The Truth About Filler (& More)
according to plastic surgeon and needle artist Dr. Christian Subbio
Hello, hello!
Did any of you happen to catch my story in The Zoe Report: The Era Of Instagram Face Is Over? It offers a stark look at the current state of injectable fillers, complete with uncensored insights from some of my favorite people, including — drumroll, please — Dr. Christian Subbio.
Dr. Subbio is a board-certified plastic surgeon in Philadelphia, specializing in breast and body work as well as tasteful injectables. His Instagram captures not only his surgical results (like the 🤌 tummy tucks he’s famous for), but also the art he creates with fillers and toxins (or “jellies and poisons,” as he calls them). He’s an educator, a thought leader, and one of the most down-to-earth doctors I’ve come to know.
He’s also very tall. And pretty funny.
When I chatted with Subbio for TZR, he gave me tons of great material, as he always does, but only a fraction of it appeared in the piece. As my writer friends know, this is par for the course. We typically interview multiple sources, often at length, and while those conversations provide invaluable background info and collectively influence the tone and direction of the story, only so many expert quotes make the final cut.
Given Subbio’s passion for this topic — and the aesthetic community’s passion for Subbio — I couldn’t just file away his transcript, rife with unshared pearls. So, here, for your reading pleasure, is: Subbio, Uncut (edited slightly for length and clarity, with his approval, but still mostly unabridged and utterly undiluted).
Q: Considering all that’s transpired in the filler world in recent years, how would you describe the current mood of injectables?
A: I think we’re seeing a sort of sea change, a little bit of a pumping of the brakes.
Fillers have been around for decades in various forms. When hyaluronic acid fillers really boomed, five or 10 years ago, it was like a free-for-all. Suddenly, all of these providers had a nonsurgical way to rejuvenate faces. More people got into the aesthetics game. And almost no one was approaching filler with any kind of hesitancy, critical thinking, or concern.
The filler companies fed into this excitement unabashedly, without any stop-checks. Claims were being made and products were being sold and poorly vetted research was being offered. Everyone was just full steam ahead: Filler, filler filler! Everything can be addressed with filler!
Over the past couple of years, we’ve started to see the consequences of all that. Fillers are lasting way longer than we previously anticipated. These gels are not gone in nine to 12 months as we once thought. That was always the big talking point, right? Nine to 12 months, or some versions, like Voluma, may last “up to two years.”
So people were getting filled every nine to 12 months, like clockwork. No one was thinking that the filler they placed eight years ago, five years ago, three years ago — it was still sitting there. Fillers were building up and, eventually, people were going, “Wait a second — I don't look like myself.” That’s the idea of perception drift: Our faces slowly change, moving us further from our baseline, but since the changes are incremental, we don’t always notice that it’s happening — not right away, at least.
We’re now realizing that fillers can block lymphatics, they can cause water retention and unnatural puffiness, they can migrate, especially when used inappropriately. Over time, as your face is moving — as you're smiling, laughing, chewing — these gels are being pushed into other tissues, losing their shape, and becoming boggy. That's the epidemic of filler face we’re all seeing.
Q: Is this common knowledge at this point? Do you think providers and patients are getting the message about filler’s staying power and potential complications?
A: I think awareness of these problems has certainly increased. But you're going to find patients all over the spectrum. Some are very savvy and informed. But there are just as many clueless patients coming in the door.
The real problem is that patients are still super-reliant on providers for guidance. And our field is filled with people who are just jumping in without the proper training and buying into the old idea that filler fixes everything. They're not thinking about potential problems. They’re not taught to be conservative. I see it all the time. At the cosmetic meetings, everyone’s still walking around with pillow faces and duck lips.
Ultimately, you can have the most educated and skeptical patient, but if they trust their provider, they can still be convinced to do things [that aren’t in their best interest].
I put the onus on injectors to be the guardians, because there are still so many patients who aren’t as educated as they should be. Unfortunately, so much of this industry has not woken up to the message. Still, it’s on us, the providers, to be the gatekeepers, and we're just not doing it.
Q: Given what we now know about filler longevity, how are you talking to patients about touch-ups?
A: I usually see my patients a few times a year for toxin or other [non-filler] treatments and I use those visits as a sort of check-in. They'll typically say, “Hey, am I ready for more lip filler? Am I ready for more cheek filler?” And often the answer is, “No, I don't think so. It's still sitting there — I can see it.” Or: “No, your issue is more laxity than deflation and filler doesn’t help with laxity.”
Really, anyone who’s interested in aesthetics is probably seeing their provider two or three times a year, be it for toxin or a laser treatment or skincare advice. Those appointments should be a check-in for filler rather than a routine touch-up.
“It’s on us, the providers, to be the gatekeepers, and we're just not doing it.”
Q: How have the latest filler findings changed your overall approach to injectables?
A: I've become more and more conservative, because I’m always thinking of the possible downsides, the potential for future complications. I’m always thinking: I do not want to be the person who overfills this woman's face.
