For most of the last decade the aesthetic answer to a complaint about the lower face was filler. More volume, more structure, done.
Empire faculty who own practices now describe a different order — and the order is the whole point, because the same three treatments in a different sequence produce a visibly different result.
The Sequence: Skin, Then Structure, Then Volume
Maritza Mejia FNP describes the order she works in now, and it inverts the old one.
“Now it's more working first into the skin quality,” she says. “Then we do Sculptra or any biostimulators, and then we move to adding a little bit of the filler.”
Melissa Pulcini-Buttine PA uses the image that makes it stick: “I love to make the skin my nice canvas, and then usually my filler is almost like the cherry on top of a sundae.”
Three layers, in order:
- Skin quality. Microneedling, PDRN, exosomes, peptides, skincare. The surface that reflects light.
- Biostimulation. Poly-L-lactic acid or calcium hydroxylapatite, building collagen over months.
- Filler. Targeted volume where structure genuinely needs it, last and least.
Why the Order Matters
The argument is optical as much as anatomical.
Skin is the surface a viewer actually sees. Poor skin quality scatters light, and no amount of underlying volume corrects that — you can place perfect structure beneath a dull, crepey surface and the face still reads as tired. Treating skin first means the structural work you do afterwards is seen through a better medium.
There is also a diagnostic benefit that is easy to miss. Treat skin first and some of the complaint resolves before you have committed any volume. The patient who thought they needed cheek filler sometimes needed light and texture, and you find that out before it is irreversible for nine months.
Mejia is explicit about what the filler is for in this model: “It's not the purpose to fill your face. It's just to enhance, and to give you a little bit more of a natural look without making you feel too overfilled.”
What Changed
The pendulum swung, and both ends were wrong.
“Back in the day we used to do like seven syringes, eight syringes,” Mejia recalls. Pulcini-Buttine describes the correction and the correction to the correction: “What was trending back then was filling and volume, and then it shifted to less filler. But now people are realising it's combination therapy. And I think it's coming back to a nice happy medium between the two, which is where we like to practise to begin with.”
So the current position is not anti-filler. It is filler in proportion, and last.
Dr. Chris Croley, Empire's Chief Medical Officer, notes that the market data followed the same curve: after a period of decline in hyaluronic acid filler, recent reports show it has not only stabilised but started to rise again. Combination protocols, rather than abandonment, appear to be what brought it back.
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Packaging It So Patients Understand
The sequence is also easier to sell than three separate treatments, because it tells a story.
Mejia runs it as a defined offering: “We have a package in my practice we call Sculpt and Lift. We work with biostimulators, and also we work with the filler.”
Two things this solves at once. Patients stop experiencing the plan as repeated upselling, because the sequence was explained at the start. And it sets the expectation that results accumulate — which is the expectation that keeps people returning rather than judging the whole thing on week two.
Mejia's standing line for that is the gym: it is not a one-time treatment, you have to keep working with your skin, and you do not get the result on the first visit. She pairs it with homecare, on the grounds that the patient's contribution between appointments is part of the protocol rather than an optional extra.
Where This Runs Into Trouble
Three cautions, from the same conversation.
Layering is not a reason to treat everything at once. Sequence means sequence. Stacking three modalities in a single visit removes your ability to attribute either the result or a complication.
Skin work has its own timeline. Biostimulator collagen accrues over months, so a plan that leads with it needs the review dates in the diary from the start.
The patient still has to do their part. Mejia is blunt that a treatment plan undone by no homecare is a shared failure, and that if a patient's result goes backwards the first questions are about weight, nutrition and lifestyle — then, crucially, about your own workflow before you conclude anything about theirs.
Empire teaches this layered approach in Facial Contouring Injectables Certification, Comprehensive Face & Body Contouring Injectables and Complete Facial Aesthetic Training.
Frequently Asked Questions
Should skin treatments come before filler?
Faculty increasingly work in that order — skin quality first, then biostimulation, then filler last and in smaller amounts. The reasoning is that skin is the surface the viewer sees, and that treating it first sometimes resolves part of the complaint before volume is committed.
What is the difference between a biostimulator and filler?
Filler adds volume immediately and is placed where structure is needed. A biostimulator works by prompting the body to build collagen over months, which is why it sits in the middle of the sequence rather than providing an instant result.
Is filler falling out of favour?
No. After a period of decline, faculty report hyaluronic acid filler stabilising and rising again — but used in proportion and later in the sequence, rather than as the first answer to every complaint.
How long does a combination plan take to show results?
Longer than a single filler appointment, because biostimulator collagen accrues over months. That timeline should be set at the first consultation, with review dates booked, or patients judge the whole plan on the first few weeks.
Disclaimer
This article is educational and intended for licensed clinicians. It is not medical advice and does not establish a clinician-patient relationship. Product selection, sequencing and treatment intervals are individual clinical decisions. Verify current product labelling and practise within your scope and applicable law.
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