The timeless adage about aesthetic treatments and plastic surgery remains accurate: we often only notice the less-than-ideal outcomes. Whether scrolling through Instagram or walking down the street, we've all encountered numerous examples of this. The most striking instances are overly enhanced faces that make us stop and take a second glance. "There are typical facial proportions that fall within a visually acceptable range," explains Dr. Catherine Chang, a board-certified plastic surgeon in Beverly Hills, California. "When these standard measurements are distorted, the face can start to look unusual."
Driven by morbid curiosity or the fear of making a poor investment, after spending an inordinate amount of time scrutinizing unnatural appearances, we sought expert opinions on what exactly we are observing when we notice substandard cosmetic work. The unsettling truth is that numerous treatments and procedures have the potential to result in a peculiar-looking face. Fortunately, much of this can be mitigated by choosing a skilled, experienced, and trustworthy provider, but being well-informed is always advantageous. Here, nine plastic surgeons and dermatologists from across the nation analyze what can make faces appear odd, from excessive under-eye filler to focusing on a single facial feature.
Neurotoxins
"The number of units, the placement, and the depth of injection can make the difference between a rested and attractive appearance or a frightening one. It requires the experience and consistency of the same injector to monitor your response to the injections. Start with one [area] at a time and have a highly meticulous and patient injector perform it each time. I am the only one who injects in my clinic. I prefer to inject without gloves – using sterile and washed hands – so that I can feel the muscle and determine the thickness of the skin and the injection plane for my clients." – Dr. Michele Koo, a board-certified plastic surgeon in St. Louis
"Poor [neurotoxin injections] are hard to overlook – they can make the face look strange and unnatural, both at rest and during expressions. Inadequate placement can lead to unnatural brow positions and movements, most commonly known as 'Spock brow.' It can also be placed too low on the cheek and affect the smile muscles, influencing how the muscles lift the corners of the mouth and resulting in an odd smile. When used in the lower face, adjacent muscles can be accidentally injected, causing asymmetrical lip motion. If [a neurotoxin] is only placed in one area of the muscle, this can lead to unusual muscle movement. Excessive use can blunt all facial expressions." – Dr. Chang
"Weirdness arises when one side is paralyzed and the other isn't – when a patient and doctor use [a neurotoxin] to treat something that should have been addressed with another tool, such as filler, fat, or skin resurfacing, or when muscles crucial in conveying an image we expect to see [such as a smile] are inadvertently paralyzed. The human eye is highly sensitive to detecting asymmetries, so even a millimeter's difference can be noticeable. Go to someone who is well-versed in facial anatomy." – Dr. Evan Garfein, a board-certified plastic surgeon in New York City
Under-eye Filler
"In small amounts, hyaluronic acid fillers work well in improving volume loss, but once the volume loss extends across the entire eye area, practitioners must use an excessive amount of filler to fill that region. An excessive amount of filler in the under-eye area can cause the Tyndall effect, an optical phenomenon caused by the way light transmits through a clear liquid beneath a thin tissue, emitting a bluish discoloration around the eyes. Additionally, the water-attracting properties of hyaluronic acid fillers cause them to absorb a significant amount of water. [When injected] in large quantities, that area becomes very swollen, and between the swelling and the Tyndall effect, it starts to look highly unconventional and unnatural.
"Typically, tear troughs shouldn't be filled with more than 0.2cc to 0.3cc of filler per eye – definitely not a whole cc, which, unfortunately, is a common practice. Coming in every six months to a year to refill that region is entirely unnecessary, as fillers persist for a long time in that area, and it further contributes to swelling." – Dr. Amir Karam, a board-certified plastic surgeon in San Diego
Fillers
"If volume loss is the issue, fillers throughout the midface [can offer] an effective correction. Less is more – the subtlety lies in the volume and plane of injection. This demands surgical knowledge, respect for the anatomy, and a diagnosis to assess the ideal intervention. In my view, the problem stems from injectors underestimating the subtleties of the anatomy and how to rectify it to achieve a 'natural' return to fullness without distortion and disproportion. No amount of filler will substitute the need to remove excess skin in the neck, jawline, or cheek/marionette area.
