See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/5933730

Human Histology and Persistence of Various Injectable Filler

Substances for Soft Tissue Augmentation

Article  in  Aesthetic Plastic Surgery · October 2003

DOI: 10.1007/s00266-003-3022-1 · Source: PubMed

CITATIONS READS

406 271

3 authors, including:

Gottfried Lemperle Vera B Morhenn

University of California, San Diego University of California, San Francisco
274 PUBLICATIONS   2,902 CITATIONS    132 PUBLICATIONS   4,772 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Humanitarian Activities View project

Soft Tissue Bulking View project

All content following this page was uploaded by Gottfried Lemperle on 11 March 2015.

The user has requested enhancement of the downloaded file.

Aesth. Plast. Surg. 27:354–366, 2003
DOI: 10.1007/s00266-003-3022-1

Human Histology and Persistence of Various Injectable Filler

Substances for Soft Tissue Augmentation

Gottfried Lemperle, M.D., Ph.D.,1 Vera Morhenn, M.D.,2 and Ulrich Charrier, M.D3
1,2
San Diego, CA, USA
3
Frankfurt, Germany

Abstract. An increasing number of soft tissue filler sub- tion) were well tolerated, slowly diminishing over 9 months.
stances have been introduced to the beauty market outside Calcium hydroxylapatite microspheres (Radiance FN) in-
the U.S. which lack experimental and clinical data in sup- duced almost no foreign body reaction but were absorbed
port of their claim. Ten commercially available filler sub- by the skin at 12 months.Host defense mechanisms react
stances were examined for biocompatibility and durability: differently to the various filler materials, but all substanc-
0.1 cc of each substance was injected deep intradermally es—resorbable or nonresorbable—appeared to be clinically
into the volar forearm of one of the authors and observed and histologically safe, although all exhibit undesirable side
for clinical reaction and permanence. At 1, 3, 6, and 9 effects. Since the mechanism of late inflammation or gran-
months the test sites were excised, histologically examined, uloma formation is still unknown, early histological find-
and graded according to foreign body reactions classifica- ings are not useful in predicting possible late reactions to
tion. Collagen (Zyplast) was phagocytosed at 6 months and filler substances.
hyaluronic acid (Restylane) at 9 months. PMMA micro-
spheres (Artecoll) had encapsulated with connective tissue, Key words: Dermal filler substances—Soft tissue augmen-
macrophages, and sporadic giant cells. Silicone oil (PMS tation—Aquamid—Artecoll—Dermalive—Evolution—New-
350) was clinically inconspicuous but dissipated into the Fill-Radiance FN—Restylane—Reviderm intra
tissue, causing a chronic foreign body reaction. Polylactic
acid microspheres (New-Fill) induced a mild inflammatory
response and had disappeared clinically at 4 months.
Dextran microspheres (Reviderm intra) induced a pro- In recent decades, dermal filler substances consisting
nounced foreign body reaction and had disappeared at 6 of highly viscous fluids [33,40,53] or polymer parti-
months. Polymethylacrylate particles (Dermalive) induced cle suspensions [21,37] have been injected beneath
the lowest cellular reaction but had disappeared clinically at wrinkles and acne scars [8,31]. These substances are
6 months. Polyacrylamide (Aquamid) was well tolerated useful for the correction of congenital or traumatic
and remained palpable to a lessening degree over the entire facial, bony, and soft tissue defects [10], and in pa-
testing period. Histologically, it dissipated more slowly and tients suffering from scleroderma, Romberg’s disease,
was kept in place through fine fibrous capsules. Polyvinyl- facial wasting, or lipodystrophy following AIDS
hydroxide microspheres suspended in acrylamide (Evolu- treatment [2,11,57]. Additional indications are uni-
lateral paralysis of vocal cords [12,24,28], augmen-
tation of the lip and soft palate in cleft lip patients,
anophthalmic orbits [10], or enophthalmus. Other
potential applications as bulking agents are lower
Presented at the 33rd Annual Meeting of the Association of esophageal sphincter in gastroesophageal reflux pa-
German Plastic Surgeons in Heidelberg, Germany, Sep- tients [22,48], and bladder neck or anal sphincter in
tember 21, 2002
patients suffering from urinary [5] or fecal inconti-
Correspondence to Gottfried Lemperle, M.D., Ph.D., nence [27,63].
Division of Plastic Surgery, University of California, San Animal studies [38] and clinical trials [15,19] have
Diego; email: [email protected] shown good acceptance and short- and long-term
G. Lemperle et al. 355

