What are Fillers?

Some surgeons express concerns about the impact of fillers and biostimulators on facelift surgery due to potential complications and challenges they can introduce during and after the procedure. According to a survey of aesthetic surgeons, 51.9% reported increased difficulty in performing facelifts on patients with a history of panfacial filler injections. Biostimulators, such as Sculptra® and Radiesse®, improve volume by stimulating collagen production, but this same process can lead to the development of scar tissue, potentially making facelifts more challenging. These treatments predominantly stimulate Type III collagen, which resembles scar tissue rather than the healthy, elastic Type I collagen typically found in youthful and unoperated skin, potentially altering tissue characteristics and complicating surgical dissection.  Excessive use of HA fillers can also result in issues that can impact facelift results. Fillers may disrupt lymphatic drainage, leading to fluid retention and prolonged swelling that can last many months and years beyond the time that the fillers were injected impacting surgical recovery. Over time, impaired lymphatic flow may cause complications like inflammation, fibrosis, or uneven skin texture. These concerns underscore the importance of moderation and expert technique to achieve natural, balanced results. 

Dr. Azizzadeh is extremely vigilant about potential factors that could impact surgical outcomes and safety. However, with his extensive expertise in facial anatomy and advanced surgical techniques, he is highly skilled at navigating the complexities of modern patients, many of whom have undergone treatments with Botox®, fillers, biostimulators, lasers and other energy-based devices such as Morpheus8®.  His advanced skillset in deep plane facelifts and neck contouring allows him to safely perform these procedures on patients with a history of fillers or biostimulators. While he typically recommends avoiding filler or biostimulator treatments for six months before surgery to optimize outcomes, he does not view it as an absolute requirement. He may or may not require his patients to dissolve the fillers on a case by case basis.  His meticulous planning and precise execution ensure natural, long-lasting results, even for patients with prior treatments. 

The decision to dissolve fillers before a facelift is complex and depends on various factors, with Dr. Azizzadeh determining the best approach on a case-by-case basis. Generally, he recommends limiting filler and biostimulator use six months prior to surgery. This precaution allows for a more accurate assessment of the patient’s natural facial contours, which is crucial for optimal surgical planning and results. 

Dissolving fillers, particularly in the cheek area, may be necessary as their presence can potentially limit the effectiveness of a full face and neck lift. Recent studies have revealed that hyaluronic acid fillers can persist in facial tissues for up to 15 years, emphasizing the importance of addressing these before surgery to prevent long-term complications or suboptimal outcomes. Fillers can also potentially block lymphatic drainage and are considered foreign bodies, which may interfere with the healing process. 

Dr. Azizzadeh often prefers to replace fillers with fat grafting during facelift procedures, as this technique provides a more natural and long-lasting volumization. However, the necessity of dissolving fillers varies depending on the specific facelift technique and the treated areas. In some cases, such as a lower facelift or mini facelift, dissolving fillers may not be necessary. The decision to dissolve or retain fillers is made based on their location, type, and potential impact on the surgical outcome, always prioritizing patient safety and optimal results. 

The decision to dissolve fillers before blepharoplasty is complex and depends on various factors, with Dr. Azizzadeh determining the best approach on a case-by-case basis. Generally, it’s recommended to limit filler use in the periocular area several months prior to surgery. This allows for a more accurate assessment of the natural eyelid contours, which is crucial for optimal surgical planning and results. 

Dr. Azizzadeh, as a double board-certified facial plastic and reconstructive surgeon, takes a comprehensive approach to blepharoplasty. He evaluates each patient individually to determine if dissolving fillers is necessary before the procedure. In some cases, the presence of fillers in the periocular area may affect the outcome of the eyelid lift, potentially limiting its effectiveness. 

During the consultation process, Dr. Azizzadeh will assess the patient’s eyelid treatment goals, identify any surgery risk factors, and determine whether existing fillers need to be addressed. He may recommend dissolving fillers if their presence could interfere with achieving the desired surgical outcome or pose potential complications during the healing process. 

