Dermal fillers for filling

When most people hear the words dermal filler, they think of lips or perhaps cheeks. But traditional dermal fillers can do much more than simply "fill a line".

Used thoughtfully, fillers can restore lost volume, improve proportions, create definition, replace volume that was never there in the first place, and sometimes correct a specific contour irregularity.

The key word is balance.

A beautiful filler result should not necessarily make you look as though you have had filler. It should make your face look refreshed, harmonious and still recognisably you.

Traditional volumising fillers are generally based on hyaluronic acid (HA), a naturally occurring substance found throughout our bodies. HA has the remarkable ability to bind water and, when formulated appropriately, can provide structure, projection and volume within soft tissues.

But where filler is placed, how much is used, what type of filler is selected and, most importantly, why it is being used are all critical to the result.

Why do we use traditional dermal fillers?

There are three broad reasons why someone may choose to have a traditional volumising filler treatment.

1. Enhancement: "I never had that"

Some people are born with facial features that are smaller, flatter or less projected than they would ideally like.

This isn't necessarily about ageing.

Someone may naturally have:

• very thin lips
• a small or retruded chin
• a less projected cheek
• a less defined jawline
• small or asymmetric earlobes
• a particular facial proportion they would like to change.

In these circumstances, we are not trying to put back something that has been lost.

We are creating something that was never there before.

A person may want fuller lips, a more projected chin or greater cheek definition simply because these proportions feel more harmonious to them.

This is enhancement rather than rejuvenation.

And it is important to recognise that there is nothing inherently wrong with wanting enhancement. The goal is simply to understand that the treatment is a choice to alter your natural anatomy, rather than an attempt to reverse ageing.

2. Restoration: "Something has changed"

As we age, the face doesn't simply develop wrinkles.

The entire architecture of the face changes.

We gradually experience changes in:

• skin thickness and elasticity
• collagen and elastin
• bone structure
• muscle
• ligaments and connective tissue
• superficial and deep facial fat compartments
• the way different tissues interact with one another.

One particularly important change is volume loss within the facial fat compartments.

The face contains a sophisticated three-dimensional arrangement of fat compartments. Some lie superficially beneath the skin, while others sit deeper and provide structural support.

With ageing, some of these compartments lose volume. At the same time, changes in bone structure and the supporting ligaments can alter the relationship between the different layers of the face. The result is not simply "skin falling down". It is a combination of deflation, redistribution, loss of support and descent of soft tissues. (PubMed)

This is one reason why an older face can appear both hollow and heavier at the same time.

The cheeks may become flatter or more hollow, while the lower face develops increased fullness around the jowls.

The temples may hollow.

The lips may lose volume and support.

The chin and jawline may lose definition.

The transition between different facial regions becomes more pronounced.

The deflated balloon analogy

One way to think about this is a balloon.

Imagine a beautifully inflated balloon. The surface is smooth because the volume inside provides support.

Now let some of the air out.

The material doesn't simply become smaller. It develops folds, changes shape and begins to hang differently because the internal support has changed.

The ageing face is considerably more complicated than a balloon, of course, but the principle is useful:

Sometimes we don't need to "pull the surface tighter". We need to understand what has changed underneath it.

This is where appropriately placed volumising filler can be useful.

Rather than trying to fill every visible crease, we may restore volume to an area that has lost structural support and thereby improve the overall facial contour.

Research into facial anatomy has demonstrated age-related changes in both superficial and deep fat compartments, with volume loss particularly relevant to the cheeks, temples, lips and lower face.

3. Correction: "Something isn't quite right"

The third reason for using filler is correction.

Sometimes there is a particular contour defect, asymmetry or volume deficiency that can be improved with soft tissue filler.

This might include:

• facial asymmetry
• a small contour irregularity
• a depressed scar
• a localised hollow
• asymmetry of the lips
• an imbalance between the chin and surrounding facial structures
• an irregularity following trauma or previous surgery.

In these cases, the objective isn't necessarily to make the whole face "younger" or "bigger".

It is simply to make a particular feature more balanced or less noticeable.

This distinction is important because the amount of filler required for correction may be surprisingly small.

Sometimes the most successful filler treatment is the one nobody can identify.

Where can traditional fillers be used?

Traditional volumising fillers may be used in many areas of the face, including:

The fascinating science of facial ageing

One of the biggest changes in modern aesthetic medicine has been our understanding that the ageing face is three-dimensional.

We used to think largely in terms of:

wrinkle → inject wrinkle.

We now understand that the wrinkle may be the visible consequence of changes occurring deeper within the facial architecture.

For example, loss of volume in deeper cheek compartments can reduce support for the tissues above them. Changes in bone and retaining ligaments can contribute further to altered tissue position, while superficial fat compartments can become more mobile and descend. (PubMed Central (PMC))

This is why simply filling a deep fold can sometimes produce a less natural result than addressing the underlying structural changes.

