Non-surgical Procedures

The overfilled face: Why the overfilled do not see

The use of hyaluronic acid fillers

The release of hyaluronic acid fillers over 25 years ago was revolutionary in the filler world. Being both ‘temporary’ and ‘reversible’ whilst providing excellent volumisation of the face made them an instant hit.

At first, hyaluronic acid fillers were most commonly used to fill areas such as the lips and nasolabial folds, the folds between the corners of the nose and mouth. With time and progress, practitioners evolved to use fillers to beautify, balance and proportion the face by injecting other areas such as cheeks, temples, foreheads, chins, jawlines, and noses.

However, as filler usage has increased, the number of distorted, unbalanced and overfilled faces has risen also. In this article, I will attempt to unravel why overfilling occurs, looking at the psychological reasons behind it, and why practitioners keep filling the overfilled, fuelling this ‘epidemic’ of overfilled faces.

What is an overfilled face?

An overfilled face occurs when there is excessive filler injected into the face, causing a distorted and puffy appearance. This is commonly referred to as “facial overfilled syndrome” or “pillow face”.

What happens when you get too much dermal filler?

Overfilling can affect anyone who has fillers. From strangers you walk past on the street to your own friends, the rich and famous, and even cosmetic practitioners.

Even though overfilling is obvious, the truth often goes unspoken, and the overfilled are not told.  Could it be like the story of the Emperor’s New Clothes, with no one willing to point out that the Emperor was wearing no clothes? Leonardo Da Vinci professed in his teachings that three classes of people exist; Those who see, those who see when they are shown, and those who do not see. 

overfilled face example

Overfilling and body dysmorphic disorder (BDD)

Dr Ben Buchanan is a clinical psychologist, who sees many patients with body image disorders. ‘I see clients who typically have body dysmorphic disorder (BDD).’ Those with BDD have an obsessive preoccupation with their appearance and are extremely distressed about what they look like.’

I told you myself that maybe BDD would be a convenient explanation for why overfilling occurs and why the overfilled don’t see it.

‘To the outside world, to other people, someone with body dysmorphic disorder looks pretty normal. However, for someone with body dysmorphic disorder themselves, they feel like they’re terribly ugly, even disfigured. Many people with this problem will seek cosmetic procedures. They don’t recognise that the issue they’ve got is psychological. They think it’s an aesthetic issue.’

Hyaluronic acid filler and body dysmorphia disorder (BDD)

I asked Dr Buchanan about the relationship between BDD and overfilling, ‘If you are overfilled, does that mean you have BDD? Can you be overfilled and not have BDD?’

‘Yeah, great question’, replies Buchanan. ‘Let’s start from the very foundations… people want to look attractive! We’re buying lots of products, adorning ourselves with beautiful clothes, and we’re putting makeup on. When we put makeup on, some women are going for the natural look, but a huge proportion of women are going for a bolder look, something that exaggerates their eyes, blush on their cheeks, high contrast makeup that doesn’t look natural… but still looks really attractive. So this assumption that if someone is getting a cosmetic procedure or having filler done, that they want to look natural, I don’t think is a correct assumption…’

Dr Buchanan’s answer made me feel uncomfortable. I’ve always prided myself on maintaining a natural look for my patients, but Dr Buchanan told me that ‘attractive’ isn’t always ‘natural’. Maybe this could explain why it’s often been a battle to convince my patients that they’ve had enough filler. Maybe they want to look attractive at the expense of looking natural.

‘Not everyone’s going for a natural look, and there are studies showing that with makeup, people will typically find those who are heavily made up more attractive than those who are lightly made up.’  Dr Buchanan explains further, ‘The way this is tested is; an image of a heavily made-up person, someone with light makeup, and someone with no makeup are flashed on a computer screen for 250 milliseconds. This is really fast, so fast you can’t think about it… you just see it, and then your brain automatically processes it. What we know is that; even when it’s flashed up so quickly, most people are saying the person that’s heavily made up is the most attractive.’