efficacy in accordance with the chemical structure slices numbered only, and being unaware of the ma-
and surface characteristics of the microparticles. terial involved.
Resorbable materials such as collagen, hyaluronic A classification of foreign body reactions, estab-
acid [19,36,49], polymethylacrylate (PMA) [6], dex- lished by Duranti et al. [19], was applied to each
tran [20], or polylactic acid [2] are removed by histological slide. The grading was performed on at
phagocytosis over a period of 3–12 months de- least four slices of the same specimen.
pending on the amount and type of bulking agent
implanted. Permanent fillers such as paraffin [33],  Grade I: slight reaction with a few inflammatory
fluid silicone [11,17], Teflon [34], or silicone particles cells
[21] have an irregular surface and cannot be phag-  Grade II: clear inflammatory reaction with one or
ocytosed but may eventually form foreign body two giant cells
granulomas due to ‘‘frustrated macrophages’’ [20].  Grade III: fibrous tissue with inflammatory cells,
Microspheres below the size of 15 microns [44,61] lymphocytes, and giant cells
are generally phagocytosed and may be transported  Grade IV: granuloma with encapsulated implants
to local lymph nodes. Larger microspheres from and clear foreign body reaction
nonresorbable polymers with a smooth surface The following commercially available filler mate-
[35,38,51] are encapsulated with fibrous tissue and rials were bought and injected in Europe:
escape phagocytosis. Clinically, all injected fluids
[45,59] and particles [54,56] have been shown to 1. Zyplast, a suspension of 3.5% crosslinked bovine
cause foreign body granulomas in a small percent- collagen, purchased from Collagen Aesthetics,
age of patients. Until the mechanism of granuloma Inc., Fremont, CA
formation is fully understood, the chance of devel- 2. Restylane, a suspension of 2.0% crosslinked
opment is not predictable. hyaluronic acid (HA) produced biotechno-
The ideal soft tissue filler substance for wrinkles, logically from Streptococcus equi [36,47,50] in
skin defects, and sphincter saline, purchased from Q-Med AB, Uppsala,
 is biocompatible and safe Sweden
 is stable at the implantation site 3. Artecoll, a suspension of 20% microspheres (40
 keeps its volume and remains pliable lm) of polymethylmethacrylate (PMMA) in
 does not cause protrusion of the skin or mucosa 3.5% bovine collagen solution [35,37], obtained
 induces minimal foreign body reaction from Artes Medical Inc., San Diego, CA
 will not be removed by phagocytosis 4. PMS 350, medical grade silicone fluid (dimeth-
 has no migration potential to distant locations ylpolysiloxane) of 350 centistoke viscosity, pur-
 does not cause foreign body granuloma. chased from Vikomed, Meinerzhagen, Germany
5. New-Fill, which comes as a powder of poly-L-
As a percentage of wet weight, the human skin is lactic acid (L-PLA) microspheres (2–50 lm) to
composed of collagen (27–39%), elastin (0.2–0.6%), prepare a 4.5% suspension in 2.7% methylcellu-
glycosaminoglycans (0.03–0.3%), and 60–72% water. lose [2], purchased from Biotech Industry S.A.,
The goal of this study was to confirm histocompati- Luxembourg
bility and permanence of various filler substances 6. Reviderm intra, a suspension of 2.5% dextran
under investigation. For some products there exist no microspheres (40 lm Sephadex) [20] in 2.0% hy-
published scientific reports on biocompatibility, his- aluronic acid (2.5 MDa) of bacterial origin
tology, or clinical studies. (Rofilan), obtained from Rofil Medical Interna-
tional N.V. (RMI), Breda, The Netherlands
7. Dermalive, a 240% suspension of hydroxyethyl-
methacrylate (HEMA) fragments in 1.14%
Materials and Methods crosslinked hyaluronic acid of bacteriological
origin [6], purchased from Dermatech S.A., Paris,
During the past 4 years, four 0.1-cc blebs of 10 dif- France
ferent dermal filler substances have been injected deep 8. Aquamid, a clear 5% crosslinked gel from poly-
intradermally into the volar skin of a forearm, next to acrylamide (PAAG) [42], purchased from Con-
an existing scar. The injection sites were inspected tura International S.A., Montreux, Switzerland
weekly and clinical changes were recorded and pho- 9. Evolution, a suspension of 6% polyvinylhidrox-
tographed. Each raw of the different implants was ide (PVOH) microspheres (5–80 lm) in 2.5%
excised after 1, 3, 6, or 9 months. At least four sec- polyacrylamide gel, purchased from Laboratoires
tions were cut from each implantation site at different ProCytech, Bordeaux, France
levels for histological examination. The sections were 10. Radiance FN, a suspension of 30% calcium
stained with hematoxilin–eosin or Masson trichrome hydroxylapatite microspheres (25-40 lm) in a
and evaluated in Frankfurt. An independent pathol- carboxymethyl-cellulose gel [9], purchased from
ogist (U.C.) was blinded, receiving the histological BioForm Inc., Franksville, WI
356 Histology and Persistence of Filler Substances

Results microspheres induce a minimal immunogenic re-

sponse.
All four implant sites in the human forearm could The relative size of the palpable Artecoll lesions in
easily be identified after 1 and 3 months; however, human skin remained unchanged over 9 months
not all implants could be visualized after 6 and 9 (Fig. 5), suggesting that dissipation of microspheres
months. In the latter cases, the whole area was ex- into the surrounding soft tissue or migration to
cised and sectioned 5–10 times in order to identify adjacent lymph nodes does not occur (Fig. 3).
microscopic traces of the implant.

PMS 350 Silicone Fluid

Zyplast
PMS 350 is a colorless oil with a low viscosity, 350
The tissue sections obtained from human skin times that of water (1 centistoke = viscosity of wa-
showed the presence of many macrophages and in- ter), but with high chemical stability. Immediately
vading capillaries at the circumference of the im- after injection, PMS 350 dispersed into the sur-
plants at 1 month. This process goes along with slow rounding tissue in form of millions of microdroplets
resorption of the crosslinked eosinophilic opaque (Fig. 6). At 1 month, each microdroplet, about 20–
material with gradual and scarce infiltration of in- 100 microns in size, was encapsulated by a monolayer
flammatory cells, and little or no deposition of of fibroblasts and collagen fibers. Macrophages and
structures, which resemble new collagen fibers at 3 giant cells, which phagocytosed the foamy, translu-
months [32]. At 6 months, no residue of cell-free cent, bifringent material, were found at 3 and 6
Zyplast could be found in the human skin. The his- months. Asteroid bodies in the cytoplasma of macr-
tological reactions were evaluated according to the ophages and giant cells were typically seen after
Duranti scale (Fig. 1). phagocytosis of the silicone fluid. At 9 months, gra-
nulomatous nodules in the dermis and subcutaneous
tissue were surrounded by strands of fibrous tissue.
Restylane

The clear hyaluronic acid gel induced erythema and New-Fill

swelling in the human skin for 2 days. Clinically,
Restylane and all other tested crosslinked hyaluronic The PLA implants were well palpable for the first 3
acid products disappeared from the skin within 4 months but had disappeared from the human skin at
months. Histologically, the blue stained hyaluronic 4 months. In the refrigerator, PLA microspheres with
acid showed little foreign body reaction (Fig. 2) but diameters between 2 and 50 lm, were still recogniz-
was slowly degraded by macrophages. Some macr- able as microspheres 2 weeks after suspension, and
ophages and rare giant cells were apparent in the were partly hydrolyzed and deformed at 1 and 3
human skin at 3 months [19]. Clusters of these cells months.
could still be found after 6 months; however, no Histologically, a fine capsule could be observed
residue could be identified at 9 months. around the implant throughout. At 3 months, the
microspheres had remained spherical and were sur-
rounded by macrophages and some lymphocytes
Artecoll (Fig. 7). At 6 months, most microspheres showed a
porous surface structure, were fissured and sometimes
At 1 month, each individual microsphere was sepa- deformed, and were surrounded by macrophages and
rated from adjacent microspheres by a thin layer of small giant cells. Their pseudopodia infiltrated the
eosinophilic material representing collagen fibers surface of some microspheres but did not degrade the
(Fig. 3). The implants were discrete and well cir- activity of these cells. The PLA was likely dissolved by
cumscribed within the soft tissue. The peripheral re- hydrolysis and extracellular enzymes [3,60] and sub-
gions of these foci had infiltrated to a depth of 2–3 sequently broken down by macrophages. At 9
microspheres and contained macrophages (1 per ap- months, the degradation of PLA microspheres was
proximately 15 beads) and few multinucleated giant completed. At 9 months, no remnant of cicatricial fi-
cells. The centers of the lesions were cell free and brosis was found after total disappearance of PLA
separated through fibrin fibers only. At 3 and 6 residues in the human skin. This finding illustrates the
months, isolated giant cells extended deeper into the excellent biocompatibility of PLA.
lesions (Fig. 4).
The implanted denatured collagen appeared to be
resorbed at 3 months. New collagen deposits, evident Reviderm intra
at 1 month, increased the spaces between individual
microspheres. The number of inflammatory cells was The injection of dextran beads caused swelling and
small at all times and indicates that collagen and redness, which continued for 10 days—possibly due
G. Lemperle et al. 357

