American Journal of Clinical Dermatology

, Volume 7, Issue 2, pp 107–120

Techniques for Soft Tissue Augmentation

An ‘A to Z’
Review Article


As society continues to seek the most opportune means to preserve youthful looks, an interest in filling substances has been reawakened. This is partly because the upper third of the face can now be successfully treated as a result of the development and recent US FDA approval of botulinum toxin (Botox®). Patients seeking cosmetic improvement need no longer resort to invasive procedures that require down-time for the upper third of the face, and they are consequently seeking similar results for the lower two-thirds of the face. Filling agents have filled this void. This article discusses current techniques for soft tissue augmentation, including fat transfer and bovine collagen injections, which enable doctors to provide their patients with highly satisfactory results using minimally invasive procedures.

Included in this review are an overview of the history of soft tissue augmentation and a brief prospectus of where this field of dermatology is headed in the future. Many of the currently available fillers are listed with a description of their most popular uses, possible adverse effects, manufacturers, and countries of use. Information regarding injection techniques and results from the most recent studies help to make this paper a useful source of information for experienced and novice injectors alike.


  1. 1.
    Klein AW. Cosmetic therapy with botulinum toxin. Dermatol Surg 1996; 22:757-9PubMedCrossRefGoogle Scholar
  2. 2.
    Neuber F. Fettransplantation. Chir Kongr Verhandl Dsch Gesellch Chir 1893; 22: 66Google Scholar
  3. 3.
    Lexer E. Either freie fettransplantation. Klin Ther Wehnschr 1911; 18: 53Google Scholar
  4. 4.
    Bruning P [cited by Broeckaert TJ]. Contribution a l’étude des greffes adipeueses. Bull Acad R Med Belg 1914; 28: 440Google Scholar
  5. 5.
    Neuhof H. The transplantation of tissues. New York (NY): Appleton & Company, 1923Google Scholar
  6. 6.
    Gersuny R. Ueber eine subcutane prothese. Ztschr Heilkunde 1900, 1Google Scholar
  7. 7.
    Knapp TR, Kaplan EN, Daniels JR. Injectable collagen for soft tissue augmentation. Plast Reconstr Surg 1977; 60: 398-405PubMedGoogle Scholar
  8. 8.
    Kammer M, Krause M. Filler substances in the treatment of facial aging. Med Surg Dermatol 1998; 5: 215-21Google Scholar
  9. 9.
    DeLustro F, Condell RA, Nguyen MA, et al. A comparative study of the biologic and immunologic response to medical devices derived from dermal collagen. J Biomed Material Res 1986; 20: 109-20CrossRefGoogle Scholar
  10. 10.
    Klein AW, Rish DC. Injectable collagen: an adjunct to facial plastic surgery. Facial Plast Surg 1987; 4: 87CrossRefGoogle Scholar
  11. 11.
    Sclafam AP, Romo III T, Jacono AA, et al. Evaluations of acellular dermal graft (AlloDerm) sheet for soft tissue augmentation: a 1-year follow-up of clinical observations and histological findings. Arch Facial Plast Surg 2001; 3: 101-3CrossRefGoogle Scholar
  12. 12.
    Morhenn VB, Lemperle G, Gallo RL. Phagocytosis of different particulate dermal filler substances by human macrophages and skin cells. Dermatol Surg 2002; 28: 484-90PubMedCrossRefGoogle Scholar
  13. 13.
    Lemperle G, Hazan-Gauthier N, Lemperle M. PMMA microspheres (Artecoll) for skin and soft tissue augmentation. Part II: clinical investigations. Plast Reconstr Surg 1995; 96: 627-34Google Scholar
  14. 14.
    McClelland M, Egbert B, Hanko V, et al. Evaluation of Artecoll polymethylmethacrylate implant for soft-tissue augmentation: biocompatibility and chemical characterization. Plast Reconstr Surg 1997; 100: 1466-74PubMedCrossRefGoogle Scholar
  15. 15.
