A practitioner to practitioner, pragmatic guide
Trainees often asked specific questions in relation to dermal filler and we cover how to anticipate complications in our anti-wrinkle and dermal filler diploma. Here are a few examples covering the appearance of lumps.
What to do if a little lump appears on one side.
Lumps should be sought out before the patient leaves the clinic room, and moulded so that they are no longer visible using the method taught in our course of gently grabbing the filler and pulling it up to the surface, whereby lumps appear as white circles, and then applying pressure to the lump for ten seconds. Repeat this if the lump is still present. If, after doing this twice, the lump is still present and unchanged, consider that perhaps it was there before you started, in which case it could be:
- Previous filler placed by you or someone else.
- A natural lump of fat.
- A cyst.
- I hesitate to add this here, but for the sake of completeness, I should say that a painless lump in the lip that you can’t otherwise explain, should be referred to a doctor as there is always a small chance that it could be cancer. This is a delicate issue, but worth having it on your radar. Most of us will never see this thankfully.
If somehow a lump is still present on review, you can show the patient how to perform this moulding process themselves, or explain it over the phone, asking them to do this 4 times per day for 1 minute each time, for a week, then review them. This won’t be as effective as if you had located and moulded the lump yourself immediately following the injections – but it is still possible to improve the appearance of a lump by effectively doing the same thing, but with a more sustained effort over a longer period as I’ve described above. If it’s still an issue after that – as in, there is still a visible lump (not just a lump they can feel, but a visible lump), then that’s when I’d step in and offer, a) lancing using a needle to prick the surface of the skin and then squeezing out the filler, and if that fails. b) using hyaluronidase to dissolve the lump.
You’ll note that hyaluronidase is the last resort, as once you use that, you don’t have as much control over the outcome as you do with the previous options. Hyaluronidase indiscriminately dissolves the hyaluronic acid you have injected in the form of filler, along with the body’s own hyaluronic acid. It takes the body two weeks to replenish this supply, so that means after this procedure, it will be two weeks before you know, and the client knows, how it’s going to look. You also must wait at least two weeks from the point of hyalasing, before you can add more filler – adding more before then would be risky as the body’s own supply is still being replenished and so you would be trying to hit a moving target.
What to do if the filler appears to be slightly above the lip.
The filler will go where you put it. If you put the tip of the needle above the lip and squeeze the plunger, that’s where the filler will go. Always be conscious of where the needle tip is when using filler. There are lots of things to remember when using filler, so it is easy sometimes to forget that wishful thinking is not enough to protect your patients from lumps. If you aren’t sure where the needle tip is – don’t inject! That said, it might be useful to think of the whole procedure of injecting filler as a two-part sequence, which includes the injecting and the moulding afterwards. It varies, but I usually consider the needle capable go getting the product only around 80-90% into the position I’d like it to be in. The last 10-20%, the ‘finessing’, is all about the moulding process. This should include checking for and smoothing out lumps (as described above), tapering off the edges and closing any gaps you have left between injections in the horizontal plane.
I hope this helps, we cover complications in more detail in our training diploma, however, we also offer complications training as a separate course if you are interested in refreshing your knowledge.
Dr Michael Aicken,
Founder and lead clinician at Visage Academy.