Fillers and Injectables

Five Things to Know About Fillers and Injectables

If a little is good a lot is not necessarily better.

— Haideh Hirmand / MD
Nonsurgical facial rejuvenation is not a substitute for facial surgery

Neurotoxins such as Botox®, Xeomin, and Dysport®, fillers including Belotero®, Radiesse®, Restylane®, Juvederm, facial resurfacing and other non-invasive skin treatments basically accomplish something very different than surgery. Simply put, surgery lifts and repositions, the other modalities address volume, lines and wrinkles. They can be used alone or as a compliment to surgery. Being under the impression that fillers can substitute for surgery, or that having surgery can take the place of fillers is an incorrect notion. Fillers can potentially delay surgery but cannot eclipse it altogether once the aging process reaches a certain point.


I have had a long term interest and expertise in combining non-invasive treatments with surgery. The perfect formula is one in which the dosage, products and surgery combine for an invisible result. The secret lies in balancing the equation. Another benefit of this approach is when you combine both you actually need less of either one. The magic is in the synergy.

An unnatural or obvious look is as prevalent a risk with fillers as it is with surgery

Too much filler, filler in the wrong place or in the wrong proportion is just as distorting and obvious as the dreaded face “pulled too tight.” Everyone wants to look “natural” but who can explain what “natural” means? This is a deeper discussion but pertinent to understanding why some people look like they are aging gracefully and others look like “something has been done.”

There have been studies on facial aging, physiology and perception. The aesthetics of aging is an intangible notion but part of the design of rejuvenation. This is where not only the technique but importantly the aesthetic judgment are paramount. The result must adjust for the aging process. The same volume at 20 years old does not look good injected into a 60 year old. When the yearning to be “younger looking” tips the scale of what others perceive as contradicting one’s real age, the mind’s eye will reject the result as strange. It doesn’t fit the total package. At 60, you cannot look 20 because nothing else about your appearance or expression is 20. The best approach is to give enough volume back to the 60 year old so it looks appropriate and suitable at that age.

All fillers are not the same

Today we have lots of options--not only different fillers, but different characteristics among fillers. Some are bio-compatible, bio-degradable and reversible. Some are bio- compatible and degradable. Others are classified as bio-stimulators. Some are permanent, like silicone, and I do not recommend those for generalized use.

The key is determining which filler to use in whom and in what combination for the desired goals. Some fillers are intended for deeper levels of the dermis, some for more superficial levels, and yet others for deep to the skin. I prefer a layering approach that can be described as “multi-planer volumization” where more than one type of fillers may be used for the best overall result.

Another important concept is to choose fillers based upon physical characteristics. The degree of lift, spread, firmness, and swelling capacity differ between fillers—their physical properties vary. It is important to first have the ability and experience to customize choice of filler based on the specific characteristic for the intended use in each area. For example, it is critical to avoid fillers with bigger swelling capacity for around the eyes. Likewise, for thin skin, some fillers spread better and more evenly, avoiding bumps and bulges. If someone has a really deep fold I use the filler with the highest lifting capacity and over time it will “wear” the best for that purpose.

Correctly identifying the issues, understanding the person’s anatomy and tissue characteristics, being fluent with the characteristics of each filler, as well as practicing meticulous technique is the only road to a great result. There are no short cuts.

Technique matters

Achieving outstanding results with injectables is a function of experience, knowledge, and a keen aesthetic eye.

Some people assume that the ubiquitous nature of injectables makes them a commodity. This is a mistake. The injectable is secondary to the injector. In fact, there is a vast disparity of skills amongst practitioners touting injectables—from aestheticians to dentists. There is even remarkable differences in results among the aesthetic surgeons. The point is, be smart about who you choose. Injectables are not cosmetics. In addition, chronic infections happen when injectors practice outside a suitable medical environment, so location matters.

Proportions matter; Avoid tunnel vision on one area

Everyone is familiar with the value of injectables and fillers for the “11’s” between the brows and rejuvenating the nasal labial folds. But there are other areas of the face, where a subtle correction can make a huge difference. Aesthetic proportions and facial balance must be considered. Filling in the cheek and forgetting the temple creates distortion. An overdone nasal labial fold will look strange because there are no flat folds in a normal face. A full lip projecting outward will be seen as weird. There exists some subjectivity, but overall, mathematical proportions for asthetics do apply to facial appearance. In breaking the rules of art and science, results will be perceived as imbalanced when the total face is not taken into account in a proportional manner.