Abstract

Fear of overfilling has become a dominant concern in aesthetic medicine, often leading to under-treatment or compartmentalized approaches. This case report challenges that paradigm by demonstrating that even with high-volume filler use 27 syringes in total a natural, balanced and emotionally restorative result can be achieved when guided by anatomical precision, thoughtful sequencing and outcome-driven planning.

We present the aesthetic transformation of a 34-year-old Asian female who received a combination of botulinum toxin (onabotulinumtoxinA), hyaluronic acid fillers (Juvéderm Voluma, Volux, Volift, Volbella), SkinVive (Volite) and cryolipolysis with CoolSculpting Elite. The patient, who was treatment-naïve and sought noticeable yet natural results, underwent a phased treatment protocol planned around structural correction, contour enhancement and skin quality improvement.

Validated outcome tools, including the FACE-Q Aesthetics Module, revealed marked improvement in perceived age, satisfaction with facial appearance and psychological well-being. Notably, despite the high filler volume, there were no signs of overfilling. This demonstrates that syringe count alone is not a reliable predictor of aesthetic heaviness or distortion. Instead, balanced results are driven by the right product, placed at the right depth, in the right patient.

Despite the cumulative syringe count, results were balanced and natural because volume was distributed by purpose and plane: deep structural support, superficial refinement and intradermal skin quality treatment, with submental debulking to improve proportion. This case supports planning by anatomy and outcome rather than syringe totals alone.

Keywords: Case Report; High-Volume Fillers; Overfilling Myths; Botox; Juvéderm; SkinVive; CoolSculpting Elite; Facial Harmony; FACE-Q

Abbreviations

HA: Hyaluronic Acid; FOS: Facial Overfilled Syndrome; DAO: Depressor Anguli Oris; MD Codes: Medical Aesthetic Landmark Injection Codes; PROM: Patient Reported Outcome Measure

Introduction

Facial aging is a multifactorial process characterized by both skeletal remodeling and soft tissue volume loss, which alter the three-dimensional topography of the face. Foundational studies have shown that the aging face undergoes significant volumetric depletion across distinct fat compartments, leading to a deflationary appearance and disruption of youthful facial proportions [1]. This compartmentalized atrophy contributes to midface descent, periorbital hollowing and jowling, among other age-related features. Concurrently, the craniofacial skeleton itself undergoes resorptive changes, particularly in the maxilla, orbital rim and mandible, reducing structural support for the overlying soft tissues [2]. These combined factors result in a net loss of projection, contour and facial harmony. As Coleman and Grover emphasized, addressing age-related facial changes requires a comprehensive understanding of both surface and deep anatomical alterations, with volume restoration playing a critical role in modern aesthetic rejuvenation [3].

As recognition of facial volume loss as a central hallmark of aging has grown, so too has the emphasis on global volumization strategies in aesthetic medicine. Dermal fillers, particularly Hyaluronic Acid (HA)–based products, have emerged as a cornerstone of non-surgical rejuvenation techniques, offering an effective means to restore youthful contours and facial harmony. Unlike earlier filler paradigms focused narrowly on nasolabial fold correction, contemporary approaches embrace full-face volumization, often referred to as the “liquid facelift.” This concept was exemplified in a study by Taub, et al., where 6 to 8 mL of HA filler was injected across multiple facial zones in ten women, resulting in an average reduction of 6.1 to 7.3 years in perceived age by blinded dermatologists and up to 9 years according to the patients themselves [4]. These findings underscore the transformative potential of strategic multi-syringe filler use in facial rejuvenation, demonstrating that aesthetic improvement depends more on anatomical precision and balance than on absolute filler volume alone.

Balancing this is the fear of facial overfilling, which has gained recent attention in aesthetic medicine, driven by both clinical missteps and the influence of exaggerated results seen in public figures and on social media. Patients and practitioners alike have become wary of using high filler volumes, associating large syringe counts with distorted proportions and unnatural outcomes. However, emerging evidence makes clear that it is not the volume of product that creates the overfilled appearance, but rather poor technique, disregard for anatomical planes and failure to respect facial dynamics and proportion [5].

Instead of focusing on limiting volume, the evolving consensus supports a shift toward anatomy-guided, depth-specific and rheologically appropriate filler use. Cotofana, et al., demonstrated that facial soft tissue fillers behave differently under dynamic forces depending on their viscoelastic properties and depth of placement, reinforcing the importance of technique over cumulative amount totals [6].

