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‘In case of emergency’ is a concept we’ve all come to be familiar with and, with any aesthetic decision, we have to be cognizant of the risks. While the majority of '[tweakments](https://aedit.com/aedition/why-im-all-about-tweakments)’ are deemed safe and effective — they're low risk and high reward — no aesthetic procedure is without side effects and complications, some of which can be severe. 

Case in point: hyaluronic acid (HA)-based filler. HA fillers are known to cause temporary [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) and [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox) at the injection site, but did you know that there is a risk (however rare) of vascular occlusion and, subsequently, skin necrosis and even blindness if the filler is injected into or near a blood vessel. So, what do you do in case of this emergency? The AEDITION spoke with two top plastic surgeons to break down the warning signs, risks, treatment options, and more.   

## **What Is Vascular Occlusion From Filler?**
[Vascular occlusion](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965121/) is a rare but potentially serious complication of hyaluronic acid filler injections. It results from accidental injection of the product into an artery, and it can also be due to compression of the artery from surrounding filler. “In certain circumstances, when filler is injected near or into the blood vessel, they become occluded due to the pressure,” says [Jason Roostaeian, MD](https://aedit.com/provider/jason-roostaeian-md-449), a board certified plastic and reconstructive surgeon in Los Angeles. “If the pressure is above a certain level, the vessels are compressed and blood flow is limited, which is what causes the damage.” 

To put it plainly, the artery or capillary is constricted due to pressure of the filler or injected with filler. As a result, it is unable to function properly. The lack of blood flow causes the skin to suffocate and thereby can be damaging to both vision and skin (more on that below). “When something causes the artery or vein to be blocked, it’s like a heart attack caused by filler, and the affected area is the skin,” explains [Amir Karam, MD](https://www.drkaram.com/about/meet-dr-karam/), a double board certified facial plastic and reconstructive surgeon. 

## **Risk of Vascular Occlusion** 
Yes, the chances of vascular occlusion occurring are quite low. A [December 2020 study](https://jamanetwork.com/journals/jamadermatology/fullarticle/2774505) in *JAMA Dermatology* found that the risk of vascular occlusion is “exceedingly low” — one in 6,410 syringes [via needle](https://aedit.com/aedition/guide-to-needles-used-for-cosmetic-injectables-botox-filler) and one in 40,882 via microcannula injector — when injected by a board certified dermatologist. 

Even so, it shouldn’t be taken lightly. “This complication, if left untreated, can lead to blindness in rare circumstances,” Dr. Jason explains. The reason? “Any vessels around the eyes, such as the nose, the glabellar region, the vessels in the temples, those vessels do not have valves,” Dr. Karam shares. “Therefore, the blood flow can go back towards the eye and cause blindness.”

But blindness isn’t the only risk. Vascular occlusion can rapidly progress to tissue necrosis if not identified and treated quickly. Symptoms of skin necrosis include skin blanching, change in tone, intense pain, and bruising. When the vessel is blocked, “there is no blood flow to that segment of the skin,” Dr. Karam notes. 

Those familiar with post-filler bruising know what it looks like on them and should be able to identify the normal from the atypical, but newbies may want to pay closer attention. “Bruising from filler does not hurt,” Dr. Karam explains. And it tends to be localized. “Discoloration of the skin that goes beyond the area of injection is a tell-tale sign of vascular occlusion,” he adds.

So, how soon after injecting do the effects of vascular occlusion start to show? Depending on the case, it can happen immediately and be treated on the spot. But Dr. Jason notes that it can also occur after you’ve left your injector. Likely, the skin will begin to blanch due to the lack of blood flow and other symptoms will follow. “Usually, you see it happen in the first 24 hours, but the symptoms don’t always happen right away,” he cautions. 

To further complicate matters, it can be difficult to diagnose. “It can devolve over six to 12 hours, and many might confuse it for a bruise,” Dr. Jason explains. “That’s why it takes a trained professional to know what they are looking at in case there is a risk of tissue damage.”

## **Vascular Occlusion Treatment Options** 
If you feel that you are experiencing a complication from your filler injections, our experts recommend seeking out your injector first. To dissolve the filler and prevent further damage, they will administer [hyaluronidase](https://aedit.com/procedure/hyaluronidase) — an enzyme that breaks down hyaluronic acid — followed by an aspirin regimen and, in some cases, warm compresses. As it relates to the latter remedy, Dr. Jason notes that the warm compress may be added to help boost blood flow but admits that the jury is still out on whether warm or cold compresses are best. 

We’ve focused this article around HA filler, but, if the filler in use is not formulated with HA, [dissolving with hyaluronidase](https://aedit.com/aedition/hyaluronidase-to-dissolve-dermal-filler) is not an option. “Other measures include using aspirin to thin the blood and adding nitroglycerin to the area of the skin until the area has been relieved of its occlusion,” Dr. Karam shares. 

As studies suggest, the best way to prevent vascular occlusion is to be treated by a skilled injector who has a deep understanding of the anatomy of the area you are looking to treat — but, even in the most well-trained hands, Dr. Jason acknowledges that it’s somewhat of a numbers game. “There are certain areas where it is more prevalent when there’s one main source of blood flow to the area, but it can still happen to any injector,” he explains. 

With that said, there is no substitute for expertise when it comes to reducing the risk of this complication. “There are certain measures, such as understanding where the blood vessels are located and having a good understanding of vascular anatomy, that can help prevent this,” Dr. Karam notes. Additionally, he says that [injection technique](https://aedit.com/aedition/guide-to-injectable-techniques-needles-for-botox-filler) is a factor, too. “Using a microcannula or using the fanning method before the deployment of filler can decrease this risk,” he adds. 

With skin necrosis, the first course of action will be to let the area heal. From there, the damage can be assessed, Dr. Jason says. Some patients who experience complications from vascular occlusion swear off filler for good. But, for those interested in returning to the office again, Dr. Jason notes that a new approach will likely be necessary. “Some people have a higher likelihood to have this occur again, and the injector would likely stay away from that area in particular,” he says. 

## **The Takeaway** 
One of the most difficult parts of treating vascular occlusion is how easily it can go undetected. When detected early, however, long-term damage is often preventable. The early warning signs manifest as bruising and sensitivity. So, while they may blend in with the discoloration and soreness that can be expected from the treatment, any abnormalities shouldn’t be overlooked. In case of emergency, always seek help from your injector immediately.

Aesthetics

When an injectable filler hits an artery or blocks one, the results are dangerous. So, how common is this and how do you avoid it? The experts weigh in.

The Risk Of Vascular Occlusion, Skin Necrosis, Blindness After Dermal Filler Injections

This Filler Risk May Be Rare, But It Can Lead To Skin Necrosis And Blindness

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We often joke about appointments for [Botox®](https://aedit.com/procedure/botox) and its fellow neurotoxins (hi, [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin)) being as routine as hair color touch-ups or mani/pedis. While it’s great that it may be true, it’s important not to overlook the fact that even a treatment as (relatively) quick and painless as Botox is still a cosmetic procedure that requires the expertise of a skilled injector. With more options on the market and handfuls of injectors offering every type of [injectable neuromodulator](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) possible, it’s more pertinent than ever to fully understand the ins and outs of the minimally invasive procedure — including what can go wrong. 

Of course, not just anyone should be injecting you, nor should just anything be injected into your face (remember, you only have one face). So, before you let the needle touch your skin, make sure that you [have answers to all of your questions](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time), you’ve [done ample research on your provider](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist), and you see the product being injected to make sure it’s 100 percent the real deal. Beyond the basics, what else do you need to know about your neuromodulator appointment? Read on for all of our safety tips and considerations.

## **The Social Effect**
Social media is a consortium for all types of images, including neuromodulators gone wrong and the scary side effects that they produce. Case in point: the [latest set of terrifying photos](https://www.instagram.com/p/CWePhmMDE_a/) show a patient’s forehead covered in lesion-like scabs as the result of illegal botulinum toxin injections. 