Social media influence and dermal filler injections

This quick flashing of attractive images reminded me of what we see in today’s social media. Here, promoting attractive yet unnatural-looking ideals may further drive people to become overfilled. I spoke to my patient, whose name will remain anonymous, about the impact of social media on her self-perception and drive to get more filler;

‘Scrolling through Instagram multiple times a day and seeing photos even photos that you don’t subscribe to, of mainly influencers or models… a lot of people on there, I think [are] touching up their photos to look a certain way, and in your mind, you don’t click straight away that it’s not reality. And for me at least, I know that was a trigger for how I should look, and if I don’t look like that, I’m not worthy. Obviously, that’s a very unhealthy thinking pattern… it’s really going to impact your mental health, but also [make you] want to get whatever you can done to look like the photos you’re seeing. For me, that was getting filler.’

‘Social media ‘turbo charges’ an underlying sense of inferiority that many people have,’ Dr Buchanan responds. ‘Since the invention of mirrors we’ve been scrutinising ourselves… social media takes that to the next level. Social media, Photoshop, and filters create this idealised image of people’s faces.’ I ask Dr Buchanan why people seek these extreme ideals.

kane lim before and after filler

“Supernormal stimuli” and too much dermal filler

He tells me, ‘There’s this fundamental psychological idea called supernormal stimuli. Supernormal stimuli essentially means; that particular looks are ‘super-normal’ or ‘more than normal’. From the animal kingdom, we know that studies have shown that animals are attracted to other animals with exaggerated features. Peacock feathers are a process of that evolution where that peacock has evolved to have this outlandish look because it’s attractive. Except we’re not going to wait around for evolution to do that for us, we’re going to use fillers and the available technologies to do it.’

But unlike other animals, humans quickly tire of these extremes and what is ‘super-normal’ quickly becomes ‘normal’.

‘You get filler, feel fantastic for a week, and then your happiness levels return to normal because that’s just how happiness typically works. And then it’s like, alright, well I felt really great last time I did this, I’ll do it again, and then they feel really great for a week, and then happiness just goes back to normal, and then you’ve got to keep on doing it in order to maintain that level of increased well-being.’

What happens if you have too much lip filler?

I speak to Emily, who has had multiple lip filler treatments and has experienced similar feelings to what Dr Buchanan has described. ‘Your appearance is something that you see every day in a mirror. It becomes normal to you, it becomes natural, and that becomes who you are. So you look at them [lips] and go, ‘oh they’ve gotten a bit smaller today I’m going to get a little bit of top-up.’’

Mr Peter Callan, a plastic surgeon from Geelong, Victoria has found that patients ‘Ask for a little bit more because some patients want to see a difference every time they get up and look in the mirror. It’s amazing how quickly you get used to the new look.’

Dr Cara McDonald, a dermatologist and experienced doctor in cosmetic injectable treatments concurs with Callan. ‘The problem is that patients very quickly adjust to their new normal and they feel that they need more, and they can’t really tell the difference between ‘striking’ and ‘slightly odd’ when they’re looking at themselves.’

Dissolving dermal fillers

In my own practice as a cosmetic doctor, I’ve often dissolved filler for patients with overfilled lips, cheeks and tear troughs. But rather than being grateful to return to normality, it is not uncommon to see these patients return quickly to have their filler replaced. They can’t tolerate having less or no filler after being overfilled. Conversely, when it comes to overfilling the patients tolerate it well; they don’t realise they have been overfilled if it is done gradually over time.

‘There’s an old story about putting a frog in a pot of warm water and then slowly bringing it up to the boil’, says Callan, ‘and if you do that, then the frog will lie there and slowly boil itself to death. But if you throw a frog into a pot of boiling water, it’ll jump out straight away! This is what we’re doing [with fillers], we’re slowly bringing people up to temperature, and you don’t feel it, you don’t notice it.’

Avoiding an overfilled face

Because of the acclimation to filling, we can’t always rely on our patients to be the best judge of when to fill, how much to fill, or what to fill in their faces. Ironically, part of the cause of overfilling may be doctors listening and fulfilling their patient’s requests. Callan tells us ‘Most people can’t put their finger on exactly what it is that’s making them age. They read about things like ‘loss of volume’, and they will go along with a specific request they need more cheek fillers or something; in other words, they’re making the diagnosis, and they’re going along to a practitioner asking for that specific thing.’