Fig. 1. The Duranti-classification reflects the extent of

histological foreign body reaction at certain times. Class 2
is determined by a few giant cells. Fig. 4. Artecoll at 6 month. All microspheres are encap-
sulated by connective tissue and some macrophages. Dur-
anti Grade II. Masson trichrome ·400.

Fig. 2. Restylane at 1 month. Minor cellular reaction of the

surrounding tissue, scattered macrophages and giant cells,
no immune response, and good biocompatibility. HE · 100. Fig. 5. Artecoll at 10 years. The microspheres are still intact
and surrounded by collagen fibers, fibroblasts, some
macrophages, and isolated giant cells. Masson trichrome
·100.

Fig. 3. Artecoll at 1 month. The two strands of implants

here have a diameter of a 26 G needle and are still packed in Fig. 6. PMS 350 silicone gel at 1 month. The gel has dis-
a fibrin network with some macrophages and giant cells. sipated into millions of microdroplets, which are sur-
Masson trichrome ·20. rounded by macrophages and lymphocytes. HE · 100.
358 Histology and Persistence of Filler Substances

to the toxic effect of free dextranomers. Edematous 7.0 to 9.0. On examination, the implants revealed no
swelling of the implants continued for more than 3 reaction and were still palpable at 9 months, but
months. The palpable deep dermal implant began to decreasing in size.
disappear at 4 months and was no longer palpable at Histologically, acrylamide gel was difficult to detect
6 months. at 1 month. The injected, non stainable transparent
Histologically, the 40-lm dextran beads produced gel produced only a fine fibrocellular capsule (Fig.
the greatest amount of granulation tissue among all 13), as expected from the literature [14,42]. At 3
injectables tested. At 1 month, the hydrophilic micr- months, no further histopathological reaction oc-
ospheres were swollen and measured up to 75 lm in curred outside the implant site, such as foreign body
diameter (Fig. 8); some were broken apart and sur- reaction. At 6 and 9 months, Aquamid had dispersed
rounded by foamy macrophages and small giant cells. into the skin and was surrounded by macrophages
The hyaluronic acid carrier had early separated from and fibroblasts (Fig. 12). The histological reaction
the beads and was found in pools, surrounded by a resembled that of injected fluid silicone. In small
rim of giant cells (Fig. 9). At 3 months, only few quantities, such as a slim strand beneath a wrinkle,
elastic fibers could be seen; instead there were great the gel appeared to be slowly absorbed, without vis-
numbers of macrophages and giant cells, which en- ible foreign body reaction. Therefore, the manufac-
veloped and tried to phagocytose the beads. The turer’s claim of ‘‘lifelong permanence’’ seems to be
surface of the dextran beads began to show irregu- dependent on the amount of implanted acrylamides.
larities at 6 months and total disintegration at 9
months. It ranged to the top of the Duranti scale
among the resorbable implants (Fig. 10), possibly due Evolution
to the carrier from an undisclosed source of hyalu-
ronic acid (Rofilan), which has been crosslinked with Clinically, the implant made of polyvinylhidroxide
a plant extract. microspheres suspended in acrylamide gel resembles
Artecoll. It was not painful during injection as was
Aquamid. Because of evaporation through the poly-
Dermalive ethylene syringe, the water content of the material
was already diminished at the time of purchase. The
The hydroxyethyl-methacrylate (HEMA) fragments implants were well visible and diminishing palpably
began to disappear in the human skin at 4 months over the whole course of 9 months. Histological ex-
and were no longer palpable at 6 months. amination showed the beads, most of them 30–40 lm
Histologically, they showed the least cellular reac- in diameter, within the clear acrylamide gel (Fig. 13)
tion of all implants. The polygonal, translucent, and surrounded by an almost invisible fibrous capsule.
irregular particles, 20–120 lm in size, which appeared Each droplet, 3–5 mm in size, was encapsulated with
like clear broken glass gravel, were packed in clusters, a very fine layer of fibroblast and fibers without in-
with minimal ingrowth of fibrous tissue, cells, and growth into the implant. No foreign body reaction
blood vessels (Fig. 11). Only a fine network of elastic was detectable. A few single microspheres outside the
fibers and occasionally macrophages were found, but implant site were covered with a fibrin layer or had
there were no apparent capillaries and no strong fi- attached macrophages and fibroblasts. At 6 and 9
brous capsule. The hyaluronic acid was separated and months, most of the carrier gel had been absorbed
surrounded by macrophages, which had disappeared and was replaced at the outer layers by granulation
at 3 months. At 9 months, only a few small clusters of tissue. At 9 months, the implant was totally infiltrated
Dermalive with rounded corners and ridges, many by macrophages, fibroblasts, and giant cells (Fig. 14),
macrophages, and lymphoid cell clusters could be which resembled the tissue ingrowth of PLA at 3
detected. The few giant cells contained abundant as- months. The surface of the microspheres was still
teroid bodies in their cytoplasma. Some pointed intact after 9 months.
particles had a tendency to irritate the surrounding
soft tissue, which showed clear evidence of low grade
inflammation. However, only about one tenth of the Radiance FN
implant volume consisted of cells and fibers (Fig. 11).
Clinically, the subdermal implants in the forearm
were swollen for 3 days. Within 1 month, the palpable
Aquamid implant diminished to half its prior size and became
whitish and shining through the skin. The hard
The clear gel of polyacrylamide was implanted into nodules diminished further in size and disappeared
human skin at four sites. Used in breast augmenta- clinically at 9 months from the skin.
tion in Ukraine and China, it had a viscosity of 1045 Histologically, Radiance microspheres stimulate
centistoke. Since no anesthetic is added, the injections almost no foreign body reaction. The 1-month sam-
into human skin caused a burning sensation for 20 ple had to be embedded in PMMA like bone tissue
sec. This was likely due to the cross-linked gel’s pH of because the implant could not be cut by conventional
G. Lemperle et al. 359

Fig. 7. New-Fill at 3 months. Macrophages and giant cells Fig. 10. The Duranti classification reflects the extent of
are surrounding the PLA microspheres and are filled with histological foreign body reaction. Class 3 is defined by
phagocytosed PLA material. HE ·400. infiltrating lymphocytes and giant cells. Zeraplast consists
of PMMA beads suspended in Rofilan. L40 are PLA beads
suspended in collagen.