Neuromodulators are one of the most popular non-surgical procedures for a good reason. In 2020, injectors performed [more than 2.6 million](https://cdn.theaestheticsociety.org/media/statistics/aestheticplasticsurgerynationaldatabank-2020stats.pdf) botulinum toxin type A procedures according to the Aesthetic Society’s annual statistics report. Botox® and the like are a [valuable tool](https://aedit.com/aedition/where-to-use-botox-from-head-to-toe) in nearly every aesthetic doctor’s toolbox. 

But as elective cosmetic procedures become more common and socially accepted, it creates openings for unlicensed providers to offer bogus services, says [Brendan Camp, MD](https://aedit.com/provider/brendan-camp-md-34645), a board certified dermatologist in New York City. That opening also paves the way for an increase in unsatisfactory and, in some cases, dangerous results. “Sadly, the incidence of ‘botched’ neuromodulator injections has dramatically increased as unqualified injectors enter the industry,” says [Jessica Weiser, MD](https://aedit.com/provider/jessica-weiser-md-34640), a board certified dermatologist in NYC. 

Besides the fact that counterfeit injectables are not anything close to the real thing, the fakes can consist of anything from other drugs and bacteria to bleach and plain old water. In addition, these illegally obtained products are not typically purified and may contain contaminants. Once contaminants enter the skin, they can lead to allergic reactions, foreign body granulomas, serious infections, skin necrosis, and other complications with severe long-term ramifications, Dr. Weiser cautions.

The net-net: “As the amount of counterfeit product has skyrocketed, unlicensed injectors have started to enter the arena, purchasing product illegally from unauthorized sources or foreign countries and more,” she shares. This has led to what she calls “a completely uncontrolled injection market.”

## **Don’t Fall for Faux-tox**
Years ago, the school of thought was that Botox® and other neuromodulators were just for the rich and famous. But that's no longer the case. With more younger patients dabbling in minimally invasive procedures — like injectables and lasers — the supply and demand for neuromodulators increases. 

The growing demand creates a black market (fake injectables are often known as ‘faux-tox’) and an easy entry point for those who are not well-versed in the procedure to be swayed easily, says [Roberta Moradfar, NP](https://www.instagram.com/effacebyroberta/), a board certified aesthetic nurse practitioner and the owner of [EFFACÉ Aesthetics](https://effacebyroberta.com/) in Los Angeles. “Sadly, several injectors are offering fake versions of the neurotoxin and passing it off as the real thing to either cut their costs or because they are not qualified even to purchase injectables,” she says. 

Another reason for the recent rise of counterfeit and illegal neuromodulators is a considerable price increase in the real thing and the supplies associated with them. Syringes, needles, and other medical supplies have skyrocketed in price, especially during the pandemic, says [Macrene Alexiades, MD](https://www.nyderm.org/biography), a board certified dermatologist in NYC. “In contrast, prices have hit a limit, and it is simply not possible to increase prices much further despite the presence of record-breaking inflation in recent months,” she explains. “As a result, it has become challenging for doctors to generate profits, which has led to less reputable doctors and shady operations to resort to black market botulinum toxins, which are extremely dangerous.” 

Dr. Weiser adds that, with each subsequent year, the cost per vial rises for Allergan-branded Botox® Cosmetic, Galderma’s [Dysport®](https://aedit.com/aedition/dysport-vs-botox-for-wrinkles), and other neuromodulators approved by the United States Food and Drug Administration (FDA). “As more people desire to work in the aesthetic space but want to undercut industry pricing, they buy products cheaper and often without a license,” she says. 

Black market injectables have always existed, yet the use of these products is surging right now. “I observed and informed the companies that manufacture injectables of Instagram, Twitter, TikTok, and Facebook accounts posting videos of people injecting themselves with illegal forms of Botox® and fillers,” Dr. Alexiades says. And in this social media-driven world, utilizing black market products opens up Pandora’s box to the world of copycats, which will only lead to problems. Not to mention the rise of DIY injectables and fillers — a scary thought indeed. “There are numerous internet pop-ups that are mailing ‘DIY Botox’ kits for people to self-inject, posing additional levels of concern,” Dr. Weiser notes.
 
Just because you think you're getting the real deal, even if you're not, doesn't mean that whatever ersatz injectable follows the same production, testing, manufacturing, and FDA-approval processes as their legitimate counterparts. “Unregulated products are not manufactured at the same standards as branded products, and, as a result, the concentration of neurotoxins in an illegal product may be too high,” Dr. Camp warns. “This can cause botulism poisoning, which can present with muscle weakness, trouble swallowing, and difficulty breathing.” 

It goes without saying that non-FDA-approved products should never be injected into the face (or body). This is because these products lack the multi-phase approval process to ensure that a drug is safe and does what it is supposed to, says [Peter Vila, MD](https://aedit.com/provider/peter-vila-md-16177), a double board certified facial plastic and reconstructive surgeon in San Rafael, CA. “Injectables that have not gone through FDA approval are huge unknowns that can potentially cause harm or just not work because we simply don't know if they are safe or effective," he says.
 
## **What Can Go Wrong**
One of the more severe and painful known reactions to faux-tox is pyoderma gangrenosum. Dr. Alexiades describes it as a festering wound associated with inflammatory and autoimmune disorders. Yet, there are [reports](https://pubmed.ncbi.nlm.nih.gov/31957116/) of ulcers forming at injection sites with illegal botulinum toxin injections. It's rare yet severe, and failure to treat pyoderma gangrenosum can lead to further problems and complications. There's also the potential for scarring and pigmentation formation, which causes a whole other host of issues that can trigger long-term management. 
 
In the event of a mishap (especially with black market neuromodulators), the wrong dose, or a contaminated vial, redness, pain, and the formation of a pimple about 24 hours following the injection can occur. In extreme cases, “if it is an overdose within a short time, the patient can have trouble breathing due to paralysis of the diaphragm and muscles of breathing,” Dr. Alexiades shares. Less severe yet still disheartening effects can take upwards of two weeks post-injection to set in. However, any muscle weakness or fatigue symptoms usually become apparent about a week after treatment and may be accompanied by a heavy feeling in the treated area or asymmetries.

And, of course, the worst-case scenarios are the most extreme ones. Dr. Alexiades says that there have been black market botulinum toxin cases causing people to end up on respirators or even dead. “You must be intubated if you go into respiratory failure,” she explains. “And you must have wound care and antibiotics for infection.”

The takeaway is simple: Don’t let just anyone inject just anything into your face — it’s just not worth it.

## **Neuromodulators Done Right**
It seems as though anyone with a pulse can inject fillers and injectables into the face and call it a success. But, truth be told, it's not that simple, nor should it be. Dr. Vila calls injecting neurotoxins “both an art and a science.” As he describes, “the key to getting good results and avoiding complications comes down to good injection technique.”

Precise and accurate product placement is vital to maintain [facial harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) while eliminating the appearance of unwanted wrinkles. “Injecting too much neurotoxin or injecting it in undesired areas can cause unwanted effects such as eyelid drooping, the appearance of heavy brows, or, in some cases, an uneven smile,” Dr. Camp says. Overly arched eyebrows, often called ‘Spock eye,’ [droopy eyelids](https://aedit.com/aedition/guide-to-eyelid-ptosis-drooping), and upper eyelids that appear heavy and hang down low, creating a tired look that can interfere with vision, are other signs of poorly administered neuromodulators. “Additionally, poorly placed Botox around the eyes can result in an unusual smile and ‘shelf’ effect,” Dr. Weiser notes. Even though nobody wants subpar results, the only positive matter is that, usually, these effects are temporary and will slowly start to correct themselves as the body metabolizes the injectable product in the coming weeks.

Hygiene and technique are also crucial to avoid infections and severe [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox). “You must use an immaculate technique and sterile delivery methods,” Dr. Alexiades says. “Injectors must always cleanse the injection area and only administer the drug with sterile needles and syringes.” These rules apply to all treatment areas of the face since not a single square inch of skin is off-limits nor immune to an adverse reaction, no matter how minor or extreme it may be. Also, your provider should always draw the injectable into a new, sterile syringe and fully clean the treatment area with alcohol, Dr. Weiser advises.

