You know “pillow face” has officially gone next-level when the phenomenon inspires a filter. While the term has long been used to describe the odd, puffy appearance that results from an exorbitant amount of filler being injected into the face, this past spring, we saw the debut of the namesake filter, which allows you to adopt the look—cartoonish lips; exaggerated cheeks; stretched, shiny skin—on Instagram and TikTok.
While the overfilled face may be good for a laugh on social media, its growing prevalence IRL is a very real concern in the aesthetics industry. “We’re reaching a point now where people have been having filler performed routinely for the past 10 years [or more], and there’s the layer-upon-layer accumulation of gel in their faces,” explains Dr. Kay Durairaj, a board-certified facial plastic surgeon in Pasadena, California. In that same time frame, she adds, multiple syringes and yearly touch-ups have become the norm—and due to this “steady filling-up of faces,” she says, “a level of distortion is beginning to become apparent societally.”
What accounts for the rise in overfilled faces?
Affecting patients and providers alike, “perception drift is a real issue,” Dr. Durairaj adds, referring to a concept first described by board-certified San Diego dermatologist Dr. Sabrina Fabi. In essence, Dr. Durairaj explains, “the more we see a repeat image of something, the more natural and normal it becomes.” Over time, after a series of treatments, even subtle tweaks here and there, people tend to forget where they started. Their augmented look becomes their reality, and they continuously seek to maintain and enhance it—drifting farther and farther away from their natural-born baseline, often without even realizing it.
While caricature-like features and hypercontoured faces are often associated with LA, the overfilled face isn’t just a West Coast problem. “What we had previously seen only on the red carpet, we’re now seeing everywhere,” notes Dr. Christian Subbio, a board-certified plastic surgeon in Newtown Square, Pennsylvania. This is partly because Hollywood “sets the tone for the rest of the country,” he points out, but also because social media promotes and normalizes the trend.
Even in the more conservative environs of Washington, D.C., board-certified facial plastic surgeon Dr. Michael Somenek encounters his share of duck lips and chipmunk cheeks. “I think it’s becoming more common, the longer injectables are around and the more aesthetic injectors enter the field,” he says, emphasizing the fact that “not everyone who is injecting respects facial proportions.” Nor does every injector understand that fillers aren’t really meant to be perfectly preserved at all times, says Dr. Ben Talei, a board-certified facial plastic surgeon in Beverly Hills, California. It’s a popular misconception, he adds—this notion “that fillers are a maintenance type of treatment, where you have to go back every six months, to keep adding.”
Unwitting injectors aren’t solely to blame, however. Our experts say that the more-is-more mindset has become a fundamental tenet of industry-based filler training programs. “The drug companies, the way they teach, they’re pushing the idea that more is better—that most patients who walk through the door can benefit from 15 syringes of filler,” Dr. Subbio says.
Injectors are also taught that every gel has a unique and definitive life span—that hyaluronic acid (HA) filler X, which is quite thin, with molecules somewhat loosely strung together, disappears after four to six months, while filler Y, a stout jelly that’s more tightly crosslinked, can persist for 12–18 months. But according to Dr. Subbio, “these prescribed longevity quotes are completely arbitrary, based on either no evidence whatsoever or extremely bad evidence.” (In studies, subjects aren’t usually followed beyond trial endpoints in order to gauge true filler duration.) Yet these numbers have conditioned patients to habitually ask injectors, “How long will my result last?”—while compelling injectors to book touch-ups based on unfounded info.
It’s a common scenario, says Dr. Durairaj: “Filler companies tell us that this gel lasts a year, and we want to do right by our patients—we want them to maintain their look and not have to start at zero and reinvest from the beginning—so we’re telling them, ‘Maybe touch it up at nine months.’ And some people perceive that there’s a value loss when you don’t touch things up.”
In most cases, when patients come back months later, “all of their filler is not gone—there is a certain amount [that’s] residual,” explains Dr. Subbio. “And exactly how much remains depends on the particular patient, their metabolism, how much filler was injected, where it was injected, the nature of the gel itself, how highly crosslinked it is. So many factors go into the longevity of a gel, and the truth is, physicians have no clear idea of how long they last.”
While there exists no tool for measuring leftover filler in a face, Dr. Subbio says that anatomy-savvy injectors can detect it, at least to some degree, during a physical exam. The closest doctors have to something more quantifiable is imaging technology, like MRI and ultrasound, which select researchers have recently begun using to track old filler. While these modalities can’t calculate ccs of gel in a cheek or tear trough, they can clearly show these substances sticking around long after purported expiration dates. In some instances, “we’re seeing filler lasting upwards of 10 years, on ultrasound,” Dr. Durairaj tells us. But since this tech isn’t ordinarily used in practice—nobody is routinely scanning faces before injecting—new filler is continuously layered over old and the pile-up is causing serious problems.
Signs and symptoms of an overfilled face
First, there’s the “obvious physical distortion of the natural anatomy,” says Dr. Subbio. “When the architecture of the human face is even slightly tweaked or pushed out of its natural boundaries, it’s acutely noticeable to the human eye.” As previously noted, however, our perception of what’s natural is gradually changing. As certain features, like oversized lips, become more ubiquitous, they’re resetting social norms and making textbook anatomical norms seem, at times, insufficient. Still, there’s a fine, malleable line between desirable and deviant.
