With more than 20 million views, #fillergonewrong is captivating the aesthetes of TikTok with its can’t-look-away content: boxy jawlines, overstuffed lips, bulging under-eyes, and horror-show vascular occlusions that are often the result of botched liquid rhinoplasties.
“I’ve seen a tremendous rise in injectables complications,” says Dr. Jessica Weiser, a board-certified dermatologist in New York City. Behind the majority of filler fails, she notes, are inexperienced injectors with inadequate anatomy training who are either choosing the wrong type of gel for a given area or injecting it improperly.
Dr. Sarmela Sunder, a board-certified facial plastic surgeon in Beverly Hills, California, also reports a strong correlation between climbing complication rates and the growing number of unqualified providers across the country (many of whom have no aesthetics background or training). “A lot of these injectors are extrapolating one technique to multiple areas of the face,” she says, and failing to realize that a method that works well for plumping the lips, for instance, isn’t suitable for smoothing the under-eyes. She also sees, among certain injectors, “a strong desire to stick to one company for all products” in order to obtain discounted rates. In her opinion, very rarely can every area of the face be treated with injectables from a single manufacturer—and so “wrong products wind up being used in wrong areas,” she says.
What’s more, as various fillers continue to earn FDA approval and enter the fold, hype builds around emerging products, putting enormous pressure on injectors to rush to use the newest thing. And being among the first to offer the latest gel can sometimes translate to patients becoming unwitting guinea pigs.
In Washington, D.C., board-certified dermatologist Dr. Noëlle Sherber has been reversing her share of injectables gaffes from other practitioners—from uneven filler placement to overfilling and migration. She finds thin-skinned areas of the face, like the lips and under-eyes, to be “the least forgiving in terms of [inappropriate] product and technique, causing contour irregularities.”
Correcting bad filler typically means dissolving unwanted gel with hyaluronidase, an injectable enzyme, before starting over from scratch one to four weeks later.
All the doctors we spoke to say they’re using much more hyaluronidase than ever before—and that the act of reversing filler has gotten more challenging. “Back when it was just classic Restylane and Juvéderm [on the market], we could get products dissolved very quickly,” Dr. Sunder tells us. “Now, with these more crosslinked fillers, we find ourselves dissolving for a lot longer.” With filler, she adds, “you really want to get it right the first time, because it can be a huge ordeal to dissolve.”
We asked top injectors about the bad work they’re fixing daily—and how you can avoid filler gone wrong.
Under-eye filler gone wrong: bumps, blue hue, chronic puffiness
“Outweighing any other filler complications I see, far and away, are [those from] injections in the tear trough area,” says Dr. Jason D. Bloom, a board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania. (Dr. Bloom’s practice routinely handles complications from other area clinics.) Whether they’re due to the wrong filler choice or too-superficial placement, under-eye issues are “the biggest thing I’m dissolving filler for.”
The unique anatomy of the lower lid can easily trip up new injectors. “Everywhere else on the face that we inject, the layers of the tissue [from top down] are skin, subcutaneous fat, and muscle,” he explains. “But in the lower eyelid, the skin is directly attached to the muscle and the fat is underneath. So if you try to place filler between the skin and the muscle, it can’t go anywhere and creates a wormlike lump or you get a Tyndall effect”—a bluish hue cast by light reflecting off gel that’s resting just beneath the skin’s surface.
Juvéderm Volbella XC recently became the first filler to be FDA approved for the tear troughs. However, some doctors insist that the gel, which is part of the Vycross family, is not the best fit for the delicate under-eyes. They claim it’s prone to create swelling and lumps and that it can be difficult to dissolve. Since tear trough injections using any other type of filler are considered off label, those filler manufacturers cannot train providers in how to treat the area. Which presents a conundrum, says Dr. Bloom, because “it’s the first thing every novice injector wants to learn—‘How do you do the tear troughs?’”
The demand for this procedure is overwhelming, he adds, because “it’s one of those areas that looks incredible when done well.”
