Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Injectable soft tissue fillers: Overview of clinical use

Alastair Carruthers, FRCPC
Jean Carruthers, MD, FRCSC
Shannon Humphrey, MD, FRCPC, FAAD
Section Editors
Jeffrey S Dover, MD, FRCPC
Charles E Butler, MD, FACS
Deputy Editor
Abena O Ofori, MD


A wide variety of injectable soft tissue fillers are available for clinical use, including biodegradable products (hyaluronic acid, collagen, calcium hydroxylapatite, and poly-L-lactic acid), products that remain indefinitely in tissue (polymethylmethacrylate microspheres, hydrogel polymers, and silicone), and viable autologous fat. Soft tissue fillers are used for multiple cosmetic and therapeutic indications. Adequate clinician training in the use of these agents is essential for the prevention of adverse events.

Examples of indications for injectable soft tissue fillers and the basic principles of treatment will be reviewed here; details on the efficacy, use, and adverse effects of specific soft tissue filling agents are discussed separately. (See "Injectable soft tissue fillers: Temporary agents" and "Injectable soft tissue fillers: Permanent agents".)


Facial aging results from a combination of changes that involve the skin (eg, wrinkling, dyspigmentation, and vascular changes) and underlying tissues. A progressive loss of tissue volume due to the atrophy and displacement of subcutaneous fat, as well as a reduction in structural support due to bone atrophy, contribute significantly to facial aging [1-3].

Soft tissue fillers can be used to restore a semblance of youth through the replacement of lost tissue volume and the filling and effacement of coarse wrinkles. Examples of age-related features that may be treated with soft tissue fillers include (figure 1):

Upper face


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Sep 25, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg 2000; 26:1107.
  2. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 2008; 121:2107.
  3. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg 2010; 125:332.
  4. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003; 29:802.
  5. Patel MP, Talmor M, Nolan WB. Botox and collagen for glabellar furrows: advantages of combination therapy. Ann Plast Surg 2004; 52:442.
  6. Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005; 31:1604.
  7. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005; 29:363.
  8. Goldberg DJ. Correction of tear trough deformity with novel porcine collagen dermal filler (Dermicol-P35). Aesthet Surg J 2009; 29:S9.
  9. Baumann LS, Shamban AT, Lupo MP, et al. Comparison of smooth-gel hyaluronic acid dermal fillers with cross-linked bovine collagen: a multicenter, double-masked, randomized, within-subject study. Dermatol Surg 2007; 33 Suppl 2:S128.
  10. Moers-Carpi M, Vogt S, Santos BM, et al. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg 2007; 33 Suppl 2:S144.
  11. Arlette JP, Trotter MJ. Anatomic location of hyaluronic acid filler material injected into nasolabial fold: a histologic study. Dermatol Surg 2008; 34 Suppl 1:S56.
  12. Lupo MP, Smith SR, Thomas JA, et al. Effectiveness of Juvéderm Ultra Plus dermal filler in the treatment of severe nasolabial folds. Plast Reconstr Surg 2008; 121:289.
  13. Salles AG, Lotierzo PH, Gimenez R, et al. Evaluation of the poly-L-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation. Aesthetic Plast Surg 2008; 32:753.
  14. Cohen SR, Holmes RE. 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.
  15. Cohen SR, Berner CF, Busso M, et al. ArteFill: a long-lasting injectable wrinkle filler material--summary of the U.S. Food and Drug Administration trials and a progress report on 4- to 5-year outcomes. Plast Reconstr Surg 2006; 118:64S.
  16. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg 2006; 118:22S.
  17. Perkins NW, Smith SP Jr, Williams EF 3rd. Perioral rejuvenation: complementary techniques and procedures. Facial Plast Surg Clin North Am 2007; 15:423.
  18. Tzikas TL. A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation. Dermatol Surg 2008; 34 Suppl 1:S9.
  19. De Boulle K, Swinberghe S, Engman M, Shoshani D. Lip augmentation and contour correction with a ribose cross-linked collagen dermal filler. J Drugs Dermatol 2009; 8:1.
