Is Everyone Abandoning Their Facial Filler?

In our three-part series, The Filler Files, Allure explores our relationship with facial filler. It's still one of the most popular nonsurgical cosmetic procedures, yet more of us are looking to dissolve our filler than ever before. What does this mean for our lips, our cheeks, and our approach to injectables?

There's an affliction plaguing the aesthetics world: "filler fatigue," a uniquely 21st-century condition that results from overindulging in hyaluronic acid fillers — in your lips, cheeks, nasolabial folds, or anywhere else on your face. And while the term aptly captures the weariness of our modern obsession with ever-plumper features, it actually started floating around dermatology circles years ago as a synonym for the overfilled face — shorthand for its uncanny puffiness. In 2023, "filler fatigue" has entered the lexicon of the average aesthetics patient — and cultural observer.

"We see a good amount of [overdone filler], unfortunately," says Jessica Weiser, MD, a board-certified dermatologist in New York City. It presents as "that classic pillow-face appearance — very puffy with strange anatomic proportions." While a myriad of factors contribute to the condition, poor judgment on the part of select injectors is, no doubt, a root cause. Case in point: Several of the doctors we interviewed shared stories of treating patients who'd previously been filled with many syringes — sometimes up to 10 in the lips alone — of hyaluronic acid. And by "treating," we mean dissolving all that filler that's been pumped into their faces.

• Jessica Weiser, MD, is a board-certified dermatologist in New York City.
• Ben Talei, MD, is a board-certified facial plastic surgeon in Beverly Hills.
• Lara Devgan, MD, is a board-certified plastic surgeon in New York City.
• Jonathan Cabin, MD, is a board-certified facial plastic surgeon in Arlington, Virginia.
• Mitesh Kapadia, MD, is a board-certified ophthalmologist and an oculoplastic surgeon in Boston.
• Flora Levin, MD, is a board-certified ophthalmologist and an oculoplastic surgeon in Westport, Connecticut.

Which may explain why filler reversals are trending right alongside hyaluronic acid injections. On the surface, it seems a little counterintuitive: Are people dissolving more filler than ever? Yes. Are doctors still injecting a whole lot of filler? Also, yes. But there's data supporting the dichotomy. The American Academy of Facial Plastic and Reconstructive Surgery's 2022 trend report showed filler was still one of the three most common minimally invasive procedures performed by the organization's facial plastic surgeon members, but that filler's popularity had decreased: Survey respondents reported doing 14 percent fewer filler injections last year than they did in 2021. Moreover, The Aesthetic Society's most recent trend report notes a 57 percent spike in filler reversals between 2020 and 2021. What goes up, must come down it seems.

• What is filler fatigue?
• Why do so many people want to dissolve their filler?
• The beginnings of a backlash

While every doctor interprets the phrase slightly differently, "too much" is a universal trait. That said, the hallmarks of filler fatigue extend beyond obvious inflation. The skin can look doughy yet stretched. The face typically lacks distinct regions and transitions, as temples blur into cheeks and tear troughs. And the lips — an area where many injectors go too far — are often taut, ducky, and shapeless from filler crossing borders and shifting out of place.

If excess gel affects the muscle of the lip, preventing it from flexing properly, "this can eventually cause a drooping and lengthening of the [upper] lip as well as a loss of 'tooth show' and an awkward appearance with speech," says Ben Talei, MD, a board-certified facial plastic surgeon in Beverly Hills. It's a result of "migration [that] tends to happen in a northbound direction, as the lip squeezes against the teeth with expression over time." 

Another symptom of the overfilled face, according to Dr. Talei, is a sort of classic discoloration — a white blotchiness to the lips or a gray, yellow, or blue cast under the eyes — that arises when hyaluronic acid interferes with light reflection.

Overdone filler is, undeniably, a product of our time. As we approach 20 years of hyaluronic acid use in America, filler fatigue is striking patients of all ages — and stigmatizing injectables in the process. But don’t get it twisted: "Filler is an extremely valuable tool that can be used to achieve very elegant outcomes," says Lara Devgan, MD, a board-certified plastic surgeon in New York City. However, "if you misuse it or allow too much to build up over time, you can destroy the character of someone’s face."

How does this happen? Who or what is to blame? Dr. Devgan calls out the "lack of aesthetic judgment" among certain providers as a main culprit, but notes that there's also a sense of instant gratification that comes from looking and feeling fantastic post-jab, which can drive patients to chase the high, getting more and more filler. "If that feeling isn't held in check, it can quickly go in the wrong direction," she says.

