Volume, placed with restraint.

The face loses fat and, over longer periods, bone. The temples flatten, the cheek loses projection over its structure, and the transitions that were once smooth become shadows and edges.

Filler placed at those specific points restores the transition. Placed indiscriminately across the midface, it produces width. That is the single most common way this treatment goes wrong.

The goal is to rebuild a transition, not to inflate a region.

Lips lose volume and definition with age. The border softens, the vermilion thins, and the upper lip lengthens. Treatment aimed at those specific changes reads as restoration.

Treatment aimed at size alone reads as filler, from a distance, to everyone. Proportion to the rest of your face is the constraint that matters.

The hollow beneath the eye is usually a deficiency rather than an excess, which is why removing fat from it so often makes it worse. Carefully placed volume can soften the transition from lid to cheek instead.

This is the most technically demanding filler area on the face. The skin is thin, the margin for error is small, and the results of getting it wrong are conspicuous and long-lasting.

Deeper folds, particularly around the nose and mouth, can be softened directly. It is worth understanding that a fold is often a downstream consequence of volume lost above it, in which case treating the fold treats the symptom and treating the midface treats the cause.

Mine is primarily a surgical practice, and for most of what filler gets used for I think lifting and fat transfer are the better answers. So I inject cautiously, and I turn down more filler requests than I accept.

I want people to look natural. I do not like a puffy pillow face.

The other reason is practical. Filler makes surgery harder later. In my experience patients with a filler history hold onto swelling considerably longer, sometimes needing repeated courses of steroids, and I have seen it produce an inflammatory response during healing. In rare cases it affects how incisions heal, particularly around the midface and eyes.

So filler in my practice is largely for patients who are genuinely not planning surgery for the next five to ten years. If you expect a facelift within a few years, I will usually advise against filler now, and where there is a lot already in place I will recommend dissolving it before we operate.

• Juvéderm in the lips and, for patients who are never going to have surgery, in the nasolabial folds and marionette lines
• Restylane around the eyes, in the tear trough and along the lower orbital rim
• Juvéderm Voluma placed deep on the bone at the cheek, in selected cases

I have moved away from doing much tear trough filler. Older patients with that concern have better and more lasting options, fat transfer in particular, and tear trough filler can sit there for years in a way that is not always a good thing.

Wherever filler goes near a fold or a line of movement, I will tell you the same thing: it will soften it, and it will not erase it. Muscles pull on those areas, and they can move product into positions nobody intended.

Contour irregularity, overfilling and lumpiness are the common ones. So is the Tyndall effect, a bluish cast where filler sits too superficially. All of these can be corrected by dissolving the product with hyaluronidase.

Vascular occlusion is the serious one: filler entering or compressing a vessel, which can cause the skin supplied by it to die. I mitigate that by using blunt-tipped cannulas for essentially all filler injection. I use a needle only for fine lines around the mouth, where placement is just beneath the dermis and well away from any major vessel.