  20. Moscona RA, Fodor L. A retrospective study on liquid injectable silicone for lip augmentation: long-term results and patient satisfaction. J Plast Reconstr Aesthet Surg 2010; 63:1694.
  21. Pallua N, Wolter TP. A 5-year assessment of safety and aesthetic results after facial soft-tissue augmentation with polyacrylamide hydrogel (Aquamid): a prospective multicenter study of 251 patients. Plast Reconstr Surg 2010; 125:1797.
  22. Carruthers J, Klein AW, Carruthers A, et al. Safety and efficacy of nonanimal stabilized hyaluronic acid for improvement of mouth corners. Dermatol Surg 2005; 31:276.
  23. Graivier MH, Bass LS, Busso M, et al. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007; 120:55S.
  24. Solish NJ. Assessment of recovery time for the collagen products Dermicol-P35 27G and 30G. J Am Acad Dermatol 2010; 62:824.
  25. Weinkle S. Injection techniques for revolumization of the perioral region with hyaluronic acid. J Drugs Dermatol 2010; 9:367.
  26. Schierle CF, Casas LA. Nonsurgical rejuvenation of the aging face with injectable poly-L-lactic acid for restoration of soft tissue volume. Aesthet Surg J 2011; 31:95.
  27. Butterwick KJ. Rejuvenation of the aging hand. Dermatol Clin 2005; 23:515.
  28. Man J, Rao J, Goldman M. A double-blind, comparative study of nonanimal-stabilized hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands. Dermatol Surg 2008; 34:1026.
  29. Sadick NS, Anderson D, Werschler WP. Addressing volume loss in hand rejuvenation: a report of clinical experience. J Cosmet Laser Ther 2008; 10:237.
  30. Marmur ES, Al Quran H, De Sa Earp AP, Yoo JY. A five-patient satisfaction pilot study of calcium hydroxylapatite injection for treatment of aging hands. Dermatol Surg 2009; 35:1978.
  31. Mazzuco R, Hexsel D. Poly-L-lactic acid for neck and chest rejuvenation. Dermatol Surg 2009; 35:1228.
  32. de Lacerda DA, Zancanaro P. Filler rhinoplasty. Dermatol Surg 2007; 33 Suppl 2:S207.
  33. Jacovella PF. Aesthetic nasal corrections with hydroxylapatite facial filler. Plast Reconstr Surg 2008; 121:338e.
  34. Pitkin L, Rimmer J, Lo S, Hosni A. Aesthetic augmentation rhinoplasty with Permacol: how we do it. Clin Otolaryngol 2008; 33:615.
  35. Rokhsar C, Ciocon DH. Nonsurgical rhinoplasty: an evaluation of injectable calcium hydroxylapatite filler for nasal contouring. Dermatol Surg 2008; 34:944.
  36. Hopkins C, Walker R, Lee S, Roberts D. Permacol in augmentation rhinoplasty: how we do it. Clin Otolaryngol 2009; 34:68.
  37. Stupak HD, Moulthrop TH, Wheatley P, et al. Calcium hydroxylapatite gel (Radiesse) injection for the correction of postrhinoplasty contour deficiencies and asymmetries. Arch Facial Plast Surg 2007; 9:130.
  38. Valantin MA, Aubron-Olivier C, Ghosn J, et al. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open-label study VEGA. AIDS 2003; 17:2471.
  39. Jones DH, Carruthers A, Orentreich D, et al. Highly purified 1000-cSt silicone oil for treatment of human immunodeficiency virus-associated facial lipoatrophy: an open pilot trial. Dermatol Surg 2004; 30:1279.
  40. Moyle GJ, Lysakova L, Brown S, et al. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Med 2004; 5:82.
  41. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 52:233.
  42. Moyle GJ, Brown S, Lysakova L, Barton SE. Long-term safety and efficacy of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy. HIV Med 2006; 7:181.
  43. Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label, 18-month trial of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virus-associated lipoatrophy: one-year durability. Plast Reconstr Surg 2006; 118:34S.
  44. Loutfy MR, Raboud JM, Antoniou T, et al. Immediate versus delayed polyalkylimide gel injections to correct facial lipoatrophy in HIV-positive patients. AIDS 2007; 21:1147.
