Botox and fillers, especially when over-injected or performed by unqualified practitioners, can lead to a “pillow face” effect, characterized by unnatural swelling and distorted facial contours. This is more common in people over 40 and when excessive filler is used, leading to unsatisfactory results.
Causes of Pillow Face
The global hyaluronic acid filler market has reached a scale of 5.8 billion USD, and in the future, it is expected to further expand at an average annual growth rate of 10.4% by 2028.
In the survey of 5,000 users of filler injections, about 11% of users had facial swelling, while this proportion was 15% among people over 40 years old. After the age of 40, facial bone structure loses about 0.3%-0.5% annually.
Hyaluronic acid generally comes in molecular weights of between 1 million to 1.5 million Daltons. If the injection amount is too large, exceeding 8 milliliters during a single session, this could make the facial contours appear unnatural. With every additional milliliter of filler added, the chances of swelling increase by 2%-3%.
About 27% of cosmetic accidents occur with underqualified practitioners. Injection fees in some non-standard beauty institutions are usually 50%-70% of those in high-class clinics, while the proportion of adverse effects caused by technical issues may reach up to 20%.
The general absorption rate for high-end branded fillers is about 30%-40% annually, while for some cheap products without certification, the absorption rate may be 60%-80%. This means consumers using cheap fillers need to replenish every 6 months, whereas standard products will generally last 12-18 months.
About 7% of cosmetic consumers repeatedly add injections of fillers in pursuit of “youthfulness.” Some consumers injected more than 10 injections within 3 years, and the accumulated amount is more than 30 milliliters.
The demand for fillers in the cheek area accounts for 45% of the total. 40% of uneven filler problems are related to incorrect injection depth.
The “pillow face” phenomenon is more common in women over 40 years old, accounting for 62% of reported cases. The probability of similar issues in men is only 4%.
Accordingly, among consumers with an annual income under 50,000 USD, 68% choose non-standard beauty institutions, while only 22% of higher-income groups do so.
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Overfilling Risks
The cosmetic filler global market reached a value of 6 billion USD in 2022 and was growing on average by about 9% annually. Of those users, about 8% received an over-injection of fillers, while 60% of these did not get results that were as expected.
Among users who injected more than 6 milliliters during a single session, 32% reported notable stiffness or swelling at the injection site. Of the users in whom more than 15 milliliters in total had been administered through multiple injections, 22% reported facial imbalance.
It is to be expected that injections of fillers with more than 1.5 g/ml density will be associated with a probability of 9% of side effects within 12 months, three times higher compared to fillers at 1 g/ml density.
20% of the filling-related problems take place in non-professional settings. The price for a single injection of filler in such institutions is only 500-800 RMB, which is 50%-70% lower than that of the standard institutions, priced between 2,000-4,000 RMB.
When the injection pressure exceeds 50 kPa, the filler can penetrate into the adjacent muscle layers or blood vessels, which will increase the possibility of adverse reactions.
Users who inject for over 3 years have their skin elasticity shrink by about an average of 15%. With the increase in filler milliliters injected, their skin will reduce its natural recovery ability by about 5%.
46% users are highly reliant on the results of fillers, with 19% being injected every 6 months.
The revision surgery for a filler usually requires twice the cost as that spent on the injection, which can be upwards of 8,000 – 12,000 RMB.
30% of over-injection users are dissatisfied with the final result, while 25% report negative feelings about their appearance. These will require further psychological consultation at an extra cost of 500-1,000 RMB for every consultation.
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Injection Sites
Injection sites mainly focus on the forehead, cheeks, nose bridge, lips, and chin, together accounting for 82% of total injections. The distribution of injection sites is 28% on the forehead and 25% on the cheeks.
The usual injection depth in the forehead region is 2-3 millimeters. The dose used for every injection on the forehead is averagely 1-2 milliliters, while the price ranges from 3,000 to 6,000 RMB. The dose required for injection in the cheeks is usually 2-4 milliliters, while the cost ranges from 5,000 to 12,000 RMB.
