Some of our massage clients are seeking both commonly practiced cosmetic procedures and extreme cosmetic measures because they want to change or enhance their appearance.

Photo courtesy of CE Institute

Some of our massage clients are seeking both commonly practiced cosmetic procedures and extreme cosmetic measures because they want to change or enhance their appearance.

Some sought-after cosmetic procedures can be used for gender identity or oncology, motor vehicle accident, self-mutilation and other reconstructive purposes beyond the commonly practiced anti-aging applications. Regardless of why a client seeks their cosmetic changes, it is important to never judge a client, their physical appearance or their life choices.

One focus for massage therapists working with these clients should be massage and bodywork  contraindications.

Unfortunately, the increase in aesthetic applications has created an alarming number of botched plastic surgeries and cosmetic procedures. Some of these problems are due to new uses of foreign materials and placement sites where these treatments are administered.

In this article, all plastic surgeries and aesthetic applications discussed will simply be referenced as cosmetic procedures. This article will focus on cosmetic procedure shifting and migration issues that are contributing to massage contraindications. Let’s review.

Cosmetic Fillers

Cosmetic fillers, including Juvéderm and Restylane, are cosmetic fillers that are injected into the skin. They are used to temporarily treat facial lines and wrinkles with a plumping effect, which is why they are called fillers. These two fillers are also examples of products that are manufactured to be absorbed by the body over time, which is why these treatments are called temporary.

Cosmetic filler placement sites are a local massage contraindication due to migration or shifting issues.

It is important to note that temporary fillers are primarily approved by the FDA for small applications on the face only, and in some cases with fat loss from HIV. Fillers should not be used on large areas. The FDA states:

“The FDA has not approved injectable silicone or any injectable fillers for body contouring or enhancement. The FDA has warned against getting filler injected into the breasts, buttocks, or spaces between the muscles. Using injectable filler for large-scale body contouring or body enhancement can lead to serious injury, including long-term pain, infection, permanent scarring or disfigurement, and even death.”

Some clients may seek massage to relieve their pain in these circumstances. Massage is not recommended and instead, the client should seek appropriate medical care to correct their medical problem with their injectable filler.

Fat Grafting, aka Fat Transfer

Fat grafts are a surgical process where fat is harvested from one area of the body and transferred or injected into another area of the body on the same individual. The fat graft harvest site is where fat has been removed. The fat graft implantation site is the site where the fat has been transferred to, placed or implanted.

There are different plastic surgery and cosmetic industry procedure terms used to describe relocating one’s own fat for cosmetic purposes, such as body contouring and liposculpture.

Fat grafts can also be used for one’s own live tissue implant, such as a breast augmentation or a Brazilian butt lift. There are usually no massage contraindications when working over a well-healed fat graft harvest site; however, working directly over the fat graft implantation site is contraindicated.

The fat graft implantation site is a local massage contraindication due to migration or shifting issues.

Cosmetic Implants

Cosmetic implants used for areas such as the cheeks, chin, tooth, breasts, testicles, pectoral or calf muscles are defined as a foreign material that is placed in the body, usually for a perceived improvement of appearance.

Working over a cosmetic implant is a local massage contraindication due to shifting issues, plus the rare occurrence where an implant could leak, rupture or fail. Any of these negative consequences could be caused or blamed on any manual pressure applied to the local area after implantation.

Definition of Foreign Materials

To better illustrate massage contraindications, let’s define, for the purposes of this article, foreign materials as a cosmetic filler, fat graft or synthetic implant that is newly lodged inside the body.

Lodging is used as a term in this article to describe the space where the foreign material will be newly housed in the body.

The foreign material is defined as foreign because it has been lodged in a new area in the body, regardless if it is a synthetic substance or the body’s own tissue such as fat. These foreign materials regularly require new physical space within the body for lodging, which is a critical criterion when discussing migration or shifting issues.

These foreign materials could be newly lodged in the skin, just under the skin, or lodged deeper inside the body such as with intramuscular or under-muscle placement. Some foreign materials and placement sites are considered safer with better success rates than others.

The Migration or Shifting Issues with Fat Grafts, Cosmetic Fillers and Implants

Migration and shifting are terms used to describe when a foreign material has moved away from its original placement site. This can also be called displacement.

Migration is the term commonly referenced when a foreign material has migrated to places such as the client’s bloodstream. Shifting is the term commonly referenced when a foreign material has shifted away from its original placement site, such as instances with physical force, capsular contraction or aging.

Migration and shifting issues of foreign materials within the body can cause physical disfigurement, swelling, pain, obstruction of circulation and even death in some cases.

Shifting of foreign materials can also occur over time and for other various reasons. Skin thickness, gravity, muscular contractures and more could all cause undesirable shifting issues.

While temporary fillers such as Juvéderm and Restylane are considered safer than a permanent filler, there is still concern that shifting or migration could occur with any foreign material, regardless if the foreign material is considered temporary, permanent, synthetic, or living tissue including fat.

MTs Cannot Reliably Control Foreign Material Shifting

Sometimes, massage or bodywork will be prescribed by a physician in an attempt to purposely influence foreign material shifting. The problem is, a practitioner cannot always control where the foreign material will shift to with their hands-on work, and sometimes shifting can result in an undesirable placement.

