Lumps in lips: How to diagnose procedure related causes
Dr Tim Pearce previously talked about diagnosing lumps in lips after filler treatment
and how you must build a complete story – the patient background, the original treatment, the presenting symptoms of a complication, and the visual and physical examination of the lip – so you have a detailed narrative upon which to make your diagnosis.
There are three broad categories of lumps in lips following dermal filler treatment:
- Procedure related causes – lumps caused by the treatment itself, the delivery method and process of placing the dermal filler into the lip which causes trauma, or may introduce infection,
- Product or substance related causes – foreign bodies as well as the filler product can play a role in lump formation,
- Medical causes – these are not related to the treatment or the product, but lumps caused by an underlying medical condition.
In this blog, the first in a small series of three, Dr Tim Pearce will share some expert tips from his Lip Masters training course on procedure related lumps in lips – those caused by the treatment itself, and any trauma or infection involved.
Shh…Dr Tim will soon be revealing a very exciting new ‘ultimate’ lip course that will cover EVERYTHING you need to know about injecting the lips. Sign up >> to be the first to know when it goes live!
What are procedure related lumps in lips?
Procedure related lumps can be divided into two types – trauma or infection.
Trauma includes inflammation, a haematoma, or a bruise.
Infection, especially in the early stages, is likely to be due to herpes simplex (the cold sore virus) or an acute bacterial infection, with biofilm reactions usually occurring much later, although they can appear at any stage.
How to diagnose procedure related lumps in lips
Referring to the ‘story’ that aesthetic clinicians should be aiming to build when assessing and diagnosing lumps in lips – patient, procedure, symptoms, and signs – Dr Tim explains some examples of the primary stories that you may encounter when considering and diagnosing specific procedure related complications that cause lumps in lips post filler treatment.
Diagnosing a haematoma in the lip
The patient may not have a significant medical history; however, risk factors would include anyone taking aspirin, or with a history of severe bruising in the past.
If you recall a lot of bleeding whilst delivering the procedure, this will increase the risk of haematoma formation.
Symptoms presented with a haematoma would include discomfort straight after the procedure, as bruising causes inflammation, although this may be heightened for the patient over regular bruising. The patient should not be in pain, but tenderness is often a factor. Inflammation and tenderness will gradually resolve over the following 24 hours after the procedure, and they should feel better. This non-worsening is a simple method for differentiating a haematoma over other more complex complications, such as a vascular occlusion.
Upon examination, signs to look for include clear discolouration of the skin where the blood is situated, a normal blood flow when checking capillary refill time in several areas of the lip, and some tenderness with an absence of acute inflammation.
A common follow on from a haematoma is induration.
Diagnosing induration in the lip
A patient may experience a large bruise after treatment but fail to seek help. They may have bruised in the past, felt no significant problems during or after the procedure, and thus regard it as a normal side effect of treatment.
This patient may go on to present 4-6 weeks post treatment with another lump formation called an induration. Symptoms include noticing a lump that does not seem to resolve.
On physical examination, you will feel signs of a non-discreet lump. Induration is essentially fibrous tissue that comes from the healing process triggered by blood being unexpectedly present in the tissue – from a past haematoma. You should feel a diffuse lump (i.e., difficult to feel the beginning and end of the lump), that has a knotty or grisly manifestation that may still be tender for the patient due to inflammation. An induration will naturally resolve with time, as a recovery stage from haematoma, thus patient reassurance is required, with no further treatment.
Diagnosing an acute bacterial infection in the lip
The patient may have a medical history that suggests risk factors for infection including auto-immune conditions treated with immunomodulators or oral steroid medication.
There may have been minor changes to the protocol or methods used during the procedure, an example would be the larger entry hole needed for a cannula giving rise to an increased risk of infection over needle. There may be clues from the patient that aftercare advice was compromised which may have led to the introduction of bacteria.
The symptoms of an infection manifest as inflammation, however this tends to appear 24-48+ post treatment rather than any immediate post-treatment inflammation which may resolve before the inflammation from infection starts. This is followed by further changes including increased pain, swelling, itchiness, and tingling as infection develops in an area and continues to worsen.
Further signs include discolouration, discharge, or visible pus under the skin if the infection has been left to progress. On examination, infection is usually more isolated than an allergic reaction, with an area of redness and pain over one part of the lip, but not necessarily affecting both the top and bottom lip. Infection can spread, so it is important to quiz the patient over progression.
Occasionally, infection takes a haematogenous route to the cause rather than through the procedure itself. A patient with a dental infection or a sore throat can create a situation where bacteria settle on the filler and grow in the area, weeks or months after the original procedure was performed, creating pain, and swelling in the dermal filler.
Diagnosing herpes simplex virus or a cold sore outbreak in the lip
This is most often a concern in a patient who reports at the point of treatment that they sometimes get cold sores. Good practice is to note this in your consultation report, and if they suffer from more regular outbreaks, you may wish to give them prophylactic Aciclovir prior to treatment. However, even with these measures, a herpes simplex outbreak can still occur.
To cause a cold sore lump, the procedure is most likely to have involved treatment to the vermillion border of the lips, although cold sores can be triggered by injections in other locations.
The start of a cold sore is usually a tingling sensation, and often a symptom reported by patients. This is followed by small vesicles on the surface of the skin which gradually develop and then start to rupture, crust or scab. The patient could present with concerns at any of these phases, so symptoms and signs on visual and physical examination are important. The scabbing over can create a sensation of fullness or lumpiness to the lips for the patient. Cold sores will resolve by themselves.
A mistake that can happen in aesthetic medicine is misdiagnosing a vascular occlusion or necrosis along the vermillion border as an outbreak of the herpes simplex virus. A cold sore post lip filler treatment should fit with a history of having outbreaks in the past, the patient should recognise the symptoms, with no additional severity, and thus it should be easily differentiated from more serious complications by the practitioner.
Lip Filler Treatment & Complications
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Dr Tim Pearce eLearning
Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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