ORIGINAL ARTICLES

Autologous Cultured Fibroblast Injection for Facial Contour
Deformities: A Prospective, Placebo-Controlled, Phase III
Clinical Trial
ROBERT A. WEISS, MD,y MARGARET A. WEISS, MD,y KAREN L. BEASLEY, MD,yz AND
GIRISH MUNAVALLI, MDyBACKGROUND Previous data indicate that injections of autologous fibroblasts increase collagen formation, accompanied by a concomitant increase in thickness and density of dermal collagen.
OBJECTIVE The purpose of this study was to determine efficacy and side effects of autologous living
fibroblast injections versus placebo in a randomized Phase III trial for the treatment of various facial
contour defects.
METHODS This was a double-blind, randomized comparison of injectable living autologous fibroblast
cells and placebo for the treatment of facial contour defects (N = 215). Live fibroblasts (20 million/mL) or
placebo (the transport medium without living cells) were given as three doses administered at 1- to 2week intervals. Efficacy evaluations were performed 1, 2, 4, 6, 9, and 12 months after the first injection.
RESULTS Living fibroblasts produced statistically significantly greater improvements in dermal deformities and acne scars than did placebo. The difference between live fibroblast injections and placebo
achieved statistical significance at 6 months (po.0001). At 9- and 12-month follow-up, live fibroblast–treated patients continued to demonstrate benefit from treatment with response rates of 75.0 and 81.6%,
respectively. No serious treatment-related adverse events were reported.
CONCLUSIONS Our results indicate that autologous fibroblast injections can safely and effectively
produce improvements in rhytids, acne scars, and other dermal defects continuing for at least 12 months
after injection.
This study was funded by Isolagen Technologies, Inc., Exton, PA. Dr. Munavalli has ongoing research grants
from Isolagen and is a consultant for Isolagen.

Dermal fillers for the correction of facial contour
deformities such as nasolabial folds,
glabellar crease, deep wrinkles of the forehead, andacne scars have been in clinical use for almost
three decades. Injectable bovine collagen was thefirst material successfully used as dermal filler,1and the armamentarium now includes synthetic andother protein-based materials. These products,
however, have some limitations. For example,
up to 6% of patients suffer hypersensitivity reactions
to bovine collagen, which can manifest as
granulomatous inflammation, necrosis, or abscessformation.2,3 Rare systemic complications havebeen reported.4–6
Bovine collagen corrections are temporary, because
protein-based fillers are resorbed by tissue collagenases within weeks to months of injection.7–9 Longer
lasting synthetic fillers, such as hyaluronic acid,still carry a small risk of granulomatous allergic
reactions, and injection technique can result in
temporary surface elevations.10–16 Problems withautologous tissues include requiring extensive
surgical tissue-harvesting procedures.

Department of Dermatology, Johns Hopkins University School of Medicine; zUniversity of Maryland School of

Medicine; yMaryland Laser, Skin, and Vein Institute, Baltimore, Maryland& 2007 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing 
ISSN: 1076-0512  Dermatol Surg 2007;33:263–268  DOI: 10.1111/j.1524-4725.2007.33060.x
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To overcome some of these limitations, an autologous living fibroblast culture technique was developed by Isolagen Technologies, Inc. (Exton, PA).
This technique may safely produce sustained
improvements in contour defects without surgery
and virtually zero risk of hypersensitivity reactions.
This method, termed the Isolagen therapy (IT) system, involves a small postauricular punch biopsy,
which is used to create an autologous fibroblast cellline through a specific culturing process. These numerically multiplied living autologous fibroblasts arethen injected directly into the patient’s dermis where
it is believed these cells create a continuous protein
repair system. Recent studies have demonstrated
objectively and subjectively measured improvements
in facial contour defects lasting at least 12 to 48
months.17,18 Histologic analysis in these studies
demonstrated that fibroblast injections increase collagen formation, accompanied by a concomitant increase in thickness and density of dermal collagen.
This process has not been associated with an inflammatory response. The purpose and design of thisstudy were to determine efficacy and side effects in arandomized Phase III trial utilizing autologous living
fibroblast injections versus placebo compared in thetreatment of eight different facial contour defects.

