As the demand for temporary, volume-enhancing injectables has risen in recent years, so too have instances of ‘pillow face’ — a tell-tale sign of too much filler. “Overfilled faces – whether cheeks, under eyes, temples, lips, chins, or jawline – can distort the normal anatomic proportions leading to alien-like facial contours,” explains Jessica Weiser, MD, a board certified dermatologist and founder of Weiser Skin MD in New York City. But it’s not just the visual impact that can cause concern. Over filling a feature or area of the face can inhibit function. So, how much is too much? Below, we explore the impacts of too much filler and what it takes to correct it.
The Aesthetic Downsides of Too Much Filler
For the majority of people keen on enhancing volume, hyaluronic acid (HA)-based dermal fillers, like Juvéderm®, Restylane®, and Belotero®, offer a simple solution: subtle plumpness and a hydrating boost. When performed by a skilled injector who understands facial harmony and values proportion, filler can work wonders. Where it takes a turn is when the filler placement goes past the point of looking appropriate for the face in question. “I think of overfilled features as looking uncanny, i.e. unsettling, not-quite-human, or realistic,” says Daniel Belkin, MD, a board certified dermatologist at New York Dermatology Group.
In the search for perfection or even just stronger contours, facial features can cease to coexist naturally. “They might be lips that lose the natural structure of human lips or are unnaturally enlarged, cheeks that are overly round and puffy, or natural folds that are effaced by filler,” he explains. In the case of the latter, he says to imagine the lower eyelid “running right into the cheek instead of being separated by a normal lid-cheek junction.” The phenomenon, he explains, can actually make others “uncomfortable because of the way they distort a human face and make it something slightly unfamiliar.”
The change doesn’t happen in a silo. Filler in one area can skew the appearance of other features. ”Cheek elevation that occurs with smiling, speech, chewing, and more can become unnatural with too much volume distorting the apple of the cheek and even sometimes pressing up above the orbital rim leading to smaller squinted eyes,” Dr. Weiser shares. And then there is the way in which the filler is injected. Superficially placed filler can create a rough appearance on the skin, adding to the other-worldly appearance of improper injections.
The Funcional Downsides of Too Much Filler
Apart from the aesthetic consequences, the function of overfilled treatment areas are at risk, too. Depending on the placement, “too much filler can impact speech, muscle movement, and lymphatic vessels,” Dr. Belkin cautions. An abundance of filler in the lip or around the mouth, for example, “can change the way speech is articulated,” he explains. This occurs because “excessive lip filler can prevent proper puckering and contraction of the orbicularis oris muscle, leading to unusual speech,” Dr. Weiser adds.
When the under-eye or medial cheek area is overfilled, Dr. Belkin says patients may experience “impaired lymphatic drainage from filler placement.” Although an artfully elevated cheek is meant to restore a more youthful appearance, taking it too far can lead to a bloated look due to the constriction. “The face has two planes of lymphatic drainage: a superficial and a deep,” Dr. Weiser explains. “Large quantities (or sometimes even smaller volumes) of filler can obstruct these channels causing fluid accumulation and facial swelling that may be difficult to reverse or correct.”
If you are curious as to whether or not too much filler can stretch the skin, Dr. Belkin says that, in most cases, “filler cannot provide enough force to overstretch skin.” In extreme cases, however, it is possible. “Overfilling to a dramatic extent can stretch the skin, especially when done repeatedly in the same area,” Dr. Weiser warns. HA fillers naturally break down and get absorbed into the body over the course of six to 12 months. That process can also be sped up by injecting an enzyme called hyaluronidase (more on that below). Whether through natural degradation or synthetic dissolving, Dr. Weiser says “the skin can be left with laxity, redundancy, and crepiness.”
A silver lining? The stretching can actually have a youth-boosting effect. “By stretching the tissue, it stimulates fibroblasts (collagen-producing cells) to produce more collagen,” Dr. Weiser notes. “Because of this, I will tell people who worry they will have to keep it up forever that even if you do filler once and stop, you are better off than never having done it at all.”
When prevention is not an option, correction is the next best thing. As Dr. Belkin advises, there is no one-size-fits-all option. The methods used for tackling overfilled features are determined on a case-by-case basis, but below are the most common:
1. Dermal Filler
Filler to treat overfilled areas? Yes, you read that right. Because proportion plays a big role in facial nuance, a feature may look ‘too plump’ simply due to its juxtaposition to a sunken area. To aptly treat an area that appears overfilled, supplementing its surroundings with volume may balance out the face for a more harmonious result. The way Dr. Weiser sees it, an overfilled appearance may be due to an uneven distribution that “can be corrected by adding small droplets of product for balance.”
For example, some patients who have their tear trough filled lack volume in the cheek, which leads to an unnatural result. Instead of dissolving the filler under the eyes, Dr. Belkin would look at the face as a whole. “I would recommend conservatively re-volumizing the cheek to match the replaced volume in the tear trough,” he says. But, again, this is not the solution for everyone. If the under-eyes look puffy and the cheek has appropriate volume, “it is likely the tear trough has been overfilled,” he says. In that case, he will “partially dissolve” the product. Speaking of dissolving...
Hyaluronidase is an enzyme that is naturally occurring in the body. Just as synthetic forms of HA can be injected to augment or sculpt, synthetic hyaluronidase can be injected to dissolve it. In certain situations, Dr. Weiser says the best solution to treat an overfilled appearance may be to start over. Getting patients on board, however, is not always easy. “Some patients are very resistant to dissolving and starting again,” she says. The alternative? “In these cases, I will encourage them to wait six to 12 months to allow the product to naturally degrade before adding,” Dr. Weiser shares.
Depending on your condition, hyaluronidase can be a relatively quick fix. Results can start to show up in less than an hour, though temporary swelling (like the kind experienced after filler injections) can keep the area looking puffy for a few days. In more severe cases, patients may need multiple sessions to fully dissolve their filler. It should also be noted that hyaluronidase degrades all HA (not just the synthetic kind), which means you can be left with even less volume than you started with until the body adjusts.
3. Prevent to Protect
We’ve said it before, and we’ll say it again: The best course of action when it comes to any aesthetic decision is to always do your due diligence and find a provider who is skilled in your specific concern or treatment and understands your aesthetic goals. “Make sure you are seeing someone who injects filler the way you want yours to appear,” Dr. Weiser says. One way to confirm this? Ask to see before and after photos and look for patients who have similar features to yours.
There is a reason hyaluronic acid-based fillers are so popular — they offer a great way to temporarily augment, enhance, or contour an array of facial features. But too much of a good thing isn’t, well, good. “Beautifully placed filler can be wonderful, but poorly placed or excessive amounts can be a struggle to correct,” Dr. Wesier cautions. For those who feel that their filler has negatively impacted their appearance or the function of certain body parts, revision may be possible in the hands of a skilled provider. Be sure to consult with a board certified plastic surgeon or dermatologist to understand your treatment options.
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