The Pursuit of Perfection: Avoiding Poorly Done Fillers and Overfilled Face Syndrome

Walk along Orchard Road, and you will notice perfectly manicured faces that stand out from the crowd. Aesthetic treatments in Singapore have grown exponentially in recent years. An article in The Straits Times [1] reported that influencers have normalised and driven this demand, often portraying themselves receiving face threadlifts, HIFU, and others.

One aesthetic treatment that stands out is fillers. Fillers have surged in popularity worldwide, with many people, including celebrities, seeking non-surgical methods to enhance their appearance and combat signs of ageing. However, this trend has also given rise to a concerning phenomenon known as Facial Overfilled Syndrome (FOS) [2]. This condition arises from excessive filler use and poor injection techniques, leading to distorted facial aesthetics. This blog explores the causes, manifestations, prevention, and treatment of poorly done fillers and FOS.

What is Facial Overfilled Syndrome?

“I want fillers to look younger, but I don’t want to look fake.” This is something I hear regularly during patient consultations. Hyaluronic acid gel-based facial injectable fillers have transformed the practice of cosmetic surgery and aesthetic medicine, offering no downtime rejuvenation by restoring facial volume and sculpting facial features. However, the epidemic of individuals with "Facial Overfilled Syndrome (FOS)" presents a concerning trend. 

Facial overfilled syndrome (FOS) is a complication caused by multiple incorrect placements of fillers [3]. Many celebrities and influencers experience facial distortion due to FOS, which becomes visible with facial expressions and worsens with tissue sagging due to ageing. It can be seen in those with excessive volume in the midface, forehead, chin, and nose. Poorly injected dermal fillers, incorrect selection of filler products, excessive treatment recommendations by the injectors, and overly zealous clients are the common causes of this phenomenon.

What does Facial Overfilled Syndrome look like?

Facial Overfilled Syndrome is characterised by an unnatural and exaggerated appearance from overusing dermal fillers. Common manifestations include:

• Flowerhorn foreheads: a bulbous forehead appearance
• Avatar nose: a broad nose bridge
• Sunset eyes: an exaggerated upper eyelid fullness
• Chipmunk cheeks: overly voluminous cheeks that appear puffy
• Witch chins: an overly prominent chin
• Pillow faces: a generalised overfilling that gives a rounded, inflated look
• Tyndall effect: undereye lumps and sausages with a bluish tint

These changes can significantly distort an individual's natural facial features and may lead to psychological distress due to perceived unattractiveness or unnaturalness.

This won’t happen to me; I’ve not had that many fillers done!

That’s what most people think, but the truth may surprise you! In 2022, Alice Hart-Davis [4], a UK-based beauty journalist, underwent a Magnetic Resonance Imaging (MRI) scan of her face to assess the residual volume of the 15 syringes of fillers she had injected between 2004-2018 into her cheeks, tear troughs, lips, chin, jawline. By conventional wisdom, these fillers should have long ago melted away, with most doctors and clinics recommending once-a-year treatment of fillers. Most filler manufacturers estimate the longevity of their hyaluronic acid gel fillers to be between 9 to 24 months based on their research and clinical studies.

The shocking truth revealed that Alice Hart Davis’ MRI showed 35 ml of excess volume attributable to hyaluronic acid gel dermal fillers, far more than the 15 ml she had injected over the course of a decade. The fact is that hyaluronic acid is hydrophilic, meaning that after being injected into the face, it swells up and draws in water, thereby increasing in volume. The second takeaway is that fillers may not break down as fast as we thought they did. Different individuals may metabolise hyaluronic acid gel fillers at different rates –  meaning that it is possible for a “slow metaboliser” to “accumulate” a lot of excess fillers over repeated treatment sessions.

In another case study [5], US-based Oculoplastic Surgeon Dr Kami Parsa shared an MRI Scan of his patient, who had 12 syringes (12 ml) of hyaluronic acid filler done over the past six years. The scan showed the fillers persisting in the face well beyond the expected 1-2 year timeframe and a 28 ml increase in tissue volume (!!!). 

What causes Facial Overfilled Syndrome?

The development of FOS can be attributed to several factors:

• Excessive volume and low metabolisers: many practitioners inject large amounts of filler in a single session, often referred to as "bolus" injections [6]. This approach can lead to rapid volume changes that the skin cannot accommodate, leading to FOS. Additionally, some people may be slow metabolisers of dermal fillers, thus slowing down or reducing the dissolving of fillers.
• Poor injection techniques and inadequate knowledge: incorrect placement of fillers can exacerbate the problem. For instance, injecting too superficially may lead to visible lumps or unevenness. This highlights the importance of choosing an experienced doctor specialising in dermal fillers and ensuring natural-looking results.
• Inappropriate dermal filler: not all dermal fillers are created equal. Using low-quality products or those that do not integrate well with facial tissues can lead to FOS.
• Overzealous practitioners and clients: the desire for dramatic results can drive both injectors and clients to pursue excessive treatments without considering the long-term implications.
• Lack of comprehensive assessment: failing to assess facial anatomy adequately before treatment can result in poor outcomes. Factors such as bone structure, muscle behaviour, and skin elasticity must be considered.
• Body dysmorphia: some people may be experiencing body dysmorphia [7] and may feel like they need more and more dermal fillers to get the appearance they visualise in their heads. 

