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In the modern medical aesthetics industry, the approach to facial rejuvenation has evolved beyond simple correction. With a deeper understanding that ‘volume loss is the core cause of ageing’, and given the advantages of injection treatments — such as short recovery periods, no scarring, and reversibility — soft tissue fillers have become an important anti-ageing treatment for the face. To achieve long-term, natural-looking rejuvenation, estheticians and patients must collaborate to combine non-surgical and surgical methods, developing personalised management plans spanning different life stages. It is a collaborative effort between estheticians and clients to achieve a shared goal of beauty.

This article aims to provide a comprehensive framework for the treatment of facial cosmetic patients at all stages of life, focusing particularly on the use of hyaluronic acid (HA) fillers. I will introduce strategies for assessment and treatment selection, and discuss the techniques applied to different anatomical regions and age groups. Supporting case studies will be presented, paying particular attention to the interaction between injection and surgery, and the considerations involved in achieving and maintaining natural-looking results over time.

01.Key principles of facial fillers

1. The needs of patients can vary significantly across different life stages, so treatment strategies must be carefully adjusted over time.
2. Although fillers are often considered a temporary treatment, they can remain in the tissues and cause inflammation or fibrosis. It is therefore essential to keep careful records of treatment history and physical examinations, and to consider selective dissolution rather than continuous filling.
3. It is crucial for doctors and patients to collaborate in establishing treatment goals in order to achieve and maintain safe and natural results in the long term.

02.Focus of Treatment at Different Stages

The following general framework can be used to help patients achieve their aesthetic goals and ensure they are managed appropriately as they age. Treatment should be tailored to each patient’s individual goals and ageing trajectory.

Aged 20–40:
Core goal: achieving facial balance and subtle enhancement
Main interventions: Skin care, selective fillers (focused areas: lips, chin, nose, and tear troughs), neuromodulation, and anti-ageing education.
Aged 40–50:
Core goal: Early volume restoration and delayed ageing
Main interventions: Targeted fillers (focused areas: temples, cheeks, and the perioral area), advanced skincare (laser/microneedling), biostimulants, and neuromodulation (including the jawline and neck). Surgical planning is also included.
The core goal for those aged 50–60 is the integration of surgical and non-surgical interventions. Main interventions include surgical intervention, fat grafting, careful filler fine-tuning, and neuromodulation (including the jawline and neck).
For patients aged 60 and over, the core goal is maintaining results. The main interventions include fillers, biostimulants, neuromodulation and advanced skincare.

03.Key considerations: The long-term performance and risk management of fillers

1. Metabolic characteristics of hyaluronic acid (HA) fillers
The degradation rate of HA fillers is affected by product characteristics, the anatomical location of the injection and individual patient differences.
HA with a high level of cross-linking in deep/low-activity areas (such as the cheeks) may persist for longer. In some cases, histological residues have been observed for up to 15 years.
Degradation in high-activity areas (such as the perioral region) is faster and more predictable.
However, residual HA can cause issues such as eyelid oedema, granulomas and fibrosis, so caution is required.

2. Avoid overtreatment due to perceptual bias
Repeated use of fillers can cause patients to deviate from their self-perception and treatment goals. Pursuing ‘gradual enhancement’ can easily result in an unnatural appearance and cause complications. Recommendations: Patients should have a primary physician who can provide long-term evaluation and guidance.
In cases of overcorrection or displacement, dissolve the filler before adding more.

3. Imaging technology: A powerful tool for filler assessment
High-frequency ultrasound is the primary method of assessing filler-related complications. It uses non-ionising radiation, is inexpensive, and provides high-resolution imaging. This enables the identification of the echogenic characteristics of different types of filler.
– HA fillers: Initially anechoic, later acoustically enhanced, exhibiting a heterogeneous, diffuse appearance after integration into tissue.
– Hydroxyapatite calcium: hypoechoic with posterior acoustic shadowing.
– Poly-L-lactic acid: heterogeneous with hypoechoic fibrosis. Integrating AI technology can further shorten the ultrasound learning curve and assist with clinical decision-making. Ultrasound can help manage overcorrection, filler displacement, inflammation and vascular adverse events, as well as preoperative dissolution when necessary.

