ORIGINAL ARTICLES

Fillers and Neocollagenesis

Jean D. A. Carruthers, MD, FRCSC, FRCOphth,* J. Alastair Carruthers, MBBS, MRCP,
FRCPC,† and Shannon Humphrey, MD, FRCPC, FAAD‡

The authors have indicated no significant interest with commercial supporters.

F acial aging is a complex biological process

influenced by a combination of endogenous and
exogenous factors that lead to cumulative and
progressive changes in the skin.1 Over the last decade,
however, much has been learned about the molecular
basis of skin aging, independent of the damage
caused by the sun or other extrinsic factors, with
intriguing implications for the therapeutic and
aesthetic use of filling agents in facial rejuvenation.
Among the many approved soft-tissue fillers
available, only a few induces neocollagenesis through
inflammatory response, but recent research argues
that even temporary agents stimulate fibroplasia
through the physical act of implantation, altering the
shape of fibroblasts, which respond to mechanical
pressure within the dermal matrix.
Injectable Fillers and Neocollagenesis
The popularity of facial rejuvenation has soared over
the last decade, with a multitude of products and tech-
niques aimed at reanimating the aging face. Until
recently, only a handful of products were believed to
stimulate neocollagenesis. Liquid injectable silicone
induces neocollagenesis through fibroplasia in addition
to direct volume restoration. Injection causes a localized
inflammatory reaction, with fibroblasts encapsulating
the silicone with thin-walled collagen, theoretically
anchoring the droplet in place and preventing migra-
tion.2 Calcium hydroxylapatite (CaHA) microspheres
comprise smooth particles suspended in an aqueous
carboxymethylcellulose gel carrier that is eventually
absorbed. The microspheres induce histiocytic and
fibroblastic response, acting as a scaffold for new tissue
formation and stimulating collagen formation around
the implant, leading to a thickening of the dermis over
time.3 Calcium hydroxylapatite lasts for about a year
before the particles are degraded as calcium and
phosphate and eliminated through the renal system.
Poly-L-lactic acid is a biocompatible and biodegradable
synthetic polymer from the alpha-hydroxy acid family.
Injection into the skin results in an immediate but
temporary response that lasts about a week, after
which the carrier solution is absorbed and a delayed
but progressive volumizing effect begins; the remaining
crystals stimulate the production of new collagen. This
inflammatory response elicits production and the
formation of fibrous connective tissue around the
implant, causing fibroplasia and a gradual increase in
dermal volume that may take 3 to 6 months to develop
and lasts for up to 2 years or longer.4
Cross-linked hyaluronic acid (HA) derivatives, now
the commonest type of filler used, have replaced
injectable collagen as temporary fillers of choice.
Hyaluronic acid was previously presumed to add
volume through hydration and space-filling properties
alone. Hyaluronic acid occurs naturally in the skin,

*Cosmetic Surgery Inc; Department of Ophthalmology, University of British Columbia, Vancouver, Canada;
†
Department of Dermatology, University of British Columbia; Carruthers Dermatology Center, Vancouver, Canada;
‡
Department of Dermatology, University of British Columbia, Vancouver, Canada

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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins
ISSN: 1076-0512 Dermatol Surg 2014;40:S134–S136 DOI: 10.1097/DSS.0000000000000227
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 CARRUTHERS ET AL

making up a significant portion of the extracellular enhancing the structural support of the ECM with
matrix (ECM) involved in tissue repair, along with a space-filling injectable material and compared skin
collagen and elastin, stabilizing intercellular structures biopsies from the forearms of individuals injected
and contributing to cell proliferation and migration.1,5 with either cross-linked HA or isotonic sodium
When injected, HA joins the body’s own HA and chloride. The fibroblasts surrounding the sites of
attracts and binds to water, adding volume for up to injection had a distinct elongated mechanically
a year. However, exciting new research suggests that stretched appearance, and immunohistology revealed
HA also induces neocollagenesis through changes in the high levels of Type I procollagen (the precursor to
structure and function of the ECM. mature Type I collagen). Increased collagen pro-
duction was observed 1 month after injection and
Collagen Deficit in Aged Skin remained elevated for at least 3 months. The authors
concluded that injection of HA induces mechanical
In the dermis, the ECM is primarily composed of the
stretching of the dermis, which in turn activates
most abundant protein in human skin—Type I
dermal fibroblasts and the production of collagen.
collagen—among other proteins, proteoglycans, and
These results are echoed by Turlier and colleagues10
glycosaminoglycans, all produced by fibroblasts.
who conducted biopsies of skin injected with HA and
Type I collagen fibrils confer strength and resilience to
found an increase in procollagen levels for at least 3
the skin through a three-dimensional network
months after treatment compared with control.
throughout the dermis, and it is the organization and
maintenance of this structure that is a primary
In a detailed analysis of aging human skin after injection
determinant of age-related changes.6 In healthy
of filler, Quan and colleagues8 injected saline or HA into
young skin, fibroblasts bind to the collagen fibrils
the buttock skin of individuals older than 70 years and
they produce, along with the other proteins in the
obtained biopsies at 1, 2, 4, and 12 weeks. Immuno-
ECM, generating a dynamic mechanical tension
histochemistry revealed intense staining within the ECM
that regulates cellular morphology and function.
and dermal fibroblasts, particularly adjacent to pockets
Increased tension stretches fibroblasts, prompting the
of injected filler. Fibroblasts tended to align around said
production of more collagen and down-regulation
pockets and exhibited an enlarged elongated appear-
of matrix metalloproteinases (MMPs), which are
ance, indicating increased mechanical force and struc-
responsible for the slow degradation of Type I collagen.
tural support within the dermal ECM. The amount of
immunostaining increased 6-fold at 4 weeks and
Over time, collagen fibrils undergo a degenerative
remained elevated for at least 3 months. Laser capture
process that compromises the structure and function
microscopy of the elongated fibroblasts demonstrated
of the fibroblasts, leading to decreased collagen
a 12-fold induction of Type I procollagen gene expres-
production, and ultimately, the wrinkled fragile
sion and up-regulation of the TGF-b pathway, which is
appearance of aged skin.6–8 Enzymatic degradation of
influenced by mechanical force and pivotal to fibroblast
collagen occurs slowly over the course of about 30
function and collagen production. Additional investi-
years and is exacerbated by the gradual accumulation
gation showed organized dense bundles of collagen
of cross-linked collagen fragments within the ECM.
fibrils in areas adjacent to the injected filler, compared
This fragmentation, itself accelerated by extrinsic fac-
with the disorganized and fragmented appearance of the
tors such as UV and infrared radiation and pollution,
fibrils in skin injected with saline. Epidermal thickness
compromises the structural and mechanical integrity of
appeared greater with enhanced epithelial cell pro-
the ECM.6 Fibroblasts collapse within the dermis,
liferation and an increased prominence of blood vessels.
collagen production slows, and MMPs step up the pace.

