shutterstock 1760754215

Hyaluronic acid-based fillers work somewhat like magic. Injecting them into the appropriate facial planes allows for deflated areas – such as the [cheeks](https://aedit.com/procedure/cheek-augmentation-with-fillers), mid-face, temples, and [lips](https://aedit.com/procedure/temporary-lip-fillers) – to experience an immediate improvement in volume and contour. Often, dermatologists and plastic surgeons veer on the conservative side and take a less is more approach when filling. After all, adding too much volume in any one area, at any one time can lead to an unnatural appearance. However, some patients require more volume than others, which may call for multiple syringes to achieve the desired effect.

Lately, we’ve talked a lot about [overfilled facial features](https://aedit.com/aedition/hyaluronidase-to-dissolve-dermal-filler), [filler migration](https://aedit.com/aedition/why-lip-filler-migrates), and [filler fatigue](https://aedit.com/aedition/dermal-filler-fatigue), which are just a few of the reasons why the concept of injecting large amounts of filler may sound scary. The truth is, in inexperienced hands, it can be. But, if you are working with a highly skilled injector who understands your aesthetic goals, it’s possible for the specialized technique to be both safe and effective. Here, top physicians break down everything you need to know about large-volume filler. 

## **Large Volume vs. Overfilling: What’s the Difference?**
The term ‘large-volume filler’ is relative. It depends on the treatment area and the anatomy of the patient. Generally, it refers to injecting more than the ‘typical’ amount of filler required for a noticeable change in the average patient, says [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), a double board certified facial plastic and reconstructive surgeon in Arlington, VA. “I consider ‘large volume’ anything more than a single syringe (one cc) of filler,” he explains. For context, about five syringes of filler are needed to achieve one teaspoon's worth of volume, says [Joshua Zeichner, MD](https://www.instagram.com/joshzeichnermd/?hl=en), a board certified dermatologist in New York City. He adds that a typical ketchup packet contains about seven syringes worth of filler — just a little food for thought.

While large-volume filler equates to a larger, albeit appropriately used, dose, there is some confusion between it and [overfilling](https://aedit.com/aedition/how-to-correct-overfilled-facial-features). A clear distinction exists between the two:

- Overfilling refers to excessive and inappropriate filler placement
- Large-volume filler precisely injects more-than-average doses into the appropriate facial planes

Dr. Zeichner explains that, when placing more volume, the outcome is 100 percent determined by the skill and aesthetic of your injector. “It is no different than going to the museum and seeing a Monet versus a van Gogh,” he shares. “It's the same oil paint just used differently on the canvas.” If the injections are appropriate, the results should be natural and complement, not hinder the patient's appearance. “When the filler is not placed where it should be, patients often look odd or overfilled,” Dr. Zeichner adds.

We all know what an overfilled face looks like, and, unless that's the aesthetic you're going for, most people try to avoid it at all costs. For that reason, it's understandable why some patients get nervous that they will end up looking overfilled when their provider lays out four or five syringes of filler. Seeing a medical [tray of needles](https://aedit.com/aedition/guide-to-needles-used-for-cosmetic-injectables-botox-filler) does more than send off sirens that a substantial bill waits for you at the front desk. Dr. Zeichner says patients are more so afraid of looking overfilled and fake, than the price tag.

## **The Ideal Candidate**
Whether you need half a syringe or five ccs, a full assessment is vital before your provider injects a single drop of filler into your face. This includes studying the anatomy of the treatment area and its relationship to the rest of the face, in addition to learning more about your aesthetic goals. Not every patient needs the major volume technique, and the degree of evident aging determines who benefits from it and who doesn't. 

Typically, those with a significant [volume deficit](https://aedit.com/aedition/best-procedures-to-restore-facial-volume) and/or [asymmetries](https://aedit.com/aedition/cosmetic-procedures-for-body-asymmetries) are candidates for multiple syringes of filler. As such, age is not a factor when it comes to who can reap the benefits. More mature patients who require significant volume restoration and younger patients who mandate facial balance are often contenders, says [Michael Schwartz, MD](https://www.drschwartz.com/), a board certified plastic and reconstructive surgeon in Los Angeles. “Full facial balance restoration improves proportions and [creates harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) within the features instead of augmenting one area,” he explains. “It requires more product because we treat the face entirely to achieve natural results.” However, patients seeking intentional exaggeration of specific features that are not harmonious with the face's natural contours may not be well-suited for large volume injections, adds [Shirley Madhère, MD](https://elementsandgraces.com/about), a holistic plastic surgeon in NYC and founder of [Jet Set Beauty Rx](https://jetsetbeautyrx.com/).

Sometimes, it can be challenging for doctors to educate their patients on how much volume loss they have – and for patients to accept it – “but it is an important conversation to avoid potential disappointment, especially if a patient does not get the result they are looking for when using fewer syringes,” Dr. Zeichner explains. The last thing any provider wants is for a patient to invest in their face and not be happy with the results simply because there is a need for more product.

## **The Right Way to Do It**
What constitutes large-volume filler depends on each patient's face and how much filler they can safely benefit from, says [Kenneth Mark, MD](https://kennethmarkmd.com/), a board certified dermatologist with offices in New York, Aspen, and the Hamptons. Despite the volumizing benefits, he finds patients can be skeptical of substantial amounts of filler because of the suboptimal outcomes they’ve seen on social media from either too much of the wrong filler or poor injections in the wrong places. This rightfully creates legitimate concern amongst patients when they hear the words ‘large-volume filler.’

Using filler as an alternative to traditional cosmetic surgery procedures (like a [rhinoplasty](https://aedit.com/aedition/facts-about-liquid-rhinoplasty) or [chin implant](https://aedit.com/aedition/best-chin-augmentation-enhancement-procedures)) and in areas that require more noticeable correction (think: jawline, temples) call for larger volume – often two syringes of filler or more – says Dr. Cabin. “The nose and chin are unique in that fillers create changes in two-dimensional shape in the profile view, as opposed to three-dimensional facial volume change goals with other areas,” he explains. The chin typically requires one to four ccs of filler to create the necessary balance. When injecting insufficient amounts of filler, the results will not be noticeable and can even call unwanted attention to a specific feature.

In the hands of an expert injector who understands the nuances of filler and anatomy, using more than moderate amounts of product can create an aesthetically pleasing result, especially when the placement is deep. “It makes a big difference," says Dr. Zeichner, who regularly uses five or more syringes (often in a single session). “Most of my injections tend to be deep, down to the level of the bone,” he notes. This technique helps provide structure, support, and mattresses to lift and reposition the overlying soft tissue and skin. “If all of the injections are superficial, it weighs down the face and makes the patient look overfilled,” he cautions. Deep placement creates the opposite effect.

Deep injections also create a smoother appearance – sans bumps, lumps, and irregularities. Not injecting more robust fillers deep enough can cause superficial lumps, nodules, and a blue tinge to the skin, known as the Tyndall effect. “When injecting thicker fillers into the skin, it is important to employ a technique that places the filler in the layer of skin that is appropriate to accept the dynamic properties of that filler,” Dr. Madhère explains.

In the case of large-volume fillers, Dr. Mark likes to use a layering technique. Layering is just what it sounds like and consists of placing fillers in various depths of the skin and locations as needed over time. He says layering filler and staging it out over multiple sessions avoids overcorrection and provides natural-looking results. “Utilizing this method and pinpointing precise placement has allowed me to avoid complications and obtain optimal cosmetic results,” he adds.

Technique aside, injecting the right fillers in the right place is essential. Dr. Madhère says thicker hyaluronic acid-based fillers, like [Juvéderm® Voluma](https://aedit.com/procedure/juvederm) and [Restylane® Contour](https://aedit.com/procedure/restylane), occupy more space. But it's not just hyaluronic acid filler that fits the bill. Injectables that fill more robustly, including [Sculptra®](https://aedit.com/procedure/sculptra), which provides a scaffold for a volumizing effect, may be used. “Additionally, thick and long-lasting calcium-based [Radiesse®](https://aedit.com/procedure/radiesse) can also be used,” she explains. “So can [fat injections](https://aedit.com/procedure/facial-fat-grafting), but they involve a surgical procedure and additional costs.” No matter what filler you and your provider ultimately decide on, it's always important to find an injector that understands the differences between the products and where to place each one.

Just like every patient isn’t a candidate for large-volume fillers, not every facial feature should be treated with the technique either. The parts of the face that tend to respond well include the temples, cheeks, midface, and jawline. Dr. Madhère advises against using a lot of volume in the [forehead](https://aedit.com/aedition/cosmetic-forehead-procedures) and [eye area](https://aedit.com/aedition/under-eye-filler-pros-cons), as they can swell and cause undesirable puffiness.

## **One Session or Multiple: Which Is Best?**
There are plenty of patients that only need a bit of filler and respond well to an average dose. Yet, the ‘a little filler goes a long way’ rule doesn't apply to everyone. Dr. Zeichner says that “more filler goes a long way” for many of his patients. And, when there is a need for significant volume and it is within a patient's budget, he prefers injecting it all at once. “This means less anxiety over the visits and a single period of downtime versus multiple visits with potential bruising after each one,” he shares.

Some providers, meanwhile, choose to space out the injections. For example, Dr. Cabin rarely does large volume filler in a single appointment. Instead, he performs spreading out large-volume injections over a few visits because, as he says, there’s a greater chance of unnecessarily high levels of short-term swelling. “The filler tends to settle better when I inject it over several sessions,” he notes. “It settles and creates a more natural correction.”

[Swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) may be one reason to break the injections up, but there's also the potential for volumetric changes that patients don't know to account for. A filler may be a specific volume when it is going in and, most of the time, that volume increases since the product naturally pulls in water from the surrounding tissue (hence, post-treatment swelling). Some of this extra water can remain, causing what Dr. Cabin describes as a more considerable volume change than you would anticipate from the syringe volume alone. Volume fluctuations are another reason why some providers avoid injecting large amounts of filler at once.

## **How Long It Lasts**
The more product your provider injects, the longer it can take to break down and for the area to return to baseline. So, injecting more filler may equate to longer-lasting results, but there is a lot that goes into how long filler results last. “Longevity depends on several factors, including, but not limited to, the main ingredient, chemical composition, amount injected, and patient's metabolism,” Dr. Madhère explains. 

While injectable brands provide an average of how long each product lasts given its intended use (i.e. up to one year), those timeframes vary from one person to the next. “Everyone metabolizes fillers differently, so I like to start with full correction treatment and then follow-up with a [maintenance plan](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel) to keep the results up,” Dr. Schwartz says.

