Aesthetic nurse Rose Poyner details the benefits of incorporating manual lymphatic drainage with facial aesthetic treatments
There appears to be little acknowledgement of the importance of the lymphatic system in the medical aesthetics speciality and manual lymphatic drainage (MLD) is usually only used as practitioner’s preference. This may be down to the fact that anyone can perform MLD and it is used more frequently in holistic therapies and alternative medicine. However, when drawing upon both current and previous research, which is limited, there are benefits to adopting this approach as a routine part of future treatments.
The lymphatic system is important when considering the valuable role of the lymphatic vasculature during acute inflammation;1 often caused by a range of aesthetic treatments. This article will explore the lymphatic system and the benefits of MLD as a routine part of facial aesthetic treatments, primarily dermal fillers, and how it can minimise the side effects experienced by patients, thus increasing satisfaction with their treatment.
The lymphatic system was first described in the 17th century by Italian physician, Dr Gaspare Aselli and is made up of a network of tissues and organs that remove waste and other unwanted materials from the body.2 Its primary function is to support our immune system by transporting lymph through a network of larger vessels and smaller, thin-walled capillaries. Lymph is the name given to the fluid found in the lymphatic system, which is comprised of interstitial fluid and other substances that are continually exchanged through the highly permeable vessel walls.2
The lymph nodes are found at various points along the lymph vessels, for example, in the neck (Figure 1) and the role of the lymph nodes is to filter passing lymph from nearby parts of the body.3 The lymph nodes also contain immune cells which help fight infection by destroying germs carried in lymph fluid.4 The most significant role of the lymphatic system in aesthetics is the ability to drain excess interstitial fluid away from the extra-cellular tissue and return it to the venous circulation, thus reducing any oedema as a result of trauma and inflammation post treatment.3 There is a close structural and developmental relationship between the vascular and lymphatic systems and they are sometimes described as being developed in parallel; however, it is unclear what role the lymphatic vasculature plays in helping to reduce acute inflammation. A study in 2011 conducted by Huggenberger et al. explored the possibility that an expanded lymphatic network reduced dermal oedema formation and therefore, limited acute skin inflammation.5 It is important to note here that this study was conducted on murine; with that in mind it would be fair to say that more human-based clinical trials would be beneficial.
Injecting dermal fillers for example, involves causing trauma to the skin and deeper tissues, triggering the body’s natural inflammatory response. The damaged cells release chemicals such as histamine and prostaglandins, which causes fluid to be leaked from blood vessels leading to localised swelling of the tissues.6 In addition, dermal fillers can cause a degree of lymphoedema by obstructing the lymph nodes and lymphatic vessels causing a build-up of lymph fluid in the affected area.7 Although there is little evidence to support the use of MLD in facial aesthetic treatments, there is a proven link between the injection of dermal fillers and oedema as a complication, due to the obstruction of lymphatic vessels and, furthermore, that manual compression is a suitable treatment for this side effect.8
There is also increasing discussion within the field of holistic therapies about the use of MLD for overall health and wellbeing and it is widely reported as being able to relieve fluid congestion, particularly around the eye area, as well as enhancing the wound-healing process by improving microcirculation to the area.9
There are additional benefits for patients which may make combining MLD with facial aesthetic treatments seem more appealing such as improved skin tone, reduced puffiness around the eye area and accelerated healing time.10 The natural ageing process contributes to deteriorating lymphatic function and promoting increased lymphatic flow can also be beneficial to patients, regardless of whether they are having aesthetic treatments or not.11
Manual lymphatic drainage is a specialised massage technique that was proposed in the 1930s by Dr Emil Vodder and his wife Dr Estrid Vodder. It works to stimulate the lymphatic system to promote resorption of the fluid from swollen tissues.12 Dr Vodder’s technique is characterised by gentle pumping, circular movements applying pressures of approximately 30mmHg (the unit of pressure, known as the millimetre of mercury) to the affected area. Other methods are described in the literature such as those pioneered by Foldi, Casley-Smith and Leduc, all of which have slightly different techniques.13 For example, the Foldi method, is based upon the Vodder technique however lays emphasis on thrust and relaxation. The Casley-Smith technique involves the use of small and gentle movements with the side of the hand and the Leduc method involves use of enticing movements which reflect how lymph is absorbed in the initial lymphatics. I have found however that Vodder’s technique remains the most commonly used and widely recognised in practice.
