In our three-part series, The Filler Files, Allure explores our relationship with facial filler. It's still one of the most popular nonsurgical cosmetic procedures, yet more of us are looking to dissolve our filler than ever before. What does this mean for our lips, our cheeks, and our approach to injectables?
If you clicked on this headline, you likely have some relationship with hyaluronic acid fillers — the injectable gels, like Juvéderm and Restylane, that millions rely on to contour, plump, and smooth their features. Whether you’re a diehard fan or a casual acquaintance, you’ve probably wondered how these sugar-based substances behave inside the body and what actually happens when we decide to quit them after years of routine touch-ups.
In posing these questions to dermatologists and plastic surgeons, we discovered that there’s a frustrating dearth of formal studies investigating hyaluronic acid fillers over the long term — how and when they break down, the ways in which they change over time, and their effects on the quality of our skin and elasticity of our tissues, both during peak injectable use and long after we’ve sworn off the stuff. Given the paucity of hard data, much of what our experts shared is anecdotal — insights informed by their decades of experience injecting and dissecting the human face. Reliable intel, nonetheless.
- Jessica Weiser, MD, is a board-certified dermatologist in New York City.
- Lara Devgan, MD, is a board-certified plastic surgeon in New York City.
- Mitesh Kapadia, MD, is a board-certified ophthalmologist and an oculoplastic surgeon in Boston.
- Elizabeth Houshmand, MD, is a board-certified dermatologist in Dallas.
- Jonathan Cabin, MD, is a board-certified facial plastic surgeon in Arlington, Virginia.
- Ben Talei, MD, is a board-certified facial plastic surgeon in Beverly Hills.
- Flora Levin, MD, is a board-certified ophthalmologist and an oculoplastic surgeon in Westport, Connecticut.
- Gary Motykie, MD, is a board-certified plastic surgeon in Beverly Hills.
In the interest of not burying the lede, we’ll start here: If you’ve been getting filler religiously for years, what happens when you stop will hinge on one critical factor: your average dose at each appointment. “People who are getting a syringe or two every 12 months — doing a little bit for specific points of volume replacement — they have a much easier time than those who are receiving 5 to 10 syringes every six months, because they’re not getting to a place of overinflation and tissue distortion,” says Jessica Weiser, MD, a board-certified dermatologist in New York City.
And make no mistake: Countless men and women are walking around with gluts of filler under their skin. While Dr. Weiser’s self-imposed limit for a single session is “two or very rarely three syringes,” she believes she is somewhat of an outlier among injectors. “There are tons of doctors doing 10 syringes at a time,” she tells us. Some of the other physicians we spoke to confirmed that they commonly encounter patients who’ve received 20 or even 50-plus syringes of hyaluronic acid over a one- to two-year span.
When “patients come in with too much filler in their faces, it can be almost disfiguring,” says Lara Devgan, MD, a board-certified plastic surgeon in New York City. The problem can be more than skin-deep, affecting both the look of the face and its functionality. It’s so common that there’s a term for it: “filler fatigue.”
Board-certified ophthalmologist and oculoplastic surgeon Mitesh Kapadia, MD, describes the overfilled face as “an epidemic” for which a growing number are now seeking a cure — namely, hyaluronic acid-melting hyaluronidase, a synthetic version of an enzyme found in the body. You’ve no doubt seen celebrities, like Courteney Cox and Amy Schumer, talking openly about being displeased with the look of their outsize cheeks or lips and having their filler dissolved with this injectable solution. They’re hardly alone. According to The Aesthetic Society’s most recent trend report, their members performed 57% more filler reversals in 2021 than they did the year before. Indeed, a common refrain among cosmetic providers is that they’re spending more time dissolving filler than injecting it.
What’s behind the about-face? “People are realizing that they’re not looking better, but looking odd,” says Elizabeth Houshmand, MD, a board-certified dermatologist in Dallas. It may be an old photo or a well-meaning family member that helps them see the error of their ways. Or a complication will clue them in, as they notice their filler migrating or swelling. Often, though, they can’t pinpoint the exact problem, Dr. Weiser says; they just know “that things feel strange.”
Sometimes, people break up with filler not because they’re overfilled, per se, but because they’re over filler — the look, the upkeep, the headaches — and this too is a form of fatigue. The filler becomes oppressive, a burden. “Especially when they’ve been through bad injectables and dissolving, they just don’t want to deal with it anymore — they’re done,” says Jonathan Cabin, MD, a board-certified facial plastic surgeon in Arlington, Virginia. In other cases, the filler has just exhausted its usefulness, no longer able to obscure insecurities in a natural-looking way and compelling once-loyal users to pursue a more powerful solution, like surgery.
