let's first do an overview scan of the upper lip in horizontal and B mode here we can see the full cross-section of the lip with the epidermis and dermis subcutaneous tissue orbicularis orus submucosal tissues and even the teeth in the submucosal fat we can see numerous oval hypo aoic structures these are not filler but labial mucus glands so don't confuse the two in the subcutaneous layer we do have a number of an aoic structures with some posterior enhancement these might be vessels or possibly ha filler remember fluid filed structures appear an aoic and exhibit posterior acoustic enhancement evident as little white sorcer shapes here in the submucosal plane we can see a tube likee structure this looks like the labal artery you'll see with vessels that if you roll the transducer slightly they come up as little sausages that you can trace compare with filler which are discrete single or round oral deposits that's how I tell the difference in B mode Let's Move Along a little the labal mucous glands are here in the submucosal plane we've got some hypo Co structures here in the subcutaneous the obicularis orus muscle and what appears to be a vessel lying beneath it let's check with doleron the labial artery stands out immediately anything that remains an aoic or hypo aoic on Dopp view in the subcutaneous plane is likely to be filler I want to show you how easily you can trace the path of the labal artery from the modiolus going into the lip we can follow its course here is where the superior labial artery snakes and pierces through the orbicularis to end up in the submucosal plane here we see an interesting phenomenon this is often observed in a lip that has filler and is called hypervascularity this is where filler causes vessels to engorge or proliferate because it irritates them we can see here there's lots of vessels in the lip tissue much more than we would otherwise expect in a normal noral lip we see this when filler has been placed into tissues and it's not just an isolated presentation in the lip this has also been discussed in a paper by Shela and others back in 2019 where they observed a hypervascular aspect to the inferior labial artery surrounded by a hypo aoic well-defined homogeneous deposit of ha multiple collateral vessels were visible as well although everyone always says ha filler is biocompatible and non-toxic it's actually irritant to vessels on a microvascular level it causes proliferation seen on ultrasound clinically this is manifested as edema we often see patients with puffy swollen lips as a result of filler it's not just the filler causing this but the filler's tissue effects let's start to remove the ha filler I use an inplane technique with the transducer and needle in line I select the deposite keep the transducer still and guide my needle there I know this is ha because I have my color box on once I'm at the deposit I place a small amount of hyaluronidase around 0.05 M you can see a color flash artifact which occurs when there's any fluid movement immediately the treated area becomes hazy this is due to the application of Highly runid a and the changes in the properties of the injected ha I move systematically along the lip here is an area of considerable hypovascularity and numerous hypo aoic deposits of ha I guide the needle to the Target site and deposit highly run a a and I can move along to the next deposit easily and place some more here saving myself multiple entry points I can tackle several ha deposits in one injection in this way
