Lip fillers: Common injection technique errors and mistakes

Dr Tim Pearce

August 24, 2023

Many aesthetic clinicians make the same common mistakes when injecting lip fillers – using the wrong technique, poor patient selection, and aiming for unrealistic results – all of which can end in unnecessary bruising, disappointment, and unhappy patients which leads practitioners to become disheartened and lack confidence in their injection ability and approach to medical aesthetics.

In this blog, Dr Tim Pearce will delve into the most common mistakes aesthetic clinicians make when injecting dermal fillers into the lips, and how to avoid them so you can achieve great results for your patients instead.

You can enjoy great educational learning on treating lips with Dr Tim Pearce’s 8D Lip Design training course – the world’s first online lip training with interactive 3D anatomy and injection animation.

What can you go wrong when injecting lip filler?

Dr Tim highlights that many very well-intentioned aesthetic clinicians can make mistakes when injecting lip fillers. These errors can lead to bad aesthetic outcomes, but also to unnecessary complications. He wants to help you to choose your patients better and avoid these common mistakes.

Trying to achieve the results you see on Instagram

Aesthetic clinicians often find themselves looking Instagram before and after pictures of lip fillers, either something they have found themselves or the patient brings with them to the consultation, and they fall into the trap of trying to aim for that particular result, only to be disappointed.

It is vital to understand that the pictures that you see on Instagram are the tip of the iceberg compared to the reality of aesthetic results; they are a selection of the best images to present the best work. Post-procedural swelling is also a common factor in these pictures which creates considerable distortion and does not represent how the patient, or the average patient treated by the best clinician, will look in a couple of weeks.

Everyone who posts on Instagram is selecting their best-case scenario – the best picture, from the best patient, often with makeup, on their best day, with the best lighting, and with a little bit of swelling to help. This all warps the perception of what is possible with a needle and lip filler. Dr Tim advises that you can regard such images as a potential goal, but do not measure yourself against them. Be inspired, certainly, and aim for the best result you can, for each patient, but do not be drawn in by them. Patient selection is key – different ages, different lip types – will render different results, not all Instagrammable.

Neglecting the upper lip crease

Not anticipating the knock-on effect of the combination of dermal filler and swelling in a patient who has the start of a small upper lip crease is an injection mistake that Dr Tim has noted as quite commonplace.

When you learn to look for this, you will start to see it in patients before you treat them, although you may indeed miss it until it occurs in one of your patients and they develop a crease on either side of the lips. If you look at the lips, they may look beautiful, but increasing the volume of the lips on their own leads to an increase in the relative weakness of the structure nearby. Where the white lip loses its attachment to the orbicularis oris, there is a nasolabial fat pad that is moving on top which can often cause the start of a new fold or even a crease in the upper lip. This will be noticeable within two to four weeks of the procedure and is avoidable.

By using less volume when treating the lip, you will not create a relative imbalance of supported tissue and unsupported tissue. Similarly, you can prevent its occurrence by strengthening the area of weakness with a small amount of product (0.05ml as a linear thread) into the crease where the orbicularis oris has lost its attachment to the skin.

Injecting too deeply

Many newer injectors or less experienced aesthetic clinicians are prone to the mistake of injecting a little bit too deep when treating lips. When describing “a little bit too deep”, Dr Tim points out that he means two or three millimetres too deep. With experience, an extra two or three millimetres appears more significant.

Practitioners will often replicate what they believe to be a particular technique that they have witnessed shown on stage at an aesthetic medical conference, for example, but they do it two or three millimetres deeper which provokes a wildly different result.

By being deeper, you get less traction in the lip by being further away from the connective tissue. However, and most importantly, a lot of the arteries and smaller vessels that branch off from those arteries are located at this level. Hence, the amount of bruising caused can be dramatically different with one, two, or three millimetres more in terms of depth of injection.

By injecting more superficially, you can avoid causing unnecessary side effects because bruising, swelling, and inflammation will be dramatically reduced, whilst avoiding other risks like vascular occlusion.

Attempting vertical injections on thin lips

The idea that you can carry out the same lip injection technique on every patient leads to the next injection mistake of carrying out vertical injections on thin lips. Dr Tim highlights that it is quite common for aesthetic clinicians to pick a technique they have learnt and run with it, especially when starting in aesthetic practice. It is an enticing idea to think that if you can master one technique and get it to work, you can use it on every lip filler patient. No technique works on all lips.

