Val Lambros m.d., f.a.c.s.

cosmetic and reconstructive surgery

Non-surgical approaches to making the face look better: Fillers

One of the revolutions of cosmetic treatments on the face has been the use of adding volume to fill in faces that look hollow. This not a new idea, it was originally used in the 1880's, but the substances injected were paraffin and Vaseline, and the results were disastrous. I was one of a number of doctors who rediscovered this principle in the 1980’s, this time using fat and other fillers to restore facial proportions.

Traditional cosmetic surgery relies on pulling on skin or taking fat out. Sometimes these approaches work well on the face — think pulling on your cheeks in the mirror. Sometimes these approaches look terrible — think of all of the odd-looking people you see in the media or at the mall who have had too much plastic surgery. The scary thing is that people who look strange with overdone cosmetic treatments think that they look terrific, but that is another entry.

Starting in 80's I saw the need for filling some faces in some places to make them look better. In the late 80's I started fat grafting by injection. This is a reasonable approach for some faces if you happen to be in an operating room. With the advent of excellent injectables like Restylane, Perlane, Voluma, Juvederm and the like, the face may be treated in the exam room without having to do something surgical. In addition, off-the-shelf fillers are usually more predictable and less expensive than fat grafting. Currently, I reserve fat grafting for people having surgery. No matter what is injected, the principles of volume replacement in the face remain the same.

The skill of using fillers is not just the placement, it is the ability to see where a small change in the face make big changes in how it's perceived. This is not always obvious and the doctor can't rely on formulas. One has to treat every face individually and not succumb to ritual and rote in analyzing and treating faces.

Why would you fill in parts of the face? I want to look thin, not fat.

A facial feature might look the same at different stages of life, but be perceived differently. High cheekbones and hollow cheeks look hot in someone in their 20’s. So do their tattoos. In later life hollow cheeks look unhealthy, gaunt and old. Filling them in a little makes the face look better, softer and younger. The same principle applies to other parts of the face. We are not talking about making faces look fat. We are talking about the amount of fill that makes a hollow into a flat. Similar amounts can accentuate cheekbone and jawlines. (Too bad about the tattoos.)

People get hollows on either side of their chin as they get older. This has an enormous unbalancing visual effect on the face, and it can be remedied simply. Using volume in the face can also hugely improve faces that have had facelifts with undesirable results. (See my article on "the Joker-Line.")

The idea with fillers and volume injections is not to make people look fat, though overdone procedures can do so. The idea is to balance the face and make it look more attractive and less gaunt.

Do injections hurt? I hear they hurt a lot.

I am one of the biggest babies in the world. I hate needles and I try to treat everyone like they are me. One of my pet peeves is that doctors don’t treat patients like they would like to be treated themselves. Some physicians are brutal — no doctor in the world would let someone inject their own lips without some kind of anaesthesia. I find that numbing creams don’t work well in the lips and there are technical reasons why local anaesthesia has advantages. I numb everyone for everything. It doesn’t hurt. I have tricks.

What is a "local preview"?

I do something that is ridiculously easy and has is very useful in showing people visual concepts that they may not have thought of. It is hard to describe a change like filling part of the face and have people understand what it would look like just from a description, people need to see it.

I like to use local anaesthetic to prevent people from hurting. But also, local anaesthetic acts just like a filler, for a few minutes at least. By injecting it in the right way and the right amounts I can show the patients pretty much what the outcome of the filler injection will be.

Visual concepts need to be shown visually. So, by filling in an area with the anaesthetic, the patients can see what they will get with the filler. Patients love it. Everyone is intrigued by the idea of seeing the look temporarily before committing to it. They get to make the decision about whether to do the filler or not. It's very much like trying on clothes before you buy them; you've seen it and approved it beforehand.

If patients don’t like the look, we don’t do the procedure and the local anaesthetic goes away in a few minutes. If they do, then we go ahead and do the filler. And happily the patient is already numb and will feel nothing.

Why don’t more doctors do this? I don’t know. It takes about 5 minutes to do and I think most doctors don’t want to take the time. You also have to be a good injector to do this as the local anaesthetic is harder to inject than the filler is. I routinely preview cheeks, temples, brows and jawlines, as these areas are not easy to understand visually.

Here is a local preview of the brows and upper lid. She has nice brows and upper lids before, but the preview lets her see the alternatives I liked the second view with the fuller brows. So did she.

local preview

What kind of fillers are there and how long do they last in the face?

