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Cosmetic Medicine

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Aesthetic Surgery Journal
2020, 1–9
Descriptive Analysis of 213 Positive Blood © 2020 The Aesthetic Society.
Reprints and permission:
Aspiration Cases When Injecting Facial Soft journals.permissions@oup.com
DOI: 10.1093/asj/sjaa075
Tissue Fillers www.aestheticsurgeryjournal.com

Fang Wen Tseng, MD; Kanthi Bommareddy, BSc; Konstantin Frank,

MD; Claudio DeLorenzi, MD; Jeremy B. Green, MD; Neil Sadick, MD;
Rebecca Fitzgerald, MD; Emy C. Onishi, MD; Arthur Swift, MD; and
Sebastian Cotofana, MD, PhD

Abstract
Background:  Pre-injection aspiration procedures could increase safety during soft tissue filler injections. However, various
influencing factors have been detected in vitro that could result in false negative aspiration results.
Objective:  A case series was retrospectively investigated to identify factors contributing to positive blood aspiration pro-
cedures in vivo.
Methods:  This study evaluated 213 clinical cases positive for blood aspiration documented in an Asian population: 208
females (43.8 ± 7.2 years old) and 5 males (46.8 ± 7.8 years old) during soft tissue filler injections. Injection location, layer
(depth) of injection, product injected, size of utilized needle (gauge), length of needle (inch), priming of needle (yes/no),
injection angle (degree), and time until blood was visible in the needle hub (seconds) were evaluated.
Results:  The most frequent location where a positive aspiration was observed was the pyriform fossa (n = 56; 26.3%),
the most frequent plane was the supra-periosteal plane (n = 195; 91.5%), and the most frequent needle utilized was a 27G
needle (n = 125; 58.7%). Statistically significantly more positive cases were identified when the needle was primed com-
pared with an unprimed needle (P < 0.001, which was independent of the product). The estimated incidence rate was
0.04% to 0.9% for having positive aspiration procedures per total performed injection procedures.
Conclusions:  Pre-injection aspiration could be a valuable tool to prevent accidental intravascular injection of soft tissue
filler. The results of the present investigation show that aspiration can be performed with an acceptable aspiration time,
that is, less than 2 seconds, if a suitable product/needle combination is chosen.

Level of Evidence: 4 

Editorial Decision date: March 17, 2020; online publish-ahead-of-print June 6, 2020.

