Beyond Surface Landmarks
Module 1 established the visible anatomy. This module goes deeper — literally. The vascular network, nerve supply, and structural changes that occur with age and across ethnic presentations all affect how you plan, execute, and predict outcomes for lip blushing procedures. This is not academic anatomy for its own sake. Every structure discussed here has a direct clinical implication.
Vascular Anatomy
The superior and inferior labial arteries supply the lip tissue with blood. They branch from the facial artery and run within the orbicularis oris muscle, approximately 2-3mm beneath the vermilion surface. Their position determines where bleeding is most likely during the procedure, which directly affects pigment retention — blood dilutes pigment and carries it away from the deposition site.
Map the high-risk zones: the lateral portions of the upper lip near the commissures, where the superior labial artery is closest to the surface, and the central lower lip where the inferior labial artery runs most superficially. Adjust needle depth and machine speed in these zones. Slower speed and shallower depth reduce vascular disruption. If excessive bleeding occurs in a specific zone, blot, apply gentle pressure for 30 seconds, then resume at reduced depth rather than pushing through the bleeding.
Clients on blood thinners (even over-the-counter aspirin or fish oil supplements) will bleed more than standard presentations. Ask about these specifically during consultation. Request that non-essential supplements be paused 7 days before the procedure, with GP guidance for prescribed medications.
Lip Innervation & Client Comfort
The mental nerve supplies sensation to the lower lip and chin. The infraorbital nerve supplies the upper lip. Sensitivity varies significantly across the lip surface — the vermilion border is markedly more sensitive than the central lip body, and the commissures are the most sensitive of all.
Understanding this distribution allows you to sequence the procedure for optimal client comfort. Begin in the less sensitive central body of the lip, allowing the topical anaesthetic time to reach maximum efficacy before working toward the more sensitive borders and commissures. If the client reports increasing discomfort during border work, re-apply topical anaesthetic and wait 3-5 minutes rather than powering through — a client in pain moves, and movement during border work creates irregularity.
Individual pain tolerance varies enormously and cannot be predicted from demographic factors. A first-time client who reports low pain tolerance may handle the procedure well with proper topical anaesthesia. A client who claims high pain tolerance may become distressed at the border. Manage comfort by monitoring the client's response continuously, not by relying on their self-assessment.
Age-Related Changes
Lip anatomy changes predictably with age. The vermilion border loses definition as the sharp demarcation between lip tissue and facial skin softens. Volume redistributes — typically decreasing in the body while the tissue becomes relatively looser. Vertical rhytids (perioral lines) develop around the lip border, creating textured channels that can wick pigment beyond the intended boundary. The commissures descend, creating a downturned appearance even in a neutral expression.
Each age-related change affects technique selection. A mature lip with diffuse borders may benefit from Shaded Liner to restore the definition that time has softened. Ombré can create perceived volume on a lip that has deflated. Perioral rhytids require particular care — pigment applied at the border can track along these lines, creating visible bleed-out. For mature clients with significant rhytids, consider stopping the application 0.5mm inside the natural border rather than on it, allowing a buffer against wicking.
Ethnic Variation in Lip Anatomy
Lip anatomy varies across ethnic presentations in border definition, volume distribution, natural pigmentation, and tissue thickness. These are population tendencies, not individual prescriptions. The diagnostic framework treats every client as an individual assessment, with awareness of common presentation patterns to help anticipate and plan.
Clients with darker natural lip pigmentation (common in Fitzpatrick types IV-VI) require specific assessment for neutralisation potential before enhancement. The natural pigment layer sits between the applied pigment and the viewer — it modifies how the applied colour is perceived. A pigment that reads as mauve on pale lips may read as barely visible on deeply pigmented lips because the natural melanin absorbs and masks the applied colour.
Individual assessment always overrides categorical assumptions. A client of South Asian heritage may have well-defined borders and minimal pigmentation. A Northern European client may have diffuse borders and significant natural colour. Diagnose what you see, not what you expect based on background.
The Lip-Filler Interface
Dermal filler has become ubiquitous in the lip PMU client population. A significant proportion of lip blushing clients either currently have filler, have had filler previously, or are considering filler alongside PMU. The practitioner does not need to understand filler administration — that is a separate discipline requiring separate qualifications. What the practitioner must understand is how filler alters the anatomical landscape they are working on, and how to make safe, informed decisions when filler is part of the clinical picture.
How Filler Changes the Tissue
Dermal filler displaces natural tissue, creates areas of variable density, and changes the way the lip responds to needle penetration. The most commonly used lip fillers are hyaluronic acid (HA) based products — Juvederm, Restylane, and similar brands. These integrate into the tissue over 2-4 weeks, attracting water molecules and creating volume through hydration. During this integration period, the tissue is unstable: swollen, vascular, and structurally unpredictable. PMU performed during this window produces unreliable results because the tissue you are working on today will not be the tissue the client has in four weeks.
Once integrated, filler creates a dual-density landscape. The zones where filler sits are denser, more hydrated, and structurally different from the native tissue surrounding them. Pigment behaves differently in each zone — filler-dense areas may resist pigment uptake (the needle meets firmer resistance), while native tissue adjacent to filler may absorb more readily. This density differential is the primary cause of uneven colour distribution in filled lips. If you apply uniform technique across a non-uniform tissue landscape, you get non-uniform results.