The face is a connected three-dimensional system.

We need to treat the architecture, not just the crease.

But doesn't the body eventually break down the filler?

Yes.

One of the fascinating things about hyaluronic acid is that it is not a foreign material that simply sits permanently inside the face.

Our bodies naturally contain enzymes called hyaluronidases, which are involved in the breakdown of hyaluronic acid.

However, the HA used in modern dermal fillers has generally been chemically modified and cross-linked to make it considerably more resistant to rapid degradation.

This is why injected HA can remain clinically useful for considerably longer than the naturally occurring HA found in our tissues.

Over time, the filler undergoes degradation through enzymatic and oxidative processes, with the precise longevity influenced by the formulation, degree of cross-linking, location, amount injected and individual patient factors.

And there is an important caveat:

"Temporary" does not necessarily mean "gone on a specific date."

Some HA fillers can persist in tissues considerably longer than patients expect, and different studies have demonstrated persistence of filler material beyond the timeframe often quoted in marketing material.

So when we say filler is temporary, we mean that it is not intended to be a permanent implant.

We should not imply that every molecule has disappeared at exactly 6, 12 or 18 months.

Biology is rarely that tidy.

What about filler migration?

This has become a hot topic, particularly with the increasing use of imaging such as MRI.

And the answer is slightly more complicated than:

"Filler always stays exactly where it was injected."

or:

"Filler migrates all over your face."

Neither statement is completely accurate.

True migration of filler away from its original placement can occur. It has been documented, including with HA fillers, and certain areas appear to be more susceptible than others. The lips, nose, nasolabial region and some highly mobile areas have been reported more frequently in the literature. (MDPI)

However, there is also increasing discussion around the difference between true migration, persistence, tissue redistribution and what appears clinically to be migration.

The face is not a static container.

It moves.

Muscles contract. Tissues slide over one another. Fluid shifts. Facial compartments change with age. Filler itself can persist in a tissue plane for longer than anticipated.

And imaging findings do not always correlate neatly with what can actually be seen clinically. A recent review highlights the difficulty of distinguishing radiological appearances from clinically meaningful migration. (PubMed Central (PMC))

So yes:

Migration is real.

But the internet version of migration, where every patient who has ever had filler is imagined to have a reservoir of filler travelling freely around the face, is an oversimplification.

This is one of the reasons that product choice, anatomical knowledge, injection plane, volume and technique matter so much.

More filler does not mean a better result

This may be one of the most important things we can tell patients.

There is a point at which adding more filler stops improving the face.

And then there is a point beyond which it begins to change the face in ways that were never intended.

The aim should not be:

"How much filler can we fit in?"

The aim should be:

"How little filler can we use to achieve the change we want?"

Overfilling can produce:

• excessive fullness
• distorted facial proportions
• loss of natural facial movement
• a heavy or puffy appearance
• exaggerated cheeks or lips
• unnatural transitions between facial compartments
• an appearance that becomes increasingly dependent on further filler.

This is particularly important because filler treatments are cumulative.

A patient may have a little filler today, another little treatment six months later, and another treatment the following year.

If every treatment is approached as an opportunity to add more volume without considering what is already present, the face can gradually become overfilled.

Knowing when to stop

One of the most important skills in aesthetic medicine is not knowing where to inject.

It is knowing when not to inject.

Every face has a point at which additional volume no longer improves harmony.

Sometimes the correct answer is:

"We don't need more filler here."

Sometimes it is:

"Let's treat a different area first."

And sometimes it is:

"I don't think filler is the right treatment for what you are trying to achieve."

That last answer is just as important as knowing how to inject.

Traditional dermal fillers are excellent tools, but they are not magic.

They cannot replace significant skin tightening, remove large amounts of excess tissue, reproduce the results of surgery or correct every structural change associated with ageing.

Good aesthetic medicine involves knowing which problem you are treating and which tool is appropriate for that problem.

The goal: natural, not "filled"

Perhaps the greatest compliment after an aesthetic treatment is not:

"Your filler looks amazing."

It is:

"You look really good. Have you been on holiday?"

Natural-looking filler doesn't mean that nothing has changed.

It means the changes make sense within the person's existing anatomy.

The lips still belong to the face.

The cheeks still move naturally.

The chin still looks like a chin.

The jawline doesn't look drawn on.

The temples don't look inflated.

The face retains its character.

And most importantly, you still look like you.

My philosophy with traditional fillers is therefore simple:

Restore what has been lost.

Enhance what you genuinely want to change.

Correct what can be corrected.

And know when to stop.

Because the best filler treatment is rarely the one that creates the most volume.

It is the one that creates the most harmony with the least unnecessary change.

Risks, who should wait and aftercare