LIP FILLER GONE WRONG

Dr Sana Sadiq shares a case study demonstrating correction of poor lip filler.

Cast your mind back to the first ever dermal filler treatment you performed on a patient. It is highly likely that we’re all imagining the same procedure- lip filler treatment. Why would it not be? After all, it seems to be the entry-level procedure of choice in facial aesthetics courses internationally and one of the most common treatments requested by patients in the UK.

Many practitioners find their facial aesthetics comfort zone lies in lip filler and upper face botulinum toxin treatments, and this may well be the bulk of the procedures you carry out on a daily basis. Doing something frequently, however, does not equate to doing something well.

In the UK, lip filler treatments have the highest rates of complaints and complications of all aesthetic treatments. What does this mean? Are we underestimating the complexity of this commonly carried out procedure? Is this just due to non-medical injectors who use questionable products with questionable techniques? This may be the wake-up call to consider lip filler treatments with a new appreciation as one of the more complex non-surgical facial treatments available.

The presentation of the lips is possibly the most variable of all facial features among individuals. It is the most dynamic part of the face, attached to the most muscles and can have a vastly different appearance between static and dynamic modes. As a result, our lip filler treatments have to be fluid and adaptable, providing volume, symmetry, structure and definition whilst also being seamless under extremes of distortion from facial expression- that’s a tall order! It follows that practitioners need to have a keen analytical eye and be able to screen patients for potential limiting factors and anatomical features that may impact final results.

The potentially dismissed complexity of this procedure, teemed with its popularity, may be the reason it takes the top spot when it comes to commonly occurring migration and unnatural results. Many aesthetic medicine practitioners are understandably reluctant to rectify these case types for many reasons; a) these cases could be treated with unknown fillers of unknown safety or composition profile, b) you may be worried about treating another practitioner’s work, c) practitioners may not know how to dissolve appropriately and d) practitioners might be uncertain that they can adequately refill these lips whilst managing expectations. This case study will cover assessment, planning and retreatment and offers a helpful algorithm for managing such cases.1,2,3,4

Consultation

This patient presented having had lip filler successfully in the past. However, her most recent lip treatment two years ago resulted in an undesirable aesthetic result. This patient had exclusively been seeing facial surgeons and dermatologists but was concerned that since her last treatment, her lips had a number of visible and palpable lumps. She also felt the shape was unnatural, and her upper lip appeared to be bulging at the wet-dry border. This was becoming more prominent with time. She felt her lips had always been ‘wonky’, but this had worsened, and now they also lacked definition. She hoped to achieve full-looking lips with more definition of the cupid’s bow, more symmetry and a more natural shape without lumps. Medically she was fit and well with no conditions or social history of note.

Clinical examination

Figure 2: Algorithm for managing poor aesthetic outcomes of lip filler treatment.

On visual assessment, the frontal view showed bulging contours at the wet-dry border. This created an over-exaggerated ‘key-hole’ aperture between the upper and lower lips in the midline when at rest. There was also unnatural fullness coincident with her upper 2nd incisors and canines. When smiling, this created a distorted smile line covering too much of the front surfaces of all her upper teeth, despite having had dental veneers placed on her upper front 10 teeth with optimal ratios for her face. The bulging areas had a non-homogenous and firm texture on palpation, and lumps were present near the wet-dry border. When smiling, her lower lip covered her upper left teeth due to a large, firm lump. This created asymmetry on smiling despite her oral commissure positions being roughly equal bilaterally. Sagittally her lips were over projected on Ricket’s E Line.5

Figure 1: Pre-treatment lips showing migration into the upper cutaneous lip (in white) and the upper wet-dry border. Visible lumps (in green) and distorted smile lines (in black) contribute to an unnatural appearance).

Discussion

I agreed with the patient that the outcome of the most recent lip filler was not satisfactory and explained in detail the clinical findings. I advised that poor aesthetic outcomes are possible even in the hands of a medical professional, and there is always a risk of lumps occurring following a lip filler treatment. I advised that certain lip anatomy features, such as pocketed lips in this case, can increase the risk of migration and lumps.

I recommended dissolving the filler and allowing the lips to recover from the current distortion for at least six weeks before attempting to refill them carefully. I advised that filling the lips sooner may increase the risk of getting an unsatisfactory aesthetic result again, as filler may tend to migrate to the wet dry border area where there is currently significant distortion. I also advised a slow and steady approach, with gradual volume addition to lower the risk of filler migration.

