Turn Down the Volume!

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).

August 1, 10:45 AM

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). 
According to Dr. Lim, FOS is a commonly seen but rarely discussed complication following soft-tissue filler use. It is  characterised by overzealous volumisation, resulting in facial and topographical distortions. In this article, we re-explore this topic by discussing the cause, how it affects patients – particularly those of Asian descent – and its solutions. In addition, we explore alternative rejuvenative methods, which can benefit patients with minimal adverse effects.
Aesthetic Physician, Dr. Lim Ting Song
Permanent Future Distortion
As stated in Dr. Lim’s article, hyaluronic acid (HA) fillers have become one of the world’s most favoured medical aesthetic procedures due to its cheaper cost and its immediate visible results. However, along with increased demands, incidences of complications have followed suit. In fact, there have been increasing reports of post-filler complications such as nodules, vascular compromise, granulomas and even blindness. Facial overfilled syndrome is a less discussed complication caused by excessive filler injection leading to anatomical and topographical distortion. 
In Dr. Lim’s experience, overfilled syndrome is frequently observed among patients whose doctors solely rely on fillers for facial rejuvenation. While immediate and drastic outcomes may be appreciated, Dr. Lim believes the abuse of 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 ageing. 
Causative Factors
There are multiple factors behind FOS. First and most importantly, both doctors and patients are made to believe that filler materials break down very quickly. This isn’t always the case, says Dr. Lim. In fact, he has observed patients who claim they haven’t been given fillers for five years but yet appear overfilled. This prompts the question: are HA fillers actually that short-lived? When fillers continue to exist, they add more weight to the soft tissues, leading to more tissue sagging. 
Furthermore, and because injectable suppliers champion sales, suppliers distribute fillers at higher numbers, recommending greater injected volumes for “better results.” When such precarious advice is heeded, physicians may instigate more distortions, causing insurmountable cases of impending FOS. Adding fuel to the fire, when tissue ptosis is worsened by fillers, treated areas will once again look hollow, prompting the belief of fillers’ biodegradability and the need for re-injection. Such theories ultimately trigger vicious cycles of injection, tissue ptosis and re-injection, sparking ludicrous volumisations, ptosis and ultimately, permanent distortion. 
Dr. Lim believes that overfilled syndrome is also the result of incorrect assessment, injection plane, applied techniques, product choice and administered volumes. Before doctors advocate solutions, it is vital they understand underlying structures. Dr. Lim shares that the face undergoes transformations due to bone resorption, facial-muscular changes, weakening of the anchoring complex, and soft tissue malpositioning. Because ageing and skeletal changes contribute to mid-face tissue malpositioning, it’s often believed to be mid-face volume loss. As noted in Dr. Lim’s findings, superficial fat pads in the mid-face do not deplete with ageing, but conversely increase until 60-years of age. While deep facial fat pads decrease by one to two percent every year from ages 30 and beyond, hollowness is mainly attributed to tissue migration rather than volume loss. 
 Malpositioning vs. Volume Loss
Most ageing modifications are explained by a weakening of the anchoring complex, states Dr. Lim. A structure that firmly adheres soft tissues to bone or fascia, it tends to weaken with age, causing patients to suffer sagging and soft tissue changes translating to eye bags, tear troughs, nasolabial folds, nasojugular lines and jowls. Because physicians don’t consider overzealous injections as problematic due to fillers’ “biodegradable” nature, the already weakened anchoring complex would not be able to withstand the laws of gravity, resulting in unnatural-looking faces. These factors are of course further exacerbated with a toxic combination of higher injected volumes, large bolus injections, frequently repeated treatments, as well as inappropriate injection techniques. 
Treatment and Prevention
To remedy instances of permanent distortion, doctors can always dissolve fillers with hyaluronidase. However, if nodules form, surgical excision may be the only solution. This is precisely why when medicine is concerned, the rule of ‘prevention is better than cure’ applies. In Dr. Lim’s view, facial rejuvenation and anti-ageing requires comprehension and artistry. Before physicians inject haphazardly, he recommends they be well-versed in the face’s topography and natural skeletal structures. Asians, for example, have dissimilar facial shapes, particularly larger malar bones. Once doctors balloon the mid-face, cheeks turn overly broad and abnormal. Dr. Lim fervently advises against Asian cheek volumisations as patients end up looking like chipmunks. Likewise, big boluses are also a no-no. His advice is to primarily understand fillers’ fundamental characteristics before employing poorly understood techniques. Similarly, physicians should combine other modalities of rejuvenation, especially those that could strengthen the anchoring complex and tighten the skin, such as microfocused ultrasound or biostimulators. 
Anti-ageing Through Awareness
Dr. Lim approaches anti-ageing through holistic, combination methods. He first assesses one’s facial anatomy and topography, looking into areas requiring enhancement or vice-versa. He also challenges current trends by advocating the idea of “less is more” and gradual treatments, preserving youthfulness over time with an end goal of keeping it as natural as can be. Therefore, in order to do a good job, it is vital to have thorough understandings of underlying structures, specifically soft tissue displacements commonly misconstrued as volume loss. Once doctors address tissue malpositionings with energy based devices and suspension sutures, they are tackling problems at a fundamental level.
Despite being a good tool, fillers cannot and should not apply as ‘quick-fix’ ageing solutions, as the particular concerns aren’t always due to volume loss.

Identifying FOS
Before treating FOS, the occurrence of this complication must be identified. Patients with FOS must fulfill the following criteria:
1.   Patients have received more than one filler injection.
2.   Patients have undergone more than 0.1cc per bolus of filler at each injection point. 
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

While true FOS is visible to the naked eyed, borderline FOS is less identifiable. Simple exercises can be used to detect overfilled conditions, such as palpations of suspected areas to assess fluidities of substances beneath skin. The infraorbital area is also easily identifiable, as skin is thin with minimal fat. By compressing the area, soft-fluid consistencies generally confirm diagnosis. Finally, overfilled regions are most noticeable during muscle animation, where fillers accumulate in lumps beneath moving muscles. If you spot any such symptoms, visit a qualified doctor who can offer appropriate corrective measures, which meet comfort levels and needs. 

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