Currently used fillers can be divided into 2 main types, Hyaluronic Acid fillers (HA), and everything else. HA fillers are currently derived from bacteria cultures and they duplicate a molecule that everyone has in them. These filler act by drawing up water from the tissues to maintain their volume, kind of like Jello. They are very unlikely to cause allergies and are very safe. They have a nice feel but most importantly they can be removed by dissolving them away with and enzyme called hyaluronidase.

This is very important because if you get a lump or bump or undesirable look, you can make the product go away. Almost all my injections are done with this class of fillers, which includes Restylane, Juvederm, Voluma and Lyft. There will shortly be a flood of new HA fillers in the United States capitalizing on the popularity of this class of material. These are considerably more similar than they are different.

This is a woman who had Juvederm injected below her eyes by someone else. Note the large disfiguring masses below her eyes. She was injected with Hyaluronidase and looked normal the next day. Here she is a week later.

This is a woman in her 20’s who had an HA filler injected below her eyes by someone else. Note the lumps, especially below her right eye. She had Hyaluronidase injected and she is seen a few days later looking normal. It is widely known that Juvederm is not the right product to inject under the eyes and this is why.

Of note: she may have been one of the first pts ever injected with hyaluronidase. I reported her in 2004 and shortly the use of Hyaluronidase became worldwide.

The duration of HA fillers depends almost entirely on where you put them. In the temples, tear-troughs, brows and nose, this class of fillers will last from 2 to 3 years, and it's not unusual to see 4 years. People who say that they last 6 months have not been paying attention or haven’t been doing injections long enough. In the cheeks, most HA fillers will last 1 1/2 years, though the projection of fillers like Voluma is maintained better than with other products. The jawline will last a year or longer. In the lips 6 months is common though occasionally one will see a year or more. Nasolabial folds and marionette lines seem to last about the same.

The public seems to think that there is a magic product that you can inject and solve all problems on the face. There isn’t. What fillers do is add some volume to the tissues of the face. There is no need to fly to Europe or someplace far from home to get the latest filler. Fillers injections are a tool, and within some limits the important thing is not what you put in, but how it is done and by whom. These injections are very easy to do badly and not as easy as you would think.

Products like Sculptra and Radiesse work by generating scar tissue. Experience with these products shows that subsequent injections are difficult because of the scar, and they can interfere with surgery later on. They are not reversible, and I prefer not to use them. There are a few permanent fillers available. Though permanent sounds good — thinking that you don’t have to go back — permanent means forever: 40 or 50 years, or more. If the filler isn’t perfect, or seems to get more prominent as your tissue thinsm or you don’t like it anymorem or it gets infected, then removing it can be a big problem. It might be necessary to cut it out leaving scars and irregularities.

Lips and Nasolabial folds

Lips are known to thin with age, and some filling is worthwhile if not done to extremes. Again, you notice the bad ones walking around, not the good ones. I am always astonished at how bad overfilling lips looks. No matter how good the rest of the face might be, big lips always makes the face look odd to me...and to everyone other than the patient. Risking being labeled as a paternalistic white male, I refuse to make overlarge (in my opinion) lips. I think they look ridiculous, and I don’t want my name on them. There are plenty of doctors who will do this but I am not one of them. 1 cc of a filler like Restylane or Juvederm will not make lips look funny.

She’s 22 and beautiful. She has a thin upper lip which was treated with 1 cc of Restylane.

She’s in her early 60's and complains of thin lips and bleed lines. She was treated with 1 cc of Juvederm, which is my preferred filler for lips at this time.

This lady in her 50's was treated with Restylane in the nasolabial folds and the lines going from the corner of the mouth downward (marionette lines). I now usually use Juvederm in the lips, patients say that it feels softer. Fillers in the lips usually last four months to a year, though occasionally they will go for longer.

Where else can you use fillers and volume in the face?

As the face gets older, it tends to change from being smooth and even to being divided by borders — like a map of the United States with and without the states marked. Smoothing facial borders is one of the things makeup does. If the borders are from indentations in the skin, fillers can help considerably. Look at the tear-toughs, the curved border that appears in the lower lid from the inner eye by the nose down and across the eyelid. It can look as if the person is tired and lacking sleep or haggard and unhealthy.

Both of these patients had the tear-trough border filled in. This is a difficult area to inject, and should be done carefully by someone who knows how to do it. Juvederm is not the right product for this area. Any other HA filler works fine.

This patient had Restylane beneath her eyes three-and-one-half years before. Look at how long lasting it is in this location.

This is a year follow-up from filling her lower lid border and tear-trough.

