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

Hyaluronic acid-based fillers work somewhat like magic. Injecting them into the appropriate facial planes allows for deflated areas – such as the cheeks, mid-face, temples, and lips – 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, filler migration, and 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, 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, 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. 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 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 and/or 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, a board certified plastic and reconstructive surgeon in Los Angeles. “Full facial balance restoration improves proportions and creates harmony 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, a holistic plastic surgeon in NYC and founder of Jet Set Beauty Rx.

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, 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 or chin implant) 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 and Restylane® Contour, occupy more space. But it's not just hyaluronic acid filler that fits the bill. Injectables that fill more robustly, including Sculptra®, which provides a scaffold for a volumizing effect, may be used. “Additionally, thick and long-lasting calcium-based Radiesse® can also be used,” she explains. “So can fat injections, 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 and eye area, 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 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 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.