## **The Takeaway**
If your doctor says you'll benefit from multiple syringes of filler, it doesn't mean you will end up with an overfilled face that looks doughy or unnatural. In fact, some patients sport numerous syringes of filler, and no one but them and their injector knows. More often than not, it’s poor injection technique and improper placement that will land you in the ‘done and don't’ category. Ultimately, the decision is yours, but, with the help of an expert injector who understands how to use more robust amounts of filler to replace lost volume or correct asymmetry, you may be happier with the outcome. In the right hands, more can be more.

Expert Opinion

Dermatologists and plastic surgeons break down the benefits of injecting large volumes of filler for certain patients.

The Pros And Cons Of Large-Volume Filler Injections For Volume, Symmetry, Contour

Why Injectors Say Not To Be Afraid Of Large-Volume Filler

engin-akyurt-4aSQwMectnc-unsplash

Lip augmentation via hyaluronic acid-based fillers can [add volume](https://aedit.com/concern/lip-size) and/or [enhance the shape](https://aedit.com/concern/lip-shape) of the lips to create a pout that best flatters your face. It’s a quick and temporary procedure (results last six to 12 months) with minimal downtime (save for a bit of swelling and bruising) that can immediately and dramatically improve the smile and the overall proportions of the face. But no aesthetic treatment is without [risk](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications), and lip enhancing procedures via filler are under more scrutiny than ever before for migration – or what TikTok calls “the filler mustache.” And the number of videos about fillers seemingly moving out of place proves it's more common than many of us realize. 

In these clips, [lip filler](https://aedit.com/procedure/temporary-lip-fillers) patients show how the product has moved into a space in the lips near the white roll (the small white line at the top of the lip) due to poor injection technique, too much product, the lip's natural anatomy, or the wrong filler. The effect can happen in other areas of the face too – like [under the eyes](https://aedit.com/aedition/under-eye-filler-pros-cons) – but the lips are especially prone to experiencing this spreading effect. Once the filler shifts out of place, the lip (often the top one) appears duck-like or distorted, which is a look no one wants.

If you’re questioning whether your filler is migrating, here’s everything you need to know to look for and how to restore a more natural-looking appearance.

## **Why Filler Migrates**
Hyaluronic acid-based fillers are gels with a liquid-y formulation. The basic rules of science tell us that any liquid can move. However, migrating filler isn't necessarily an immediate effect. Instead, it’s one that happens gradually over weeks, if not months or even years. All ‘temporary’ fillers aren't necessarily temporary, and some mysteriously stay in these particular areas, says [Paul Jarrod Frank, MD](https://www.instagram.com/drpauljarrodfrank/?hl=en), a board certified dermatologist and founder of PFRANDMD in New York City. The filler can move in virtually any direction, although it usually transpires more in the upper lip because of constant movement and motion (think: smiling and talking). As a result, there can be a strange appearance to the upper lips with visible product sitting in the area right above the lip, which causes it to protrude outward.

When fillers shift out of their intended place, the result is unnatural-looking lips that jut out or look fuller in unexpected areas, says [Samuel Hahn, MD](https://aedit.com/provider/samuel-hahn-md-20403), a double board certified facial plastic and reconstructive surgeon in Cockeysville, MD. The displacement also often gives the appearance of bulging or excessive fullness above or below the pink portion of the lip called the vermillion border, which causes a prominent shelf or unnatural roll. In addition, some types of filler are more apt to push up into that white space than others.

So, how can someone know if their fill has migrated or if it's just a case of bad lip injections? First, look at the border of the lip and if it lacks a crisp perimeter between the lip edge and above or below the lip border or a distended area across the upper lip cutaneous (vermillion border and philtrum), says [Madhuri Chadha, MD](https://drmadh.com/), the founder of Chadha MD Aesthetics in Beverly Hills. “This is what gives the effect of 'trout pout,’” she adds. Other indicators to look for include the appearance of prolonged swelling or difficulty closing the lips. If the white part of the lip looks like a duckbill, then the filler has shifted and it's not over-projection, adds [Ava Shamban, MD](https://aedit.com/provider/ava-shamban-md-2325), a board certified dermatologist in Santa Monica, CA.

Filler can migrate for one or more reasons. The most common include: 

### **1. Bad Placement**
Migrating filler can happen when injectable products are placed into the wrong plane. As Dr. Hahn explains, a thin plane – known as the pars marginalis and pars peripherals – separates the lip muscle (orbicularis oris), and injecting it into the wrong plane can allow the filler to move. By placing more product into the lip, the path of least resistance for the filler is into the lip's peripheral tissues, leading to a deviation, he adds. Therefore, the depth of the filler placement and the [needles used](https://aedit.com/aedition/guide-to-needles-used-for-cosmetic-injectables-botox-filler) are essential to a successful outcome.

Depending on where the filler is injected, it can “migrate” into the white roll and even further into the cutaneous or white lip, Dr. Shamban says. “So, the truth is, the product doesn't usually ‘migrate’ but results outside the area, which is more about not placing it into the tissue at the location or depth it should be,” she explains.
 
Injectors use many techniques to inject the lips depending on the look a patient wants, their natural lip shape and volume, and the inherent structure of the lips. Some buzzy injection techniques, like tenting and [Russian lips](https://aedit.com/aedition/biggest-non-surgical-aesthetics-trends-of-2022), which create more volume in the middle of the lips for a heart-shaped appearance, promise to limit the incidence of displaced filler. However, there's no foolproof method other than being mindful of how and where to place the product. “The result of lip injections is directly related to the technique and the original shape and size of the lip,” Dr. Shamban notes.

### **2. Over-Injecting**
Filler migration can also occur by [over-injecting](https://aedit.com/aedition/dermal-filler-fatigue) the lips. Movement can happen if too much filler is placed at once. Though no set amount causes a migrating-like effect – even small amounts can shift – it's best to stage out significant volume enhancement over time. But, as Dr. Frank explains, the features on the face are not that different than something like our shoe size. You can only fit so much into a specific space. “People expect to do more with filler than can be accomplished with their natural anatomy,” he says. “[Overfilled](https://aedit.com/aedition/how-to-correct-overfilled-facial-features) lips, nasolabial folds, and cheeks are due to overaggressive filler.”

Injecting too much product into the lips forcefully stretches them out to accommodate the additional volume. Since the tissue can’t hold the filler properly, it starts getting into the neighboring areas. Injectors can control how much filler is going into any area, which is why it’s essential to take a less-is-more approach. Dr. Shamban says that using specific techniques, like microdosing the lips over several appointments, allows the product to adapt to the tissue. “We can assess the lip architecture to improve the look and appearance of size and shape or build the structure around the lips for more of a 3D appearance without overfilling the lips,” she shares.

### **3. The Wrong Product**
Not all fillers are the same, and using the wrong product can allow it to shift beyond the placement area. Your injector must use the appropriate filler to ensure that it stays put. For starters, only hyaluronic acid-based fillers belong in the lips — never [Radiesse®](https://aedit.com/procedure/radiesse) or [Sculptra®](https://aedit.com/procedure/sculptra). When it comes to HA, “there is no best hyaluronic acid filler, but there are ones that are more amenable to certain areas of the face to reduce lumping, bumping, and migration,” Dr. Frank notes. 

### **4. Inflammation**
Inflammation can occur as a natural response to injecting a foreign substance into the face. While an inflammatory response isn’t as common as poor technique or too much product as the reason behind filler that extends beyond the lips, it can happen. “There can be temporary inflammation, swelling, or a [hematoma](https://aedit.com/aedition/risk-of-hematoma-after-facelift) at the injection site,” Dr. Shamban says. Additionally, “it can also be attributed to a patient's reaction or an allergy to a filler, although this is rarer and an autoimmune response,” Dr. Chadha adds.

The bulging effect is most evident when smiling or puckering the lips, but it can also be noticeable when the mouth is at rest. Some patients complain of a stretched-out feeling accompanied by discomfort depending on where the filler has moved. Although drifting filler is often more cosmetic than anything, Dr. Chadha says it’s important to address it quickly if [certain symptoms](https://aedit.com/aedition/risk-of-vascular-occlusion-after-dermal-filler) are present. “Look for changes in color, skin-blanching, pain, increased pressure, and continued swelling, all of which can cause concern and should be addressed by a medical professional,” she says. If the provider is not well trained, practicing proper protocol, or ensuring a sanitary environment, Dr. Shamban says infection is also a concern. 

## **How to Fix Migrating Filler**
There are two ways to fix migrated fillers: 

1. Dissolve them with hyaluronidase
2. Wait for them to break down and dissipate on their own

For a number of reasons, the former is usually preferred. Dr. Frank says the best way to deal with migration is to dissolve the filler with [hyaluronidase](https://aedit.com/procedure/hyaluronidase) (an enzyme that breaks down hyaluronic acid gels). In just a few hours, hyaluronidase softens the filler and returns the lips to a more natural shape, projection, and size. Not all of the filler necessarily needs to be removed. If it's just one area that shows signs of migration, it can be spot treated. Depending on the amount of movement, the lips may need to recover before injecting them again (if you decide to) to prevent it all from happening again. For most, that’s a four- to six-week process. Patients that opt to dissolve and refill their lips need to go slow and avoid overfilling, “as this will open up the previous tissue planes that allowed for migration,” Dr. Hahn cautions.

Filler will naturally degrade for patients who do not wish to [dissolve with hyaluronidase](https://aedit.com/aedition/hyaluronidase-to-dissolve-dermal-filler). Needless to say, this is a much longer process because the body may not entirely break down all of the product in the lips. It can take, on average, anywhere from six to 12 months to dematerialize. Going this route doesn’t mean every last drop of filler will be gone. 

Migrated filler can be a one-off experience for some people and a constant problem for others. “That means you may have to consider not treating that area with filler,” Dr. Frank says. “There are people who have a naturally higher propensity to migration due to their anatomy.” You may also want to look for a better-trained provider, as Dr. Shamban suggests. “Sometimes, the area around the lip needs to be filled for structure rather than the lip itself,” she notes. A skilled injector can make significant differences and improvements with the proper support structure.

## **Can Filler Migration Be Prevented?**
There is no perfect solution, but the best way to make sure that lip filler stays where you want it to is to be injected by a highly skilled provider who specializes in the procedure. “Generally, be concerned about your provider's experience level,” Dr. Shamban says. “The best practice is to do your due diligence and research your injector.” That includes their training and [body of work](https://aedit.com/aedition/importance-of-before-and-after-photos-in-plastic-surgery). “Their aesthetic approach and results should be individualized and aligned with your look and aesthetics,” she notes. 

