General contraindications in orofacial harmonization

Knowing when not to treat is as important as knowing how to treat. In orofacial harmonization (HOF), most procedures are elective: there is no urgency that justifies injecting under unfavorable conditions. Postponing a session costs a reschedule. Treating when you should not have can cost a serious complication.

This guide gathers the general contraindications, common to several procedures, at review level. Each product has its own package insert, and it takes precedence. The final decision always rests with the qualified practitioner, following the rules of their professional board (in Brazil), after the medical history in HOF and the clinical assessment.

Absolute contraindication, relative contraindication, or postponement?

It helps to sort situations into three groups, because the approach changes:

The same condition can fall into different groups depending on the product, the area, and the severity. A controlled autoimmune disease may be a relative contraindication; when active, it usually leads to postponement.

What are the most commonly cited absolute contraindications?

• Known allergy to the product or to components of the formulation. This includes the anesthetic present in some fillers and proteins present in some botulinum toxin formulations, according to the package insert.
• Previous severe hypersensitivity to the same procedure. A major past reaction calls for investigation before repeating.
• Neuromuscular diseases, for botulinum toxin. Conditions that affect the neuromuscular junction are usually listed as a contraindication in package inserts.
• Refusal or inability to consent. Without valid informed consent, there is no procedure.
• Expectations incompatible with any possible result, when conversation cannot align them.

Which situations call for postponement?

These are temporary conditions. The procedure can be done later, after reassessment.

When postponing, record the reason and agree on a reassessment date. The patient understands a "not yet" better when they know what needs to happen for it to become a "yes".

What are the relative contraindications?

They call for caution and, often, a conversation with the patient's physician.

• Autoimmune diseases, mainly when active or under immunosuppressive treatment. There are reports of delayed inflammatory reactions to fillers in patients with these conditions.
• Coagulation disorders and use of anticoagulants or antiplatelet drugs.
• Uncontrolled diabetes, because of healing and the risk of infection.
• Tendency toward keloids or altered healing.
• History of a delayed reaction to filler, such as inflammatory nodules.
• Permanent or unknown product in the area. Injecting over a material you cannot identify increases the risk of reaction and complicates management.
• Recent isotretinoin use, following the dermatologist's guidance.
• Heavy smoking, which compromises vascularization and healing.
• A mental health condition that affects body image. Here the indication depends on a careful conversation and sometimes specialized follow-up.

What changes depending on the product?

The general contraindications apply to almost everything. Some weigh more for specific products:

Before adding any new product to your portfolio, read the entire package insert, especially the contraindications and warnings section. It differs between manufacturers and is updated.

What about high-risk areas?

Some areas are not a contraindication in themselves, but vascular risk makes relative factors weigh more. In the glabella, nose, nasolabial fold, temples, and the tear trough, in the under-eye area, a condition that would make the case "acceptable with caution" elsewhere can lead to not treating or to choosing another approach. The map of the areas is in the overview of injection areas.

When is the expectation the contraindication?

Not every contraindication shows up on the exam. A patient who wants someone else's face, who brings a filter as a reference, or who expects the procedure to solve an emotional problem will hardly be satisfied, even with flawless execution.

In these cases:

• Explain the limits with concrete examples, without judgment.
• Propose a more conservative or staged plan, when it makes sense.
• If the expectation does not align, do not treat. It is an ethical choice, not a lost sale.

A projection with moderate volumes can help show what is realistic. In Harmy, the projection changes only the marked areas and at the intensity of the planned volume, which tends to produce subtle changes. If the patient looks at an honest projection and says "that's all?", the conversation about expectations has to happen before any procedure. See also patient objections and responses.

How do you document the decision not to treat?

The decision not to treat or to postpone protects the patient and the practitioner, as long as it is in writing.

• Record in the patient record the finding that led to the decision (for example, "active herpetic lesion on the upper lip").
• Record the action taken: postponement, referral, request for medical assessment.
• Record what was explained to the patient and the reassessment date.
• If the patient insists, record the refusal to treat and the reason. Do not give in to pressure.

How do you say "no" or "not yet" to the patient?

Declining or postponing a procedure is a delicate conversation. The patient came with an expectation, sometimes blocked off the day, and may read the postponement as unwillingness to help. How you communicate it makes a difference to the relationship and to the chance they will come back.

Some practices help:

• Explain the reason in plain language. "With that active lesion on your lip, injecting now increases the risk of infection and of making the herpes worse" is more convincing than "it's not indicated".
• Show the path to yes. Say what needs to happen (healed lesion, physician clearance, end of breastfeeding) and when it makes sense to reassess.
• Offer what is possible today. Sometimes another area or another type of care can be done safely, at the practitioner's discretion.
• Do not charge as if you had treated. Agree beforehand on the clinic's policy for assessments that end without a procedure.
• Record and schedule. A reassessment date in the patient record and the calendar shows that postponement is part of the care, not a dismissal.

Common mistakes

• Treating "just a little" so as not to disappoint the patient.
• Taking the patient's word about a previous product without recording the doubt.
• Forgetting to ask about pregnancy at every session, not only the first.
• Discovering the active infection after starting asepsis.
• Trusting that a relative condition "has always been fine" in other patients.

Contraindication checklist before the procedure

1. Medical history updated on the day, with questions about what has changed.
2. Allergies checked against the composition of the chosen product.
3. Pregnancy and breastfeeding ruled out.
4. Skin of the area free of active infection or inflammation.
5. Recent procedures in the area checked.
6. Risk medications assessed, with the treating physician when needed.
7. Autoimmune and neuromuscular diseases considered for the chosen product.
8. Previous products in the area identified or documented as unknown.
9. Expectations aligned and consent signed.
10. Hyaluronidase available when the plan includes hyaluronic acid.

For signs of complications and clinic preparation, see the overview of safety and complications.