Materials and Methods
This IRB-approved study enrolled 158 patients, ofwhich 151 were treated, at 10 US sites. The study
population consisted of patients with facial contour
deformities including acne scars of boxcar andcraterform type; nasolabial and melolabial folds;
periorbital, vermilion, and glabellar lines; foreheadwrinkles; and other defects. Patients were randomized in a double-blinded 3:1 fashion to live fibroblast
cell or placebo injections and then underwent a
postauricular skin biopsy. The skin sample was sent
to an Isolagen Technologies, Inc., laboratory where
the fibroblasts were selected, cultured, and multiplied over a several-week period using a proprietaryprocess. This yielded approximately 20 million cells
in 1 mL for injection. Injections with live fibroblasts
or placebo (the transport medium without living

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cells) were given as three doses administered at 1- to
2-week intervals. These intervals were randomized.
The injections were given using the threading technique with a 30-gauge needle, without the use of
injected or topical anesthetics. Application of cold
was permitted.
Efficacy evaluations were performed 1, 2, 4, 6, 9,
and 12 months after the first injection. The primary
efficacy end point was a 2-point shift in at least one
treated area using a standardized 7-point photoguide, as determined by the investigator during a live
assessment of the patient 4 months after beginning
treatment (Figure 1). Patients achieving this shift
were considered responders. After the 6-monthevaluation occurred, patients were unblinded totreatment. Those who received live fibroblast injections returned for evaluation at 9 and 12 months.
Placebo-treated patients were given the option ofcrossing over to active treatment (all of whom requested active treatment at our site). All fibroblasttreated patients including crossover were to be followed for a full 12 months after the first injection.
Fisher exact test was used to evaluate the primary
end point of successful response, as gauged by theinvestigator assessment, between treatment groups
and a p value of less than .05 was considered statistically significant.

Results
Of the 151 treated patients, 6 were excluded fromthe evaluable population for several reasons: receiving additional cosmetic treatments and procedures
during the study, voluntary patient withdrawal, orinvestigator withdrawal. Of the 145 total evaluable
patients, 106 were treated with live fibroblast injections, and 39 with placebo. The population was
89.7% women and 10.3% men. Mean age at thetime of the first injection was 46.7 (SD, 7 10.5)
years. Caucasians comprised 92.4% of the study
population; 4.8% of patients were Asian, 1.4% wereHispanic, and 1.4% were African-American. Treatedsites are described in Table 1.

WEISS ET AL

Figure 1. Standardized photoguides used for judging efficacy. (A) Acne scars. (B) Nasolabial lines. Patients were considered
responders if there was a 2-point shift as determined by the investigator during a live examination.

The proportion of responders was dramaticallyhigher in the Isolagen live fibroblast treatment groupthan in the placebo group throughout the controlled
study (Figure 2). At 1-month follow-up, the responder rate among fibroblast-treated patients was
54.4% versus 30.8% with placebo. At 2 months, thefibroblast responder rate increased to 77.3%,
whereas the placebo responder rate remained relatively the same at 34.3%. At 4 months, rates were
75.5% versus 34.3%, and at 6 months, 81.0% ver-sus 36.4%. The difference between live fibroblast
injections and placebo achieved statistical significance at 6 months (po.0001). The short-term
improvements seen with placebo injections were
mostly attributable to temporary subcisionlike effects induced by dissection with transport media injections. At 9- and 12-month follow-up, live
fibroblast–treated patients continued to demonstrate
benefit from treatment with response rates of 75.0
and 81.6%, respectively.

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TABLE 1. Facial Deformities Treated with at Least
One Dose of Injectable Fibroblasts
Treated sites

Number of patients

Facial scars
Nasal labial folds
Melolabial folds
Periorbital lines
Vermilion lines
Glabellar lines
Forehead wrinkles
Othery

50
95
10
9
31
11
5
24

Most patients were treated in multiple areas and are therefore

counted in multiple areas.
The ‘‘others’’ include lower corner of mouth (7 patients); chin (6patients); lip scar (5 patients); and eyes, nasal scar, cheek, temple,
trough, and spider bite (1 patient each).

y

The clinical effect of fibroblast injection was particularly pronounced among patients treated for acne
scars (Figure 3). In this subgroup, the response rate
at 6-month follow-up was 48.4%, compared with
7.7% for placebo, a statistically significant difference (po.05).
At 4-month follow-up, 87 patients with nasolabial
folds and, at 6 months, 84 patients with nasolabial
folds had visible improvement. The response rate
at the 4-month visit was 34.8% for patientstreated with live fibroblast injections versus 9.5%
for placebo. At 6 months, the rates were 42.2%
versus 10.0%, respectively. The differences at bothtime points achieved statistical significance (po.05).

90.0%
79.6%

80.0%

82.2%

77.1%

70.0%
60.0%

57.0%

50.0%
40.0%

36.1%

36.1%

38.2%

32.5%

30.0%
20.0%

Figure 3. Improvement in acne scarring following a series ofthree live fibroblast injections 2 weeks apart at 6-month follow-up. Treated areas are circled.

