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Vascular Occlusion Associated With Needles vs Cannulas for Filler Injection
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Three hundred seventy board–certified dermatologists with over 7000 person-years of experience reported injecting a total of 1.7 million syringes of filler over the previous 10 years. At least 1 vascular occlusive episode was reported by almost a third of participating dermatologists. There were reduced odds of vascular occlusion with poly-L-lactic acid compared with hyaluronic acid filler, which was thought to possibly be due to the lower viscosity of this compound and its biostimulatory (rather than direct space–filling) mechanism. Almost half of the occlusions with hyaluronic acid fillers occurred in the nasolabial fold and lip locations.
- This study demonstrates the odds of vascular occlusion to be 77.1% lower with the use of cannulas compared with needles, with an incidence of 1 occlusion per 6410 needle injections and 1 occlusion per 40,882 cannula injections. Injection experience greater than 5 years was associated with >70% lower odds of vascular occlusion compared with less experience.
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Soft-tissue augmentation with skin fillers can be delivered with needles or microcannulas, but unwanted vascular occlusions are possible.
Objective
To determine whether filler-associated vascular occlusion events of the face occur more often with injections performed with needles than with microcannulas.
Design, Setting, and Participants
This retrospective cohort study included a random sample of board-certified dermatologists deemed eligible based on membership in relevant professional societies and attendance at relevant national professional meetings. Participants completed detailed forms in which they could enter deidentified data and volume statistics pertaining to patients undergoing filler procedures in their practices. Data were collected from August 2018 to August 2019.
Exposures
Injectable fillers approved by the US Food and Drug Administration delivered via needles or microcannulas.
Main Outcomes and Measures
The primary outcome measure was intravascular occlusion. Occlusion events were graded by severity (no sequelae, scar, and ocular injury or blindness).
Results
A total of 370 dermatologists (mean [SD] years in practice, 22.3 [11.1] years) participated and reported 1.7 million syringes injected. The risk of occlusion with any particular filler type using needle or cannula never exceeded 1 per 5000 syringes injected. Overall, 1 occlusion per 6410 per 1-mL syringe injections was observed with needles and 1 per 40 882 with cannulas (P < .001). Of the 370 participants, 106 (28.6%) reported at least 1 occlusion. Multivariate analysis found that injections with cannula had 77.1% lower odds of occlusion compared with needle injections. Participants injecting fillers for more than 5 years had 70.7% lower odds of occlusion than those who were less experienced. For each additional injection per week, the odds of occlusion decreased by 1%, and 85% of occlusions had no long-term sequelae. Nasolabial folds and lips were most likely to be occluded, with mean severity level of occlusions highest at the glabella.
Conclusions and Relevance
In this cohort study, filler injections with either needles or cannulas were associated with a very low risk of intravascular occlusion events. Moreover, the vast majority of such events were minor and resolved without scar or other injury. Injections with microcannulas were less often associated with occlusion events than injections with needles. Occlusion risk per syringe appeared decreased after the first few years of clinical practice and was also lower among those who more frequently inject fillers. Whether a needle or cannula is most appropriate for injection may depend on patient factors, anatomic site, and the type of defect being treated.
Additional Info
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Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection
JAMA Dermatol 2020 Dec 30;[EPub Ahead of Print], M Alam, R Kakar, JS Dover, V Harikumar, BY Kang, HT Wan, E Poon, DH JonesFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Dermatology
This nice retrospective cohort study by a group of our colleagues across the United States evaluated the risk of intravascular occlusion events during the injection of FDA-approved fillers injected with needles or microcannulas by board-certified dermatologists. The aim was to characterize the rate of intravascular occlusion events and the associated characteristics of the events.
The data were from 370 US dermatologists with injections over a 1-year period. Overall, the risk of occlusion with any filler or needle or microcannula never exceeded 1 in 5000 syringes injected. There was a significant difference in events between needles (1 in 6410) and microcannulas (1 in 40,822), which represents a 77.1% lower odds of occlusion with microcannula. Overall, those with more than 5 years of experience injecting had a 70.7% lower odds of occlusion than those less experienced. Fortunately, 85% of occlusions had no long-term sequelae.
The areas more likely to suffer an occlusive event were the lips and nasolabial folds, but the area with the most severe outcomes was the glabella.
These data are consistent with our experience in practice. Certainly, with experience, the risk of occlusion does decrease; however, it is still advisable to be extremely cautious when injecting with either needles or cannulas, and carefully observe the tissue and watch and listen to the patient for signs of occlusion or reports of pain or visual changes. The first step is recognizing the occlusive event and stopping the injection.
Although microcannulas do pose a smaller risk of occlusion than needles, the injector must choose what is best for the patient based upon individual factors. Some indications and areas are more amenable to needle injections. Much of injection technique is an art, and many precautions (such as keeping the tip of the needle moving and slow injections with low injection pressure) can further lower the risks. Injectors should continue to seek education on the latest techniques and safety measures as injecting safely is a learnable skill. However, even in the best trained hands, occlusion can occur and must be recognized and managed properly.