    Constantino PD, Friedman CD. Soft-tissue augmentation and replacement in the head and neck: general considerations. Otolaryngol Clin North Am 1994; 27: 1-12Google Scholar
  16. 16.
    Cohen SR, Holmes RE, et al. Artecoll: a long-lasting injectable wrinkle filler material. Report of a controlled, randomized, multicenter clinical trial of 251 subjects. Plast Reconstr Surg 2004; 114: 964-79PubMedCrossRefGoogle Scholar
  17. 17.
    Hamilton D. A pilot study of the first patients treated in United States with Artecoll implantation for the aging face. Cosmet Dermatol 2000 Sep: 151Google Scholar
  18. 18.
    Ersek RA, Beisang AA. Bioplastique: a new textured copolymer microparticle promises permanence in soft-tissue augmentation. Plast Reconstr Surg 1991; 87: 693-702PubMedCrossRefGoogle Scholar
  19. 19.
    Sclafam AP, Romo T, Jacono AA, et al. Evaluations of acellular dermal graft in sheet (AlloDerm) and injectable (micronized AlloDerm) forms for soft tissue augmentation. Arch Facial Plast Surg 2000; 2: 130-6CrossRefGoogle Scholar
  20. 20.
    Swinehart JM. Pocket grafting with dermal grafts: autologous collagen implants for permanent correction of cutaneous depressions. Am J Cosmet Surg 1996; 12 (4): 321-31Google Scholar
  21. 21.
    Rohrich RJ, Rios JL, Fagien S. Role of new fillers in facial rejuvenation: a cautious outlook. Plast Reconstr Surg 2003 Dee; 112 (7): 1899-902Google Scholar
  22. 22.
    Cisneros JL, Singla R. Intradermal augmentation with expanded polyte-trafluoroethylene (Gore-Tex) for facial lines and wrinkles. J Dermatol Surg Oncol 1993; 19: 539-42PubMedGoogle Scholar
  23. 23.
    Maas CS, Eriksson T, McCalmont T, et al. Evaluation of ePTFE as a soft tissue filling substance: an analysis of design-related implant behavior employing the porcine skin model. Plast Reconstr Surg 1998; 101: 1307-14PubMedCrossRefGoogle Scholar
  24. 24.
    Burres S. Recollagenation of acne scars. Dermatol Surg 1996; 22: 364-7Google Scholar
  25. 25.
    Peer LA. The neglected `free fat graft’, its behavior and clinical use. Am J Surg 1956; 92: 40-7PubMedCrossRefGoogle Scholar
  26. 26.
    Gurney CE. Studies on the fate of free transplants of fat. Proc Staff Meet Mayo Clin 1937; 12: 317Google Scholar
  27. 27.
    Fischer A, Fischer GM. Revised technique for cellulitis fat: reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977; 2: 40Google Scholar
  28. 28.
    Illouz YG. The fat cell `graft’, a new technique to fill depressions. Plast Reconstr Surg 1986; 78: 122-3PubMedCrossRefGoogle Scholar
  29. 29.
    Illouz YG. Body contouring by lipolysis: a five-year experience with over 3000 cases. Plast Reconstr Surg 1983; 72: 591-7PubMedCrossRefGoogle Scholar
  30. 30.
    Illouz YG. De l’utilization de la graisse aspirée pour combler les defects cutanés. Rev Chir Esthet Lang Franc 1985; 10: 13-20Google Scholar
  31. 31.
    Wetmore SJ. Injection of fat for soft tissue augmentation. Laryngoscope 1989; 99: 50-7PubMedCrossRefGoogle Scholar
  32. 32.
    Teimourian B. Blindness following fat injections [letter]. Plast Reconstr Surg 1988; 82 (2): 361Google Scholar
  33. 33.
    Illouz YG. Present results of fat injection. Aesthetic Plast Surg 1988; 12: 175-81PubMedCrossRefGoogle Scholar
  34. 34.