Although there has been further development of MLD techniques over the years, the overall aim remains the same; to promote variations in interstitial pressures by stretching the skin in specific directions incorporating slow, repetitive movements and allowing a brief resting phase where the skin can return to ‘normal’.14
When considering when MLD would be most useful for aesthetic practitioners it is important to carefully review the anatomy and physiology of the face. As mentioned, oedema is a very common side effect of most aesthetic treatments, regardless of the area injected, although it is more prevalent in the lips, the periorbital and malar regions.15 This could be due to the hydrophilic nature of some hyaluronic acid based fillers, but could equally be caused by the compression of lymphatic vessels or the temporary paralysis of facial musculature after anti-wrinkle injections causing lymphostasis.16 This emphasises the importance of MLD post-delivery of facial aesthetic treatments in anticipation of lymphostasis, hopefully reducing the amount of swelling experienced by the patient.
If the treating practitioner is using local anaesthetics during treatment, consideration should be given to secondary oedema as a result of this and, in my experience, MLD post procedure could be beneficial to reduce this. If a patient experiences localised oedema post treatment it is reasonable to expect it to dissipate within two weeks, although most cases will resolve earlier than this.17 If swelling persists, the patient should be assessed face-to-face by the treating practitioner to determine the underlying cause of the problem.
It is important to be able to distinguish between straightforward oedema and other causes of swelling such as infection. The area affected by oedema should feel soft and be easily compressed when palpated and may feel tender due to the procedure itself; however, if there is a localised infection, the area may appear red, inflamed and hot to touch. MLD is generally suitable for the majority of aesthetic patients, however, the technique should not be performed on patients with lymphatic disorders such as Milroy disease which affects the way the lymphatic system functions.18
MLD is a well-established technique to aid the reduction of fluid build-up, which can be the cause of reduced patient satisfaction post treatment. With additional benefits as well as reducing oedema, there is an argument for combining MLD with facial aesthetic treatments routinely to maximise results and improve the overall appearance of the skin.
1. Huggenburger, R and others, ‘An important role of lymphatic vessel activation’, Blood: American Society of Haematology, 117 (2011) <http://www.bloodjournal.org/content/117/17/4667?sso-checked=true> (p.4667-4678)
2. Oliver, G, Lymphatic vasculature development, Nature Reviews: Immunology, 4 (2004) 35-34 (p.35)
3. Lymphoma Action, The Lymphatic System <https://lymphoma-action.org.uk/about-lymphoma-what-lymphoma/lymphatic-system>
4. Lymphoma Action, Lymph nodes and cancer: What is the lymph system? <https://lymphoma-action. org.uk/about-lymphoma-what-lymphoma/lymphatic-system>
5. Huggenburger, R and others, ‘An important role of lymphatic vessel activation’, Blood: American Society of Haematology, 117, 2011 <http://www.bloodjournal.org/content/117/17/4667?sso-checked=true> (p.4667-4678)
6. MedlinePLus.gov, Immune Repsonse, 2019 < https://medlineplus.gov/ency/article/000821.htm>
7. King, M, Management of Edema, The Journal of Clinical and Aesthetic Dermatology, 10 (2017) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300735/>
8. NHS Direct Wales, Oedema, 2016 <https://www.nhsdirect.wales.nhs.uk/Encyclopaedia/o/article/oedema/> [15/05/2019]
9. Loskotova, A, Myofascial-manual lymphatic drainage for burn trauma: a service evaluation, British Journal of Community Nursing, (2017) S8-S12
10. Williams, A, ‘Manual Lymphatic Drainage: exploring the history and evidence base’, British Journal of Community Nursing, S18-S24
11. Neill, U. S, ‘Skin Care in the Ageing Female: Myths and Truths’, Journal of Clinical Investigation, 122 (2012) https://search-proquest-com.rcn.idm.oclc.org/health/docview/921471707/fulltext/BB82574127854E9APQ/1?accountid=26447 (p.473-477)
12. Williams, A, ‘Manual Lymphatic Drainage: exploring the history and evidence base’, British Journal of Community Nursing, S18-S24
13. MLDUK.org.uk, MLD Courses, 2019 < http://www.mlduk.org.uk/courses-casley-smith/>
14. Williams, A, ‘Manual Lymphatic Drainage: exploring the history and evidence base’, British Journal of Community Nursing, S18-S24
15. King, M, ‘Management of Edema’, The Journal of Clinical and Aesthetic Dermatology, 10 (2017) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300735/>
16. Funt, D & Pavicic, T, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches, Clinical Cosmgation Dermatol, 6 (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865975/>
17. Funt, D & Pavicic, T, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches, Clinical Cosmgation Dermatol, 6 (2013 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865975/>
18. U.S. National Library of Medicine, Milroy Disease, 2019 <https://ghr.nlm.nih.gov/condition/milroy-disease>