Who’s a good candidate? It’s a recurring question in aesthetics—and for excellent reason. When doctors appropriately match patients and procedures—by taking a fastidious history, examining anatomy and areas of concern, discussing goals and expectations—they essentially stack the deck in our favor, improving the odds of beautiful, complication-free outcomes.
But there’s one treatment that’s become so ubiquitous, it seems to almost defy the concept of patient selection: hyaluronic acid (HA) filler. “I think the perception is, if I am human and I have a face, then filler will make me look better—and that’s just not the case,” says Dr. Sinehan Bayrak, a board-certified facial plastic surgeon in Philadelphia. “There are lots of people walking around with filler who never should’ve been filled—or never should’ve been filled to the extent that they were filled—and this is how people wind up looking artificial and cartoonish.”
Contrary to what our social feeds convey, filler isn’t for everyone. Discerning injectors routinely turn away those they suspect won’t do well with HA. There’s also a small but growing faction who are simply anti-filler, for one reason or another. Among modern aesthetics patients, notes board-certified New York City dermatologist Dr. Paul Jarrod Frank, “there’s an increased knowledge that filler can go wrong,” coupled with a heightened awareness “that maybe there’s more to life than just injectables.” Which amounts to countless women and men aiming to improve their skin, in a meaningful way, without HA injections.
Poor candidates for hyaluronic acid filler
Those with autoimmune conditions and allergies
Chief among questionable HA candidates: those with autoimmune conditions. While many doctors consider such diseases to be a contraindication, says Dr. Jessica Weiser, a board-certified dermatologist in New York City, there aren’t any hard-and-fast rules here. “Broadly speaking, we always have to be careful of patients with autoimmune conditions and treat them with a gentler hand,” says Dr. Sarmela Sunder, a board-certified facial plastic surgeon in Beverly Hills, California (and an advisor to Allergan, maker of Juvéderm products). While plenty of autoimmune patients “do fine with filler”—in small doses—there’s a sizable subset whose immune systems overreact to some, if not all, types of HA filler, she says.
Dr. Sunder may also avoid filling “the allergenic-profile patient,” as she calls it—those with a persistently swollen look, related to allergies and lymphatics. “I ask every patient, ‘Do you have seasonal allergies? How bad are they? How often do you have to take an antihistamine?’” she tells us. Tear trough and cheek filler can be especially problematic for these patients, as water-binding HA gels can trigger a kind of fluid buildup known as malar edema, making them look “puffy and strange—like they have gallons of filler under their eyes,” Dr. Sunder says. Even lips can look overdone when allergies act up, she adds. Dr. Weiser has also seen filler “cause significant congestion of the lymphatic channels, leading to chronic swelling of treated and adjacent areas.”
People looking to lift lax, sagging skin
Another group that risks looking overfilled is the 40-plus set with obvious skin laxity and jowling. “There are a lot of providers who use filler to quote-unquote ‘lift’ sagging skin,” explains Dr. Sunder. “But filler cannot lift, and it cannot address skin laxity”—at least, not in a natural-looking way. Hiking the jowls to a discernible degree, she says, would require providers “to use multiple syringes and inflate [the face] so much, you’d look bizarre.”
Likewise for folks with more advanced signs of collagen loss—an abundance of wrinkles and crepe-paper texture: “There is no amount of filler that is going to smooth that out,” says Dr. Bayrak. “I almost hate to do anything in that situation, because the cost of a syringe is not lost on me.” She finds that, in general, HA filler delivers the best result in younger patients with decent skin quality and strong bone structure, which gives something to build upon.
The importance of that foundation can’t be overstated. “We now have a burgeoning population of patients receiving large volumes of filler—especially as lumps over the bone—during years when that bone is being lost due to the aging process,” explains Dr. Hema Sundaram, a board-certified dermatologist in Fairfax, Virginia, and Rockville, Maryland. When piles of filler blur eroding bone, “the result can be a gelled-up mass of soft tissue that’s relatively unsupported by the age-depleted bony foundation and moves over it in a very unnatural way.”
Patients with body dysmorphic disorder
Doctors also refrain from filling those with certain mental health concerns. Dr. Sunder pauses when there’s even “an inkling of body dysmorphic disorder or less extreme perception drift, where patients forget what they used to look like [before filler] and want to keep adding more.”
Anti-filler sentiment
When unscrupulous injectors fill indiscriminately, they invariably create unnatural looks. And since tasteful filler often goes unnoticed, it’s these wonky outcomes that become the public face of filler. Beyond merely perpetuating the stigma around injectables, these unsavory effects—distortion, pillow face, migration—are fueling a sort of filler backlash, experts say.
“I absolutely have patients who aren’t interested in having filler injections,” says Dr. Weiser. “There’s a significant stigma associated with filler. Often noticeable, higher-volume filler can look unnatural and lead patients to believe that all injections may be unsightly.”
