Monday, April 04, 2005
Soft tissue augmentation (STA) techniques are minimally invasive
surgical procedures in which filling agents (fillers) or surgical
techniques alone are used to increase or replace local volume. They
are highly effective in the rejuvenation, as well as the aesthetic
and functional restoration, of the face. As cited by Arnold Klein,
they represent three-dimensional treatments and the results are
Fat grafting is recognized as the first STA technique used for
cosmetic purposes. 1 The constant improvements in
liposuction techniques have permitted this technique to remain up
to date, as fat is still considered to be a filler of great utility
Since the end of the nineteenth century, the need for filling
materials has increased. Fillers are used to replace volumes lost
as a result of aging or certain pathological conditions, or in
order to enhance the beauty of the face. Over this period, oils and
paraffins,2,3 followed by liquid silicones, were used as
filling agents,4 later to be abandoned due to the
problems that they caused. STA techniques developed slowly until
the 1980s, when there was renewed interest in the use of these
The introduction of bovine collagens, the first fillers
recognized as being effective, led to a new era in the use of
fillers, in which their value and importance in the treatment of
aging and in beauty enhancement of the face were consolidated.
The main indications for fillers are lip augmentation (see
Figures 1 and 2), facial wrinkles and lines (see Figures 3 and 4),
depressed scars (see Figures 5-7), asymmetries, and other
subcutaneous facial defects.4,6,7 In recent years, lost
volume of the face is a new, modern and natural indication for
Figures 1 and 2: Before Restylane® and 2 months after
Restylane® in the correction of nasolabial fold,
peri-oral wrinkles, and lip augmentation
Before Restylane® and 2 years after
Restylane® in the treatment of nasolabial fold
Before treatment with liquid injectable silicone of 350cs, 3
months after, and 5 years after the correction of trauma scars on
the upper lip (from Sebbin Laboratories, France)
Lips are considered to be one of the most important facial
structures in the beauty of the face. Because of the natural loss
of volume of the lips with aging, as well as the appearance of
peri-oral wrinkles, lips and the peri-oral area are often classical
targets for fillers. Transitory fillers, such hyaluronic acid and
collagen, are the preferred fillers for lips.8
Wrinkles have a number of causes (photodamage, muscular action,
sleep habits) and should be approached based on the nature of their
origin. As tissues vary in their consistency, different fillers may
be recommended, and even combined, in the treatment of the same
Some fillers can be injected only at specific skin levels;
others are more versatile and can be injected at various levels,
superficially or at greater depth. Different materials may be
necessary to replace lost volume to achieve an appropriate degree
of consistency and to obtain a more natural appearance. Different
fillers can be injected during the same treatment session,
depending on the nature of the treatment to be
Superficial wrinkles are usually fine lines and can be treated
with intradermic and transitory fillers. Deeper wrinkles and folds
require subcutaneous fillers. Currently, the most widely used
transitory fillers contain hyaluronic acids and collagens, such as
Restylane® and Perlane®, Hylaform®
and Hylaform Plus®, Juvederm® in three
different concentrations, and CosmoDerm® and
CosmoPlast®. These versatile fillers produce very
natural results, as they replace natural compounds from the skin. A
further advantage offered by these products is that they can be
injected superficially and subcutaneously.
All permanent fillers provoke some fibrosis around the implant,
leaving the skin with a harder-than-normal consistency.9
They can be used for the replacement of denser tissues, like bone
and cartilage, and in the restoration of the facial contour.
Polylactic acid (PLA) represents a new generation of fillers that
can promote a new collagen formation from small volumes injected at
deep levels for facial contour restoration. Liquid-injectable
silicone seems to be safe in small amounts delivered by
micro-droplet technique. In the correction of scars, it gives
long-lasting results (see Figures 5-7).
As yet, there is no definitive classification of filling agents.
Here, we present classifications based on materials and
Table 1. Classification of fillers according to
|I - FILLERS THAT USE BIOLOGICAL MATERIALS
FROM HUMAN BODY
a) Autologous fat transplantation
b) Autologous dermal grafting
d) Vein grafting
|II - FILLERS THAT USE BIOLOGICAL MATERIALS
FROM OTHER LIVING BEINGS
|1. Bovine collagen
a) Zyderm I and II®
f) Koken Atelocollagen®
|2. Porcine collagen
|3. Hyaluronic acid from coxcombs of domestic
b) Hylaform Plus®
c) IAL System®
4. Hyaluronic acid bacterial fermentation
b) Restylane Fine Lines®
|III - NONBIOLOGICAL OR INORGANIC
|1. Injectable silicone
a) Liquid Injectable Silicone Sebbin®,
SilSkin®, Silikon® 1000
b) Biopolimer III® or Biocell
|3. Expanded polytetrafluoroethylene (e-PTFE)
|5. Polylactic acid
a) New Fill®
Table 2. Classification of fillers according to
|1. Temporary fillers
a) Autologous fat
c) Hyaluronic acid
e) Polylactic acid
|2. Long-life or permanent fillers
a) Injectable silicones
|3. Biphased fillers (2 phases: combination of 1
temporary and 1 permanent filler)
Most complications resulting from the use of STA techniques are
transitory and secondary to the trauma caused by the technique,
injection, or implant of the filler.6,10 In general,
they are common to all techniques and to all fillers and include
erythema, edema, hematomas (see Figure 8), ecchymosis, and some
infections, such as a recurrence of herpes.6
Hematoma and edema in the upper lip, after lip
augmentation with Restylane®
Allergic reactions may occur with some fillers, such as
hyaluronic acids11-13 and collagens,14,15 and
but with prior testing they can be prevented. Granulomas and
infections may occur and may be related to the patient, the
technique, or the materials used.6,9
Greater, more persistent, and delayed complications are more
common with permanent fillers and may also be provoked by
technique-related problems.6 They include allergic
reactions; recurrent edema with or without erythema; idiosyncrasy;
granuloma;13,16 alterations to skin texture,
consistency, and sensitivity in the treated region; the emergence
of erythema and telangiectasia similar to rosacea;17
infections; and migration as well as spontaneous extrusion of the
Excessive elevation, overcorrection and nodules, asymmetries and
distortion, disease transmission, necrosis, lymphatic blockage, and
embolism are eminently technique-related problems.
