Lip Occlusion Reflection

I was performing a routine lip filler treatment on a regular patient requiring a lip contouring treatment. As I was injecting 0.05ml of Belotero balance HA with a yellow 30g needle, I noticed a sudden blanching of the right upper corner of the vermillion border of the lateral lip. I immediately withdrew the needle and inspected the area. As I had injected Belotero balance, I knew that the product was not highly viscous and this was not a large bolus, I do recall aspirating for 5 seconds with a negative result. 

 I checked CRT on the area which was sluggish and remained blanched. I began to massage and obtained a warm compress to try and restore blood flow, but the pallor was still present. No pain was observed by the patient nor was there any tracking or reticular livedo pattern which is a netlike pattern of reddish-blue skin discoloration sometimes present in occlusion. The presence of the lidocaine in the product could have reduced pain sensation so I could not rely on that symptom. I contemplated observing over 24 hours, but I felt that the vascular occlusion was the highest probability. I felt my decisions at that moment needed to be backed by my NMC code as a well as ethical and professional considerations.  

• Prioritise people 
• Practise effectively 
• Preserve safety 
• Promote professionalism and trust  

I consented the patient who I had kept fully informed from the beginning. I always mention the risk of occlusion in the consultation so that the patient is aware they are in safe hands should this event occur. Clear photographs were taken of the area and stored in the online Phorest system which offers a secure online information storage. 

 During consultation for hyaluronidase, I particularly ensure that no allergy to bee stings was ever experienced as well as checking the medical history thoroughly. I proceeded to reconstitute an amp of 1500u of hyaluronidase in 5ml sodium chloride as per ACE global protocol. I decided not to patch test as I am aware of secondary presentation of allergy risk.   

I cleansed the area and injected slowly, observing the skin with a 30 g yellow half inch needle a total of 0.5 ml in 3 separate aliquots along the course of the pallor. I gentle massaged to ensure dispersal of the product. After 5 minutes I noticed the colour returning to the area and I checked CRT which was now at 3 secs. The areas were slightly marked from a small bruise and slightly swollen from needle trauma and fluid volume. I kept my patient fully informed at all times throughout the treatment regime. 

After 30 minutes I decided to discharge the patient giving her my direct mobile number as well as instructions on what to look out for should the area deteriorate over the next 24 hours.  

I texted the patient later and asked her to forward a photograph of the area to view progress of treatment. 

The patient was calm and compliant with all of my instructions. I reviewed the patient the next morning and noted that apart from a small bruise there were no other presentations to note. 

I reflected on the anatomy of the area and concluded that the superior labial artery that was flowing superficially in the right vermillion border area. I additionally confirmed this with the use of a small handheld ultrasound device. The details were clearly marked on the patient notes and a new appointment was made as the patient requested. The treatment plan was to inject with a cannula 25 g 0.5 ml of Belotero shape to the body of the lip to reduce the risk of future issues.