This case report reflects that modern thinking. It presents the aesthetic transformation of a 34-year-old Asian woman using a multimodal approach involving botulinum toxin, cryolipolysis and a total of 27 syringes of hyaluronic acid filler, including products designed for structural support, contour refinement and intradermal skin quality enhancement.  Juvederm filler was administered across multiple sessions, resulting not in distortion or imbalance, but in enhanced facial harmony, structural support and exceptionally high patient satisfaction. This case illustrates that when guided by anatomical precision, a deep understanding of facial dynamics and a nuanced aesthetic vision, high-volume filler interventions, when appropriate, can yield refined, natural outcomes.

This case report has beenis reported in line with the SCARE 2023 criteria [7].

Case Presentation

The patient, a 34-year-old Asian female, presented with signs of premature aging. She described feeling shocked by her reflection and noted significant aesthetic changes since giving birth four years earlier. She had never undergone any aesthetic procedure and had no known medical conditions or allergies. Changes following childbirth four years were described by the patient, including earlier and reported a persistently tired appearance. She was treatment-naïve, had no relevant comorbidities or allergies and requested natural but noticeable improvement without surgery [8].

Age Related Changes included the following: 1) at baseline the patient recorded a FACE-Q Aging Appraisal score of 3.3/4, indicating that she felt older than her chronological age; 2) clinician assessment documented midface volume loss with flattening, temple hollowing, chin retrusion, jawline blunting and lower-face broadening, 3) Also, her skin was characterized by generalized dullness, uneven pigmentation and areas of dryness accompanied by superficial fine lines. Muscle analysis showed hyperactivity in the glabellar region and dominant action of the depressor anguli oris and platysma, which created a downward pull contributing to the aged and fatigued expression. These findings, together with patient-reported dullness and fine lines, guided a plan that addressed structure, proportion and skin quality. Her primary concerns included a persistently tired appearance, noticeable skin laxity and the perception that she had gained weight in the face, particularly in the lower third. She explicitly stated a desire for natural-looking results and was not open to surgical procedures. At the same time, she expressed interest in solutions that could deliver fast but refined aesthetic improvements [8].

Clinical assessment revealed several contributing factors to her presentation. Her skin was characterized by generalized dullness, uneven pigmentation and areas of dryness accompanied by superficial fine lines. Muscle analysis showed hyperactivity in the glabellar region and dominant action of the depressor anguli oris and platysma, which created a downward pull contributing to the aged and fatigued expression. Volume loss was evident in both the midcheek and temple regions and there was moderate chin retrusion, as well as loss of jawline definition. From a full-face perspective, she demonstrated a shift away from youthful facial proportions, with lower face broadening that significantly masculinized her overall appearance [9]. Baseline FACE-Q scores provided insight into the patient’s emotional state and self-perception before treatment [10]. The following dimensions were measured:

• Psychological Function: 1.9/4

This domain reflects emotional well-being related to one’s appearance, including confidence and comfort in social settings.

Interpretation: A score of 1.9 indicates reduced psychological well-being related to appearance, potentially affecting self-esteem and confidence in social situations. This emotional burden may heighten the patient’s investment in achieving noticeable aesthetic improvements.

• Expectation: 3.29/4

This scale measures how much benefit the patient expects from the treatment, including improved appearance and psychosocial outcomes.

Interpretation: This high expectation score indicates the patient anticipated substantial aesthetic enhancement from treatment. Managing such expectations is critical to ensuring realistic outcomes and maintaining patient satisfaction.

• Aging Appraisal: 3.3/4

This domain captures how aged the patient feels they look, relative to their actual age.

Interpretation: With an Aging Appraisal score of 3.3, the patient reported feeling considerably older in appearance than their actual age. Such self-perception often reflects deeper concerns about facial aging and can influence treatment goals and satisfaction.

• Satisfaction with Facial Appearance: 1.8/4

This score evaluates how satisfied the patient is with their overall facial appearance and specific features.

Interpretation: Scoring 1.8 out of 4 on facial satisfaction reflects significant dissatisfaction with one’s appearance. Such low baseline satisfaction emphasizes the importance of addressing patient concerns holistically during treatment planning.

• Perceived Age: +5 years above actual age

This subjective measure reflects how much older or younger the patient believes others perceive them to be.

Interpretation: At baseline, the patient believed she appeared five years older than her actual age, suggesting a significant disconnect between her perceived and chronological age. This perceived age discrepancy often correlates with reduced self-esteem and a stronger desire for rejuvenation.