Filler fatigue can also come into play when hyaluronic acid is used to treat issues outside of its scope, adds Jonathan Cabin, MD, a board-certified facial plastic surgeon in Arlington, Virginia. Filler should be used to restore lost volume, not do heavy lifting. "When you're using filler to camouflage signs of gravitational aging, like jowls, by filling around areas that are hanging — that can get you into trouble," Dr. Cabin says. Most doctors insist that attempting to "lift" sagging tissues with hyaluronic acid cannot be done without ballooning the face to cartoonish effect. Another maneuver that can go awry is "trying to reshape the face," he adds, by imposing unnatural contours or indiscriminately applying "Instagram-face" proportions to every patient.

One more glaring example of filler abuse: aiming to blend away pronounced undereye bags in order to avoid a lower-lid blepharoplasty (the gold-standard fix). While the filler "may look okay temporarily, it often migrates [downward] within weeks to months and causes [a type of chronic swelling known as] malar edema," says Mitesh Kapadia, MD, a board-certified ophthalmologist and an oculoplastic surgeon in Boston. "When this happens, the whole face looks 'odd' and the patient is left with [the preexisting] bags under their eyes and new bags in their cheeks."

Also fueling the overfilled phenomenon is what some doctors refer to as "the syringe mentality." In many clinics, charging by the syringe is standard practice. Since the cost of fillers can run upwards of $1,000 a pop, "people often make [aesthetic] decisions based on being reluctant to waste any product," says Dr. Devgan. "They'd rather put it in their face somewhere than discard it."

Not only are patients potentially getting more filler than they need at each visit, they're often rebooking prematurely, based on "an incorrect belief that filler goes away at six months and should be reinjected [at that time]," says Dr. Talei. The widely heralded myth that hyaluronic acid vanishes on a predictable timetable springs from clinical trials, whose fixed end points (of 6 or 12 or 24 months) have been misconstrued as concrete filler lifespans — an answer to the common question: How long will my filler last? But study duration doesn't accurately reflect filler duration. In reality, Dr. Talei explains, these trials were merely demonstrating that the clinical effect of the filler in a first-time user wasn’t as noticeable in photos after X number of months.

While filler longevity varies by product and patient, recent MRI studies have shown it lingering much longer than advertised. "Parts of it can last for well over 10 years," says Dr. Talei, especially in certain areas of the face. Flora Levin, MD, a board-certified ophthalmologist and an oculoplastic surgeon in Westport, Connecticut, regularly sees patients who had undereye filler injected five or more years ago — "and it's still hanging around," she says. In her experience, traces tend to persist when the wrong type of injectable is used (some gels are stiffer, for example, while others are softer) and/or it's placed too superficially in the tear troughs.

What's more, overly frequent top-offs can slowly carry people away from their OG appearance, causing them to forget how they used to look and to continuously strive to enhance their ever-shifting status quo. It's called perception drift — and even injectors aren't immune. Doctors have become accustomed to seeing overfilled faces, so they too have a bit of dysmorphia and will just keep injecting without recognizing a problem, Dr. Talei says.

None of these factors exists in a vacuum, mind you, and all are playing out against a filtered backdrop of social-media illusion. "We have a little bit of a broken-mirror situation, where what is considered 'normal' is very much skewed and the slightest asymmetries are seen as something to be fixed," says Dr. Levin. "It's almost like there's this stencil that everyone is trying to fit into."

While concerns over filler fatigue don't seem to be curtailing the overall demand for these products on a widespread, statistic-altering scale, doctors say they are starting to see patients pull back in various ways. Some are minimizing the role of filler in their regimens, adopting a more natural vibe and leaning into energy-based devices, like Sofwave and Morpheus8, for firming. Others are flat-out forsaking hyaluronic acid and/or attempting to dissolve the gels they once paid a pretty penny for.

But we're not suggesting anyone ghost their injector. Rather, choose that person wisely: board certification, anatomic expertise, loads of experience, impeccable taste, an obsession with safety, and a willingness to say "no" are musts. Then, adopt a less-is-more mindset. If you have obvious fat loss or bone erosion, you may benefit from multiple syringes, but the key, doctors say, is to treat every issue with as little filler as possible and to place it with the utmost care.

As patients' beauty preferences and attitudes evolve, questions are being raised. What happens to your face when you've gotten filler for years — and then stop? Can dissolving filler with hyaluronidase — a controversial subject on its own — do even more damage? We'll be exploring these issues and more in upcoming installments of The Filler Files.

Read more on injectables:

• What Is Daxxify, and Why Would I Want to Inject It in My Face?
• Black Americans Are Getting Botox More Than Ever
• A New Filler for Laugh Lines and More Procedures That Are Safe for Dark Skin

Watch as a dermatologist explains how fillers work: