Case Study: Correcting Lip Filler Migration

Dermal filler procedures can cause migration and unnatural results if not performed appropriately. Lip fillers are a common procedure for these complications to occur in. Over recent years, I have observed an increasing visibility in the media and general populous of over-filled, migrated and unnatural lip proportions owing to lip filler. For many aesthetic practitioners, there is a reluctance to try to rectify these cases.^1,2,3 

There are many reasons for this. Often, these cases have unidentifiable fillers with an unknown safety or composition profile, there is a reluctance to touch other practitioners’ work, practitioners may be uncertain how to dissolve appropriately or may not be confident that they can adequately refill these cases while managing patient expectations. This article follows a case study from presentation through to assessment, planning and retreatment, and offers an algorithm which I prepared based on the Aesthetic Complications Expert (ACE) Group World guidance for managing such cases.^2,4 

Treating another practitioner’s complication 

Unfortunately, due to a poorly regulated market, we see different levels of quality aesthetic treatments from questionable sources, such as beauticians and lay injectors. As a result, many practitioners are reluctant to deal with cosmetic complications from unknown origins as there is a lot of undisclosed information surrounding the treatment performed, including filler choice, injection technique, aseptic preparation and pre-treatment lip appearance, to name a few. 

One of the reasons practitioners might avoid involving themselves in another practitioner’s complication is to not be connected in an indemnity investigation against themselves or a previous treating practitioner. When you start treating a patient, the duty of care becomes yours, and although you may be acting in your patient’s best interest, the nature of aesthetic work is subjective and emotional for patients. Starting a treatment on a difficult baseline, which you have little prior knowledge about, sets up both practitioners and patients for a potentially stressful treatment experience. 

Practitioners should be cautious when considering whether to treat a complication from another injector. Efforts should be made to collect accurate information regarding the filler used, the date of the treatment, and where appropriate, contacting the previous practitioner, as this may aid retreatment. It is likely that all practitioners will face a complication in their career, however this should not be a point of anxiety and stress if we are trained and confident in managing them prior to treatment. 

It should also be emphasised that practitioners must only work within their scope and competency. Therefore, if a practitioner feels unable to adequately resolve a complication, they should convey this to the patient and be aware of experienced practitioners to whom they may refer these more complex cases. 

Consultation 

A 41-year-old female patient presented to my clinic having had lip filler successfully in the past, however, her most recent lip treatment two years ago had resulted in an undesirable aesthetic result. The patient had exclusively seen facial surgeons and dermatologists for her treatments as she was fearful of experiencing complications or poor outcomes and therefore wanted to see someone who could achieve safe and natural results. The patient noticed she had lumps from the beginning of her most recent filler treatment but felt they had become more obvious over time. She also felt the shape was unnatural and her upper lip was bulging in the wet-dry border and was becoming more prominent with time. 

The patient felt that her lips had always been ‘wonky’, but they had become more unsymmetrical and lacking in definition. She hoped to achieve fuller looking lips with more definition in the cupid’s bow, better symmetry and a more natural shape without lumps. The patient had a breakdown of communication with the original practitioner as she felt pressured into aesthetic treatments by them. As a result, the patient didn’t want to return to the practitioner to rectify her complication. In the consultation, the patient appeared fit and healthy with no medical conditions or social history to note. She was unsure what dermal filler product had been injected into her lips by her previous practitioner. 

Assessment 

On visual assessment, the frontal view showed bulging contours at the wet-dry border. This created an exaggerated ‘key-hole’ aperture between the upper and lower lips in the midline when at rest. There was also an unnatural fullness coincident with her upper second incisors and canines bilaterally. Despite having 10 aesthetically optimised upper porcelain veneers placed, the patient’s lip line was distorted when smiling. The lip covered a significant portion of the labial surfaces of all her upper anterior teeth, except her central incisors. The bulging areas had a non-homogenous and firm texture on palpation, with discrete lumps present near the wet-dry border. Her lower lip covered her upper left incisors when smiling due to a large, firm, palpable lump. This created a clear asymmetry upon smiling despite her oral commissure positions being roughly equal bilaterally. Sagittally, her lips were over projected on Rickett’s E-line.⁵ 