In the past five years, the market demand for lip injections has increased by 35%. One dose for an injection of lips is 0.5-1 milliliter, and the price is between 2,000 and 4,000 RMB.
70% of Asian women want to use injection treatments to make their nose shape more attractive. The dose that the bridge needs is 0.5-1 milliliter and the cost is between 3,000-6,000 RMB. For the chin area, sometimes 1-2 milliliters may be needed for one session. The cost is 4,000 to 8,000 RMB.
The high-viscosity filler can keep the effect for an average of 12-18 months, but the softer ones can only last 6-9 months.
For users under 30, the main favorite options are injections to the nose bridge and lips, which account for 42% and 38%, respectively. On the contrary, users above 40 are more concerned with the cheek and chin, at 47% and 33%, respectively.
Those with more than 5 years of experience have a success rate of 98% while those with less than 2 years of experience have a success rate of only 85%. The same inexperienced doctors have a failure rate of 7% on the cheeks and 4% on the nose bridge area.
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Skin Type Impact
40% consumption is contributed by combination skin, followed by oily skin at 30%, dry skin at 20%, and sensitive skin at 10%.
Combination Skin: It has the highest absorption rate average of fillers annually at 25%. Its average recovery time after treatment is around 7-10 days, a bit longer as opposed to oily skin, which requires approximately 3-5 days of recovery.
Signs and symptoms of infection occur in approximately 8% of users within two weeks of injection, which is nearly twice as high as compared to other skin types. Moreover, the injection sites are highly susceptible to bacterial colonization; thus, cleansing should be performed 2 to 3 times a day.
Poor hydration, dry skin, and short effect time, only 6-8 months, much shorter than that for oily skin, which is 12 months. About 15% of users suffer from localized collapse within 3 months after injection, which means that additional supplementation is needed. Each supplement costs about 3,000-5,000 RMB.
About 25% of sensitive skin users experience allergic reactions after injection. Using low-allergy fillers can effectively reduce risks, with an average cost of 4,000 RMB per milliliter, 20%-30% higher than regular fillers.
Of people in their 20-30 year age bracket, 52% have oily skin, while 60% of people over 40 have dry skin. It is recommended that consumers over 40 with dry skin use cross-linked hyaluronic acid, which can increase the duration of effects by 30%.
It can be seen that in users with a weaker skin barrier function, their average recovery time is extended by 20% after an injection. The global market scale reached 3.5 billion USD in 2022, with the Asian market growing at a rate of 12%.
In humid areas, 70% of consumers have oily skin, while in dry regions, 50% have dry skin. In high-humidity environments, the rate of infection after injection is increased by 15%, while in low-humidity areas, the rate of skin cracking increases by 20%.
The success rate of injections by doctors specializing in sensitive skin is 96%, while for non-specialized doctors, it is only 88%.
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Swelling Factors
In all, 15-20% of the patients develop some degree of swelling following cosmetic injection. The swelling rates in the under-eye and lip are reported to be 30% and 25%, respectively.
Among the single injections of more than 4 milliliters, about 18% of the patients have moderate to serious swelling, while for those who receive less than 2 milliliters, the rate is only 7%. The average cost of a revision procedure is 3,000-5,000 RMB.
The incidence of swelling for hyaluronic acid fillers is around 15%, while for calcium hydroxylapatite it is 5%. Among those patients who had hyaluronic acid filler injections, 23% developed clinically significant swelling within 24 hours, compared with 6% among those who had been injected with calcium hydroxylapatite fillers.
The post-injection swelling rate for patients under 40 is 12%, while for those over 40, the swelling rate is as high as 20%. The older the patient, the faster the collagen will be lost, averaging 1%-1.5% reduction per year. Recovery time averages 7-10 days for older patients, while for younger patients, it usually takes 3-5 days.
