'I may become the world's most hated plastic surgeon but I had to raise my dermal filler fears'

Plastic surgeon Spero Theodorou said the evidence suggests all filler patients will suffer lymphatic blockage and possibly worse

Many women, and a growing number of men, opt to get cosmetic dermal filler procedures. Plastic surgeon Spero Theodorou says they could be storing up long-term problems, while other experts maintain lymphatic blockages can be dealt with without difficulty. Picture: iStock 

Dermal fillers, fillers, popularised by TV shows such as Love Island, may interfere with the immune system’s ability to fight disease by blocking and damaging important lymphatic channels in the face, research suggests.

Spero Theodorou, founder and surgical director of bodySCULPT plastic surgery practice in Manhattan, New York, said that evidence now suggests that all filler patients will have some degree of lymphatic blockage — even if there are no lumps or visible swelling.

Lymphatic channels form a fundamental part of the immune system, draining fluid as well as flushing toxins and waste. The lymphatic system helps the body to fight disease.

Filler can block and permanently damage these vital and delicate structures, Dr Theodorou has found — in a major study due to be published in the coming weeks.

The research, which he hopes may force change in the hugely lucrative aesthetic industry, was unveiled at the annual scientific conference of the British Association of Aesthetic Plastic Surgeons in London in September.

Dr Theodorou said the problem is with the substance itself. No matter how skilled the injector, the substance can still block these lymphatic channels.

He immediately stopped providing filler at his practice following the research findings, he said.

“I cannot in good conscience provide this to my patients anymore because of what I saw,” Dr Theodorou told the Irish Examiner.

“I have a daughter, she’s 16 years old and I don’t want her — when she’s 20 — putting this stuff in her face.

Ailesbury Clinic founder Patrick Treacy. Dr Treacy agrees that dermal fillers may block the lymphatic system, but said that the study should not be cause for undue worry. Picture: Eddie O'Hare

“I see these 22-year-olds and 19-year-olds and 25-year-olds — and they look great to begin with, and I understand they want to look better on Instagram and all these things — but at the end of the day, these choices will have repercussions down the road for them, and it’s very hard to fix.

“And if we don’t raise our hand as doctors and say: ‘Hey this has to stop or somehow has to be changed’ we’re not doing our jobs.”

The filler industry is now worth an estimated $5bn (€4.6bn) globally, and is forecast to grow to some $9bn (€8.3bn) by 2030.

But the substance — a modified form of hyaluronic acid — has been injected into faces, necks, hands, and bodies with very little to no regulatory oversight, even though it can cause blindness, stroke, and necrosis (the death of tissue). Dermal fillers plump up the skin and are most commonly associated with the lips, but are also used to fill acne scars, reshape a person’s nose, and to replace lost volume.

It is used in procedures dubbed “liquid facelifts” to lift and reinforce structures of the face.

Consultant dermatologist Caitriona Ryan said there is no scientific foundation for fears that filler could impact the immune system or increase cancer risk, but said people should consider how many filler procedures they get for aesthetic reasons. File picture 

The procedures are fast, minimally invasive, and cost from approximately €200 to over €1,000 in Irish clinics — depending on how much product is injected.

The new study used a SPY camera made by Stryker — a global medical technologies company which employs more than 4,000 people in its facilities in Cork.

Dr Theodorou and a team of doctors used the SPY camera to examine the lymphatics in some 50 women who have had facial filler.

A special dye was injected into the women’s faces, which the camera could then track as it moved through the women’s lymphatic channels.

The study showed dye injected into the faces of women with filler pool under the eyes and in the cheeks, and is still stuck there one week later.

A functioning lymphatic system should have drained that dye out almost immediately, Dr Theodorou said: 

It’s just accumulating because lymphatics are blocked. That stuff stays there because it has nowhere to go.

“This is not innocuous. The lymphatic’s job is to remove the impurities from the skin all over the body.

“The lymphatics drain into what we call the lymph nodes, which are your neck or your groin or your axilla. That’s how all the impurities get cleaned up. It also helps for detection of cancer.

“I’m not saying this impacts cancer detection. I’m just saying that all we know is that lymphatics are blocked. And they’re blocked irreversibly.”

Beauty journalist and recent Safety in Beauty Award winner Mary-Jane O’Regan says many people are moving away from dermal fillers: 'A lot of bad work has been done, a lot of ‘Kardashian face’.' Picture: Dan Linehan

Although a substance called hyaluronidase can be used to dissolve filler, it is very difficult to remove it all.

Dr Theodorou said he will be “the most hated plastic surgeon in the world” for highlighting concerns with such a lucrative and popular non-surgical procedure. But, he said, he felt ethically bound to investigate his suspicions and share his findings.

