KaramMD Journal

Facial Filler FAQ: An Expert's Answers to Your Top 15 Questions

dermal fillers and syringe for injections

Written by Founder, Amir Karam MD

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"Ask me anything about fillers."

I recently posed this question to our Instagram followers and the response was overwhelming. Tons of questions came flooding in, and it showed me that a lot of you are curious about this topic--so I thought it would be a fun and informative to choose some of the most commonly asked questions and give you my honest opinion.

Let me start by saying, I do fat transfers literally every day. This is a technique in which I harvest fat from one area of the body and use it as a filler material to plump up somewhere else, so in my case, I am primarily using it for facial rejuvenation. For the last 20 years, I have used fat transfer along with my surgical approaches, so I feel like my notion of where fat should be in the face has been significantly refined in that time. I've continued to see and understand more and more where volume depletes in the face, and where volume should be added to look natural and youthful. 

As many of you know, I have strong opinions on fillers, but it's not that I am totally opposed to them. In fact, I recognize they're part of a comprehensive strategy for cosmetic enhancement, a tool in the toolbox, similar to fat transfers. My problem is they have overused and people are getting overfilled, so I feel this is an important topic to break down and help people understand how to responsibly use fillers.

My aim here is to share my professional perspective, coming from someone who has an extensive background with not just fillers, but volume loss in the face as a whole. I talk about this on a daily basis, and I hope that by bringing the conversation here, I can help you to understand what fillers can and can’t do.

Whether you're new to fillers, already know a bit, or seeking answers to your own questions as you're looking to make future decisions about volume loss, I hope this FAQ can serve as a valuable resource.

01.

Can you continue getting filler to avoid a facelift?

This is one of the biggest misconceptions regarding fillers. And my answer is no, fillers won't halt or eliminate the need for a facelift in the future.  

While fillers can address volume loss in the face, they don't solely combat the sagging associated with aging. Despite their ability to replenish lost volume, sagging is often more related to hormonal changes, typically occurring in the late 40s and early 50s. Thus, while fillers may temporarily improve facial appearance, they aren't a definitive solution to prevent the need for a facelift in the future.

02.

Should you use filler under the eyes?

100%, yes to using filler under the eyes. However, the problem is, people overdo it.

I have done a couple of videos on lower eyelid aging issues and how to manage them, and if this is something you’re considering, I suggest you check them out because there's more going on with the lower eyelid than just volume like bags, extra skin, tear troughs, etc. 

Overfilling the under-eye area can potentially distort your features and worsen your appearance. Therefore, my recommendation would be to use small amounts of filler, like .25-.3 CCs, which is about a quarter to a third of a syringe. A little bit under each eye and the tear troughs is all you need.

Ideal candidates for this injection are often in their mid-30s, seeking subtle rejuvenation. As individuals get into their 40s and 50s+ and additional concerns arise, solely relying on filler isn’t going to cut it anymore. If you put too much, that excessive filler can result in complications like the Tyndall Effect, puffiness, or swelling due to fluid retention. 

Hence, while I advocate for under-eye filler, I caution against using high volumes and often combine filler with other treatments, such as fat transfer, for optimal outcomes.

03.

Can filler be used to fill lines around the mouth?

These lines around the mouth are typically an extension of the nasolabial fold, which we all naturally have. Even children have these nasolabial fold lines, so they aren't solely indicative of aging. 

What happens, is when the cheeks descend with age, the nasolabial folds naturally deepen due to the shifting facial structures.

If you want to fill here, the key is to apply a tiny amount of filler very superficially, injected perpendicular to the skin to restore some plumpness to the dermis where it's folded and creased. This delicate approach can yield subtle improvements without creating unnecessary thickness or distortion in the surrounding areas.

If filler is used in this area, it must be done with extreme caution to avoid overfilling. Overfilling can lead to the filler spreading beyond the lines, resulting in an unnatural appearance.

04.

How long do fillers last?

Initially it was believed that fillers completely dissolve in our body, and are only going to last anywhere from six months to a year or two, and then it all goes away. Well, it turns out that isn't entirely accurate.

MRI studies have confirmed that fillers can have long-term effects, with some patients still retaining filler in their tissues for 5 to 10 years after treatment. We are now finding, it never fully dissolves away, in fact, it's always leaving behind some residual filler and potentially scar tissue as well.