## **How to Fix Bad Results**
When it comes to correcting the effects of black market products or just a bad result, there are a few different approaches to take:

- **Time heals all wounds.** You can let the effects of the product wear away on their own, which takes about three months. Dr. Camp says that, for the most part, the goal is to encourage the body to metabolize the injected product so that the unwanted effects fade faster. “This can include applying vibration to the treated area, warm compresses, increased contractions of the affected muscles, and exercising, which may also help,” he shares.
- **Use special drops to mitigate the effects.** According to Dr. Weiser, you can use alpha-adrenergic drops, like iopidine, to give mild relief of droopy eyelid or brow by activating the Muller's muscle in the eye to help create a subtle lifting effect. 
- **Correct it with additional injections.** In the case of a droopy lid, the issue should resolve in a few weeks. When there’s an unnatural appearance from poorly injected toxins, Dr. Vila says that the area can usually be treated with a touch-up of extra toxin to create a more natural look.
- **Immediately intervene when necessary.** “Infections and foreign body reactions are much more serious concerns because they can leave behind permanent tissue damage and scarring,” Dr. Weiser warns. They “require immediate intervention with antibiotics, steroids, debridement, or more,” she adds.

## **Why You Always Need to Do Your Homework**
No matter what injections you are considering, it’s of the utmost importance to always do your research, which includes:

1. **Vetting Your Injector**: Search for a good, reputable provider in your area. It’s okay to ask around and get recommendations, but make sure the injector you choose is in good standing and does not have a reputation for using fake products or inferior results. “It is the patient’s responsibility to ensure they are seeking care from a vetted professional, such as a board certified dermatologist,” Dr. Camp says.
2. **Avoiding Price Shopping**: We love a bargain, too, but aesthetic medicine is not the area skimp. If you’re purchasing deeply discounted injectables, there’s always the threat of it not being the real deal, which leads us to...
3. **Getting the Real Thing**: Only seek treatment from a licensed physician who buys brand-name, FDA-approved injectables directly from the manufacturer. Don’t be afraid to ask your injector to show the bottle and its packaging. 

At the end of the day, a little research goes a long way. Even in the best hands, it is always possible for something to wrong, but finding a qualified provider who you trust (and [not doctor hopping](https://aedit.com/aedition/dangers-of-doctor-hopping)) is one of the best ways to ensure the safety and efficacy of your treatment.

From finding a qualified provider to ensuring the product is legit, here's how to ensure your neuromodulator injections are as safe and efficacious as possible.

How To Prevent Botox Complications From Unskilled Injectors And Counterfeit Product

What You Need To Know About How Botox Can Go Wrong

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Even if you only have a casual interest in beauty and aesthetics, you’ve likely seen the results of [plasma fibroblasting](https://aedit.com/procedure/plasma-skin-resurfacing) on your social media feeds over the past few months. The procedure leaves a (selfie-ready) pattern of tiny dots on the areas that were targeted immediately after treatment. Even though you may have flipped through some [before and after photos](https://aedit.com/aedition/importance-of-before-and-after-photos-in-plastic-surgery) already, you might not know what plasma fibroblasting is or how it works. That’s where we come in. Below, top dermatologists and plastic surgeons break down everything you need to know about the trendy treatment — including how it stacks up to other non-surgical skin tightening and resurfacing procedures. 

## **What Is Plasma Fibroblasting?**
In simplest terms, plasma fibroblasting is a minimally invasive technology “designed to tighten and smooth skin,” says [John Burns, MD](https://aedit.com/provider/john-burns-md-1204), a board certified plastic and reconstructive surgeon in Dallas, TX. It does so by specifically targeting fibroblasts in the skin. “Fibroblasts are a type of cell that produce collagen and protein in the dermis,” explains [Dendy Engelman, MD](https://aedit.com/provider/dendy-engelman-md-312), a board certified dermatologist in New York City. With age, these cells weaken, which leads to visible signs of aging (think: fine lines, wrinkles, skin laxity). “Fibroblast skin tightening procedures — or plasma fibroblasting — target these cells in order to tighten and smooth the skin and improve wound healing,” she adds.

So, how does plasma fibroblasting work? “It uses a pen-like device and emits an electric current that creates micro-injuries,” says [Marisa Garshick, MD](https://aedit.com/provider/marisa-garshick-md-313), a board certified dermatologist in NYC. “It is thought to work as the thermal energy and heat damage causes denaturing, or protein breakdown, in the skin, tissue regeneration, fibroblast activity, and subsequent tissue contraction resulting in skin tightening.”

As you’re probably starting to notice, the name of the treatment speaks directly to how it functions. “Plasma technology creates dual zone micro-trauma using an arc of energy,” says [Ava Shamban, MD](https://aedit.com/provider/ava-shamban-md-2325), a board certified dermatologist in Santa Monica, CA. “Using the electrostatic energy, it creates and emits a positively ionized nitrogen gas arc in the air between its tip and skin.” This ionized plasma arc “works in resurfacing and controlled tissue injury stimulating the repair process,” she noets.

What makes the technology unique is its multifactorial approach to skin rejuvenation. “It targets the superficial zone of skin while simultaneously creating a thermal injury zone at deeper dermal layers, home to fibroblasts,” Dr. Shamban says. This is why you see both short- and long-term benefits from treatment.

## **What Are the Benefits of Plasma Fibroblasting?**
Plasma fibroblasting is often referred to as a ‘skin tightening’ treatment, but that miniker doesn’t tell the whole story. “Plasma fibroblasting can be used to address multiple skin concerns on different areas of the face and delivers many skin benefits,” Dr. Engelman says. The treatment improves overall [skin texture](https://aedit.com/concern/uneven-skin-texture) and [tone](https://aedit.com/concern/uneven-skin-tone), reduces the visibility of unwanted marks and [scars](https://aedit.com/concern/scars) (including [stretch marks](https://aedit.com/concern/stretch-marks)), and boosts collagen and elastin production.” That last piece is what “firms the skin and helps patients look younger,” she adds.

Based on all the post-procedure pics you’ve no doubt seen, you likely know that plasma fibroblasting is most often performed on the face (though it can also be used below the neck). Dr. Shamban says its “specifically effective” for treating areas like:

- Periocular area (think: eyelids and crow’s feet) 
- Perioral area (i.e. around the mouth and above the lips)
- Neck and décolleté 
- Knees

“Fibroblast skin tightening is often used on areas with dynamic wrinkles, like crow’s feet around the eyes, and areas that tend to sag with age, like the neck and jowls,” Dr. Engelman says. You can also think about treatment areas in terms of aesthetic concerns. “It can help with skin laxity — especially involving the upper or lower eyelids — fine lines, wrinkles, acne scarring, and sun damage,” Dr. Garshick adds. 

## **Who Is the Ideal Candidate for Plasma Fibroblasting?**
As with its fellow non-surgical skin tightening treatments, plasma fibroblasting “is a good option for someone who wants to help with skin tightening without going to surgery,” Dr. Garshick says. An ideal candidate for plasma fibroblast treatments, according to Dr. Engelman, “is someone with mild to moderate textural skin concerns such as acne scarring, fine lines and wrinkles, and creping.” Another beneficiary? “Any males or females who have thinner skin,” Dr. Shamban adds. 

While Dr. Shamban says the treatment “can be used on all ethnicities and [Fitzpatrick types](https://aedit.com/aedition/guide-to-fitzpatrick-skin-types)” because “it does not target or affect melanin,” those who are prone to pigmentation concerns (common of melanated skin) should be mindful. “It should be used with caution in those with darker skin or those prone to hyperpigmentation,” Dr. Garshick notes. Additionally, “the patient should not have any serious medical disorders, pigmentation disorders, or active infections and should be in overall good health if considering receiving this treatment,” Dr. Engelman says.

## **What Happens During a Plasma Fibroblasting Treatment?**
A [topical anesthetic](https://aedit.com/aedition/numbing-cream-breakouts) is applied before plasma fibroblasting procedures to minimize discomfort. The plasma pen delivers electric current to the skin, resulting in tiny, scab-like dots. “Depending on the treatment area, it can take 15 minutes to one hour to complete,” Dr. Garshick says. Generally speaking, Dr. Shamban says the treatment “is well tolerated by most patients without pain.”