These baseline FACE-Q scores offer a multidimensional understanding of the patient’s concerns, expectations and emotional state prior to treatment. High expectations and aging appraisal scores, combined with low satisfaction, perceived age discrepancy and diminished psychological function, underscore a strong desire for aesthetic improvement and a heightened emotional investment in the outcome. This structured assessment was critical for tailoring treatment and for measuring post-treatment improvements.  Although 34 is relatively young, the plan targeted documented deficits rather than age alone. The 27 syringes were staged over three visits and distributed across the entire face, neck and decolletage. Volume correction started withMost product restored deep structural support and contour; a smaller fraction refinedquantity improved dynamic subunits; six syringes were intradermal for skin quality. Adjunctive submental cryolipolysis reduced lower face volume to improve proportion. No area was volumized in isolation and no adverse events occurred.

Treatment Protocol

The treatment protocol was executed over a two-month interval, comprising three staged sessions. This approach allowed gradual volumization and tissue adaptation, minimized procedural edema and enabled iterative assessment of aesthetic endpoints and patient satisfaction [11]. Filler selection was based on anatomical location, treatment goals and product rheology. Higher G′ and more cohesive fillers were used for deep structural support and contour projection, while lower G′ and less cohesive products were reserved for superficial or dynamic areas requiring smooth integration [12]. Accordingly, Vycross 25 mg/mL was placed along the jawline and chin for lift and shape retention; Vycross 20 mg/mL restored midface projection; Vycross 17.5 mg/mL refined the midface and softened folds; Vycross 15 mg/mL enhanced delicate zones such as lips and tear troughs; and Vycross 12 mg/mL was injected intradermally to improve skin texture and hydration [12].

The treatment protocol was executed over a two-month interval, comprising three systematically staged sessions. This approach enabled incremental volumization and tissue adaptation, reduced risk of overcorrection and allowed for iterative assessment of aesthetic endpoints and patient satisfaction. Spacing sessions also supported better hyaluronic acid integration within facial compartments and minimized procedural edema, contributing to safer and more predictable outcomes [11].

Different fillers were selected based on anatomical location, skin quality and treatment goals, using rheologic and physicochemical properties as a guide.   G′ or elastic modulus, quantifies a filler’s firmness and resistance to deformation  essentially, its ability to retain shape under mechanical stress. Clinically, a higher G′ is associated with greater lifting capacity, making such fillers ideal for structural support and contour projection in deep tissue planes. In contrast, lower G′ fillers integrate more softly, suiting them for superficial or dynamic areas requiring subtlety over lift [12].

Cohesivity reflects how well the filler gel holds together after injection, determining its spread and stability under compressive forces. High-cohesivity fillers maintain a more defined, compact shape and resist lateral migration, which is crucial in areas requiring long-lasting projection and contour. Low-cohesivity fillers disperse more easily within tissue, promoting smooth blending and natural movement in mobile or superficial zones [12].

Vycross 25mg/ml (Juvederm® Volux) with the highest HA concentration, high elasticity (G′ = 665 Pa) and high cohesivity, was chosen for structural enhancement in the jawline and chin, offering maximal lift and shape retention under compression. Vycross 20mg/ml (Juvederm® Voluma) with a G′ = 398 Pa, moderate cohesivity) was used for midface volumization, providing balanced projection and integration in the malar region.  Vycross 17.5 mg/ml ( Juvederm® Volift, G′ = 340 Pa, lower cohesivity) was selected for areas requiring moderate support and flexibility, such as the nasolabial folds. Vycross 15 mg/ml (Juvederm® Volbella, G′ = 271 Pa, low cohesivity) was used in delicate zones like the tear troughs, where soft, smooth integration is critical. Lastly, Vycross 12 mg/ml (Juvederm® Volite, the softest product (12 mg/mL, G′ = 166 Pa, very low cohesivity), was employed intradermally to enhance skin texture and hydration and for treatment of the tear trough area [12].