So what ends up happening is this filler lives there long term, which can become a problem if you’re continuously adding more filler on top of filler. Over time it can result in a sort of stacking, leading to what can effectively become a permanent and potentially undesirable change in that region. 

It's crucial to avoid overfilling and understand that less is often more when it comes to volume. It's also important to differentiate between sagging and volume loss to avoid pushing the boundaries of what your fillers can actually achieve.

05.

Do you dissolve fillers before surgery? How far in advance do you dissolve it?

Yes, I do dissolve any previous filler, but only under the eyes.

Dissolving filler in other areas like the lips, cheeks, jawline, or temples can be challenging because it's difficult to precisely target the exact location of the filler. Attempting to dissolve filler in these areas can result in uneven removal, leading to lumpy or bumpy deformities in the tissues. 

Some practitioners may use ultrasound to locate the filler and inject the dissolving enzyme directly into that spot, but it's a complex process that requires time and effort. While this approach may be suitable for some individuals, it's not something I typically recommend for my patients, nor do I personally perform it. However, I do regularly remove filler under the eyes for patients undergoing surgery, typically to replace it with a fat transfer. In other areas of the face, I prefer to leave the filler undisturbed.

06.

Do you suggest filler in the temple to lift the eyebrows?

No, I don't recommend filling the temple area to lift the eyebrows. Adding too much volume there will appear unnatural. 

The reason for eyebrow sagging often lies in the sagging of the entire side of the face. Injecting filler in the temples in an attempt to plump up this area isn't going to solve that laxity issue. If you attempt to inject enough filler to lift sagging skin, you are going to wind up with a noticeable bulge. While this method may work in theory, it's not anatomically sound, and sagging and laxity should really be addressed surgically. 

Volume loss in the temple area can be treated with filler, but it must be done in a very conservative and gentle way. If you do decide to fill the temple area, it doesn’t need to be fully filled or even, just having it not appear deeply hollow will help to promote a healthier appearance.

07.

Where do you recommend getting fillers, and how often?

Based on my experience, background and knowledge of where fat should be in the face, where it depletes, and what makes someone look youthful, here is my consensus of where I think filler should go.

  • Temple: Loss of volume in the temple area can be subtly addressed with filler to even out deep hollowness and restore a more youthful appearance.
  • Lower Eyelid: Addressing volume loss in the lower eyelid area can contribute to a more youthful appearance by helping to reduce hollowing under their eyes, dark circles due to shadowing, and can help give patients a refreshed, less tired look.
  • Upper Eyelid: Filler can be used to replenish volume lost in the upper eyelid region.
  • Lips: Adding filler to the lips can restore lost volume and enhance their appearance.
  • Pre-Canine Fossa: Filler can be injected into this area around the nose to reduce the depth and appearance of the nasolabial folds which can improve overall facial harmony.

Caution should be exercised to avoid overfilling certain areas like the cheeks and jawline, which could lead to undesired, unnatural-looking outcomes.

It's important to note that filler tends to yield the best results for individuals with firm soft tissue bases, typically in their 30s to early 40s. For those experiencing significant laxity or sagging in their mid-50s or above, the filler isn’t going to produce the same noticeable improvements.

08.

Can you use fillers to address the smile lines?

This is similar to the answer above, but basically, you can't get rid of a smile line.

The parenthesis around your mouth, call it what you want--smile lines, laugh lines, marionette lines--are an inherent part of facial movement, so you have to except that lines around your mouth are going to happen as you use those muscles to laugh and smile. 

It's essential to understand that laugh lines become more prominent due to facial laxity rather than just continuous smiling or laughing. To test this, put your hands on your cheek bones and lift the face upwards; notice the lines will smooth out when you lift the face.

However, even with the face held tightly, smiling still produces some creasing in this area, indicating that filler alone cannot entirely eliminate these lines. 

If you do want to use a very small amount of superficial filler, you can do this to subtly soften them, but only if the surrounding facial structure is firm, and I would be very cautious about overfilling this area as it has potential to distort your natural smile.

09.

I got lip filler four years ago and it hasn't gone away. Is this bad?

Lips are actually an area that, for most people, the filler does kind of dissipate pretty quickly because the mouth is moving a lot. However, if you got a lot of filler injected in that area, it might last longer than you anticipated.

Is it bad? No, it's not harmful, but I would say it's "bad" if it you expected it to be temporary and you don't want it or like it anymore.

