Aspiration: A thin needle is used to remove some of the filler physically.

What are the potential downsides of using too much filler?

While fillers offer great benefits, it’s important to use them judiciously. Overfilling can lead to a few potential concerns:

  • An overly full face may appear puffy and mask your natural features.
  • Bruising and swelling are more common after procedures with significant filler use.
  • The risk of infection and allergic reactions can be slightly higher with larger amounts of filler.
  • Excessive filler can make it difficult to smile, frown, or express yourself naturally.

How much filler for cheeks is considered ideal?

The ideal amount of filler varies depending on your unique facial structure and desired results. A qualified healthcare professional will carefully assess your face and recommend the appropriate amount of filler to achieve a natural-looking fullness that complements your features.

Is it normal to feel the filler after injection?

It’s quite common to feel the filler immediately following the injection. However, it shouldn’t feel like distinct lumps or bumps. Over time, the filler settles and integrates with surrounding tissues and becomes less noticeable. If you have concerns about lumps or unevenness, consult your healthcare provider for an evaluation.

What are the signs of an overfilled face?

An overfilled face often presents with the following characteristics:

  • Puffy appearance: The skin may appear stretched and swollen, lacking definition.
  • Masked features: Natural contours like cheekbones and jawline become obscured.
  • Unbalanced proportions: Certain areas may appear overly plump compared to others.

What is a “pillow face”?

“Pillow face” refers to the overly full, rounded appearance that can occur after injecting too much filler in the cheeks and around the mouth. This can make the face look smooth but lacking in natural contours.

What is filler fatigue?

Filler fatigue refers to the over-injection of dermal fillers in a specific area, leading to adverse effects such as a doughy appearance, lack of distinct facial regions, and stretched skin. This condition can result from injecting too much filler at once or consistently over time, causing heaviness in the skin and a loss of natural facial contours. Over time, excessive use of fillers can lead to disfigurements, skin laxity, and an unnaturally wide face. 

How long does face filler take to settle?

The settling period for face fillers can vary depending on the type of filler used. On average, it takes two to six weeks. 

How can I tell if I have too much filler?

If you experience any of the following, it could be a sign of overfilling:

  • Unnatural-looking fullness that doesn’t complement your features.
  • Difficulty with facial expressions due to restricted movement.
  • Persistent lumps or bumps.
  • Ongoing discomfort or pain.

References

  1. Lim T-S, Wanitphakdeedecha R, Yi K-H. Exploring facial overfilled syndrome from the perspective of anatomy and the mismatched delivery of fillers. J Cosmet Dermatol. 2024; 00: 1-5. doi:10.1111/jocd.16244
  2. Vedamurthy, M. (2018). Beware What You Inject: Complications of Injectables—Dermal Fillers. Journal of Cutaneous and Aesthetic Surgery, 11(2), 60-66. https://doi.org/10.4103/JCAS.JCAS_68_18
  3. Lamb, J. (2010). Volume Rejuvenation of the Face. Missouri Medicine, 107(3), 198-202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188315/
  4. Clark, Nicholas & Pan, Debbie & Barrett, Dane. (2023). Facial fillers: Relevant anatomy, injection techniques, and complications. World Journal of Otorhinolaryngology – Head and Neck Surgery. 9. 10.1002/wjo2.126. 
  5. Schelke, L., Harris, S., Cartier, H., Alfertshofer, M., Doestzada, M., Cotofana, S., & Velthuis, P. J. (2023). Treating facial overfilled syndrome with impaired facial expression—Presenting clinical experience with ultrasound imaging. Journal of Cosmetic Dermatology, 22(12), 3252-3260. https://doi.org/10.1111/jocd.16013
  6. Coimbra, D.D., Stefanello, B. Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series. Aesth Plast Surg 47, 1162–1174 (2023). https://doi.org/10.1007/s00266-022-03193-y