Face:

• Session 1:
• Session one began with neuromodulation using a total of 42 units of OnabotulinumtoxinA (Botox®), strategically distributed to modulate dynamic facial expressions and harmonize muscle activity. Injections targeted the glabellar complex (to reduce frown lines), frontalis (for forehead smoothing), orbicularis oculi (to soften crow’s feet), depressor anguli oris (DAO, to elevate oral commissures) and platysma (for lower face and neck refinement). This foundational step aimed to both soften lines and optimize the canvas for subsequent filler application.
• Simultaneously, midface enhancement and lower face contouring were commenced using hyaluronic acid fillers. Eleven syringes of Vycross 20 mg/ml were strategically placed to restore structure and volume in the midface, zygomatic arch, pre-auricular area, chin and prejowl sulcus. These were injected using a combination of deep bolus and fanning techniques with a cannula and needle, depending on anatomical location. This targeted augmentation restored midfacial volume loss, improved malar projection and provided foundational lift to the lower face through vertical vector suppor
• Additionally, 5 syringes of Vycross 25 mg/ml were injected along the mandibular angle, jawline and chin contour to define the lower facial contour and enhance jawline continuity. Deep supraperiosteal and subcutaneous techniques were employed, utilizing both needle and cannula approaches for precision and safety
• Cryolipolysis (Coolsculpting Elite): To complement facial rejuvenation and enhance lower facial balance, targeted submental contouring was performed using non-invasive cryolipolysis. Two treatment cycles of CoolSculpting® Elite were applied to the submental and jowl fat pads. This technology selectively targets and reduces subcutaneous fat through controlled cooling, leading to gradual adipocyte apoptosis and clearance without surgery or downtime. Its safety and efficacy for submental fat reduction are well established [13]. In this case, reducing excess volume in the submentum and jowl regions was critical to sharpening the cervicomental angle and restoring jawline definition. By addressing localized adiposity in conjunction with structural facial support, the treatment contributed to a more youthful and contoured lower face
• Session 2
• Session two, conducted four weeks after initial volumization, targeted refinement of facial contours with a focus on midface definition, dynamic line softening and subtle enhancement of delicate features
• Vycross 17.5 mg/ml (4 syringes) was employed to refine the midface without adding excessive bulk, enhancing contour and support along the malar transition zones. Additional product was precisely placed in the nasolabial folds and marionette lines to soften expressions and restore youthful curvature around the mouth. This filler’s moderate elasticity and lower cohesivity made it ideal for natural integration in these mobile regions
• For periocular rejuvenation, 2 syringes of Vycross 12 mg/ml were injected in the pre-periosteal area in the tear troughs. This provided subtle volumization and improved skin luminosity without contributing to puffiness ideal for this anatomically sensitive zone
• Vycross 15 mg/ml (1 syringe) was primarily used to enhance lip volume and definition, with a small amount placed in the tear troughs for additional smoothing. This filler’s soft rheologic profile enabled gentle correction of fine lines and ensured seamless integration in both static and dynamic areas
• Session 3
• Session three marked the final phase of treatment, aimed at optimizing skin quality and enhancing superficial tissue texture. This session was dedicated to improving hydration, radiance and cutaneous smoothness across larger aesthetic zones
• Four syringes of Vycross 12 were delivered via microdroplet technique into the subdermal plane of the cheeks, forehead, neck and décolletage. With its low HA concentration, low G′ (166 Pa) and minimal cohesivity, Vycross 12 was ideal for superficial tissue application – improving dermal hydration, fine lines and skin elasticity without adding bulk. This final step reinforced overall skin luminosity and contributed to a polished, youthful appearance

A total of 27 syringes of hyaluronic acid filler were administered across structural, contouring and refinement zones over the course of three sessions. Despite the relatively high cumulative volume, strategic product selection based on rheologic properties and precise anatomical placement enabled a harmonious and natural aesthetic outcome without evidence of overfilling.

Each treatment session was intentionally staged to build upon the preceding interventions, allowing for real-time assessment of tissue integration, volumetric response and patient feedback. The integration of cryolipolysis into this protocol further enhanced lower face rejuvenation. Emerging data support the synergistic potential of combining dermal fillers with fat-reducing modalities, particularly in contour-critical regions like the jawline and submental area, where addressing both volume loss and adiposity yields superior aesthetic results (Fig. 1,2) [14].

Figure 1: Full Face Treatment Plan showing filler placement across upper, mid and lower face regions.

Figure 2: CoolSculpting Elite Treatment Plan targeting submental and jowl fat pads.

Outcomes

1. Clinical and Visual Results:

Following completion of the staged, multimodal aesthetic protocol, the patient exhibited global facial rejuvenation characterized by enhanced structural harmony, optimized volume distribution and significant improvement in skin quality. Treatments were intentionally staged across three sessions, enabling progressive refinement.  Despite the use of 27 syringes of hyaluronic acid filler, the final result was balanced and natural, with no evidence of overfilling or facial disharmony.

