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History of Dermal and Subdermal Injectable Fillers Before Collagen: The Early Years


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: Dermal fillers are a mainstay of aesthetic medicine. Currently, the most common ingredient in fillers in hyaluronic acid (HA). However, there was an evolution of products that brought us to where we are today. We review the fillers from fat to synthetic fillers in this review paper. We present notable figures in history who used such fillers and key legislation on the use of such fillers. The early evolution of the use of volumization has been reviewed. This is an important milestone in the history of fillers that is rather brief in the present literature.
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J Skin Stem Cell. 2020 March; 7(1):e104559.
Published online 2020 June 10.
doi: 10.5812/jssc.104559.
Review Article
History of Dermal and Subdermal Injectable Fillers Before Collagen:
The Early Years
Omeed Memar 1, *
1Academic Dermatology and Skin Cancer Institute, Chicago, USA
*Corresponding author: Academic Dermatology and Skin Cancer Institute, Chicago, USA. Email:
Received 2020 May 05; Revised 2020 May 28; Accepted 2020 June 05.
Dermal fillers are a mainstay of aesthetic medicine. Currently, the most common ingredient in fillers in hyaluronic acid (HA). How-
ever, there was an evolution of products that brought us to where we are today. We review the fillers from fat to synthetic fillers in
this review paper. We present notable figures in history who used such fillers and key legislation on the use of such fillers. The early
evolution of the use of volumization has been reviewed. This is an important milestone in the history of fillers that is rather brief
in the present literature.
Keywords: Fat Transfer, Silicone Injection, Paraffinoma
1. Context
This review aims to cover the data on soft tissue volu-
mizers before the advent of collagen.
2. Introduction, Discussion and Conclusion
Soft tissue augmentation dates back to the 19th cen-
tury, when Neuber (1) excised fat lobules from the arm
for facial scar, and concluded that larger grafts were less
predictable than smaller ones. Czerny (2) used fat from
a lipoma to introduce for breast reconstruction in 1895.
Lexer (3) studied fat survivability, and concluded that ex-
cised fat grafts should be handled with care in both ex-
cision and implantation in order to achieve good results.
By 1890s, the hypodermic syringe was being developed in
glass and silver (Figure 1) (4,5).
Lexer (6) presented successful volumization of the face
and breasts. By 1911, the hypodermic needle/syringe was
use to inject particles of excised fat for post-rhinoplasty ir-
regularities, with excellent results in the short term, and
significant subsequent resorption (7). In 1912, the first pho-
tographic evidence of fat transplantation using a hypoder-
mic needle/syringe for facial lipoatrophy was published
(8). In 1923, the first histologic evidence of transplanted
fat that had engrafted was published, and therefore, fat
was not just a mass that would be converted to scar tis-
sue, but a true live tissue transplantation (9). In 1926, the
term cannula was introduced in the realm of fat transplan-
tation, when Miller (10) presented his technique of face
and neck scar correction with injection of fat through a
cannula. In 1931, facial lipoatrophy was treated success-
fully with fat grafting (11). Next, breast reconstruction with
fat grafting was reported in 1941, with one breast receiv-
ing a large fat graft and another receiving a combination
fat/fascia graft, with the fat/fascia graft having better vol-
ume retention (12). In 1950, Peer predicted that his tech-
nique yielded a 50% survivability of fat grafts (13). He ex-
amined histologic samples of transplanted fat to develop
the “cell survival theory,” concluding that fat viability was
correlated to graft volume (14).
In 1951, Gray et al. (15) performed dermis/fat grafts,
and reported complications, including cyst formation. In
1969, Sawhney et al. (16) reported animal studies of der-
mis/fat grafts done on pigs. Fat/dermis grafts measuring
1.5 ×1.5 cm were transplanted with dermis side down. At
one week, the grafts had a reduction of volume by 6.7%;
2 weeks, a 9% reduction of volume; 3 weeks a 20% reduc-
tion of volume; 4 weeks, a 33.3% reduction of volume vis-
a-vie the original transplant. All the fat was replaced with
fibrous tissue, yet the volume was maintained in the 4-
week study. Ben-Hur and Neuman (17) determined that ep-
ithelial cells were causing cysts and hence the cyst forma-
tions reported by Gray et al. were most likely due to inad-
equate de-epithelialization (18). The game changes came
in 1975, when a father/son gynecologist team changed the
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Memar O
Figure 1. Hypodermic needle: patent drawing of the device designed by Mitchell
and Gillespie, 1896.
way fat was harvested, and set in motion a technique that is
ever more popular today (17). The Fischer (18) used a blunt
metallic suction cannula and invented modern-day lipo-
suction. This allowed procurement of abundant viable fat
cells (19).
Concurrently, petroleum was discovered, from which
came mineral oil. Refined mineral oil produced liquid
paraffin. Gersuny (20) published the first medical use of
paraffin with a hypodermic needle/syringe in 1900 for cre-
ation of a testicular prosthesis in a man who had a bilateral
orchiectomy due to tuberculosis. From 1899 to 1914, paraf-
fin was used for breast augmentation. The Derma Featu-
ral Company, incorporated in England, was focused on cos-
metic surgery, and a court case in 1908 describes the use of
hot paraffin injected into the nasal skin and molded to the
desired shape. Derma Featural’s largest account was a der-
matologist named John Humphrey Woodbury (Figure 2) in
New York, NY, who had established cosmetic surgery cen-
ters in New York, Boston, Philadelphia, Chicago, St. Louis,
and Washington, DC. However, he got tied up with many
law suits and committed suicide in 1909 (21). The most no-
table victim of paraffin injection was the beautiful Gladys
Marie Spencer-Churchill, Duchess of Marlborough (Figure
3). She tried to even a small nasal tip asymmetry with paraf-
fin and had some injected into her jaw. The procedure
caused major deformities to the point that she became a
recluse. She died at the age of 96 in 1977 (22). By 1912, com-
plications of paraffin injection were reported, including,
draining persistent fistulas, pulmonary embolism, ulcera-
tion, necrosis, breast amputation, and death (23,24).