    Gormley DE, Eremia S. Quantitative assessment of augmentation therapy. J Dermatol Surg Oncol 1990; 16: 1147-51PubMedGoogle Scholar
  35. 35.
    Agris J. Autologous fat transplantation: a 3-year study [abstract]. Am J Cosmet Surg 1987; 4: 111Google Scholar
  36. 36.
    Smahel J. Adipose tissue in plastic surgery. Ann Plast Surg 1986; 16: 444-53PubMedCrossRefGoogle Scholar
  37. 37.
    Zocchi M. Méthode de production de collagène autologue par traitement du tissu graisseux. J Med Esthet Chirur Dermatol 1990; XVII, 66: 105-14Google Scholar
  38. 38.
    Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir Esthet Lang Franc 1985; 10: 36-40Google Scholar
  39. 39.
    Fournier P. Facial recontouring with fat grafting. Dermatol Clin 1990; 8 (3): 523-37PubMedGoogle Scholar
  40. 40.
    Fournier PF. Collagen autologue: liposculpture ma technique. Paris (France): Amette, 1989: 277-9Google Scholar
  41. 41.
    Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4: 236-67Google Scholar
  42. 42.
    Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988; 14: 1145-8PubMedGoogle Scholar
  43. 43.
    Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. Dermatol Surg 1995; 21: 459-62PubMedCrossRefGoogle Scholar
  44. 44.
    Nguyen A, Pasyk K, Bouvier T, et al. Comparative study of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 1990; 85: 378-86PubMedCrossRefGoogle Scholar
  45. 45.
    Epply BA, Sidner RA, Platis JM. Bioactivation of free-fat transfers: a potential new approach to improving graft survival. Plast Reconstr Surg 1992; 90: 1021-30Google Scholar
  46. 46.
    Saunders MC, Keller IT, Dunsker SB, et al. Survival of autologous fat grafts in humans and mice. Connect Tissue Res 1981; 8: 85-91PubMedCrossRefGoogle Scholar
  47. 47.
    Gurney CE. Experimental study of the behavior of free fat transplants. Surgery (St. Louis) 1938; 3: 680Google Scholar
  48. 48.
    Johnson G. Body contouring by macroinjection of autogenous fat. Am J Cosmet Surg 1987; 4: 103Google Scholar
  49. 49.
    Pinski KS, Roenigk HH. Autologous fat transplantation: long term followup. J Dermatol Surg Oncol 1992; 18: 179-84PubMedGoogle Scholar
  50. 50.
    Jones JK, Lyles ME. The viability of human adipocytes after closed-syringe liposuction harvest. Am J Cosmet Surg 1997; 14: 275-80Google Scholar
  51. 51.
    Campbell GL, Laudslager N, Newman J. The effect of mechanical stress on adipocyte morphology and metabolism. Am J Cosmet Surg 1987; 4: 89-94Google Scholar
  52. 52.
    Skouge JW, Canning DA, Jets RD. Long term survival of perivesical fat harvested and injected by microlipoinjection techniques in a rabbit model. 16th Annual American Society for Dermatologic Surgery Meeting; 1989 Mar, Fort Lauderdale (FL)Google Scholar
  53. 53.
    Glogau RG. Microlipoinjection. Arch Dermatol 1988; 124: 1340-3PubMedCrossRefGoogle Scholar
  54. 54.
    Ersek RA. Transplantation of purified autologous fat: a 3-year follow-up is disappointing. Plast Reconstr Surg 1991; 87: 219-27PubMedCrossRefGoogle Scholar
  55. 55.
    Narins RS. Microlipoinjection. In: Klein AW, editor. Tissue augmentation in clinical practice: procedures and techniques. New York (NY): Marcel Dekker, 1998: 24-35Google Scholar
  56. 56.
    Billings Jr E, May Jr JW. Historical review and present status of free graft and autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg 1989; 83: 368-81PubMedCrossRefGoogle Scholar
  57. 57.