Frontal images (Fig. 3) revealed restoration of midface projection, improved facial symmetry and a noticeable increase in skin luminosity. Structural support and lift were achieved using Vycross 20 mg/ml in the cheeks and zygomatic arch, while Vycross 15 mg/ml and Vycross 12 mg/ml were used to correct the tear troughs and define the lips. Vycross 20 mg/ml and 17.5 mg/ml were placed in the temples to restore lateral volume loss and re-establish an oval facial shape. These interventions collectively contributed to a refreshed, youthful appearance, improving transitions between facial subunits without producing heaviness or distortion.

The right-side view (Fig. 4) demonstrated a sharply defined mandibular angle, improved chin projection and smoother contour continuity across the pre-jowl sulcus.  Vycross 25 mg/ml, with its high G′ and cohesivity, was placed along the mandibular body and angle for projection and sculpting, while Vycross 20 mg/ml was used in the chin and prejowl sulcus to restore structural balance. These fillers, placed at a deep structural plane, provided durable support for overlying soft tissues and significantly improved the cervicomental definition. Vycross 17.5 mg/ml was used in the nasolabial and marionette zones to soften expression lines and maintain dynamic integration in high-mobility areas.

The left-side view (Fig. 5) mirrored these improvements, with evident lifting of the cheek, attenuation of nasolabial folds and softening of marionette shadows. Vycross 17.5 mg/ml contributed to perioral refinement, while Vycross 20 mg/ml  elevated the midface and restored submalar convexity. Together, these treatments produced a smooth and sculpted jawline, with a youthful contour extending from the zygomatic arch through the gonial angle.

Beyond volumetric enhancements, skin quality demonstrated significant improvement. There was a marked increase in dermal brightness and radiance, especially across the malar and temple regions, with reduced fine lines and improved surface uniformity. These changes were attributed to the intradermal administration of Vycross 12 which enhanced hydration and skin texture without adding visible volume. This contributed to a natural, luminous finish.

Lastly, the submental region, treated with two cycles of cryolypolysis exhibited a clearly reduced fat pad and enhanced cervicomental angle. This non-invasive cryolipolysis modality reduced subcutaneous adiposity in both the submentum and jowl fat pads, providing anatomical contrast and enhancing the structural definition created by filler augmentation. Together, these synergistic interventions produced a comprehensive, three-dimensional facial transformation with precise contouring, visible lifting and rejuvenated skin quality.

1. Patient-Reported Outcomes:

Using the FACE-Q Aesthetics Module, as described above, post-treatment scores demonstrated clinically significant improvements across all domains, reflecting both objective aesthetic changes and their psychosocial impact [11].

• Psychological Function improved from 1.9/4 to 3.7/4, indicating a substantial positive shift in the patient’s emotional well-being related to her appearance. At baseline, the patient expressed diminished self-esteem, limited confidence in social environments and distress associated with visible signs of aging. Following the staged aesthetic protocol, her score nearly doubled – suggesting a restoration of self-confidence, greater comfort in interpersonal interactions and a reframing of self-image grounded in satisfaction with her rejuvenated facial features. This magnitude of change suggests meaningful clinical improvement and aligns with findings in the aesthetic literature linking facial rejuvenation with enhanced quality of life and psychological resilience
• Aging Appraisal improved markedly, with the score decreasing from 3.3/4 to 1.4/4, reflecting a substantial shift in how the patient perceived her age relative to her chronological baseline
• At the outset, she felt she looked significantly older than her actual age, a perception that likely fueled motivation for aesthetic intervention. Post-treatment, the low score suggests she viewed herself as visibly younger, with enhanced facial harmony, smoother transitions and lifted contours likely contributing to this change. Importantly, the reduction in Aging Appraisal aligns with both the structural outcomes and the patient’s emotional narrative, supporting the treatment’s ability to meaningfully reverse subjective signs of aging.
• Perceived Age shifted dramatically from +5 years to –5 years relative to the patient’s chronological age, representing a 10-year reversal in self-perceived aging
• Initially, the patient reported feeling that her facial appearance aged her prematurely – likely driven by midface volume loss, soft tissue descent and lower facial heaviness. Following treatment, she perceived herself as five years younger than her actual age, a shift that underscores not only the visual impact of the intervention but also its psychological resonance. This degree of perceptual change is uncommon and highlights the synergistic effect of harmonizing structural support, fat reduction and dermal enhancement, resulting in an outcome that was both aesthetically compelling and emotionally validating.
• Satisfaction with Facial Appearance increased from a baseline of 1.8/4 to markedly higher scores across all subdomains, reflecting a global positive shift in how the patient evaluated her facial features