While [choosing the right provider](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) is, first and foremost, key to a successful outcome, there are other factors to be aware of when it comes to minimizing the potential for filler migration:

1. **Understand what your injector is putting into your lips.** The only appropriate type of filler to inject into the lips is hyaluronic acid-based product, like those within the [Juvéderm®](https://aedit.com/procedure/juvederm) and [Restylane®](https://aedit.com/procedure/restylane) families. Although many different injectable brands exist, only HA fillers are safe for this area. Biostimulatory injectables, including Radiesse® and Sculptra®, do not belong in the lips.
2. **Appropriate filler viscosity plays a role.** Using the wrong filler in the wrong plane of the lips can cause the product to shift. “The viscosity and density of the filler are important,” Dr. Hahn says. “In general, less dense, less viscous fillers are less likely to migrate.” Only your provider (not you) will know what filler best suits your lips.
3. **Take a less is more approach.** If you want fuller lips than what genetics blessed you with, a slow and steady approach is always best. “It is better to do little bits at a time rather than overstuff an area,” says Dr. Frank, who also suggests that injectors be attentive to make sure the [patients' expectations](https://aedit.com/aedition/how-plastic-surgeons-balance-patients-cosmetic-surgery-desires-and-safety) are appropriate. “Follow-up and retreatments are beneficial,” he shares. “It's also helpful to check in with patients every few months anyway to assess the work done whether they are getting refilled or not because even the best placement of filler sometimes does change in terms of positioning.”
4. **The injection technique is paramount.** Probably the most crucial rule for your injector must follow is product placement. Dr. Hahn says that while the amount of filler injected plays a role, technique and placement of the filler are equally important to avoid migration. For example, he says it's essential to inject filler close to or at the vermillion border, which precisely outlines the [cupid's bow](https://aedit.com/aedition/cupids-bow-cosmetic-surgery-fillers-for-lip-augmentation). Otherwise, the filler can migrate into the surrounding tissue. “In general, there is an increased chance for filler migration as you inject more filler,” he adds.

## **Beyond Filler**
If migrating filler becomes a recurring issue or you are looking to avoid the threat all together, there are other surgical and non-surgical lip-enhancing procedures to consider:

- **Lip Lift**: The trending [lip lift](https://aedit.com/procedure/subnasal-bull-horn-lip-lift) procedure is a permanent way to enhance the lips. The procedure shortens the length between the upper lip and nose to show more of the pink part of the lips. Keep in mind that addressing the shape of the lips is more the objective here than adding volume, which your surgeon can accomplish by adding fat during the surgery. 
- **Lip Flip**: A lip flip utilizes neuromodulators (i.e. [Botox®](https://aedit.com/procedure/botox)) rather than filler (although many injectors choose to combine the injectables). Dr. Shamban says lip flips can be done in a similar but different way to improve lip size and shape. By relaxing the muscles around the lips, the lips flip (hence the name) out to make them a little poutier. The technique is also helpful for those with thin lips or a gummy smile.
- **Fat Transfer**: Autologous fat can be used to add volume and fullness to the lips when they’re inherently thin, prone to migrating filler, or just not as responsive as you’d like them to be to synthetic injections. [Lip augmentation with fat transfer](https://aedit.com/procedure/lip-augmentation-with-fat-transfer) is usually performed alongside other surgical procedures (like a [facelift](https://aedit.com/aedition/best-procedures-to-combine-with-a-facelift)), since liposuction on a donor site must first be performed to harvest the fat. After the initial absorption period, the results are long-lasting and  the shape and volume can be corrected. 

## **The Takeaway**
If you think your lip filler is on the move – be it days, weeks, months, or years after your injections – you may not be imagining it. Fillers that are incorrectly injected or not suitable for the lips can end up migrating outside the vermillion border, resulting in a ‘trout mouth’ or ‘duck lip’ appearance. While there is no surefire way to prevent this from happening, choosing an expert injector is one of the best ways to ensure an optimal outcome.

Dermatologists and plastic surgeons explain why your lip filler might be moving and how to correct it.

Why Lip Filler Migrates And How To Fix It

 Why Lip Filler Migrates And How To Handle It

neonbrand-5ddH9Y2accI-unsplash

There’s a lot that goes into [preparing for cosmetic surgery](https://aedit.com/aedition/how-to-prepare-for-your-first-plastic-surgery-procedure). Choosing a procedure and finding the right board certified plastic surgeon are paramount. You’ll also need to make necessary plans for recovery ([we’ve got a guide for that](https://aedit.com/aedition/best-plastic-surgery-recovery-nurses-centers-products)). But all of this is naught if you are not physically fit to undergo the surgical or non-surgical procedure you are interested in. As we’ve covered, [cosmetic surgery is not a substitute for weight loss](https://aedit.com/aedition/why-you-should-lose-weight-before-plastic-surgery), nor is it safe or effective to treat patients who are not at a healthy weight. It increases the [risk of complications](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications) and lessens the likelihood of an optimal result. 

Because of this, it’s important to understand what role weight and body mass index (BMI) play in cosmetic surgery. From there, you may also be curious as to how you should safely go about losing any necessary weight. While taking the time to drop the lbs will cost you exactly that – time – it will almost certainly lead to a safer and more satisfactory outcome. Here, we’re breaking down what you need to know about getting in shape before cosmetic surgery. 

## **The Relationship Between BMI & Cosmetic Surgery**
You want to be at your healthiest before undergoing any elective procedure — including cosmetic surgery. From an aesthetic perspective, it is often recommended to be as close to your ideal weight as possible prior to surgery to maximize the results. “For body contouring procedures, ideal weight on your surgery day is within five to 10 percent of your goal weight,” says [Olivia MaDan, MD](https://aedit.com/provider/olivia-madan-md-34660), a board eligible plastic and reconstructive surgeon in Nashville. “Maintaining this weight range post-operatively should allow for long-lasting surgical results.”

But, depending on your weight, there are additional, non-aesthetic factors to consider. In 2011, an American Society of Plastic Surgeons (ASPS) task force classified patients with a BMI over 35 as ‘high risk.’ A more recent [2018 study](https://pubmed.ncbi.nlm.nih.gov/29595724/), meanwhile, determined a BMI over 30 – coupled with other factors – to be ‘high risk.’ Today, it is generally accepted that ‘high risk’ patients include those with body mass index between 30 and 35, with an elevated BMI being identified as an independent risk factor for surgical complications. 

BMI is meant to act as a measurement of body fat based on height and weight, though all you have to do is think back to your high school health class to remember that BMI is not a perfect measurement. Even so, it can be helpful marker. “Sometimes an elevated BMI can be an indicator for other medical comorbidities – like diabetes, obstructive sleep apnea, hypertension,” Dr. MaDan explains. All of these conditions can interfere with both the surgery itself and the recovery process.

## **Why Lose Weight Before Cosmetic Surgery?**
The goal of any cosmetic procedure (surgical or otherwise) is to achieve a safe and effective result. Being in the best possible shape pre-op is an important part of that. “I view surgery as a partnership with the patient,” Dr. MaDan shares. “The patient may not be concerned about their weight, however, when it affects patient safety, I explain to them why I may not want to take that risk as a surgeon.” In such cases, they can work together to “develop a plan to optimize patient safety and surgical outcome,” she notes.

As Dr. MaDan explains, elevated BMI carries a “[significant increased risk](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950544/)” of wound healing problems. This is especially true of patients with comorbidities. “Strict blood sugar control is essential to facilitate wound healing and minimize risk of infection,” she says. “Strict blood pressure control can help to minimize the risk of bleeding ([hematoma](https://aedit.com/aedition/risk-of-hematoma-after-facelift)) after surgery.” Furthermore, “patients with obstructive lung disease or obstructive sleep apnea may not be candidates for the ambulatory surgery setting and may be more appropriate in the hospital setting,” she adds.

While every surgeon will have their own parameters, Dr. MaDan has a “strict rule” of only operating on patients with a BMI under 35 for [body contouring surgeries](https://aedit.com/procedure/body-contouring-solutions). “For patients in the 30 to 35 range, I review some before and afters that aren't dramatic transformations – but not necessarily suboptimal – to gauge the patient's expectations,” she explains. “I tell them that a similar result is a realistic outcome and that I would rather disappoint them before surgery instead of afterwards.” This, she says, is usually what kickstarts a discussion about weight loss to achieve more optimal results.  

Depending on the circumstances, Dr. MaDan says she has “[bariatric](https://aedit.com/aedition/what-its-like-to-get-plastic-surgery-after-bariatric-surgery-weight-loss) surgeon and a weight loss clinic” to whom she refers prospective patients. While she offers “check-ins” during the journey, she believes these cases are often best managed by experts, especially when medications, nutrition, and other factors may be involved. Once the patient has made progress, “I will re-evaluate the patient in further consultation before booking surgery,” she explains. This will likely involve both a virtual and in-person appointment. “If a patient is not within that goal weight range, I do not schedule surgery,” she says.

There are, however, some notable exceptions to the rule. “In my practice, I discuss the risk factors associated with elevated BMI and have some leniency when considering certain procedures,” Dr. MaDan notes. A prime example: [breast reduction](https://aedit.com/procedure/breast-reduction). “Some breast reduction candidates have elevated body mass index,” she shares. “It can be understandable – the patient can't necessarily exercise easily due to the size and weight of their breasts.” As such, most patients she treats with elevated BMI are undergoing a breast reduction surgery.  

## **How to Safely Lose Weight Before Cosmetic Surgery**
To start, we have to acknowledge just how personal weight loss is. Each and everyone of us has a different relationship with our body. Regardless, the goal should always be about improving overall health in a safe and sustainable way. That will hopefully parlay itself into a lifetime commitment to your health and wellbeing, which is why we are here to remind you to be patient and kind to yourself on the journey. 

Whether you are preparing for a weight loss surgery or a cosmetic procedure, proper nutrition will be vital to success. “It’s important to note that weight loss surgery patients who achieve some weight loss before surgery actually get better results than those that leave it to surgery alone, and this includes aesthetic procedures such as [CoolSculpting®](https://aedit.com/procedure/cool-sculpting) and CoolTone®,” says [Jennifer Hanway](https://jenniferhanway.com/), a board certified holistic nutritionist. Education, or a lack there of, has a lot to do with this. “[Surgery] does not help the client with the negative effects of overweight or obesity, nor does it help to educate them on which foods nourish the body or build great eating habits,” she notes.

Regardless of whether you are preparing for surgery or not, Hanway approaches all clients who are looking to “achieve healthy weight loss and improve their metabolic health” in a similar way. “My approach is not about rapid fat loss or fad diets, as these can lower the metabolism and a client’s ability to lose weight,” she explains. “I help my clients to improve all aspects of their health, including insulin resistance and inflammation, which, in turn, leads to healthy weight loss.” Achieving “optimum health” is particularly important for those in a pre-op stage because “they will need to be able to recover quickly and easily post-surgery,” she shares.

