Lip augmentation with soft tissue fillers is an artistic and technical challenge. Not only does one need meticulous injection technique and skill, but an in-depth understanding of lip anatomy and lower face aesthetics is imperative for optimal results. In addition, proper knowledge of the filler products themselves, including the individual and unique characteristics of each, expert uses and potential complications, is needed for safe and effective treatment.
A recent realself.com post described lip nodules and swelling that became painful and noticeable soon after injection. Here’s why this may have happened and why she was right to be concerned:
Consequences of Filler Injections
As stated in my previous posts, common side effects such as bruising, swelling, redness and pain, are most typical of the injection procedure itself rather than the product used. The use of medications prior to injection that predispose to bleeding, such as aspirin, NSAIDs, fish oil, Ginko and/or vitamin E, can increase the risk further. Fortunately, these complications are more irritating than serious, and can be easily managed with cool compresses, camouflage makeup and/or laser treatments (pulsed dye, Excel V).
Rare complications are more frequently due to poor technique, lack of experience, or just frank bad luck. Symptoms you should be concerned with after injectable filler treatment are reports of significant pain or change in skin color beyond the typical pain and redness or bruising from injection. These symptoms have serious implications and should be evaluated immediately if reported after treatment.
Choosing the Right Filler
The lip is unique in its anatomy. Treatment in this area is less forgiving than other areas of the face primarily due to the increased vasculature, complexity in shape and dimension, wet and dry borders, as well as frequent, active nearby muscular movements. Pristine technique and proper filler selection is needed to limit complications and give optimal aesthetic improvements. The rheological principals of the filler chosen are much more or less likely to cause acute complications such as nodules or swelling as seen in the presented case. For example:
- Voluma has a much higher G prime then other forms of Juvederm and has the capacity to “lift” the lips more than others, potentiating the ability to form nodules, pain and swelling.
- Particulate fillers such as Restylane can give more structure to the lip, but may compromise the softness seen with other homogenous hyaluronic acid fillers such as Juvederm or Belotero.
- The hydrophilic nature of hyaluronic acid fillers requires the practitioner to avoid over treatment in order to prevent prolonged swelling and unpredictable results leading to patient unhappiness.
- Semi-permanent fillers such as Radiesse, Artefill and/or Sculptra (biostimulant) should not be injected into this area, as the muscular movement can cause clumping of filler product and potentiate nodule formation, leading to permanent irregularity requiring surgical removal.
Techniques for Success
Since swelling is immediate in areas of increased vascularity and can cause the local anatomy to quickly alter, optimal aesthetic results of the lip are more difficult to attain if the procedure is not performed swiftly and precisely. Therefore, I teach a “10-second” rule, where choosing your injection site, performing the injection and deciding if you need to make edits, takes a total of, at most, 10 seconds. Microcannulas limit the amount of swelling and bruising by being blunt rather than sharp, and being more flexible than rigid, compared to needles. Through only a few access points, microcannulas can be used contour and lift an area that would otherwise need a number of serial puncture injections or threads. The lack of tissue trauma by the blunt nature of the product makes treatments virtually pain free and bloodless. My only caveat is that the ability to “fine-tune” the lip shape, create eversion and/or define the vermillion or lip corners is more restricted/difficult with cannulas compared with a sharp needle. Finally, it is important not to forget:
- Treatment around the lip/mouth into the vermillion can improve lip lines and give eversion and lift.
- Treatment of the upper cutaneous lip and pyriform aperture, as well as the lower cutaneous lip and chin fat pads, can give the lip/mouth support that often decreases with age due to fat atrophy and bony resorption beneath.
- To always check the inside of the mouth for good dentition, as lack of teeth or periodontal disease can be a cause for lack of lip/mouth shape, contour and support.
Post Treatment Care Instructions
Meticulous technique, pressure and icing, and homeopathic treatments, such as arnika, bromelain and vitamin K, can help to limit minor complications from filler injections. Patients should be informed and instructed on proper at-home care of the treated areas to limit the more serious consequences such as necrosis and infection, as well as migration and asymmetries. Manipulation of the treatment areas with massage should be avoided for at least 24 to 48 hours after treatment. While filler rarely migrates, it has been reported at distant sites and in different planes (superficially) from injection. This may be a result of the technique used, but also the result of at-home management.
I have seen inflammatory reactions, product migration, excessive swelling and extensive bruising from hot yoga, saunas, massage table or CPAP machine/mask pressure, and trauma to treatment areas in the early post-treatment phase. For patients with significant post-procedural swelling or potential angioedema, oral antihistamines (Zyrtec, Allegra), corticosteroids (prednisone), and/or diuretics (furosemide, hydrochlorothiazide) have been useful in my practice.
Fixing Good Lips Gone Bad
The best treatment is avoidance by using good technique, including very low volumes and strategic placement, having a thorough understanding of product characteristics, being well versed in the discrepancies between individuals and lip anatomy, and advising patients on proper at-home care:
- Supply detailed post-treatment instructions to each patient.
- Suggest avoidance of manipulation or trauma to treated areas for 24 to 48 hours after treatment.
- Avoid intense exercise, extreme temperatures and applying chemicals or irritants to treated areas.
When in a situation where you need to treat patients:
- Reverse extensive swelling or nodules with hyaluronidase injections, roughly 10 to 20 units per 1 cm2 area.
- For extensive bruising, consider laser treatments (pulsed dye, Excel V) in the first 24 to 48 hours after treatment.
- If the patient reports extensive pain, blanching or duskiness, and/or mucosal change/sloughing, consider impending tissue necrosis and follow established guideline protocols for treatment.
What Can We Learn From This Post?
The most important take-home message from this realself.com post, is to educate your patients on the potential complications from filler injections and supply them with comprehensive at-home care guidelines. Lip nodules are a potential complication, most commonly occur from poor filler technique or inappropriately chosen filler product, and can be avoided.
Jason Emer, M.D., is a board-certified and fellowship-trained general, cosmetic and procedural dermatologist who is passionate about advancing safe and effective treatments in the field of cosmetic dermatology and laser surgery. Dr. Emer’s expertise and interests include the full range of general dermatological conditions, novel therapeutics, cosmetic face and body treatments, including aging skin, veins, body sculpting, fat harvesting and fat transfer.