Regional Practice: Anatomical Points and Injection Techniques
As mentioned in the previous article(Which cosmetic injection techniques are commonly used in clinical practice?), the face is usually divided into three parts for assessment purposes: the upper face, the middle face, and the lower face.

04.Long-term management and patient education.

A comprehensive evaluation of a patient undergoing facial filler treatment should begin with a detailed medical history. Key elements include understanding any previous injection treatments, including the type of product used, the volume injected and the injection site. Particular attention should be paid to any previous surgical procedures or trauma, as well as to other facial treatments involving energy devices, as these may affect tissue morphology. The physical examination should not only focus on areas of concern, but also involve a comprehensive analysis of the face as a whole. High-frequency ultrasound evaluation can help confirm the presence of fillers and determine their type. Detailed photographic documentation is essential and should ideally include multiple angles and facial expressions to capture static and dynamic features.
Patient education is fundamental to long-term management. Patients should be informed about the interplay between skincare, injectables, and procedures in managing facial ageing and be encouraged to practise self-care routines.

05.Planning surgery and fillers synergistically

Fillers can interfere with lymphatic drainage, particularly around the cheekbones and lower eyelids. When planning surgery, any existing fillers must be assessed and dissolved (especially in these areas), if necessary, to enable accurate evaluation and optimisation of surgical results. Ultrasound can confirm whether all the fillers have been removed and can also be used with fat grafting to achieve a more natural-looking correction of volume.

The following case studies involve surgery and injections in the following areas:
– the perioral region (Figure 1)
– the lower third of the face and jawline (Figure 2)
– the full face (Figure 3)

Figure 1: The top right shows the patient’s perioral region before treatment. The bottom left shows the region after surgery, and the bottom right shows the final result after filler treatment.

Preoperative condition: Signs of ageing around the mouth accompanied by sunken temples and sagging lower eyelids.
Treatment plan: Lower eyelid blepharoplasty, hyaluronic acid filler for the temples, roof of the upper eyelid, lips and chin, poly-L-lactic acid filler for the mid-face and calcium hydroxyapatite filler for the jawline.
Core logic: The surgery addresses structural laxity, while the different types of filler improve volume loss specifically, achieving overall harmony between the perioral area and the rest of the face.

Figure 2 shows the lower third of the face and the mandibular line in the ‘before’ (left) and ‘after’ (right) positions.

Pre-operative condition: Blurred jawline, loose neck skin, and ageing upper eyelids.
Treatment plan: Facelift, neck lift, upper eyelid surgery and 3 ml of HA filler for the chin and jawline.
Core logic: The surgery reshapes the facial contour support, while the HA filler optimises the proportions of the chin and jawline to avoid the ‘stiff contour’ issues that can occur after surgery.

Figure 3: Comprehensive departmental long-term dynamic management

Figure 3, top left: A 56-year-old patient (preoperative), who underwent non-surgical treatment involving 3–4 annual injections of neurotoxin, calcium hydroxyapatite, poly-L-lactic acid (PLLA) and hyaluronic acid (HA), the latter of which was used for the tear trough and perioral areas, while PLLA was used for the entire face.
Top right: A 58-year-old patient who underwent upper and lower eyelid surgery, a facelift, and fat grafting due to signs of ageing.
Bottom left and bottom right: Two patients aged 59 and 65 (post-operative maintenance) who continued to receive three to four annual injections of neurotoxin, PLLA and HA, with adjustments to the injection sites and dosages as required.
Core logic: Early non-surgical methods are used to delay ageing. Mid-term surgery addresses structural problems, while late-term fillers maintain the effects of surgery, achieving ‘step-by-step anti-ageing’.

In conclusion, comprehensive facial ageing management focuses on ‘integration’ and ‘personalisation’.
‘Integration’ involves combining surgical and non-surgical treatments with other interventions, such as skincare, neuromodulation, and energy devices. Soft tissue fillers play a unique role at different stages of ageing. They can restore facial balance and volume and fine-tune and maintain surgical results.
‘Personalisation’ enables the achievement of safe, natural-looking and long-lasting rejuvenation results by providing comprehensive patient education, arranging regular follow-ups and making dynamic adjustments to treatment strategies. This management framework, which encompasses ‘injection-surgery-maintenance’, may provide you with practical guidance for clinical decision-making.