Hyaluronic Acid in the Philtrum: Indication and Risks

The philtrum is the small groove between the base of the nose and the upper lip. Despite its size, it is one of the areas that most influences how the lower third of the face reads: a short, long, flattened or asymmetric philtrum changes how the lip looks, even when the vermilion is perfect. That is why it is a common concern in the office, and why it demands the same caution as the "big" areas.

This content is a review of indication, anatomy and risks for the orofacial harmonization (HOF) professional. It is not an injection protocol. Product, volume and approach are the decision of the licensed professional, after assessment, according to the rules of their professional board and the product's instructions for use.

What is the philtrum and what does it depend on?

The philtrum is formed by two columns (ridges) that descend from the columella to Cupid's bow, with a depression between them. This structure comes from the arrangement of the orbicularis oris muscle, the skin and the bone base. Its length and depth vary a lot from person to person and change with age, with use of expression and with loss of dental support.

When assessing the upper lip, many professionals look at the philtrum together with the lip vermilion, the labial tubercles and the lip proportion. Treating the philtrum in isolation, without looking at the whole, is one of the origins of the artificial look.

When does the philtrum usually enter the plan?

The situations most cited in clinical practice include:

• Loss of column definition with aging, leaving the philtrum "flattened".
• Asymmetry between the columns.
• The patient's wish for greater harmony of the upper lip, within natural proportions.
• Complement to a plan that already involves the lip and the vermilion border.

There are also situations in which philtrum filler is not the best answer. If the concern is a long philtrum due to bone or dental position, filler does not correct the cause, and the patient needs to know that. The assessment of the whole is in aging of the perioral area and thin lips: assessment.

Which arteries deserve attention?

The area receives branches of the superior labial artery, which runs near the vermilion, and of the columellar artery, which rises toward the tip of the nose. Both are part of a network with anastomoses and individual variation (see lip vascularization: variations).

In practice, this means that a vascular occlusion in the philtrum can show up in the upper lip, the columella or the tip of the nose. The ischemia can progress to necrosis. The reasoning also applies to labial vascular occlusion and nasal vascular occlusion, which are worth reading together.

What are the most relevant risks?

How to assess the patient before recommending treatment?

Asking about cold sores is part of the medical history. In patients with a history, the preventive approach is the professional's decision (see herpes prophylaxis before a procedure).

How to talk to the patient about expectations?

Patients usually arrive with a reference image, often filtered or edited. It is worth explaining that the philtrum has natural variation and that the goal is to improve definition within what their face allows, not to copy a photo. The discussion about beauty filters and dysmorphia helps calibrate the dialogue.

If the patient tends to ask for more and more volume, it is worth remembering what the page less is more in facial harmonization discusses: excess is usually noticed first by others and only later by the patient.

What to do if something does not turn out as expected?

For irregularities and excess volume, hyaluronidase is an option, using the criteria in dissolving filler. For the "heavy lip" look, compare with excess volume after filler. Always record product, lot, amount and course in the patient record.

What to show the patient during the consultation?

An illustrative simulation helps to talk about lip proportion without promising results. In Harmy, the Lips point lets you set the ml and the intensity (Subtle, Moderate or Pronounced) and see, on the Before/After slider, how the area may look. The app uses a front-facing photo and has no dedicated point for the philtrum, so the projection helps more in reading the lip as a whole than the philtrum alone. See the Lips area and the lip filler procedure.

How to record and follow up the case?

Document the initial state of the philtrum and upper lip with standardized photos, the product used, the lot, the volume and any complication. Agree with the patient on a direct channel for the first few days and explain which signs require immediate contact: pain that increases, pallor, color change, blister or sore. Good documentation protects the patient and the professional, and helps decide on a possible touch-up based on the already stabilized effect, not on the swelling of the first day.

At follow-up, compare the photos, palpate the columns for irregularity and ask about the patient's perception when speaking, smiling and eating. A philtrum that is well defined at rest but becomes rigid when smiling is a sign of excess volume or gel that is too superficial, and can be reassessed. Guidance on massage, heat and exercise should be given in writing, according to the professional's approach (see massage after filler and biostimulator).

In summary

The philtrum calls for less volume than the patient imagines and more anatomical knowledge than its small appearance suggests. Assess the lip as a whole, know the course of the arteries, work with the right consent and keep hyaluronidase within reach. When the cause cannot be treated with filler, telling the patient so is also part of good care.