Immune response

Filler has also been found to trigger an immune response — where the body sends killer T-cells to attack what it recognises as a foreign object — causing swelling, he said.

Cancer has been detected in a small number of patients where T-cells attacked some breast implants, Dr Theodorou said.

In lymph nodes removed during surgery, biopsies showed they suffered a foreign body reaction to filler.

“That proves not only that the filler migrated to different areas, but also that there’s a reaction to it on a microscopic level. Whenever you have something foreign in the body, the body attacks it.”

Rheumatologists identified the potential problem with dermal filler some 10 years ago, he said.

“They know there’s an issue with these fillers, and they know there’s a long-term safety issue. So everyone knows this is going on — including the companies — but everyone’s ignoring it.”

'Unknown long-term implications'  

Dr Theodorou said that when they discovered the inflammatory T-cell response to filler and their blocking of the lymph system, they brought their findings to industry.

“Our job, as scientists, is to bring it to your attention, and we did, and nothing happened. We don’t know the long-term implications of messing with this [lymphatic] system,” he said.

Dr Theodorou said it usually takes 20 years for problems with implants and these kinds of medical devices to emerge.

Patrick Treacy — founder of the Ailesbury Clinic in Cork and Dublin, who has treated Michael Jackson — was one of the first doctors to use and contribute to the study of hyaluronidase, an enzyme which breaks down hyaluronic acid.

A woman receiving a brow lift. Beauty journalist Mary-Jane O’Regan says she doesn't intend to stop getting fillers. See below. Picture: iStock 

Dr Treacy agreed that dermal fillers may block the lymphatic system, but said that the study should not be cause for undue worry.

“Although dermal fillers may block the lymphatic system in localised areas and potentially affect the efficacy of the immune system in those specific regions, it is important to note that this should not have a systemic effect on the overall function of the immune system,” he said.

“This can be likened to a road crash temporarily blocking an ambulance from reaching the injured, but the rest of the emergency response organisation continues to function normally.”

'Fillers can block lymphatics but are not dangerous'

Caitriona Ryan — a consultant dermatologist at the Institute of Dermatologists and Blackrock Clinic, and associate clinical professor at University College Dublin — said that although dermal fillers can block lymphatics, they are not dangerous.

“Hyaluronic acid is a jelly-like substance that can compress lymphatic vessels,” Prof Ryan said.

“What they’re saying is definitely true — in that filler can be a blockage to lymphatics, especially in certain areas, like tear-trough filler under the eyes.

“But hyaluronic acid can be dissolved away with hyaluronidase.”

Consultant dermatologist Caitriona Ryan is assured of the safety of dermal fillers, but warns against what she calls 'filler creep'. See below. Stock picture 

However, Prof Ryan said there is no scientific foundation for fears that filler could impact the immune system or increase cancer risk. But she advised people to reduce the filler they are having.

“There’s an epidemic of what I call ‘filler creep’,” she said. "Residual filler builds up over time and their face gets this doughy look.

“These women looked great for the first couple of years of doing filler, but they kept doing it every six months to every year, and they’ve developed this sort of doughy-like pillow face.

“It’s not in any way medically dangerous, but it does give a sort of warped look to people’s faces.

“I think people should pare back how much they’re doing fillers, and maybe opt for things that are going to stimulate their own collagen — like CO2 lasers and radio frequency microneedling.”

There is 'a lot of Kardashian face'

Beauty journalist Mary-Jane O’Regan — who was recently selected for a Safety in Beauty Award in London — said that one research paper was unlikely to stop many people from getting filler, but the industry is moving away from filler and towards more regenerative medical procedures instead anyway.

“It’s not going to stop me from having it done, because I don’t see any problems with mine,” she said.

“But the future I see is people getting less filler and more regenerative medicine, things like platelet-rich plasma — your own blood injected back into your system. People are already moving away from fillers.

"A lot of bad work has been done, a lot of ‘Kardashian face’. A Love Island contestant recently had all their filler taken out." 

Dermal fillers are classified as medical devices under the European Union medical device legislation.

The Health Products Regulatory Authority (HPRA) is responsible for medical devices in Ireland. The Department of Health is now working with the HPRA, as it considers the current regulation of dermal fillers in Ireland.

A new EU regulation introduced in June requires all dermal fillers to be CE-marked — to indicate a valid medical device meets the basic safety and effectiveness requirements under European law.

However, this change is subject to transitional timeframes and may not yet impact all filler on the Irish market.

This regulation requires the instructions for use to state that dermal fillers “are not to be used in persons who are less than 18 years old”, and that they should only be administered by appropriately trained healthcare professionals.

The HPRA does not regulate the administration of dermal fillers.