The history of substances for soft tissue augmentation.

SOFT TISSUE AUGMENTATION has seen a renaissance of interest as an increasing number of patients seek aesthetic improvement without major downtime. Why this renewal of interest in filling agents? One huge reason is the availability of Botox (Allergan, Inc., Irvine, CA) which works superbly in the upper face. This accomplishment of rejuvenating the upper face using Botox has created a need for agents that work equally well in the lower face. A second reason is that the introduction of many new implantable materials and techniques has contributed to the advancement of the field of cosmetic surgery over the past 15 years. Another reason for this re-interest is the concept of the three-dimensional face. The youthful face has a much fuller look, not a pulled, flat, two-dimensional look. This has become one of the central tenets of the field of soft tissue augmentation. Filling can augment and even, at times, replace pulling. In addition, subtle lip enhancement is something that is here to stay. In fact, it is the number one indication for injectable fillers. Moreover, affordable outpatient surgery has replaced much of the expensive hospital-based surgery and less invasive techniques provide a whole new repertoire of therapeutic options. Finally, more and more physicians of all specialties are becoming trained in cosmetic surgery and are offering cosmetic services as part of their office practice. Courses in cosmetic surgery techniques are becoming increasingly popular at medical meetings among almost all specialties. As a result of all the foregoing developments, we have seen a remarkable reawakening of interest in tissue augmentation. Today, physicians have a much larger armamentarium of techniques and materials with which to improve facial contours, ameliorate wrinkles, and stall the tell-tale signs of the aging face. For a substance or device to be amenable for soft tissue augmentation by the general medical community, it must meet certain criteria. It must have both a high “use” potential, producing pleasing cosmetic results with a minimum of undesirable reactions, and a low “abuse” potential, in that widespread and possibly incorrect or indiscriminate use would not result in significant morbidity. 1 It must be nonteratogenic, noncarcinogenic, and nonmigratory. In addition, the material must provide predictable, persistent correction through reproducible implantation techniques. Finally, if not autologous, the substance, agent, or device must be regulated by the US Food and Drug Administration (FDA). FDA regulation of an agent or device assures purity and accessibility, as well as provides information regarding use. Though no currently available implant fulfills all of these criteria, many options exist that are adequate for a given task, satisfy patients, and offer excellent safety profiles. The field of soft tissue augmentation has a long and colorful history. Over the years, many implantable substances and devices have been promulgated to cosmetically improve soft tissue defects and deficiencies. The search for the perfect material to eradicate rhytides, smooth scars, and fill traumatic defects continues. New products are continually appearing at an ever-increasing rate, sometimes with great fanfare, but often fail to fulfill the promise of a better alternative to that which is currently available. A list of available filling agents 10 years ago may have consisted of five substances, but now there is a veritable cornucopia of agents that are available to the practitioner to use.