- So what’s all this filler doing to our faces?
- What happens when you stop getting filler?
- What to do once you quit
So what’s all this filler doing to our faces?
Overdone or poorly placed filler can muck up the mechanics of a face. “The facial muscles may not move properly, and that changes not only how you look, but also how you drain,” says Ben Talei, MD, a board-certified facial plastic surgeon in Beverly Hills. By way of explanation: Muscle contractions ordinarily help keep lymphatic channels flowing, but when filler envelops the muscles it restricts movement, straining our expressions and causing lymphatic fluids to stagnate and lymphatic channels to swell. All the while, the hyaluronic acid is pulling in fluid — notorious water hogs, these gels — intensifying bogginess and bloat. “When there’s such a high volume of filler going in there that the face is not draining properly, it can give the skin a sort of puffy or doughy look,” adds Dr. Weiser.
Filler can also integrate with our tissues over time. In small quantities, it’s no big deal. It may just make certain layers of the face “stronger and slicker,” notes Dr. Devgan. But when copious gel piles up from repeated injections, this fusion can elicit a “microcystic expansion effect,” says Dr. Talei. (He describes the concept in a new study published in the Aesthetic Surgery Journal.) As he explains, “the filler penetrates as little gel particles, soaks into the various layers of the soft tissue, and [acts] like a million tiny water balloons, stretching it all out.”
The soft tissue expansion reads as bulkiness, he says, “sometimes with a bit of a gargoyle appearance in certain patients.” In the lips, it can lend a “flaccid, low-hanging” look. The consequences of this distension will be more dramatic in those who’ve been grossly overfilled for many years.
What happens when you stop getting filler?
“Patients who were filled ‘normally’ shouldn’t have any issues. The filler either sits around harmlessly or slowly metabolizes over time,” says Dr. Talei. Dr. Weiser agrees that if judicious doses (treating every issue with as little filler as possible) were carefully injected (in tiny droplets, versus large blobs, at a safe and imperceptible depth), the body’s own hyaluronidase enzymes should gradually digest it. (In areas of little movement, like the undereyes, hyaluronic acid fillers can be rather tenacious, though, and can sometimes outstay their welcome.)
As filler fades and its effects wear off, previously treated features will shrink and flatten, creases and folds may emerge, and shadows can creep in. Whatever you were aiming to veil will be unmasked — and likely accompanied by age-related changes that landed, perhaps unbeknownst to you, during your filler’s tenure. Uncovering what’s happened while filler’s been in your face can be a lot if you’re not psychologically prepared for it, cautions Dr. Cabin. On the upside, hyaluronic acid injections have been shown to stimulate collagen production, so your skin could, consequently, be a tad thicker following years of repeated pokes.
And the post-filler expansion phenomenon — the stretching and warping of tissues — shouldn’t really concern the low-key filler user, who is not obviously inflated. “Appropriate amounts of filler do not cause this problem,” Dr. Talei reassures us. “It is more likely seen when excess amounts are placed [for] over a year.”
Whether you let filler dissipate on its own or use dissolver to speed things along, don’t expect to be left entirely filler-free. “I don’t think you ever get 100% back to having no filler in your face,” Dr. Weiser says. A portion of it does integrate and “it’s extremely challenging to remove every drop.”
Dr. Devgan also acknowledges that trace amounts of filler can remain interwoven with our natural collagen, much like ivy that’s grown into a lattice in a garden. But she stresses that this is not something to fear. “Filler disappears on a decay curve, steadily disintegrating at a consistent rate, until it becomes almost imperceptible,” she explains. Even if remnants are visible on an MRI [or ultrasound], she adds, they’re not necessarily significant enough to alter a person’s appearance.
If you can’t see or feel your old filler, and it’s not acting up, the doctors we spoke with all advise against chasing it with hyaluronidase because that little bit of filler that’s sticking around could be totally benign. While the gel may “change character in the future, move a tiny bit, or draw in water,” Dr. Talei says, in such scenarios, “dissolving it is usually easy and predictable.”
“Overfilled” patients can also stop and/or dissolve what’s in their face at any time, but it may take them longer to reach their no-filler destination — and they may not love the view once they get there.
When people have been filled forever and “don’t remember what they looked like before, they need to know they may be opening a can of worms,” says Flora Levin, MD, a board-certified ophthalmologist and oculoplastic surgeon in Westport, Connecticut. “My consent for dissolver clearly states that you may be just as unhappy, or more unhappy, after I dissolve the filler than you were prior to dissolving.”