For this sustained success, Hanway offers the following tips:

1. **Focus on Food**: In Hanway’s estimation, 80 to 90 percent of weight loss comes down to nutrition alone. But that doesn’t mean you shouldn't be working out. “Combining [exercise](https://aedit.com/aedition/best-fitness-classes-workouts-exercises-to-try-at-home) with a strategic weight loss diet is the best way to get results fast – and results that last,” she notes.
2. **Don’t Count Calories**: “There is a big difference between ‘diet culture’ and eating foods that create a state of optimum health in the body,” Hanway emphasizes. From the 1970s until about five years ago, the focus was (wrongly) on calorie counting, low fat diets, and deprivation. “New nutrition science actually shows us that these methods do not contribute to healthy weight loss and can actually be harmful to metabolic health,” she cautions. Instead, she says the key to “achieving a healthy weight” is “eating foods as close to their natural state as possible” and “minimizing processed foods.” 
3. **Skip Sugar**: This likely goes without saying, but [sugary, processed foods](https://aedit.com/aedition/the-impact-of-candy-sugar-sweets-on-teeth-and-skin) are no one’s friend. “Blood sugar balance and insulin sensitivity is the key to helping your body burn fat for fuel and boosting your metabolism,” she explains. “When we eat foods that are high in added sugar and refined carbohydrates, they spike your blood sugar.” That increase tells the pancreas to release insulin. “When insulin is present in the body, we store our food as fat, rather than burning it for fuel,” she says.
4. **Treat Food as Fuel**: “Eating a diet that is [high in veggies, protein, and healthy fats](https://aedit.com/aedition/how-food-impacts-skin-aging) keeps your blood sugar and insulin levels low, allowing your body to tap into its stored body fat for fuel,” Hanway shares. 
5. **Work With a Pro**: “It can be hard to switch from that calorie counting mindset that so many people grew up with, but I love to educate my clients on how to eat foods that nourish their body, help them feel full and satiated, and help them achieve a healthy weight,” Hanway shares. In addition to private coaching, she developed her [Lean & Clean 8-Week Online Program](https://jenniferhanway.com/8-week-clean-eating-meal-plan-for-weight-loss) with this in mind. 

Just as no two cosmetic surgery patients are the same, no two weight loss journeys are alike. With the correct approach, however, there are some general rules of thumb for what is feasible. But, for starters, you have to be clear about what you are working towards. “It’s important to clarify that when we are talking about ‘weight’ what we actually mean is body fat, as we do not want to lose any lean muscle mass as that will actually lower the metabolism,” Hanway says. 

With that in mind, she typically likes to see a 20 pound weight loss over the course of three months in clients that have 30 (or more) pounds to lose. “For me, this means that the client is losing body fat — not water or muscle mass — and will actually keep that weight off in the future,” she explains. From there, a 40 to 50 pound weight loss can be achieved in six months, with up to 100 pounds in a year.

## **The Takeaway**
Deciding to undergo a cosmetic procedure is an extremely personal decision, as is deciding to be at your healthiest prior to proceeding with it. If you are unsure about whether or not you are a candidate for surgery, a consultation with a [board certified plastic surgeon](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) will shed light on the safest and most effective course of treatment for your anatomy and goals. If lowering your BMI is necessary, working with a nutritionist or weight loss specialist can help ensure you do so in a sustainable way. Whatever you choose, it’s all about feeling healthy and confident in your body!

Wellness

A plastic surgeon and nutritionist share their tips for safely getting in shape before undergoing elective procedures.

Do You Need To Lose Weight Before Cosmetic Surgery?

ernesto-norman-R5CX8XDQLV0-unsplash

A seemingly quick fix treatment that has caught on like wildfire, your social media feed may have you thinking that [under eye filler](https://aedit.com/procedure/under-eye-filler) is a universal solution for common aesthetic eye concerns. While the treatment can be very effective for the right candidate, it – like just about every other cosmetic procedure – is not for everyone. 

Until recently, under eye filler was an ‘off label’ (read: not approved by the United States Food and Drug Administration) use of hyaluronic acid-based dermal fillers. Earlier this year, the [FDA approved](https://aedit.com/aedition/fda-approves-juvederm-volbella-xc-under-eye-filler) Juvéderm® Volbella XC for the improvement of infraorbital hollows in adults over the age of 21. As part of this new indication, Allergan Aesthetics will be providing training programs, including how to assess facial anatomy holistically and the identification and management of [potential complications](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications), to anyone who wishes to inject. This is because injecting the tear troughs and hollows beneath the orbital rim is not without risk.

Good under eye filler can be transformative, but it can be hard to get it right. Not everyone wielding a needle is well-versed in the procedure, and not everyone who thinks they want the procedure is actually a candidate. Here, we investigate the under eye filler craze and why it's not a singular solution for all under eye concerns.

## **How Under Eye Filler Works**
For some, under the eyes lives a slight depression in the skin that absorbs light rather than reflecting it. When darkness casts a shadow on this inner part of the eye, known as the tear trough, a crease between the upper cheek and the lower eyelid becomes evident. Most patients who desire under eye filler complain of a hollow, dark, tired-looking eye that does not seem to go away, no matter what [skincare they use](https://aedit.com/aedition/best-eye-serums-for-fine-lines-dark-circles-puffiness) or do or how much concealer they layer on.

Blame your genes and the natural aging process for the cause of shadowing under the eyes. “The tissue structures supporting the eyelids weaken from aging or genetics,” says [Michele Green, MD](https://aedit.com/provider/michele-green-md-34642), a board certified dermatologist in New York City. “This weakening causes a hollowness and sagging of the skin in the under eye area, but hyaluronic acid fillers replenish volume to the area.” Although remediation with fillers is a relatively quick process, the procedure relies on dermal fillers placed into the deep hollows to replenish lost volume. Putting HA filler into deep under eye creases plumps them up so that the skin is smoother and can reflect light properly.

That, in turn, addresses more than just the tear trough. Injections can also help alleviate dark circles, which sometimes develop from volume loss in the lower eyelid fat pads, creating hollows, explains [Snehal Amin, MD](https://aedit.com/provider/snehal-amin-md-308), an NYC-based  board certified dermatologist. “By correcting underlying volume loss, shadows under the eye reduce,” he shares. “Volbella is FDA-approved for this indication, but it is imperative to seek out an experienced, qualified provider.”

Well-injected filler under the thin skin of the eyes are a great way to brighten up the eyes and reduce hollowness and that tired appearance from some of the tissues underneath the eye, says [Usha Rajagopal, MD](https://aedit.com/provider/usha-rajagopal-md-1330), a board certified plastic and reconstructive surgeon in San Francisco. She adds that smoothing out the grooves under the eye helps to improve the overall contour of the lower eyelid and, secondarily, reduce discoloration.

Since not all discoloration is an effect of shadowing and hollowing, it is crucial to identify the cause of discoloration before jumping into the under eye filler pool. For example, Dr. Amin says discoloration under the eyes can also be caused by rubbing the skin in cases of [eczema](https://aedit.com/aedition/comparing-eczema-vs-psoriasis) or allergies. And, for this type of darkness, filler isn't the answer. “Instead, [chemical peels](https://aedit.com/aedition/guide-to-superficial-medium-deep-chemical-peels) or [lasers](https://aedit.com/aedition/guide-to-ablative-laser-skin-resurfacing) best address this discoloration,” he says. 

With no downtime, the effects of under eye injections using hyaluronic acid-based filler are immediate (save for some minimal and typical [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox) and swelling). Within minutes of injecting the under eyes, patients can see a smoothness to the area, less darkness, and no more shadowing. The results generally last about a year.

## **Choose Your Injector Wisely**
This is where it starts to get a little dicey. The array of providers offering under eye filler treatment ranges from board certified dermatologists and plastic surgeons to your strip mall med-spa injector. And because those who don't hold a medical degree or have years of experience don't know the pitfalls of injections around the eye or facial anatomy, you may be putting yourself in a dangerous position by not going to a qualified provider. “The success of under eye fillers is not solely dependent upon the product used, but also the skills of the injector, their experience, and their comfort level using the filler product,” Dr. Green says. “There is an increased risk for developing unwanted side effects when performing injections with an inexperienced or unqualified injector.” 

All filler should be injected by a highly trained provider, but the under eye presents its own unique set of challenges. “This is not a med-spa procedure,” Dr. Amin cautions. “This is a medical procedure because of the complexity of the anatomy and the dangers of complications.” Additionally, the injector must be able to suss out who is a candidate and [manage expectations](https://aedit.com/aedition/how-plastic-surgeons-balance-patients-cosmetic-surgery-desires-and-safety) accordingly. For example, filler is an acceptable treatment option when a patient has a bothersome hollowness without large under eye bags, says [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), a double board certified facial plastic and reconstructive surgeon in Arlington, VA. However, the addition of filler to bulging under eye bags (caused by protruding or displaced fat pads) will not do much of anything to correct the hollowness. “Patients must have realistic expectations of what can and cannot be corrected with filler and understand that filler will not improve wrinkles or primary dark circles,” Dr. Cabin explains. 

In most cases, filler cannot correct excess skin or [pigmentation-related](https://aedit.com/aedition/under-eye-hyperpigmentation) color changes to the skin. Also, people with fluctuating lower lid and mid-cheek swelling (known as malar edema) are usually not fit for filler treatment since injections can exacerbate this condition.

## **The Issues with Under Eye Filler**
Under eye filler is tricky because, as Dr. Rajagopal explains, volume deficits under the eye exist in many layers. “It can be deep and right next to the bone, just above the bone, or in the muscle layer or the skin layer,” she shares. “All these areas may need to be addressed differently in different patients.” Generally, the deeper the injection, the less visible the product. Furthermore, doctors must use a very thin filler in patients who require more superficial placement. If not, lumps, bumps, and even discoloration (i.e. the infamous blue tint) can ensue.

The most important takeaway with under eye fillers is that less is more. “A tiny amount of filler goes a long way,” Dr. Rajagopal says. “And the result should be an improvement of the area and not full correction because full correction leads to overcorrection, [overfilling](https://aedit.com/aedition/how-to-correct-overfilled-facial-features), a lumpy look, and often swelling underneath the eye.” It is important to remember that it is entirely normal to have mild depressions and some lines under the eyes. Attempting to eradicate them with too much smoothness can lead to an unnatural look.  

Overcorrection is, unfortunately, a common mistake. It creates less distinction between the cheek and the tear trough, which causes the eye to get smaller from above, says [Doris Day, MD](https://dorisdaymd.com/), a board certified dermatologist in NYC. Too much filler makes the eyes appear small and squinty and, conversely, the cheeks look disproportionately big. “When you keep filling and adding layers, the eyes can look off-balance,” she explains. “Instead, the eyes may require opening and the skin may need some tightening, but the key is not to erase those points of distinction.” When you do, “the face looks distorted, and it's a look that everyone is walking around with,” she adds.

