M any people opt for filler as a facial rejuvenation solution, but is it an ideal solution for people who are 50 and older? In today's episode I discuss the three components of facial aging: skin, volume, and structure, and talk about the benefits and limitations of addressing aging with injectable fillers.
For patients who are 50 and above, aging in the lower part of the face is most visible. Does filler help this? I discuss how frequently filler should be utilized, and underscore the importance of making an informed decision when you and your surgeon/injector are coming up with your long-term facial rejuvenation treatment plan.
Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I'm your host, Dr. Jason Hall.
Dr. Hall: All right, so welcome back to the show. Now, I see patients almost every week in my office for facial rejuvenation surgery who have spent thousands of dollars and years getting injectable filler only to have really minimal if any improvement. And to a person, they all told me they wish they would have just done surgery a lot earlier than they are. This show is really to discuss filler, what it can do, and how it fits into a facial rejuvenation plan for patients who are in that 50 and older age group.
Now, I want to start out by saying filler is a great option for volume replacement. It certainly has a role in a facial rejuvenation or pre-rejuvenation—so preventing signs of aging—it is wonderful for that. And we are talking here about hyaluronic acid fillers, not semi-permanent fillers, not injectable collagen-building fillers. These are your HA gels. So, brands like Restylane, the RHA line, Juvederm, things like that.
And while filler has great potential benefits, it also has its limitations. And before you spend a dime on injectable fillers, you need to understand what those limitations are. As time passes and we get older, there are three components of facial aging that we need to address to really be able to understand why we, as core aesthetic providers, recommend certain treatments. Because there is no one magic bullet that's going to address every component of facial aging, we really need a comprehensive plan to break down each different component and to design treatments for each one of those.
And I did a whole podcast on this. I can't remember which podcast number it is, but it's about how the face ages. But really briefly, there are three components to that: there's skin, there's volume, and then their structure, and the structure being underlying muscle and things like that.
These translate into three areas that we can design treatment plans to improve: the first being skin texture, color, pigment, things like that; the second being volume replacement; and the third being we'll term anti-gravity procedures to lift and restore tissues that have drooped and sagged over time. As you can guess just by its name, injectable filler really only addresses one of those three main areas.
So, in the state of Tennessee—which is where we are, obviously—anybody can do injectable fillers. Tennessee is kind of like the wild west for aesthetic medicine. All a person—you don't even need to really have a medical license—all a person needs is a doctor who will agree to oversee them and really put their license—their medical license—on the line for whomever they delegate injectable tasks to. And because of this, as you can imagine, there are tons of places for you to get injectable treatments. They're practically in every corner in every strip mall.
And what I think it's important for you the listener to understand is that when you're buying filler, when you're buying an injectable neurotoxin, such as Dysport or Botox, you're not buying that product, you're not buying the drug, you're not buying the syringe. If you were out shopping for a syringe of filler you would be, but what you're looking for, or at least what most patients are looking for, is the result that that filler provides. And the result is not what is in the syringe. Your result really is a combination of the right diagnosis, the injector or the person you go to for treatments understanding not only the anatomy that is there, but how that anatomy has changed over time, and how using whatever injectable product they use can change your anatomy to create the look or reverse the changes that you're seeing and provide the proper treatment.
So, you've heard this if you've listened to other episodes of this podcast, you've heard me talk about this in the past. This is one of the fundamental tenets of medicine. You first provide a proper diagnosis and then design a proper treatment after diagnosing the problem. And it really, with filler, this is one of my pet peeves. It drives me crazy hearing injectors and hearing marketing collateral from some of these injectable companies telling patients that they can lift a jowl or lift a neck or lift a fold with injectable filler.
By definition, injectable filler doesn't lift; it fills. It doesn't lift ever. It may give a subtle illusion of lift, but in truth, the filler won't lift anything. The only way we can lift things is by surgically elevating those things back to where they need to be. And this idea that filler can lift which gets—you here on social media all the time, ends up getting us as a group of aesthetic providers and you as a group of patients to where we are today with lots and lots of overfilled, alienized faces that look completely unnatural. They're over-full in an attempt to lift tissues that can't be lifted with what has the structural equivalent of jello.
Let's get back to how things change with time and what it is that we can accomplish with filler. As time passes, the face changes in fairly predictable ways—and again, I'll refer you back to the facial aging podcast to really take a deeper dive into this—in the late-30s, you start seeing descent of what we call the upper third of the face. So, the eyebrows, the upper eyelids start to droop and the eyebrows start to flatten. By the early-40s, this descent has moved into the middle third of the face and is accompanied by the beginnings of volume loss in the cheeks.
By the early-50s. You start seeing the lower third of the face and the neck involved as well. And by the lower third, what I mean is the jowls, the jawline, the neck. And once you're in this, once you're in this position where you're starting to see jowling, you're starting to see neck skin and muscle laxity—you know, people refer to it as the turkey gobbler, you really start to see diminishing returns on your investment in injectable fillers. For the most part, filler really doesn't address aging changes in the lower third of the face, along the jawline, or in the neck because it can't lift.