    Roenigk Jr H, Rubenstein R. Combined scalp reduction and autologous fat implant treatment of localized soft tissue defects. J Dermatol Surg Oncol 1988; 14 (1): 67-70PubMedGoogle Scholar
  58. 58.
    Afifi AK, et al. Partial (localized) lipodystrophy. J Am Acad Dermatol 1985; 12: 198-203PubMedCrossRefGoogle Scholar
  59. 59.
    Moscona R, Ullman Y, Har-Shai Y, et al. Fat free injections for the correction of hemifacial atrophy. Plast Reconstr Surg 1989; 84: 501-7PubMedCrossRefGoogle Scholar
  60. 60.
    Chajchin A, Benzaques I. Fat grafting injection for soft tissue augmentation. Plast Reconstr Surg 1989; 84: 921-34CrossRefGoogle Scholar
  61. 61.
    Lauber IS, Abrams H, Coleman III WP. Application of the tumescent technique to hand augmentation. J Dermatol Surg Oncol 1990; 16: 369-73PubMedGoogle Scholar
  62. 62.
    Hudson DA, Lambert EV, Bloch CE. Site selection for autotransplantation: some observations. Aesthetic Plast Surg 1990; 14: 195-7PubMedCrossRefGoogle Scholar
  63. 63.
    Barnes HO. Augmentation mammoplasty by lipotransplant. Plast Reconstr Surg 1953; 11: 404-12CrossRefGoogle Scholar
  64. 64.
    Coleman WP, Lawrence N, Sherman RN, et al. Autologous collagen? Lipocytic dermal augmentation: a histopathologic study. J Dermatol Surg Onco11993; 19: 1032-40Google Scholar
  65. 65.
    Spira M, Liu B, Xu Z, et al. Human amnion collagen for soft tissue augmentation: biochemical characterizations and animal observations. J Biomed Mater Res 1994; 28: 91-6PubMedCrossRefGoogle Scholar
  66. 66.
    Balazs EA, Leshchiner EA. Hyaluronan, its crosslinked derivative hylan, and their medical applications. In: Inagake H, Phillips GO, editors. Cellulosics utilization: research and rewards in cellulosics. New York (NY): Elsevier Applied Science, 1989: 233-241Google Scholar
  67. 67.
    Piacquadio D. Crosslinked hyalmonic acid (hylan gel) as a soft tissue augmentation material: a preliminary assessment. In: Elson ML, editor. Evaluation and treatment of the aging face. New York (NY): Springer-Verlag, 1994: 304-308Google Scholar
  68. 68.
    Grossman K. Hyaluronic acid gel fillers: hypersensitivity reactions. Aesthetic Surgery Journal 2005; 25: 403-5PubMedCrossRefGoogle Scholar
  69. 69.
    Leonard JM, Lawrence N, Narins RS. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid. Dermatol Surg 2005; 31: 577-9CrossRefGoogle Scholar
  70. 70.
    Krajcik R, Orentreich DS, Orentreich N. A novel injectable autologous material for soft tissue augmentation. Journal of Aesthetic Dermatology and Cosmetic Surgery 1999; 1: 109-15Google Scholar
  71. 71.
    Olenius M. The first clinical study using a new biodegradable implant for the treatment of lips, wrinkles and folds. Aesth Plast Surg 1998; 22: 97-101CrossRefGoogle Scholar
  72. 72.
    Sengelmann RD, Tull S. Dermal fillers. Available from URL: [Accessed 2006 Jan 9]
  73. 73.
    Barondes R, Judge WD, Towne CG, et al. The silicones in medicine; new organic derivatives and some of their unique properties. Mil Surg 1950; 106: 379-87PubMedGoogle Scholar
  74. 74.
    Dzubow LM, Goldman G. Introduction to soft tissue augmentation: a historical perspective. In: Klein AW, editor. Tissue augmentation in clinical practice: procedures and techniques. New York (NY): Marcel Dekker, 1998: 1-22Google Scholar
  75. 75.
    Ellenbogen R, Ellenbogen R, Rubin L. Injectable fluid silicone therapy: human morbidity and mortality. JAMA 1975; 234: 308-9PubMedCrossRefGoogle Scholar
  76. 76.