Sometimes what we read as overfilled isn’t pure puffiness—it’s the weird way the face moves when gorged with filler. “The human face is a finely tuned instrument, with fat pads and muscles and skin sliding this way and that, in harmony,” Dr. Subbio says. “But if you stuff a bunch of HA gel into its machinery, it’s not going to glide or behave naturally.” Facial movement gets restricted; features and expressions, contorted. Outsize cheeks encroach on the eyes, warping their shape—most notably, when smiling. Sausage-y lips interfere with speech. “Some patients with too much gel in their lips can’t form words properly,” Dr. Subbio notes. “The muscles surrounding the mouth that are responsible for creating crisp, refined sounds have been mucked by gel that’s distorting their movement.”
Muscles become especially impaired when filler is injected too superficially, says Dr. Durairaj, and this causes a domino effect that upsets our lymphatic channels. “If filler is placed improperly, it can impede normal facial muscle contractions, which are required to assist the flow of lymphatic fluids,” she explains. “Lymphatic vessels normally have very low force of contraction, so it is easy for them to become obstructed.” In certain areas, the sheer pressure of overlying filler can also hamper lymphatic flow, she notes, contributing to long-term swelling.
Moreover, when hyaluronic acid filler, which attracts and holds many times its weight in water, isn’t deposited deeply enough, it can make the skin itself look bloated, doughy, and thick. Particularly as HA fillers degrade, “they globally draw in water in a way that changes the turgor of the face and its hydration level to the extent that, as an experienced injector, I can see someone’s skin and know they’ve had filler,” says Dr. Durairaj. “There’s something about the water pressure—it’s beyond what normal skin looks like.”
Dr. Talei agrees that the water HA gels accumulate can significantly alter the face, inside and out. “The face starts getting more watery-looking over time, the muscles become swollen and don’t function well, and the lymphatics—depending on the area injected—get clogged up and the face doesn’t drain well,” he says. “Now not only is it drawing in more water [due to the HA], but it also can’t release the water, so people just get bulkier and bulkier.”
Dissolving filler to get back to baseline
Once doctors diagnose an overfilled face, they’ll typically suggest dissolving excess HA with an injectable enzyme called hyaluronidase, which begins to work immediately, melting away the bulk of old filler within 24 hours or so, to bring patients back to baseline. Hyaluronidase affects only hyaluronic acid. There is no reliable antidote for injectable volumizers made from other materials, like calcium hydroxylapatite (aka Radiesse) or poly-L-lactic acid (Sculptra).
While a shot of enzyme seems a simple enough fix, the aftermath can be unsettling—especially if someone has been getting clockwork injections for years and their fillers have effectively masked much of the inevitable facial aging that has transpired in that time.
Dr. Talei uses “traumatic” to describe the process of dissolving filler. “All this time, the face has been filled, not just with filler but with water, so its hydrational status is going to change dramatically when you dissolve and dehydrate the face,” he says. When consulting with overfilled folks, he says, “first I have to see if they can tolerate the trauma.” If they’re not a good candidate for dissolver, he’ll instead use RF microneedling to help speed up the metabolism of the filler—“it doesn’t melt the filler, but it can denature it a little bit,” he explains, and basically kick-start the degradation process. If someone is ready to start from scratch and their tissues are in good shape, he’ll inject dilute dissolver wherever he sees fit.
In Dr. Talei’s experience, the under-eyes and the lips are where it’s easiest to dissolve, due to their anatomy and innate ability to rebound from hyaluronidase. More “treacherous” zones are the anterior cheek (near the nose) and anywhere around or above the nasolabial fold, he says, since it’s “difficult to dissolve [there] without flattening and deflating someone.”
While hyaluronidase protocols vary, depending on the patient; the provider; and the filler in play (the specific type, amount, placement), our experts say most HA can be reduced in one or two sessions. Doctors then typically have patients wait at least two weeks or more before injecting fresh filler. “I like everything to get broken down and cleared, to give the skin time to revert to its native architecture and just allow everything to settle down a bit so that when I look at them again, I’m truly seeing a new baseline,” Dr. Somenek says.
That two-week window also allows the tissues to partially rehydrate and recover from the hyaluronidase-induced “dehydrational damage” before new filler is introduced, Dr. Talei says. Patients generally look better a couple weeks out, even without the addition of fresh HA, because everything has plumped up a bit on its own.
The hyaluronidase debate: Can it cause lasting damage?
We can’t discuss hyaluronidase without acknowledging the current controversy over the dissolver. In the past few years, a number of patients have come forward, claiming to have suffered permanent volume loss from hyaluronidase—insisting that the treatment for HA overload is worse than the disease, so to speak. The standard response from doctors is that there are no published studies proving the enzyme capable of irreparably destroying human tissue and while yes, hyaluronidase can break down the body’s own native hyaluronic acid near the injection site, HA regenerates so quickly that permanent wasting or deformities in the skin are very unlikely. Injectors commonly attribute any lingering depletion to natural aging—the signs of which may become apparent when filler is removed after many years. “But it’s all conjecture at this point,” Dr. Subbio says. “No one actually has scientific evidence either way.”