But the aesthetic concerns related to overfilling are just the half of it. There are also more serious issues to be aware of, including:

- **Swelling**: Mild swelling for 24 to 48 hours after treatment is to be expected, but long-term [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) that never goes away can occur. Patients with poor lymphatic drainage tend to hold onto more water and fluid in the eye area, so the addition of HA filler (which attracts water to plump) causes lasting fluid retention. Since certain fillers are more hydrophilic (meaning it holds onto water) than others, this presents the potential for the filler to puff a bit. Dr. Green adds that patients who present with bulging from water retention or sagging skin due to loss of elasticity should avoid under eye filler. 
- **Filler Migration**: Filler that moves under the eyes isn't atypical. As Dr. Day explains, migration partially occurs because of constant movement in the area and ligaments that push the filler around a bit. When filler migrates, it can shift downwards or to the side and even take on a bumpy or lumpy appearance depending on the filler used and how much of it there is. “Sometimes, we don't see the effects for months or even years later,” she notes.
- **Visible Product**: Known as the Tyndall effect, a bluish tint to the skin can occur from placing the filler too close to the surface of the skin. Some fillers are more prone to this than others. “I prefer using [Belotero®](https://aedit.com/procedure/belotero) for the tear troughs because there is no Tyndall effect,” Dr. Amin says. Although this discoloration can technically happen in any area of filler used, Dr. Cabin says it is most commonly seen under the eyes because the skin is fragile. However, he adds that your provider can prevent the Tyndall effect by injecting filler in the deeper areas (over bone) and only injecting small amounts per injection while keeping the cannula moving.
- **Vascular Occlusion**: One of the more severe complications that can arise, [vascular occlusion](https://aedit.com/aedition/risk-of-vascular-occlusion-after-dermal-filler) refers to accidentally injecting into an artery. When not immediately corrected (via HA-dissolving [hyaluronidase injections](https://aedit.com/procedure/hyaluronidase)), an occlusion can result in skin necrosis or skin death. While vascular occlusion and necrosis are rare, they do happen. Injection techniques that involve a pulling-back effect are critical, as is the correct type of injection tool (more on that below).
- **Blindness**: Blindness from filler injections is the most serious byproduct of an occlusion or blood clot that arises and blocks the typical blood flow pattern throughout and around the eyes. It's crucial to understand facial anatomy when injecting this area because there are far more blood vessels around the eye than other areas in the face. Although blindness from under eye fillers is the rarest complication, it is nothing to take lightly. A 2015 [study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554164/) found 98 cases of blindness related to the use of filler.

Your injector should use only [hyaluronic acid-based filler](https://aedit.com/aedition/hyaluronic-acid-filler-vs-biostimulatory-injectables) under the eyes. “Non-hyaluronic acid fillers, like [Sculptra®](https://aedit.com/procedure/sculptra) and [Radiesse®](https://aedit.com/procedure/radiesse), are too thick for this area,” Dr. Cabin says. "Also, Sculptra® and Radiesse® work over time by stimulating the body's collagen creation mechanisms, and movement around the eye can create irregularities as these fillers settle in.” While lumpiness as a result of HA filler is dissolvable with hyaluronidase, biostimulatory injectables are not reversible.

## **The Right Way to Inject Under the Eyes**
When injecting under the eyes, your injector has the choice between two different tools to prevent less-than-ideal results and complications: a [blunt-tipped cannula](https://aedit.com/aedition/guide-to-injectable-techniques-needles-for-botox-filler) (a soft plastic catheter that cannot interrupt a vessel) or a [needle](https://aedit.com/aedition/guide-to-needles-used-for-cosmetic-injectables-botox-filler). Both have their place, and it's up to your provider to choose the best one.

“The use of a blunt-tipped cannula to access the treatment area from below and just to the side of the lower eyelid is the gold standard for under eye treatment,” Dr. Cabin says. It nearly eliminates the risk of [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox), significantly reduces post-injection swelling, and also dramatically lessens the chance of a rare complication by preventing entry into the veins or arteries around the eye. “With all filler injections, injecting small aliquots while actively withdrawing the cannula helps reduce the risk of lumping or clumping and vascular or lymphatic disruption,” he adds.

All you have to do is think of how many times a day you blink to know the under eyes are an area of movement. They're anatomically complex, thin, and delicate, with an intricate network of several blood vessels and lymphatic drainage pathways. This makes filler placement more taxing than other parts of the face. “Therefore, under eye filler needs to be placed deep, just over the bone (periosteal), to be in an area that corrects the hollowness without causing any injury or disruption to the delicate structures of the under eye,” Dr. Cabin explains. “Placing the filler in a deep plane, just under the bone, also minimizes the risk of filler migration over time and will lower the risk of the Tyndall effect.”

Perhaps the best way to ensure good results (in addition to seeing a board certified dermatologist or plastic surgeon) is to make sure your injector has a deep understanding of facial anatomy, especially the periorbital area. “Many doctors inject filler as they withdraw the needle out of the skin; in other words, they push the plunger on the syringe as they pull the syringe backward,” Dr. Amin says. This technique prevents cannulation of blood vessels and limits the risk of intravascular filler injections.

## **Taking a Holistic Approach**
The features of the face live in [harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine), not isolation. To ensure that the under eyes look natural and not artificially augmented, Dr. Rajagopal says to look at the face as a whole. “When you look at a beautiful face, it's the entire face,” she shares. “Generally, not just one area makes someone beautiful, but rather a complement of how one area flatters the other.” Selectively filling the under eye and failing to treat the surrounding areas, like the [cheeks](https://aedit.com/aedition/cosmetic-procedures-to-define-cheekbones), isn't usually the best approach. “Often, the eyelid-cheek conjunction is in continuity,” she shares. “So, to give the best results, it's important to inject part of the cheek along with the lower lid.”

A higher cheekbone or zygoma will pull the skin taught under the eyes. “Your doctor can inject filler into the cheek area to improve the under eye area,” Dr. Amin says. Plus, injecting directly into the cheeks instead of under the eyelids is safer. “Filler placement in the cheeks lasts a lot longer than the fillers used in the periorbital area,” he adds. Beyond the cheeks, the [temples](https://aedit.com/aedition/cosmetic-forehead-procedures) also need to be considered. 

Sometimes, addressing the neighboring features is all it takes to create the effect of more refreshed eyes. “That’s why I address everywhere around the eyes before correcting them because it may just be an adjustment to the cheeks or brows that a patient needs instead,” Dr. Day says.

## **Does the Recent FDA Approval Change Anything?**
As we mentioned, under eye filler was an off-label use (meaning it did not hold an FDA-approved indication) until the recent approval of Juvéderm® Volbella XC. “Volbella is a hyaluronic acid dermal filler with an innovative combination of low and high molecular weight technology, which improves the cross-linking efficiency of the hyaluronic acid chains,” Dr. Green explains. “In addition, this new Vycross technology delivers an ultra-smooth gel that is malleable, which results in a natural look and feel to improve the appearance of under eye bags.”

However, just because there’s now an FDA-approved filler for use under the eyes doesn’t equate to every dermatologist and plastic surgeon jumping on the Juvéderm® Volbella XC bandwagon. Some physicians, including Dr. Day, do not use like to use it under the eyes. “In general, I think it’s a problematic product,” she explains. “It can be somewhat unpredictable, and Juvéderm® tends to swell under the eyes.” While she concedes that the data from Juvéderm® Volbella XC “doesn’t show issues with it,” she prefers [Restylane®](https://aedit.com/procedure/restylane) and Belotero® for correcting under eye hollows.

So, does a new FDA indication mean that everything we know about under eye filler and its safety go entirely out the window? No. Like all aesthetic treatments, patients must weigh risk and reward. Dr. Cabin says whether a treatment or specific product is categorized as on-label or off-label has very little to do with safety and efficacy. “Receiving FDA approval is a very complicated and expensive process that can take years, so some filler manufacturers have to decide which on-label indications to pursue given these constraints,” he explains. “When a filler (or other aesthetic treatments) is not on-label, it doesn't mean they are less effective or more dangerous.”

Aesthetics

Dermatologists and plastic surgeons weigh in on why the popular procedure isn’t for everyone.

The Pros And Cons Of Under Eye Filler

The Truth About Under Eye Filler

mikelya-fournier-y9ieqSSLfgU-unsplash

One of the wonderful things about beauty is that there are so many ways to apply your makeup, and, with [social media](https://aedit.com/aedition/march-2020-study-shows-relationship-between-social-media-cosmetic-surgery), tips and tricks spread farther and faster than ever before. From professional makeup artists and celebrities to self-taught beauty lovers and content creators, there’s no shortage of experts willing to share the best way to make any step of your beauty routine even easier. 

Recently, [lashes](https://aedit.com/concern/eyebrow-and-eyelash-hair) have been a popular topic. [Eyelash extensions](https://aedit.com/aedition/what-its-like-to-get-eyelash-extensions) remain a perennial favorite, but, as with so many pro treatments, a lot of us are searching for ways to [achieve similar results at home](https://aedit.com/aedition/false-eyelashes-mascara-for-thicker-fuller-lashes). Normally, even the best strip lash application will require a lot of blending and tweaking to ensure that your natural lashes don’t peek through the lash strip. And, even if you perfect that piece of the process, the lash band will still likely be visible when you blink or turn to the side, disrupting the illusion. 

Enter the ‘under lash’ technique. Instead of applying your falsies on top of the lash line, you cut the strip into smaller sections and apply them underneath your lashes (yes, that’s where the name come from). The seemingly new technique has been all over [TikTok](https://www.tiktok.com/tag/underlash) for a few months now – though, as we revealed earlier this year, [under lashing isn’t new at all](https://aedit.com/aedition/expert-tips-for-applying-false-lashes-mascara-more). As with most innovative beauty tricks, it’s had a long history in the drag scene. 

No matter the technique, there is a learning curve to applying false lashes and under lashing is no exception. Some people aren’t sold on the idea of putting lash glue so close to their eyes, while others struggle to get the placement just right. To clear up any confusion about the safety and efficacy of the under lash technique, we tapped a top expert.

