Why I Started Saying “No” to Fillers: How My Perspective Has Evolved & What's Changed

To understand why hyaluronic acid fillers became so popular, it helps to understand the prevailing theory of facial aging at the time.

Many physicians viewed aging primarily as a problem of volume loss. A youthful face was compared to a plump grape. With age, it became a raisin. The answer seemed straightforward: restore the missing volume.

On the other side of the debate were plastic surgeons who viewed aging primarily as a problem of tissue descent and laxity. Their answer was to reposition the tissues through surgeries like a facelift or neck lift. 

As I entered practice, neither explanation felt completely right. My observation was that aging wasn’t one thing: some patients lost volume, others developed laxity, and most experienced both. That belief would eventually shape my entire approach to facial rejuvenation.

As fillers gained popularity, the volume-loss theory became increasingly dominant.

One of the first areas hyaluronic acid fillers became popular in “correcting” was the nasolabial fold—the crease that runs from the side of the nose to the corner of the mouth. For years, many practitioners believed this fold was one of the primary signs of aging and therefore one of the most important areas to fill.

The problem was that young people have nasolabial folds, too. Depending on the person, they are not necessarily a sign of aging. Still more and more filler was being placed directly into these folds.

At the same time, fat transfer was becoming increasingly popular. Some surgeons began approaching facial aging almost entirely as a volume deficiency. Large amounts of fat were transferred throughout the face in an effort to restore youthfulness.

For me, this was one of the first signs that something wasn’t quite adding up.

The faces looked fuller. But they didn’t always look younger.

Over time, the philosophy expanded and then came the concept of the “liquid facelift.” Fillers moved from the nasolabial folds into the cheeks, temples, jawline, lips, chin, and under-eye area. The idea was to inject enough filler and restore a youthful appearance. 

The problem was that we were increasingly asking fillers to perform a job they were never designed to do. Fillers are excellent at adding volume but they are not effective at repositioning descended tissues.

New products entered the market. New techniques were developed. More physicians adopted the philosophy that volume replacement was the primary answer to facial aging.

If some filler was good, more filler seemed better. At least that was the thinking.

By the late 2010s, I found myself saying “no” to filler far more often. Patients would return requesting additional filler, and increasingly I felt that this wouldn’t deliver the result they wanted.  

I was seeing faces become wider, cheekbones broader, and jawlines heavier—often the opposite of what creates a youthful appearance.

Youthful faces tend to have a softer, heart-shaped contour. As we age, tissues descend and collect lower in the face. Adding more volume to already sagging tissues can gradually make the face appear wider, squarer, and older.

Ironically, filler was often giving the exact opposite effect of what creates a youthful appearance.

What many patients were hoping would make them look younger was sometimes making them look different instead.

And not always in a good way.

This was around the time I began moving away from the idea that filler could serve as a primary anti-aging strategy.

Then something interesting happened. The public started noticing that faces were getting bigger but not younger. The term “pillow face” entered the conversation, and patients began questioning whether fillers could be overused.

As public awareness grew, a number of celebrities began speaking openly about dissolving their fillers. Courtney Cox discussed removing fillers that she felt had altered her appearance, and members of the Kardashian family were reported to be dissolving filler, too. The filler-dissolving movement was born.

At the same time, our understanding of the longevity of fillers shifted. For years, the conventional understanding was that hyaluronic acid filler would dissolve naturally in 6 to 12 months. Then imaging studies using ultrasound and MRI started teaching us that filler can persist significantly longer than expected.

This helped explain something many practitioners had observed clinically. Patients were returning every six or so months because they believed the previous filler had disappeared. More was added and more again. Over time, volume was being layered on top of volume.

At the same time, we started learning more about the body’s long-term response to filler. Because filler is a foreign material, the body’s immune system can respond with tissue remodeling and fibrosis (excessive buildup of tough, fibrous scar tissue).

This is one reason why dissolving long-standing filler isn’t always as simple as many people expect. 

The first thing I would tell you is not to panic. One of the most common mistakes I see is patients assuming every facial change they dislike is filler and that all of it needs to be dissolved immediately. That’s not necessarily the case. 

If your filler was placed recently and you’re unhappy with the result, we can inject hyaluronidase (an enzyme that breaks down hyaluronic acid) to easily reverse the effect. 

When filler has been placed repeatedly over many years, however, we may be dealing with a combination of residual filler, tissue remodeling, and fibrosis. It’s also important to understand that filler is rarely distributed evenly throughout the face. If someone has had filler placed throughout the cheeks, jawline, lips, temples, and under-eye area over many years, dissolving everything can be a lengthy process.

Occasionally, the face can temporarily appear uneven, wavy, or lumpy as different areas respond differently to treatment. For this reason, I generally recommend approaching filler dissolution thoughtfully and gradually.

There are physicians who specialize in ultrasound-guided filler dissolution and perform multiple treatments over a period of months. While that isn’t something we routinely perform in our practice, it is an available option for patients who are pursuing more comprehensive removal.

One area where we do routinely dissolve filler is under the eyes. Under-eye filler frequently attracts water and can create persistent puffiness or a tired appearance. In these situations, dissolving the filler can often be extremely helpful. Once the filler is removed, I frequently prefer fat transfer when volume replacement is still needed.

This article is not an argument against filler. They are one of the most important advancements in aesthetic medicine.

Today, in our practice, we use fillers every week. The difference is that we use them very differently than we did 15 years ago. 

Today, whether I’m using filler or fat transfer, my philosophy is much more conservative than it was earlier in my career.

I frequently restore volume around the eyes, temples, lips, and select areas around the mouth and chin. I rarely place significant volume into the cheeks.

Part of that evolution has come from my experience with the Vertical Restore technique. When tissues are repositioned back where they belong, I often find there is far less need to fill them. The result is often a more natural appearance that still looks like the patient.

My biggest takeaway from the evolution of filler is that sometimes we don’t fully understand the long-term impact of a treatment until years later. This is one of the humbling realities of medicine.

After thousands or even millions of treatments, we learned where fillers shine and where they fall short. We learned that some filler can persist longer than we once believed. Perhaps most importantly, we learned that replacing volume and restoring youthful anatomy are not always the same thing.

After more than 20 years of practice, that’s the lesson I carry with me every time I evaluate a patient considering filler today.