The patient was anxious about dissolving the filler as she was concerned about having small lips while waiting to recover. I reassured her that her lips would not appear significantly smaller than they were prior to her first lip filler treatment and that in order to achieve natural results, we could not continue to add filler to the existing lip filler (see Figure 2 for treatment algorithm). I consented the patient for the risks of dissolving the filler with hyaluronidase.6

I informed the patient there was a possibility that the filler present was not dissolvable, in which case a referral would be required for surgical excision. We also discussed the risks of lip filler treatment, including serious vascular occlusion leading to skin necrosis, lumps, migration, infection and lumps.7 The patient understood and agreed to proceed.

Dissolving appointment

The patient admittedly has a low pain threshold, therefore, was numbed with 2ml of plain 2% lidocaine labial infiltrations intraorally across the upper and lower lip. The lips were disinfected with a hypochlorous acid solution. 1500IU of hyaluronidase was diluted in 5ml of 0.9% bacteriostatic saline8. A total of 2ml (600IU) was injected across the upper and lower lips using a 30G 8mm needle.

A serial puncture and fanning technique was used with a focus on the palpable lumps and bulging areas. The lips were vigorously massaged until the lumps were softened. Post-op instructions were provided, and a review and retreatment visit was arranged for six weeks later.

Figure 3: Presentation six weeks after dissolving with hyaluronidase. New smile lines are annotated in black.

Review and retreatment

Six weeks post-dissolving, we reassessed her lips. They no longer had unnatural contours, bulging or palpable lumps. Her smile line was restored to a natural aesthetic arc, revealing an optimal amount of the upper teeth. There was still some asymmetry in her lower lip; however no palpable lumps, and no longer did the lower lip cover her upper teeth when smiling. The lips had a pocketed appearance, and there was some skin laxity in the upper lip in the region of the wet-dry border.

I recommended retreating with a humble volume of soft hyaluronic acid filler. The patient was numbed with 2ml of plain 2% lidocaine labial infiltrations intraorally across the upper and lower lip and cleansed with a hypochlorous acid solution. 0.5ml Teosyal RHA2 was administered using a 30G needle. This product was selected due to its low G prime and high flexibility. Care was taken to keep all injections within the body of the lips whilst avoiding injection near the wet-dry border. No vertical threads or tenting technique was used as this carried a larger risk of allowing migration into the more lax and previously bulging wet dry border. Horizontal linear threads and fans were administered in a superficial plane. The lips were massaged throughout to ensure no residual lumps. Post-op instructions were provided.

Figure 4: Healed lips three months post-retreatment. New aesthetic smile lines and asymmetry correction are shown in black.

Results

The patient was very pleased with the outcome and has not required further filler administration since treatment three months ago. Figure 4 shows the settled three-month post-retreatment results. No migration had occurred, and the natural contours achieved at the treatment appointment have been maintained. This case highlights the importance of respecting the unique natural anatomy of each patient’s lips and not continuing to build on an already compromised result. It is key that medical practitioners assess facial anatomy and risk assess for potential complications prior to treatment. By reference to the simple algorithm (Fig 2), it is straightforward to decide which cases may require dissolving and which alternative options may be employed in order to achieve the best possible aesthetic outcomes for our patients.

Resources

• 1. Land S, ‘The Last Word: Complication Management’, Aesthetics journal, 2021, <https://aestheticsjournal.com/feature/ the-last-wordcomplication-management>

• 2. Ranjbar H, ‘Addressing Filler Complications’, Aesthetics journal, 2021, <https://aestheticsjournal.com/feature/addressing-fill-ercomplications>

• 3. Bennett S, ‘The Last Word: Other Practitioner’s Complications’, Aesthetics journal, 2017, <https://aestheticsjournal.com/feature/ the-lastword-other-practitioner-s-complications>

• 4. King M, Convery C, Davies E, ‘This month’s guideline: The Use of Hyaluronidase in Aesthetic Practice (V2.4)’, J Clin Aesthet Dermatol, (2018).

• 5. Ricketts R, ‘A foundation of cephalometric communication’, American Journal of Orthodontics, (1960), p.330-357.

• 6. Jung H, ‘Hyaluronidase: An overview of its properties, applications, and side effects’, Arch Plast Surg, (2020).

• 7. Snozzi P, van Loghem JAJ, ‘Complication Management following Rejuvenation Procedures with Hyaluronic Acid Fillers-an Algorithmbased Approach’, Plast Reconstr Surg Glob Open, (2018).

• 8. Murray G, Convery C, et al., ‘Guideline for the Safe Use of Hyaluronidase in Aesthetic Medicine, Including Modified High Dose Protocol’, Journal of Clinical and Aesthetic Dermatology, 2021, <https://jcadonline.com/guideline-hyaluronidase-aes-thetic/>