Brows and upper lids

People think that their eyes were different than they really were. People remember eyes that were very defined and without any fat. The truth is very different. Look at your yearbook from high school or college. You will see that the young eyes didn’t look hollow and empty; they were full and long. Surgery does almost the same thing to upper lids as aging. It removes fat and hollows out the eyes. Some people like this look, some don’t. The eye with no fat may look dramatic with makeup if you put enough on, but it will look younger if it is fuller. Sometimes people call this a nursing home eye.

Here is a woman from age 21 to 65. She has not had surgery. She has the type of eyes that get hollower with age.

Here is another patient from 24 to 63. The eyes on the right are hollow and defined but they don't look young.

Look at the upper lids in the following patients; they have been hollowed out from age or from surgery, which frequently makes people look older. Taking out more skin or fat only makes them look worse. See how much better they look with some fill.

She is in her 60's. Her eyes have gotten hollow with age. Look how much better the eyes look with 1 cc of Restylane in the brows. She no longer looks hollow. This picture is two years after her injection with 1 cc of Restylane.

Here is another patient who is 70-years old. It would make no sense to do regular cosmetic surgery of the lids as it would make her look worse. We both think she looks better with 1 cc of Restylane in each upper lid. It has lasted two years at the time of this picture.

In some patients by filling in the upper lid and brow you use up some of the extra skin.

She had her upper lids done some time before. Even though it looks like there is extra skin, it is mainly the crinkly skin that she needs to close her eyes with. By filling in her brows, she looks less hollow, and the Restylane has smoothed out her lid skin. This is 10 months later.

In some patients the hollow at the center-inside of the orbit parallels the eyebrows when they have a look of consternation or concern. They look anxious. Like this:

See what a difference a little Restylane makes in this location. The art of plastic surgery on the face is in seeing the curves that have meaning — that project emotions or states of being — and correcting them.

She had 1 cc of restylane, and needs more, but look at how different the emotional expression of the eyes is.

Cheeks

Some people like hollow cheeks when they are young. As you age it gets less attractive and looks old. It is one of the things that can stay the same but looks worse when you are old than when you are young.

This patient had a medical problem which predisposed her to getting irregular fat loss in the cheeks. She had a total of 3 cc's of Restylane placed into the cheeks which smoothed them out considerably.

She had 2 cc's of HA filler in her cheeks, which we both agree looks better.

This patient had a facelift at 40, which I think was too young. She was left with hollow cheeks and rounded hollow eyes. Some people like these looks, but she didn’t. She had HA fillers and some fat injected into her brows and face.

Temples

Most people don’t think about temples, but they are a crucial component of the face. If your temples get hollow, the head starts to look like a peanut (simile courtesy of one of my patients), and the ends of the brow seem to disappear. By filling in the temples one can make the face look hugely improved and the brows seem to lengthen. I started to do temple filling with custom carved implants in the early 1990's, then with fat injection. I think the best results are achieved with fillers. I tell patients they will last at least two years, but the usual is three or even four years. The best thing about this procedure is that the patient looks hugely better in pictures and in life, but no one can tell why because the effects blend in with the big picture of the face.

Look at this patient. She had 1½ cc's of Juvederm injected into each of her temples. Look how the face loses the pinched look and the eyebrows seem to lengthen and elevate. This will last for years.

Look at this gentleman with hollow temples. He looks like less of a peanut head — much improved and more youthful with 2 cc's of filler per side.

Look at this 62 year old woman. The top picture is before any treatment. The middle is about 2 years after injecting her brows and the bottom picture is a year after filling in her temples.

This woman had filler in her temples. You can see the effect on the temple shadow as well as the eyebrows. She just looks better and you can’t tell why.

This patient is in her 40's. She has hollow temples, which have gotten worse. You can see how it makes the face look bony and hollow and makes the brows look shorter. A year after an injection to her temples her face looks less bottom heavy and the brows have expanded.

Jawline

One of the very first areas to show aging is the jowl area. This happens to people as early as the 30's. If you fill in front of the jowl, it straightens out the jawline and creates an illusion of the face appearing much younger than it actually is. You can’t really explain this to someone; they have to see it. So I usually put in a little local anaesthesia which duplicates the effect of the filler in that location. I call this a local preview and it lets the patient see exactly what the visual effect of filling there will be. If the patient doesn’t like it the local anaesthetic will just go away in 20 minutes.

This patient had filler in her jawline, which now looks straight. Look at the difference this makes in the balance of the face.

Noses

One of the best areas to use fillers is in noses that have been operated on already and need irregularities smoothed or flattened areas filled.