That said, under-eye filler is not for everyone, and judicious patient selection is key to skirting complications. “In my opinion, only 20–30% of patients are candidates for tear trough filler,” says Dr. Kami K. Parsa, a board-certified oculoplastic surgeon in Beverly Hills, California. “People who have fluid retention under the eyes, chronic allergies, or a history of autoimmune disease are not candidates.” In these folks, hyaluronic acid (HA) gels can trigger malar edema, a transient swelling of the lower lids.
When the puffiness becomes persistent, bags called malar mounds can take up residence atop the cheeks. The usual remedy is hyaluronidase—which, by melting the HA, addresses the cause of the swelling and prevents the overlying skin from stretching and getting lax.
Lip filler gone wrong: lumps, migration, and more
“Lip filler has been a major problem recently,” Dr. Weiser says. “I’ve seen numerous cases of filler being placed much too deep in the lip, resulting in a ridge along the moist mucosa of the lip, where it should not be.” Bad technique also manifests as asymmetrical outcomes, “sausage-like, amorphous lips,” duck-bill contours, and overdone white rolls, she notes.
Lumps can surface for all kinds of reasons, but in active areas, like around the mouth, it’s not unusual for “the muscles to take over and ball up the filler,” Dr. Bloom says. Using a gel in the lips that’s too thick or overly firm—such as one intended for cheeks or jawlines—can also promote a lumpy look.
Filler migration—product shifting from its original locale and distorting features—has become a social media phenomenon of late. According to our experts, when an appropriate dose of a suitable filler is injected at the right depth, it really shouldn’t travel—but sometimes does. While “I can’t tell you with 100% certainty how it happens, I can tell you that it does happen,” says Dr. Bloom. And some gels are more likely to move than others. “The older generation of fillers was more slippery and prone to migration,” notes Dr. Sherber, “but the newer, more elastic forms of hyaluronic acid should be less susceptible to this if placed properly.” While highly mobile areas, like in and around the lips, can be especially susceptible to filler migration, she adds, it can also occur in the cheeks and jawline when filler is injected too shallowly.
In lip filler patients, a desire to go big can contribute to migration. “When I see a patient come in with migrated lip filler, I ask to see a photo of their previous lip shape as well as the goal photo they gave to their last injector,” says Dr. Sherber. “I often find that their goal photo is not realistic for them anatomically and that their lips have been overfilled [to accommodate their request], which has led to the filler spilling into the surrounding tissues over time.”
Even when the ideal filler is placed perfectly, she explains, if the lips can’t hold the volume injected, the gel will seep into adjacent areas.
Hyaluronidase can be injected into the lips and the skin above—small amounts over several sessions—to gradually bring lips back to baseline (or closer to it). “The key is knowing when filler must be dissolved and when it can be corrected,” Dr. Weiser says. “Lumps or ridges in the lips or gums need to be dissolved, while asymmetry can typically be corrected.”
Nose filler gone wrong: blocked vessels and scarring
Dr. Sunder counts nose filler among the big three types of injectables complications she treats in her practice. (Since Dr. Sunder is a rhinoplasty specialist, injectors frequently send their dire nose cases her way.) Unlike most other filler mistakes—which tend to be reversible cosmetic concerns—nose filler gone wrong can carry consequences that are both disfiguring and permanent. With noses, Dr. Sunder explains, it can be an emergency situation, where there’s an active vascular occlusion that demands swift attention to save the patient’s skin, or it may be a case of prolonged scarring from an occlusion that was previously treated but perhaps not fully resolved—“a part of the skin never got reperfused properly, so there’s long-term damage,” she says.
In some cases, she’s using lasers or microneedling to improve the texture of and any hyperpigmentation in the skin. In others, she’s relying on reconstructive procedures, like regional flaps, to rebuild parts of the nose—commonly, the side of a nostril or a portion of the tip—that were lost to necrosis.