  45. Levy RM, Redbord KP, Hanke CW. Treatment of HIV lipoatrophy and lipoatrophy of aging with poly-L-lactic acid: a prospective 3-year follow-up study. J Am Acad Dermatol 2008; 59:923.
  46. Mest DR, Humble GM. Retreatment with injectable poly-l-lactic acid for HIV-associated facial lipoatrophy: 24-month extension of the Blue Pacific study. Dermatol Surg 2009; 35 Suppl 1:350.
  47. James J, Carruthers A, Carruthers J. HIV-associated facial lipoatrophy. Dermatol Surg 2002; 28:979.
  48. Carruthers A, Liebeskind M, Carruthers J, Forster BB. Radiographic and computed tomographic studies of calcium hydroxylapatite for treatment of HIV-associated facial lipoatrophy and correction of nasolabial folds. Dermatol Surg 2008; 34 Suppl 1:S78.
  49. Carruthers A, Carruthers J. Evaluation of injectable calcium hydroxylapatite for the treatment of facial lipoatrophy associated with human immunodeficiency virus. Dermatol Surg 2008; 34:1486.
  50. Collins E, Wagner C, Walmsley S. Psychosocial impact of the lipodystrophy syndrome in HIV infection. AIDS Read 2000; 10:546.
  51. Hanke CW, Redbord KP. Safety and efficacy of poly-L-lactic acid in HIV lipoatrophy and lipoatrophy of aging. J Drugs Dermatol 2007; 6:123.
  52. Kavouni A, Catalan J, Brown S, et al. The face of HIV and AIDS: can we erase the stigma? AIDS Care 2008; 20:485.
  53. Smith KC. Repair of acne scars with Dermicol-P35. Aesthet Surg J 2009; 29:S16.
  54. Beer K. A single-center, open-label study on the use of injectable poly-L-lactic acid for the treatment of moderate to severe scarring from acne or varicella. Dermatol Surg 2007; 33 Suppl 2:S159.
  55. Sadick NS, Palmisano L. Case study involving use of injectable poly-L-lactic acid (PLLA) for acne scars. J Dermatolog Treat 2009; 20:302.
  56. Sadove R. Injectable poly-L: -lactic acid: a novel sculpting agent for the treatment of dermal fat atrophy after severe acne. Aesthetic Plast Surg 2009; 33:113.
  57. Ralston JP, Blume JE, Zeitouni NC. Treatment of postoperative soft tissue loss with injectable poly-L-lactic acid. J Drugs Dermatol 2006; 5:1000.
  58. Kasper DA, Cohen JL, Saxena A, Morganroth GS. Fillers for postsurgical depressed scars after skin cancer reconstruction. J Drugs Dermatol 2008; 7:486.
  59. Rendon MI, Keeling J. Poly-L-lactic acid for the treatment of trauma-induced facial lipoatrophy and asymmetry. Cutis 2008; 81:218.
  60. Franz FP, Blocksma R, Brundage SR, Ringler SL. Massive injection of liquid silicone for hemifacial atrophy. Ann Plast Surg 1988; 20:140.
  61. Onesti MG, Monarca C, Rizzo MI, et al. Minimally invasive combined treatment for Parry-Romberg syndrome. Aesthetic Plast Surg 2009; 33:452.
  62. Onesti MG, Troccola A, Scuderi N. Volumetric correction using poly-L-lactic acid in facial asymmetry: Parry Romberg syndrome and scleroderma. Dermatol Surg 2009; 35:1368.
  63. Schweiger ES, Riddle CC, Tonkovic-Capin V, Aires DJ. Successful treatment with injected hyaluronic acid in a patient with lip asymmetry after surgical correction of cleft lip. Dermatol Surg 2008; 34:717.
  64. Reytan N, Gutsche N, Rzany B. Aesthetic correction of the upper lip in a patient with mandibular prognathia with a novel long-lasting collagen filler: a case report. Dermatol Surg 2007; 33:1274.
  65. Vagefi MR, McMullan TF, McCann JD, Anderson RL. Osteoplasty using calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg 2008; 24:190.
