• Dr. Henry Ngai

Why less is more in dermal fillers


The use of dermal fillers to reversing the sign of aging has gained great popularity in the past 20 years. Hyaluronic acid filler (HA) has changed the landscape of the dermal filler market. HA is by far the most commonly used liquid implant for the face. Not only HA is safe, the manufacturers of the products can change the lifting capacity, cohesivity (stickiness) and elasticity of the hyaluronic acid. For example, one would choose a stiffer product for the cheek and chin. However, areas such as the lips which have a lot of dynamic movements will do much better on a softer product.


Just like any other technologies, HA only works only if it is used properly. We all see some people who look round and puffy after filler injection. One of the major problems is many injectors are moving away from filling in lines and skin folds but mainly focusing on reinflation of the face. Many believe, which is mostly true, the sign of aging and skin sagging is a direct result of volume loss as well as bone resorption. Therefore, by replacing the volume, one can restore a more youthful facial appearance. Filling in lines and folds is no longer in vogue.


Unfortunately, when the pendulum swings too far to the side of reinflation, some injectors are just trying too hard to lift the folds and flatten the wrinkles with mere volume augmentation. As a result, too much fillers are added to the face, often at the wrong areas or at the wrong skin depth. Excessive filler not only makes the face look “chubby”; it also has a tendency to move “south” with time by the pull of gravity, thus accentuating the jowls and facial sagging. Some injectors are putting in 6-8 tubes of dermal fillers at one session. While a few people do need this quantity to replace the volume loss, in majority of the cases, 2-3 tubes of fillers or less would suffice.


To avoid the “facial overfill syndrome”, one should pay attention not so much on how much to inject, but rather where to inject. Placing the fillers at a correct area will rejuvenate the face without overfilling it. Also, facial rejuvenation is more than just filler or neurotoxins. It is also important to tighten up the facial skin envelope by means of energy-based devices, such as laser, ultrasound and/or radiofrequency.


Another good adjunct treatment in facial volumization is the use of collagen stimulators. Products such as Sculptra (PLLA) or Radiesse (Calcium hydroapatite) are used to improve the quality of the skin and facial contour without making the face looks filled. These are not fillers so they do not give immediate result. Instead, the products are injected under the skin to stimulate the body to make collagen. I particularly like Sculptra because the process is gradual and subtle. The result is very natural and the face does not look “done”. Radiesse, on the other hand, is good for sculpting the face, such as the jawlines and even the temporal areas. These materials have to be injected at a correct depth of the skin in order to work. Collagen stimulators have the advantage of reinflating the face in a more even manner. It might take a few months to get the final result but it is well worth the wait.


In conclusion, facial volume replacement with HA is not a be all and end all. There are many components in facial rejuvenation. Overzealous use of HA filler can result in poor outcome and facial overfill syndrome. In order to get a natural result, it is important to utilize different technologies and products to achieve a good and natural result.