It’s important to note that Dr. Azizzadeh’s approach to blepharoplasty is highly personalized. He collaborates with each patient to ensure comprehensive support throughout the eyelid surgery process. If dissolving fillers is deemed necessary, Dr. Azizzadeh may incorporate fat grafting to restore lost volume and improve outcomes.  Regardless, Dr. Azizzadeh always prioritizes patient safety and optimal results. 

“TORCH syndrome” refers to the overfilled, unnatural appearance often seen in individuals who repeatedly rely on fillers instead of undergoing appropriate surgical interventions like a facelift. This approach can distort facial proportions, creating a swollen or bloated look, highlighting the importance of balanced, strategic rejuvenation methods. 

Sculptra® works differently than HA fillers because it stimulates the body’s natural collagen production over time, gradually restoring volume and improving skin texture rather than providing immediate results.  Sculptra® typically requires multiple treatment sessions spaced 4-8 weeks apart to achieve optimal results. Most patients require 2-4 sessions, depending on the severity of volume loss and the treatment area, with full results becoming apparent several months after the final session. This incremental process ensures natural-looking, long-lasting outcomes, as the collagen builds up gradually, enhancing facial contours and reducing signs of aging.  

Severe pain, unusual skin discoloration (such as pale, dusky, or mottled patches), prolonged blanching, or sudden changes in vision—including blurred vision, sudden vision loss, or a severe headache—can be warning signs of vascular occlusion or other serious complications. These symptoms demand immediate medical attention, as delays in treatment may result in irreversible tissue damage, scarring, or even blindness. 

If you notice any of these concerning symptoms, it is critical to contact your injector without delay. Should your injector be unavailable to see you immediately, seek care from a qualified expert in filler-related complications. Prompt intervention, such as the administration of hyaluronidase to dissolve the filler, restoring blood flow, or other necessary treatments, can significantly reduce the risk of permanent harm. Quick action is essential to preserve your health, safety, and the best possible outcomes. 

During a fillers consultation, Dr. Azizzadeh conducts a thorough assessment to help you achieve your aesthetic goals. Using tools like three-dimensional imaging, he provides a detailed view of your facial structure to align expectations and outcomes. With decades of experience as an internationally renowned facial plastic surgeon, Dr. Azizzadeh takes the time to educate you on the causes of your concerns and the available treatment options, ensuring you are fully informed. His personalized approach ensures natural, satisfying results tailored to your unique needs. 

Dermal fillers provide immediate visible results upon injection, but the full effect develops gradually over time as the filler settles and integrates into the tissue. This process typically takes 2-4 weeks, during which initial swelling subsides, and the filler binds with water molecules in the skin, enhancing volume and smoothing wrinkles. The timeline can vary based on factors such as the type of filler, treatment area, and individual patient characteristics. Hyaluronic acid-based fillers, for example, are hydrophilic and continue to attract water, potentially enhancing results over time, while biostimulatory fillers take longer as they stimulate collagen production. To ensure optimal settling, patients are advised to stay hydrated and avoid intense exercise or heat exposure for the first 24-48 hours post-treatment. 

Recent scientific research has reshaped the understanding of dermal filler longevity, particularly for hyaluronic acid (HA) fillers. A 2024 study using magnetic resonance imaging (MRI) revealed that HA fillers can persist in the mid-face for much longer than previously believed, with detectable presence lasting between 2 and 15 years post-injection. This finding contrasts with the conventional belief that HA fillers last only 3-12 months. 

The longevity of HA fillers varies significantly depending on the injection site. Dynamic areas, such as the lips, typically experience shorter durations of effect due to constant movement and high vascularity, which accelerate filler breakdown. Conversely, fillers placed in less mobile regions like the cheeks or tear troughs can maintain their effects for a year or more. This variation is attributed to the mechanical stress on the filler material; areas with frequent movement undergo more rapid degradation, while stable regions allow the filler to remain intact longer. Additionally, the depth of injection influences longevity, with deeper placements in areas like the cheeks often yielding longer-lasting results than superficial injections in areas like the lips or fine lines around the mouth. 

In comparison, biostimulatory fillers like Radiesse® (calcium hydroxylapatite) and Sculptra® (poly-L-lactic acid) function differently. Radiesse provides both immediate volumization and biostimulation of collagen, while Sculptra only stimulates collagen production, with effects lasting up to two years. The enhanced longevity of modern HA fillers, attributed to improved cross-linking technologies and site-specific factors, has significant implications for treatment protocols. These findings may reduce the need for frequent re-injections, allowing for more personalized and effective filler management practices. 