"Marionette lines and cheekbones are ideal areas for filler to fill in the lines and crevices or to soften and gently plump the cheek. The odd look occurs when there is simply too much skin and the cheek pad has dropped. This requires repositioning of the entire cheek pad and the removal of extra skin. The second reason the cheek area can look strange is simply too much filler in the incorrect place." – Dr. Koo
"It is always preferable to be under-filled – being overly filled can cause problems with appearance. As we age, we tend to acquire a flatter, two-dimensional appearance, losing both fat and bone. The location where the filler is placed, the quantity of filler used, and the density of the product can cause or exacerbate heaviness issues and fail to recreate the correct 3D version of ourselves. Altering the location of filler placement and techniques can assist in avoiding the issue and the strange, heavy appearance." – Dr. Raymond Douglas, a board-certified oculoplastic surgeon in Beverly Hills, California
Liquid Facelifts
"People are using fillers with the notion that if you place a considerable amount of volume in the upper face – such as around the outer cheeks and along the cheekbone region – somehow you're going to obtain a volumetric lift of the face that can replace surgery. To achieve that, you'd have to add an enormous amount of volume. Outer cheeks never naturally look that large in person, so they start to look very unusual – more alien-like than human. [Then] these fillers never completely disappear, so you're layering fillers on top of one another. Eventually, the fillers transform into collagen. The moment fillers are placed, an inflammatory process attempts to break down these foreign substances. That process leads to scar formation, which is more or less permanent. In many respects, the face becomes permanently disfigured." – Dr. Karam
"It is widely understood by everyone dealing with facial aging that sagging of the midface is a clear sign of getting older – the full, youthful cheek becomes a more hollow and sad midface. It seems reasonable to suggest that by injecting volume into the cheek this change can be reversed. To a certain extent, that is true – but like with Botox, the key lies in knowing which tool to use for which task. But some patients require [filler or fat grafting] and a facelift or that and skin tightening. If patients and their doctors keep returning to the same approach too frequently – each time adding more substance to the area – eventually, something will seem out of place. When cheeks are overly filled, our eyes tell us something is odd." – Dr. Garfein
Silicone Injections
"Silicone injected into the lips might initially appear favorable, but as the lips deflate with age and the mouth tissue atrophies, silicone filler leads to a lumpy texture that is highly visible during animation – and even at rest in some cases. Previously injected silicone is perceived as an unnatural 'ball' or nodule. Removing these silicone beads can be risky, even in the most skilled hands. Additionally, since the silicone does not dissolve, it has a high tendency to migrate due to the repeated movement of the oral and perioral muscles. Finally, the act of injecting silicone into the body is very risky, not only due to the risk of infection and inflammation but also because of the risk of vascular occlusion and/or thromboembolism, which can be fatal." – Dr. Hardik Doshi, a board-certified plastic surgeon in New York City
Thread Lifts
"I'm not fond of the thread lift. The barbs from the threads can penetrate the skin and create a very indented 'dotted-line' appearance. Additionally, the effect might not last more than a year or two." – Dr. Koo
"Studies have shown that the results of threads last at best three to six months and have complication rates of approximately 10% to 30%, including infection, contour irregularities, pain, nerve damage, and erosion. A thread lift is not an alternative to surgery – it will not provide you with permanent results, it comes with potential complications, and it is costly. It's exposing yourself to risk for very little gain." – Dr. Karam
Buccal Fat Removal
"This is currently trending everywhere. This overly researched and overused procedure creates an unnatural hollowness in the cheeks. Additionally, this procedure does not age well, so as the patient gets older, they often need to add volume back to the face. A youthful face is more rounded and full. We should not create an overly sculpted face on a young individual." – Dr. Jennifer Levine, a board-certified plastic surgeon in New York City
"Eliminating too much fat in areas such as the buccal fat pads in the cheeks can cause hollows as we age. It also contributes to additional sagging later, which creates complications in the harmony of the face. Restoring the fat or using filler will not yield a natural effect – cheeks may be overfilled, like on the Pillsbury Doughboy." – Dr. Ava Shamban, a board-certified dermatologist in Beverly Hills, California
Cosmetic Canthoplasty, aka "Fox Eye" Surgery
"A canthoplasty refers to tightening the lower eyelid ligament. Tightening the lower eyelid will invariably result in a change of the eye shape. Unless performed for reconstructive purposes, [cosmetic canthoplasty] will often change the shape of the eye in an unnatural manner, making the eye appear smaller and blunting the corner of the eye, creating an unnatural form. The eye will also appear horizontally shorter." – Dr. Chang
"Due to the popularity of a certain face type, for example, Bella Hadid, many patients rushed to get threads to lift the corner of their brows. However, threads are designed to dissolve over time and leave behind a 'scar band' in the hope that the elevation of the targeted tissue from these scar bands remains over time. The fox eye treatment, however, falls short – it unnaturally lifts the corner of the brow without properly releasing the ligamentous attachments of the brow to the underlying periosteum. As a result, a portion of the orbicularis oculi muscle is temporarily lifted. This can lead to paralysis of the muscle that helps to close the eye, dry eyes, infection, asymmetric elevation of the brows, paralysis of the muscle that elevates the brow, and the risk of injury to the eyeball. I've had a few patients come to my office to have their fox eye treatment reversed [because] they experienced some of these unfortunate side effects." – Dr. Doshi
Stand-alone Fat Transfer
"Fat transfer in a young face, to increase volume, is generally a poor idea, as the transferred fat is susceptible to weight changes the individual might undergo over the years. Also, as the individual undergoes changes to their skin, fat, muscle, and bone structure with age, these deposited fat transfer parcels can lead to the appearance of unnatural 'bags' or lumps, depending on where they were injected. Removing them can be challenging, as they often integrate into the surrounding tissue and sometimes cannot be excised. However, judicious fat transfer in the appropriately selected patient can be a powerful and effective treatment." – Dr. Doshi
Focusing on One Feature Rather than Considering Holistic Treatment
"Remaining overly focused on one area of the face or body is one of the most common flaws in the cosmetic industry. By over-treating one area, you not only draw attention to it but also bring negative attention to the rest of the face or body. For instance, if you are undergoing treatments to keep your face refreshed and wrinkle-free but completely neglect your neck, it will be obvious that you've had work done." – Dr. Kim Nichols, a board-certified dermatologist in Greenwich, Connecticut
"Many patients come in with concerns about hollowness or bags under the eye and desire filler in this area. The exposure of the orbital rim is caused by the descent of the cheek. The correction of the area must commence with filler in the cheek. After that, filler under the eye may be placed if necessary. There are ligaments in this area that are not supported, which can lead to a 'hammock' effect. The under-eye area also has poor lymphatic drainage, so overfilling the area can result in swelling." – Dr. Levine
"The lower face and neck are anatomically connected – beneath the skin, the soft tissue of the face extends down and is connected to the neck. Therefore, when someone starts to notice that their neck is aging, the lower face is anatomically contributing to the neck sagging. When performing an isolated neck lift without addressing the lower face, this can cause facial disharmony, as the neck will be tight but jowls and sagging of the lower face will persist. Additionally, often there will be bunching around the lower earlobe, as excess skin will accumulate there. Furthermore, as the face continues to age, the neck and face will age at different rates, exacerbating the disparity between them, causing an unnatural appearance." – Dr. Chang