Assessment Protocol for Filled Lips
Every consultation should include a direct question about filler history. Do not rely on visual assessment alone — well-placed filler is often invisible. Ask three specific questions: Have you ever had lip filler? When was it most recently injected? What product was used? The answers determine your treatment timeline and technique adaptation.
Palpate the lips during assessment. Run your fingertip gently along the body of the lip, feeling for distribution. Well-integrated filler should feel smooth and uniform. Lumps, nodules, or asymmetric firmness indicate areas of uneven filler placement or early migration. These zones will behave unpredictably under the needle and should be documented on the treatment plan with adjusted technique notes.
Pay particular attention to the vermilion border on filled lips. Some injectors place filler along the border to create definition — this creates a firm ridge that changes how your border pass feels and behaves. Filler-enhanced borders may resist pigment differently than natural borders, and the border position itself may shift as filler migrates or dissolves over time. Document whether the border definition you are mapping to is anatomical or filler-created, because a filler-created border is temporary.
Sequencing: Filler and PMU
The sequencing question — should the client get filler first or PMU first — comes up frequently. There is no single correct answer, but there are clear principles.
PMU before filler is generally preferable. The pigment is placed in native tissue with predictable behaviour. When filler is subsequently injected, it may displace the pigment slightly, but the effect is usually minimal and evenly distributed. The client gets to see and approve their lip colour before any structural changes from filler.
Filler before PMU requires a minimum wait of 4-6 weeks for integration. After this period, the filler has settled, swelling has resolved, and the tissue density has stabilised. Assess the lip as it presents now — the filler is part of the anatomy you are working on. Adjust needle depth and pressure for filler-dense zones. Build saturation incrementally rather than in heavy passes, because tissue response in filled areas is less predictable.
Filler and PMU in the same week — or worse, the same day — should always be declined. The tissue is in active inflammatory response from one procedure and cannot safely tolerate another. The risk of migration, infection, and unpredictable healing is unacceptably high.
Recognising Filler Complications
You are not responsible for diagnosing or treating filler complications. You are responsible for recognising when something you observe during assessment warrants referral back to the injector before you proceed with PMU. Three presentations should prompt a pause and a referral conversation.
Filler migration: pigment appears above the vermilion border (the "shelf" or "duck lip" effect) or has moved asymmetrically. Migrated filler changes the structural geometry of the lip in ways that make your mapping unreliable. The border you map to may not be where the tissue stabilises.
Vascular compromise signs: if the client reports persistent blanching, unusual pain, or dusky discolouration in the lip following recent filler, these are potential signs of vascular occlusion — a medical emergency. Do not proceed with any cosmetic procedure. Refer immediately to the injector or to A&E.
Granuloma or chronic inflammation: firm, well-defined lumps that persist beyond the expected integration period suggest granulomatous reaction to the filler material. These areas will not accept pigment predictably and indicate an immune response that makes additional needle trauma inadvisable.
Communicating with Injectors
Building professional relationships with local aesthetic injectors benefits both practices. When you can communicate directly with a client's injector, you can coordinate sequencing, share relevant observations about filler distribution, and create a treatment plan that accounts for both procedures. This professional network also provides a referral pathway when you identify filler complications during assessment.
Frame these conversations as collaborative, not territorial. You are the pigment specialist; they are the injectable specialist. The client benefits when both practitioners share relevant observations. A simple professional letter or message — "I am planning lip blushing for our mutual client and noticed asymmetric filler distribution in the right lateral border. Can you advise on whether this should be addressed before I proceed?" — establishes you as thorough and competent.
Scar Tissue Assessment
Scar tissue from previous cold sore outbreaks, trauma, or surgical procedures creates zones of altered pigment behaviour. Scar tissue is denser, less vascular, and less predictable in its pigment uptake. Some scars absorb more pigment than surrounding tissue, creating dark spots. Others reject pigment entirely, creating gaps. Map scar tissue locations during assessment using magnification and palpation, noting them on the treatment plan for zone-specific technique adjustment.
Case Study: The Mature Lip
A 58-year-old client requests "full lip colour to bring back the colour I had at 30." Assessment reveals: diffuse vermilion border bilaterally, moderate perioral rhytids, volume loss primarily in the upper lip, commissures descended approximately 3mm from neutral, Cupid's bow peaks softened but identifiable, and well-hydrated tissue in good overall condition.
The diagnostic conflict: Full Lip Colour requires precise border adherence across multiple sessions. The diffuse border means there is no sharp anatomical line to follow — the practitioner would be placing pigment at an estimated border position. Perioral rhytids create wicking channels that pull pigment beyond the intended boundary. The risk of visible colour bleeding on a mature lip is significantly higher than on a youthful lip with defined borders.
The recommendation: Shaded Liner to restore border definition, combined with a moderate Lip Blush fill in the body. This gives the client the colour return she is seeking while working with her current anatomy rather than against it. The Shaded Liner creates the definition that time has softened, and the body fill adds warmth without the multi-session commitment and border-precision demands of Full Lip Colour. Present the reasoning with reference to the specific anatomical findings — the client can see the softened border in the mirror and understand why the adaptation serves her better.