Biostimulators, Fillers and fat grafting are highly effective techniques employed by Dr. Azizzadeh for minimally invasive facial rejuvenation and volume restoration, either as standalone procedures or in combination with treatments such as Botox®, deep plane facelifts, blepharoplasty, and energy-based devices. While both methods achieve impressive results, they differ significantly in composition, longevity, and procedural complexity, allowing for tailored approaches based on each patient’s unique needs and goals.  Injectable fillers, commonly composed of hyaluronic acid (HA) or biostimulators like Radiesse® (calcium hydroxylapatite) and Sculptra® (poly-L-lactic acid), offer effective volume enhancement and wrinkle reduction with minimal downtime, making them a popular choice for facial rejuvenation.  Injected directly into targeted areas, fillers are ideal for their simplicity, in-office application, and precision when used judiciously. Recent research has shown that HA fillers can persist in the mid-face for 2 to 15 years, far longer than the previously assumed 3-12 months, though longevity varies by injection site. Dynamic areas like the lips, with constant movement and high vascularity, break down fillers more quickly, while less mobile regions such as the cheeks or tear troughs retain fillers longer. However, overuse or improper placement of fillers can lead to issues such as impaired lymphatic drainage, resulting in fluid retention and a puffy or bloated appearance, especially in delicate areas like the lips and under the eyes. 

In contrast, fat grafting, or autologous fat transfer, involves harvesting fat from the patient’s own body—typically from areas like the abdomen, flanks, or thighs—processing it, and injecting it into facial areas needing volume. This technique allows for larger volumes to be used, making it an excellent option for individuals with significant volume loss. Fat grafting offers unique advantages, including the use of natural tissue, which eliminates the risk of allergic reactions and often provides a more natural look and feel. Dr. Azizzadeh often incorporates fat grafting into deep plane facelifts and blepharoplasty procedures, as it can be easily harvested during surgery with minimal additional time. This approach provides three-dimensional enhancement to traditionally two-dimensional procedures, offering natural, long-lasting volume restoration that he prefers over fillers for his surgical patients.  Unlike fillers, fat grafting has shown less inflammatory response and may contain stem cells that enhance skin quality and rejuvenation. When performed as a standalone procedure, fat grafting by Dr. Azizzadeh can be done under local anesthesia, making it an appealing alternative to pan-facial fillers and biostimulators. It is particularly beneficial for patients who no longer wish to use fillers, have experienced significant inflammatory issues, or require substantial volume restoration that would otherwise necessitate frequent and repeated filler injections.  While fat grafting is more complex, time-intensive, and requires a longer recovery period, it often provides longer-lasting results. However, not all transferred fat survives, with 30-50% potentially reabsorbed within the first few months, necessitating slight overcorrection during the procedure and, at times, touch-ups. 

Both options have distinct benefits, and the choice between fillers and fat grafting depends on individual goals, anatomy, and desired outcomes, which can be determined during a thorough consultation. 

Yes, dermal fillers can be safely and effectively combined with botulinum toxin treatments such as Botox®, Dysport®, and Xeomin®. This combination approach, often referred to as a “liquid facelift,” utilizes the complementary mechanisms of these injectables to achieve comprehensive facial rejuvenation. Botulinum toxins relax muscles to reduce dynamic wrinkles, such as crow’s feet and frown lines, while dermal fillers restore volume to static wrinkles and areas of volume loss, like the cheeks, lips, and nasolabial folds. Together, these treatments provide synergistic effects, enhancing overall results and creating a more youthful, harmonious appearance. 

Recent studies suggest that combining hyaluronic acid (HA) fillers with botulinum toxin injections may increase the longevity of both treatments. For example, evidence indicates that the presence of dermal fillers may extend the duration of botulinum toxin effects, possibly due to reduced mechanical stress in the treated areas. This makes the combination particularly effective for areas prone to movement, such as around the mouth or forehead. 