How many treatments you’ll need depends on your anatomy and aesthetic goals. “The age, tone, condition, laxity of the skin, genetics, lifestyle and ethnic backgrounds can all play a factor in the final results,” Dr. Shamban explains. While the eyelids or perioral area may only need one session, “the [neck and décolleté](https://aedit.com/concern/neck-and-jawline-definition) or [knees](https://aedit.com/aedition/best-cosmetic-procedures-for-knees) might require an additional treatment to see a final result,” she says. 

In Dr. Engelman’s experience, multiple sessions (think: one to three) are typically required to see “visibly noticeable results.” Even if you do see results after your first session, Dr. Burns says that “subsequent treatments do offer benefits also.” 

## **What Does Recovery From Plasma Fibroblasting Entail?**
If there is one main downside to plasma fibroblasting, it’s the downtime. “The recovery is longer than most non-invasive treatments,” Dr. Burns concedes. “Scabs are present and generally fall off at about a week with persistent redness for two to three weeks.” As a result, Dr. Shamban says “this is not done within a week or two before a [red carpet](https://aedit.com/aedition/cosmetic-procedures-treatments-for-the-red-carpet-and-special-events), corporate presentation, TV appearance, or [holiday party](https://aedit.com/aedition/non-surgical-cosmetic-procedures-to-get-for-the-holidays).” Instead, she recommends allowing “two full weeks for the tiny red dots that form in a pattern across the treated area and scab to darken and fall off.”

According to Dr. Burns, the most common side effects of plasma fibroblsating are “delayed healing, scarring, and skin pigment irregularities.” 

## **How Long Do Plasma Fibroblasting Results Last?**
Generally speaking, Dr. Burns says the results of plasma fibroblasting can last anywhere from six months to two years. At that point, it may be time to re-book. “Aging is a progressive condition, so reassessing the area and re-treating within two years for maintenance may be recommended,” Dr. Shamban notes.

<BeforeAfterModule
  title={Before & Afters: Plasma Fibroblasting}
  procedureId={846}
/>

With that in mind, you could call the results of plasma fibroblasting the gift that keeps on giving. “While some benefits can be noticed right away, some changes may take three to six months to be seen,” Dr. Garshick says. So, what will you see when? “Both resurfacing and tightening will be seen and felt as soon as the area heals, within a few weeks,” Dr. Shamban explains. Even still, the healing process (including that collagen boost), will continue to progress with a final result of improvements seen in about 12 weeks and sometimes even as far out as 12 months,” she adds.

## **How Does Plasma Fibroblasting Stack Up?**
If you’re curious how plasma fibroblasting stacks up to other non-surgical firming and resurfacing treatments, there is much to take into consideration. “In comparison to radiofrequency (RF) [skin tightening](https://aedit.com/aedition/best-nonsurgical-skin-tightening-procedures), plasma fibroblasting requires more recovery time and and overall discomfort due to the micro-injuries sustained by the skin,” Dr. Engelman explains. “However, plasma fibroblasting only requires one to three office visits and lasts a long time (up to two or three years), while RF treatments can take about five visits and need to be maintained monthly.”

As for lasers? “[Plasma fibroblasting] is a device used to remodel skin and tighten tissue similar to a [resurfacing laser](https://aedit.com/aedition/guide-to-ablative-laser-skin-resurfacing),” Dr. Shamban shares. “It will resurface to smooth texture and reduce fine lines and wrinkles, as well as tone and provide tissue tightening.” When it comes to downtime and longevity, Dr. Engelman also likens the two. “Plasma fibroblasting and laser treatments usually require similar downtime — about a week, give or take, depending on the patient, extent of the treatment, and post-care practices,” she says. “Laser treatments can also last several years, especially if the skin is well taken care of.”

There is currently no research comparing plasma fibroblasting to other non-surgical tightening devices, but Dr. Garshick notes that [some studies](https://jamanetwork.com/journals/jamadermatology/fullarticle/411275) have shown that plasma fibroblasting can lead to a 37 percent reduction in facial wrinkling and 68 percent overall improvement in facial appearance. Even so, it’s important to remember that everyone is unique and what works for one person might not be the best course of action for another. As Dr. Garshick says, “it is always best to discuss the best treatment option for your concern with your provider.”

You’ve seen the post-treatment selfies on social media, but do you know what those tiny dots are actually doing? We didn’t think so.

Plasma Fibroblasting: Benefits, Treatment, Recovery, Results

Everything You Need To Know About Plasma Fibroblasting

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From private nurses to meal plans, make sure your plan is anything but basic.

The Best Plastic Surgery Recovery Centers, Nursing Services, Products

How To Recover From Plastic Surgery In Comfort And Style

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Sloughing off dead skin cells to make way for brighter, healthier skin sounds like a recipe for a glowing countenance — and, for the most part, it is. “Exfoliating can improve the efficacy of your skincare products by removing dead skin cells so products are better able to penetrate the skin and deliver better results,” says [Michele Green, MD](https://aedit.com/provider/michele-green-md-34642), a board certified cosmetic dermatologist in New York City. “Exfoliants can fade discoloration, improve fine lines and wrinkles, and clear blemishes.” 

But, as the cliché goes, you *can* have too much of a good thing. Thanks to the abundance of skincare products on the market and armchair aestheticians on social media sharing their recommendations, it’s easy to think a skincare routine isn’t complete without dozens of steps (see: Shay Mitchell’s [58-step beautification process](https://www.youtube.com/watch?v=SCS0bZucQ20)) and daily exfoliation. But dermatologists tell us that not only is it possible to over-exfoliate the skin, it’s actually quite common among skincare enthusiasts. Here, the real experts explain how often to exfoliate and how to tell if you’ve gone overboard.

## **How Often Should I Exfoliate?**
First things first, a quick refresher on exfoliators. Generally speaking, there are two types of exfoliation: chemical and physical. The former uses a chemical solution (usually composed of [alpha](https://aedit.com/aedition/guide-to-topical-alpha-hydroxy-acids-in-skincare), [beta](https://aedit.com/aedition/guide-to-beta-hydroxy-acids-salicylic-acid-in-skincare), and/or [polyhydroxy](https://aedit.com/aedition/guide-to-topical-polyhydroxy-acids-in-skincare) acids or enzymes) to loosen up the bonds between dead skin cells and impurities so they slough off, while the latter involves manually buffing the skin. “Chemical exfoliation is gentler on the skin than mechanical exfoliants, which can cause microscopic tears in the skin,” Dr. Green says. “Plus, the benefits of a chemical exfoliation are immediate — once the skin is cleaned you are left with new, fresh glowing skin.”

Before an exfoliating product becomes a regular part of your skincare routine, [Hadley King, MD](https://www.drhadleyking.com/), a board certified dermatologist in NYC, suggests testing it a couple of times on a smaller area of skin to see how you react. Keep an eye out for any irritation and notice if your skin feels unusually tight after using it. Once it passes muster, gradually increase it to the level recommended on the package. 

How often you can and should exfoliate depends on a myriad of factors including your skin type and the product you’re using. [Taylor Worden](https://www.taylorworden.com/), a NYC-based facialist, says that most of her clients exfoliate about two times per week. Those with [dry](https://aedit.com/aedition/skin-drying-habits-to-avoid) or [sensitive](https://aedit.com/aedition/difference-between-sensitive-vs-sensitized-skin) skin may scale down to just once a week, while those with [oily skin](https://aedit.com/aedition/difference-between-oily-and-acne-prone-skin) may be able to handle three times per week. Take your time to [slowly introduce](https://aedit.com/aedition/safely-trying-new-skincare-products-ingredients) exfoliating products to your routine and let your skin guide you.

## **What Are Signs That I’m Exfoliating Too Often?**
If that fresh, glowing skin turns dry, irritated, red, or flaky, your exfoliator might be to blame. You may even notice breakouts, which can happen as a result of stripping the skin of its natural moisture. While exfoliants can be sensitizing, any tingling and redness should be temporary and resolve quickly. When it lingers or worsens, it’s likely because the product doesn’t agree with your complexion or you’ve overdone it.
 
According to Dr. King, both chemical and physical exfoliants can lead to over-exfoliation if they are used too frequently, with too much pressure, at too high of a strength, or with too many other potentially irritating or drying ingredients. 