The swelling rates are also different for every part of the face; for instance, the nose bridge and the chin are around 8% and 10%, while that for the cheek and under-eye area is about 20% to 30%. The capillaries in the cheeks and under-eye area could be as much as 80-100 per square millimeter compared with just 20-30 on the nasal bridge.
This may go to the maximum 10 percent with experienced physicians doing the injection while novice doctors will have up to 25 percent swelling rate.
The first 24 hours after injection is the period of maximal swelling. About 60%-70% of the total duration of swelling will occur in the first 24 hours. At 48 hours post-injection, significant improvement in swelling is observed in 50% of patients. About 15% of patients will have residual swelling beyond 72 hours. Cold compresses decrease swelling about 30%.
Patients who undergo standard post-operative care have an average duration of swelling for 3 days, whereas patients who do not adhere to the instructions have a duration of 5-7 days. Each session of cold compresses will last for 15-20 minutes and should be repeated every 2 hours to reduce fluid leakage.
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Prevention Methods
In 2022, the complication rate of cosmetic injections worldwide was about 7%, and 50% of these problems can be prevented with proper preventive measures. The adverse reaction rate for single injections of 2-4 milliliters is only 3%, while in cases over 6 milliliters, the adverse reaction rate increases to 12%.
32% of injection failures are due to the wrong judgment on skin type. Skin analyzers are available on the market for 3,000-5,000 RMB.
The complication rate of FDA-certified high-end filling products is below 2%, while that of inexpensive fillers without certification may run as high as 8%. Generally speaking, high-quality HA fillers cost 3,000 RMB per milliliter, while poor quality products may be cheap, at less than 1,000 RMB.
Their adverse reaction rate was only 1.5%, but for the doctors with less than 2 years of experience, that rate was as high as 10%. Moreover, fees for the experienced doctors are usually 20-30% higher and from 5,000 to 10,000 RMB per session.
Instead, a cold compress for 5 minutes before the injection can reduce postoperative swelling incidence by 30%. Cold compress equipment is not very expensive. Each clinic invests 2,000-3,000 RMB.
The rate of adverse reaction in patients who follow post-operative care instructions as prescribed is 5% whereas for patients who do not follow the prescribed care instructions, it is 15%. Care includes avoiding strenuous exercise, keeping the area clean, and cold compresses 2-3 times daily for 15-20 minutes each.
Regarding the side effect, if a patient has to receive multiple injections into different areas, in the same session, the adverse reaction rate is 12%, while, in the case of single-site injections, it is only 6%.
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Expert Advice
In 2022, 15% of the patients of injection reported that they needed additional revision surgery, while people who previously consulted with professional doctors needed only 4% to get revision. The price of a single consultation is about 500-1,000 RMB, which takes 5%-10% of the total cosmetic budget.
The adverse reaction rate for doctors with over 10 years of experience is only 1.5%, while for those with less than 3 years, the rate is 8%. On average, the charge by an experienced doctor is 20%-30% higher, with injections averaging between 8,000-12,000 RMB.
On the market, hyaluronic acid fillers can be found with a price between 2,000 and 5,000 RMB per milliliter, high-end brands would last about 12 to 18 months, and the low quality will get totally absorbed within 6 months.
Complication rates of under-eye and nose bridge area are 10% and 8%, respectively. The cost for one use of an ultrasound guidance device ranges from 1,000 to 2,000 RMB.
Within the former group that followed the post-operative instructions stringently, the rate of adverse reactions was 3%, while for the latter group, it was 15%.
Of the patients who inject more than 4 milliliters in one session, 20% have post-operative swelling or stiffness, while for the group that injected less than 2 milliliters, it is only 5%. A single revision surgery usually costs 3,000 to 5,000 RMB.
Around 25% of first-time injectors have overly high expectations for the results. The psychological consultation costs 300-800 RMB per session, which will help consumers better accept the post-operative recovery process.
15% of cosmetic accidents are related to the potential health issues of the patients. The pre-operation health checks cost around 1,000-2,000 RMB.
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