Initially, she expressed dissatisfaction with proportion, contour and age-related changes, particularly in the midface and lower third. Post-treatment, her responses indicated improved satisfaction with facial harmony, soft tissue contour and aesthetic balance, especially in areas previously identified as high-concern including the cheeks, jawline and skin texture. This transformation suggests that the anatomically guided, layered approach not only addressed volumetric deficits but also restored the patient’s sense of facial identity and aesthetic congruence.

Together, these outcome measures support the success of the treatment in achieving not only visual rejuvenation, but also emotional and psychological benefit which are key markers of a full circle aesthetic approach. The patient also described her experience in her own words: I used to look in the mirror and feel like a stranger.

After the treatment, I recognized myself again; but better. I don’t feel like I’m hiding anymore.” She noted that the transformation was not simply cosmetic, but also restorative to her self-esteem and professional confidence: “I feel like I’ve reclaimed the face that matches how I feel inside; strong, rested and more in control.” She also shared appreciation for the natural aesthetic achieved: “People tell me I look great, but no one can tell I had anything done. That’s exactly what I wanted.”

These testimonials support the value of aesthetic interventions not just in correcting visible signs of aging, but in restoring a sense of identity and well-being.

1. Adverse Events:

There were no serious adverse events. Minor bruising was observed at some cannula entry points, which resolved within a few days without intervention. There were no reports of nodules, granulomas, delayed hypersensitivity reactions or contour irregularities. Overall, treatment tolerance was excellent and the patient expressed a high level of comfort throughout the process. These observations are in line with the established safety profile of hyaluronic acid fillers and botulinum toxin when administered using appropriate techniques and product selection [11].

1. Photographic Documentation:

Figure 3: Full face before and after. Frontal view.

Figure 4: Full face before and after. Right Side view.

Figure 5: Full face before and after. Left Side view.

Discussion

Aging involves changes at multiple layers — bone, fat, ligaments and skin — and balanced rejuvenation requires addressing these in sequence: restoring deep structure, refining dynamic zones and enhancing skin quality while respecting proportion [15]. In this case, most filler was placed deep for lift and support, smaller amounts refined mobile areas and intradermal microdroplets improved texture without bulk. Submental cryolipolysis complemented the injectabletreatment plan by reducing lower-face heaviness [16].

This approach contrasts with the clinical features of Facial Overfilled Syndrome (FOFS), where distortion stems less from absolute volume and more from poor technique, superficial placement or disregard for facial dynamics. Here, 27 syringes were essential to address both structural deficits and surface quality in a postpartum, treatment-naïve patient [17]. Product selection by rheology and placement depth ensured integration without heaviness, aligning with published data that distribution — not syringe count predicts aesthetic success.

Validated patient-reported outcomes confirmed both visual and psychological benefit, with marked improvements in FACE-Q Aging Appraisal, Psychological Function and Perceived Age scores. These gains underscore that high-volume treatment, when applied with anatomical precision and patient-centered planning, can achieve results that are natural, expressive and emotionally restorative.

Facial aging is a multifactorial, multidimensional process involving skeletal remodeling, fat compartment atrophy and descent, dermal thinning and changes in skin elasticity and texture. Rather than a simple gravitational descent, age-related changes follow a complex interplay of volumetric deflation, ligamentous laxity and surface degradation, each contributing to the phenotypic signs of aging [15]. Among these, volume loss particularly in deep and superficial fat compartments – is a critical and often underappreciated driver, leading to loss of structural support, midface flattening, hollowing and exaggerated nasolabial and jowl formation. Addressing this volumetric deficiency is thus essential not only for restoring youthful contours but also for preserving harmony with the patient’s natural anatomy and expression.

The paradigm of facial rejuvenation has evolved from targeting individual lines and folds to restoring global structural support and facial balance through volumization and lift. Earlier approaches focused on superficial dermal injections aimed at smoothing isolated nasolabial folds or marionette lines. However, this often led to an unnatural appearance, particularly when volume was over-concentrated in a single area. Contemporary strategies recognize that facial aging is primarily volumetric and three-dimensional, requiring deeper, layered augmentation that mimics youthful contours. As illustrated in recent treatment models, emphasis is now placed on strategic restoration of deep fat pads, skeletal projection points and retaining ligaments to achieve subtle lifting and harmonious transitions across facial zones [16]. This shift underscores a more anatomical and holistic philosophy – one that moves beyond chasing wrinkles to recreating structural integrity and youthful proportions [17].