## **How Can I Correct Over-Exfoliation?**
First and foremost, hide the offending product in the back of your cabinet and avoid using it until your complexion looks and feels less irritated. While your skin is inflamed, take a step back from all harsh products, including scrubs, acids, and [retinol](https://aedit.com/aedition/guide-to-vitamin-a-retinol-retinoids-in-skincare). In its place, go back to basics and treat your skin the way you would in the [aftermath of a resurfacing treatment](https://aedit.com/aedition/skincare-after-facial-plastic-surgery-procedures) such as a laser or a chemical peel.

Dr. Green suggests opting for a mild, non-sudsing gel cleanser like [Cetaphil Gentle Skin Cleanser](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.ulta.com%2Fp%2Fgentle-skin-cleanser-pimprod2028662) or [CeraVe Hydrating Facial Cleanser](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.ulta.com%2Fp%2Fhydrating-facial-cleanser-with-ceramides-hyaluronic-acid-xlsImpprod4190255). Both contain soothing ingredients like [niacinamide](https://aedit.com/aedition/guide-to-topical-niacinamide-vitamin-b3-in-skincare), [ceramides](https://aedit.com/aedition/guide-to-topical-ceramides-in-skincare), and [glycerin](https://aedit.com/aedition/guide-to-glycerin-in-skincare) to calm sensitized skin. [Amanda Doyle, MD](https://aedit.com/provider/amanda-doyle-md-31526), a board certified dermatologist at Russak Dermatology in NYC, is a fan of the [SkinCeuticals Phyto Corrective Mask](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.dermstore.com%2Fskinceuticals-phyto-corrective-masque-60ml%2F11339142.html) because it cools the skin on contact and visibly reduces redness. 

Speaking of cooling the complexion, Dr. Green recommends trying to alleviate skin sensitivity with a cold compress, followed by an over-the-counter topical hydrocortisone. If you have broken skin, try the [Aquaphor Healing Ointment](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.walgreens.com%2Fstore%2Fc%2Faquaphor-healing-ointment%2FID%3Dprod14801-product) or [Doctor Rodgers Restore Healing Balm](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.dermstore.com%2Fdoctor-rogers-restore-restore-healing-balm-0.5-oz.%2F12915562.html) to lock in moisture and speed up recovery. 

If swapping your harsh products for sensitive ones doesn’t calm down your skin, speak to your dermatologist about a prescription topical — and, while you’re at it, ask for their tips for gentler exfoliation. For some, trying an application technique like [short contact therapy](https://aedit.com/aedition/short-contact-therapy-in-skincare) can allow you to reap the benefits with less of the side effects. Glowing skin is a delicate balance, but it’s absolutely achievable with the right products and a bit of patience.

*All products featured are independently selected by our editors, however, AEDIT may receive a commission on items purchased through our links.*

Beauty

As the cliché goes, you can have too much of a good thing. Here’s how to tell if you’ve gone too far.

What Happens When You Over-Exfoliate Your Skin

Am I Exfoliating Too Much?

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When [dermal fillers](https://aedit.com/procedure/dermal-filler-and-injectable-solutions) first became popular some umpteen years ago, it seemed like no one would ever tire of their ability to [sculpt and rejuvenate](https://aedit.com/aedition/how-to-reshape-your-face-with-filler-botox-injectables) sans surgery. And it certainly didn’t seem like anyone would ever be on the quest to find the next best thing. The truth is though that filler fatigue can happen — and it is becoming more prevalent — but not for the reasons you might think. 

## **Why Filler Fatigue Happens**
In some patients, the more often they receive filler injections, the less content they become with the results. They still want to see definition and volume like they once did, but it becomes a game of chase. The phenomenon is known as filler fatigue, and it boils down to the simple premise of a patient feeling as if filler no longer works for them.

Why some say they no longer notice positive changes with filler comes down to a few causes:

- **Societal Standards**: There is mounting pressure to look young, which creates fatigue and leads patients to turn to other modalities. “They become tired of hyaluronic acid gel fillers to lift and fill the midface,” says [Ryan Neinstein, MD](https://neinsteinplasticsurgery.com/), a board certified plastic and reconstructive surgeon in New York City.
- **Gravity**: There's the gravitational factor. Gravity's effect on the skin and body never takes a day off, nor does it stop. The aging process continues even when injecting fillers.
- **Overuse**: The overuse of fillers and [even neuromodulators](https://aedit.com/aedition/botox-immunity-neurotoxin-resistance) can lead to less-than-ideal results and leave patients wanting more.
- **Misuse**: The products are misused by unqualified professionals, says [Julie Russak, MD](https://aedit.com/provider/julie-russak-md-4645), a board certified dermatologist in NYC, which can lead to unsatisfactory results. In some cases, even if an injectable is used correctly, a patient may need an additional procedure, besides filler, to treat their concern.
- **Overfilling**: “It’s when a filler is used only for volume replacement — especially in large volumes — that people refer to filler fatigue as the skin stretching out due to the overuse of product,” Dr. Russak notes. This stretching effect impairs skin elasticity, making it appear not as tight as it once was. 

The concept of filler fatigue does not affect every patient. Plenty never tire of the remedy and are filler patients indefinitely. But those who feel filler burnout starting to settle in — Dr. Neinstein says it tends to occur in the mid- to late-forties — often begin to make more rational decisions about why they are potentially overspending on temporary remedies instead of considering customized and lasting surgical results. “Filler products are [reversible](https://aedit.com/aedition/hyaluronidase-to-dissolve-dermal-filler) and lack long-term sustainability, plus the costs can be overwhelming,” he shares. “There is a lower barrier to surgical entry when patients exhaust the non-surgical arena because they do not have to wonder if they are overdoing it or reaching beyond the psychological threshold they have set.”

## **Too Much of a Good Thing?**
For all of the benefits filler provides, having too much injected (a.k.a. [overfilling](https://aedit.com/aedition/how-to-correct-overfilled-facial-features)) can lead to an unnatural and distorted look that disrupts the natural balance of the face. “You can immediately recognize this imbalance in someone whose appearance is unnaturally plump,” suggests [Brendan Camp, MD](https://aedit.com/provider/brendan-camp-md-34645), a board certified dermatologist in NYC. Because a lack of [harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) can result from improper use of filler, it is crucial to seek out and choose a board certified dermatologist or plastic surgeon who understands facial anatomy and takes a prudent approach that yields natural-looking results.

It's not so much about the type of filler or technique used as it is about knowing what is and is not suitable for the face. “It can happen with any filler or any part of the face,” says [Debra Jaliman, MD](https://www.drjaliman.com/), a board certified dermatologist in NYC, though she adds that it’s less likely for younger patients to notice the effects of filler fatigue. The recurrence of injecting over and over can cause the face to look heavier, as each treatment session draws water to the area so the product can plump as intended. All this extra water can be retained in the face and potentially impede lymphatic drainage. In extreme cases, it can even change the skin's elasticity and cause it to be less resilient due to the skin having to support above average amonuts of water. 

### **Rejuvenating vs. Refilling**
As we age, the amount of volume in the face decreases and gravity sets in, forcing the face to sink. “We also see a loss of collagen in the skin, which results in sagging and loose texture,” Dr. Russak explains. However, she says, if you only look at the face in terms of using filler as a volumizing agent to stretch out the skin so lines disappear, it’s easy to run the risk of overfilling the face and creating a doughy, distorted look. “It’s important to take into account all of the factors of an aging face and not just [volume loss](https://aedit.com/aedition/best-procedures-to-restore-facial-volume),” she advises. Those other elements include skin laxity, fat loss, decreased collagen and elastin, and even bone resorption.

Even an aging face can appear full (or very full), which, Dr. Russak shares, is because volume has sunk to the lower face and created marionette lines, cheeks that drop down, and deep nasolabial folds. “Because of this, it’s important to lift the face to work against gravity rather than ‘fill,’” she says.

## **How to Avoid Filler Fatigue**
Injectable fillers are great for minor tweaks, but when they become more habitual or routine than necessary, they can start to cause problems. Unlike neuromodulators, which should follow a [maintenance schedule](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel) every three to four months, inject fillers only when needed.

