With over 20 million views, #fillergonewrong is captivating TikTok's aesthetic enthusiasts with its hard-to-avert-eyes content: square jawlines, overly plump lips, bulging under-eye areas, and horrifying vascular occlusions that often result from botched liquid rhinoplasties.
"I've witnessed a significant increase in injectable complications," states Dr. Jessica Weiser, a board-certified dermatologist in New York City. She notes that behind the majority of filler failures are inexperienced injectors lacking adequate anatomy training, either choosing the incorrect type of gel for a specific area or injecting it improperly.
Dr. Sarmela Sunder, a board-certified facial plastic surgeon in Beverly Hills, California, also reports a strong connection between the rising complication rates and the growing number of unqualified providers across the country (many of whom have no aesthetic background or training). "A considerable number of these injectors are extending one technique to multiple areas of the face," she says, and failing to recognize that a method that works well for enhancing the lips, for instance, isn't suitable for smoothing the under-eyes. She also observes, among certain injectors, "a strong inclination to stick to one company for all products" to obtain discounted rates. In her view, it's very rare that every area of the face can be treated with injectables from a single manufacturer – and thus "incorrect products end up being used in the wrong areas," she remarks.
Furthermore, as various fillers continue to obtain FDA approval and enter the market, excitement builds around emerging products, exerting considerable pressure on injectors to rush to use the latest offerings. And being among the first to offer the newest gel can sometimes result in patients becoming involuntary test subjects.
In Washington, D.C., board-certified dermatologist Dr. Noëlle Sherber has been rectifying her share of injectable blunders from other practitioners – ranging from uneven filler placement to overfilling and migration. She finds the thin-skinned areas of the face, such as the lips and under-eyes, to be "the least forgiving in terms of [inappropriate] product and technique, causing contour irregularities."
Correcting bad filler typically involves dissolving unwanted gel with hyaluronidase, an injectable enzyme, before starting anew one to four weeks later.
All the doctors we spoke to mention that they are using much more hyaluronidase than before – and that the process of reversing filler has become more challenging. "Back when it was just classic Restylane and Juvéderm [on the market], we could dissolve products very rapidly," Dr. Sunder tells us. "Now, with these more crosslinked fillers, we find ourselves dissolving for a much longer time." Regarding filler, she adds, "you truly want to get it right the first time because dissolving it can be a considerable challenge."
We asked top injectors about the poor work they are fixing daily – and how you can avoid filler gone wrong.
Under-eye filler gone wrong: bumps, blue hue, chronic puffiness
"Outweighing any other filler complications I observe, by a considerable margin, are [those from] injections in the tear trough area," says Dr. Jason D. Bloom, a board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania. (Dr. Bloom's practice routinely handles complications from other area clinics.) Whether due to the wrong filler selection or overly superficial placement, under-eye issues are "the most significant thing I'm dissolving filler for."
The unique structure of the lower eyelid can easily confuse new injectors. "In every other area of the face where we inject, the layers of the tissue [from top to bottom] are skin, subcutaneous fat, and muscle," he explains. "But in the lower eyelid, the skin is directly attached to the muscle and the fat is beneath. So if you attempt to place filler between the skin and the muscle, it has nowhere to go and creates a worm-like lump or you get a Tyndall effect" – a bluish tint cast by light reflecting off gel that's just beneath the skin's surface.
Juvéderm Volbella XC recently became the first filler to be FDA approved for the tear troughs. However, some doctors insist that the gel, which is part of the Vycross family, is not the ideal choice for the delicate under-eyes. They claim it's prone to cause swelling and lumps and can be difficult to dissolve. Since tear trough injections using any other type of filler are considered off-label, those filler manufacturers cannot train providers on how to treat the area. Which presents a dilemma, says Dr. Bloom, because "it's the first thing every novice injector wants to learn – 'How do you do the tear troughs?'"
