• Dr. Carin Litani

The Skinny on Injectables, Part 2: Fillers

What are they? What are they made of? Do I need them? When should I start? What goes where?


So now you know how Botox® works. Now let’s discuss fillers. There are many different brands and within those brands there are multiple types of fillers. I am going to review Hyaluronic Acid (HA) fillers in this blog.


Hyaluronic acid is a naturally occurring sugar that holds water in our skin and joints. It acts like a sponge in our bodies and can hold a thousand times its weight in water. It keeps our joints padded and our skin looking hydrated and glowy naturally. That’s why we love HA in our serums and creams!


So, what does Hyaluronic Acid have to do with fillers?

Hyaluronic Acid fillers consist of a gel version of hyaluronic acid. Since HA works by drawing and retaining water, HA fillers can plump and smooth out folds and wrinkles in the skin. It looks like jelly if you just inject it on a piece of paper. HA fillers have been around for over a decade and they have come a long way from just filling in fine lines and folds. They have been modified and cross-linked in various ways to give the jelly different properties. They can be more or less cohesive, lift or smooth, stay stiff or flexible, can be injected deep on bone or barely into the dermis.

Although there is a whole arsenal of different HA fillers on the market, it’s really the injector (and by injector I mean your board certified dermatologist or plastic surgeon and not their nurse or PA) and not the filler that makes the difference. I have to stress that getting filler injections is a medical procedure and also an art. This is not a lunchtime facial. Like any medical procedure there are risks of complications which your doctor should feel comfortable handling. This is also an art rather than a paint-by-numbers procedure. I like to customize an approach for every patient. No one should be able to tell where filler has been placed. It should look and feel natural. Poorly placed filler can make a person look cartoonish.

Let's Pro-Age


Remember, aging is a gift. Let’s pro-age rather than resist it. Still, there are some drawbacks that we can address. Personally, I believe we have earned our fine lines and wrinkles. They show we have experience and have lived! However, I feel that sagging makes us look tired, old, and unfriendly. Gravity is not our friend. Our skin naturally loses elasticity and collagen as we age, and gravity pulls it inward and downward. We lose bone and fat as well which makes the skin appear loose and easier to pull inward and down which:


  • Creates folds that extend from the inner corners of the eyes down to the mid-cheek

  • Creates folds by our smile lines

  • Creates folds near the corners of our mouth, and

  • Creates a double chin and jowls!


Too many folds!

Bring Back More Youthful Looks

We become more square-shaped and lose definition between our jawline and neck. I recommend addressing these structural changes to rebalance the face to bring back the youthfulness of a straight jawline, projected chin, lifted lateral cheek … creating an oval or heart shaped balance to the face …. rather than fixing a fold or line. Look at some older women like Helen Mirren, Martha Stewart, Susan Sarandon, Christie Brinkley and Vanessa Williams (I don’t know what they have or have not done cosmetically). Some have more wrinkles than others but they all look good for their age because they have a youthful facial balance regarding lifted cheeks, projected chins and straight jawlines.


So let’s think of the face like an aging house. The support beams can buckle and walls can sink or thin out making the house change shape and look old. This changes the position of the windows (eyes) and door (mouth). By addressing these structural changes first, the house can look better and more radiant without even touching the doors and windows. (Can you tell I'm mid-renovation on my house!?!) Let’s apply this to the face. By addressing the deep fat and bony support of the face, the eyes and mouth look lifted and younger, and folds and lines end up correcting secondarily.


I like to assess the face with photos at different angles and discuss what bothers the patient and design an approach to make the patient look and feel better about their face and the aging process. For example, if a patient is bothered by deep nasolabial folds, I like to see if sagging cheeks is causing this. If we address the folds and not the cheeks, it may look better for a few months but then as the cheeks continue to sag, the lower face with the filler ends up looking too full and unnatural.

Filler Brands and Where I Use them


As mentioned earlier, there is an arsenal of fillers and many can be interchanged. Your physician may have a preference because a particular filler in a certain location has given great and predictable results with minimal complications.

The fillers I tend to use are the Galderma Restylane® brands (Lyft, Refyne, Silk, Kysse, Defyne) and the Allergan Juvederm® line (Voluma, Volbella, Vollure, Ultra, Ultra Plus). I like to use only Voluma or Lyft in the cheeks and chin whereas in the lips I like to use either Ultra, Ultra Plus, Refyne, or Kysse depending on the age of the patient and the result we are trying to achieve (more pouty or slightly smoother without projection).


These are areas that can be injected with filler:

  • The temples (lifts the eyebrows and eyelids, avoids the being peanut head look)

  • The cheeks (creates a more oval and youthful facialshape, lifts jowls, helps correct tear troughs or undereye circles, lifts up nasolabial folds, makes the face and eyes look less tired, smooths out lines near eyes)

  • The nasolabial folds (best done in combination with cheek filler)

  • The tear troughs or hollows under the eyes (best done with cheek filler)

  • The lips (can be subtle or dramatic but always takes years off the face by creating a better ratio between the upper lip and lower lip/chin area)

  • The chin (game changer, really. This supports the entire face, makes the lips look better and can make a double chin smaller or even disappear)

  • The marionette lines/the lines extending from the corner of the lips down

  • The jawline (lifts jowls and neck. Best done in combination with cheek and chin filler)

  • The nose (straightens and lifts the tip)

  • Fine lines around the lips and cheeks (usually are smoothed out secondarily as structural support addressed but can be injected with a thin hydrating intradermal filler to smooth out and make the skin more dewey appearing )

  • The forehead (can make it look more rounded and catch the light)

  • The earlobes (gives those piercings support so your earrings sit higher and straighter on the ear)

  • The neck (smooths out the horizontal lines )

  • The hands (your hands should not look older than your face! Filler can make then look less veiny and skeletal)

  • A-frame deformity in the medial upper eyelid (some upper eyelids can appear more hollow and skeletal and tiny bit of filler can soften this )


Common and Not-So-Common Things to Know


The most common issue after filler injection is bruising and swelling. I tend to use a blunt-tipped cannula (check out my Instagram where I show how it works) which minimizes bruising, but some areas (especially around the mouth and chin) will always have some bruising. The area under the eyes, the lips and chin tend to swell and can take a few days and even up to 2 weeks to settle down.


Major complications include vascular occlusion and embolus. This means that filler presses on a vessel or actually enters it which can cause skin necrosis or sloughing. This can be treated and prevented if caught when it occurs or soon thereafter.


Immediate and delayed bumps can occur and are easily reversed with massage or an enzyme that dissolves the filler.


Rarely (key word here), some bumps can appear months later after a vaccination, dental procedure, or other immunologic process (like the flu or severe allergy). This is very rare and resolves on its own or with antihistamines or oral steroids.


The scariest complication, blindness, is also rare and can be avoided by not treating high risk areas or using a very safe and methodical approach in those areas (like the nose and forehead).


Please don’t be scared by these complications. By seeing an experienced physician, complications can be recognized and addressed early. Remember, these are medical procedures and that’s why I stress not being swayed by an injector's Instagram or marketing ploys. Training and experience matter the most.


I want my patients to look and feel their best and I try to educate them about the aging process and how we can roll with it and pro-age. I do recommend starting your aesthetic journey early to be ahead of the effects of gravity and volume loss but I treat all ages and it’s never too late to be your best self. I injected an 85 year old woman’s lips recently and she was so happy that they no longer hung down over her teeth and she sent me card saying how happy her 90-year old husband was with her new look! We can achieve amazing and natural results at any age.


To find out more or make an appointment, contact me!