If you attempt vertical lip injections on thin lips, there is not enough room, and the result is that you will end up doing far more injections to get a different result because you cannot create the traction that a vertical injection is designed to achieve. To get the best result from vertical lip injections, you must start with lips that are of moderate, if not slightly larger size, because this is the shape that best lends itself to the technique.

Over injecting

The mistake of over-injecting is not always because the patient has asked for something that is not sensible or because the clinician has tried to achieve it for them, but often it is more to do with a lack of ability to guide a patient on what is best achievable or possible with lip filler treatment, especially if that might involve difficult conversations, and even saying no.

Classically a scenario unfolds of a patient who had a great result and then comes back six to nine months later requesting re-treatment, hoping for a similar feeling and elation with the result. The aesthetic clinician may try to improve the definition of the lip, for example, and fail to realise that old filler persists in the area. This makes re-treatment more difficult, but the patient keeps returning each time and requesting improved definition, whereupon more product is added. This is like colouring over the same lines and area of a drawing, again and again, explains Dr Tim. You cannot improve the definition by adding more of the product; this is a misapprehension, when in fact you are adding to a problem of migration or lost definition. Aesthetic clinicians do this with the best intentions, but ought to tell their patients the awkward truth that you cannot keep adding more and more; better to have it reversed and to start again if they want to have more definition back.

If you are unsure where to start with elective filler reversal treatment – how to effectively discuss it with your patients, carry out the procedure, including how much hyaluronidase to use, and when you can re-treat the lips, then sign up for Dr Tim Pearce’s elective lip reversal eLearning online course.

Another problem with over-injecting or over-filling is when the result covers the top teeth with the lip because it gives the impression, even in animation, that the patient has no teeth or is missing teeth. Dr Tim warns practitioners to be careful when treating a patient who has a relatively low top lip because overfilling could initiate this result – less is more, stop before you reach that point.

Overfilling the low lip laterally

As humans, we should have a lower lip angle. On most people, this angle follows the line of the philtrum and connects with the angle on the chin. If you fill lateral to that and add volume to the lower lateral lip, the result is an aura of unhappiness, creating a little bit of a downward smile, a sullen appearance. The lip looks like it is rotating outwards slightly due to overfilling which creates the negative expression.

The ‘sausage lip’ look

This mistake gets its name from the resulting appearance of the lips. A sausage is a continuous cylindrical shape. If we think about ‘sausage lips’, these would be two cylinders next to each other, therefore there is a complete loss of shape to the lip. Instead of a lower lip that tapers off gently from the middle towards the sides, and similarly on the top, the central part of the lip being dominant and tapering off slowly, there is a continuous seam of filler product that creates a squareness or a sausage-like shape to the lips.

This is easy to avoid, explains Dr Tim. Think about where most of the dermal filler should be placed, i.e., more centrally, in the middle two-thirds of the lips is the ideal placement for most injections. The more you try to fill laterally, the more likely outcome is that you will either create sausage lips or the slightly miserable look that was discussed previously.

Too much projection

The dramatic overinflation of the medial part of the lip which causes a crease creates the ‘beakiest’ mistake of all, says Dr Tim. There is nothing more duck-like than having two grooves running on either side of the lip with over projection in the middle. This is caused by trying too hard to add volume at the expense of everything else. The result no longer fits in with the profile of the face and is not supported by the tissue which is giving way due to the enlargement in the middle part of the lip causing a bend in the tissue.

Get more tips from Dr Tim on how to avoid, prevent and treat lip filler migration and 6 lip filler safety tips: how to avoid lip filler complications, amongst many other blogs from Dr Tim on lip fillers.

You can find Dr Tim Pearce on Instagram if you have any questions or comments about lip filler treatments.

Julie Horne’s Lip Technique

Dr Tim recently worked with master lip injector, Julie Horne; he wants to share what he learned from his experience of training in some of her techniques. You can download the guide to master the basics of Julie Horne’s lip technique.

This guide breaks down the basics of what you need to know to recreate Julie’s lip treatment plan, including the amount of product needed, the techniques you need to master, injection points and her top tips for a great result.

Aesthetics Mastery Show

6 Lip filler Mistakes Injectors Make

In this episode, Dr. Tim discusses the most common mistakes he sees injectors making with lip filler AND what to do instead for great patient results. Includes real life examples of ‘bad’ results and how to can avoid them. Watch the full Aesthetics Mastery Show here.

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.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.