In Dr. Sundaram’s D.C.-area practice, she finds it’s her over-50 patients who are most likely to have reservations about filler. “They don’t like what they’ve seen of the aesthetic,” she says. “We’re now approaching 20 years of using hyaluronic acid in our country, which is ample opportunity to see the long-term issues [that can arise] when fillers are used inappropriately.”
Dr. Sunder too meets people every day who are turned off by filler. “My patients are mostly in L.A.—they see people who are overdone,” she says. Plus “there’s so much messaging against filler, and it scares people.” In some cities, it’s driving an uptick in filler reversals. “I dissolve HA weekly in patients who have old filler or swelling,” says Dr. Ellen Marmur, a board-certified dermatologist in New York City. “People would rather be wrinkled and saggy than puffy—especially now, with bad filler memes going viral on social media.” And many who choose to retire their filler find “it’s refreshing to feel natural again,” Dr. Marmur adds.
Doctors on both coasts acknowledge the soaring number of patients committed to a “clean” lifestyle, who are leaning into autologous enhancements like PRP and view self-derived products as safer than and superior to synthetic HA injections.
None of this means filler is going anywhere, however: millions of injections are still being performed, year over year, in the U.S. alone. Still, certain demographics seem to be leading a resistance—or at least rethinking their reliance on HA. Even in Beverly Hills, “people who went all in with the Instagram face—the full lips, big cheeks, prominent chin—are now realizing that they overdid it,” says Dr. Sunder. “As their personal pendulum swings the other way, they’re either not doing any filler at all or they’re doing much, much less.”
Rejuvenating skin without HA filler
If you don’t love filler but still want to look fresh and youthful while delaying surgery for a time, where does that leave you? While Dr. Frank admits he rarely advises patients to give up on injectables altogether (barring contraindications or patient opposition), he finds that “when someone feels like they want to pull back on filler, that’s really when combination treatments come into play,” he notes. “I’ll say, ‘Let’s be more conservative [with filler] and start considering things that are going to work on other aspects of aging’—first and foremost, skin elasticity.”
Happily, there are numerous ways to ramp up collagen and boost the skin’s tone and texture. “Improving tissue quality is really the key—whether one is striving to avoid a facelift or to prepare for one in the future,” Dr. Sundaram says. If you haven’t already established a solid skin-care regimen—with SPF 50+ and a retinoid as underpinnings—start there. “I’ll tell you, the surgical result I can get in someone with good skin is a little bit different from the surgical result I can get in someone with not-so-great skin,” Dr. Bayrak says.
When considering in-office fixes, realize that certain nonsurgicals can complicate future facelifts by compromising circulation, stripping fat, and promoting scar tissue, which can muddy the face’s planes of dissection. “Whenever we refer to a procedure inducing collagen, that’s scar tissue it’s leaving behind—that’s what you’re seeing as a visible result,” Dr. Sunder explains. In other words, anything that “works” can leave a mark. But some treatments, she adds, offer more benefit than risk, leaving less of a trace long term.
Resurfacing lasers
Depending on the severity of your sun damage and the amount of downtime you can tolerate, resurfacing lasers can do everything from reviving the skin’s surface to fully vaporizing it, spurring new skin cells to rise up while jump-starting collagen. Within this vast category of tools, happy-medium lasers include the Fraxel Dual—which Dr. Frank says “will make the skin be healthier, age slower, and look better almost immediately” (following a week of redness, bronzing, and flaking)—and the Halo, which marries ablative and non-ablative wavelengths and “does a nice job of addressing hyperpigmentation,” according to Dr. Bayrak. For next-level resurfacing, she relies on her ablative CO2 and erbium lasers. “There’s no topical, no injectable, no surgery that can do what an ablative laser does,” she insists. “These patients, I can’t even describe their skin after… it’s like suede.”
Skin tightening devices
Skin tightening tools use radiofrequency (RF) and ultrasound energy to heat the tissues and spark collagen growth for smoother, firmer skin over time—but none is a substitute for surgery. When discussing RF microneedling with patients, Dr. Sunder uses the word toning versus tightening, to help set expectations. Usually, by the time someone comes in inquiring about a facelift, “they already have two to four centimeters of laxity palpable on exam,” she tells us. “Morpheus8 is not going to tighten the skin by centimeters or give you back the neck you had in your 20s.” The effect is far subtler. Still, “a couple of millimeters is pretty impressive for a nonsurgical device,” she says—especially around the eyes.
In Dr. Bayrak’s experience, the Morpheus8 shines more as a “texture tool.” She recommends it mainly to those concerned with pores, scars, fine creases, and the like.
When treating mildly slack skin with RF needling, Dr. Weiser favors the Secret RF and the Genius (she’s a speaker for both companies). “The needles smoothly enter the skin without force and deliver a precise amount of RF heat to the tissue at a consistent depth,” she explains. If addressing crepey skin and fine lines along with early laxity, she may reach for Sofwave instead. This newish device sends ultrasound energy 1.5 millimeters deep into the dermis—sparing fat—to modestly firm the skin and refine its texture.
