A surgeon's view

By Stephen McCulley / 01 Dec 2013

Stephen McCulley MBChB, FCS(SA)Plast, FRCS(Plast) on the use of Hyaluronic Acid (HA) fillers in his facial aesthetics practice

I have been combining the use of HA fillers and surgery in my practice for the last 12 years. As treatments they complement each other but cannot replace each other. Therefore, it is important that a surgeon understands the value of fillers, just as it is for the cosmetic practitioner to know the limitations of fillers.


There has been a shift recently in the use of fillers to a concept of volumising tissues, as opposed to simply filling lines. This is hardly a surprising evolution as the connection between facial youthfulness and volume has long been recognised. The child’s full cheeks and short
lower eyelid length give the mid-face its youthful appearance. As we age there is a huge change in both fat and bone volumes in the face. This ‘volumising approach’ has been part of the face-lift culture for many years. However, the days of filling facial wrinkles are far from over! Just as the modern concepts in breast augmentation have moved away from being about volume to dimensions, make no mistake, for many patients it remains about volume. Similarly in facial fillers as we move towards ‘volumising’ it remains about wrinkles for many. There is obviously a place for both to complement each other. In youth we observe the movement or mimetic wrinkles such as around the eyes and forehead that turn into the permanent dermal creases of age. 

“There has been a shift recently in the use of fillers to a concept of volumising tissues, as opposed to simply filling lines. This is hardly a surprising evolution as the connection between facial youthfulness and volume have long been recognised.” 

Then with time we see the emergence of what I call ‘decent’ or ‘gravity wrinkles’ as the combination of volume loss and skin elasticity changes create skin folds such as the marionette naso-labial changes amongst many others.


There is no clear distinction between the role of fillers or surgery. However, the jowls, jawline and neck laxity remain the main roles of face-lift surgery. The square jawline created by the descent of the jowl can only be improved significantly and long term with surgery. Yet of all cosmetic surgery to the face, the eyes are one of the most successful and are important to discuss. Many patients I see come in requesting a face-lift to ‘improve their appearance’. I always ask them, as we all should with any treatment, what are the aims of the treatment for them. If they tell me they wish to look fresher or more youthful, I suspect in over 50% of patients, surgery to their eyes is probably the single biggest change they can make. This is very important to recognise as a patient can have all the fillers and toxin treatments possible, however, if it is the eyes that make them look tired or older then eyelid surgery should be at least discussed to augment their non-surgical treatments. Patients and alas some professionals, are not always that good at assessing what the real issues may be. Look at the face as a whole. If you are treating wrinkles alone you may not open your eyes to the whole face. Similarly, there is no point doing a face-lift when the real issue for the patient is actually just peri-oral lines.


There are many face-lift techniques. The short scar techniques are becoming more popular and have real advantages of both shorter scars and quicker recovery. They are good at managing the jowls and to a degree the mid-face and neck. However, a full face-lift is still better at managing large amounts of loose skin and neck laxity. Most techniques will show good changes to the jowls at five years and beyond, although changes to the neck do not always maintain as well. Many of these surgical techniques can improve mid-face fullness and now with the addition of fat injections this has become even better. However, reliable mid-face fullness can be elusive with surgery. There are some areas of the face that surgery will not impact upon. If one draws a line down from the inside of each pupil, very little to the midline of these lines will be changed by surgery.

Therefore, the peri-oral, the inner mid-face and the glabellar remain the remit of cosmetic treatments in my practice.


A further useful tool to help assess the potential role of surgery for a patient is to take a photograph of them lying down and compare it to a photograph of them sitting up. This is a reasonable prediction of what a face-lift, and to a degree eye surgery, will achieve once it has settled. This can be done a few weeks following non-surgical treatments. If there are good changes noted then facial surgery will have a good additional role to non-surgical treatments administered. If there is little change noted with this photograph test then the continued use of non-surgical treatments remains reasonable. I think there is also a misconception that there should be a choice between surgery or cosmetic treatments. I tell all my face-lift patients they will probably still benefit from fillers or toxin injections. The major difference is they may require less and the impact of the treatments can be even more dramatic in terms of eradicating troublesome areas. When fillers are needed in larger volumes, particularly in the naso-labial or lower face to create change then one must at least question using fillers alone. Indeed the use of large volume sub-dermal filler is questionable full stop as it creates skin changes over time. The exception to this volume rule has come in terms of deep cheek fillers creating cheek fullness. This concept has enabled larger volumes of HA to be used to good effect and safely, albeit it is quite expensive to patients. Skin re-surfacing must also be considered as part of the regime for a patient particularly around the peri-oral area.

Resurfacing in combination with fillers later can give excellent results. 

So when to use fillers and when to use surgery? Obviously it is not black and white. However, when a relatively modest volume of filler can create changes to the areas that bother a patient in that corridor of the face between the pupils then this remains a good treatment option as surgery is not going to impact these areas. In my practice this will be the glabellar lines with toxin and a combination of toxin and filler if deep; the peri-oral area, with or without resurfacing; the lips; small volume changes to the naso-labial folds and marionette lines. The deep filling of the cheeks is the only exception to these conservative rules in terms of absolute filler volume.

However, when the main problems for the patient are the eyes, the jowls, the neck, marked lateral brow ptosis or large volumes of filler are required around or particularly below the mouth then the question of surgery should be raised. Not to eliminate the need for non-surgical treatments, but to return them to their ideal role of providing fine or finishing touches to the face and adding proportional volume changes without damaging the skin. Don’t forget the photograph test to assess the impact of surgery. Of course, look at the face as a whole and always question what the patient wants to achieve. Finally, always question yourself, as a surgeon or cosmetic practitioner, to ensure you are delivering the optimal and tailored treatments the patient needs. 


Upgrade to become a Full Member to read all of this article.