The safety profile of live fibroblast injections was
also favorable. The majority of the reported adverse
events were either unrelated to or unlikely to berelated to study treatment and were seen in a similar
proportion of patients in both study arms. Of theadverse events considered by an investigator to
be possibly, probably, or definitely related to live
fibroblast injections, one case of edema lasting forseveral hours at the injection site of one patient wasconsidered significant. No serious adverse events
considered related to the study treatment werereported. Routine laboratory results including
hematology and chemistry were unremarkable andshowed no abnormalities or definitive trends.

10.0%
0.0%
Month 1Month 2Month 4Month 6

Figure 2. Percentage of responders by visit for all treatmentareas. (&) Isolagen; (&) placebo.

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Conclusions
Our results indicate that autologous fibroblast injections can safely produce improvements in rhytids,

WEISS ET AL

acne scars, and other dermal defects. The injections
are made superficially in the dermis and are fordermal remodeling. This is not for deep furrows
because it is not a volume filler. The results are
consistent with those of Watson and colleagues17
who reported reductions in large rhytid and depressed facial scars of 10% to 85% as measured
by profilometry. Boss and colleagues9 reported
high rates of short- and long-term patient satisfaction with the Isolagen process (92% at 12 months
and 70% at 36–48 months), as well as continuing
correction during the entire observation period.
As in these studies, our findings are similar indicating that autologous fibroblast injection is safe andefficacious in the treatment of wrinkles and acne
scars.
Dermal fillers have been in clinical use since the late1970s. Bovine collagen was the original filler ofchoice, but dermal filler technology has greatly
improved with the addition of synthetic materials
such as hyaluronic acid derivatives.19,20 Other fillers
still commercially available are protein-based fillers
such as purified human dermal tissue and other synthetic materials such as purified polymethylmethacrylate suspended in bovine collagen.8,20–26
Although these technologies can safely and effectively
repair dermal defects, they can be associated with rare
hypersensitivity and allergic reactions, swelling,bruising, granulomatous foreign body formation,
infection, and malalignment.3,4,6,10–13,15,27–31 In
the case of some synthetic products, results may not
be evident for up to 2 years after implantation.
Results with animal-based collagen injections may
be more immediate but are transient, being measured
in weeks, because animal collagen is quickly resorbed, although reactions have been described as
lasting as long as 24 months with bovine collagen.2,8Hyaluronic acid fillers may last 6 to 12 months oreven longer but also require reinjection at regularintervals to maintain results.19
The use of autologous materials has the potential tocircumvent some of these limitations. For example,
autologous fat may obviate the risk of hypersensi-

tivity responses. Unfortunately, as is the case withbovine collagen, autologous fat is easily resorbed
and, importantly, fat must be harvested using a moreadvanced technique.17,32,33 Another processpreviously on the market utilized intact autologous
collagen fibers (Dermalogen) from a patient’s own
dermis. But due to a complicated procedure required
to extract the collagen fibers, this procedure is nolonger being performed.8,18
The Isolagen autologous cell system does not require
extensive surgical extractionFa small biopsy is
performed at a nonvisible site, typically postauricularin the fold, and the fibroblast cells cultured andmultiplied in the millions. Unused cells can be storedin liquid nitrogen for new and repeat procedures. Our
initial experience with the autologous living fibroblast
injection process indicates that it is likely capable ofproducing ongoing improvements in facial contour
defects without the hypersensitivity complications
and harvesting challenges associated with othertreatments. Numerous clinical trials are in progress tocorroborate these results and reconfirm the longevityof clinical improvement in rhytids and scars.

Acknowledgments We thank and express gratitude
to the Isolagen Study Group, which includes all the
primary investigators for this study: Suzanne Bruce,
MD, Houston, Texas; Greg Chernoff, MD, Indianapolis, Indiana; Stephen Krant, MD, La Jolla,
California; David McDaniel, MD, Virginia Beach,
Virginia; Henry Mentz, MD, Houston, Texas; Jeffrey
Popp, MD, Omaha, Nebraska; Stephen Senft, MD,
Bethlehem, Pennsylvania; Nancy Silverberg, MD,
Newport Beach, California; and Deborah Watson,
MD, San Diego, California. We thank Dr. Marie
Lindner, Isolagen Medical Director, for collecting
and organizing the data.
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Address correspondence and reprint requests to: Robert A.
Weiss, MD, 54 Scott Adam Road, Suite 301, Hunt Valley(Baltimore), MD 21030, or e-mail: rweiss@mdlsv.com.