The first case of soft tissue augmentation was performed on a patient who had cutaneous tuberculosis in the late nineteenth century. The condition caused destruction of the soft tissues of his face. At that time, the surgeon used the patient’s body fat as the filler of choice. Fat was transferred from the abdomen to the face. While the patient did not survive the procedure, this spoke on many levels the importance of soft tissue augmentation as a method to enhance facial aesthetics. To this day, fat is still considered to be a popular natural filler in the plastic surgery world and advances in its transfer and injection still continue. It is readily preferred over the synthetic materials when injecting the body or other larger areas. Its use in the face has waned, however, with the rise of synthetic fillers.

Given that fat was such an unpredictable filler in the process of soft tissue augmentation, as it was a comprised of viable biologically active cellular components, it was important to find an alternative synthetic form that was readily available and much more stable when it came to injecting. This paved the way for silicone and paraffin to be used. These material gained wide popularity in the mid-1900s. The essence of the procedure became popular, though it was soon realized that these permanent fillers, though at first were inert, have begun to cause long-standing inflammatory reactions.

The use of collagen began in the early 1980s with the introduction of bovine collagen in the market. This was revolutiuonary at the time as these fillers were biologically based albeit being xenografts. The materials were tested for immunogenicity initially and when a reaction failed to occur, the procedure was performed 2 weeks after. It became popular with the main area of injection being the nasolabial fold . That area, along with collagen based fillers, became the gold standard where all subsequent fillers were compared.

Collagen synthesized from human cadavers followed suit and negated the need to perform an immunologic testing of the material. While these fillers did their job very well and the results were generally accepted, they did not last long. This created a need for repeated injections on a rate of every 2–3 months. This process was not something that was attractive to patients who would need to undergo this on a regular basis, especially with those who are needle averse.

For a filler to be accepted for use on a massive scale, the material should be of lower immunogenicity, relatively long-standing and may be reversible if needed. It wasn’t until 1996 that such a filler utilizing hyaluronic acid (HA) from a non-animal source became approved. The first use of HA was a few years earlier when the material was cultivated from rooster combs. The filler was made up of essentially a polysaccharide that comprised the ground substance of the extracellular matrix of tissues. It was a ubiquitous material that was found in nearly all living organisms. In addition, given that it was synthesized from a non-animal source, HA caused the least immunogenicity of all. Twenty years later and although with many other fillers, the so-called collagen stimulating, named because of their ability to produce a controlled inflammatory response, hyaluronic acid remains the benchmark amongst which all other fillers are compared to.