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Limitations of Dermal Fillers

With the boom of Aesthetics globally, especially since the pandemic, when most of us have been looking at ourselves via a Zoom lens far more than ever before, coupled with hours spent mindlessly scrolling through perfectly curated, often photoshopped and filter-heavy images on Social Media, has come a demand for aesthetic procedures, especially dermal fillers in addition to anti wrinkle treatments.

As someone who has been doing this for many years now, the problem I am seeing more of, especially among my patients who first began with me several years ago and who are therefore now several years older than they were, is the mistaken belief that fillers will fix all problems.

At least weekly, I see a patient who committed and spent the necessary time, energy and money to invest in what I call "full face rejuvenation aka facial renovation", and who became used to compliments from others she met, on how great she looks, how she passes for someone 20 years younger etc, and who is nonetheless, some years older than she was when we began and beginning to see the underlying bony changes of ageing that none of us, even surgery, can fully reverse or halt.

So read on as I explore the limitations of what dermal fillers can do, and what they cannot.

Mistaken Belief # 1 - Dermal Fillers can erase wrinkles.

I had a patient in her late 30s on the weekend who is beginning to notice accordion lines, those smile lines on the sides of the mouth due to volume loss that is a sign of ageing, and asked if I do facelifts or if I know a surgeon who does.

She was half joking, and yet she was not. So among other things possible, we spoke of using small amounts of dermal filler in the area to help add some volume - when she smiles, the wrinkles are still there, but the muscles are not pulling on thin tissue as much as before, thereby softening the lines, giving the illusion of "erasing or easing lines".

Accordion lines are also hard to erase completely and best treatment options in this area would be a series of sessions of  laser toning, small amounts of dermal filler applied very superficially and mono threads and similar collagen inducing therapies such as skin needling and RF microneedling.

Mistaken Belief # 2 - Dermal Fillers lift sagging tissue.

This is among THE commonest reasons older patients ask for more filler. Filler does not lift, and it certainly does not lift sagging tissue by as much as 2-3cm which is what people expect fillers (or threadlifts for that matter) can do - they simply cannot.

In a volume depleted person, when we begin by adding filler, we are replacing lost volume, and restoring sagging, deflated tissue back to where it belongs- as a result of this, a subtle lift is apparent, not because we have done any lifting, but because we are lifting skin folds that have occurred due to lost volume, back to their correct anatomical position.

With age, even if we had perfect sun protection habits and perfect diets and great genetics that allowed us to age beautifully, there is bony depletion that occurs, along with ligaments that begin to sag and collagen that is being rapidly depleted, that simply cannot restore a 45 or a 50 or a 60 year old face to one in its 20s or 30s with its cherubic qualities. 

Yet for some reason, people continue to believe (and erroneously be told) that fillers can lift when they cannot.

The definitive treatment for truly sagging tissue and ligaments and really lax, poor quality skin is a face (and neck) lift. Other cheaper options include options such as threadlifts which temporarily lift sagging tissue and reposition them, but they last 12+ months and are by no means a replacement for surgery.

Mistaken Belief # 3 - Starting dermal fillers when you are younger can help you stay younger.

In large part due to social media influencers, many young women are literally waiting to begin their aesthetic journey as soon as they turn 18.

This group is often short on cash, and so may opt to turn to a chain clinics and groupon deals, where the "price is right" as opposed to a reputable clinician with many years of experience under their belt for their lip enhancement, or non surgical rhinoplasty or tear trough fillers.

The problem is, you cannot fix a problem you do not have. Most young people are the epitome of youth and beauty, and do not have any medical need of "fixing" anything unless it is skin problems such as acne or dermatitis from overuse of skin products.

Once we get into the habit of getting lip filler, or any other type of filler, to plump up lips, or fill other perceived defects, it becomes a case of returning on a regular basis once we feel the filler is "gone" when it usually hasn't, for more;  it is the swelling and side effects that are gone, leaving in their place, compliments and comments from people that massages our egos. 

Over time, these regular top ups when unnecessary can lead to stretching skin and contributing to an unrealistic and excessive focus on what needs "fixing" as opposed to recognising all the other beautiful attributes one has. Which leads to Mistaken Belief # 4.

Mistaken Belief # 4 - Dermal fillers (or any injectables) will not treat unrealistic expectations or a desire to look Forever 21.

It is important in clinic, to regularly remind patients of what they used to look like when they first began attending the clinic 3,4,5 or 6 years ago and how much improvement we have made and how great they look now, compared to when they first began investing in themselves.

It is human nature to lose sight of the bigger picture; to forget what we used to look like, and to become almost addicted to regular comments about how young, youthful and amazing we look. It is also human nature, when we have invested huge amounts of time, effort and money into ourselves and especially our faces, to start hyper-focusing on flaws, real and imagined that no one else might notice (because none looks at us as much as we look at ourselves!) 

I am regularly struck by how much people comment on how their fillers look "wrong" under certain lighting, but "perfect" in others. Or how they have noticed "this line here" or "I want this side to match the other side" and "I am unhappy and I want you to fix this".

Despite extensive conversations, it is becoming more common now than when I began, to remind patients that ultimately, we can only:

- improve, but not perfect any aesthetic outcome as we are working with living tissue and anatomy. 
- the limitations we discussed the first time we met remain after 5 or 6 years of working together- namely, we are both some years older now, with associated ageing related changes, not all of which are amenable to fixing; your unique anatomy limits what is possible, alongside your expectations and budget because you may well be a candidate for surgery (facelift/ necklift/ blepharoplasty) for anything that bothers you enough and even then, surgery will only improve sagging skin and tissue, it will not replace lost volume due to age. 
- it is possible that along the way, you have become so used to loving the face you see in the mirror, any sign of ageing that is not easily fixed is distressing ie your expectations are veering into the unrealistic. 

When this happens, when your clinician has an extensive skillset that goes beyond just anti wrinkle treatments and dermal fillers, coupled with the ethics of "first do no harm", we can say no, redirect you to other treatments that may be beneficial to address some of the  (new) concerns, or refer you for surgery if that is your wish, when using more fillers would be detrimental or without much benefit and risk pillowface.

This is why, at Skin Essentials, we harp on about the importance of building a longterm, therapeutic relationship with each and every one of our patients, so that we can be blunt, and upfront and say no when we feel it is in your best interests, because the relationship can sustain it. 

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