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Dr Tim Pearce
Getting the diagnosis right when presented with a confusing complication in the lips can be tricky and often causes panic for many aesthetic practitioners – is it a vascular occlusion or a haematoma?
In this blog, Dr Tim Pearce will discuss effective ways to diagnose, manage, and more importantly avoid causing haematomas in lips when delivering dermal filler injections for lip enhancement and augmentation.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
How to diagnose a haematoma in the lips
Often, aesthetic clinicians can be shocked by the occurrence of a haematoma in the lips after the injection of dermal filler. Thankfully, they are not that commonplace, but the result can be quite dramatic leading to a rising panic within the practitioner that something very serious has occurred. This is where medical diagnosis is so vital – firstly, you must rule out the most serious complication and then move to the more benign as you evaluate the patient. Therefore, in the first instance it is important to rule out a vascular occlusion, which can be done using capillary refill checks, before moving on to potentially diagnosing a haematoma.
Often, the patient will make contact the day after their procedure concerned and agitated about a large bruise that is sore. They may send you a photograph using a messaging App or email, for example. Without them directly in front of you at this point, diagnosis is difficult.
Your priority is to rule out a vascular occlusion by accessing capillary refill and blood supply within the lips. It is not ideal to do this by video but is certainly better than nothing if your patient is not nearby at the time of contacting you.
However, to help you gauge the extent of the problem, you must ensure a good methodology is followed. Using a good quality video, recorded in good lighting with a patient who compresses the entire arterial field around the area before releasing it, will allow you to see if there is good blood flow equally on both sides of the lip. A light touch when compressing the lip is inadequate as it will only squeeze blood out from the very surface area of the lips and can be misleading if a compromise is located deeper within the structure because enough blood will remain to make capillary refill appear to be functioning.
Patients must be guided to press hard on the lip in the area being tested, for a minimum of five seconds, even if it feels uncomfortable and sore. Ideally, they should compare it with the other side of the lips simultaneously and press firmly on both areas. Upon release, you will be able to assess the refill, and be reassured if blood flow is equal. However, the problem with haematomas is that there is usually a discoloration of the skin, and you may not be able to adequately see the result of the capillary refill on a video, which is why it is best practice to call your patient back into your clinic to check them in person.
Another element that helps diagnosis and assessing the difference between haematoma and a vascular occlusion is pain. Initially, if there is a lot of bruising in the hours after the procedure, there is tenderness, swelling, and it can be uncomfortable for the patient if the area is squeezed, but this pain starts to subside. This should be very different to a vascular occlusion where they will experience increasing pain within 12 to 24 hours after the procedure.
Having ruled out a vascular occlusion, you can make a firm diagnosis of a haematoma. Do ensure that you explain this to your patient, calm their anxiety, and gain their understanding of the mechanisms of bruising and haematoma formation; many do not understand that bruises are formed by blood that has leaked out into the tissue from a damage blood vessel under the skin, in this case caused by needle entry. Give reassurance that it will resolve, and there will be no long-term injury or damage. It is crucial that they feel safe and then you can explain what will happen and how you can manage the haematoma.
How to manage a haematoma in the lips
A haematoma is essentially a large bruise with a blood clot just underneath the skin. If you do nothing, it will recover on its own. Patients should understand that it should not get worse and should steadily improve. However, for added safety, inform them that if it starts to go down another route with increased pain, a reaction, or infection within the hematoma, that you will require a totally different response, and they should refer to you again.
There are occasions with very large haematomas where intervention and active management may be required, although this is unlikely with lips. With very large blood clots, they will take a long time to heal and there is a lack of direct blood flow at the core which can increase the risk of infection.
For most patients, the required management for a haematoma in the lip is simply time – wait and it will go away. You can consider compression, especially if it is quite fluid filled and not long after occurrence. Compressing with gentle massage can spread the haematoma, increasing the total surface area which will allow it to be broken down a little quicker by the body. This is not a magic wand, so do manage patient expectations.
Another possible method of management involves the use of hyaluronidase – although clinicians are advised that there is little clinical evidence and published data for this unlicensed use of hyaluronidase. However, it can be used to break down the blood clot so it can be aspirated, particularly in the case of a very large or complex haematoma. In rare cases with a large haematoma that is causing serious distress to the patient, with a risk of infection, or fluctuance underneath the skin, you might be able to get it to break down much quicker if you inject hyaluronidase into the area and then aspirate out the haematoma. The downside is that it might cause additional bruising, hence why this is not appropriate for managing a small hematoma.