Figure 2. John Humphrey Woodbury
Paraffin complications opened the door to a new
comer, “Cleopatra’s needle” (25), where liquid silicone was
used for breast augmentation. Liquid silicone was devel-
oped and used during world war II as insulation for elec-
trical transformers (26). This began in Japan, where stolen
Army stocks of industrial silicone were being injected into
the breasts of local prostitutes, creating a more Western
appearing contour. Dr. James Brown applied silicone to
2 J Skin Stem Cell. 2020; 7(1):e104559.
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Memar O
Figure 3. Portrait of Gladys Marie Spencer Churchill, Duchess of Marlborough; the
most notable victim of paraffinoma syndrome
soft tissue supplementation in 1947 (27). He further studied
the safety and complications, concluding that silicone is
biocompatible and a safe tissue enhancer (28). Dow Corn-
ing introduced a liquid silicone called MDX4-4011, which
was FDA approved for coating syringes, but started being
used in an unregulated manner for soft tissue augmenta-
tion. In 1964, Carol Doda became the face of silicone in-
jections, as she flaunted her breasts in topless burlesques.
(Figure 4). Some even mixed different oils, including olive
oil and paraffin to the silicone oil to develop their individ-
ualized mixtures (29). However, many complications be-
gan being reported (30), including granulomas, product
migration (31), granulomatous hepatitis, and death (32).
In 1975, Nevada became the first state to outlaw the use
of injectable silicones. Currently, only two liquid forms
of silicone are FDA approved, and only for intra-ocular in-
jection to treat retinal detachment (33). Many have used
medical grade silicone off-label for soft-tissue augmenta-
tion and by using the droplet-technique. This technique
induced fewer complications. However, the illegal use of
non-medical grade liquid silicones in the hands of non-
medical or ill trained individuals has skyrocketed and re-
sulted in multiple deaths (34). The hunt for the ideal filler
was now hotter than ever, since a market had been devel-
oped, which demanded easy and affordable soft-tissue vo-
lumization. Collagen and a slew of other fillers followed,
but the ideal filler is still quite elusive.
Figure 4. Ticket to a show by Carol Doda
Authors’ Contribution: The author contributed all the
work in this manuscript.
Conflict of Interests: There are no conflicts of interest for
the author.
Funding/Support: No funding was needed for this work.
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4 J Skin Stem Cell. 2020; 7(1):e104559.
ResearchGate has not been able to resolve any citations for this publication.
John H. Woodbury was an incredibly entrepreneurial, self-trained dermatologist who, between 1870 and 1909, built an empire of cosmetic surgery institutes in 6 states, with 25 physician/surgeon employees and an advertising budget of $150,000/year (1892 data). Under his management, his surgeons, and perhaps Woodbury himself, performed multiple facial cosmetic surgeries, including early versions of browlifts, frown excisions, lower facelifts, mid-face lifts, rhinoplasties, double-chin reductions, and dimple creation. In addition, Woodbury developed a proprietary soap and cosmetic line, which he sold to Jergens for $212,500 in 1901 (retaining a 10% royalty). Woodbury's story has been unknown until now because this nonacademic concentrated his publishing in articles and advertisements in lay magazines. Woodbury's life ended in bankruptcy, litigation, and suicide when the corporate practice of medicine and advertising were made illegal. In his legal proceedings, Woodbury conceded that he was not a doctor, although he went by the title. Regardless, his surgical innovations are of major historical significance, as these cosmetic procedures are the first of their kind to be noted in the lay or academic press and predate, by years and even decades, the previously earliest known cosmetic surgeries in the United States. © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission:
Three cases of siliconomas, two developing in the breast and one in the skin of the face, are reported. All occurred several months after liquid silicone injections for cosmetic and prosthetic purposes. Histopathological evidence is presented to show these reactions to be typical of a foreign body granuloma. Utilizing the polarized microscope the location of the crystals in tissue was determined and compared with similar preparations in the ape. One of the cases is presented with mammographic evidence of the silicone in the breast tissue. The evidence in respect to incidence and types of reactivity following silicone injections will not be known for many years. Because of this, the indiscriminate use of silicones should be avoided.
Four patients who had received silicone injections had the following complications: migration, hepatic disease manifested as granulomatous hepatitis (previously undescribed, to our knowledge), hypopigmentation, and death. Silicone should now be considered as a possible cause of hepatic granulomas in an appropriate host. (JAMA 234:308-309, 1975)
The use of liquid injectable silicone for soft tissue augmentation is controversial. Proponents of its use consider it safe when highly purified medical-grade product is employed appropriately by well-trained and experienced physicians, whereas opponents believe complications from silicone injections are inherently inevitable and unpredictable and that they outweigh the benefits. One of the feared complications is granuloma formation. In this article, the authors report two cases of granulomatous nodules from silicone injections and present the histological features. These cases highlight the need for continued vigilance among clinicians about this complication and the importance not only of careful selection of filler products, but also of patients knowing the credentials of their injection practitioners.