Dr. Amiya Prasad: Thank you for your question. You’re asking based on some confusion as to why there are so many differing doctor’s opinions about how to handle lumps and bumps on the lips after Juvederm and why there’s such a range of answers from conservative observation and stating that this is a normal process while others recommend seeking medical attention immediately.

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Well, I can certainly give you my perspective as a specialist. I’m a board-certified cosmetic surgeon and a fellowship-trained oculofacial plastic surgeon. I practice in Manhattan and Long Island and I’ve been using fillers for over 20 years in practice, starting with the original Zyderm and Zyplast made by collagen.

So Restylane and Juvederm and all the other hyaluronic acid fillers are something that I do provide in my practice and certainly there is a lot of confusion out there as to what to do and when. But I can give you just some simple basic rules of how we evaluate patients in our practice and how we monitor whether or not intervention is necessary.

To begin with, as far as lips are concerned, for example, I believe very much in a natural look. In fact, the majority of people that come to us who want lip augmentation being their request by saying, “I don’t want duck lips,” or they refer to celebrities or other people that they know on reality shows or whatever, who have very large lips and that’s because lips, of course, are very much a critical part of facial harmony.

When lips look disproportionate or unnatural, they naturally draw a lot of attention. But in terms of management, let’s start with the first part. In the evaluation and in the artistry of using a filler, you know, a filler is like using a material but it is the sculptor, the doctor, who actually has a vision as to what that lip should look like and how to employ that filler.

So I believe very much more in a very natural look and there is a golden ratio for lips where there’s a proportion of 1 to 1.6 for the upper lip to the lower lip or a one-third, a two-thirds rule that in my experience I’ve found is to be very useful.

Now when this type of correction is done to try to add volume – when you’re treating lips, you’re not just treating one area. There’s the volume in the upper lip volume and the lower lip. There’s the border of the upper and lower lips. There are the corners. There are a lot of places at different levels of the tissue in which fillers can be applied.

So when we’re talking about the volume in the lip, that’s what I refer to as the ratio and then how it fits the face. When you enter the lip with a needle, to place this volume, there is going to be a certain amount of short-term reactive swelling. That reactive swelling can camouflage the presence of a little bit of additional material causing a small elevation or a bump.

Now I explained to my patients that if there is any evidence of an elevation or a bump early, that it is not – it can be normal as long as it’s not too obvious and it is normal for the movement of the lips and activity to help kind of internally massage the material into place.

What I usually do is have patients come in and see me again in two weeks to see how things look. There’s always a possibility of the need for enhancement. Maybe adding a little bit of volume in one place or another. Usually not much is necessary but it gives me a sense of what – how it looks, if it looks natural, it looks good if the patient is satisfied. There’s a lot of value in having people come back after two weeks doing an injectable.

Times of concern is when there’s pain. There’s inflammation, possible infection. There can be times when the material can be present and become hard. So there are certainly appropriate reasons when a physician would be concerned and would recommend a more urgent visit.

So I always tell patients that choosing the right doctor is not about buying a syringe of a filler. Unfortunately, the commoditization of the fillers has made people seek cheaper prices for various levels of injectors including physicians and non-physicians and at the same time, there is often a compromise in the quality of the follow-up care.

Injectables are invasive procedures and I think that is – there’s often a diminishing of the seriousness of an injectable filler. But people think that surgery is invasive and I would propose that placement of an injectable filler is comparable because you are now violating or going through the barrier of the skin and you are placing a foreign material under the skin.

So I look at it as a surgeon as being equivalent to surgery. So my patients are always – I’m always accessible to patients and they can always find me if they need attention.

So I would say that the close relationship with the doctor who performs the injectable and the doctor being able to examine you determines whether or not something is more urgent or less urgent. So it is understandable that when you – when some posts photos and has a certain history, it is often natural for physicians to then respond by saying, “Seek medical attention.” But in general, in the short term, in the first two weeks, if there are subtle irregularities which are not disfiguring or draw too much attention, then there are no other symptoms that can be unusual – and again, it’s based on the description to the doctor of hardness, inflammation or possible infection. Then usually waiting is appropriate.

It comes down to relationships and knowing the patient. My patients, my injectable patients, we see them for a long time because this is the kind of thing that does require maintenance. So get to know them. Get to know their anatomy. Get to know what they like and that is critically important.

I find that when people come to me for corrections and very often they have gone in a – kind of a fragmented way going from one place to another place to another place. They went to a friend or they went to somebody – they went with another friend where they found a deal or there was a party or something of that nature.

So that hopefully gives you a certain understanding that essentially, there are things that could happen short term and long term that do require medical attention. But as a general rule, volume correction doe require about two weeks in the lip area for example, which can allow for normalization without urgent intervention.

So I hope that was helpful. I wish you the best of luck. Thank you for your question.

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