Fig. 8. Reviderm at 1 month. Most dextran beads (its

empty vacuoles) are surrounded by macrophages and giant
cells with conspicuous foamy cytoplasm. The HA carrier is Fig. 11. Dermalive at 3 months. The PMA particles are
separated from the beads and surrounded by a rim of giant packed and cause little foreign body reaction. Invading
cells. Masson trichrome ·100. macrophages and some giant cells gather at edges and
corners. Masson trichrome ·400.

Fig. 9. The HA carrier of RevidermTM at 1 month has Fig. 12. Aquamid at 6 month. The big droplets have been
separated early from the beads and is slowly phagocytosed dispersed into millions of mini-droplets, surrounded by fine
by a rim of multinucleated giant cells. Masson trichrome fibrous capsules with minimal foreign body reaction. This
·400. picture resembles fluid silicone. HE ·100.
360 Histology and Persistence of Filler Substances

Fig. 13. Evolution at 3 months. Most PVH microspheres Fig. 14. Evolution at 9 month. Macrophages and multi-
are still suspended in acrylamide gel, which results in a fine nucleated giant cells have phagocytosed most of the acryl-
fibrous capsule without foreign body reaction. Aquamid amide carrier. At that stage, each single microsphere is
induces the same inconspicuous histological reaction at that encapsulated with fibrin and some macrophages. Masson
time. Masson trichrome ·100. trichrome ·400.

Fig. 15. Radiance at 3 months. The calcium microspheres are packed, the interstitium is filled with fibrin and scattered
fibroblasts and macrophages. Masson trichrome ·100.

methods. The beads were packed and surrounded by diameter and the microspheres deformed and slowly
some fibrin fibers but little cellular tissue. At 3 adsorbed (Fig. 16). Since few macrophages were seen
months, a method of rapid decalcification was ap- it is suggested that calcium hydroxylapatite micro-
plied prior to cutting and staining. The beads were spheres are degraded by enzymatic breakdown rather
still packed (Fig. 15) and tissue ingrowth started from than phagocytosis.
the fine outer capsule of the implant. The main ‘‘in-
terstitium’’ still consists of fibrin fibers and few cel-
lular elements like fibroblasts and flattened Discussion
macrophages. No vascularity could be detected. At 6
months, the whole implant is surrounded by a fine Collagen Gel
fibrous capsule and single microspheres are encap-
sulated by a thin fibroplastic stroma with flattened Bovine collagen is the ‘‘gold standard’’ for all
cells. At 9 months, the voids are much smaller in other newly introduced injectables. To date, Zyderm
G. Lemperle et al. 361

Fig. 16. At 9 months, the Radiance microspheres appear deformed and partly degraded, probably by osteolytic enzymes and
not by phagocytosis. Masson trichrome ·100.

and Zyplast have been the only FDA-approved PMMA Microspheres

dermal filler substances in the U.S. for more than
20 years. The limited longevity of Zyderm and Zy- These microspheres showed the most stable appear-
plast, ease of use, low incidence of allergic reactions ance throughout the experiment. Once injected, the
(<1%), and safety are well established [32]. Late PMMA microspheres cannot be broken down by
granuloma formation occurs at a lower rate [26,45] enzymes, since a methyl group in the alpha-position
than with slowly resorbable gels and particulate stabilizes the molecule. Interestingly, the volume of
materials. the injected collagen (80%) remained stable in the
implant over the years (Fig. 5). The microspheres act
merely as a scaffold and a stimulus for constant
Hyaluronic Acid Fluids connective tissue production. Here, the implant car-
rier is truly ‘‘replaced’’ by the body’s own tissue. In
Human hyaluronic acid, a polysaccharide of 4–5 kDa contrast to other ‘‘dead’’ permanent filler substances
molecular weight has a half-life of only 1–2 days. It like acrylamide or Radiance, the ingrowth of con-
forms the cellular interstitium of the dermis and nective tissue creates a ‘‘living’’ implant.
creates volume by binding water. A human body Artecoll gives predictable results; however, at the
contains approximately 15 g HA. To avoid an early same time it is ‘‘non-forgiving’’ when mistakenly
breakdown, injectable hyaluronic acids have to be implanted in an incorrect plane. To avoid technical
crosslinked. The HA in Restylane has a molecular mistakes, introductory courses and a careful learning
weight of 1 · 106 Da, but 0.5% or every 200th amino curve are required. It may induce granuloma forma-
acid of the molecule is crosslinked (‘‘stabilized’’) with tion in very rare instances [35], as all other substances
a neighbor molecule. The company claims that it will do in certain patients. Artecoll has a 10-year
contains a suspension of 1 · 105 HA particles of 40– history [35] and has been used in more than 200,000
60 lm size in HA fluid. A similar product, Perlane, is patients worldwide outside the U.S.
said to contain 8 · 103 gel particles/ml of approxi- Another injectable implant of PMMA micro-
mately 100 lm in diameter, and Fine Lines approxi- spheres, 1–80 lm in diameter but suspended in Mg-
mately 2 · 105 gel particles/ml of 20–30 lm in carboxy-gluconate (Metacrill), is produced and
diameter. These gel particles, however, cannot been distributed in Brazil [47].
seen under the microscope. Residues from the process
of fermentation of Streptococcus equi (>107 lg/ml
[41] may induce allergies to this bacterial protein in Silicone Fluid
certain patients. Acute and late inflammatory skin
reactions have been occasionally reported As we know from ruptured breast implants, silicone
[13,25,39,41]. gel causes the rarest foreign body reaction among the
362 Histology and Persistence of Filler Substances