To avoid expending the benefits of fillers, Dr. Jaliman recommends sticking with hyaluronic acid-based injectables because they easily dissolve if they are causing problems. More permanent fillers cause inflammation within the skin, leading to scar tissue to build up and adverse effects down the road. Rather than rely solely on one treatment, she also says that multiple modalities often need to be used together (think: [lasers](https://aedit.com/aedition/guide-to-ablative-laser-skin-resurfacing), [peels](https://aedit.com/aedition/guide-to-superficial-medium-deep-chemical-peels), radiofrequency, Botox®, fillers, and [skincare](https://aedit.com/aedition/best-skincare-routine-products-ingredients-for-30s)) for a comprehensive result.

Fillers play an essential role in the aesthetic arena, and most dermatologists and plastic surgeons agree that they have their place in proper patients. “When used in the appropriate setting, fillers are great at making subtle changes in skin lines and shadows that trim years of one's appearance in a matter of minutes,” Dr. Camp says. Yet, when they no longer provide the desired result, it may be time to weigh the options and decide if a switch is in the cards. 

Beyond injectables, age-rejuvenating surgical procedures, like a [facelift with fat grafting](https://aedit.com/aedition/guide-to-facial-fillers-fat-grafting-after-facelift) or [blepharoplasty](https://aedit.com/aedition/combining-blepharoplasty-and-brow-lift) (among many other things), may be the better choice to create a youthful look that offers longer-term satisfaction. Just keep in mind that, even when going under the knife, there still may be a reason to go under the needle. At the end of the day, it’s a balancing act to create a harmonious face.

Everything you need to know about this serious phenomenon.

Dermal Filler Fatigue Due To Overfilling, Unsatisfactory Results

Is Filler Fatigue Real?

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As the demand for temporary, volume-enhancing injectables has risen in recent years, so too have instances of ‘pillow face’ — a tell-tale sign of too much [filler](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers). “Overfilled faces – whether cheeks, under eyes, temples, lips, chins, or jawline – can distort the normal anatomic proportions leading to alien-like facial contours,” explains [Jessica Weiser, MD](https://aedit.com/provider/jessica-weiser-md-34640), a board certified dermatologist and founder of [Weiser Skin MD](https://www.weiserskin.com/) in New York City. But it’s not just the visual impact that can cause concern. Over filling a feature or area of the face can inhibit function. So, how much is too much? Below, we explore the impacts of too much filler and what it takes to correct it.

## **The Aesthetic Downsides of Too Much Filler**
For the majority of people keen on [enhancing volume](https://aedit.com/aedition/best-procedures-to-restore-facial-volume), hyaluronic acid (HA)-based dermal fillers, like [Juvéderm®](https://aedit.com/procedure/juvederm), [Restylane®](https://aedit.com/procedure/restylane), and [Belotero®](https://aedit.com/procedure/belotero), offer a simple solution: subtle plumpness and a hydrating boost. When performed by a skilled injector who understands [facial harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) and values [proportion](https://aedit.com/aedition/plastic-surgery-results-are-about-proportion-not-perfection), filler can work wonders. Where it takes a turn is when the filler placement goes past the point of looking appropriate for the face in question. “I think of overfilled features as looking uncanny, i.e. unsettling, not-quite-human, or realistic,” says [Daniel Belkin, MD](https://www.nydermatologygroup.com/doctors/dr-daniel-belkin/), a board certified dermatologist at New York Dermatology Group. 

In the search for perfection or even just stronger contours, facial features can cease to coexist naturally. “They might be [lips](https://aedit.com/procedure/temporary-lip-fillers) that lose the natural structure of human lips or are unnaturally enlarged, [cheeks](https://aedit.com/procedure/cheek-augmentation-with-fillers) that are overly round and puffy, or natural folds that are effaced by filler,” he explains. In the case of the latter, he says to imagine the [lower eyelid](https://aedit.com/procedure/under-eye-filler) “running right into the cheek instead of being separated by a normal lid-cheek junction.” The phenomenon, he explains, can actually make others “uncomfortable because of the way they distort a human face and make it something slightly unfamiliar.”  

The change doesn’t happen in a silo. Filler in one area can skew the appearance of other features. ”Cheek elevation that occurs with smiling, speech, chewing, and more can become unnatural with too much volume distorting the apple of the cheek and even sometimes pressing up above the orbital rim leading to smaller squinted eyes,” Dr. Weiser shares. And then there is the way in which the filler is injected. Superficially placed filler can create a rough appearance on the skin, adding to the other-worldly appearance of improper injections. 

## **The Funcional Downsides of Too Much Filler**
Apart from the aesthetic consequences, the function of overfilled treatment areas are at risk, too. Depending on the placement, “too much filler can impact speech, muscle movement, and lymphatic vessels,” Dr. Belkin cautions. An abundance of filler in the lip or around the mouth, for example, “can change the way speech is articulated,” he explains. This occurs because “excessive lip filler can prevent proper puckering and contraction of the orbicularis oris muscle, leading to unusual speech,” Dr. Weiser adds. 

When the under-eye or medial cheek area is overfilled, Dr. Belkin says patients may experience “impaired lymphatic drainage from filler placement.” Although an [artfully elevated cheek](https://aedit.com/aedition/restylane-contour-cheek-filler) is meant to restore a more youthful appearance, taking it too far can lead to a bloated look due to the constriction. “The face has two planes of lymphatic drainage: a superficial and a deep,” Dr. Weiser explains. “Large quantities (or sometimes even smaller volumes) of filler can obstruct these channels causing fluid accumulation and facial swelling that may be difficult to reverse or correct.”

If you are curious as to whether or not too much filler can stretch the skin, Dr. Belkin says that, in most cases, “filler cannot provide enough force to overstretch skin.” In extreme cases, however, it is possible. “Overfilling to a dramatic extent can stretch the skin, especially when done repeatedly in the same area,” Dr. Weiser warns. HA fillers naturally break down and get absorbed into the body over the course of six to 12 months. That process can also be sped up by injecting an enzyme called [hyaluronidase](https://aedit.com/aedition/hyaluronidase-to-dissolve-dermal-filler) (more on that below). Whether through natural degradation or synthetic dissolving, Dr. Weiser says “the skin can be left with laxity, redundancy, and crepiness.” 

A silver lining? The stretching can actually have a youth-boosting effect. “By stretching the tissue, it stimulates fibroblasts (collagen-producing cells) to produce more [collagen](https://aedit.com/aedition/guide-to-collagen-in-skincare-supplements-aesthetic-medicine),” Dr. Weiser notes. “Because of this, I will tell people who worry they will have to keep it up forever that even if you do filler once and stop, you are better off than never having done it at all.” 

## **Correction Options** 
When prevention is not an option, correction is the next best thing. As Dr. Belkin advises, there is no one-size-fits-all option. The methods used for tackling overfilled features are determined on a case-by-case basis, but below are the most common:
	
### **1. Dermal Filler** 
Filler to treat overfilled areas? Yes, you read that right. Because proportion plays a big role in facial nuance, a feature may look ‘too plump’ simply due to its juxtaposition to a sunken area. To aptly treat an area that appears overfilled, supplementing its surroundings with volume may balance out the face for a more harmonious result. The way Dr. Weiser sees it, an overfilled appearance may be due to an uneven distribution that “can be corrected by adding small droplets of product for balance.” 

For example, some patients who have their [tear trough filled](https://aedit.com/aedition/how-i-quit-crying-about-my-tear-troughs) lack volume in the cheek, which leads to an unnatural result. Instead of dissolving the filler under the eyes, Dr. Belkin would look at the face as a whole. “I would recommend conservatively re-volumizing the cheek to match the replaced volume in the tear trough,” he says. But, again, this is not the solution for everyone. If the under-eyes look puffy and the cheek has appropriate volume, “it is likely the tear trough has been overfilled,” he says. In that case, he will “partially dissolve” the product. Speaking of dissolving... 

### **2. Hyaluronidase** 
Hyaluronidase is an enzyme that is naturally occurring in the body. Just as synthetic forms of HA can be injected to augment or sculpt, synthetic [hyaluronidase](https://aedit.com/procedure/hyaluronidase) can be injected to dissolve it. In certain situations, Dr. Weiser says the best solution to treat an overfilled appearance may be to start over. Getting patients on board, however, is not always easy. “Some patients are very resistant to dissolving and starting again,” she says. The alternative? “In these cases, I will encourage them to wait six to 12 months to allow the product to naturally degrade before adding,” Dr. Weiser shares.