    Gross J, Kirk D. The heat precipitation of collagen from neutral salt solutions: some rate-regulating factors. J Biol Chem 1958; 233: 355-60PubMedGoogle Scholar
  77. 77.
    Davidson PF, Levine L, Drake MP, et al. The serologic specificity of tropocollagen telopeptides. J Exp Med 1967; 126: 331-49CrossRefGoogle Scholar
  78. 78.
    Schmitt FO, Levine L, Drake MP, et al. The antigenicity of tropocollagen. Proc Natl Acad Sci U S A 1964; 51: 493-7CrossRefGoogle Scholar
  79. 79.
    Stegman SJ, Tromovich TA. Injectable collagen. In: Stegman SJ, Tromovich TA, editors. Cosmetic dermatologic surgery. Chicago (IL): Yearbook Medical Publishers, 1984: 131-49Google Scholar
  80. 80.
    Watson W, Kay RL, Klein AW, et al. Injectable collagen: a clinical overview. Cutis 1983; 31: 543-6PubMedGoogle Scholar
  81. 81.
    Collagen Corporation. Bulletin re: bovine spongiform encephalopathy. Palo Alto (CA): Collagen Corporation, 2001Google Scholar
  82. 82.
    Wallace DG, McPherson JJ, Ellingsworth LE, et al. Injectable collagen for tissue augmentation. In: Nimni ME, editor. Collagen. Volume III: biotechnology. Boca Raton (FL): CRC Press, Inc., 1988: 117-44Google Scholar
  83. 83.
    Kaplan EN. Clinical variations in the utilization of Zyderm I and II. Plast Reconstr Surg 1984; 73: 329PubMedGoogle Scholar
  84. 84.
    McPherson JM, Ledger PW, Sawamura S, et al. The preparation and physicochemical characterization of an injectable form of reconstituted, glutaraldehyde cross-linked, bovine corium collagen. J Biomed Mater Res 1986; 20: 79-92PubMedCrossRefGoogle Scholar
  85. 85.
    Klein AW. Implantation techniques for injectable collagen: two-and-one-half years of personal clinical experience. J Am Acad Dermatol 1983; 9: 224-8PubMedCrossRefGoogle Scholar
  86. 86.
    Kaplan EN, Falces E, Tolleth H. Clinical utilization of injectable collagen. Ann Plast Surg 1983; 10: 437-51PubMedCrossRefGoogle Scholar
  87. 87.
    Cooperman LS, Mackinnon V, Bechler G, et al. Injectable collagen: a six-year clinical investigation. Aesthetic Plast Surg 1985; 9: 145-51PubMedCrossRefGoogle Scholar
  88. 88.
    DeLustro F, Smith ST, Sundsmo J, et al. Reaction to injectable collagen: results in animal models and clinical use. Plast Reconstr Surg 1987; 79: 581-92PubMedCrossRefGoogle Scholar
  89. 89.
    Kamer FM, Churukian MM. The clinical use of injectable collagen: a three-year retrospective study. Arch Otolaryngol 1984; 110: 93-8PubMedCrossRefGoogle Scholar
  90. 90.
    Kligman AM, Armstrong RC. Histologic response to intradermal Zyderm and Zyplast (glutaraldehyde cross-linked) collagen in humans. J Dermatol Surg Oncol 1986; 12: 351-7PubMedGoogle Scholar
  91. 91.
    Castrow II FF, Krull EA. Injectable collagen implant: update. J Am Acad Dermatol 1983; 9: 889-93PubMedCrossRefGoogle Scholar
  92. 92.
    Siegle RJ, McCoy JP, Schade W, et al. Intradermal implantation of bovine collagen: humoral responses associated with clinical reaction. Arch Dermatol 1984; 120: 183-7PubMedCrossRefGoogle Scholar
  93. 93.