The nice thing about most of the hyaluronic acid-based fillers, like Restylane or Juvederm and that whole category, is that you can put enzymes in and diminish it. You have to be aware that when you do this, you run the risk of creating irregularities, but, it can be done. So just know, you're not stuck with something forever. 

When you use some of the other types of fillers, like Radiesse or Sculptra, then you're kind of stuck if you don't like it. Or if you go to somebody who does fat transfer and they don't do a very good or natural-looking job, that's not easily reversed either.

But, in short, no, it's not necessarily bad for you.

10.

What are your thoughts on filler in the chin?

I believe using a small amount of filler in the chin can be quite effective and look nice.

Applying a bit of structural filler, such as Luma, in this area can enhance the chin subtly and smoothly, and it’s obviously going to be much simpler than opting for a chin implant.

While filler may not offer the same long-term durability as an implant, it does provide a convenient option for minor augmentation.

11.

What are your thoughts on fillers in the horizontal necklines?

My opinion is makes zero sense to put filler in these horizontal lines.

These lines are formed by the connection between the skin and specific muscles, which provide support to the area. If you try to put filler here, it goes on either side of the connection and you end up creating these ridges, making them look deeper.

While minor injections might slightly improve the appearance, if your neck is sagging due to age, filler won't address the underlying issue, and in most cases, I think it's best to not overcomplicate things and I say just avoid fillers in this area.

12.

What do you think about cheek filler?

Yes, you can put filler in the cheek, but it's important to be cautious.

The issue with cheeks isn't typically volume loss but rather a descent of the cheek, causing a loss of definition. To address this, the aim should be to lift the cheek rather than simply adding volume.

If you're not considering a facelift but want to soften the area, use very small amounts of filler. Avoid aiming for a round look, as it can result in an unnatural appearance. Additionally, be mindful of adding too much volume to the outer part of the cheek, as it can make the temples and the area in front of your ear look hollow. If you naturally have high cheekbones, be conservative with adding filler to avoid an exaggerated look. However, if you're looking to enhance your cheekbones cosmetically, a small amount of filler can be used to provide subtle contouring.

Just ensure that the process is approached delicately and artistically to avoid overdoing it.

13.

Are there some people who metabolize fillers faster than others?

Yes, there's a possibility that some individuals could metabolize fillers faster than others.

Essentially, once the filler is injected into the tissue, the body immediately begins breaking it down. Some individuals may be more efficient at this process in the same way there are variations in the way different people’s bodies react to inflammatory or immune responses, but it's not necessarily linked to traditional metabolism or exercise factors.

It would come down to how effectively your body reacts to breaking down the presence of something foreign entering the system.

14.

Will your face sag when fillers dissolve?

When fillers dissolve, your face may experience some changes. If you had a significant amount of volume added and the fillers are diminished, you might notice some increased laxity.

However, it's important to note that fillers don't typically lead to drastic sagging as extreme weight loss can. Unlike the "ozempic face" phenomenon where sudden weight loss can make someone appear older, fillers don't have this effect because they don't cause the same type of volume loss. 

Fillers are usually placed strategically in specific areas, so their dissolving shouldn't dramatically alter your overall facial appearance.

15.

Are all fillers dissolvable? And if you do choose to dissolve them, are you dissolving your natural Hyaluronic acid too?

No, not all fillers are dissolvable.

Hyaluronic acid fillers, such as Restylane and Juvederm, can be dissolved using an enzyme called hyaluronidase. This enzyme breaks down hyaluronic acid, essentially melting away the filler.

However, fillers like Radiesse and bio-stimulators such as Sculptra do not have a reversal agent. Once injected, they cannot be removed.

Regarding concerns about the effect on natural hyaluronic acid, while the enzyme can affect any hyaluronic acid in the area, the body continuously produces hyaluronic acid naturally, so this isn't usually a significant issue.

Natural hyaluronic acid has a short lifespan in tissues, typically around 24 hours. Fillers are engineered macromolecules that do not break down on their own but are susceptible to enzymes like hyaluronidase.

The advantage of hyaluronic acid fillers is that they offer a potential reversal option. However, it's essential to be cautious about what fillers you choose and where you inject them.

Amir Karam MD

Board Certified Facial Plastic Surgeon
Founder / Creator of KaramMD Skin

Dr. Amir Karam is a renowned facial cosmetic surgeon and an authority in his field. With over two decades of experience helping patients achieve a younger, refreshed appearance. In addition to surgical procedures that sculpt a youthfully-defined facial shape, Dr. Karam takes the quality of the skin into account.