The minimally invasive, RF-fueled FaceTite can melt fat and shrink the skin slightly, making “jawlines look a little bit sharper,” says Dr. Bayrak, who always pairs it with lipo in order to bolster the effects. Dr. Frank finds that oftentimes, FaceTite can sculpt the lower face better than HA, which frequently “makes jowls and jawlines look wider and heavier,” he says.
Fat grafting and fat replacement
“When performed well, fat grafting absolutely transforms tissue quality,” Dr. Sundaram says. “I find fat to be the best nonsurgical ‘substitute’ for significant bone loss, especially for the jawline and chin, where I see dramatic improvement not only in facial contour but also in skin elasticity and radiance.” In her experience, these skin benefits can extend beyond the areas where fat is injected to give neighboring regions, like the neck, a similar boost. As with filler, fat ameliorates hollows and deflation—not pronounced sagging.
Renuva offers another way to add fullness—to cheeks, temples, jawlines—without HA. Derived from donor fat tissue, “Renuva is a scaffolding of growth factors, proteins, and collagen that impels natural fat cells to rejuvenate and grow, to help restore the volume that we lose with age or sun damage,” explains Dr. Marmur, who is a researcher for the brand. “My patients may need a few sessions over a one-year period—and then they come in yearly for skin checks and lasers, but they need less injectables.”
Non-HA injectables
Sculptra (poly-L-lactic acid) and Radiesse (calcium hydroxylapatite) are injectables—but they’re distinct from HAs. While they’re commonly called biostimulators, since they turn on collagen production, some doctors dub them “non-HAs,” for clarity, since standard HA fillers have also been shown to spark collagen growth. Unlike hyaluronic acid, however, these materials don’t attract and hold water, so bloating and distortion are less of an issue. And their effects tend to be longer-lasting. In the con column, they’re not reversible, like HAs.
Sculptra works by “creating a scaffold on which the body itself forms collagen,” Dr. Weiser says. Volume comes on gradually, over the course of several months (and usually multiple sessions). Unlike traditional filler, there is no instant oomph with Sculptra—beyond the daylong swell from the saline the product is mixed with—and some injectors find the drug to be unpredictable, working like gangbusters for select patients but disappointing others. Regardless, Sculptra has a strong and growing fanbase. “I think it gives beautiful results for volume enhancement and skin texture improvement, and there’s even a little bit of toning that happens with it,” Dr. Sunder says. Again, scar tissue is an inevitable by-product of the procedure, she adds, but “I don’t find it makes it so difficult for me when I have to do a facelift later on.”
Radiesse is thicker than Sculptra—imparting on-the-spot volume—but needs to be diluted, to trigger collagen. Dr. Frank prefers dilute Radiesse to Sculptra for restoring the temples and the hollows of the buccal fat pads as well as for defining bony prominences like cheekbones and jawlines. “I will not put HA in the jawline,” he says. “It just leads to a doughy look over time.”
There’s some debate among doctors over which of these non-HAs builds more collagen—and precisely how much of that collagen comes from the products themselves versus the instruments used to inject them, says Dr. Sundaram, noting that “repeated cannula passes or needling during injection can itself stimulate collagen.”
Coming-soon technologies
Two new technologies will soon expand our filler-free options: Ellacor, a recently launched micro-coring machine, and the muscle-focused Emface, which we may see as early as this summer. As we’ve previously reported, Ellacor scarlessly removes thousands of microscopic columns of skin for a smoother, more lifted look over time. From the makers of Emsculpt Neo, Emface is said to combine RF and electromagnetic energy, to simultaneously tone the skin and muscles of the face. Dr. Frank tells us that the device will likely appeal to those who want to curb their filler intake but still look taut and sculpted.
The future of filler
On the horizon are new kinds of injectables “that could be promising for precision sculpting and contouring, since they may not pull in water the way HAs can,” Dr. Sundaram says. One is an algae-derived gel filler called Algeness. It’s a sugar molecule, like HA, but “since it’s prehydrated, it doesn’t swell after injection.” (Dr. Sundaram is a clinical investigator and/or scientific consultant for various filler companies, including the makers of Algeness.)
A novel class of uniquely formulated HAs—designed to regenerate rather than volumize—“can achieve a stunning improvement in skin quality,” Dr. Sundaram adds. Some, like the hotly anticipated Profhilo, are already being used elsewhere in the world and should be arriving stateside at some point in the future. “When we begin to conceptualize fillers as restorative tools to improve tissue quality and contour, then I believe there will be appropriate applications for pretty much every patient,” she says.
The bottom line: If you’re looking for HA alternatives, options abound. Just bear in mind that optimizing your appearance is rarely an either/or proposition, since no single procedure—be it filler or a facelift—can do it all. But that doesn’t mean you have to check all the boxes, in some prescribed sequence. What’s most important is that you share your concerns—and boundaries—with your doctor and come up with a plan that feels true to you.