polyglycolic acid (PGA) have been used safely in

suture materials (Vicryl, Dexon), in resorbable plates
and screws, in guided bone regeneration, in ortho-
pedic, neuro-, and cranio-facial surgery, and as drug
delivery devices [60]. PLA does not stimulate the
natural production of collagen [2], but causes a for-
eign body reaction, characterized by macrophages,
giant cells, and some elastic fibers. The PLA polymer
New-Fill disappeared within 6 months, probably due
to extracellular hydrolysis, ester cleavage, and the
catalytic effect of hydrosoluble acid monomers
formed in the polymer matrix during degradation [3].
Whether the mild inflammatory response elicited by
PLA can be ascribed to degradation activity of
macrophages is not clear.
Fig. 17. Duranti classification reflects the extent of foreign The degradation rate of PLA polymers in vivo is
body reaction at certain times. Class 4 defines granuloma said to be almost twice that in vitro [60]. Our experi-
formation. Bioplastique is a suspension of silicone particles ments with microspheres, however, have shown the
in PVP. Embosphere are soft microspheres of trisacryl- opposite. After refrigeration for 6 months, the micr-
gelatin used for tumor embolization [4]. ospheres in their fluid cellulose carrier had dissolved
totally, whereas the microspheres in living tissue were
still recognizable as round with irregular surface. The
filler materials. In most patients, silicone gel remains degradation of different PLAs is affected dramatically
very soft and is encapsulated by only a very thin layer by the amount of glycolic units in the lactic acid chains
of fibroblasts. The lack of fibrous capsule formation [60]. Degradation only appears when the molecular
may lead to the displacement of larger quantities, weight of the PLA decreases below 20 · 103 Da. The
aided by gravity, which may migrate downwards PLA in New-Fill has a molecular weight of 170 · 103
from the glabella to the cheeks and from the naso- Da. Nine months after implantation, no polymer
labial folds to beneath the chin. In time, the implant residue or remnant cicatricial fibrosis were found,
can harden through ingrowth of connective tissue, confirming the good biocompatibility of PLA micro-
macrophages, and foreign body cells, which form a spheres. Since PLAs contain no animal proteins, al-
granuloma [53]. lergies are not expected; however, late granulomas
The reputation of ‘‘medical grade’’ silicone fluid has have been reported as with any other filler substance.
been damaged by five facts: (1) the use of large
quantities, e.g., in breast augmentation or facial dys-
Dextran Microspheres
trophies [17,18], has led to deformation; (2) the pos-
sibility of gravity induced ‘‘migration’’ in patients with
Dextrans are the substrate of chromatography col-
very lax skin and subcutaneous tissue; (3) the possi-
bility of late (5–20 years) granuloma (siliconoma) umns (Sephadex) used for the separation of proteins.
Dextran molecules of 40,000 and 80,000 Da are used
formation; (4) the substitution of cheaper, non-medi-
as plasma expanders, since dextran molecules
cal-grade silicone fluids by nonprofessionals; and (5)
<20,000 Da will be filtered by the kidney. Dextran
the lack of experience of most physicians in the
beads of 100 lm in diameter were found intact 2 years
treatment of rare cases of late siliconoma. Though
after implantation in the back skin of rats. Eppley et
difficult to remove surgically, siliconomas respond
al. [18] emphasized that the positive surface charges
favorably to multiple injections of corticosteroid [7] or
of dextran beads apparently attracted macrophages.
antimitotic agents [58]. The wrinkles and lips of
The macrophages in turn release TGF-beta and
thousands of patients in Europe and Asia have been
interleukins, which stimulate fibroblasts to produce
treated successfully with the micro-droplet technique
collagen fibers. After extensive resorption of the
with small amounts of medical-grade silicone fluid. On
dextran beads at 9 months, however, little or no
the other hand, hundreds of women required total
cicatricial residue could be detected at the implanta-
mastectomy due to chronic inflammation of large
amounts of silicone oil injected directly into the breast. tion sites in these studies. Dextran beads of 100 lm in
diameter (Deflux, Q-Med, Uppsala, Sweden) are
As so often in medicine, success depends on the right
currently used in clinical trials for the treatment of
dosage, volume, and knowledge of side effects.
stress urinary incontinence.

Polylactic Acid Microspheres HEMA Fragments

Polylactic acids do not occur naturally, but were first Dermalive is a by-product of the manufacture of in-
synthesized by French chemists in 1954. PLA and traocular lenses and was introduced in the European
G. Lemperle et al. 363

