Dermal Filler: How We Decide Who Needs It, Which Type and How Much

What is filler?

The filler we use is hyaluronic acid, a substance found naturally in the skin that attracts water and gives fullness and support. It breaks down gradually and naturally over time and can be dissolved if needed with an enzyme called hyaluronidase, which is an important safety feature. Filler is different from bio-stimulators, which prompt the skin to build collagen gradually rather than filling directly.

Who is filler for?

• Loss of cheek volume and the sagging of the mid-face that follows.
• Hollows under the eyes (dark circles caused by volume loss), in selected cases.
• Lips: to define shape, add balanced volume or restore thinning with age.
• Chin and jawline: to define features and improve facial proportions in profile.
• Temples: to replace the hollowing that makes a face look tired.
• Smile lines around the nose and mouth, where we often treat the cause in the cheek first.

When is filler not suitable?

• Pregnancy and breastfeeding.
• Active skin infection or inflammation at the treatment site, including an active cold sore on the lip.
• Permanent or unknown filler previously injected in the same area.
• A previous allergy to filler or to lidocaine.
• Some under-eye cases, such as large fat bags or chronic swelling, where filler can make things look worse and a different solution is needed.
• Unrealistic expectations or a wish for exaggerated change.

How we decide: reading the whole face

1. We treat the cause, not the symptom: a deep smile line is often the result of lost support in the cheek, so restoring the cheek can improve the line more than filling it directly.
2. We look at the face as one unit: upper, middle and lower thirds, and the balance between forehead, nose and chin, from the front and in profile.
3. We consider the skin, bone and fat in each area, your age and your features.
4. We review your medical history and medicines, especially blood thinners, and any previous cosmetic treatments.
5. We agree a clear goal: a balanced improvement that still looks like you, not a different face.

Type of filler: why one product does not suit every area

Hyaluronic acid fillers differ in density, cohesiveness and flexibility, and each area has a type that suits it:

• Firm, high-density filler: for areas that need structure and support, such as the chin, jawline and cheekbones.
• Medium-density filler: to restore volume in the cheeks and temples.
• Soft, flexible filler: for thin or mobile areas such as the lips and under the eyes, so it moves with the face and does not show.

Using the wrong type for an area is one of the commonest causes of unnatural results, such as puffiness or visible filler under the skin.

The amount: how is it decided?

Filler is measured in millilitres, and there is no fixed amount that suits everyone. It is decided after examination, based on:

• The area: each area needs a different amount depending on its size and role.
• How much volume has been lost: mild loss is different from marked loss.
• Your skin, bone and fat structure.
• Your goal: a subtle improvement or a clearer change, while keeping your features.
• Any filler already present in the area.

We prefer to start with the smallest amount that achieves the goal and review at two weeks. Adding a little later is easier and safer than overdoing it at the start, and it is what keeps results natural.

What happens during the session

1. Consultation and photographs: assessment, agreeing the plan and amount, and before photographs.
2. Preparation: thorough skin disinfection. Most fillers contain a local anaesthetic (lidocaine), and numbing cream can be added.
3. Injection: with a fine needle or a cannula (a blunt-tipped injection tube that reduces bruising in some areas), depending on the area. The session usually takes 20 to 45 minutes.
4. Shaping and immediate review: we check symmetry and look at the result with you before you leave.
5. Review at two weeks: once swelling has settled, to assess the final result.

Aftercare

• Mild swelling for two to seven days is normal, more noticeable in the lips.
• Avoid pressing or massaging the area unless your doctor asks you to.
• Avoid strenuous exercise, high heat (sauna) and heavy make-up for one to two days.
• The result settles in about two weeks and usually lasts 6 to 18 months, depending on the area, the type of filler and your body.

Safety: side effects and how we manage them

Common and mild: swelling, bruising, mild tenderness, usually gone within days.

Less common: slight asymmetry or a lump you can feel. Many improve with time or guided massage, and the filler can be dissolved if needed.

Rare but important: blocked blood vessel (vascular occlusion). This happens if filler enters or presses on a blood vessel. Signs are severe, unexpected pain and the skin turning white, blue or mottled. It is an emergency treated immediately by dissolving the filler with hyaluronidase. This is why filler should be injected by a qualified doctor who knows facial anatomy, in a medical facility equipped to treat complications. If you notice these signs after treatment, contact your doctor straight away.

Frequently asked questions

Will filler look natural?
Yes, when the right type is chosen for the area and a moderate amount is used. An "overfilled" face is usually the result of too much filler or the wrong type.

Can filler be removed if I don't like the result?
Hyaluronic acid filler can be dissolved with hyaluronidase, which is one reason it is considered a safe option.

Does filler cause sagging once it wears off?
There is no evidence that filler used in moderate amounts causes sagging. What happens over time is natural ageing.

What is the difference between filler and bio-stimulators?
Filler restores volume directly; bio-stimulators prompt the skin to build collagen gradually. We sometimes combine them. Read: Types of dermal fillers

Do I need Botox or filler?
Botox treats lines caused by muscle movement; filler treats loss of volume and support. Read: Botox vs Filler