Finally, you should prepare your patients for the occurrence of induration after the blood clot has resolved in the haematoma. This is a natural part of the healing response within the body and creates a fibrous area of extra connective tissue that has a fullness or lumpy nature that can be tender to the touch. Induration will also resolve and be self-limiting as part of the prolonged healing process.
How to avoid causing a haematoma in the lips with filler injections
Haematomas can, and do happen, and they are a normal part of aesthetic practice, even when regular and accepted injection techniques are employed; thus, is there something more you can do to reduce bruising?
With experience, and as you reflect on your techniques, the ratio of how often it happens compared to the number of treatments you perform should drop. The key skill to master being millimetre perfection in terms of the depth and placement of your injections. You must not go unnecessarily deep, nor high into the white part of the lip where the artery is located. The aim it to stay far away from the known location of the arteries and to carry out as few injections as possible, thus entering the skin as little as possible, gently, superficially, and via accurate entry points to get the filler product into the right place, followed by gentle massage. Conversely, entering the skin multiple times, quickly, with little care is very likely to result in haematoma formation.
There are some nifty tips to avoid bruising, as shared by Dr Tim – at the point of bleeding, do not be tempted to just wipe away the blood and carry on, stop injecting and place pressure on the bleed instead. The rule of thumb is to hold it for 1-2 minutes if it is a ‘gusher’ and 30 seconds for a ‘trickler’. If as you pull the needle out, there is a sudden trickle of blood, simply stop and hold for an appropriate amount of time. If you do not give into the temptation to lift and have a look underneath, you will find that after a minute or so, there is a high chance of not seeing any bleeding once you lift your finger. This means that, hopefully, underneath the skin the same is happening and blood is not perpetually leaking out into the tissue which could otherwise cause a haematoma over time. Explain to your patients, the reason why you have stopped injecting to apply pressure, they will usually appreciate your efforts to avoid bruising and haematoma formation.
Another option is to consider using cannulas in the lips, in lieu of needles. Although tricker to master and not able to create definition in the lips, this technique significantly reduces the risk of swelling, bruising and haematoma formation. Dr Tim encourages you to have a look at his training course entitled Lips Masterclass with Cannula & Needle if you wish to consider this option.
Finally, Dr Tim always recommends checking capillary refill at the end of any procedure in the area where you have injected before you send the patient home. Safety first.
For more information on diagnosing haematomas and induration, read lumps in lips: How to diagnose procedure related causes. Dr Tim also has a full library of blogs on treating lips for you to explore.
If you have any further questions about bruising, haematomas, or vascular occlusions, or wish to comment on anything you are going to reflect upon and maybe change in your practice, Dr Tim would love to hear them, you can find Dr Tim Pearce on Instagram. You can also look at some of the downloadable free resources on injection techniques available on his website.
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 brand-new ultimate lip course is going to teach you the different techniques, anatomy, and skills you need to create medically beautiful lips.
Aesthetics Mastery Show
How to diagnose, manage and avoid a haematoma in the lips
In this episode, Dr. Tim explains more about haematomas in lips. Watch the full Aesthetics Mastery Show here.
This video has had over 12k views and there are over 20 comments from practitioners and patients.
Injector Ian G said:
“New to doing lips and still building my confidence, this video was a HUGE help for me, thanks Tim for the great video and well explained advice”
Fellow practitioner Rachel Henderson commented:
“Thanks for the video, dealing with a lip haematoma now, very helpful to watch”
Patient Genni Mae spoke from her personal experience of haematoma:
“So I had this thing happen to me last week, I ended up using hyaluronidase to help break up my hematoma, I had a black eye that went around the whole right side of my face but it is 98% healed in 1week. I do think it was hyaluronidase and basically pulling the blood out from the area with a syringe. It was scary but all is well now. I’ve just started the journey to become an aesthetic master and wanted to have procedures so help me understand what I will be doing for others ️ it was a mess last week but now I’m aware of how bad it could get! ( I do realize it could always be worse, however this created chaos in the office therefore within me as well thank you, you are ALWAYS helpful”
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Filler Complications eLearning Courses
If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:
Both give CPD and certificates on completion.
In addition, browse our FREE downloadable resources on complications.
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.