Hyaluronic Acid and Neocollagenesis Conclusion

Wang and colleagues9 hypothesized that fibroblast A clearer understanding of the molecular process of
function in naturally aged skin could be stimulated by aging and the effects of both intrinsic and extrinsic

40:12S:DECEMBER SUPPLEMENT 2014 S135

Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
 FILLERS AND NEOCOLLAGENESIS
factors on the skin has led to the recognition that
collagen deficit derives primarily from a decrease in
mechanical pressure in the ECM. Although several fill-
ing agents induce neocollagenesis through inflammatory
granulomatous reactions, recent studies have shown
that collagen production after injection of HA occurs
through enhanced structural support within the dermal
ECM, which induces fibroblast elongation and activa-
tion and initiates the synthesis and deposition of Type I
collagen. These findings provide exciting opportunities
for future use, particularly for the therapeutic stimula-
tion of collagen in aging facial and corporal human skin.
References
1. Ganceviciene R, Liakou AI, Theodoridis A, Makrantonaki E, et al. Skin
anti-aging strategies. Dermatoendocrinol 2012;4:308–19.
2. Jones DH, Brody HJ. Liquid injectable silicone. In: Carruthers J,
Carruthers A, Dover JS, Alam M, editors. Procedures in cosmetic
dermatology: soft tissue augmentation. New York: Saunders Elsevier;
2013; pp. 62–69.
3. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for
facial rejuvenation: a histologic and immunohistochemical analysis.
Dermatol Surg 2008;34(Suppl 1):S64–7.
4. Lacombe V. Sculptra: a stimulatory filler. Facial Plast Surg 2009;25:95–9.
S136 DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
5. Monheit GD, Narins RS, Mariwalla K. NASHA family. In: Carruthers J,
Carruthers A, Dover JS, Alam M, editors. Procedures in cosmetic
dermatology: soft tissue augmentation. New York: Elsevier; 2013; pp.
10–22.
6. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast collapse and
therapeutic implications. Arch Dermatol 2008;144:666–72.
7. Varani J, Dame MK, Rittie L, Fligiel SE, et al. Decreased collagen
production in chronologically aged skin: roles of age-dependent
alteration in fibroblast function and defective mechanical stimulation.
Am J Pathol 2006;168:1861–8.
8. Quan T, Wang F, Shao Y, Rittié L, et al. Enhancing structural support of
the dermal microenvironment activates fibroblasts, endothelial cells, and
keratinocytes in aged human skin in vivo. J Invest Dermatol 2013;133:
658–67.
9. Wang F, Garza LA, Kang S, Varani J, et al. In vivo stimulation of a de
novo collagen production caused by cross-linked hyaluronic acid dermal
filler injections in photodamaged human skin. Arch Dermatol 2007;143:
155–63.
10. Turlier V, Delalleau A, Casas C, Rouquier A, et al. Association
between collagen production and mechanical stretching in dermal
extracellular matrix: in vivo effect of cross-linked hyaluronic acid
filler. A randomised, placebo-controlled study. J Dermatol Sci 2013;69:
187–94.
Address correspondence and reprint requests to: Jean D. A.
Carruthers, MD, FRCSC, FRCOphth, Jean Carruthers
Cosmetic Surgery Inc, 943 West Broadway, Suite 820,
Vancouver, BC V5Z4E1, Canada, or e-mail:
drjean@carruthers.net