INTRODUCTION
Injectable fillers have become a cornerstone of modern aesthetic plastic surgery owing to their versatility, predictable outcomes, and minimal downtime when compared with surgical interventions. Globally, non-surgical aesthetic procedures now account for a substantial proportion of all cosmetic treatments, with injectable fillers representing one of the fastest-growing modalities. In China, the rapid expansion of aesthetic plastic surgery has been driven by socioeconomic development, increased disposable income, and the widespread influence of social media and digital platforms, which have collectively reshaped patient expectations and treatment preferences.
Beyond their technical advantages, injectable fillers allow clinicians to individualize treatment according to facial anatomy, aging patterns, and patient-specific aesthetic goals. This adaptability is particularly relevant in Asian populations, where facial skeletal configuration, soft tissue distribution, and age-related changes differ significantly from those commonly described in Western populations [1]. Consequently, injection techniques, aesthetic ideals, and treatment algorithms developed in Western contexts cannot be directly applied to Chinese patients without careful anatomical and cultural modification [2,3].
Over the past decade, aesthetic plastic surgery practice in China has undergone a marked transformation in both technique and philosophy. Early market growth was largely driven by surgical procedures that emphasized dramatic and immediately visible changes. More recently, practice patterns have shifted toward minimally invasive, maintenance-oriented treatments, with injectable fillers assuming a central role in long-term aesthetic management. This transition reflects not only advances in filler materials and injection techniques but also an increasing preference for natural appearance, facial harmony, and sustainable aesthetic balance.
In this context, the expanding diversity of available filler materials, including hyaluronic acid (HA) fillers, collagen fillers, and collagen stimulators, has broadened therapeutic options while simultaneously increasing the complexity of clinical decision-making related to material selection, injection depth, longevity, and safety. Treatment strategies have accordingly shifted from isolated volumization toward facial contour stabilization approaches that emphasize structural support and global facial balance, defined as proportional harmony among the skeletal framework, soft tissue volume, and dynamic facial movement. At the same time, growing recognition of complications such as facial overfilled syndrome (FOS) highlights the need for evidence-based treatment planning and meticulous anatomical precision.
Against this background, the present review aims to provide a clinically relevant overview of injectable filler trends in China, with a specific focus on material characteristics, facial contour stabilization injection strategies, emerging treatment areas, and safety considerations. By integrating current evidence with accumulated clinical experience, this review seeks to promote informed, conservative, and anatomically grounded injectable filler practice within the rapidly evolving field of aesthetic plastic surgery.
INJECTABLE FILLERS AND MATERIAL CHARACTERISTICS
Injectable filler practice in China has evolved alongside the diversification of available materials, each characterized by distinct rheological and biological properties that influence clinical performance, longevity, and risk profile. From a practical standpoint, material selection should be guided not only by volumization requirements but also by tissue dynamics, target injection depth, reversibility, and the desired degree of collagen stimulation. Within the current trend toward facial contour stabilization, materials that provide higher structural support and predictable tissue integration are increasingly favored for framework restoration, whereas softer or more superficially acting materials are reserved for refinement and surface quality improvement.
HA fillers remain the most widely used injectable materials in China due to their favorable safety profile, broad versatility, and reversibility with hyaluronidase. In contemporary Chinese aesthetic practice, HA fillers are frequently employed for structural contouring of the temples, jawline, chin, and nasolabial folds. Depending on their rheological properties and specific treatment objectives, HA fillers may be injected into subcutaneous, submuscular, or periosteal planes to achieve immediate volume restoration and contour definition. However, clinicians must exercise caution with superficial placement, particularly in periorbital regions, because of the potential risk of the Tyndall effect associated with highly hydrophilic HA products [4].
Collagen fillers represent an important non-HA option within Chinese injectable filler practice, particularly for anatomically delicate regions. Clinically, collagen fillers are most commonly applied in the periorbital area, where subtle contour refinement rather than volumetric augmentation is required. Their relatively low hydrophilicity reduces the risk of the Tyndall effect, making them particularly suitable for superficial subcutaneous placement [4]. Nevertheless, because collagen is a protein-based material, clinicians should remain attentive to the potential for allergic reactions and perform appropriate patient assessment before treatment [5].