market in 1998. Because of a rather high incidence of Polyvinyl Gel Microspheres

granuloma formation, it is now used mainly in the
form of Dermadeep with HEMA fragments 80–110 The mixture of apparently slowly resorbable Polyvi-
lm in size for deep dermal and epiperiosteal im- nyl microspheres with a longer lasting polyacryla-
plantation. Inside the implant, the HEMA particles mide gel (Evolution) showed similar histological
were packed closely, probably due to diminished reactions to Aquamid within the first 6 months, and
viscosity of the carrier medium hyaluronic acid. This from then on was like Artecoll. Clinically and histo-
carrier dissipated from the particles just after im- logically it showed the least reactions and remained
plantation of Dermalive and was found outside of the visible and palpable throughout the 9 months. Future
clusters of particles. clinical experience has to show whether late side ef-
The great advantage of collagen as a suspension fects are as high as with acrylamides.
medium for filler substances is its high viscosity,
which keeps the particles or microspheres apart
weeks after implantation. Since little host tissue for- Calcium-Hydroxylapatite Microspheres
mation is stimulated, more Dermalive has to be in-
jected compared to other fillers. On the other hand, Ca-hydroxylapatite is the primary component of
HEMA has a free OH-group, which should stimulate bone and dents. In form of particles it was first used
macrophage activity. Endogenous esterases in serum as onlay grafts for bone regeneration in dentistry. Ca-
and liver break down HEMA. Interestingly, the hydroxylapatite microspheres of 75-125 lm in dia-
amount of tissue reaction is no indication for the rate meter (Coaptite) are injected as a bulking agent in
of granuloma formation. In the studies described urinary incontinence. It is highly biocompatible,
here, Dermalive evoked the least new tissue forma- causes little tissue reaction, well defined at the injec-
tion but clinically causes a rather high rate of gran- tion site, radio-opaque, and can therefore be used as
uloma formation [54]. a tissue marker (Radiance FN). In the skin and es-
pecially in the lip, it does not ‘‘remain soft’’ but ex-
hibits a clear hardening of the implant, which resolves
Polyacrylamide Gel over time. Since March 2002, Radiance FN can be
used ‘‘off-label’’ in the US for wrinkle treatment and
Like dextran beads, polyacrylamide is used mainly lip augmentation. Since it disappeared from the skin
for protein separation by molecular biologists. The within 12 months, it is a semi-permanent implant like
use of polyacrylamides as injectable filler materials many others (Aquamid, Dermalive, New-Fill, Revi-
was initiated in 1983, and they were used clinically in derm) and not a ‘‘near-permanent solution’’. While
the Ukraine and China as Interfall [14] or ‘‘Amazing Radiance is well tolerated beneath wrinkles, it should
Gel’’ in thousands of patients. However, to date few not be recommended for lip augmentation. The
clinical and scientific data have been published in concomitant movement of the orbicularis muscle in
Western literature [23]. Since Interfall’s patent ex- women during chewing compresses every injected
pired, at least seven European companies are mar- strand to a lump!
keting polyacrylamides as dermal filler substances Histologically, the calcium hydroxylapatite micro-
(Royamid, Argiform, Bioformacryl, OutLine, Aqu- spheres do not ‘‘provide a scaffold for tissue infil-
amid, Evolution, Kosmogel). So far, they have been tration consistent with the form of the surrounding
injected in large quantities for breast, buttock, and tissue’’. Because of little tissue ingrowth [16, 43] and
calf augmentation, in facial lipodystrophy and con- absence of granulation tissue, triamcinolone (Kena-
genital malformations [14], and have been called log) injections into Radiance lumps will be ineffec-
‘‘endoprotheses’’ [42]. If overcorrection occurs, the tive and should be omitted. In some patients,
fluid can be withdrawn from the implant even after however, Radiance microspheres may induce a kind
years. Reportedly, it has a half-life in the human of foreign body reaction - as demonstrated by one
body of >20 years. This may be true for large histological picture in the company’s advertisement,
quantities; however, the injection of 0.1 cc Aquamid which of course will react to intralesional cortico-
was resorbed in human skin within 9 months. steroids.
The concentration of acrylamide monomers that can In general, the histological examination of all
be toxic was reported to be <10 ppm or 0.04%. samples showed distinctive morphological findings
Side effects were enlarged lymphnodes in 10%, mi- for each type of micro-implant, which can help dis-
gration of gel in 3%, and edema in 2%. The U.S. tinguish different injected substances. The differential
Environmental Protection Agency classifies acryla- diagnosis could also be of medico-legal interest be-
mide as a medium-hazard probable human carcino- cause adulterated or improper substances are some-
gen. Even if there are few published reports [30], times injected fraudulently [54]. PMA-particles
granuloma formation after Interfall implantation is (Dermalive) showed multiple sharp edges and points
well known in China since 1997 [14] and has to taking on a ‘‘broken glass’’ appearance, whereas
be expected in certain patients as with all other microspheres are devoid of any jagged or sharp edges
injectables. that might serve as a continued source of irritation.
364 Histology and Persistence of Filler Substances

Complications The CE mark controls only Good Manufacturing

Practice (GMP) of an injectable agent but does not
Besides well-known allergies, displacement, and guarantee a maximum of biological safety. Therefore,
granuloma formation, another potential complica- a central office similar to the FDA should be estab-
tion of dermal filler substances was documented only lished in Europe to which all severe clinical side ef-
recently [62]. Localized fat atrophies in the cheeks, fects have to be reported. Some manufacturers report
similar to those seen in facial lipodystrophy after HIV the complication rates as a percentage of treatments
treatment [11,57], occurred 2–3 months after the im- (Restylane, Hylaform, Dermalive)— most probably
plantation of Restylane or New-Fill in the nasolabial of syringes sold—, whereas other manufacturers re-
folds of healthy patients. At 9 months, the implants port the side effects as percentage of treated patients
could still be identified and were interspersed with [35]. Only a careful statistical analysis of these data
giant cells and granulomatous tissue. The residues will shed some light on the true incidence of side ef-
were encapsulated and surrounded by fat necroses fects for each dermal filler substance.
and vacuoles. No explanation has been found for this
side effect since there is no obvious link in the
chemical structure of these two filler substances and
HIV protease inhibitors. Conclusions

The differences in histological reactions and in per-

Granulomas manence lead to a classification of injectable filler
substances into five types:
All injectable filler materials cause normal foreign- 1. Autologous fat rarely is permanent and its fate is
body-type reactions that may develop into a foreign unpredictable. The mechanism for long-term
body granuloma in selected patients. Its cause is still survival of fat or stem cells has yet to be un-
unknown and no predictions can be made. Some of derstood.
the patients reported a severe generalized viral or 2. Natural filler substances such as collagen and hy-
bacterial infection [37,41,53], vaccination, or local aluronic acids are phagocytosed slowly with min-
trauma some months before the appearance of the imal histological reaction.
granulomas. 3. Fluid filler substances, such as fluid silicone and
Granulomas occur in patients at a rate of 0.01% to acrylamides, cause little fibrosis but can dislocate
1.0% according to the chemical composition, shape, larger volumes through muscle movement and
and surface structure of the particles [38]. They occur gravity; they are considered ‘‘dead implants.’’
significantly less often after implantation of micro- 4. Particulate materials like PMA gravel and PLA
spheres with a smooth surface (Artecoll, New-Fill, microspheres are packed and induce minimal for-
Evolution) [37,38] than after implantation of particles eign body reaction and fibrosis. They are pure
with irregular surface (Bioplastique, Dermalive) fillers and are slowly resorbed.
[6,54]. As would be expected, they also occur less 5. Microspheres from non-resorbable PMMA or re-
frequently after injection of resorbable implants sorbable dextran are stimulants for encapsulation
(collagen [29,45], hyaluronic acid [13,25,39-41,59]) and scaffolds of permanent or temporary connec-
compared to long-lasting implants [53,54]. tive tissue formation, considered ‘‘living im-
plants.’’
Legal Aspects Host defense mechanisms reacted differently to
each filler material; however, all substances—resorb-
In contrast to the FDA, Notified Bodies of the Eu- able or nonresorbable—appeared to be clinically and
ropean Community do not require animal or clinical histologically safe. None of the tested substances is
studies for the registration and approval of injectable without undesirable effects [1,46,52,55]. Since the
filler substances or surgically introduced artificial cause of late inflammation or granuloma formation is
implants. The European product quality control not yet known, predictions can be not be made from
systems classify injectable dermal fillers as Medical early histological results for possible late reactions of
Devices Class IIa (resorbable substances), and Class the host to an individual filler substance.
IIb (substances that cannot be reabsorbed). The FDA Therefore, materials must be selected according to
has determined that collagen is a Class III.A device the needs of the individual patient. The patient
and injected particles are a Class III.B device. In should be informed and involved in the choice of
November 1997, a new provision was added to the resorbable or long-lasting filler substance. Hyaluronic
Federal Food, Drug, and Cosmetic Act to allow any acid and new collagen products such as Cymetra,
legally marketed, FDA-approved product to be ad- Fascian, or CosmoDerm could not be demonstrated
ministered for any condition within a doctor-patient to last longer than bovine collagen. The development
relationship. This is called ‘‘off-label use’’ of an FDA- of a possibly disease- and allergy-free human rec-
approved product. ombinant collagen from yeast (Fibrogen, San Fran-
G. Lemperle et al. 365