Depending on your condition, hyaluronidase can be a relatively quick fix. Results can start to show up in less than an hour, though temporary [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) (like the kind experienced after filler injections) can keep the area looking puffy for a few days. In more severe cases, patients may need multiple sessions to fully dissolve their filler. It should also be noted that hyaluronidase degrades all HA (not just the synthetic kind), which means you can be left with even less volume than you started with until the body adjusts.

### **3. Prevent to Protect**
We’ve said it before, and we’ll say it again: The best course of action when it comes to any aesthetic decision is to always do your due diligence and [find a provider](https://aedit.com/aedition/dangers-of-doctor-hopping) who is skilled in your specific concern or treatment and understands your aesthetic goals. “Make sure you are seeing someone who injects filler the way you want yours to appear,” Dr. Weiser says. One way to confirm this? Ask to see [before and after photos](https://aedit.com/aedition/importance-of-before-and-after-photos-in-plastic-surgery) and look for patients who have similar features to yours. 

## **The Takeaway** 
There is a reason hyaluronic acid-based fillers are so popular — they offer a great way to temporarily augment, enhance, or contour an array of facial features. But too much of a good thing isn’t, well, good. “Beautifully placed filler can be wonderful, but poorly placed or excessive amounts can be a struggle to correct,” Dr. Wesier cautions. For those who feel that their filler has negatively impacted their appearance or the function of certain body parts, revision may be possible in the hands of a skilled provider. Be sure to consult with a [board certified](https://aedit.com/aedition/medical-board-certification-in-plastic-surgery-cosmetic-dermatology) plastic surgeon or dermatologist to understand your treatment options.

Dermal filler is a great tool for restoring volume, creating balance, and contouring, but too much of a good thing can lead to an overfilled look that may require its own treatment plan.

How To Correct Too Much Dermal Filler In The Face

How To Correct Overfilled Facial Features

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Linda Evangelista made headlines on social media this week when she candidly opened up about her experience with paradoxical adipose hyperplasia (PAH), which she says she developed after a series of cryolipolysis treatments five years ago. In an emotional [Instagram post](https://www.instagram.com/p/CUJZa40tWXC/), the supermodel alleges the CoolSculpting® procedures “increased, not decreased” her fat cells and left her “permanently deformed even after two painful, unsuccessful, corrective surgeries.”

<CaptionImg url={https://images.contentful.com/zw35sfestf1t/5tUYfh7YSiYd0xHs77qCwi/eb88a5821865ba0aef90405f401b176c/LindaEnvangelistaIG.png}>
  Linda Evangelista's Instagram post about her experience with PAH. (@lindaevangelista/ Instagram)
</CaptionImg>

By sharing her story, Evangelista (who filed a lawsuit against the device’s manufacturer, Zeltiq Aesthetics, which is a subsidiary of Allergan) has paved the way for a renewed conversation around one of the lesser known adverse effects of the popular [fat-freezing procedure](https://aedit.com/aedition/comparing-fat-melting-sculpsure-and-fat-freezing-coolsculpting). So, what is paradoxical adipose hyperplasia and how common is it? Here, a top dermatologist and plastic surgeon break down everything you need to know about PAH — including how to treat it.

## **What Is Paradoxical Adipose Hyperplasia?**
To understand paradoxical adipose hyperplasia (PAH), it’s first important to understand cryolipolysis. Also known as ‘fat freezing’ or by its brand name, [CoolSculpting®](https://aedit.com/procedure/cool-sculpting), the non-invasive body contouring procedure is a controlled cooling technique that works by freezing fat cells at negative 11 degrees Celsius to permanently destroy them. “Cryolipolysis uses cooling to damage and destroy subcutaneous fat cells without damaging the skin to reduce the amount of fat in the treated area,” says [Paul Jarrod Frank, MD](https://pfrankmd.com/), a board certified dermatologist in New York City. 

Most patients experience a 20 to 25 percent reduction of fat in the treatment area, and CoolSculpting® is approved by the United States Food and Drug Administration (FDA) to address visible fat bulges on the back, buttocks, thighs, upper arms, flanks, and abdomen and under the chin and jawline. According to the [CoolSculpting® website](https://www.coolsculpting.com/index.html), post-treatment side effects include “temporary redness, swelling, blanching, bruising, firmness, tingling, stinging, tenderness, cramping, aching, itching, or skin sensitivity, and sensation of fullness in the back of the throat after submental or submandibular area treatment.” 

The site also notes that “rare side effects” may occur: “CoolSculpting® and CoolSculpting® Elite may cause a visible enlargement in the treated area, which may develop [two] to [five] months after treatment and requires surgical intervention for correction.” The paradoxical adipose hyperplasia Evangelista describes was [first reported in 2014](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171727/). “It is a rare, previously unreported adverse effect of cryolipolysis,” Dr. Frank notes.

PAH refers to hardened areas of localized fat that develop after cryolipolysis. “PAH is the unintentional growth of adipose, or fat, after cryolipolysis,” explains [Melissa Doft, MD](https://doftplasticsurgery.com/), a double board certified plastic and reconstructive surgeon in NYC. “Patients complain of a thick layer of hard fat in a similar shape to the applicator used for CoolSculpting®, and it has been described as looking like a stick of butter.”

[Studies show](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171727/) that less than one percent of patients (about 0.05 percent to 0.39 percent) experience the condition after cryolipolysis, though [more recent data](https://www.sciencedaily.com/releases/2018/06/180629182037.htm) indicates the figure may be as high as 0.72 percent. “It is unclear why some patients have the growth of fat cells instead of reduction, but what is known is that the incidence is higher than was previously expected,” Dr. Doft says. “Researchers estimated that it affects one in 138 patients who undergo cryolipolysis and is more common in male patients.”

As such, providers increasingly believe PAH does not get enough attention. “This complication is more common than we think, along the spectrum of mild to severe,” Dr. Frank shares. In her IG post, Evangelista laments that she was “not made aware” of the risk prior to undergoing treatment. 

While it is not life threatening, PAH can be physically and emotionally distressing — and it will not go away without treatment. “I do not have a CoolSculpting® machine, but I have seen several complications unfortunately,” Dr. Doft shares. “It is devastating to the patients.”

## **What Causes Paradoxical Adipose Hyperplasia?**
The tricky thing about paradoxical adipose hyperplasia? We don’t really know exactly what causes it. “We assume the cooling effect has some sort of stimulatory stem cell activation which causes multiplication of fat cells,” Dr. Frank explains, adding that it is “typically a localized phenomenon.” That means most patients who experience PAH do so in the area where the cryolipolysis applicator was placed, and it can happen anywhere on the body. 
 
Additionally, it can happen to anyone. “There is no data on why someone is more susceptible than others,” Dr. Frank says. “That makes it such a problem because it's unpredictable.” One potential factor? “People who get too many repetitive treatments in the same area may be more inclined to have PAH,” he adds. 

For example, there could be situations in which a patient is misdiagnosed after CoolSculpting®. “The most common cause is when a patient says they have a CoolSculpting® cycle, and they start noticing growth in the area,” Dr. Frank explains. Rather than recognize the growth as PAH, an untrained provider may blame it on weight gain and have the patient undergo another session. “It usually happens when you have too many CoolSculpting® treatments in a short period of time to the same area,” he says.

## **How to Treat Paradoxical Adipose Hyperplasia**
The most important thing to know about treating paradoxical adipose hyperplasia is that additional cryolipolysis treatments are not the answer. Instead, [liposuction](https://aedit.com/procedure/tumescent-liposuction) or, in more severe cases, [abdominoplasty](https://aedit.com/procedure/abdominoplasty) (read: tummy tuck) are the most effective ways to improve or completely correct PAH. Be aware that multiple surgeries may be needed.
 
The coldness of cryolipolysis creates inflammation that destroys fat cells, but it can also cause panniculitis, or the inflammation of fat. “That causes a rebound and exacerbation of scar tissue that comes from the inflammation,” Dr. Frank explains. As such, “it is necessary for patients to wait six to nine months after the [cryolipolysis] procedure to confirm that the inflammation and growth has plateaued,” Dr. Doft adds. During that time, “people who are experiencing the active stage of growth soon after CoolSculpting® treatment require systemic steroids,” Dr. Frank notes. 
 
