How to avoid Facial Overfilled Syndrome with fillers? 4 things you should know.
Facial Overfilled Syndrome (Woman)

Fillers Outcome You Don’t Want to Get:  Facial Overfilled Syndrome (FOS)

As dermal fillers became more widely acceptable, we started to observe increasing numbers of people developing Facial Overfilled Syndrome (FOS). These overfilled faces are commonly seen among those who have undergone multiple dermal filler injections, large amount of dermal fillers used per treatment (more than 5 syringes per treatment, more than 10 syringes in a year), ending up having unnatural look after certain period of time.

Common names such as “pillow face”, “sausage lips”, “plastic face” are signs commonly seen in people with Facial Overfilled Syndrome.

Common Symptoms of Facial Overfilled Syndrome (FOS)

The facial overfilled syndrome can be seen in those who has swollen cheeks, forehead, chin and nose. Many of patients are not aware that they are overfilled, but they just feel that they looked a bit “swollen”. Their friends are also hesitate to tell them that they looked “different”.

How to avoid Facial Overfilled Syndrome with fillers? 4 things you should know. - Facial Overfilled Syndrome Man 1
Facial Overfilled Syndrome (Man)
How to avoid Facial Overfilled Syndrome with fillers? 4 things you should know. - Facial overfilled syndrome 2
Facial Overfilled Syndrome (Woman)

Identifying FOS

Patients with FOS must fulfill the following criteria:
1.   Patients have received many dermal filler injection.
2.   Patients have undergone “bolus” injections where dermal fillers are only concentrated on certain spots (point injections)
3.   Patients display one or more of the following features:
  • Loss of normal topography of the face
  • Heavy mid to lower face
  • ‘Setting sun’ eyes
  • Broadened nose
  • Round over-protruding forehead
  • Pointy chin
  • Sausage-like lips

Why do people get Facial Overfilled Syndrome (FOS)?

FOS is a commonly seen but rarely discussed complication following dermal filler use. It is characterised by overzealous volumisation, resulting in facial and topographical distortions. Many of those who have facial overfilled syndrome lost their original facial topography and may or may not be aware of such condition. The facial distortion can be exaggerated by facial expressions and movements.

Facial aging involves bone resorption, facial-muscular behaviour changes, weakening of the anchoring complex, and soft tissue malpositioning. The skeletal changes and tissue movements often cause some “hollowing” and always preceived as “volume loss”. Many injectors often make a mistake by injecting huge amount of dermal fillers to combact that “volume loss”.

Another common misconception is that dermal filler materials break down very quickly. This isn’t always the case. Many overfilled cases continues to have distorted looks even after many years of not having dermal fillers done. This prompts the question: are HA dermal fillers actually that short-lived? When dermal fillers continue to exist, they add more weight to the soft tissues, leading to more tissue sagging.

There are many reasons to Facial Overfilled Syndrome:

  1. Incorrectly placement of dermal fillers: most often than not, FOS is due to incorrect assessment, injection plane, applied techniques, product choice and administered volumes.
  2. Poor selection of filler products: using poor quality dermal fillers or dermal fillers that does not integrate well with the tissues. Not all dermal fillers are the same.
  3. Overzealous attempts by the injectors and overly enthusiastic clients: Many of the facial overfilled syndrome cases are due to using large amount of dermal fillers in every injection (“bolus” injection) driven by the desire to have very drastic and visible results.
  4. Only use fillers for treatment: Dermal filler is a good treatment modality but it should also be combined with other treatments to get better results. When the treatment is only limited to dermal fillers, the face is more prone to be overfilled.

Treatment and Prevention

Most facial aging are explained by a weakening of the anchoring complex, a structure that firmly adheres soft tissues to bone or fascia. The anchoring complex tends to weaken with age, causing facial sagging, eye bags, tear troughs, nasolabial folds, nasojugular lines and jowls. Large dermal filler volume used, large bolus injections, frequently repeated treatments, as well as inappropriate injection techniques will lead to facial overfilled syndrome.
To treat Facial Overfilled Syndrome, doctors can always dissolve dermal fillers with hyaluronidase, an enzyme that dissolves the HA dermal fillers. However, the longer the dermal fillers is in the tissues, the harder is it to treat. Also, mutilple attempts are needed to correct the overfilled face. Once a face is overfilled and the structure is distorted, diminishing the volume with hyaluronidase will help to minimize the distortion, but will not necessarily restore the face to its natural look. Therefore, it is very important to prevent this from happening.
This is precisely why when medicine is concerned, the rule of ‘prevention is better than cure’ applies.
Facial Overfilled Syndrome is underdiagnosed. Having the awareness of the overfilled syndrome is crucial among the public to prevent it from happening. While true FOS is visible to the naked eyed, borderline FOS is less identifiable. Overfilled regions might be picked up or noticeable during facial animation. If you spot any such symptoms, visit a qualified doctor who can offer appropriate corrective measures, which meet comfort levels and needs.
Ways to prevent Facial Overfilled Syndrome:
  • “less is more”
  • gradual treatments
  • address skin tightening before addressing “volume loss”
  • not overuse dermal fillers (try minimizing the numbers of dermal fillers to 3-4 syringes per treatment and 2-3 times a year)
  • preserving youthfulness over time with an end goal of keeping it as natural as can be

Moving forward: Anti-aging Through Awareness

Anti-aging through holistic, combination methods is the best way. Addressing tissue sagging and tightening the skin needs to be done hand in hand with dermal filler injections. Also, the use of biostimulator in appropriate amount is also very crucial.
Despite being a good tool, dermal fillers cannot and should not apply as ‘quick-fix’ aging solutions. While immediate and drastic outcomes may be appreciated with large amount of dermal fillers,  the abuse of dermal fillers in this way are best avoided as there are risks of future distortions to patients’ natural facial structures and contours. Apart from causing permanent emotional and physical stress, overzealous injections also emphasise profits over patient’s interests. It also highlights a doctor’s lack of anatomical knowledge or comprehension regarding the physiology of aging.

Note:

Malaysia’s renowned aesthetic physician, Dr. Lim Ting Song contributed to the January/February 2018 issue of PRIME Journal, authoring an article titled ‘Facial Overfilled Syndrome: Complications of Inappropriate Filler Delivery’. In this comprehensive article, Dr. Lim thoroughly discusses common issues related to over-volumised faces following excessive filler injection. He aptly names this complication Facial Overfilled Syndrome (FOS). In 2017, Dr. Lim won the Best Abstract Award for Aesthetic Dermatology for his presentation ‘Facial Overfilled Syndrome in Asia.’ 

References and more reading materials:

  1. Lim TS. Facial overfilled syndrome complications of inappropriate filler delivery. PRIME J. 2018. Accessed April 9, 2019.
  2. Identifying and Managing Facial Overfilled Syndrome
  3. Cotofana S, Gotkin RH, Frank K, Lachman N, Schenck TL. Anatomy Behind the Facial Overfilled Syndrome: The Transverse Facial Septum. Dermatol Surg. 2020 Aug;46(8):e16-e22. doi: 10.1097/DSS.0000000000002236. PMID: 31688233.
  4. Facial Overfilled Syndrome in Japanese
  5. Turn down the Volume
  6. Dermal Fillers – Can We Have Too Much?

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