Some noses, like this patient, didn’t want an operation and we filled in her tip and the hollow going up her columella with a little Restylane. The pictures here are three years apart.

This patient had an apparent hump on her nose. A small amount of filler makes the nose looks straighter. The picture is from two years after the procedure.

Lines and wrinkles

This is what most people think about when they think about fillers. I use magnification, and, using a very tiny needle, place filler products into the very top layers of the skin. Product lasts longer here.

This patient had microfiller placed into the wrinkles of her cheeks. This is 8 months later.

Correction of facelift deformities

If you hadn’t noticed, many people who have too much facelift surgery (either too many times or pulling too hard) look decidedly strange. They may be in the public eye, and had their surgeries done by well-known and expensive plastic surgeons. This should tell you something about well-known and expensive surgeons. The treatment of many complications should primarily be by prevention and careful-enough surgery to keep this from happening, but many of these people have deformities that can be well corrected by the use of some volume in the face.

This patient had an overaggressive facelift with liposuction below the cheekbones. The doctor apparently thought that this would look good. It didn't. She was filled in with fat grafting and a lovely result.

This patient had a previous facelift that left her with “joker lines”, shadows that go from the corner of the mouth toward the ears. This looks great in a young person. But as a person ages, it looks facelift-y and odd. She was corrected with 3 cc's of Restylane which lasted 2 years.

This patient in her 60's also had an over-aggressive facelift. She looked obviously facelifted and pulled before she was treated with 3 cc's of Restylane. Here she is 5 months afterward. In my experience, Restylane in the cheeks on a female lasts a year to a year-and-a-half.

Here is a patient in her 70's. She had a facelift that left her with a streaky hollow across her cheek. She did not like the look. She was treated with a secondary facelift with the addition of 6 cc's of fat in the central face. Look how improved she looks after one year.

I have been doing this a long time. It takes a long time to be able to understand the complexities of the face. It looks easier than it is. With fillers in particular it is possible to make large differences in some faces with only office visits. It is also possible to ovedo these. If you keep getting lips nasolabial folds and cheeks filled you will wind up looking smooth overexpanded and without any definition. You won’t look like yourself. Small tasteful amounts of fillers won't do this.

fat grafting vs. fillers

Though doctors had been doing fat grafting sporadically for a hundred years, it really did not receive much interest until liposuction entered the scene. All of a sudden doctors had bottles of fat sitting in their operating rooms and thoughts of recycling it danced in their heads. Soon fat was injected all over the face and body. I started doing facial fat grafting in the late 1980's.

The good things about injecting fat are that it was the first volume-increasing tool that we had except for facial implants. All of a sudden faces that were thin and hollow could be made to look less gaunt unhealthy and old. The hallmark of young faces is that they have some fullness as well as smooth skin, and volume injections could do both. In many people, there's a large amount of fat available and wider areas can be covered.

The disadvantages are that it is unreliable; sometimes it works and sometimes it doesn’t, especially in older faces.

Also the grafted fat can grow. This happens most commonly in young people who get fat grafting. As they have yet to enter the phases of life where people may get thicker, such as menopause, they may look fine for years. Then, when they put on weight, the injected fat grows in the area where from where it came as well as the areas into which it was grafted. This almost never looks good and is difficult to correct.

Grafted fat is not easily removed. This is a particular problem under the eyes, where it seem like an obvious treatment to fill in the tear-trough hollow. Even in skilled hands this is a difficult area which can result in visible bumps that are visible and difficult to treat. Make sure your doctor has plenty of experience with this. A safer option is to use HA fillers which can easily be removed if necessary.

Fat grafting can be done under local anaesthesia, though it is most commonly done as part of a facelift. My practice is comprised of mainly older people for whom the fat growth problem is not an issue. Fat grafting is free, as I don’t charge for it with a facelift. And though it is not always predictable, some take is better than not trying at all, and residual hollows can be treated with fillers later. I routinely use some fat grafting, usually one or two tablespoons full with most facelifts that I do. You will see some of them in the facelift section of this website.

Fillers are priced to fill wrinkles and lips which (usually) make them prohibitively expensive to use in the large quantities one needs in the face. A teaspoon is 5 cc's. A syringe of most fillers is 1 cc. One can actually do some very noticeable and lovely things with upwards of 5 cc's in the face, but it will be very expensive. In some areas like the brows, temples and lower lids, a small amount has a big effect and will last for many years, so in these areas it is a good deal. Very critical areas like the lower lids, brow and nose are better done with HA fillers than fat, as HA fillers can be modified or removed and fat cannot.