Does Filler Make Your Face Sag? The Science Behind a Common Myth
Does dermal filler cause sagging or permanent damage? Dr. Sinan Akyürek breaks down the myth and why correct planning changes everything.
“I’d like to have filler, but I’m afraid my face will sag.” I hear this sentence very often in consultations. Some patients heard it from their mother, some from a friend. Others are wary of the puffy, heavy-looking faces they see on social media. They have a point. I see those faces too.
So does filler really make the face sag? Filler placed in the right spot, in the right amount, does not. In fact, we often use filler to lift an area that has already sagged. Filler placed in the wrong spot, or layered on again and again, can make sagging worse in some areas, though. I’ll explain both.
First, why does the face sag?
Think of the face in layers. Bone is at the bottom. Above it there is a layer of fat, with muscles in between, then another, more superficial layer of fat, and skin on top. Running through these layers are ligaments that tie the skin to the bone and keep the face, in a sense, suspended.
With age, our bones even thin out in some places. The fat pads under the skin shrink. And gravity never stops; as it keeps pressing down, these structures are slowly flattened. Most of the time we don’t even notice. Then one day we look in the mirror and say, “my cheeks have dropped.”
So sagging is a process that carries on whether you have filler or not. If someone who had filler at forty sees that their face has changed at fifty, most of that change is the work of time.
So what does filler do here?
When the ligaments that hold the face up loosen and the support beneath them decreases, the face moves down. We gather those sagging structures upward and place the filler underneath them, almost like a wedge. As long as the wedge stays in place, that structure doesn’t drop again. You have put the sagging area back where it used to be, and without puffiness or an odd look.
Of course, a lot of this comes down to technique. It doesn’t always turn out that way. We see plenty of bad examples around us.
When does filler really cause sagging?
There are two situations, and I see both often in consultations.
The first is the under-eye area. The most common cause of hollowing under the eye is the volume loss that comes with age or weight loss. The midface moves down, the cheek drops, and under the eye a structure forms that hangs like a hammock, or a swing. If you put filler straight onto this hammock, it looks great on day one. But you have added the weight of the filler to a structure that already can’t carry its load. Over time it sags further. A worm-like line appears under the eye, along with a greyish-blue, puffy pouch. To avoid this, the sagging structures first need to go back to where they belong. If the under-eye area needs anything, we treat it last, with fine, careful work.
The second is filler layered on top of filler. Patients are usually told that “the effect wears off after a year.” That’s true. On average it takes about a year for half of a cross-linked hyaluronic acid filler to leave the body. So if you had 2 millilitres, your body brings that down to roughly 1 millilitre in a year. Meanwhile, ageing doesn’t stop: gravity, sun, smoking, diet. The face keeps moving down, you no longer see the lifted look of the first day, and you go back to the doctor and say, “it’s worn off.”
Half of that filler is still there, though. It takes roughly five or six years for it to be fully broken down and cleared. If more filler goes on, again and again, on top of the half that remains, the face starts to look heavy. Part of what people call “sagging” is actually this build-up.
There is also an approach I describe as “more, more, more”: use plenty of filler so that not even the smallest shadow is left. We call this overcorrection. Chins that look as if someone bought a loaf of bread at the corner shop and stuck half of it on the chin are the result. And if you only push the chin forward without supporting it from the sides, after a while you end up with a chin that droops downward. All of this comes down to the depth of the filler, the technique and the amount.
Can it be reversed if you don’t like it?
Hyaluronic acid filler has an enzyme that breaks it down, hyaluronidase. It is injected where the filler was placed, and the filler dissolves. When filler done elsewhere has thrown off the proportions, we correct it sometimes by dissolving it and sometimes by supporting the area that is lacking. So these problems can be corrected.
One thing to know, though: not every filler is hyaluronic acid. In mixed products that contain calcium hydroxylapatite, the enzyme dissolves only the hyaluronic acid part. Once three months have passed, the other part largely can’t be reversed. That’s why it matters that you know what is being injected.
How do I decide in the consultation?
When a patient comes in for filler, I first look at the face as a whole. Where did the sagging start, and what has been lost in which layer? Sometimes the answer is filler, sometimes threads, sometimes treatments that increase collagen, sometimes none of these.
Sometimes I also have to say, “this won’t give you the result you want.” Patients are disappointed, and honestly, so am I. But I would sooner say it at the start than have both of us live with the result of misplaced filler a year later. Which option suits which face only becomes clear in the consultation.