How to create safe lips results using the 4mm needle technique

Dr Tim is often sent videos of injection techniques and asked for his opinion. He likes to turn these into teaching opportunities to help other aesthetic clinicians understand his mental model when treating so you can inject more safely and increase your resolution of understanding of both the anatomy and the risks present with different injection techniques.

In this blog, Dr Tim Pearce reviews a video clip with a version of the 4mm needle technique for lips fillers; critiquing it, he explains the best point and angle of entry and how to use the technique more safely to lower the risk of bruising and injury to the lips.

To be among the first to receive exclusive updates on the launch of Dr Tim’s new movement, featuring an immersive 3D learning experience, comprehensive Botox lessons, and much more, simply sign up here to join the priority waiting list.

What is wrong with this 4mm needle technique for lip filler?

On reviewing a video clip sent to him demonstrating a version of the 4mm needle technique, specifically the volumising component where the dermal filler is being injected directly into the lip body to add a roundness or fullness to the middle third of the lip, Dr Tim noted several aspects that made him uneasy.

The entry point and angle of entry

In the highlighted video, the angle of the syringe relative to the facial plane (and thus the angle of entry) is relatively low which means that the needle is pointing upwards with the syringe bevel nearly resting on the chin. Similarly, the point of entry into the lip is relatively high, approximately in the top two-thirds of the upper lip. Hence, Dr Tim believes that the combination of this chosen entry point and the angle of entry places the needle relatively close to the location of the superior labial artery – i.e., directly behind the orbicularis oris muscle and straight into the path of the superior labial artery – which could be compromised upon injection.

To further explain why this approach is worrisome, Dr Tim used a 3D render of the lip anatomy which is to scale and includes the positions of the labial arteries, accurate to the millimetre. Watch his explanation in this video.

Compression of the tissue

Another cause for concern for Dr Tim within the highlighted video is that as the needle goes in, there is some compression of the tissue. If you are compressing tissue, the 4mm safety margin is less effective because you are essentially making the needle act as if it is longer, perhaps making it reach 5mm in, which is the likely depth of the artery.

Aspiration

Similarly, Dr Tim notes a lack of aspiration in the video. A 4mm needle is a very good needle to aspirate with because it makes aspiration extremely sensitive. He notes that if you are performing a bolus injection, as in this video, then why not aspirate? There is no movement going on and no other safety measures appear to be employed, so it makes more sense to add the additional step of aspiration for safety. He reminds you that if you aspirate, you have negative pressure in your syringe and movement increases the sensitivity of your aspiration because as you are moving, you are scanning more of the area.

Dr Tim has recorded various video clips to demonstrate aspirating, and how movement draws the tip of the needle back into a vessel, which you have already gone through, meaning you get a positive flashback before you start injecting. Therefore, a little bit of movement when aspirating and changing your angle could make the injection a lot safer.

See more tips on aspirating in:

• Does aspirating work?
• How many seconds should you aspirate for when injecting fillers?
• Increase your injection safety with this aspiration trick
• You can also download the results of Dr Tim’s aspirating experiment, testing different brands of dermal filler.

How does Dr Tim perform the 4mm needle technique for lip filler?

After reviewing the areas of concern in the video, Dr Tim goes on to explain how he would improve upon the injection technique to make it safer.

1. The entry point and angle of entry
   His entry point would not be as superior as that used in the video, coming down lower, by approximately 2mm. Next, he would change the angle of entry away from a shallow angle meaning that when injecting, the needle (and filler) should pass underneath most of the arteries we aim to avoid. The needle is pointing directly towards the body of the lip, but not underneath the orbicular oris.
2. Aspiration
   Once you have found the depth, he recommends aspirating. By moving the needle a little, you will be moving in and out of the area where the bolus of filler will go, and this will increase the sensitivity of getting a positive aspiration – increasing your ability to detect an intravascular insertion point – which would tell you not to inject. Dr Tim offers caution that a negative aspiration result does not mean that you are not in a vessel.
3. Small boluses
   Once, you are happy, you can start injecting, using small boluses of filler product, e.g., 0.015ml or 0.01ml. If you want to make it a little bit safer, he advises you could change the angle – perhaps moving laterally, not superiorly – and repeat the process for another small deposition. By continuing like this, you will be placing small boluses (rather than one large one) using multiple safety steps and a safer angle of entry.

For additional information, read Dr Tim’s blog on lip augmentation using the 4mm needle technique.

Dr Tim’s take-home message on needle techniques

In conclusion, Dr Tim shares a take-home message to other aesthetic clinicians. Every time you see someone injecting – on a training day, on a video, at a conference – and it differs to how you are currently injecting, the worst-case scenario is that you immediately switch to doing it their way because you think they are more experienced or better than you in some way, but you do not understand what is going on underneath the tissue.

He advises that you do not copy other people’s techniques, including copying his technique or blindly change your technique. You must understand more about what the practitioner is imagining as they are injecting. This will allow you to make better sense of multiple approaches so you can pick out something that makes the most possible sense to you, given your prior learning. It is not about pitting technique versus technique; the key is mental model resolution.

Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

How to create safe lip results using the 4mm needle technique

Dr Tim says:

“I recently got sent a video of someone injecting using the 4mm needle technique. In this video I explain the best angle of entry for this technique, how to use this technique safely to lower the risk of bruising and injury and demonstrate this on a 3D digital model so that you can see all of this in action under the skin. “

Watch the full Aesthetics Mastery Show here.

The video has received over thousands of views and many comments of appreciation including:

@katagarayponticas

“Thank you Dr Tim, love all your videos”

@tee3287

“By far, one of the most in-depth down to earth doctors/mentors ever. Absolutely love Tim’s and Amanda’s content everything is so much more clear once Dr tim not only explains but actually demonstrates too”

@abbygodfrey3282

“So helpful”

Read more comments and join in the debate on our YouTube channel.

You can also subscribe to our YouTube channel for really useful regular tips and advice.  

8D Lip Design

With all the conflicting advice out there about lip filler treatments – vertical or horizontal? needle or cannula? – it can be difficult to know how to inject to create the lips your patient desires.

If you are suffering from technique overwhelm, worrying about causing a vascular occlusion (VO), or panicking about injecting thin lips, then Dr Tim Pearce’s 8D Lip Design Course will teach you the different techniques, anatomy, and skills you need to create medically beautiful lips.

3D Anatomy Learning Experience

In the next few weeks, Dr Tim Pearce is going to be launching something amazing that involves an incredible 3D learning experience for injectors, a community of clinicians on the same mission as you to help you achieve your goals, and exclusive online access to him and his team, to help you become a pro injector. Be the first to join the movement by joining the priority waiting list.

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.