At the beginning of the injectable “Baby Face” boom, we all saw the overzealous use of filler, creating the overfilled swollen, sometimes unrecognizable, look in women across the country. Then as techniques were refined, and doctors learned from their mistakes, things seemed to improve. But, surprisingly, still there is a trend in America for women to get the slightly overfilled, and even more alarming, the stuffed animal look. Nowadays, some women have the goal of a cyborg-ish animated cartoon look in a quest for every line and crevice to be filled. In their mind this makes their face look “perfect.” But, in reality, for younger women, it makes them look oddly older and usually less attractive; they no longer have the look of a “girl.” For women who are trying to look younger, it can just make them look strangely fake, and everyone begins to look alike. This phenomenon makes other women very skeptical of getting filler or Botox at all because they recognize the look and don’t want this to happen to them, and incorrectly think that all women who get filler look like this.
So, what is the issue going on in these women that makes them look oddly less attractive and sometimes older. I have one answer: “No division of cosmetic units.” The first thing you learn when you are learning how to do reconstructive surgery in Dermatology or Plastic Surgery is to put the surgical scar within a “ cosmetic unit” and never cross over a “cosmetic unit” with a surgical scar. So what is a cosmetic unit? Cosmetic Units and Subunits are junction lines that are fixed landmarks that separate the cosmetic unit of the face. They are aesthetic, regional units that represent the major structural areas of the face that are separated by contour or junctional lines/boundaries. These units are designated based upon their similarity in topographic anatomy, texture, and color, solar exposure, hair density, and sebaceous features. The major cosmetic units are forehead, temples, eyelids, nose, cheeks, upper and lower lips, chin, and ears. Within each division, there are even smaller subunits that are separated by topographical changes, texture, etc. (Below is a photo of the major cosmetic units and subunits.)
So, what seems to happen in women and men who get too much filler or misplaced filler? It is normal to have cosmetic units; they are the junction/boundaries on your face that separate the face into its distinct unique areas. These areas are generally the same for all of us, but for each of us, we have individual slight variations in the separations. Think of Cosmetic Units as areas separated by “seams.” Think of a puppet and the vertical separations on either side of the chin that allows the puppet’s mouth to open and allow the chin to move up and down. Those vertical lines are the lateral borders of the lower lip and chin cosmetic units. If this line were to be blurred by a surgical scar that crossed either of these lines, it would be very visually noticeable. If the scar were kept in between those 2 lines, it is less noticeable. It is even less noticeable if it falls either above or below the chin crease that defines the upper border of the chin cosmetic unit in the middle of the chin because crossing that “invisible” crease is crossing a cosmetic unit. So what happens if these subtle “seams” in the face are obliterated? Basically your face becomes a homogenous round mass like a stuffed animal face. There are no topographical indentations, creases, elevations, or depressions to denote a separation of the cosmetic units. And, obviously, a stuffed animal looks fake! It is not real! And this is exactly what happens with overdone or misplaced injectables. The injector purposely is filling the lines, creases, depressions, and other “seams” that make the face a face!!!! So, in essence, these women and men who have filler placed in these areas in an attempt to obliterate the junction, end up looking like an animated cartoon character that has no defining features on their face. Even if they technically don’t have a huge volume of filler, an “overcorrection,” they do have a misplacement of the filler. The fact that the creases and folds are being erased, creates a very amorphous uninteresting face.
This situation is most often seen when the provider lets the patient tell them where they want filler. Most times the patient has no idea why or if they need filler, but they are concerned that they look older or feel something is out of place if they are younger. They often point out their normal creases and folds as the root of their problem because these are things they can see. Their uneducated perception is that these seams must be the problem area. But, if the injector isn’t properly trained in the aesthetics of the face, they can fall into the trap of injecting and obliterating these junction points. In the aesthetic assessment of a patient, the goal of the examination is to find deficiencies in balance and to restore those imbalances. The goal is not to fill every crevice in the face.
The take home point of this article is to actually try to put a finger on what is causing the hard to describe subtle and sometimes not so subtle instant recognition of a face that has incorrectly placed filler, because once the cause is identified it becomes easier to correct. If you are a patient, you can talk to your provider about your concerns and discuss the cosmetic units and his/her approach to avoiding blurring the lines. For the provider, hopefully this sheds some new light on filler placement to give a natural look. Ultimately, the goal with filler is to look as though you have nothing in your face. You should have the normal grooves, elevations, and hollows that make up the components of a human face. When the face has minimal contours and “seams'' the brain immediately recognizes this discrepancy. If you are a young person, I would encourage you to study the images of older models and women before filler existed. What made these women beautiful? What makes any woman exotic, unique, and beautiful. I submit to you that beauty comes in endless forms. Don’t try to erase your unique features that make you look youthful and balanced. It really is all about balance.