Clinical outcomes from full-face rejuvenation increasingly affirm the benefits of a comprehensive, anatomy-guided approach over isolated, indication-specific corrections. Dhillon, et al., underscore that treating the face holistically results in more natural, balanced and age-appropriate outcomes, particularly when deep structural layers are addressed in tandem with superficial refinements [18]. These treatments not only improve facial symmetry and contour but also enhance skin quality and light reflection due to better tissue support. Notably, patient satisfaction appears closely tied to achieving subtle yet transformative changes that respect individual facial identity – a hallmark of global facial strategies.

In a multicenter 6-month study by Rzany, et al., participants undergoing full-face rejuvenation with a suite of hyaluronic acid fillers demonstrated robust and durable aesthetic improvements, with 92.1% showing global enhancement at six months and nearly 80% expressing satisfaction with longevity of results [19]. On average, patients received 6.7 mL of filler to address multiple areas, ranging from tear troughs and cheeks to marionette lines and lips. Despite the breadth of treatment, adverse events were limited to expected injection-site reactions, reinforcing the safety profile of multimodal volumization. These data support that well-executed, full-face filler rejuvenation not only restores youthful contours but also meets the psychological and aesthetic expectations of patients across a range of ages.

Successful full-face rejuvenation requires careful matching of filler characteristics to anatomical requirements. The Juvéderm VYCROSS™ range offers a versatile toolkit, with products engineered to deliver specific mechanical properties such as projection, spreadability and integration based on location and desired outcome [12]. High G, high-cohesivity products like Juvéderm Vycross 25 mg/ml and 20 mg/ml are ideally suited for deep structural support in the midface and chin, where they can restore foundational volume and lift underlying tissues. Intermediate fillers such as Juvéderm Vycross 17.5 mg/ml and Vycross 15 mg/ml strike a balance between structure and flexibility, making them suitable for areas like the marionette lines and nasolabial folds where definition and movement coexist. For fine-tuning superficial concerns, lower-viscosity fillers such as Vycross 15 mg/ml and Vycross 12 mg/ml enable refinement of perioral lines, tear troughs and skin quality, enhancing surface smoothness and radiance without bulk.

This product stratification supports a logical treatment sequence: foundation, contour and refinement. Addressing the midface first is paramount it not only re-establishes vertical lift and projection but also improves the appearance of lower face features indirectly [20]. Once structural balance is restored, contouring the mandibular line or temporal hollow becomes more precise and conservative. Finally, fine-tuning in dynamic zones such as the lips or infraorbital area ensures natural expression and soft transitions. This phased approach minimizes the risk of overcorrection and allows for real-time aesthetic recalibration, ultimately delivering cohesive, harmonious outcomes that respect facial anatomy and expression.

Successful aesthetic outcomes are not defined by syringe count alone. They arise from the convergence of anatomical precision, sequenced planning and the thoughtful integration of multiple modalities tailored to a patient’s unique structural and expressive needs. In this case, interventions ranging from neuromodulation and layered filler placement to intradermal injectables and cryolipolysis worked synergistically to produce a natural, harmonious result aligned with the patient’s aesthetic goals.

This case presents a clear contrast to the clinical features of Facial Overfilled Syndrome (FOFS), which is typically characterized by distorted facial contours, impaired expression and a loss of individual facial identity. Evidence suggests that FOFS is less about excessive filler volume and more about poor technique, including superficial placement, inappropriate product behavior and failure to respect anatomical planes [5]. FOFS often results from overcorrection, suboptimal product selection and a lack of strategic treatment planning. When dense or hydrophilic fillers are incorrectly placed in superficial layers, especially over thin or mobile skin, they can disrupt natural topography and produce an exaggerated, unnatural appearance.

The threshold for what constitutes “too much” volume is inherently subjective and context-dependent. Fakih, et al., caution that volumes exceeding 10-12 mL per session can raise aesthetic red flags if distributed indiscriminately, especially in the absence of integration or reassessment. Cumulative treatments without respecting natural fat compartments or product rheology can lead to “pseudohypertrophy” a disproportionate appearance even with modest top-ups. Thus, FOFS represents not merely a technical error, but an aesthetic misjudgment, where volume becomes a misguided proxy for rejuvenation.