The timing and technique of combined treatments are critical and should be tailored by a qualified practitioner. Factors such as the order of injections, the type of fillers and toxins used, and the targeted facial areas can significantly influence outcomes. With expert planning, combining dermal fillers and botulinum toxin treatments can deliver natural-looking, long-lasting results for patients seeking non-surgical facial rejuvenation. 

Hyaluronic acid (HA) fillers, such as Juvederm® and Restylane®, and biostimulators like Radiesse® and Sculptra® can be injected during the same treatment session, but this approach requires meticulous planning and expertise to ensure safe and effective results. Combining these injectables allows for a highly customized rejuvenation strategy: HA fillers provide immediate volume and contouring for areas like the lips or tear troughs, while biostimulators stimulate collagen production for gradual, long-term improvements. For example, Radiesse® is often used in areas requiring structural support, such as the jawline or cheeks, while Sculptra® is ideal for addressing broader volume loss in areas like the temples or midface. 

The key to successful combination treatments lies in strategic placement to avoid overcorrection or product interference, as HA fillers and biostimulators differ in consistency and mechanisms of action. Practitioners must carefully assess the patient’s unique anatomical needs, select appropriate injection zones, and be mindful of potential risks such as vascular compromise or nodule formation. By tailoring the approach to each patient, these treatments can complement one another to deliver balanced, natural-looking results. Consulting a highly trained professional with expertise in combining these products is essential to achieving optimal outcomes. 

Fillers are not considered permanent, but their longevity varies depending on the type of filler, the treatment area, and individual factors. Hyaluronic acid (HA) fillers, such as Juvederm® and Restylane®, typically have been thought to last 6-24 months, though recent research suggests they may persist much longer in certain areas, with detectable presence lasting up to 2-15 years in some cases. Biostimulatory fillers like Radiesse® and Sculptra® work differently, stimulating collagen production for gradual and longer-lasting results, with effects lasting up to 12-24 months or more. Over time, all fillers naturally degrade, but advancements in cross-linking technologies and strategic placement have extended their durability, allowing for less frequent touch-ups. While not permanent, these injectables provide long-lasting and customizable solutions for facial rejuvenation. 

The Tyndall effect in dermal fillers is an optical phenomenon that occurs when hyaluronic acid (HA) fillers are injected too superficially in the skin, causing light to scatter through the colloidal particles in the filler. This results in a bluish or grayish discoloration at the injection site, most commonly seen in areas with thin skin, such as the tear troughs. The physics behind this phenomenon involves the scattering of shorter blue light wavelengths more than longer red light wavelengths, creating the characteristic bluish hue. Factors like the refractive index mismatch between the filler and surrounding tissues, as well as the particle size and concentration of the filler, can exacerbate the effect. 

Dr. Azizzadeh prevents the Tyndall effect by using precise techniques, including injecting the appropriate HA filler deep to the muscle under the eye, ensuring proper placement and integration with the surrounding anatomy. This approach minimizes the risk of light scattering and discoloration, particularly in delicate areas like the tear troughs. 

If the Tyndall effect does occur, treatment options include gentle massage to disperse the filler, stab excision or aspiration to remove excess product, and, most effectively, hyaluronidase injections to dissolve the HA filler. Hyaluronidase typically resolves the discoloration within 24 hours, though some cases may require additional treatments. Dr. Azizzadeh’s expertise ensures optimal outcomes and significantly reduces the likelihood of this complication. 

There is no definitive “ideal age” for dermal fillers, as the decision depends on individual needs, goals, and anatomical factors. While most practitioners recommend starting fillers early 30s, when volume loss starts, they can be safely used across a wide age range, from young adulthood to the senior years. 

For teenagers and young adults, fillers are generally not recommended unless addressing specific concerns such as genetic maxillary or mandibular underdevelopment, lip augmentation, non-surgical rhinoplasty, or chin augmentation. These treatments can offer temporary improvements, providing a way for individuals to “test” potential outcomes before committing to permanent surgical procedures. This approach is particularly valuable for those who may be uncertain about making irreversible changes. However, it is crucial to have a thorough discussion of the risks, benefits, and limitations of fillers, as not all surgical results can be effectively replicated with non-surgical treatments. 