cisco) or cow milk (Cohesion Technologies, Palo 17. Duffy DM: Injectable liquid silicone: new perspectives.
Alto) has a long way to go. The search for the perfect In: Klein AW (Eds.) Tissue Augmentation in Clinical
permanent injectable material with maximum safety Practice: Procedures and Techniques. Marcel Dekker,
is ongoing. Time and a centralized registry of adverse New York, pp 237–267, 1998
18. Duffy DM: The silicone conundrum: A battle of an-
events—similar to the registries for silicone breast
ecdotes. Dermatol Surg 28:590, 2002
implants—will bring improvement in efficacy and 19. Duranti F, Salti G, Bovani B, Calandra M, Rosati M:
safety of new generation filler substances. Injectable hyaluronic acid gel for soft tissue augmen-
tation. Dermatol Surg 24:1317, 1998
20. Eppley BL, Summerlin D-J, Prevel CD, Sadove AM:
Effects of positively charged biomaterial for dermal and
References subcutaneous augmentation. Aesth Plast Surg 18:13,
1994
1. Alster TS, West TB: Human-derived and new synthetic 21. Ersek RA, Beisang AA: Bioplastique. A new textured
injectable materials for soft-tissue augmentation: Cur- copolymer microparticle promises permanence of soft-
rent status and role in cosmetic surgery. Plast Reconstr tissue augmentation. Plast Reconstr Surg 87:693, 1991
Surg 105:2515, 2000 22. Feretis C, Benakis P, Dimopoulos C, et al.: Endoscopic
2. Amard P: PLA (New-Fill) as management of lipoat- implantation of Plexiglas (PMMA) microspheres for
rophy of the face. Magazin Aesthet Surg 1:28, 2001 the treatment of GERD. Gastrointest Endosc 53:423,
3. Athanasiou KA, Niederauer GG, Agrawal CM, 2001
Landsman A: Applications of biodegradable lactides 23. Filatov AV, Mirolyubov SN: Contour plasty of max-
and glycolides in pediatry. Implant Biomater 12:475, illofacial soft tissues with biocompatible polyacryla-
1995 mide gel (Russian). Stomatologiia (Mosk) 77:45, 1998
4. Bendszus M, Klein R, Burger R, et al.: Efficacy of 24. Flint PW, Corio RL, Cummings CW: Comparison of
trisacryl gelatin microspheres versus polyvinyl alcohol soft tissue response in rabbits following laryngeal im-
particles in the preoperative embolization of menin- plantation with hydroxylapatite, silicone rubber and
giomas. Am J Neurorad 21:255, 2000 Teflon. Ann Oto Rhino Laryngol 106:399, 1997
5. Bent AE, Foote J, Siegel S, Faerber G, Chao R, 25. Friedman PM, Mafong EA, Kauvar AN, Geronemus
Gormley EA: Collagen implant for treating stress uri- RG: Safety data of injectable nonanimal stabilized
nary incontinence in women with urethral hypermo- hyaluronic acid gel for soft tissue augmentation. Der-
bility. J Urol 166:1354, 2001 matol Surg 28:491, 2002
6. Bergeret-Galley C, Latouche X, Illouz Y-G: The value 26. Garcia-Domingo MI, Alijotas-Reig J, Cistero-Bahima
of new filler material in corrective and cosmetic sur- A, Tresserra F, Enrique E: Disseminated and recurrent
gery: DermaLive and DermaDeep. Aesth Plast Surg sarcoid-like granulomatous panniculitis due to bovine
25:249, 2001 collagen injection. J Invest Allergol Clin Immunol
7. Bigata X, Ribera M, Bielsa I, Ferrandiz C: Adverse 10:107, 2000
granulomatous reaction after cosmetic dermal silicone 27. Geile D, Zinner I, Erbel F, Schaefer M, Osterholzer G:
injection. Dermatol Surg 27:198, 2001 Diagnosis and non-surgical treatment of faecal incon-
8. Burres S: Recollagenation of acne scars. Dermatol Surg tinence in the proctological practice. In: Fruehmorgen
22:364, 1996 P, Bruch H-P Eds. Non-Neoplastic Diseases of the
9. Busso M: Soft tissue augmentation with Radiance FN. Anorectum. Kluwer Academic Publishers, Dordrecht,
Aesthetic Trends & Technologies 2(3): 2003 2001
10. Cahill KV, Burns JA: Volume augmentation of the 28. Hallen L, Johansson C, Laurent C: Cross-linked hya-
anophthalmic orbit with cross-linked collagen (Zy- luronan (Hylan B gel): an injectable remedy for treat-
plast). Arch Ophthalmol 107:1684, 1989 ment of vocal fold insufficiency—an animal study. Acta
11. Carr A, Samaras K, Burton S, et al.: A syndrome of Otolaryngol (Stockholm) 119:107, 1999
peripheral lipodystrophy, hyperlipidaemia and insulin 29. Hanke CW: Adverse reactions to bovine collagen. In:
resistance in patients receiving HIV protease inhibitors. Klein AW (Eds.) Tissue Augmentation in Clinical
AIDS 12:F51, 1998 Practice. Procedures and Techniques. Marcel Dekker,
12. Chan RW, Titze IR: Viscosities of implantable bio- New York, pp 145–154, 1998
materials in vocal cord augmentation surgery. Lar- 30. Kazachkov EL, Fridman AB, Friss SA: Granuloma-
yngoscope 108:725, 1998 tous pleurisy after mammoplasty induced by poly-
13. Chen AL, Desai P, Adler EM, Di Cesare PE: Gra- acrylamide gel. (Russian). Arkh Patol 60:58, 1998
nulomatous inflammation after hylan g-f 20 viscos- 31. Kinney BM, Hughes III CE: Soft tissue fillers: An
upplementation of the knee: a report of six cases. J overview. Aesth Surg J 21:469, 2001
Bone Joint Surg (Am) 84-A:1142, 2002 32. Klein AW, Elson ML: The history of substances for
14. Cheng N-X, Wang Y-L, Wang J-H, Zhang X-M, soft tissue augmentation. Dermatol Surg 26:1096, 2000
Zhong H: Complications of breast augmantation with 33. Kolle FS: Plastic and Cosmetic Surgery. D Appleton,
injected hydrophilic polyacrylamide gel. Aesth Plast New York, pp 209–230, 1911
Surg 26:375, 2002 34. Lemperle G, Hoehler H: Granulome nach Unt-
15. Cohen SR, Holmes RE (2004) Artecoll: A longlasting erspritzung von Gesichtsfalten mit Teflon-Paste. In:
wrinkle augmentation material. To be published in Hoehler H (Ed.) Plastische und Wiederherstellungs-
Plast Reconstr Surg 113: chirurgie Schattauer, Stuttgart, pp 335–340, 1975
16. Drosbeck HP, Rothstein SS, Gumaer KI, Sherer AD, 35. Lemperle G, Gauthier-Hazan N, Lemperle M: PMMA-
Slighter RG: J Oral Maxillofac Surg 42:143, 1984 microspheres (Artecoll) for long-lasting correction of
366 Histology and Persistence of Filler Substances

