Why does Restylane cause little bumps under the skin?

Keep in mind that Restylane, Juvederm, Perlane and Radiesse are all surgical implants. Although we are injecting them with a needle, they are supposed to be adding volume to correct a defect (or create an enhancement) in the shape or contour of your face.

During and after the injection, a good injector will massage the filler to make sure it is smooth and distributed properly. This will help avoid any visible lumps. Visible lumps are rarely a good thing unless you are trying to enhance an area such as the cheekbones or chin.  It is not unusual for you to be able to feel the filler after the procedure.

Having said that, if you can see a lump where there is not supposed to be a lump, such as the smile lines or the lips, then that is usually a problem with the injection technique. The good news is that these lumps are pretty easy to massage away during the first week after the injection. They can also be dissolved (except for Radiesse injections) at almost any time.

I think that’s injector error. There’s really no reason why you have to have bumps that last and persist. In fact, in the event that a bump does form, there are things that you can do, especially within the first two weeks of an injection, to improve them.

Let’s say you have an injection in the nasolabial fold, that line that goes from the nose down to the mouth. A little bump is noticeable from the outside of the skin. If you come back to the office in that first two-week period, with some gentle massage, with ultrasound gel on the area so that it is not uncomfortable, that can usually be massaged out, unless it’s too close to the surface and it was placed in the skin incorrectly. If it was and it was placed in the skin incorrectly, it can be removed. That means making a very tiny incision in the skin, either with a needle or a very small blade, and squeezing it out almost like a pimple. That means it usually has a slight blue hue to it.

If, however, it does not look bumpy at all, it looks perfectly smooth and looks beautiful but on the inside of your mouth you feel a little bump, then what it may be is that there was some irregularity in the tissue and some pockets and vacuoles or little areas where it was uneven in the actual tissue inside your mouth. Now no one likes to feel that bump on the inside because your tongue is drawn to it and you keep playing with it over and over and over again. It drives you nuts but sometimes, in order to keep the fill looking completely natural and completely smooth from the outside, it is somewhat unavoidable. I still think that I can usually smooth those.

That’s just it: if you’re injecting then walking away I think you are doing a disservice. I always do smoothing afterwards, gentle, use a little ultrasound gel, take my glove or my hand and just put it inside the mouth and go down the area and feel if there are any lumps or bumps. So, I think lumps are injector error.

Restylane does not cause bumps under the skin unless:

1. It is injected too superficially
2. It is injected unevenly

Skin reactions or prolonged inflammation related to the injection of Restylane are extremely rare (I, personally, have never seen it). Areas where the skin is thicker, such as the nasolabial folds, are much less likely to end up with bumps, compared with areas where the skin is very thin, such as the tear troughs below the medial lower eyelids.

I recommend that patients do nothing other than gently apply ice to areas injected with fillers, including Restylane, for the first 3 days following their treatment. This allows for most of the initial swelling to resolve.

After the 3rd day and before the 7th day post-injection, I recommend massaging any area with a visible bump, excess fullness, or asymmetry, several times a day, until it smooths out. This massage can be performed with a fingertip or the tip of a Q-tip.

Patients should recognize that injected fillers may be palpable for several months, however, only visible lumps or bumps are of concern. It would certainly be a mistake to massage an injected filler out of the area that it was meant to fill.

The good news, in case of a Restylane or Juvederm bump that fails to resolve in a timely fashion, is that these materials (hyaluronic acid gels) can easily be dissolved with the injection of hyaluronidase (Amphadase or Vitrase).

Bumps composed of other injectables, such as Radiesse or Artefill, are more difficult to treat. Injection of steroids along with vigorous massage would be a good first step. Surgical excision is rarely, but sometimes required as a last resort.