For example, non-surgical rhinoplasty using fillers can provide subtle enhancements, but it cannot address structural issues such as a deviated septum or nasal function, and it carries significant risks, including vascular compromise or blindness. Similarly, while fillers can augment the chin or lips, their results may not fully mimic the long-lasting effects of surgical options like chin implants or lip lifts. Proper consultation with an experienced surgeon is essential to evaluate the feasibility, risks, and expected outcomes of fillers in these scenarios. 

For older adults, even up to those in their 70s and 80s, fillers can be effective in restoring lost volume, smoothing wrinkles, and enhancing facial contours. However, a thorough assessment of skin quality, elasticity, and overall health is essential to ensure optimal and safe outcomes. 

Safety and natural results are priorities across all age groups. Proper product selection, precise technique, and an experienced injector are crucial to minimizing risks and achieving balanced, age-appropriate enhancements tailored to each individual. 

Botox® and dermal fillers are distinct cosmetic treatments, each addressing different aesthetic concerns, making it impossible to declare one universally “better” than the other. Botox, derived from botulinum toxin, temporarily relaxes facial muscles to smooth dynamic wrinkles caused by repetitive expressions, such as crow’s feet, forehead lines, and frown lines. Its effects typically last 3-6 months, with some patients experiencing longer-lasting results over time due to muscle atrophy. Dermal fillers, often hyaluronic acid-based, are injectable substances that restore lost volume, smooth static wrinkles, and enhance facial contours. They can plump lips, rejuvenate cheeks, and refine the jawline, with results lasting 6 months to 2 years or longer, depending on the product and treatment area. 

The choice between Botox and fillers depends on individual concerns and desired outcomes. Botox is ideal for treating upper face wrinkles and preventing new lines, while fillers are better suited for addressing volume loss, deep wrinkles, and enhancing facial features. Many patients benefit from combining both treatments for a comprehensive facial rejuvenation approach. Recent studies have revealed that hyaluronic acid fillers may persist in facial tissues much longer than previously believed—potentially up to 15 years in some cases—offering extended benefits. Additionally, the reversibility of hyaluronic acid fillers adds to their appeal. Ultimately, the “better” option depends on the patient’s unique facial anatomy, aesthetic goals, and the expertise of a qualified practitioner. 

Non-surgical rhinoplasty, or liquid rhinoplasty, has gained popularity as a minimally invasive alternative to traditional surgical rhinoplasty. This procedure involves injecting fillers, typically hyaluronic acid-based, to temporarily enhance the shape and appearance of the nose. While generally safe and effective when performed by experienced practitioners, it is not without risks and limitations. 

The primary benefits of non-surgical rhinoplasty include immediate results, minimal downtime, and lower costs compared to surgical options. The procedure typically takes less than an hour, and most patients can resume normal activities the same day. Results are temporary and reversible, making it an excellent option for patients who want to “test” changes before committing to permanent surgery. However, fillers are primarily used to address specific aesthetic concerns, such as smoothing nasal bumps or correcting minor asymmetries, and are not suitable for correcting structural issues like tip bulbosity, significant dorsal hump, deviated septum or breathing problems. Emerging research indicates that filler results in the nose may last longer than previously thought, with some cases showing effects lasting several years rather than the typical 6-12 months. 

Despite its advantages, non-surgical rhinoplasty carries potential risks, including serious complications such as vascular occlusion, which can lead to tissue necrosis or even vision loss if filler enters a blood vessel. Other side effects include bruising, swelling, redness, and filler migration. Due to the proximity of the nose to critical vascular structures, this procedure is more technically demanding than other filler applications, underscoring the importance of choosing a highly qualified and experienced injector. 

Alternatives to non-surgical rhinoplasty include traditional surgical rhinoplasty, which provides permanent and more comprehensive results, especially for patients with significant structural or functional concerns. Surgical rhinoplasty can address not only cosmetic issues but also breathing problems, making it a better choice for those requiring structural correction. 

In summary, non-surgical rhinoplasty with fillers can be a safe and effective option for minor nasal aesthetic enhancements but requires careful consideration of its risks and limitations. Patients should consult with a board-certified facial plastic surgeon or dermatologist experienced in facial aesthetics to determine the most appropriate treatment for their needs and goals.