  66. Taban M, Mancini R, Nakra T, et al. Nonsurgical management of congenital eyelid malpositions using hyaluronic Acid gel. Ophthal Plast Reconstr Surg 2009; 25:259.
  67. Mancini R, Khadavi NM, Goldberg RA. Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler. Ophthal Plast Reconstr Surg 2011; 27:1.
  68. Naik MN, Ali MJ, Das S, Honavar SG. Nonsurgical management of epiblepharon using hyaluronic acid gel. Ophthal Plast Reconstr Surg 2010; 26:215.
  69. Mancini R, Taban M, Lowinger A, et al. Use of hyaluronic Acid gel in the management of paralytic lagophthalmos: the hyaluronic Acid gel "gold weight". Ophthal Plast Reconstr Surg 2009; 25:23.
  70. Vagefi MR, McMullan TF, Burroughs JR, et al. Injectable calcium hydroxylapatite for orbital volume augmentation. Arch Facial Plast Surg 2007; 9:439.
  71. Kotlus BS, Dryden RM. Correction of anophthalmic enophthalmos with injectable calcium hydroxylapatite (Radiesse). Ophthal Plast Reconstr Surg 2007; 23:313.
  72. Panettiere P, Marchetti L, Accorsi D. Filler injection enhances the projection of the reconstructed nipple: an original easy technique. Aesthetic Plast Surg 2005; 29:287.
  73. Lennox K, Beer KR. Nipple contouring with hyaluronics postmastectomy. J Drugs Dermatol 2007; 6:1030.
  74. Schulman MR, Lipper J, Skolnik RA. Correction of chest wall deformity after implant-based breast reconstruction using poly-L-lactic acid (Sculptra). Breast J 2008; 14:92.
  75. Hertegård S, Hallén L, Laurent C, et al. Cross-linked hyaluronan used as augmentation substance for treatment of glottal insufficiency: safety aspects and vocal fold function. Laryngoscope 2002; 112:2211.
  76. Hertegård S, Hallén L, Laurent C, et al. Cross-linked hyaluronan versus collagen for injection treatment of glottal insufficiency: 2-year follow-up. Acta Otolaryngol 2004; 124:1208.
  77. Remacle M, Lawson G. Results with collagen injection into the vocal folds for medialization. Curr Opin Otolaryngol Head Neck Surg 2007; 15:148.
  78. Min JY, Hong SD, Kim K, Son YI. Long-term results of Artecoll injection laryngoplasty for patients with unilateral vocal fold motion impairment: safety and clinical efficacy. Arch Otolaryngol Head Neck Surg 2008; 134:490.
  79. Rosen CA, Gartner-Schmidt J, Casiano R, et al. Vocal fold augmentation with calcium hydroxylapatite: twelve-month report. Laryngoscope 2009; 119:1033.
  80. Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg 2015; 41 Suppl 1:S120.
  81. Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg 2007; 26:34.
  82. Dinehart SM, Henry L. Dietary supplements: altered coagulation and effects on bruising. Dermatol Surg 2005; 31:819.
  83. Lafaille P, Benedetto A. Fillers: contraindications, side effects and precautions. J Cutan Aesthet Surg 2010; 3:16.
  84. Hirsch RJ, Stier M. Complications of soft tissue augmentation. J Drugs Dermatol 2008; 7:841.
  85. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg 2008; 34 Suppl 1:S92.
  86. Monheit GD, Rohrich RJ. The nature of long-term fillers and the risk of complications. Dermatol Surg 2009; 35 Suppl 2:1598.
  87. Rohrich RJ, Monheit G, Nguyen AT, et al. Soft-tissue filler complications: the important role of biofilms. Plast Reconstr Surg 2010; 125:1250.
  88. Levy PM, De Boulle K, Raspaldo H. Comparison of injection comfort of a new category of cohesive hyaluronic acid filler with preincorporated lidocaine and a hyaluronic acid filler alone. Dermatol Surg 2009; 35 Suppl 1:332.