At Dr. Frank’s practice, [vaser liposuction](https://pfrankmd.com/lipo/) is the “gold standard” of treating fat adipose hyperplasia. “[Most patients](https://www.instagram.com/p/CMUeHjRFm46/?utm_medium=copy_link) get enormous improvement after one treatment,” he explains, but many patients “will require two rounds of surgical intervention to really reduce the irregularities.” 
 
Dr. Doft agrees that liposuction often “works well to remove the excess fat tissue,” though it is not always enough. “Some patients not only have excess fat but also significant scar tissue and will need an abdominoplasty to correct the problem,” she says.
 
## **The Takeaway**
Even non-invasive treatments that are generally considered safe and effective, like CoolSculpting®, can have negative outcomes that require costly revision. “[PAH] is a more common than discussed complication, particularly in the hands of unlicensed professionals and med spas,” Dr. Frank cautions. While all aesthetic procedures carry the possibility of side effects and complications, visiting a [board certified provider](https://aedit.com/aedition/medical-board-certification-in-plastic-surgery-cosmetic-dermatology) who specializes in the treatment you are interested in can help mitigate risk and ensure you are in qualified hands should something go wrong.

Cryolipolysis is generally considered a safe and effective form of body contouring, but adverse effects (however rare) are possible. Here’s what you need to know about PAH.

What To Know About Paradoxical Adipose Hyperplasia (PAH) After Cryolipolysis, CoolSculpting

What You Need To Know About Paradoxical Adipose Hyperplasia

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Raise your hand if you’ve experienced buyer’s remorse. The feeling that is familiar to many is not just reserved for retail therapy — it can happen post-aesthetic treatment, too. Results don’t always live up to expectations, and, in certain cases — specifically minimally invasive injectable treatments that temporarily alter the appearance — waiting for the results to dissipate can feel like an eternity. 

Hyaluronic acid (HA)-based dermal fillers, like [Juvéderm®](https://aedit.com/procedure/juvederm), [Restylane®](https://aedit.com/procedure/restylane), and [Belotero®](https://aedit.com/procedure/belotero), naturally dissolve over time depending on the treatment area, the amount injected, and the patient’s metabolism (for men, [it will likely dissolve faster](https://aedit.com/aedition/guide-to-lip-filler-for-men)). Those who are left feeling dissatisfied with their results, however, will be relieved to know that turning back time is an option. Enter: [hyaluronidase](https://aedit.com/procedure/hyaluronidase). 

Whether it’s the [lips](https://aedit.com/procedure/temporary-lip-fillers), [under the eyes](https://aedit.com/procedure/under-eye-filler), [in the cheeks](https://aedit.com/procedure/cheek-augmentation-with-fillers), or any of the other areas where HA filler is placed, injecting hyaluronidase can speed up the degradation process and reduce plumpness and/or lumpiness in a matter of days. But is the revision really as simple as it sounds? We tapped two top dermatologists to break down everything you need to know about hyaluronidase. 

## **What Is Hyaluronidase?**
Like [hyaluronic acid](https://aedit.com/aedition/guide-to-hyaluronic-acid-in-skincare-dermal-filler), the human body naturally produces hyaluronidase. “Hyaluronidase is an enzyme that occurs naturally in the body to break down hyaluronic acid, which is a naturally occurring molecule that helps give turgor and support to our skin and joints,” explains [Daniel Belkin, MD](https://www.nydermatologygroup.com/doctors/dr-daniel-belkin/), a board certified dermatologist at New York Dermatology Group. 

Just as we can inject synthetic forms of hyaluronic acid to augment and contour the face and body, we can inject synthetic forms of hyaluronidase to undo the effects. “[It] can be synthetic and used deliberately for the non-surgical removal of unwanted effects of a HA filler treatment,” says [Jessica Weiser, MD](https://www.weiserskin.com/md-jessica-weiser.html), a board certified dermatologist and founder of [Weiser Skin MD](https://www.weiserskin.com/). “Beautifully placed filler can be wonderful, but poorly placed or excessive amounts can be a struggle to correct.”

## **How Hyaluronidase Is Used**
As you may have predicted, hyaluronidase is a way to revise HA filler procedures that go awry for any number of reasons. “Because HA is the essential component of HA-based fillers, hyaluronidase may be injected into the skin by a dermatologist or plastic surgeon to rapidly dissolve filler,” Dr. Belkin says. This correction may be due to “a poor cosmetic outcome” or 
“for a complication,” he adds.

Yes, hyaluronidase can help remove volume or soften contour for patients who are unhappy with the outcome of their injectables, but it can also address some of the possible side effects of HA filler — chiefly, lumps and nodules. “The same applies to hyaluronidase for small bumps and blebs,” Dr. Weiser shares. “I will often start with diluted hyaluronidase to see if I can reduce excess product or product placed too superficially without wiping out everything.” In other words, a skilled injector may be able to smooth lumpiness without compromising the rest of the result.


## **When Will You See Results from Hyaluronidase?** 
Depending on your condition, hyaluronidase can be a relatively quick fix. “It often works to dissolve or partially dissolve HA filler in less than an hour,” Dr. Belkin says. “It may take until the next day to see the effects, though typically not more than 24 hours.” Like the temporary swelling experienced after [dermal filler injections](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers), dissolving filler may cause the treatment area to initially look even more plump. “This is because injecting the hyaluronidase requires the injection of more fluid into the area, not to mention the potential to bruise, which may leave the area looking puffy or full despite the filler having been dissolved,” Dr. Belkin explains. 

Fear not: As the swelling goes down, the actual results will show in a matter of days. 

## **What If I Want To Get Filler Again?**
No matter your reasoning for dissolving your filler, a refill, if you will, is allowed in due time. After your first hyaluronidase treatment, an evaluation will be necessary to see if additional sessions are needed. All the while, you’ll want to make sure any swelling has fully resolved before going under the needle for HA filler again. “I typically would wait a week before putting new filler in to make sure swelling has resolved, and we can see the full effect of the dissolver,” Dr. Belkin says. 

To ensure a more desirable outcome moving forward, Dr. Weiser recommends taking things slow. “Placing numerous syringes of filler in the face in a single appointment may be appealing right away, but it often settles poorly or leads to unnatural cosmetic outcomes,” she cautions. So, rather than going all in at once, she suggests taking a modest approach of one to two syringes (max) to start, after which more can be added upon request. 

## **Potential Complications**
This wouldn’t be an article on The AEDITION if we glossed over the potential side effects and complications of hyaluronidase injections. Dr. Belkin notes that the primary side effects are [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) and [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox) (a common occurrence post-filler, too) that tend to last a week.

It should also be noted that the dissolver may leave you with less volume than you started with because hyaluronidase can impact both synthetic and naturally occurring hyaluronic acid in the treatment area. While Dr. Belkin says that the body corrects this over time by producing more HA, it may take a few months for the atrophy to fully resolve. “To avoid this, assuming it is not an emergency, I will dilute hyaluronidase with saline to get just the right amount of activity that I want,” he shares.

Additionally, the use of hyaluronidase is not recommended in individuals who have experienced anaphylaxis, are on certain medications, or have an allergy to any component of hyaluronidase. Be sure to discuss your medical history with your provider to avoid complications.

## **The Takeaway** 
A plump lip or a fuller cheek may provide a more youthful appearance, but, when overfilled features become a point of contention, hyaluronidase may dissolve those concerns. While the enzyme provides peace of mind for patients who experience undesirable outcomes or complications, one of the best ways to avoid the need for a revision is to [take the time to find the right provider](https://aedit.com/aedition/how-i-found-my-plastic-surgeon-dont-rush-it) for your aesthetic goals. “Every doctor has a different technique and varying end goals,” Dr. Weiser says. “So, if your injector has a very full face, they are likely desiring to give you this same endpoint.” Her advice: “Do your research!” 

Not all aesthetic procedures can be reversed, but hyaluronic acid-based filler can be dissolved. Here’s what the experts have to say about hyaluronidase.

The AEDITION

Safety