The demand for this procedure is overwhelming, he adds, because "it's one of those areas that looks remarkable when done correctly."
That being said, under-eye filler isn't suitable for everyone, and careful patient selection is crucial to avoiding complications. "In my opinion, only 20–30% of patients are candidates for tear trough filler," says Dr. Kami K. Parsa, a board-certified oculoplastic surgeon in Beverly Hills, California. "People who have fluid retention under the eyes, chronic allergies, or a history of autoimmune disease are not candidates." In these individuals, hyaluronic acid (HA) gels can trigger malar edema, a temporary swelling of the lower lids.
When the puffiness becomes persistent, bags called malar mounds can establish themselves on top of the cheeks. The usual solution is hyaluronidase – which, by melting the HA, addresses the cause of the swelling and prevents the overlying skin from stretching and becoming loose.
Lip filler gone wrong: lumps, migration, and more
"Lip filler has been a significant problem recently," Dr. Weiser says. "I've seen numerous instances of filler being placed too deeply in the lip, resulting in a ridge along the moist mucosa of the lip, where it shouldn't be." Poor technique also shows up as asymmetrical outcomes, "sausage-like, shapeless lips," duck-bill contours, and overly done white rolls, she notes.
Lumps can surface for various reasons, but in active areas, like around the mouth, it's not uncommon for "the muscles to take over and bunch up the filler," Dr. Bloom says. Using a gel in the lips that's too thick or overly firm – such as one intended for cheeks or jawlines – can also lead to a lumpy appearance.
Filler migration – the product shifting from its original location and distorting features – has become a social media phenomenon lately. According to our experts, when an appropriate dose of a suitable filler is injected at the correct depth, it really shouldn't move – but sometimes it does. While "I can't tell you with 100% certainty how it occurs, I can tell you that it does happen," says Dr. Bloom. And some gels are more likely to shift than others. "The older generation of fillers was more slippery and prone to migration," notes Dr. Sherber, "but the newer, more elastic forms of hyaluronic acid should be less susceptible to this if placed correctly." While highly mobile areas, like in and around the lips, can be particularly prone to filler migration, she adds, it can also happen in the cheeks and jawline when filler is injected too shallowly.
In lip filler patients, a desire for excessive size can contribute to migration. "When I see a patient come in with migrated lip filler, I ask to see a photo of their previous lip shape as well as the goal photo they gave to their last injector," says Dr. Sherber. "I often find that their goal photo is not anatomically realistic for them and that their lips have been overfilled [to meet their request], which has led to the filler spilling into the surrounding tissues over time."
Even when the ideal filler is placed perfectly, she explains, if the lips can't hold the injected volume, the gel will seep into adjacent areas.
Hyaluronidase can be injected into the lips and the skin above – in small amounts over several sessions – to gradually bring the lips back to the baseline (or closer to it). "The key is knowing when filler must be dissolved and when it can be corrected," Dr. Weiser says. "Lumps or ridges in the lips or gums need to be dissolved, while asymmetry can typically be corrected."
Nose filler gone wrong: blocked vessels and scarring
Dr. Sunder includes nose filler among the top three types of injectable complications she deals with in her practice. (Since Dr. Sunder is a rhinoplasty specialist, injectors frequently send their severe nose cases her way.) Unlike most other filler errors – which tend to be reversible cosmetic concerns – nose filler gone wrong can have both disfiguring and permanent consequences. With noses, Dr. Sunder explains, it can be an emergency situation where there's an active vascular occlusion that requires prompt attention to save the patient's skin, or it might be a case of prolonged scarring from an occlusion that was previously treated but perhaps not fully resolved – "a part of the skin never got properly reperfused, so there's long-term damage," she says.
In some cases, she's using lasers or microneedling to improve the texture and any hyperpigmentation of the skin. In others, she's relying on reconstructive procedures, like regional flaps, to rebuild parts of the nose – commonly, the side of a nostril or a portion of the tip – that were lost to necrosis.