wrinkles: Refinements and statistical results. Aesth gastroesophageal reflux: a pilot study of 10 medically
Plast Surg 22:365, 1998 intractable patients. Gastrointest Endoscop 34:106, 1988
36. Lemperle G: Hyaluronsäure zur Faltenunterspritzung. 50. Olenius M: The first clinical study using a new biode-
Arzneimittel-, Therapie-Kritik 3:635, 2000 gradable implant for the treatment of lips, wrinkles and
37. Lemperle G, Romano JJ, Busso M: Soft tissue aug- folds. Aesth Plast Surg 22:97, 1998
mentation with Artecoll: 10-year history, indications, 51. Pannek J, Brands FH, Schewe J, Senge T: Particle
technique and complications. Dermatol Surg 29:573, migration following transurethral injection of carbon
2003 coated beads for stress urinary incontinence. J Urol
38. Lemperle G, Legaz ME (2004) Biocompatibility of in- 165(Suppl 5):74, 2001
jectable microparticles. Aesth Plast Surg, submitted 52. Pollack S: Some new injectable dermal filler materials:
39. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K: Hylaform, Restylane, and Artecoll. J Cutan Med Surg
Hyaluronic acid skin fillers: Adverse reactions and skin 3Suppl 4:S4–S29, 1999
testing. J Am Acad Dermatol 45:930, 2001 53. Rapaport MJ, Vinnik C, Zarem H: Injectable silicone:
40. Lupton JR, Alster TS: Cutaneous hypersensitivity re- cause of facial nodules, cellulites, ulceration, and mi-
action to injectable hyaluronic acid gel. Dermatol Surg gration. Aesth Plast Surg 20:267, 1996
26:135, 2000 54. Requena C, Izquierdo MJ, Navarro M, et al.: Adverse
41. Manna F, Dentini M, Desideri P, De Pita O, Mortilla reactions to injectable aesthetic microimplants. Am J
E, Mars B: Comparative chemical evaluation of two Dermatopathol 23:197, 2000
commercially available derivatives of hyaluronic acid 55. Rudolph CM, Soyer HP, Schuller-Petrovic S, Kerl H:
(Hylaform from rooster combs and Restylane from Foreign body granulomas due to injectable aesthetic
streptococcus) used for soft tissue augmentation. J Eur microimplants. Am J Surg Pathol 23:113, 1999
Acad Dermatol Venerol 13:183, 1999 56. Rubin JP, Yaremchuk MJ: Complications and toxici-
42. Mazzoleni F, Dominici C, Lotti T, et al.: Formacryl: ties of implantable biomaterials used in facial recon-
Un nuovo biopolimero al servizio della medicina ‘‘piu structive and aesthetic surgery: A comprehensive
un endoprotesi che un filler.’’ Dermatologia 1:13, 2000 review of the literature. Plast Reconstr Surg 100:1, 1997
43. Misiek DJ, Kent JN, Carr RF: Soft tissue responses to 57. Saint-Marc T, Partisani M, Poizot-Martin I, et al.: A
hydroxylapatite particles of different shapes. J Oral syndrome of peripheral fat wasting (lipodystrophy) in
Maxillofac Surg 42:150, 1984 patients receiving long-term nucleoside analogue ther-
44. Moscona RR, Bergman R, Friedman-Birnbaum R: An apy. AIDS 13:1659, 1999
unusual late reaction to Zyderm I injections: a chal- 58. Senet P, Bachelez H, Ollivaud L, Vignon-Pennamen D,
lenge for treatment. Plast Reconstr Surg 92:331, 1993 Dubertret L: Minocycline for the treatment of cutane-
45. Morhenn VB, Lemperle G, Gallo RL: Phagocytosis of ous silicone granulomas. Br J Dermatol 140:985, 1999
different particulate dermal filler substances by human 59. Shafir R, Amir A, Gur E: Long-term complications of
macrophages and skin cells. Dermatol Surg 28:484, facial injections with Restylane (injectable hyaluronic
2002 acid). Plast Reconstr Surg 106:1215, 2000
46. Naoum C, Dasou-Plakida D: Dermal filler materials 60. Spenlehauer G, Vert M, Benoit JP, Boddaert A: In
and botulin toxin. Int J Dermatol 40:606, 200 vitro and in vivo degradation of poly(D,L-lactide/gly-
47. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, colide) type microspheres made by solvent evaporation
Smith S: A randomized, double-blind, multicenter method. Biomaterials 10:557, 1989
comparison of the efficacy and tolerability of Restylane 61. Tomacic-Jeciz VJ, Merritt K, Umbreit TH: Significance
versus Zyplast for the correction of nasolabial folds. of type and the size of biomaterial particles on phag-
Dermatol Surg 29:588, 2003 ocytosis and tissue distribution. J Biomed Mater Res
48. Neto MS, Passy S: Rellenamiento cutaneo y correccion 55:523, 2001
de las deformidades del rostro con el uso de microesf- 62. Voy E-D, Mohasseb J: Lipoatrophie als seltene Kom-
eras de PMMA—un nuevo enfoque. In: Proceedings of plikation nach Auffüllung der Nasolabialfalten mit in-
the 28th Argentinian Congress of Plastic Surgery, Cor- jizierbaren Implantaten. Magazin Aesth Chir 2:, 2002
doba, pp 1–8, 1999 63. Whitehead WE, Wald A, Norton NJ: Treatment op-
49. O’Connor KW, Lehman GA: Endoscopic placement of tions for fecal incontinence. Dis Colon Rectum 44:131,
collagen at the lower esophageal sphincter to inhibit 2001

View publication stats