Calcium hydroxylapatite (CaHA) fillers provide both immediate volumization and delayed collagen stimulation, making them particularly suitable for structural contouring of the jawline, midface, and chin. Owing to their high elastic modulus, CaHA fillers are typically injected into deeper anatomical planes, including submuscular or periosteal layers, where they deliver strong scaffolding effects and lifting capacity [6]. Within facial contour stabilization strategies, CaHA may therefore function as a key structural support material, especially in regions where durable framework reinforcement is required. While CaHA offers prolonged longevity and effective tissue stimulation, its lack of reversibility necessitates precise anatomical understanding and conservative dosing.
Poly-L-lactic acid (PLLA) and poly-D,L-lactic acid (PDLLA) are biostimulators widely used for gradual collagen neogenesis in larger treatment areas. In China, these materials are commonly applied to the forehead, buccal region, nasolabial folds, hands, and knees. Injection is generally performed in the subcutaneous plane, with clinical effects developing progressively over weeks to months [5]. Owing to their delayed onset of action and relatively low risk of abrupt overcorrection, PLLA and PDLLA are particularly well suited for staged treatment protocols. However, clinicians should remain aware of the risk of delayed nodule formation, especially when inappropriate dilution, uneven product distribution, or overly superficial injection occurs. This complication is more frequently associated with inadequate post-injection massage, insufficient spacing between injection points, or excessive product concentration. Adherence to recommended reconstitution protocols, uniform deep placement, and careful post-treatment monitoring are therefore essential for minimizing this risk and achieving predictable outcomes [7,8].
Polycaprolactone (PCL) fillers combine immediate volumetric effects with long-term collagen stimulation and are characterized by a relatively natural tissue texture. They are commonly used for contour enhancement of the temples, forehead, nose, buccal region, and nasolabial folds, with injections performed in subcutaneous, submuscular, or periosteal planes depending on the treatment objective. While PCL fillers provide durable results, their irreversible nature necessitates prudent patient selection and conservative dosing strategies [9,10]. Within facial contour stabilization injection strategies, PCL fillers offer the advantage of immediate volumetric support combined with sustained collagen stimulation. However, because PCL is not reversible, clinicians must apply rigorous patient selection criteria and conservative dosing to minimize the risk of persistent contour irregularities (Table 1).
FACIAL CONTOUR STABILIZATION INJECTION STRATEGIES
Contemporary injectable filler techniques increasingly emphasize restoration of facial contours rather than isolated correction of localized defects. The concept of facial contour stabilization divides the face into outer and inner aesthetic units. Outer contour stabilization focuses on structurally important regions such as the hairline, temples, lateral cheeks, jawline, and chin, which collectively define the facial framework and contribute to lifting and redistribution of overlying soft tissues [1,11].
Inner contour refinement addresses central facial areas, including the orbital rims, anteromedial cheek, nasolabial folds, and marionette lines. By prioritizing outer contour support before correcting inner contour deficiencies, clinicians can often achieve balanced rejuvenation using lower overall filler volumes. This approach reduces the risk of overfilling and contributes to more natural, durable, and harmonious aesthetic outcomes [11].
Layer-based injection planning is essential for achieving predictable and reproducible clinical results. Strategic placement of fillers across the dermal, subcutaneous fat, submuscular, and periosteal planes allows clinicians to tailor treatment to both anatomical requirements and material-specific properties. A thorough understanding of facial anatomy and filler rheology is therefore critical for optimizing safety while maintaining clinical efficacy.
Effective injectable filler treatment in Chinese patients requires a structured clinical decision-making framework that integrates anatomical assessment, patient expectations, and material selection. Initial evaluation should focus on skeletal support, soft tissue distribution, and age-related changes in facial contours. Identification of primary structural deficiencies enables clinicians to prioritize treatment targets and avoid excessive volumization of secondary areas [12].
Material selection should be guided by both rheological characteristics and clear patient communication. HA fillers are generally preferred for dynamic areas requiring flexibility and reversibility, whereas collagen stimulators are better suited for subtle contour enhancement and long-term improvement in tissue quality. Clear communication regarding realistic outcomes and treatment timelines is essential. Emphasizing long-term facial harmony rather than immediate dramatic change aligns clinical practice with contemporary aesthetic values and helps reduce patient dissatisfaction.
EMERGING TREATMENT AREAS
Beyond conventional facial contour indications, injectable fillers are increasingly utilized for body and auricular rejuvenation in China, reflecting a broader aesthetic focus on overall body harmony and age-related changes in tissue quality. Among non-traditional facial applications, hand, knee, and auricular rejuvenation have emerged as the most established and clinically accepted indications.