## **How to Under Lash Safely**
Let’s get this out the way upfront: If you are curious about whether or not under lashing is safe, the short answer is yes – with some careful instructions. “It is safe to apply lashes under your lashes as opposed to on top of your lashes because they don’t actually get glued to the skin of the waterline, or the edge of the skin under your top lashes,” explains [Lynn Simpson](https://www.instagram.com/lynnsimpsonmakeup/?hl=en), a celebrity makeup artist at [Facial Lounge](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Ffaciallounge.com%2F) in Corona Del Mar, CA. “They are glued to the lashes themselves.” In case all of those social media videos haven’t made it clear, below are four things to keep in mind for a simpler and more successful under lash application:

1. **Prep Properly**: When it comes to applying false lashes, where you apply them is most important factor to keeping your eyes safe. To ensure you’re not putting glue on your waterline, use a bright light and a mirror. This will give you a full view of your lashes. 
2. **Work in Small Pieces**: While a few brave souls have tried under lashing using a full strip lash, Simpson says it’s much easier to work in smaller sections that are more flexible and easier to line up correctly. You can either cut up your strip lash, buy individual lashes, or opt for lash sets that are specifically made for this technique, like the ones from [Lashify](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Flashify.com%2Fproducts%2Flashify-control-kit%3Fview%3Dcontrol-kit) and [FlutterHabit](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fflutterhabit.com%2Fcollections%2Fall-products%2Fproducts%2Foriginal). 
3. **Give It a Beat**: Much like a normal lash application, tacky glue has a stronger hold. When applying under your lash line, put the glue on the falsies, then wait 15 to 30 seconds before applying them to your lashes. Only apply the glue to the side that’ll be touching your lash. If it gets on the other side, it could end up touching your eye.
4. **Plan Ahead**: Even the best laid plans can go awry, which is why Simpson recommends preparing for any mistakes by keeping [makeup remover](https://aedit.com/aedition/best-makeup-removers-for-every-skin-type) and cotton swabs, Q-tips, and/or a washcloth nearby. They can be used to remove any glue or residue that ends up someplace you don’t want it to. 

As with anything new, there is a learning curve to under lashing. Our best advice: Take it slow and try not to get frustrated!

### **What Do I Do If I Get Lash Glue in My Eye?**
In the rare event that some glue does transfer from the underside of your lashes to your bottom lashes, waterline, or eyeball, [flush the eye](https://www.allaboutvision.com/eye-care/cosmetic/glue-in-eye/) with lukewarm water. If irritation continues, do not hesitate to reach out to your optometrist or ophthalmologist for further treatment.

## **The Takeaway**
Applying lashes under the lash line (a.k.a. under lashing) creates a more seamless and natural lash look that many liken to [lash extensions](https://aedit.com/aedition/lash-extensions-for-monolid-hooded-eyes). While it may sound scary, it’s actually no less safe than traditional false lash applications – provided you follow a few simple rules. For starters, remember that you are adhering the falsies to your natural lashes (read: not the waterline). From there, work in small sections and keep cotton swabs and makeup remover on standby in case you need to clean up any miscues.

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

Beauty

The trending lash application is said to offer a more seamless look, but are you risking your eye health? Here’s what we found out.

How To Under Lash Safely, According To A Celebrity Makeup Artist

The Simplest And Safest Way To Master The Under Lash Technique

arun-sharma-LP-7jIY0YSI-unsplash

There is a reason that [rhinoplasty](https://aedit.com/procedure/rhinoplasty-nose-job) (a.k.a. nose job) is perennially one of the most popular cosmetic surgeries. Whether it’s performed for [aesthetic or functional reasons](https://aedit.com/aedition/difference-between-cosmetic-rhinoplasty-vs-functional-rhinoplasty), the procedure can be transformative. Rhinoplasty is generally considered safe and effective, especially when carried out by a board certified facial plastic or plastic surgeon. Even so, there is always a [risk of complications](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications) and/or unsatisfactory outcomes. Furthermore, the results of rhinoplasty, while long lasting, are still at the mercy of age and gravity, which means they can change over time.

For some patients, one or more of these factors can be reason to undergo a revision rhinoplasty. Generally speaking, secondary surgeries are [more costly](https://aedit.com/procedure/rhinoplasty-nose-job/cost) and involved than primary procedures, and rhinoplasty is no exception. In fact, the revision is considered one of the most complex in plastic surgery. With that in mind, making an informed decision with the help of a highly skilled surgeon is key. Here, we hear from two patients who had a [revision rhinoplasty](https://aedit.com/procedure/revision-rhinoplasty) to learn more about their experience and any advice they have for people considering the surgery.

## **When Is Revision Rhinoplasty Appropriate?**
Although revision rates are not published, it is generally accepted that it is around 20 to 25 percent for rhinoplasty. That means one in every four or five patients pursues a corrective surgery down the line. There are two main reasons a [revision rhinoplasty](https://aedit.com/aedition/what-you-need-to-know-about-revision-rhinoplasty) may be necessary. One is chiefly cosmetic in nature and the other has a medical component. 

1. You’re unhappy with how your nose looks and would like to further refine the results
2. Your primary surgery was meant to address a deviated septum or other anatomical issue, but did not resolve the problem(s)

Rhinoplasty has one of the longest [recovery periods](https://aedit.com/procedure/rhinoplasty-nose-job/recovery) of any cosmetic surgery. While you may be cleared to resume most normal activities after a few months, it can take a year (or more) for the  body to fully heal – that includes clearing up any residual [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery), however mild, that can influence how the nose looks. But what if your patience is not rewarded with your desired result? Or what if you have a rhinoplasty [as a teenager](https://aedit.com/procedure/youthteen-rhinoplasty) and, as an adult, aren’t thrilled with how the surgery has aged? Revision is an option.

[Functional rhinoplasty](https://aedit.com/aedition/difference-between-septoplasty-rhinoplasty), meanwhile, is medically necessary surgery often prescribed for people who have a [deviated septum](https://aedit.com/procedure/septorhinoplasty), cleft palate, polyps, or even trauma from an accident or injury. In these cases, the surgery will be considered ‘[failed](https://aedit.com/aedition/guide-to-revision-surgery)’ if the functional concern the surgeon sought to address with the procedure is not resolved after healing is complete (think: your [breathing issue](https://aedit.com/concern/breathing-issues) is still, well, an issue). Again, revision is an option.

In either instance, the first step is usually to meet with your surgeon to discuss the differences between what you were looking for and what you ended up with. You are [under no obligation](https://aedit.com/aedition/what-to-do-if-you-are-unhappy-with-your-plastic-surgery-results) to pursue revision with the same surgical team, and it is best to consult with multiple surgeons. Ultimately, choose someone who specializes in revision rhinoplasty specifically, as the secondary surgery is more nuanced.

Whether it’s the first revision or the fifth (yes, seriously), there is often a great deal of scar tissue to contend with, which may also impact the skin and its ability to be stretched and re-draped. If there is not enough cartilage available to reshape the nose while maintaining its function, grafting may be required. For all of these reasons, seeking out a highly skilled revision expert is key for both the safety and efficacy of the corrective procedure.

<BeforeAfterModule
  title={Before & Afters: Revision Rhinoplasty}
  procedureId={737}
/>

## **Patient Perspective**
Needless to say, there is a lot to consider before opting for a revision rhinoplasty. To help you understand what it’s really like to get and [recover from](https://aedit.com/aedition/rhinoplasty-recovery-healing-process) the procedure, we’ve spoken to two patients about their experiences. 

### **Sam, 28, Providence, RI**
*Sam had a nose job to address concerns about the bridge of her nose and a bulbous tip. Unfortunately, the results from her first procedure weren’t satisfactory, so she decided to have a revision with another surgeon.*

<Dialogue>
  <Question party={The AEDITION}>
    What led to your revision rhinoplasty?
  </Question>
  <Response party={Sam}>
    I had a first nose job in my late teens and went to a random local surgeon purely out of convenience. We never got on very well, and, looking back, I don’t think he took enough notice of what I was hoping for from the procedure and just stuck to a standard nose shape — at least that’s what it felt like. Once I was more established in my career and had some cash available to give it another go, I asked a few friends who’d had nose jobs about their surgeons and consulted based on recommendations this time.
  </Response>
  <Question party={The AEDITION}>
    How did the second surgery compare to the first?
  </Question>
  <Response party={Sam}>
    It was honestly a completely different experience. I think, in part, that came from the fact that by the time I tried again, I’d learned to advocate for myself more than I could as a teenager. I had honest discussions with a few surgeons, discussed if what I was hoping for was realistic, and looked at some projected results that were produced from scans and photos. The actual process of the surgery was similar, though. I feel that having already done it once meant the recovery seemed less daunting than before.
  </Response>
  <Question party={The AEDITION}>
    Have the results from your revision surgery met your expectations?
  </Question>
  <Response party={Sam}>
    My new nose is as close to perfect as possible. Honestly, it wasn’t entirely what I had in mind, but my surgeon took the time to explain why this would be the best approach, and it suits me so much better than before. It’s been a couple of years now, but I still catch it in the mirror sometimes and just kind of take it in and thank myself for bearing with the process and giving it another go.
  </Response>
  <Question party={The AEDITION}>
    Do you have any advice for patients considering revision rhinoplasty?
  </Question>
  <Response party={Sam}>
    Don’t be afraid of being picky. It’s your face, after all! You’re spending a lot of money on it and you’re getting a revision for a reason, so don’t feel like you’re wasting people’s time by asking questions.
  </Response>
</Dialogue>

### **Paola, 33, Austin, TX**
*Paola needed surgery to [fix a deviated septum](https://aedit.com/procedure/septorhinoplasty) that was affecting her breathing. The first surgery was unsuccessful due to excessive scarring that left her nose looking asymmetrical, so she underwent a second procedure.* 

<Dialogue>
  <Question party={The AEDITION}>
    What led your surgeon to suggest a revision rhinoplasty?
  </Question>
  <Response party={Paola}>
    I had some complications after my original procedure that meant my nose had some scar tissue that made it look asymmetrical and overall a bit weird. There’s no other way of describing it. My surgeon and I decided to leave it a couple of years while carefully monitoring how I recovered with regular checkups. Eventually, we decided there was no further improvement, so revision was the best option.
  </Response>
  <Question party={The AEDITION}>
    Did you experience any difficulties in the period between the two procedures?
  </Question>
  <Response party={Paola}>
    It was more of a mental struggle than anything else. It’s tough when you think you’re resolving an issue and going through the unpleasant period of post-surgical healing, only being told they need to do it again. The healing time in between both procedures gave me a chance to get my head around the idea of needing further surgery. The fact that it was a medical procedure instead of an elective procedure in the first place was probably a contributing factor.
  </Response>
  <Question party={The AEDITION}>
    How was your recovery from the revision surgery?
  </Question>
  <Response party={Paola}>
    It was pretty similar to the first time. I had some bruising, and the swelling was similar, too. I think there are some tricks you pick up during recovery that are helpful to go back to a second time around. For example, after my first surgery, I found a pillow that was particularly comfortable to sleep on, so I made sure I had that all set up for when I got home. Knowing what to expect made my recovery feel smoother this time than the first time around.
  </Response>
  <Question party={The AEDITION}>
    Do you have any advice for patients considering revision rhinoplasty?
  </Question>
  <Response party={Paola}>
    My advice to others would be what I told myself at the time: It’s not something you can control. Your surgeon knows what they are doing, and you have to trust them. It can be difficult going through the whole process again, but, in the long run, it’s worth it.
  </Response>
</Dialogue>

## **The Takeaway**
In an ideal world, every procedure would end in a successful outcome. Unfortunately, for a myriad of reasons, that’s not always the case. If you are unhappy with your rhinoplasty for aesthetic or medical reasons, a revision surgery may be able to improve your results. Be sure to [choose a board certified plastic surgeon](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) who specializes in the corrective procedure and be realistic about what can be achieved.