The Anatomy Behind Facial Overfilled Syndrome

Understanding the facial anatomy is crucial in preventing FOS. The face comprises various fat compartments that change as we age. This is due to multiple factors, such as bone resorption and redistribution of soft tissue. These changes can create the illusion of volume loss, prompting the desire to fill this hollowness with fillers.

An experienced doctor will understand the following when administering dermal fillers to patients:

Ageing contributes to bone loss, change in muscle contraction patterns, and fat redistribution.

How do you fix an overfilled face?

• Dissolve the fillers with hyaluronidase: thankfully, hyaluronic acid-based dermal fillers can be dissolved with the injection of hyaluronidase enzyme, which rapidly breaks down the fillers. However, it is not uncommon for patients to develop skin sagging and a sunken appearance after having their fillers dissolved (link to service page of dissolve filler), leading many to request fillers again—a never-ending cycle!
• Don’t inject too much in one session: an astute and experienced doctor will know that less is more and anticipate some swelling and tissue expansion. It is prudent to perform filler treatments over two sessions to minimise pain and swelling, and the filler volume required for a good cosmetic outcome can be accurately determined.
• Do other treatments: fillers play an important role. Still, they should not be the only component of a comprehensive aesthetic treatment plan. An experienced doctor will recommend a holistic approach utilising energy-based devices such as Ultherapy or Oligio RF for lifting and skin tightening and collagen stimulators such as Sculptra or Juvelook.
• Choose a trusted doctor/clinic: some cases of Facial Overfilling Syndrome develop due to patients' doctor-hopping habits, who move around clinics to seek out the latest filler promotion or cheap deals. However, this means that no doctor has a clear overall picture of the situation, increasing the risk of being overfilled. Find a trusted doctor and clinic and stay there; an ethical doctor with a good eye for beauty will tell clients when to stop.

Is this the end of hyaluronic acid dermal fillers?

Hyaluronic acid dermal fillers are here to stay. The global dermal fillers market is on track for significant growth, with sales estimated to reach US $6.4 billion in 2024 and projected to soar to US $8.8 billion by 2034. However, the increasing awareness of Facial Overfill Syndrome among doctors should lead to a change in practices, where doctors stay alert in preventing, diagnosing, and treating overfilled faces.

Fillers at Bay Aesthetics Clinic and Medispa

Dr Bernard Tan and Dr Hoe Ying Min are both experienced, internationally trained dermal filler injectors with over 20 years of combined experience and thousands of successful cases. The clinic stocks a wide selection of hyaluronic acid fillers, including established brands such as Juvederm, Restylane, Teosyal, Belotero, and EPTQ. 

Patients undergoing filler treatment receive a detailed medical consultation as well as 3D camera photography with volumetric analysis. Our treatment philosophy is: “Less is more”, taking a careful and conservative approach to filler injections, using the minimum treatment volume to achieve optimal results, typically 4-8 syringes (4-8 ml) for full face rejuvenation. 

References

1. Cheng, K. (2023, August 22). Social media influencers driving demand for aesthetic treatments in Singapore. The Straits Times. https://www.straitstimes.com/singapore/social-media-influencers-driving-demand-for-aesthetic-treatments-in-singapore
2. Mehta, R., & Khan, A. (2023). Complications of facial fillers: A systematic review of literature and recent advances in management. Journal of Cosmetic Dermatology, 22(8), 1761-1772. https://pubmed.ncbi.nlm.nih.gov/37977678/
3. Baek, J. (2023). The long-term safety of hyaluronic acid fillers and the potential complications in aesthetic medicine. Journal of Cosmetic Dermatology, 22(5), 1432-1440. https://onlinelibrary.wiley.com/doi/full/10.1111/jocd.16244
4. Hart-Davis, A. (2022, October 5). How much filler did Alice's MRI reveal? The Tweakments Guide. https://thetweakmentsguide.com/blog/how-much-filler-did-alices-mri-reveal/
5. Cockburn, H. (2023, August 24). MRI scan of 33-year-old woman's face shows filler that ended up needing surgery. Newsweek. https://www.newsweek.com/mri-scan-33-year-old-woman-face-shows-filler-ended-surgery-1925089
6. Wollina, U., & Goldman, A. (2022). Dermal fillers for aesthetic facial treatments: Complications and management. Journal of Cutaneous and Aesthetic Surgery, 15(3), 181-187. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255720/
7. Coleman, S. R., & Saboeiro, A. P. (2018). An analysis of 17 years of facial fat grafting. Plastic and Reconstructive Surgery, 142(6), 1724-1733. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986110/