    Klein AW. In favor of double testing [letter]. J Dermatol Surg Oncol 1989; 15: 263PubMedGoogle Scholar
  94. 94.
    Elson ML. The role of skin testing in the use of collagen injectable materials. J Dermatol Surg Oncol 1989; 15: 301-3PubMedGoogle Scholar
  95. 95.
    Klein AW, Rish DC. Injectable collagen update. J Dermatol Surg Oncol 1984; 10: 519-22PubMedGoogle Scholar
  96. 96.
    Klein AW. Injectable bovine collagen. In: Klein AW, editor. Tissue augmentation in clinical practice. New York (NY): Marcel Dekker, 1998: 125-54Google Scholar
  97. 97.
    Klein AW. Implantation techniques for injectable collagen: two and one-half years of personal clinical experience. J Am Acad Dermatol 1983; 9: 145-52CrossRefGoogle Scholar
  98. 98.
    Klein AW. Indications and implantation techniques for the various formulations of injectable collagen. J Dermatol Surg Oncol 1988; 14 Suppl. 1: 27-30Google Scholar
  99. 99.
    Robinson JK, Hanke CW. Injectable collagen implant: histopathologic identification and longevity of correction. J Dermatol Surg Oncol 1985; 11: 124-30PubMedGoogle Scholar
  100. 100.
    Bailin MD, Bailin PM. Case studies: correction of surgical scars, acne scars, and rhytides with Zyderm and Zyplast implants [abstract]. J Dermatol Surg Oncol 1988; 14 Suppl. 1: 31Google Scholar
  101. 101.
    Armstrong R, et al. Injectable collagen for soft tissue augmentation. In: Boretos JW, Eden M, editors. Contemporary clinical applications, new technology and legal aspects. Park Ridge (NJ): Noyes Publications, 1984: 528-36Google Scholar
  102. 102.
    Bailin PL, Bailin MD. Collagen implantation: clinical applications and lesion selection. J Dermatol Surg Oncol 1988; 14 Suppl. 1: 49Google Scholar
  103. 103.
    DeLustro F, Smith ST, Sundsmo J, et al. Reaction to injectable collagen in human subjects. J Dermatol Surg Oncol 1988; 14 Suppl. 1: 49Google Scholar
  104. 104.
    Stegman SJ, Chu S, Bensch K, et al. A light and electron microscope evaluation of Zyderm collagen and Zyplast implants in aging human facial skin: a pilot study. Arch Dermatol 1987; 123: 1644-9PubMedCrossRefGoogle Scholar
  105. 105.
    Hanke CW, Hingley HR, Jolivette DM, et al. Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. J Am Acad Dermatol 1991; 25: 319-26PubMedCrossRefGoogle Scholar
  106. 106.
    McGrew RN, Wilson RS, Havener WH. Sudden blindness secondary to injections of common drugs in the head and neck. I: clinical experiences. Otolaryngology 1978; 86: 147-51Google Scholar
  107. 107.
    McCoy JP, Schade WJ, Siegle RJ, et al. Characterization of the Immoral immune response to bovine collagen implants. Arch Dermatol 1985; 121: 990-4PubMedCrossRefGoogle Scholar
  108. 108.
    Cooperman L, Michaeli D. The immunogenicity of injectable collagen. II: a retrospective review of seventy-two tested and treated patients. J Am Acad Dermatol 1984; 10: 647-51Google Scholar
  109. 109.
    Klein AW. Bonfire of the wrinkles. J Dermatol Surg Oncol 1991; 7: 543-4Google Scholar
  110. 110.
    Ellingsworth LR, DeLustro F, Brennan JE, et al. The human immune response to reconstituted bovine collagen. J Immunol 1986; 136: 877-82PubMedGoogle Scholar
  111. 111.
    DeLustro F, Dasch J, Keefe J, et al. Immune response to allogeneic and xenogeneic implants of collagen and collagen derivatives. Clin Orthop Relat Res 1990; 260: 263-79PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.Department of DermatologyDavid Geffen School of Medicine at UCLABeverly HillsUSA

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