In Dr. Durairaj’s opinion, “the majority of what hyaluronidase does is over by the time patients leave our chair”—so she doesn’t believe long-term changes should occur when the enzyme is used appropriately, by experienced providers. However, if an injector is fully flooding the face with dozens of vials, in an attempt to melt away old filler or reverse a vascular occlusion, “then yes, you may be changing the facial constitution,” she concedes. But again, she stresses, there’s no proof that hyaluronidase can reduce one’s baseline HA in a noticeable way.
While the scientific literature may not provide evidence of hyaluronidase damage, the body sometimes does, Dr. Talei tells us. He sees it when he operates on faces that have been previously injected with the enzyme. “I can treat someone’s lip that was dissolved 5–10 years earlier and know that their SMAS [the connective tissue covering muscles] is half the size it’s supposed to be,” he says. Hyaluronidase side effects manifest outwardly as well: “It changes the radiance of the face, and people look deflated and gaunt because the tissues can’t retain hydration anymore in the SMAS layer, which normally carries all the water,” he says.
To be clear, Dr. Talei adds, this doesn’t always happen. “Realistically, most of the time, you’re fine—we dissolve in one of those benign areas [like lips or under eyes], and you don’t have any problems,” Dr. Talei says. “But there are times when patients are permanently damaged.”
The right way to restore a face after dissolving HA
In a word: conservatively. To avoid reverting back to overdone, our experts urge restraint—a slow and judicious refilling of the face. Two or three weeks after dissolving, Dr. Talei says, he injects “the most minimal amount of filler possible,” to help rehydrate the tissue. “I inject a little, wait for it to rehydrate, then have the patient come back in a couple weeks and do it again. At that point, we’re in a pretty good position to prevent falling into that cycle of filling and dissolving,” he says. Going forward, he veers on the side of undercorrection and offers touch-ups only when results have visibly waned in order to protect patients’ new aesthetic.
Dr. Durairaj takes a similar approach with recovering filler addicts, placing tiny droplets of HA in various locations, to capitalize on its powers of hydration. HA is the only type of filler that can deliver water to withered tissues—but it’s this humectant property that tends to breed trouble over time. Indeed, says Dr. Durairaj, “the overfilled-face problem is a gel-filler problem.” Dr. Subbio cosigns: “HA is the main culprit—it’s the most widely used filler in the US and the only one that binds water and encourages swelling.”
Keen to this pitfall, certain injectors are leaning more on biostimulators, like Radiesse and Sculptra. Dr. Durairaj frequently reserves HAs for the lips; under-eyes; and “occasionally, a deeply etched line in the nasolabial area,” she says, but in the majority of cases, she’s using Radiesse to enhance bone structure by contouring along the cheeks, the lower jaw, and the chin. “These bolsters of support give a very lovely look and allow the face to retain its character instead of appearing bloated,” she says. Her technique also addresses bone resorption of the facial skeleton—which starts in our 30s, she says, causing skin to drape differently across the face—with the goal of making people less dependent on gel fillers.
When appropriate, Dr. Durairaj targets deep areas of volume loss with collagen-boosting Sculptra. Dr. Somenek is also a fan of biostimulators. “HAs are most commonly used,” he says, “but I think everyone needs to consider [alternatives] at some point in their injectables journey.”
Since biostimulators are not reversible, they require more precision and a greater knowledge of anatomy. “But if we don’t evolve our thinking and start teaching injectors to use [non-HA fillers],” says Dr. Durairaj, “we’re going to be a doughy-faced nation.”
When it may be better to refrain from filler
While some physicians say a modest dose of HA is almost essential to replenish tissues affected by dissolver, others like to take this moment to reassess the face at its new baseline.
Rather than reflexively picking up a syringe, Dr. Subbio aims to figure out if the patient is actually a good candidate for filler. “A huge subset of overfilled faces are people who were looking to rejuvenate their face—and what they probably needed in the first place was tightening and lifting and repositioning of structures that have descended.” In other words: a facelift.
On the same page is Dr. Somenek, who adds that filler is simply not powered to hold up an aging face. When someone tells me that their jowls—or the overall lower third of their face—is really bothering them, and [the laxity] is beyond what I can contour or disguise with filler, then my answer is always: “You need to consider some type of surgical intervention.’”
Or do we? Once free of unwanted HA, we don’t necessarily have to choose between injectables and surgery. There is another, albeit less conventional, option: acceptance. In Dr. Durairaj’s office, about 30% of patients who have filler dissolved are happy to reclaim their former face, she says, even if it does bear a few more wrinkles or folds than they remember. For these folks, “dissolving bad filler is a very gratifying procedure,” she explains. “They’re aware that there was something dysmorphic about their overfilled face that they no longer liked or identified with. And once we remove the offending filler, they feel much more like themselves again.”
