Are dermal fillers linked to health risks like lymphatic blockage?

As aesthetic clinicians, the safety of our practice and the products used are paramount. But what if you were unknowingly putting patients at risk with dermal fillers? Some speculation and recent articles have suggested that soft tissue fillers used for cosmetic enhancement may be linked to lymphatic system blocking.

In this blog, Dr Tim Pearce will review these claims and aim to get to the truth, exploring the presented study, the moisture-retaining properties of hyaluronic acid and how this could affect the experiment undertaken, whether dermal fillers can indeed block the lymphatic system, and if they can impact the immune system, alongside general safety.

Can hyaluronic acid dermal fillers cause lymphatic blockage?

Speaking to The Irish Examiner, American plastic surgeon, Dr Spero Theodorou noted that there is evidence to suggest that dermal filler patients will suffer from lymphatic blockage and possibly worse. But where did his claims come from?

His hypotheses are based on a study* involving injecting a special dye into patients who had previously had facial fillers and observing the lymphatic drainage of the dye using specialised camera technology. From his findings – noting that the dye pooled in places and remained for longer than expected within a functioning lymphatic system – he has inferred that there may be a more global effect on the immune system – quite a leap.

[* The study was unpublished at the time of this commentary.]

I have many questions about the experiment, the inferences made, and the dangers of sensationalised news articles that can lead to unfounded worry, which we will explore further.

Presented at the UK’s British Association of Aesthetic Plastic Surgeons (BAAPS) conference, they issued a cautionary statement on the impact dermal fillers may have on the immune system.

Dr Theodorou is quoted as stating;

“Under-eye filler is one of the biggest problems. You see women everywhere with swollen eyes. You have young women having fillers in their faces. It’s never going to go away. It’s very hard to remove and it blocks lymphatics in your face. This is a very important system. Not all patients will have swelling, but evidence suggests all will have some degree of lymphatic blockage.”

Arguably, under-eye filler is an easy example to target because it manifests excess very well due to thin skin, (0.2mm thick), making over-filling more obvious, or if filler breaks down slowly and attracts more moisture, or if there is (debatable) lymphatic drainage, there will be a noticeable protuberance. However, I dispute that it is hard to remove – or poses a significant challenge – because hyaluronic acid-based products dissolve quickly with hyaluronidase.

Like collagen, hyaluronic acid (HA) is a collection of molecules naturally found in the skin. Collagen is not drained through our lymphatic system, it stays put and gives skin structure; similarly, natural HA is part of the extracellular matrix and holds on to moisture in the skin without causing a problem – being continually enzymatically denatured and made afresh. We know from studies in mice that if you destroy the gene that makes the main type of hyaluronidase enzyme responsible for degrading HA, the animal becomes ‘puffy’ because their lymphatic system does not work. It cannot process the HA present throughout the body which would otherwise be degraded into smaller HA fragments by hyaluronidase that could be metabolised.

The question posed by this study is whether fragments of injected HA could get into the lymphatic system and block it.

If a small fragment of HA breaks off from a deposit of filler, it will float off, and, like a natural HA fragment in the body, it will go down into the lymphatics and be digested and distributed. The study is unclear if the hypothesis relates to intermediate HA fragments blocking the lymphatics. Similarly, we have to question if the concept of any lymphatic blockage is erroneous given that HA holds on to moisture in the tissue as its mode of action, which could include absorption of a dye.

Could the hyaluronic acid hold onto the dye in the same way it attracts water?

Based on the available information, we do not know how the specialised dye used in the experiments interacts with HA.

Suppose you inject a dye into the tissue where a molecule that holds onto moisture is present, the hyaluronic acid. The result (proposed as pooling and thus not draining) could be a simple observation of dye within the HA because it has been attracted to and retained by it, in the same way as other moisture, meaning that the lymphatic drainage system is not being tested. Lymphatic drainage would still be occurring, but the dye would not be draining because it has interacted with the HA – and you could not therefore conclude that lymphatic channels were blocked.

Similarly, if the suggestion is that HA filler is locally blocking lymphatic channels, would that make a difference, or pose a systemic threat to the overall immune system anyway? Probably not when we consider how localised skin infections are still managed effectively by the immune system and lymphatics.

I can agree that some patients get ‘puffy faces’ after treatment, which is a known risk, especially with over-treatment that draws in too much moisture to the mid-face, but this is not routine with good practice and product choice.

Are hyaluronic acid dermal filler treatments safe?

The study author has noted that his findings are enough to persuade him to no longer offer dermal filler products to his patients.

Many people treat risk assessment as rooted in absolute truth, but in reality, it is always a balance of pros and cons. Plastic surgeons have historically dismissed non-surgical cosmetic techniques like dermal fillers, despite their lower risks and costs compared to surgery, raising questions about their motivations – concerning study findings of this kind – and whether their alternatives genuinely provide safer or better patient outcomes.

Should you stop offering dermal filler treatment?

Having discussed the newspaper article and claims made within, (which included many additional sensational interjections not mentioned in this blog which I feel were more useful as click-bait), my take-home message is that as aesthetic clinicians, we should pay attention to news reports and published studies, but it is important to critically evaluate the risks without succumbing to disproportionate fear, because alarming cases or concepts often receive amplified attention, especially by mainstream media.

A good clinician helps patients navigate the complexities of treatment decisions, balancing known risks and benefits in the context of their lives – which for some can be a real turning point – rather than adopting extreme stances or avoiding treatments altogether because of one report or opinion.

When encountering new information, it is crucial to seek out the source material and assess the science critically, especially if the study is unpublished or lacks clarity about its methods, (as was when this study was featured in the press and at the BAAPS conference). Always interpret findings within the context of the treatment modality’s pros and cons, balancing the risks of treatment against the emotional and social challenges of doing nothing for your patient.

For more insight into complications management for dermal filler treatments, why not download Dermal Filler Complications: The Essential Guide or learn how to diagnose, treat and avoid delayed onset nodules caused by dermal fillers with Dr Tim’s incredibly detailed guide to non-inflammatory lesions and inflammatory lesions. His Dermal Filler Complications Mastery eCourse is also available, with an illustrated and animated video guide to every dermal filler complication; diagnosis, pathogenesis, treatment guide and preventative techniques.

If you have any questions or topics for discussion, you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

COSMETIC FILLERS LINKED TO SERIOUS HEALTH RISKS? Is it true or scare tactics by media!?

Dr Tim says:

“Are YOU unknowingly putting your patients at risk with dermal fillers? If you’re a clinician working with dermal fillers, you’ve probably come across the articles stating that dermal filler can cause cancer and lymphatic blockage. As clinicians, it’s our job to inform patients about the risks.”

Watch the full Aesthetics Mastery Show here.

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