  89. Levy PM, De Boulle K, Raspaldo H. A split-face comparison of a new hyaluronic acid facial filler containing pre-incorporated lidocaine versus a standard hyaluronic acid facial filler in the treatment of naso-labial folds. J Cosmet Laser Ther 2009; 11:169.
  90. Weinkle SH, Bank DE, Boyd CM, et al. A multi-center, double-blind, randomized controlled study of the safety and effectiveness of Juvéderm injectable gel with and without lidocaine. J Cosmet Dermatol 2009; 8:205.
  91. Raspaldo H, De Boulle K, Levy PM. Longevity of effects of hyaluronic acid plus lidocaine facial filler. J Cosmet Dermatol 2010; 9:11.
  92. Brandt F, Bank D, Cross SL, Weiss R. A lidocaine-containing formulation of large-gel particle hyaluronic acid alleviates pain. Dermatol Surg 2010; 36 Suppl 3:1876.
  93. Lupo MP, Swetman G, Waller W. The effect of lidocaine when mixed with large gel particle hyaluronic acid filler tolerability and longevity: a six-month trial. J Drugs Dermatol 2010; 9:1097.
  94. Monheit GD, Campbell RM, Neugent H, et al. Reduced pain with use of proprietary hyaluronic acid with lidocaine for correction of nasolabial folds: a patient-blinded, prospective, randomized controlled trial. Dermatol Surg 2010; 36:94.
  95. Buck DW 2nd, Alam M, Kim JY. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg 2009; 62:11.
  96. Donofrio LM. Soft-tissue augmentation. In: Fitzpatrick, 7th ed, Wolff K, Goldsmith LA, Katz SI, et al. (Eds), McGraw-Hill, 2008. Vol 2, p.2380.
  97. Matarasso SL, Carruthers JD, Jewell ML, Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg 2006; 117:3S.
  98. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg 2006; 118:92S.
  99. Bachmann F, Erdmann R, Hartmann V, et al. The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study. Dermatol Surg 2009; 35 Suppl 2:1629.
  100. Georgescu D, Jones Y, McCann JD, Anderson RL. Skin necrosis after calcium hydroxylapatite injection into the glabellar and nasolabial folds. Ophthal Plast Reconstr Surg 2009; 25:498.
  101. Grunebaum LD, Bogdan Allemann I, Dayan S, et al. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg 2009; 35 Suppl 2:1635.
  102. Beleznay K, Humphrey S, Carruthers JD, Carruthers A. Vascular compromise from soft tissue augmentation: experience with 12 cases and recommendations for optimal outcomes. J Clin Aesthet Dermatol 2014; 7:37.
  103. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32:276.
  104. Kim DW, Yoon ES, Ji YH, et al. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg 2011; 64:1590.
  105. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007; 33:357.
  106. Dayan SH, Arkins JP, Mathison CC. Management of impending necrosis associated with soft tissue filler injections. J Drugs Dermatol 2011; 10:1007.
  107. Andre P, Fléchet ML. Angioedema after ovine hyaluronidase injection for treating hyaluronic acid overcorrection. J Cosmet Dermatol 2008; 7:136.
  108. Kang MS, Park ES, Shin HS, et al. Skin necrosis of the nasal ala after injection of dermal fillers. Dermatol Surg 2011; 37:375.
  109. McCleve DE, Goldstein JC. Blindness secondary to injections in the nose, mouth, and face: cause and prevention. Ear Nose Throat J 1995; 74:182.
  110. Park SW, Woo SJ, Park KH, et al. Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol 2012; 154:653.
  111. Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face. Plast Reconstr Surg 2012; 129:995.
  112. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding and Treating Blindness From Fillers: A Review of the World Literature. Dermatol Surg 2015; 41:1097.
  113. Christensen L. Normal and pathologic tissue reactions to soft tissue gel fillers. Dermatol Surg 2007; 33 Suppl 2:S168.
  114. Braun M, Braun S. Nodule formation following lip augmentation using porcine collagen-derived filler. J Drugs Dermatol 2008; 7:579.
  115. Smith KC. Reversible vs. nonreversible fillers in facial aesthetics: concerns and considerations. Dermatol Online J 2008; 14:3.