In most cases of overfilling, a specific area of the face is overfilled, creating disproportion with the rest of the face. Patients are often hyper-focused on a single area of concern driving them to come in for more filler and often not seeing the big picture. ‘The problem is you can totally lose perspective and if you’re looking at something through a straw where you’re narrowly focused you’ll be seeing a totally different thing than if you stand back and look at the whole face’, states Dr Buchanan. Similarly, Callan believes that the effect of the whole, or the Gestalt, is more important than the parts, ‘When you look at somebody, it’s the whole that you want to look rejuvenated attractive, beautiful.’

courtney cox before and after filler

Cosmetic practitioners and dermal filler

Ultimately fillers are not injected by the patients themselves and overfilling may occur only when both the doctor and the patient don’t see the Gestalt. ‘I think the old adage that a camel is a horse designed by a committee’, says Callan with some candour and comedy. ‘In other words, you design the back, you design the leg, you design their head, and they put them all together, alluding to what happens when both patient and doctor focus on the parts, not the whole.

Dr Cara McDonald thinks that this problem with doctors is about having only hammers and seeing only nails, ‘You know we see a lot of practitioners who have a limited skill set with what they can do, and if their skill set is ‘cheeks and lips’ then they’re usually going to recommend ‘cheeks and lips’.’

Maybe we can blame the problem of overfilling on practitioners who lack experience? Personally, when I first started injecting, I was younger, more enthusiastic, and maybe somewhat overzealous. I felt I couldn’t do much wrong. I have certainly developed since then, and the volumes of filler I use now are significantly less.

‘Some people very early on think they’ve got a great gift,’ Callan tells me. ‘They get a few good results, and they haven’t practised for a long time, but they think that they’re very good at this when it’s a skill that takes years to develop. But because they get a few good results, and a few home runs, they feel pretty good about themselves. We call this the ‘Peak of Mount Stupidity’, where you haven’t actually learnt anything… you’ve stumbled across a couple of good results. But then things start to go awry, some patients come back complaining, others come back looking weird, and then you suddenly realise you don’t know as much as you did.’

Cosmetic practitioners and body dysmorphic disorder (BDD)

Cosmetic practitioners may also suffer from body dysmorphic disorder or BDD, which has further implications when treating their patients. Dr Steven Harris, a cosmetic doctor from London, and a strong advocate against overfilling and ‘alienisation’ of faces explains; ‘Practitioners with BDD have been found to have greater left-sided brain activity when it comes to processing facial detail and so they’ll have a tendency to focus on areas more than usual.’ Immediately, this reminds me of the pattern of thinking of patients afflicted with BDD. Dr Harris confirms that ‘They will have this tendency, and we know this from studies in patients, that they’ll become very preoccupied with detail rather than seeing the whole.’

You might ask at this point, what are the chances of being overfilled by a practitioner with a skewed aesthetic perspective? Dr Harris investigated this question after noticing many practitioners with distorted and overfilled faces at cosmetic conferences. He decided to study the prevalence of body dysmorphic disorder in cosmetic practitioners together with Dr Neetu Johnson – a dual qualified psychiatrist and cosmetic doctor. By compiling the results of a self-reporting survey to assess symptoms of BDD, they found that;

‘The prevalence of body dysmorphic disorder amongst practitioners was higher than that amongst our patients at 16%, and patients are between 8 and 15%, so we found a significantly higher rate of BDD amongst practitioners.’

Dermal filler longevity

However, there is one overriding factor that I believe underpins all overfilling and that is; filler longevity. We commonly believe that temporary hyaluronic acid fillers only last from six to eighteen months. Dr Mobin Master, dual qualified in radiology and cosmetic medicine, is the doctor that doctors send patients to when they have problematic filler. He’s like the ‘answer book’, as he can visualise filler in the face, often injected years ago using MRI. In January 2021 Dr Mobin Master published an article in the Plastic and Reconstructive Journal about filler longevity that showed fillers might last a lot longer than we commonly believe. He found on MRI that;

…of 10 patients who had fillers more than two years ago, all ten showed persistence of the filler longer than two years including one lasting 12 years.

According to his study, the difference between the actual and commonly-accepted longevity of ‘temporary’ hyaluronic acid fillers could be very different.

Overfilled tear trough filler

I spoke with Sally who put up with overfilled tear troughs for over four years because no doctor believed that her filler would last that long. ‘In 2016 I had some tear trough fillers done, and at the time it looked great. Approximately 12 to 18 months later I started to develop bags under my eyes.’ But despite working in an eye clinic, no practitioner believed that Sally’s bags were due to filler. They didn’t believe it would last that long. ‘I went to two oculoplastic surgeons, two ophthalmic surgeons, and one plastic surgeon who told me that I had to have half a facelift… and I was horrified!’

