Aspiration Before Tissue Filler—An Exercise in Futility and Unsafe Practice

Goodman, Greg; Magnusson, Mark; Callan, Peter; Roberts, Stefania; Hart, Sarah; Lin, Frank; Rahman, Eqram; McDonald, Cara B; Liew, Steven; Porter, C. B.; Corduff, Niamh; Clague, Michael

doi:10.1093/asj/sjab036

Cited by 27 publications

(13 citation statements)

References 40 publications

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“…Although the real-time clinical utility of pre-injection aspiration is controversial, [74][75][76][77][78][79][80] all injectors are ultimately aligned in avoidance of intravascular incidents. No single method guarantees safety, despite individual preference for aspiration or constant needle movement, thus the following should be borne in mind.…”

Section: The Aspiration Controversymentioning

confidence: 99%

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments

Heydenrych

Boulle

Kapoor³

et al. 2021

CCID

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Dermal filler treatments require constant reassessment for improving and safeguarding the rapidly evolving aesthetic field. Suboptimal injection technique, patient selection and product knowledge have touted a concerning increase in filler complications, with new challenges such as the COVID-19 pandemic leading to new paradigms in the understanding, prevention, diagnosis and treatment of complications. The updated 10-point plan has been developed to curtail complications through consideration of causative factors, categorized as patient, product, and procedure-related. Patient-related factors include a preprocedural consultation with careful elucidation of skin conditions (acne, rosacea, dermatitis), systemic disease (allergies, autoimmune disease, underlying bacterial and viral disease (herpes simplex virus, COVID-19 infection), medications (antineoplastic drugs, recreational drugs) and previous cosmetic procedures (including fillers and energy-based devices). Patient assessment should include standardized photography and also evaluate the role of social media, ethnicity, gender, generational, and LGBTQ+ needs. Specified informed consent for both adverse events and their treatment is essential due to the increase in vascular complications, including the risk of blindness. Product-related factors include the powerful advantage of reversibility when using hyaluronic acid (HA) products. Product characteristics such as molecular weight and filler degradation should be understood. Product layering over late or minimally degradable fillers is still inadvisable due to the initial filler being teased into reactivity. Procedural factors such as consistent photographic documentation, procedural planning, aseptic non-touch technique (ANTT), knowledge of topographical anatomy and angiosomes, and technical dexterity including pinch anatomy and needle skills are of pivotal importance. The final section is dedicated to algorithms and checklists for managing and treating complications such as allergic hypersensitivity reactions, vascular events, infection, edema and late-onset adverse events (LOAEs). The updated 10-point plan is a methodical strategy aimed at further minimising the risk of dermal filler complications.

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Section: The Aspiration Controversymentioning

confidence: 99%

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments

Heydenrych

Boulle

Kapoor³

et al. 2021

CCID

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“…While anecdotally, the practice is common in many areas of medicine, such as in anesthesia, its validity in aesthetic practice relating to filler injection is being increasingly challenged. [1][2][3][4][5][6][7] One of the key pillars that underpin the validity of aspiration is the premise that once the needle tip has been placed in the desired injection area, it cannot move again. In other words, for the result of the aspiration to be meaningful, it requires the injector to hold the needle tip completely still during the aspiration maneuver (the pull phase), and the subsequent injection (push phase).…”

Section: Resultsmentioning

confidence: 99%

Movement of the Syringe During Filler Aspiration: An Ultrasound Study

Lin

Goodman

Magnusson

et al. 2022

Aesthetic Surgery Journal

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Background Aspiration prior to hyaluronic acid filler injection is often taught as a safety maneuver to minimize the risk of intravascular injection; however, the validity of this technique in aesthetic practice is being increasingly challenged. One key assumption underpinning the validity of the aspiration test is that the needle tip does not move during the aspiration and subsequent injection of filler. Objectives The aim of this study was to visualize and measure needle tip movement in real time during aspiration and injection of filler. Secondary objectives were to assess the impact of injector experience and double-handed versus single-handed aspiration technique in maintaining stability of the syringe. Methods Under real-time ultrasound visualization, 3 injectors with different levels of experience injected hyaluronic acid filler into pork belly tissue utilizing both double-handed and single-handed aspiration techniques. Needle tip movements were recorded and measured by means of ultrasound and video. Results The aspiration maneuver is in all cases associated with retrograde movement of the needle tip, ranging from 1.1 to 5.3 mm (mean, 2.9 mm), whereas injection leads to anterograde movement ranging from 0.6 to 4.1 mm (mean, 1.9 mm). Double-handed aspiration is associated with less needle tip movement than single-handed aspiration (P = 0.037). Greater experience is also associated less movement of the needle tip (P < 0.0001). Conclusions In all cases, the aspiration and injecting maneuver is associated with micromovements of the needle tip, of a magnitude consistently significant relative to the typical size of facial vessels. Although needle tip movement is only a single factor limiting the usefulness of the aspiration test, the results of this study suggest that it is not advisable to rely only on aspiration as a method to prevent intravascular injection.

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“…Although a positive aspiration may equate with a higher likelihood of intravascular placement, the unsteady movements transmitted to the tip during aspiration may arguably negate any preventative value from this maneuver beyond that of false reassurance. Furthermore, the routine use of a stationary injection technique, itself necessitated by the practice of aspiration, mandates the bolus-based placement of filler that could magnify the potential degree of injury [ 135 ]. In addition, filler-primed needle hubs, which characterize the majority of injections, carry a high incidence of false-negative aspirations, creating a misleading perception of safety [ 136 ].…”

Section: Pathophysiology Of Ha-mediated Vascular Occlusionmentioning

confidence: 99%

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

Soares

2022

Molecules

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Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.

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Aspiration Before Tissue Filler—An Exercise in Futility and Unsafe Practice

Cited by 27 publications

References 40 publications

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments

Movement of the Syringe During Filler Aspiration: An Ultrasound Study

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

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