I realize that facial aging is a very complex, multifactorial thing — it’s not just about volume loss. So to address every issue with filler is a dated, overly simplistic, harmful approach. A certain portion of facial aging is deflation, and for that aspect, I will use fillers. A certain portion is due to decreased collagen, and for that, more superficially, I may use lasers. On a slightly deeper level, I may use biostimulatory agents.
Most importantly, I realize the limitations of what I'm doing, since a very substantial part of facial aging is tissue laxity and descent. And the only solution for that, I maintain, is facelifting — skin excision and surgical redraping of the tissues.
One of the biggest problems in aesthetics right now is that many performers of noninvasive modalities don’t recognize or respect the limitations of these treatments. You can only fill a sagging face so much. You can only paralyze the muscles so much. And furthermore, other modalities such as threads, in my opinion, are garbage. I don't want to be too harsh about that. But, ultimately, I do not believe there is any reliable modality that is going to lift and tighten a face other than surgery.
Q: While some providers do push the limits of nonsurgicals, shrewd patients seem to know what these treatments can and cannot do. Do you think this is lowering the threshold for surgery? Is the facelift becoming a more viable option for folks who, in the past, perhaps wouldn’t have entertained the idea of surgery?
A: I’d like to think that’s the case — that patients are becoming more open to surgical rejuvenation. And I have to add a caveat here: I don't do facelifts anymore, so I truly am speaking from a place of impartiality. I think maybe, slightly, as a whole, patients are more open to the idea of early surgical intervention, because they've been desensitized to it by social media. But I wish more people understood that there really isn’t a good nonsurgical option for tightening and lifting.
The onslaught from the med-spa complex embracing these “tightening” devices is just so unrelenting. The messaging from the noninvasive side of the industry is too strong. It's always going to be difficult to sell someone a surgery when you have 10 people trying to sell them a nonsurgical facelift, which costs less and has no downtime.
“One of the biggest problems in aesthetics right now is that many performers of noninvasive modalities don’t recognize or respect the limitations of these treatments.”
Q: I recently spoke to a facelift surgeon who says he’s noticing a trend of 40somethings sort of eschewing nonsurgicals, due to the social media messaging coming from anti-filler surgeons. He worries that younger patients are being pushed into surgery before they’re truly ready, because they're constantly hearing, “Filler is bad! Devices don’t work! Surgery is the best option!”
A: There definitely are those patients. But there are two edges of the sword. On one side are patients being talked into surgery in their 30s and early 40s. On the other side are patients being convinced to do nonsense treatments, which are blowing up their faces, or having no results, or making future facelifts more difficult. While both are a problem, I think the edge of the sword that is surgical is tiny compared to the other edge, which is broad. Which makes sense, right? It's much harder to convince a 34-year-old she needs a facelift than it is to convince a 52-year-old that she needs an extra syringe of filler.
These plastic surgeons who are anti-filler — I see them. Not only is it unrealistic to think that people are going to completely stop doing these treatments, it's ridiculous to suggest they should. There is a place for filler. Do you really think everyone's just going to wait until they need a facelift at 50? No, people want to be doing less invasive things along the way to make themselves feel better.
When a 43-year-old comes in and their face is starting to sag a little, and they say, “I just want...” and then start pulling up on their cheeks, I’ll usually say, “Look, the only thing that is going to reliably tighten your skin, unfortunately, is a facelift. But I would not recommend that right now. It would be very aggressive for you to do that at this moment. It’s going to be a lot of expense and downtime and the payoff will be small compared to what you're investing.” I suggest they wait until they’ll get more out of that facelift. In the meantime, there are things we can do to make them feel happier when they look in the mirror, without having to rush to the scalpel.
As someone who’s performed facelifts, done injectables, and tried every kind of device out there, I can confidently say there is a place for almost all of these modalities, as long as they’re done intelligently and conservatively. I don't believe that filler is right for everyone. I don't believe that facelifts are right for everyone. It's about the right treatment being tailored to the right patient with a critical mind.
Q: What’s your go-to for improving skin quality: skin boosters or devices?
A: I prefer lasers from a theoretical standpoint, because lasers — and I say this to patients every day — lasers are actually rejuvenating the skin as opposed to just pumping it with sugar molecules. They’re causing microscopic trauma, which is like kicking the engine and spurring the body to create its own collagen and elastin, to thicken itself and heal itself.
Because skin aging is complex, I do think there's a place for SkinVive and other skin boosters. The skin, itself, does need more volume, more hydration, but I wouldn't throw all my eggs in that basket. I wouldn't blast the face with skin boosters every six months perpetually. SkinVive provides an artificial hydration: It is artificially plumping the skin with an extra boost of hyaluronic acid. But truly rejuvenated skin has its own natural collagen and elastin and ground substance that attracts moisture.
In the right hands, lasers allow the skin to rejuvenate itself without messing with the facial architecture and risking the distortion that comes from too much filler.