On hearing Sally’s story, Dr Master says, ‘That if a patient comes to you and says ‘I believe this is filler’ you need to believe the patient. There are so many patients who have come to me and said, ‘I’ve gone to experts… and they don’t believe me,’ and I do an MRI and it’s full!’. Sally comments further and states ‘Everybody believes filler dissolves in 12 to 18 months, and you have a very hard time telling a doctor this is filler!’ Eventually, after four years of having eye bags, Sally convinced a doctor to order an MRI for her to help reveal what was causing them.

Dr Master interprets Sally’s MRI to find what she had suspected all along. ‘It’s literally right here (pointing at the filler on the MRI). Fat is black, and filler is white. You can see the filler on the right side; the bright stuff,’ confirming the presence of filler in her lower eyelid and the cause of her eye bags.

After waiting four years and seeing more than five specialists who told her that she needed surgery to remove the bags under her eyes, Sally eventually dissolved the filler that was causing her eye bags.

Too much filler, too frequently

Filler longevity is also directly related to how often filler top-ups are performed. If filler lasts a lot longer than we expect, then the regular top-ups may be more frequent than required. Lips, for example, are commonly injected with 1 ml filler every 6 months. But if filler lasts significantly longer than the interval between injections an accumulation of filler and overfilling might occur.

Emily, whom we spoke to early about the normalisation of her lip filler, recounts her lip filler experience in more detail; ‘The first time I got my lips done was about 2016, so five or six years ago now. I always had one mL done, and I’ve probably had them done around about five or six times. I was always told that people get a top-up every six months to a year.’

We performed an MRI on Emily’s face to see what was happening with the filler she had injected into her lips. Dr Master, on reviewing Emily’s MRI states, ‘I see a little bit up the top, and there’s a little bit more down the bottom, so there’s still some [lip filler] residue from five years now.’ Again, showing the longevity of filler to be much longer than the commonly believed six to eighteen months.

Emily was very open about her situation. She also appeared on national television with me to have her lips dissolved, hoping to help spread this information to others.

Saying no to dermal fillers

Given the potential of filler to last a long time, as practitioners, we have to be able to assess patients before filling and say ‘no’ if required if overfilling is to be avoided. ‘A lot of practitioners are scared to say no because they think they’ll lose the business,’ says Dr McDonald. Mr Callan also tells patients to stick to what they initially wanted and not ask for more, ‘The patient can be their own worst enemy.  They say ‘I want to look totally normal doctor’, and then they come back and you think you’ve done a good job, and they say ‘I want more!’  It’s then your job to say, ‘Stop! This is what you wanted, and this is what I wanted, and you look great!’

How to prevent an overfilled face

Dissolving filler occasionally

After seeing the filler accumulation radiologically on MRI, Dr Master suggests occasionally dissolving filler if required to prevent overfilling, ‘You create a sculpture… but over time you can’t keep adding that putty on, because it becomes bigger and bigger and bigger, so you have to carve and chisel away to put it back to a normal looking face.’

But why should those who spend their hard-earned money on fillers dissolve them especially if the underlying motivation maybe stand out? In the same study mentioned previously about heavily made-up faces being more attractive when flashed for 250 milliseconds, a different result was shown when given an unlimited inspection time. Inferences were then made about trustworthiness, authenticity and genuineness, detracting from the increased attractiveness afforded by the high contrast makeup.

Dr Buchanan explains ‘When you show that image for longer, people still agree that the heavily made-up one is most attractive, but then there’s this other process that happens in the mind where we say, ‘Why do they have so much makeup on, are they less authentic, are they making up for something?’, and so I think when it comes to overfilling the same process occurs.

Reduce social media usage

Reducing social media use and exposure to unrealistic ideals may also help reduce our drive to be overfilled to more extreme levels. ‘The research is really clear on social media’, says Dr Buchanan. ‘If you spend more than about 20 minutes on social media a day your level of overall satisfaction with your life and your appearance will go down.’

Use smaller amounts of dermal filler

To prevent overfilling practitioners need to more carefully consider using smaller amounts of filler, injecting less frequently, and looking at the face as a whole rather than just filling the same areas repeatedly. We must understand that filler may last much longer than we have always believed and fill accordingly. Overfilling has psychological implications as the overfilled keep on filling and overfilled becomes the norm. But like I always say, ‘If you can tell something’s been done it’s not a good job’.