Above that, in the upper cheeks around the eyes, injectable filler really does a nice job. It does a nice job at adding some subtle volume to the lips. But again, the lower third, which is where the majority of the aging changes start to happen once you hit your early-50s, the neck and the jawline really aren't affected to a large extent. Now, there is some focus—some patients focus on the nasolabial fold, which in my opinion is a result of good marketing by the injectable companies. Nasolabial folds are really normal features of a human face and if you try and fill those up and remove those, it flattens the central part of your face and can contribute to almost kind of a simian appearance, which does not look natural in the least.
And so, I tried to steer patients into looking at the cause of the nasal labial folds and why those are deeper, which is an accumulation of fatty tissue kind of on the outside of that fold coupled with a loss of volume in the central cheek. And so, by adding, conservatively adding a little bit of volume in the cheek, we can make that nasolabial fold much less apparent, but we're not going to lift it and pull it out of the way. But below that—so again around the neck and jawline—there really is minimal improvement that can be made with injectable filler. Surgery really is the mainstay to reshape and maintain a neck and jawline in a beautiful, natural appearance.
Filling in the lower third of the face, in some patients, can do, okay; it's a decent treatment option. But what happens over time is that as the jowls start to form, the heart shape, which most women's faces have when they are youthful—even guys to some extent—where the center part of your face or in your cheekbones tends to be the widest, and your chin and jawline tend to narrow as they go down, that balance starts to get turned over where your lower face gets wider with time. And that's one of the characteristic ways that our faces change. So, it makes sense that if you take something that's already wide, you add more volume to it, you just create a heavy appearance as opposed to a rejuvenated, refreshed appearance. It actually tends to make people's lower face look square because you're adding volume where volume already is.
So, I'm very careful at the use of filler in the lower face because most patients, especially patients who are in their 50s and beyond, really don't benefit significantly from a lot of lower face fillers. In the, kind of, 50 and older age group, I do recommend fillers in smaller areas: their lips that we talked about before, cheek correction, even around the eyes. But these, you know, 4, 5, 6, 8 syringe full-face filler corrections are not a good treatment option for the vast majority of patients, certainly don't need to be done every six months. I've had some patients come to the office say that they got filler injections to touch them up every six months for years, which is a complete waste of money because the fillers, these HA fillers in the cheeks and mid-face and any place you're augmenting that isn't moving all the time like the lips are going to last you for a year at the minimum. And there's been a lot of recent ultrasound data that has shown these fillers stick around for even longer than that.
So, every six months for filler is kind of ridiculous in my opinion. The other way that filler is beneficial in the over-50 age group is for touching up things and maintaining volume after surgery. In all of my facelifts, fat injections to restore lost volume is a part of that treatment plan, but we know that after about the age of 55, the amount of fat that survives that transfer decreases. And so, some filler, specifically in the cheeks may be needed down the road for maintenance. But this is to maintain volume that we have put there, not to try and lift a jawline or jowl. Lifting has already been done surgically.
So, the take-home here for the show is that filler is really a great option for patients. I don't want anybody who's listening to think that I'm this anti-filler, surgery-only guy. That couldn't be further from the truth. I think filler has a very definite place in the facial rejuvenation armamentarium but is certainly not the best treatment for everybody. Once you get into your late-40s, early-50s and start seeing signs of tissue descent—so specifically, jowls, neck laxity—you need to understand that filler is not going to give you a great treatment. It might give you an okay treatment for a little while, but you need to know that your best option is to discuss surgical interventions—whether that is a neck lift—you need to know that surgery is an option that will give you a long-lasting result.
And if you choose not to have surgery and accept the limitation of fillers and understand the costs involved, then that's okay. I have a number of patients that we do small amounts of filler injections who just aren't ready for surgery and we discuss that upfront and we both accept that we're doing a treatment that may not be the best right now in terms of result, but gives the patients a little bit of improvement which they're happy with, and we can wait until they're ready for surgical intervention. But they go into that knowing their different options and making a conscious choice other than being sold a filler option without really considering from someone who does the surgery what the other options are. Filler is expensive. You know, if you're paying by a syringe, you're like $700 to $1000 depending on what your filler is and it didn't take too many of those treatments or too many of those syringes before you pay for a facelift once, twice. I've heard patients that have spent so much on filler they could have gotten two facelifts for the amount that they've spent on filler at other places.
Again, the moral of the story is, be informed and make an informed choice. I want you to understand the anatomy that we're trying to treat so that you can choose, along with your surgeon, injector, you can choose a treatment and treatment plan that works best not only for your face but for your pocketbook and your life. Again, I would refer you back to the facial aging podcast, which I've referenced two or three times this episode already so that you can understand why you are seeing the things that you see in the mirror and will help you understand what treatment options are recommended. Thanks again, and we'll see you on the next show.
Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.