Younger patients tend to rebound fairly seamlessly, “likely because they haven’t been filled for as many years, which means less filler in some cases and less time for expansion [of the soft tissues of the face],” says Dr. Talei. Their tissues are also more resilient with a greater healing capacity.
Rarely, in extreme and prolonged cases of filler use, “the face can never go back to what it was,” says Dr. Talei, because the gel has damaged and, in a way, aged the tissues. He hesitates to dissolve these patients, because removing the HA (to whatever extent possible) can leave stretched tissues unsupported and desiccated, causing areas of the face to collapse and appear darker. He can usually get them to a better place: They may need to maintain some degree of HA filler while also considering surgery to address laxity, plus stem cell-rich nanofat or platelet-rich plasma (PRP) injections to help regenerate depleted tissues.
The lips are, arguably, the most frequent victims of superfluous filler — and, over time, this can carry serious consequences.
But how much filler is reasonable in the lips department? It depends on your individual starting point — the undoctored size and shape of your lips. While everyone’s are different, a unifying characteristic is that they all have a tipping point: Upon assessing your lips, your injector should know precisely how much gel they can receive without complication.
“For lips, I very seldom do more than half a cc at once,” Dr. Levin says. “And I don’t have people come back [for touch-ups] at a specific time period. We leave it open-ended.”
When lips are repeatedly filled beyond their inherent capacity, filler can seep across the vermilion border (a.k.a., the lip line) into the philtrum (the area between the lips and nose), “producing a shelf-like appearance or ‘filler mustache,’” says Beverly Hills board-certified plastic surgeon Gary Motykie, MD. Filler migration is common here because the muscle encircling the mouth is in near-constant motion.
Beneath the skin of the philtrum is a cushy layer of fibrous tissue called the SMAS (short for superficial musculoaponeurotic system), which overlies muscle. “This tissue is responsible for [providing] supple support and hydration to the lip skin,” Dr. Talei explains. When an abundance of filler sits in the body of the lips and/or the SMAS for an extended period of time, these tissues can stretch and expand — sometimes permanently.
“If the filler is left to slowly go away [on its own], the lips may eventually return to normal, or the filler could just stay in place for years,” Dr. Talei tells us. Alternatively, patients may choose to melt lip filler with hyaluronidase to take control of the process. “Many people dissolve without issue and don’t require any follow-up,” says Dr. Talei. Occasionally, though, dissolving overfilled lips can backfire: The tissues don’t snap back to their original state, he adds, and removing the filler actually “may reveal the [tissue] expansion and accelerated aging” that occurred while the hyaluronic acid was in place. The lips can look lax, shriveled, or asymmetric, and the skin above the vermilion may appear darker and wrinkled due to changes in the SMAS.
Ironically, the fix for this may be more lip filler — a conservative dose, injected periodically, to revolumize and rehydrate the tissues. If the area above the lips looks long and droopy in the wake of overfilling, a surgical lip lift can shorten the space to youthful effect. As with other parts of the face, nanofat or PRP injections may also help repair damaged tissues.
This all sounds a little scary, we realize, and we never aim for sensationalism, so let’s be 100% clear on this point: A modest amount of lip filler, even sustained over years, “will not accelerate tissue aging — it just doesn’t do that,” Dr. Talei says. But when lips — or any part of the face, for that matter — have housed a ton of hyaluronic acid for a time and “it’s inhibiting movement and stretching skin, that can speed aging tremendously.”
What to do once you quit
Once you’ve decided to take a break from filler — for however long — consider diversifying your treatment portfolio. “When I see patients who’ve been getting only filler for 20 years and have never had any kind of radiofrequency or ultrasound or laser treatment, what I find is that their skin — the luminosity, tone — it just doesn’t look that good,” Dr. Weiser says. Try refining your complexion with a proven device or getting a subtle volume increase from collagen-stimulating Sculptra. Don’t lean on hyaluronic acid exclusively. “I think if you really maintain the quality of the skin and keep collagen levels boosted, the need for volumization is less,” adds Dr. Weiser.
Ultimately, all procedures have limitations — and respecting them can keep you looking “undone” through the years. When your old reliables start to fall short, you can either pause and accept your reflection as is or explore the next-level surgical realm. Happily, the choice is yours.
Check back for the third installment of our three-part series, The Filler Files.
Read more on injectables:
- In 2023, Will Everyone Abandon Their Facial Filler?
- A New Filler for Laugh Lines and More Procedures That Are Safe for Dark Skin
- What Is Daxxify, and Why Would I Want to Inject It in My Face?
Watch a dermatologist explain how hand fillers work:
