Fillers for the Body
Wednesday, December 14, 2011
Fillers are increasingly being used for both medical and
cosmetic purposes - not only for facial areas but also for body
contour and rejuvenation. Medically relevant body deformities may
be caused by trauma or post-surgical defects, eg after tumor
removal. They also result from medication-induced lipoatrophy, as
seen with HIV treatment, or can be genetically determined, as in
the case of Bernardinelli-Sapie syndrome.1
The aesthetics of the body immediately after puberty, in both
men and women, derive from the volumetric proportions of muscle and
fat in the proximal limbs, breast, abdominal area and buttocks.
Ageing leads to significant body fat redistribution: fat
accumulates in the abdomen, whereas there is progressive
subcutaneous and muscular atrophy in the limbs.2,3
Fillers can contribute to a more aesthetic and healthy
appearance of the body by restoring or improving volumes in
deficient areas. As a general rule, volumes required to treat body
areas are much larger than those used for the face. Therefore, this
limits the choice of fillers to those products that are
Fillers can be divided into self- or non-self-derived products.
Non-self-derived fillers are classified either as resorbable or
non-resorbable (permanent) products. A list of common fillers is
displayed in Table 1. This article will summarize important aspects
of fillers used for the body - their indications, advantages and
drawbacks. Emphasis will be given to fat and hyaluronic acid (HA)
fillers because they are safe and cost-effective, and provide
Table 1. Common fillers used for body correction are
marked in bold.
Tissue can be extracted from the body and re-injected elsewhere
as a filler. Self-derived fillers require collection, processing,
and an implantation technique specific for each tissue used.
Fat is used immediately after being collected by blunt cannulae.
Liposculpture has been used for many decades, and offers excellent
results in the hands of experienced surgeons. Risks are low,
especially when tumescent anesthesia is used. Results are immediate
and can last months to years (Figure 1).
Figure 1. Left-hand image: Cicatricial
depression after wide melanoma excision. Right-hand image: Results
1 week after a second course of filler correction. The total volume
used in the two sessions was 40 mL. Fat was aspirated from the
abdominal wall. Results have been maintained 5 years after the
Fat remains the gold-standard procedure because it addresses
simultaneously two major concerns of our patients: (i) removal of
undesired fat, which tends to accumulated in anatomic areas such as
the belly, love handles or thighs; and (ii) replacement with
virtually identical tissue, providing similar properties to the
lacking structure in the recipient area. Nevertheless, in addition
to inherent complications of a surgical procedure, donor fat is not
always available, particularly in those patients who need it most,
ie those affected by lipoatrophy (Figure 2). In addition,
graft-taking is not easily predictable - it may encapsulate, be
irregularly or completely reabsorbed, or induce calcification. The
latter may be mistaken in fat-augmented breast for neoplastic
mammographic changes by an inexperienced
Figure 2. Fat collection from the abdomen.
Amounts of filler are usually enough for facial procedures, but may
not be sufficient for body filling, especially in patients who need
it most, such as those affected with HIV-related lipoatrophy.
Fat transfer is an evolving technique. As well as improvements
in fat harvesting, the placement of small volumes over several
sessions (Coleman technique) can lead to prolonged graft survival.
Enriching grafts with pre-adipocites can also improve results, as
it is assumed that these cells are required for ultimately
enhancing volume by replacing fat progenitor cells in the recipient
area. Recently, mixing fat tissue with platelet-rich plasma (PRP)
has become popular. However, there is not enough evidence as yet to
prove that PRP significantly improves results.8-10
Cultured pre-adipocities may theoretically be a source of
abundant filler after extraction of minimal amounts of tissue. The
long-term risks of manipulating cells in Petri dishes for
subsequent reinjection into our bodies, including the potential for
inducing neoplasia, are realistic limitations to using cultured
cells for cosmetic purposes.11-13
The ideal filler for the body is a sterile material that can be
promptly placed into the subcutaneous compartment, producing
significant long-lasting, fat-like volumetric changes without being
Non-resorbable (Permanent) Fillers
Liquid silicone, polyacrylamide gel and poly-methyl-methacrylate
(PMMA) are non-resorbable fillers approved for body use in many
countries. Non-resorbable fillers require fewer procedures for
achieving satisfactory results and are inexpensive. The fibrotic
reaction induced by permanent fillers may contribute to further
volumetric improvement, in addition to the actual amount injected.
Fibrosis may induce textures that are harder than fat, but this
should not represent a problem if the filler is placed deeply
enough in the subcutaneous layer; accordingly, most patients
treated with permanent fillers describe satisfactory long-term
However, permanent fillers present a lifetime risk of inducing
foreign-body granulomas. Devastating foreign-body reactions can
develop decades after filler placement, particularly in the setting
of distant bacterial infections or when pro-inflammatory drugs,
such as interferon, are used. Intravascular injection of permanent
fillers can also lead to irreversible necrosis, particularly when
performed by untrained persons, as demonstrated below (Figure
Figure 3. Skin necrosis after inadvertent
intravascular injection of liquid silicone for cellulite treatment
in the buttocks. The injection was performed in a "cosmetic saloon"
a week before.
Poly-l-lactic acid and hydroxyapatite are slowly resorbed
products that also induce fibrosis. They are used for the treatment
of lipoatrophic aging signs in the hands and décolleté. If injected
superficially, granulomatous reactions may cause significant
distress and require surgical removal. HAs and collagens
traditionally marketed for the face also provide excellent results
for smaller dermal scars (Figure 4). However, their cost is usually
prohibitive for breast or gluteal augmentation.
Figure 4. Treatment of dermal scars in the
abdomen using porcine collagen (EvolenceTM) (blue and
green arrows). The figure shows the scarred area before treatment
(left-hand image) and 3 years after treatment (right-hand image),
demonstrating long-term results. The scar indicated with the pink
arrow was surgically removed.
Body HA Fillers
Large-particle HA preparations for body implantation are
available. The products are provided in large (10 mL or 20 mL)
sterile syringes ready for injection. MacrolaneTM was
the first product available and is the body-designed version of the
traditional biphasic, non-animal, stabilized HA
Restylane® line. There is a harder form for deeper
application and a softer one for superficial corrections.
VariofillTM is a monophasic HA filler alternative for
The use of HAs in the face for more than two decades has
provided good evidence for their safety. Body preparations of HAs
are now marketed for breast augmentation - injection under the
breast gland does not seem to cause problems and is easily
identified by mammography. Nevertheless, the safety of placing HA
into glandular tissue has been disputed. HA breast augmentation is
less invasive than placement of silicone prostheses; however,
because HA is a fast-reabsorbing material, the overall cost for
maintaining results is significant.4,17
HA provides excellent and cost-effective results for reshaping
smaller body-surface depressions, such as post-liposuction
irregularities. It is also excellent for treating lipoatrophy in
patients without enough donor fat areas. Accordingly, strategic
placement of even moderate amounts of HA can lead to dramatic
improvements, as seen in the gluteal correction of patients with
severe lipoatrophy (Figure 5). The duration of results seen with HA
body fillers is variable, ranging from a few months to
years,15 and depends on technique and individual
Figure 5. Significant improvements in gluteal
HIV-related lipoatrophy following an injection of 30 mL HA acid
(MacrolaneTM FR20) into the depressed medial
Adverse effects following the application of large amounts of HA
filler to the subcutaneous compartment include migration and
encapsulation. They can be reduced by using small volumes over
several sessions, and treated by repositioning the product with
massage or needle puncture of the fibrotic capsule, and subsequent
pinching the area manually in order to spread the material into the
The use of fillers for the treatment of cellulite is
controversial. Much of the problem is related to the large spectrum
of presentation of cellulite and difficulties with its
classification. Flacidity of the skin may also be mistaken as
cellulite, further complicating conclusions.
Nevertheless, in my personal experience, fillers can be used for
the treatment of superficial body irregularities in the buttocks
and thighs in selected cases. The best available filler, and the
only one I have experience with, owing to its acceptable risk, is
HA. Its texture is very similar to natural tissue and can be
applied with good results for deep furrows after the attached
fibrous septum has been released with the subcision technique.
Although some doctors use it immediately after the subcision, I
prefer to wait at least a few months to avoid over-correction or
unnecessary treatment with the filler.
I have not used volumizing fillers for minimal degrees of
cellulite because I fear that the hygroscopic properties and
potential for encapsulation can actually worsen skin surface
irregularity, similar to what happens with localized weight gain.
However, I speculate that injecting very soft fillers with
mesotherapy techniques could potentially be helpful, possibly by
improving dermal firmness.
In summary, although I believe fillers are potentially helpful
for a subgroup of patients with cellulite, further studies are
necessary to determine what are (i) the precise indications, (ii)
the most appropriate fillers, and (iii) the best injection
Although fat remains the gold-standard filling material for body
subcutaneous placement, large-volume resorbable HA fillers sold at
reasonable cost have recently become available. They allow for
convenient and minimally invasive procedures, turning body filling
into a more attractive and safe cosmetic alternative. However,
expertise in filling injection techniques and knowledge of the
anatomy and aesthetics of the body are required for obtaining
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