From Puffy to Proportional: How to Avoid Pillow Face

Most have seen it, even if they have struggled to describe what is so often uncanny about it. Commonly referred to as “pillow face,” it is the swollen and distorted appearance of the face due to the placement of too much filler, usually in the wrong location(s). Pillow face consists of:

1. Overfilled, swollen upper cheeks near the junction with the lower eyelids, which can lead to the appearance that the eyes are narrowed and difficult to open.
2. Overfilled, swollen upper lateral cheek, making the face look too wide.
3. Overfilled, swollen lower cheek around the upper lip, which can make the face look aged.

All three are important factors. The overall effect is an over-enlarged, upside-down triangle on either side of the face that looks unnatural and distorts the surrounding anatomy.

It simultaneously makes patients look older because of the flattening of the ogee curve. The s-shaped ogee curve consists of the convexity extending from the junction of the lower eyelid and cheeks that then transitions to a concavity lower in the cheek near the upper lip from an angled view of the face. Drooping volume in the cheeks with age also flattens the ogee curve. The concern about pillow face is likely one reason for filler fatigue in some patients.

Less Likely Potential Causes of Pillow Face

Another, less likely explanation for pillow face is related to filler migration. Hyaluronic acid fillers can very rarely migrate into the lower eyelids and upper lip. It is highly unlikely that a significant amount of filler can migrate such that it is noticeable in, for example, the cheek. However, when filler does migrate into the lower eyelids and/or upper lip skin, this can also distort the appearance of the face near the cheek.

It is also highly unlikely that an inappropriate product is the cause of pillow face, as the major brands producing hyaluronic acid filler are Food and Drug Administration (FDA) approved for the specific locations in which they are being injected.

Pillow Face Filler: Recognizing the Red Flags

There are multiple red flags that an injector should recognize that would suggest adding more fillers could cause or worsen pillow face:

• Importantly, a general recognition of what looks abnormal and/or unnatural. Such an aesthetic eye requires extensive training and experience.
• When someone requests ever more filler to address minor imperfections and/or asymmetries that they feel are related to previous filler injections. Again, what is too much is largely based on the experience and sound judgment of the injector. The extreme cases are easier to identify but occur less frequently.
• Obviously, measurable features such as flattening the ogee curve. As a reminder, a high-peaked, well-defined ogee curve is a sign of youth. Too much volume added low in the cheeks near the buccal space is highly likely to flatten this curve.

Two (2) Ways to Correct Pillow Face

1. Dissolve the filler in place using the enzyme hyaluronidase. Dr. Harmon prefers Hylenex® because it is modelled after the human form of the enzyme – as opposed to bovine (cow) – which makes it less likely to cause an allergic reaction. He sometimes needs to dissolve filler prior to deep plane facelift surgery because of the potential effects of filler on the appearance of facial anatomy during surgery.
2. Rarely, and only in “extreme” cases, Dr. Harmon asks patients to take a “break” from filler for a period. The distortions associated with pillow face often creep up on individuals because they begin to forget what they looked like prior to treatments. This is because the development of pillow face is usually progressive, occurring over a period of months to years.

Choose Dr. Harmon

Most patients with pillow face would likely have been better served by undergoing deep plane facelift surgery and a neck lift. These procedures can actually lift fallen volume rather than simply adding more volume, which makes for a more natural, youthful appearance. Then, more conservative volumes can be added using, for example, the patient’s own fat.

Alternatively, a lower volume of hyaluronic acid filler can be placed more selectively after surgery. Also, if the decision is made to use fillers, then a staged, gradual injection process is more appropriate in some individuals. In addition, it is important to establish a minimal time to wait between additional injections after aesthetic goals have been reached.

Book Your Consultation

If you’re concerned about facial volume loss or the appearance of pillow face, a consultation with Dr. Harmon can help you understand your options and determine the safest, most natural approach for your face.