In the last column I said that body filler is not a matter of dividing up volume but of deciding the shape to be built: draw the target silhouette first, then work seated, checking it in the mirror together.
There is one more thing to confirm before that drawing begins, though. Whether the shape has any chance of showing. Skip that check and a well-built shape can end up buried exactly where it was made.
Building a shape and seeing a shape are two different problems. However well something is carved, the contour will not read if a cloth is draped over it.
When good filler, accurately placed, still looks heavy
The consultations I find hardest are the ones where nothing obvious went wrong. The product was appropriate, the position was not far off, the amount was not short — and the result is heavy. The shoulder is rounded rather than angular; the collarbone is still indistinct.
In these cases the cause usually sits above the filler rather than within it. Filler works by pushing a shape up from beneath the tissue, and if the layer covering it is thick, that pushed-up contour never reaches the surface. It is much like placing something under a duvet: make the duvet thick enough and no shape comes through.
The usual next step is to add more. That direction rarely helps. The covering layer is unchanged while the volume beneath it grows, so instead of an angle appearing, the whole area simply thickens. The goal was definition and the result travels in the opposite direction.
The order decides the result
So in body sculpting the order is itself a design decision. What is done matters, and what is done first matters just as much.
| The wrong order | The right order |
|---|---|
| Start with filler | Clear the layer obscuring the contour first |
| The fat lying over it stays where it is | Create a surface on which shape can show |
| The shape reads as heavy | Then build the shape with filler |
| More volume only makes it heavier | The angle appears with only what is needed |
What is regrettable about the left-hand column is not only that the result falls short. The next step now has to be taken above filler that is already in place, which narrows the options, and above all the time and expense do not accumulate in the direction anyone wanted.
Conversely, changing nothing but the order sometimes reduces the amount of filler required. Once the covering layer is dealt with, the contour of the bone and muscle that was always there emerges first, and only what is missing needs filling. Which comes first differs from person to person, and for some there is nothing much to clear at all. It is a judgement made by examination.
What to look at first, area by area — shoulder, collarbone, arm
For the three areas of the upper body we treat most often, what obscures the line is of a slightly different character in each.
| Area | What hides the line | What we check first | The role of filler afterwards |
|---|---|---|---|
| Shoulder | The fat layer over the deltoid | Whether the muscle contour can be felt | Build the outer point to create the angle |
| Collarbone | Fat sitting above and below the bone | How far along the bone line shows | Refine where the contour starts and ends |
| Arm | Laxity at the back of the upper arm | Whether the line runs on with the arm down | Join the line from shoulder into arm |
The collarbone is the clearest example. Many people assume it does not show because the bone is small, when in fact a layer sitting above and below it is covering the line. What is called for there is not a line to be built by filling, but a line already present that needs revealing.
The shoulder works the same way. Build up the outer point while the layer over the muscle is still thick and the shoulder tends to look raised rather than angular. So in shoulder consultations I begin by checking whether the muscle contour can be felt by hand. That is the first criterion for deciding the order in this area.
Preparing the ground the filler will go into
Once it is clear that something needs clearing, the question becomes how. Sometimes a broad area is involved; sometimes only a specific point obscuring the contour needs attention. The options differ with the extent and thickness, and there are several approaches used at this preparatory stage — injection-based options that treat a defined area precisely, or device-based options that first release tissue that has become bound and adherent.
Which approach suits is not something to state in general terms, since it depends on the area and its condition. There is one thing in common, though. The purpose of this stage is not weight reduction in itself but creating a surface on which the next stage can do its work. A different purpose changes how much is treated, and where.
This preparation also takes time. It is often not something to be run straight into shape-building on the same day; tissue is given time to settle before moving on. That is why "can it all be done today?" sometimes has to be answered honestly with a no.
The preparatory stage is not one more procedure stacked on top. It is what allows the next one to be worth what it costs.
An honest answer to "can I not just have the filler?"
Explaining this order leads naturally to that question.
Sometimes the answer is yes. If the covering layer is thin and the contours of bone and muscle already show, adding shape is enough to produce the line you want. For those patients, filler alone is what I recommend.
The difficulty is the other case. Skipping the order and starting with filler there means beginning while already knowing the result is likely to disappoint. So I do not begin by recommending filler. I would rather say, at the time, that what is needed now is clearing and that shape comes after.
I am aware that is not the most welcome answer. It is not a matter that finishes in one visit. But the gap between the result you get by keeping to the order and the result you get by skipping it is wide enough that saying so plainly at the outset seems to me the right thing to do.
If you are in a body filler consultation and the conversation is only about filler, there is one more thing worth asking: whether anything is hiding your line, and if so what should be dealt with first. Whether the answer contains an order tells you whether the consultation is designing anything.
So much for clearing the way for a shape. Beyond what is hidden under a covering layer, though, there is also something that breaks the line by standing up too high. In the next column I will explain why filler that adds and botulinum toxin that subtracts should be designed together.
