Dr Anushka Reddy takes a look at the phenomenon that is “pillow face” (the facial overfilled syndrome that is currently trending on popular social media platforms) and imparts advice to those who wish to correct or dissolve their plumped up filler appearance.
You know “pillow face” has officially arrived when the phenomenon inspires a filter! This term has long been used to describe the exaggerated, puffy appearance that results from a ridiculous amount of filler being injected into the face. Due to the larger than usual number of people looking over-inflated, the debut of the namesake filter introduces one to adopt the current on-trend look that is of cartoonish lips, exaggerated cheeks and stretched, shiny skin made popular by Instagram and Tik-Tok.
Yet while the overfilled face filter may elicit a good laugh on social media, the growing prevalence of overfilled faces in real life is a very real concern in the aesthetics industry. The probable reason for the growing number of “pillow faces” is due to individuals having repeated filler injections over the last two decades. The layer-upon-layer accumulation of gel in their faces ultimately results in a level of distortion that is beginning to become apparent in society (with the overfilled-face dilemma being caused by a gel-filler mishap). Needless to say, hyaluronic acid (HA) is the main culprit—it’s the most widely used filler in the world and is the only one that binds water and encourages swelling.
That said, one could be forgiven for associating the caricature-like features and hyper-contoured faces with long term filler use (as this is generally the case), but sometimes it’s actually the newbie injectors who contribute to this look. Not every injector understands that fillers aren’t really meant to be perfectly preserved at all times. Indeed, it’s a popular misconception that fillers need to be ‘topped-up’ every six months for maintenance. This is completely false, by the way…
On the other hand, inexperienced injectors aren’t solely to blame. The more-is-more mindset has become a fundamental tenet of industry-based filler training programs. The drug companies and their training modalities are well known for pushing the idea that results are better if more filler is injected.
Doctors are also taught that gels have a certain lifespan – despite the fact that there is no definitive study to measure the longevity of fillers in tissue. Hence doctors may bring patients back every 6-9 months for a ‘top-up’, which further contributes to the puffy look. In my experience, I have found palpable residual filler in the face five years later, so I am particularly cautious not to add excessive amounts of filler in these areas. I expect MRI imaging may be used in the future to track old filler residues, although it will not be able to measure quantities in the tissue.
Signs and symptoms of an overfilled face
The biggest indication is the physical distortion of the natural anatomy. It is imperative for doctors to respect the architecture of the human face because when it is pushed out of its natural boundaries, it becomes glaringly obvious to the human eye.
Sometimes what we read as overfilled isn’t pure puffiness – but rather the strange way the face moves when it is gorged with filler.
This occurs when the fat pads, muscles and skin (which should ideally all be working in harmony), gets crammed with a whole lot of filler into them instead, thus resulting in the restriction of facial movement, and its features and expressions being distorted.
Chipmunk cheeks squish on the eyes, thereby warping their shape (especially visible when smiling). Meanwhile, too much filler in the lips results in a thick sausage shape, which may even interfere with speech.
Conversely, if the filler is injected too superficially, muscles can also become impaired. Superficial filler has the effect of impeding lymphatic drainage since improperly placed filler can affect normal facial muscle contractions. In certain areas, like the eyes, the sheer pressure of overlying filler can hamper lymphatic flow, eventually leading to long-term swelling.
Back to baseline
Once doctors diagnose an overfilled face, they’ll typically suggest dissolving excess HA filler with an injectable enzyme called hyaluronidase. The enzyme begins to work immediately, melting away the bulk of old filler within 24 hours to bring patients back to baseline.
Now, while this process may seem easy enough, the aftermath can be unsettling for patients. This is especially true if someone has been getting regular injections for years and their fillers have effectively masked much of the inevitable facial ageing that has occurred over time. What’s more, the dissolving of filler not only changes the hydration status of the skin, but it may also cause the skin to look worse.
The under-eyes and lips are 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, since it’s “difficult to dissolve in these areas without flattening and deflating someone.
After dissolving, patients have to wait at least two weeks or more before injecting fresh filler. The two-week window also allows the tissues to partially rehydrate and recover from the hyaluronidase-induced “damage” before a new filler is introduced. Patients generally look better a few weeks later, even without the addition of new HA, because everything has plumped up a bit on its own.
Can hyaluronidase cause long-lasting damage?
We can’t discuss hyaluronidase without acknowledging the current controversy over the dissolver. There are patients who claim to have suffered permanent volume loss from hyaluronidase, insisting that the dissolving treatment is worse than the overfilled face.
However, there are no published studies proving the enzyme is capable of irreparably destroying human tissue. Although hyaluronidase can break down the body’s own natural hyaluronic acid around the injection site, HA regenerates so quickly that permanent wasting or deformities in the skin are very unlikely.
I believe that there could be long-term facial changes when the enzyme is used inappropriately. If an injector is flooding the face with dozens of vials in an attempt to melt away old filler or reverse an occlusion, then there is a possibility to change the facial constitution. Nevertheless, there’s no scientific proof that hyaluronidase can reduce one’s baseline HA in a noticeable way.
My approach would be a very conservative one. To avoid reverting to being overdone, I advocate a slow refilling of the face. Two weeks after dissolving, I inject the most minimal amount of filler possible to help rehydrate the tissue. Going forward, it is best to veer on the side of under-correction and offer touch-ups only when results have visibly waned in order to protect patients’ natural contours.
To prevent pillow face, I feel certain injectables made up of calcium hydroxyapatite or poly L lactic acid –(which are called bio-stimulators), may bolster facial support and provide a more natural look – thus allowing the face to retain its character instead of appearing bloated.
The flip side to this is that since biostimulators are not reversible, they require more precision and greater knowledge of anatomy. For doctors, it will be critical to evolve their thinking and start using bio-stimulators more often to prevent creating a doughy-faced nation.
Once free of unwanted HA, patients don’t necessarily have to reinject the face. There is another easier and cheaper option: acceptance. Sometimes dissolving bad filler can be very gratifying for patients.
Once the offending filler is dissolved, patients feel like themselves again… and who doesn’t want to be given another chance at looking natural?
Written by Dr Anushka Reddy MBChB (Wits)
Dr Anushka Reddy is the owner of Medi-Sculpt, Aesthetic & Anti-Ageing Solutions www.medisculpt.co.za
- President of the South African Association of Cosmetic Doctors (SAACD) www.cosmeticdoctors.co.za
Dr Reddy has regularly contributed to various publications such as A2 Aesthetic & Anti-Ageing Magazine, Woman and Home, Longevity, Elle and The Star. She has also appeared on TV programmes such as Carte Blanche Medical, Top Billing, Eastern Mosaic, Maatband, Hello Doctor as well as CNBC Africa.
A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice.
This article was written by Dr Anushka Reddy and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Spring 2021 Edition (Issue 38 – Sep 2021 to Dec 2021).
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