When faux fillers fail

The quest for physical perfection has a dark side - when procedures go wrong and lead to disfigurements or worse. - ST FILE PHOTO

The quest for physical perfection has a dark side - when procedures go wrong and lead to disfigurements or worse.

Increasingly, the cases that have been ending up in doctors' clinics recently are due to botched filler injections which contain either hyaluronic acid or other unknown substances.

Some public hospitals and plastic surgeons here told Mind Your Body that they see between two and 10 cases each year of people who run into such trouble. Some were treated by unlicensed practitioners who used unapproved products as fillers, while others had aesthetic treatments that simply went wrong even when they were performed by licensed professionals.

The most egregious cases often happen when people are treated by unlicensed practitioners using unapproved filler products.

In Singapore, only qualified medical practitioners can perform filler injections.

Under the Health Products Act, non-health-care professionals who give filler injections can be fined up to $50,000, jailed up to two years, or both.

Unfortunately, as most of those affected do not file formal complaints with the authorities, the Health Sciences Authority has prosecuted only one case since 2012, for selling counterfeit hyaluronic acid fillers to the public.

Hyaluronic acid products are used to plump up hollows around the eyes, the nasolabial folds that run down from the nose to the mouth and marionette lines around the lips that are caused by sagging skin and fat loss that comes with age.

They can also be used to augment the nose, chin, cheeks and lips.

There are 13 such products that have been approved by the Health Sciences Authority (HSA) for use here.

  • Looking out for possible complications

  • The complications from the use of fillers range from minor adverse effects, major complications that threaten skin loss and vision, undesirable aesthetic outcomes to late complications, said Dr Mohamed Zulfikar Rasheed, consultant at the department of plastic, reconstructive and aesthetic surgery at Singapore General Hospital.

    The injection of any dermal filler may occasionally be accompanied by minor side effects, such as pain, a burning sensation, itching, redness, and swelling or bruising, even with excellent technique, he said.

    Undesirable aesthetic outcomes include the formation of nodules and surface irregularities when too much filler is injected or when the filler is injected too close to the surface of the skin.

    Fillers may migrate away from their intended site of injection, causing lumps in other parts of the body.

    Infections occasionally occur and may require antibiotics and skin care.

    The most feared complications are vascular ones, in which the filler is accidentally injected into a superficial artery, resulting in a blockage of the blood vessel.

    The skin supplied by that artery dies, becoming dusky and eventually sloughing off over the next few days to weeks, often leaving discolouration or an unsightly scar, said Dr Mohamed.

    Doctors said these are just some reasons why it is so important to have filler injections done by doctors and to use only approved products.


    1. There is a long expiry date on the box.

    2. The outer box, syringe lot number and expiry date do not match.

    3. Poorer quality paper and box used to package the product.

    4. Poorer print quality on the packaging.

But with more fake products appearing on the market and becoming easily available from online sources, one filler maker and distributor has kicked off an awareness campaign to warn people of the risks of using them.

Though the number of cases each year is still small, they are increasing, say doctors.

Said Dr Leslie Kuek, a consultant plastic surgeon whose practice is in Mount Elizabeth Novena Specialist Centre: "It is not as prevalent as the silicone cases years ago, but people are still getting injections done by those who are untrained and unqualified to do these procedures and with products of unclear origins.

"If you add up all the cases that all the doctors see, it could be a significant number."


Dr Colin Tham, a consultant plastic surgeon at Asia Health Partners at Lucky Plaza, said both local and foreign patients who had procedures done in the region have come to him for help.

One recent case involved a 39-year-old woman who had breast enhancement injections in 2009. Early this year, an infection set in her left breast which destroyed some breast tissue, despite treatment.

Her breasts are now uneven in size.

"She will need to go for breast reconstruction surgery to correct the disparity," said Dr Tham.

For Dr Tan Ying Chien, a consultant plastic surgeon at The Sloane Clinic Plastic Surgery Centre at Novena Medical Centre, the most common problems he treats are lip fillers gone wrong.

"They look like their lips have been stung by bees," he said.

He removes the filler and the surrounding tissue. Done properly, you can remove them without leaving a trace, he said.

In many cases, according to him, the botched jobs were done mostly by beauticians. The second most common problem he has to fix are breast fillers gone wrong.

"We often don't know what material has been injected. But there is a notorious one called Amazing Gel which is injected directly into the breasts," he said.

Within a few years, the patient develops swelling and redness in the area.

"When you open the breast, the filler comes out like mayonnaise," he said.

Across the Causeway, Dr Anna Hoo, an aesthetic physician in private practice in Petaling Jaya, said fake fillers are a problem there as well, usually with patients who go to China for more affordable treatments.

"They say when they opt for Restylane fillers in China, they can choose either the original one or the counterfeit product, which is, naturally, cheaper," said Dr Hoo.

"It saddens me to see patients, in their eagerness to save money, opt for a product which may not be safe."


According to filler manufacturer Galderma, some unapproved products are transported into Singapore in vehicles from across the border.

Many can also be ordered online and shipped here.

The Swiss-headquartered company, which makes and distributes filler products such as Restylane and Macrolane, is embarking on a campaign to warn and educate people about unapproved products, said Ms Christina Hsu, sales and marketing manager for Galderma Singapore.

The original products may be sold illegally to people who are not trained to administer them, said Ms Hsu.

Fake products, on the other hand, are generally produced under unsafe manufacturing conditions, she said.

Nor are they inspected and approved by the authorities.

They may not contain the ingredients listed on their labels and, therefore, may not be efficient or safe, Ms Hsu added.

When people buy anything online, they usually do not have the original source, or the means to trace the source of the product, she said.

Medical aesthetic products undergo strict manufacturing, transportation and clinical guidelines that are designed to ensure patient safety.

"You should consult and proceed with a medical aesthetic treatment only with registered medical practitioners and with the products and treatment options they use," said Ms Hsu.

Some of the risks people face when buying products online include unstable products which may contain illegal substances and be riddled with germs, she added.

The HSA said dermal fillers can be used only by qualified medical practitioners who can manage complications that arise during and after treatment.

In Singapore, dermal fillers can be legally supplied only to doctors registered with the Ministry of Health (MOH) for use on patients.

Doctors who require the use of a dermal filler that is not available here must file a special request to the HSA.

Under the Health Products Act, those who supply counterfeit health products can be fined up to $100,000, jailed up to three years, or both.


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