Hand rejuvenation primarily addresses age-related volume loss, dermal thinning, wrinkle formation, and increased visibility of veins and tendons. Collagen stimulators such as PLLA and PDLLA are commonly applied in this region because of their ability to induce gradual collagen neogenesis and improve dermal thickness over time. In contrast to purely volumizing fillers, collagen stimulators allow restoration of skin quality while maintaining a relatively low risk of overcorrection [13].
Knee rejuvenation has emerged as a growing aesthetic indication, particularly among patients concerned about skin laxity, wrinkles, and textural irregularities. Similar to hand treatments, PLLA and PDLLA are favored in this region for their biostimulatory effects rather than for volumetric augmentation. Conservative use of collagen stimulators may contribute to improved skin firmness and overall appearance when combined with appropriate patient selection and realistic treatment expectations.
Auricular rejuvenation has also gained increasing attention in Chinese aesthetic plastic surgery. Most notably, inverted ear projection with an elven shape, commonly referred to as the “elf ear,” has become increasingly popular among younger patients. HA fillers are suitable materials for this procedure. This trend reflects evolving aesthetic preferences that emphasize individuality and perceived facial balance. However, such procedures require careful anatomical understanding, conservative design, and thorough patient counseling. Excessive projection or overcorrection may result in an unnatural appearance or long-term dissatisfaction (Table 2).
SAFETY CONSIDERATIONS AND FILLER OVERFILLED SYNDROME
As the utilization of injectable fillers continues to expand, safety considerations remain a central concern in aesthetic plastic surgery practice. While acute vascular complications are well recognized, delayed and cumulative adverse outcomes associated with excessive or poorly planned filler use have received increasing attention. Among these, FOS has emerged as a clinically significant condition characterized by progressive facial distortion, loss of natural contours, and an unnaturally swollen or heavy appearance [14].
FOS does not typically arise from a single treatment session but instead reflects the cumulative effect of repeated volumization over time, often occurring without adequate reassessment of facial structure, tissue behavior, or prior filler placement. Contributing factors include excessive reliance on volumetric correction of secondary areas and failure to address underlying structural deficiencies. Additional risks stem from inappropriate material selection, insufficient attention to injection depth, and inadequate consideration of age-related tissue changes. In high-demand aesthetic markets such as China, where patients may undergo frequent maintenance treatments, the risk of gradual and unrecognized overcorrection is particularly pronounced.
Prevention of FOS requires a conservative, anatomy-driven treatment philosophy. Clinicians should prioritize restoration of structural support and overall contour balance rather than isolated volume replacement. Staged treatment planning, judicious dosing, and periodic global reassessment of facial proportions represent essential strategies for avoiding cumulative overfilling. Equally important is appropriate filler material selection based on rheological properties, reversibility, and intended injection depth.
Effective patient communication plays a critical role in preventing FOS. Clear discussion of realistic outcomes, treatment limitations, and the long-term implications of repeated filler injections helps align patient expectations with safe clinical practice. Emphasizing gradual improvement and long-term facial harmony, rather than immediate dramatic change, reduces pressure for excessive intervention.
In selected cases, imaging modalities such as ultrasound may assist in identifying filler location and guiding subsequent management decisions [15]. Beyond FOS, clinicians should remain cautious when considering emerging aesthetic procedures promoted through social media without sufficient anatomical rationale or safety evidence. Interventions such as shoulder contour injections or plantar injections for height augmentation lack robust clinical validation and are generally not recommended. These trends underscore the importance of critical appraisal, ethical responsibility, and prioritization of patient safety when adopting new aesthetic techniques.
CONCLUSIONS
Injectable fillers have become an integral component of aesthetic plastic surgery in China, with clinical practice evolving from isolated volumization toward anatomy-based facial contour restoration. Appropriate selection of filler materials, including HA fillers, collagen fillers, and collagen stimulators, together with application in suitable anatomical planes, is essential for achieving predictable and natural aesthetic outcomes. Facial contour stabilization injection strategies, combined with conservative dosing and layer-specific planning, help minimize overfilling and support long-term aesthetic balance [14]. Ultimately, successful injectable filler treatment depends on the integration of material knowledge, anatomical precision, and realistic patient communication rather than the pursuit of short-term aesthetic trends.
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