*Patient names have been changed

Patient Perspective

Two patients share their firsthand accounts of undergoing the corrective surgery.

What It's Like To Get A Revision Rhinoplasty Surgery

What It’s Really Like To Get A Revision Rhinoplasty

peng-yang-PC09fQDCSoo-unsplash

Thinking about a [tummy tuck](https://aedit.com/aedition/tummy-tuck-recovery-healing-process) post-pregnancy or weight loss? Or perhaps a sculpting [liposuction](https://aedit.com/aedition/high-definition-liposuction-techniques-for-body-contouring) session? In your research, you may have come across something called a seroma. If you’ve had surgery, maybe you’ve even experienced it first hand. It can be likened to having a puddle inside of you. A seroma is “a build-up of tissue or healing fluid inside the body, which can happen after surgical procedures of any type,” says [Ryan Neinstein, MD](https://neinsteinplasticsurgery.com/), a board certified plastic and reconstructive surgeon in New York City. 

One of the most common [cosmetic surgery complications](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications), a seroma is most likely to occur after [body contouring surgeries](https://aedit.com/procedure/body-contouring-solutions). Here, we’ll talk more about what a seroma is, why it happens, and what you can do to avoid it. 

## **What Causes a Seroma?**
“Seroma is a collection of normal body fluid that accumulates in dead spaces,” says [Elise Min, MD](https://www.drcassileth.com/surgeons/dr-elise-min.html), board certified plastic and reconstructive surgeon at Cassileth Plastic Surgery in Beverly Hills. The clear (i.e. serous) fluid pools under the skin and is usually found near incisions. It can happen soon after surgery or, in some cases, weeks later.

While it’s natural for some amount of body fluid to accumulate at a surgical site, it becomes problematic if it does not subside. “Generally, [the fluids] get reabsorbed by the body in the postoperative period and go away on its own,” Dr. Min explains. “Sometimes, too much fluid can accumulate and form a pocket of fluid collection.” This is most common, she adds, after operations “where a surgical space is created” due to tissue removal. In cosmetic surgery, this can include:

- [Abdominoplasty](https://aedit.com/procedure/abdominoplasty) (a.k.a. tummy tuck) 
- Breast surgery 
- Lifts (such as [arm lift](https://aedit.com/procedure/arm-lift), [butt lift](https://aedit.com/procedure/butt-lift), or [thigh lift](https://aedit.com/procedure/thigh-lift))
- [Liposuction](https://aedit.com/procedure/liposuction) 

As Dr. Neinstein explains, our bodies respond to the inflammation from surgery by creating fluid and scar tissue. “When the healing capacity is overwhelmed, the fluid becomes apparent and a seroma develops,” he shares. “This can happen because surgery was aggressive, too much energy – such as a laser – was applied, no drains were used, or improper garments or aftercare were applied.” Other times, he says, seromas can happen for no reason at all.

## **Symptoms of a Seroma After Cosmetic Surgery**
While they can usually be identified via a physical exam, an ultrasound may be needed to confirm a seroma diagnosis. Most seromas don’t pose a health risk to the patient. They usually look like a swollen lump and feel like a cyst that may or may not be tender to the touch. Clear discharge is common and changes in color may be indicative of an infection that requires medical attention. If the seroma becomes infected, it may look red and feel painful and/or warm to the touch. An infected seromas can lead to the formation of an abscess.

## **How to Treat a Sermona After Cosmetic Surgery** 
How a seroma is treated depends on its size. A small seroma usually goes away on its own with compression, but larger ones may need professional intervention. “Some may require aspiration in the clinic by the physician,” Dr. Mi says. Dr. Neinstein says that seromas can be dealt with in a minor office procedure where the fluid is drained and pressure is applied through dressings and garments to prevent re-accumulation.

If a large or infected seroma is left untreated, it may eventually require a full removal of the seroma and the fibrous [capsule](https://aedit.com/aedition/capsular-contracture-breast-implants) that comes to surround it, Dr. Min cautions. In very rare cases, calcification (read: hardening) of the fluid may occur. “Once in a while, the seroma can harden and form a scar ball inside that may need to be removed surgically,” Dr. Neinstein notes. “Luckily, these are rare.”

## **How to Prevent a Seroma After Cosmetic Surgery**
In the case of seroma, like so many things, the best treatment is prevention. That prevention begins in the operating room. In his textbook chapters and masterclasses on liposuction, Dr. Neinstein shares many strategies to reduce the occurrence of seroma. “It all starts with finesse surgical technique and gentle handling of tissues,” he says. “After this, I discuss an outlet for surgical fluid to get out.” Those outlets can include various forms of drains or leaving small liposuction sites open so that excess fluid can drain. 

Dr. Min adds that surgeons try to prevent seromas by either placing drains in the surgical space or by placing progressive tension sutures in the surgical site internally. “All of the techniques strive to minimize the dead space created during the surgery,” she says. 

After surgery, [lymphatic drainage massages](https://aedit.com/aedition/benefits-of-lymphatic-drainage-massages-after-cosmetic-surgery) can help reduce the risk of seroma by promoting healing, Dr. Neinstein says. Additionally, it’s important to follow your post-op instructions to a T. Beyond healthy eating and [proper rest](https://aedit.com/aedition/sleeping-better-after-cosmetic-surgery-aesthetic-procedures), they will likely include recommendations for elevating the treatment area and wearing compression garments and tell you when to return to your surgeon to have drains removed. If you need help assembling your post-op recovery kit, we’ve got guides to the best [meal plans](https://aedit.com/aedition/meal-plans-diet-before-after-cosmetic-surgery), [pillows](https://aedit.com/aedition/best-pillows-for-plastic-sugery-recovery-healing), and [compression garments](https://aedit.com/aedition/benefits-of-compression-garments-after-cosmetic-surgery) to consider after cosmetic surgery.

It should be noted that, in some cases, seroma is unavoidable – no matter your surgeon's or your own best efforts. If you think you might have a seroma, contact your provider. Early diagnosis and treatment can be key to preventing infection. 

There is much that can be done to prevent the common complication.

The Risk Of Seroma After Cosmetic Surgery

What To Know About The Risk Of Seroma After Cosmetic Surgery

anthony-tran-i-ePv9Dxg7U-unsplash

During the cosmetic surgery consultation process and again before you enter the operating room, your plastic surgeon will explain the [side effects and complications](https://aedit.com/aedition/guide-to-cosmetic-surgery-complications) that can occur after a facelift. On the side effect front, bruising and swelling can be expected and usually begin to subside after the first couple of weeks. On the complication front, [hematoma](https://journals.lww.com/prsgo/Fulltext/2021/08000/Methods_for_Minimizing_Bleeding_in_Facelift.21.aspx#) – a word that means ‘collection of blood’ – occurs after an estimated 0.2 to 8 percent of rhytidectomy (read: [facelift](https://aedit.com/procedure/facelift-rhytidectomy)) surgeries, making it the most common postoperative complication of the procedure. 

Without proper attention, hematoma can negatively impact the [healing and recovery process](https://aedit.com/aedition/facelift-recovery-healing-process). So, whether you're preparing for surgery or just got home, what should you keep an eye out for? Here’s what you need to know about the causes, symptoms, and prevention of hematoma after a facelift.

## **What Causes a Hematoma?**
Hematoma occurs most often in the first 24 hours after surgery, says [Mark M. Hamilton, MD](http://www.hamiltonfps.com/), a double board certified facial plastic and reconstructive surgeon in Indianapolis and board member of the American Academy of Facial Plastic and Reconstructive Surgery ([AAFPRS](http://www.aafprs.org/)). The reason for this is that, “during a facelift, small blood vessels are disrupted in the process of lifting and tightening the skin,” explains [Samuel Lin, MD](https://www.linplasticsurgery.com/about/dr-samuel-lin/), a board certified plastic and reconstructive surgeon and associate professor of surgery at Harvard Medical School. That disruption can cause a pooling of blood beneath the skin but *outside* of a blood vessel.

As your surgeon is wrapping up your facelift, they will check to make sure that the bleeding has stopped. But, in rare cases, “bleeding may restart or unnoticed bleeding may continue after the surgery ends,” Dr. Lin notes. The collection of blood that results becomes a hematoma. Some of the most noteworthy risk factors for bleeding and bruising after a facelift include:

- High blood pressure
- Taking blood thinners (including [herbal medication](https://aedit.com/aedition/vitamins-supplements-to-avoid-before-cosmetic-surgery), ibuprofen, and the like)
- [Smoking](https://aedit.com/aedition/impact-of-cigarette-smoking-vaping-on-skin-hair-teeth-health)
- [Combining it with a neck lift](https://aedit.com/aedition/pairing-facelift-neck-lift-procedures)

Additionally, male patients are at a higher risk of hematoma than females because they have more blood vessels and a stronger blood supply in their faces (learn more in our [comprehensive guide to facelifts for men](https://aedit.com/aedition/facelifts-for-men)).

## **Symptoms of a Hematoma**
While [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox) is common after a facelift, patients should be aware of the difference between a hematoma and a standard bruise. After all, hematomas often look like very dark bruises. There are, however, a few key differentiators to keep in mind. A hematoma is a firm and [swollen](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) red, black, or blue lump that can grow in size over time. It may or may not be painful. On the contrary, a bruise is usually flat and slightly tender – though not hard – to the touch. In general, bruises are much less serious than hematomas.

If you suspect you may have a hematoma, contact your surgeon as soon as possible. “Smaller hematomas may be drained in the office,” Dr. Hamilton says, though they can also require a return trip to the OR “to remove the clot and control any bleeding.” In extreme cases, a hematoma can “expand and put pressure on the airway, interfering with the patient’s ability to breathe,” Dr. Lin cautions. 

## **How to Prevent a Hematoma After a Facelift**
The fact of the matter is, hematomas are not 100 percent preventable. But there are a few steps patients can take to reduce the likelihood. The first is establishing that you are in [good overall health](https://aedit.com/aedition/why-you-should-lose-weight-before-plastic-surgery). Halting any medications that can impair the body’s natural clotting mechanism – including anticoagulants like Coumadin and Plavix – for at least two weeks before surgery is a must, says [P. Daniel Ward, MD](https://www.wardmd.com/), double board certified facial plastic and reconstructive surgeon in Salt Lake City. He notes that if a patient is on those two meds, they may not actually be healthy enough for surgery to begin with. This assessment should occur during the consultation process. 