What is important to remember is the client’s wish to change their physical appearance is met by having a foreign material placed at a specific site in their body. That physical appearance can be drastically changed or undesirable when the foreign material shifts away from its intended placement site.

Permanent Silicone Injectables

Silicone injectables are an example of fillers used that are not approved by the FDA because they are permanent and remain within the body. The FDA warns, “It can move throughout the body and cause serious health consequences, including death. In fact, when injected into areas with many blood vessels, such as the buttocks (butt), silicone can travel through those vessels to other parts of the body and block blood vessels in the lungs, heart, or brain. This can cause a stroke or even death.”

The FDA’s warning of foreign material migration is a huge concern for massage practice. Massage should not be applied over foreign materials; it is simply ill-advised.

It should be noted that whole and intact silicone implants used for cosmetic procedures such as breast augmentation would not apply to this referenced FDA migration warning. While silicone implants have their own worrisome concerns such as they can shift away from their original placement site with incorrect placement or when they are too large for the area and more, this FDA warning is about silicone injectables.

The Brazilian Butt Lift Mortality Rate is 1 in 3,000

The American Academy of Plastic Surgeons reports that one in three thousand Brazilian butt lift (BBL) patients die after their Brazilian Butt Lift procedure. The most common cause in these deaths is a migration of the fat graft. This can cause a fat embolism, which is also known as fat embolism syndrome or FES.

This is another example of a foreign material shifting or migration issue that can cause death.

Post-surgical swelling and pain with the Brazilian Butt Lift procedure is something that can be treated with manual lymphatic drainage. However, a practitioner should reconsider that working with risky and high-mortality surgical procedures when shifting and migration are possible is a grave concern. It is a massage contraindication to work directly over a Brazilian Butt Lift fat implantation site.

The Brazilian Butt Lift procedure has been given a new second name due to its unacceptable high mortality rate. It has been referenced as the world’s most dangerous cosmetic surgery.

Working Over Foreign Materials is a Contraindication

When a practitioner manipulates soft tissue over a foreign material, the practitioner could be blamed for shifting the material away from its original placement site due to manual pressure or application.

While the chance of this happening might depend on the technique and force used with hands-on treatment, it is an incalculable risk for the potential of client injury or lawsuit. Any failure caused with shifting or migration could be blamed on a practitioner who has physically manipulated the affected area, which is why we have labeled foreign material location sites as a local massage contraindication.

As such, it is not recommended to provide any hands-on service manipulation over a site that has lodged foreign material such as a cosmetic filler, fat graft or implant

Be Aware: Plastic Surgeon and Physician Referrals

Sometimes a plastic surgeon will refer a patient for post-surgical manual lymphatic drainage to treat swelling, or they may prescribe deep tissue massage for new muscular contracture over an implant, or more.

Even with a doctor’s written prescription and direction, shifting or migration of foreign material could happen or be blamed on manual therapy, and may have already occurred, hence the referral.

In addition to the undesirable health and placement consequences that can result with cosmetic foreign material procedures, it is important to note that a client can take legal action any time they are unhappy, regardless if a doctor has prescribed their bodywork. There is no amount of prescriptions, medical releases or documentation that could prevent a client’s action or reaction, especially when they feel their procedure was botched.

Sometimes physician referrals are made in good faith because there are real massage treatment benefits that could be achieved by working with some of these cosmetic procedures. However, while some well-trained bodywork applications may improve the client’s condition, there could also be some significant risks in trying to achieve it.

Sometimes it is not worth the risk to try to achieve the benefit, especially given the lack of certainty with both.

Breast Implant Massage: A Lack of Evidence

Massage therapists will need much better research and evidence-based proven application processes before they should feel confident in working over foreign materials.

A 2017 published and extensive review of over 40 years of literature regarding breast massage with breast implant shifting concluded:

• There was no standard measure used to apply massage pressure,

• Massage for implants provided almost no improvement for its intended purpose,

• The massage techniques used to reduce implant shifting remain controversial,

• “ … some skeptics believe breast massage may increase the rate of capsular contracture by increasing fibroblast activity and inflammation.”

Seek Additional Directions and Training

Even when not working on a locally contraindicated foreign material placement site, it may be best to check with the client’s physician for any special considerations immediately after a cosmetic procedure has been administered.

For example, a client cannot lie supine on a massage table immediately after a BBL procedure for foot reflexology or any other service. Requesting a client to lie in supine position immediately after a BBL procedure would be a medical error, and something that could be avoided with proper questioning or training.

Practitioners should observe general massage and bodywork contraindications at all times, in addition to what was shared here. 

In this article, we focused on foreign material migration and shifting issues with cosmetic procedures that create massage contraindications. Practitioners should seek additional training when working with cosmetic procedures and post-surgical clients. There are many more massage precautions, contraindications and important details that should be understood prior to attempting to work with these clients.

Selena Belisle

About the Author

Selena Belisle is the founder of CE Institute LLC in Miami, Florida, where they teach massage, nursing and cosmetology industry CE courses. She has been practicing massage therapy and bodywork for over 30 years. She is approved as a continuing education provider by many industry state boards and the National Certification Board for Therapeutic Massage & Bodywork.