Adding to this complexity is the evolving public perception of beauty, driven by social media filters and curated aesthetics. Hermans, et al., report that repeated exposure to idealized imagery can recalibrate baseline norms and foster unrealistic patient expectations [3]. This social lens has made volume both a sought-after commodity and a source of clinical apprehension. Yet, as the HARMONY study demonstrates, patient satisfaction is closely linked to the anatomical distribution of volume rather than its absolute amount. High FACE-Q satisfaction scores were associated with lateral cheek augmentation and conservative medial correction, as well as more generous filler use in the lower face when appropriately placed. This underscores the importance of zone-specific planning that respects both anatomy and perception. In this case, the administration of 27 syringes was not excessive but essential to address structural and superficial deficits in a postpartum, treatment-naïve patient. High G′ fillers provided deep foundational support and jawline redefinition, while lower G′ products refined contours and rejuvenated sensitive areas like the lips and tear troughs. These choices align with Cotofana, et al., findings that filler behavior under movement is dictated by both product properties and depth of placement and with anatomical data underscoring volume loss in deep compartments and bony remodeling [21].

Notably, adjunctive CoolSculpting Elite for submental fullness further enhanced lower face contour and supported the lifting effects of filler, demonstrating the value of multimodal strategies. Though often overlooked in injectable protocols, non-invasive fat reduction can complement facial design by reducing volume where necessary, thereby restoring proportion and structure.

Finally, the FACE-Q Aesthetics Module provided an essential patient-centered lens, revealing improvements not only in facial appearance but also in psychological well-being, self-confidence and perceived age. These findings affirm that strategic aesthetic interventions can move beyond surface-level enhancement to support emotional restoration and identity alignment. Ultimately, volume is not the enemy. When guided by anatomical precision, depth-aware placement and a deep understanding of product behavior, even high-volume filler treatments can achieve results that are subtle, expressive and virtually undetectable. The true aesthetic risk lies not in how much product is used, but in how, where and why it is applied.

This case exemplifies the power of a fully integrated aesthetic strategy one that values anatomical foundation, strategic sequencing, proportional design and patient-centered goals over arbitrary volume limits. It challenges the reductive notion that syringe count alone predicts unnatural outcomes and instead calls for a more nuanced conversation centered on personalization, artistry and structural intent. Importantly, the use of validated patient-reported outcome tools further underscores that, when volume is applied with anatomical insight and emotional awareness, it becomes not a liability but a precise instrument for aesthetic restoration and psychological uplift.

Conclusion

This case underscores a fundamental shift in how high-volume filler treatments should be understood and evaluated. It demonstrates that natural, emotionally resonant outcomes are achievable – even with substantial syringe counts when treatment is anchored in anatomical precision, phased planning and individualized design. The administration of 27 syringes across structural, contouring and skin-quality layers resulted not in distortion, but in a balanced, expressive and undetectably rejuvenated appearance. Crucially, this outcome reinforces that volume alone is not the primary risk factor for overfilling. Rather, it is the intersection of technique, product selection, depth of placement and anatomical harmony that determines aesthetic success. As recent literature confirms, Facial Overfilled Syndrome rarely stems from quantity alone but from misalignments between filler rheology and facial dynamics. Thoughtful sequencing, beginning with midface structural support and progressing through contour and refinement, paired with adjunctive modalities such as cryolipolysis, further enhances proportionality and lift. This multimodal, systems-based approach represents a maturation in aesthetic philosophy – one that prioritizes integration over isolation. While limited by its single-patient design and lack of long-term imaging, this case illustrates that volume, when applied with anatomical insight and intention, is not something to fear but rather a potent tool to restore harmony between internal vitality and external appearance.

Conflicts of Interest

The authors declare no conflict of interest in this paper.

Funding
No financial support was received for the preparation or submission of this case report.

Consent

The patient provided written consent for the use of her image and clinical data in publication.

Ethical Approval

This case report did not require IRB approval per Singapore guidelines.

Authors’ Contributions

All authors contributed to conceptualization, treatment execution, manuscript writing and final approval.

Statement on Use of Artificial Intelligence

This manuscript was reviewed for grammar, clarity and structure using OpenAI’s ChatGPT-4.0. All intellectual content, clinical interpretation and conclusions were developed and verified by the authors.

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