In his practice, Dr. Hamilton tells patients to avoid alcohol for at least one week before surgery and to quit smoking for at least one month prior, as the former thins the blood and the latter can cause bleeding and impact the healing process. In case it’s not obvious, laying off both post-op will only help your [facelift recovery](https://aedit.com/procedure/facelift-rhytidectomy/recovery).

There are also steps that can be taken after surgery to mitigate the risk of both hematoma and bruising. If provided, you’ll want to wear a gentle [compressive dressing](https://aedit.com/aedition/benefits-of-compression-garments-after-cosmetic-surgery) or strap as per your surgeon’s guidelines. Additionally, you’ll be advised to avoid activities that raise your blood pressure – such as [exercise](https://aedit.com/aedition/when-to-start-exercising-again-after-cosmetic-surgery-procedures). Since hematomas are most likely to occur within the first 24 hours, getting as much rest as possible and keeping any movement mindful will be key. 

## **The Takeaway**
Hematoma is the most common complication patients experience after a facelift, and, as with any procedure, risks and rewards must be weighed. While every case is unique, Dr. Ward agrees that there usually isn’t a reason for healthy individuals to skip out on the surgery for fear of hematoma. Instead, patients should feel empowered to call their surgeon if they have concerns about how they are healing. “We’re doing this to help care for our patients and make them feel better – we don’t want them to suffer,” Dr. Ward says. “Call us and make us earn our keep.”

Without proper attention, it can negatively impact healing and recovery.

The Risk Of Hematoma After A Facelift

What You Need To Know About The Risk Of Hematoma After A Facelift

shutterstock 730340866

Neuromodulators have been called everything from a miracle in a syringe to the ultimate skin smoother to a life-changer and everything in between. Yet, some say that long-term use of botulinum toxin type A injections (think: [Botox®](https://aedit.com/procedure/botox), [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), [Xeomin®](https://aedit.com/procedure/xeomin)) – particularly in the masseter muscle (read: the jaw) – can potentially lead to muscle atrophy. But does the claim hold up, or is it another one of those anti-aging tall tales that swirl around the world of aesthetics? We tapped the experts to dig deeper and unearth the truth about muscle atrophy from Botox.

## **What Is Muscle Atrophy?**
No matter where in the body a muscle lives, failure to exercise it and ‘flex’ it regularly (often daily) can render the muscle atrophied or pretty much useless — almost as though the muscle is wasting away and shrinking in size. Treating muscles with neuromodulators is no different. 

For a neuromodulator to work correctly, it must limit the activity of a given muscle or muscle group. For that limitation to be visible in terms of a wrinkle-free or slimming result, there must be some form of temporary paralyzation and, in turn, atrophy. It's only natural that the muscle inherently becomes smaller with less activity as a result of the neuromodulator — it’s expected to happen. After all, the goal of Botox® and the like ([in most uses](https://aedit.com/aedition/where-to-use-botox-from-head-to-toe)) is to minimize the appearance of fine and wrinkles. The less time there is between touch-ups and the more product added continuously to the face, the higher the likelihood for atrophy to set in.

Neuromodulators are perhaps one of the most popular aesthetic treatments available today, with more than four million Americans choosing to ‘get popped’ [in 2020](https://www.plasticsurgery.org/documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf) alone. BoNT-A injections work by blocking the nerve and muscle communication signals, and, without that interaction, the muscle does not contract. Just like when wrapping a limb in a cast temporarily shrinks the muscle, the same thing happens to a muscle at rest via neuromodulators, says [Dustin Portela, MD](https://www.instagram.com/208skindoc/), a board certified dermatologist in Boise, ID. “This is desirable when we want to diminish the appearance of lines and wrinkles,”he adds.

Some muscle fragility must occur for neuromodulator treatments to be effective. The muscle softening (which can happen in any area on the face) transpires when the muscles are injected with Botox and weaken, in turn getting smaller over time, says [Michael Schwartz, MD](https://www.drschwartz.com/), a board certified plastic and reconstructive surgeon in Westlake Village, CA. “However, once the muscle starts moving again, it tends to regain its size and strength,” he explains.

Neurotoxin-induced atrophy is when the muscle atrophies (i.e. wanes in strength or shrinks) as a result of treatment. It likely occurs temporarily in any muscle into which we inject Botox, says [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), a double board certified facial plastic and reconstructive surgeon in Arlington, VA. “In general, Botox atrophy is most likely to be noticed when someone has a target muscle that is particularly defined or large or in muscles that more significantly contribute to the facial shape and shadowing,” he says. “The jaw, temple, [chin](https://aedit.com/procedure/botox-for-dimpled-chin), and [brow](https://aedit.com/procedure/chemical-brow-lift) muscles are the most common to have noticeable atrophy.”

In some cases, this is the desired effect that wears away over the lifespan of the injection. In others, it’s an unwelcome side effect that lingers Typically, within three to nine months, after treating the muscles with the chosen neuromodulator, they will begin to regain their normal function, says [Babak Azizzadeh, MD](https://www.facialplasticsbh.com/), a double board certified facial plastic and reconstructive surgeon in Beverly Hills. However, in particular (rare) cases, this does not occur for reasons that are still unknown. 

## **What Botox-Induced Muscle Atrophy Looks Like**
Just because you opt for treatment with neuromodulators doesn’t necessarily mean that the area will atrophy to the point that it’s noticeable or detrimental to how your face looks. “It can happen with the first treatment, but atrophy tends to be more common in patients who consistently receive Botox on a regular schedule in the same area,” says [Steven Williams, MD](http://trivalleyplasticsurgery.com/), a board certified plastic and reconstructive surgeon in Dublin, CA, and the vice president of the American Society of Plastic Surgeons ([ASPS](https://www.plasticsurgery.org/)). In this instance, the treated areas weaken, and the surrounding muscles may need to overcompensate for the loss of functionality. Plus, as the muscles begin to shrink, they will not fill out the space they consume and a lack of volume may ensue.

Certain parts of the face are more likely to show the effects of atrophy than others (if it even truly happens at all). “It's generally not noticeable in the area between the eyes, like the eleven [lines],” Dr. Portela says. “However, aggressively treating the forehead can cause the frontalis muscle to thin over time.” The impact of atrophied muscles can also lead to what some would describe as an undesirable appearance. For this exact reason, Dr. Portela recommends younger patients who seek out [preventative Botox](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time) do it one to two times per year. “This allows the muscles a chance to recover and move to prevent atrophy,” he says.

Why are some parts of the face more inclined to atrophy than others? It comes down to the fiber type of the muscle, Dr. Azizzadeh says. “For example, the neck muscles have different fibers — they contain a lower portion of type I fiber and a higher component of type IIb fibers — and these muscles respond differently to neuromodulators than those in the face,” he explains. “Skeletal muscles are composed of three types of fibers, type I, IIa, and IIb, and we could postulate that muscles abundant in type I fibers recover better.” It's also believed that certain muscle groups take longer to regain movement than others.
 
Atrophy may also be seen in the temple area when using neuromodulators as a treatment modality for migraine headaches. “The temporal muscle makes up a significant amount of volume in the temples, and volume loss in the temples can lead to a skeletonized, aged appearance of the upper face,” Dr. Cabin cautions. So, if you rely on Botox® to help alleviate the symptoms associated with recurring migraines, be aware that there is the potential for this to occur – especially in those patients who require long-term use. “We can easily correct any temple hollowness with temple filler,” he adds.
 
If some form of atrophy occurs, it doesn't take effect right away – it usually takes four to six weeks to become evident. “The muscle must first weaken, which takes up to two weeks before it starts to shrink from inactivity,” Dr. Cabin explains. Need an analogy to better visualize? “You can compare this to someone who works out a lot and then suddenly stops,” he shares. “Although the person's muscles will rapidly get weaker, there is a delay until the muscle size is actually impacted.”

### **The Botox-Masseter Relationship**
Let's talk about about the jaw for a moment. There's a small space where the angle of the ball-and-socket of the jaw meet that houses a muscle known as the masseter. Overactivity and an abundance of strength in the muscle can make the jaw appear square and even be the reason for persistent teeth grinding while you sleep. One of the easiest ways to tone down the muscle's hyperactivity is with a few injections of a neuromodulator. 

Years ago, doctors started injecting neuromodulators, specifically Botox®, to slim the jaw and create (in women) less of a square-shaped face and more of a heart-shaped one. This off-label use of the muscle-relaxing injectable provides benefits for three to four months before repeat injections are necessary. While there's still mobility and functionality in the jaw, force is put on a small part of the muscle to relax it and, in turn, soften the jaw. In addition to [slimming the jawline](https://aedit.com/procedure/jawline-slimming-with-botox), those who experience side effects from [temporomandibular joint (TMJ) disorders](https://aedit.com/aedition/botox-to-treat-tmj-disorders-and-jaw-slimming) also enjoy relief.

There is, however, research that suggests there could be ramifcations to long-term use. “When treating the masseter muscles to narrow the jaw and or to treat TMJ, if the muscle is kept weak over a while with repeated Botox injections, there is [some evidence](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466904/) to suggest that it can negatively impact the strength of the surrounding bone,” Dr. Cabin notes. Any changes to the muscle itself, meanwhile, are believed to be temporary. Dr. Cabin says neuromodulator-related atrophy poses no risk of direct long-term damage to the muscle. 
 
## **The Net-Net on Muscle Atrophy From Botox**
So, is short-term atrophy post-injections all that bad? No. True muscle atrophy – which depends on if the entire area is compromised – can carry risk. However, the chances of long-lasting muscle atrophy occurring from a neuromodulator is rare. Remember that facial paralysis from poorly injected toxins can cause droopiness, laxity, and a change in how the face looks. “But this is different than true atrophy that isn't related to Botox,” Dr. Azzizadeh says.

In the end, a reduction of lines and wrinkles is what everyone wants from Botox. Hence, most see any short-term atrophy as a positive event because the wrinkles they are treating tend to be less visible and potentially require either less Botox or less frequent treatments. On the other hand, once a patient stops using a neuromodulator, the muscle starts to reactivate slowly. With time, it will (with rare exception) regain full strength and size. “Additionally, the functions that that muscle is responsible for and the wrinkles the muscle is responsible for will also come back to typical pre-treatment strength over time,” he adds.
 
Patients need to know there is not a clinically significant problem since any muscle atrophy is temporary and is often even a desired effect, Dr. Schwartz advises. When it comes to neurotoxin injections, atrophying muscles isn't top of mind for most patients or providers. Plus, true ‘Botox atrophy’ is not commonly seen, Dr. Azizzadeh says. “I've done Botox on over 1,000 patients and have not seen this,” he shares. “Even the patients who are getting Botox don't experience this in their lifetimes.”

Why top plastic surgeons and dermatologists say there’s no need to worry.

Safety