Knowledge of the characteristics of the different cutaneous
fillers (such as the level at which they can be implanted, depth to
be injected, and others) is of fundamental importance for the
correct indication and to obtain the best results.6
Fillers can be used in combination with other medical or
surgical treatments in the same or different treatment
sessions.6,9,18 As well as this advantage and the proven
efficacy of these treatments, other advantages when compared to
conventional surgery (such as the absence of scars, quick recovery,
ambulatory nature, and minimal risk) make fillers an attractive
alternative for doctors and patients and explain the enormous
demand for such procedures in dermatological clinics throughout the
New filling agents are launched each year, stimulated by this
promising market. These materials should neither be judged nor used
solely on the basis of the patient's initial satisfaction or
publicity campaigns, but rather on the medium-to-long-term results
obtained from well-conducted scientific studies that permit their
approval by competent authorities.6,9
The ideal filler should provide natural results in terms of both
appearance and sensation, and it should be safe and effective for
- Neuber F. Fettransplantation. Chir Kong Verhandl Dsch
Gesellsch Chi. 1893;22:66.
- Gersuny R. Ueber eine subcutane prosthese. Z Heilkd.
- Khoo Boo-Chai MB. Paraffinoma. Plast Reconstr Surg
- Orentreich DS, Orentreich N. Injectable fluid silicone. In:
Roenigk RK, Roenigk HH Jr. Dermatologic surgery: principles and
practice. New York: Marcel Dekker; 1989:1349-1395.
- Dzubow LM, Goldman G. Introduction to soft tissue augmentation:
a historical perspective. In: Klein AW, ed. Tissue Augmentation
in Clinical Practice: Procedures and Techniques. New York, NY:
Marcel Dekker; 1998:1-22.
- Hexsel D, Dal-Forno T. Técnicas de Preenchimento Cutâneo. In:
Ramos-e-Silva M, Castro MCR, eds. Fundamentos da
Dermatologia. Atheneu: Rio de Janeiro, in press, 2004.
- Brown LH, Frank PJ. What's new in fillers? J Drugs
Dermatol. 2003 Jun;2(3):250-253.
- Fulton JE Jr, Rahimi AD, Helton P, Watson T, Dahlberg K. Lip
rejuvenation. Dermatol Surg. 2000;26(5):470-474;
- Hexsel D, Hexsel C, Iyengar V. Liquid injectable silicone
history, mechanism of action, indications, technique, and
complications. Sem Cut Med Surg. 2003;22(2):107-114.
- Duffi DM. The Silicone Conundrum: A battle of anecdotes.
Dermatol Surg. 28(7):590-594,2002.
- Lupton JR, Alster TS. Cutaneous hypersensivity reaction to
injectable hyaluronic acid gel. Dermatol Surg.
- Friedman PM, MD, Mafong EA, MD, Kauvar ANB, MD. Safety Data of
Injectable Nonanimal Stabilized Hyaluronic Acid Gel for Soft Tissue
Augmentation. Dermatol Surg. 2002:28:491-494.
- Acenero MJF, MD, Zamora E, Borbujo J. Granulomatous Foreign
Body reaction Against Hyaluronic Acid: Report of Case After Lip
Augmentation. Dermatol Surg. 2003;29:1225-1226.
- Sclafani AP, Romo T. Injectable Fillers for Facial Soft Tissue
Enhancement. Facial Plastic Surgery.
- Ruszczak Z, Schwartz RA. Collagen Uses in Dermatology - An
Update. Dermatology. 1999;199:285-289.
- Duffy DM. Injectable Liquid Silicone: new perspectives.
Tissue Augmentation in Clinical Practice: Procedures and
Techniques. Los Angeles, Marcell Dekker: 237-267,1998.
- White MI. Smart LM, MacGregor M et al. Recurrent facial oedema
associated with a silicone-rubber implant. B J Dermatol.
- de Maio M. The Minimal Approach: An Innovation in Facial
Cosmetic Procedures. Aesthetic Plast Surg. 2004;4.