Re-treatment and complications 

I agreed with the patient that the outcome of the most recent lip filler treatment was not satisfactory and explained in detail the clinical findings. I advised that poor aesthetic outcomes are possible even in the hands of a qualified 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. The reason for this is there is a natural tendency for filler to collect in the areas of the lip with the least tension, so if too much filler is administered, it will preferentially cluster in a pocketed area. I recommended dissolving the filler and allowing the lips to recover from the current distortion for a period of at least four weeks before attempting to refill them in a careful manner.⁴ I advised that although the filler will be dissolved within two weeks after hyaluronidase administration, allowing longer for the lips to recover from distortion may decrease the risk of getting an unsatisfactory aesthetic result again.⁴ I also advised a slow and steady approach, with gradual additional volume to lower the risk of filler migration. 

The patient did have some anxiety 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 to achieve natural results, I could not continue to add product to the existing lip filler. I referred to the ACE Group World guidance and converted its advice into an easy flow chart, which helped me come up with the correct plan.⁴ 

I informed the patient of the risks of dissolving the filler with hyaluronidase.⁶ These included local irritation or a severe allergic reaction. I did not perform a patch test on the patient as literature highlighted the poor sensitivity of intradermal patch testing as there’s no validated test concentration.⁷ If the patient had a history of bee/wasp allergies, then I’d refer to a specialist allergy testing clinic. 

I reassured the patient that in the event of the latter, I was able to appropriately manage the complication with adrenaline administration. I also advised her that there is a possibility that the filler used is not dissolvable, in which case, aspiration or referral would be required for surgical excision. The patient felt that the general lip size had become larger so I was concerned that it could be a poly-methyl methacrylate-based filler. I also discussed the risks of lip filler treatment, including vascular occlusion, which could lead to skin necrosis, migration, infection and lumps.⁸ The patient understood and agreed to proceed. 

Dissolving the filler 

The patient admittedly had a low pain threshold, and therefore was numbed with 2ml of plain 2% lidocaine which was added by labial infiltrations intraorally across the upper and lower lip. The lips were disinfected with hypochlorous acid solution. I prepared 1500IU of hyaluronidase in 5ml of 0.9% bacteriostatic saline. A total of 2ml (600IU) was injected across the upper and lower lips using a 30 gauge 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-procedure instructions were provided, which included no makeup, exercise, alcohol, sunbathing or saunas for 24 hours. I also recommended the patient to avoid omega three supplements to reduce post-procedure swelling. I advised the patient that swelling and bruising were normal and would be strongest in the first 48 hours. A review and retreatment visit were arranged for six weeks later. 

Review and retreatment 

After six weeks, I reassessed the patient’s 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 labial surfaces of her maxillary teeth. There was still some asymmetry in her lower lip, however no palpable lumps were evident, and her lower lip covered her upper incisors 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 soft hyaluronic acid filler. The patient was numbed with 2ml of plain 2% lidocaine which was added by labial infiltrations intraorally across the upper and lower lip and cleansed with hypochlorous acid solution. I used 0.5ml of Teosyal RHA 2 using a 30 gauge needle. This product was selected due to its low G prime, high flexibility and dynamic stretch. 

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 lax and previously bulging wet-dry border. In my experience, a vertical thread involves deposition close to the wet-dry border. Horizontal linear threads and fans were administered in a superficial plane. The lips were massaged throughout to ensure no residual lumps, and post-procedural instructions were provided. 

Results 

The patient was pleased with the outcome and has not required further filler administration since treatment three months ago. Upon smiling, no migration has occurred, and the natural contours achieved at the treatment appointment have been maintained. The patient experienced no side effects or bruising. 

Respect the anatomy 

This case highlights the importance of anatomy, technique and product selection, 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 risks for potential complications prior to treatment. Practitioners should also consider the drawbacks of taking on another injector’s complication and whether they are experienced enough to help the patient. If not, practitioners should inform the patient and refer them to a competent injector.