Dr Tseng is a physician in private practice in Taipei, Taiwan. Mr
Bommareddy is a Medical Student, Division of Anatomy, Department
of Medical Education, Albany Medical College, Albany, NY. Dr Frank
is a Resident, Department for Hand, Plastic, and Aesthetic Surgery,
Ludwig – Maximilians University, Munich, Germany. Dr DeLorenzi is
a plastic surgeon in private practice in Toronto, Canada. Dr Green
is a dermatologist in private practice, Coral Gables, FL. Dr Sadick
is a Physician, Department of Dermatology, Weill Cornell Medical
College, New York, NY. Dr Fitzgerald is a Physician, Division of
Dermatology, University of California Los Angeles (UCLA), Los
Angeles, CA. Dr Onishi is a physician in private practice in Manila,
Philippines. Dr Swift is a physician in private practice, Montreal,
Canada. Dr Cotofana is an Associate Professor, Department of
Clinical Anatomy, Mayo Clinic College of Medicine and Science,
Rochester, MN.
Corresponding Author:
Dr Sebastian Cotofana, Department of Clinical Anatomy, Mayo Clinic
College of Medicine and Science, Mayo Clinic, Stabile Building 9–38,
200 First Street, Rochester, MN 55905, USA.
E-mail: cotofana.sebastian@mayo.edu; Instagram:
@professorsebastiancotofana
2
According to the annual statistical report released by The
Aesthetic Society, a total of 810,240 soft tissue filler in-
jections were performed in 2018 in the United States.1
Concomitantly, the number of reported adverse events,
of which tissue loss and intravascular related visual com-
promises are considered to be the most catastrophic,
increased by 130% between 2015 and 2019.2,3 The cur-
rent accepted pathophysiological mechanism behind in-
travascular related visual compromises is the inadvertent
injection of filler material into the arterial vascular circu-
lation with subsequent transportation to the ophthalmic
artery vascular territory. There, either the central retinal
artery itself or the multiple posterior ciliary arteries can be
embolized by the filler material, resulting in occlusion and
subsequent ischemia of the retina.4
Safety recommendations include low-pressure injec-
tions,5 utilization of a small bolus per pass,6 utilization (if
possible) of larger sized cannulas (22 gauge),5,7,8 the se-
lection of safer injection planes,9 and the implementation
of a pre-injection aspiration procedure.10 The latter, how-
ever, is to date not universally accepted as mandatory in
all facial areas due to the potential for false negative re-
sults. A false negative result would be defined as a nega-
tive aspiration occurring despite intravascular location of
the needle tip. This effect could be due to collapse of the
arterial wall by the applied negative pressure during the
aspiration process11 or by a through and through phenom-
enon,10 where the needle tip is located intramurally or by
an impaired combination of filler viscosity and needle
characteristics (size and length). The latter false negative
aspiration scenario could result from the filler material
being too viscous to allow retrograde migration and thus
aspiration of blood in a needle with a small diameter and/
or increased length.
Previous studies investigated in vitro factors that could
influence the outcome of performed aspiration proced-
ures, which included the viscoelastic properties of the
product,11-13 the plunger withdrawal time,12 the priming
of the needle,11 and the pullback volume.13 However, all
these studies were conducted in a laboratory setting,
which had obvious shortcomings when equated to real-
life conditions.
We present a retrospective study summarizing data
collected from 213 positive aspirations obtained in true
clinical settings over a period of 4 years. The analysis of
this largest-to-date case series will hopefully increase
the understanding of the role of positive blood aspir-
ations and reduce the incidence of adverse vascular
events and ultimately increase patient safety during soft
tissue filler injections. Although no predictive statistical
inferences can be generated, descriptive data still have
practical value.
Aesthetic Surgery Journal
METHODS
Study Sample
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This study is a retrospective analysis of 213 positive blood
aspiration procedures obtained during facial soft tissue
filler injection in Asian patients. All documented cases were
consecutive patients injected between September 2015
and August 2019 (48 months) by the first author (F.W.T. has
12 years of experience with facial soft-tissue filler injections
at the time of submission) in various facial regions utilizing a
variety of facial soft tissue fillers (Tables 1 and 2). All patients
were injected by the same specialist (F.W.T.) according to
their individual aesthetic indications. Patient records were
retrospectively analyzed and anonymized for further stat-
istical processing. Written information and verbal explan-
ations about the scope and goals of this retrospective
analysis were given to participants before inclusion in this
study. Patient records were not analyzed if willingness
to participate was declined. Following the Declaration of
Helsinki, written informed consent and signed picture and
photo release agreement were obtained from every pa-
tient included. Patients were treated according to regional
laws and good clinical practice independent of their will-
ingness to share their data for this retrospective analysis.
It is estimated that approximately 5760 to 7200 patients
(ie, 120-150 patients per month) were injected during the
48-month observational period.
Data Collected
The following data were collected on a routine basis and
documented by the first author of the study during his
daily clinical practice treating consecutive patients: age,
gender, facial region injected, layer (depth) of injection,
product injected, whether lidocaine was added to the in-
jected product, needle gauge and length, whether needle
priming was performed, injection angle, and time until
blood was visible in the needle hub (Tables 1-4). Data col-
lection was conducted in various clinics (F.W.T. practices in
multiple clinics) and during international travels of the first
author. Data analysis (not data collection) is the subject of
this study.
The products injected were Restylane Lyft/Perlane,
Restylane, Restylane Vital (Galderma Pharma SA, Uppsala,
Sweden); Juvederm Voluma, Juvederm Volift, Juvederm
Ultra Plus (Allergan PLC, Dublin, Ireland); Belotero
Balance (Merz Pharma GmbH & Co. KGaA, Frankfurt am
Main, Germany); Hyadermis Smile (SciVision Biotech
Inc., Kaohsiung, Taiwan); Elravie Deep line (Humedix,
Anyang-si, Republic of Korea); Princess Volume (Croma-
Pharma GmbH, Leobendorf, Austria); Sculptra (Sinclair
Pharma Ltd., London, UK); Sunmax Collagen Implant
Tseng et al 3

Table 1.  Number of Observed Positive Blood Aspirations at Respective Location and Depth of Needle Injection

Subdermal/superficial fat Submucosal Supraperiosteal Total count

Anterior inferior temple 0 0 2 2

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Anterior superior temple 0 0 42 42

Chin 0 0 15 15

Deep midfacial fat compartments 0 0 54 54

Forehead 0 0 8 8

Lateral midface (zygomaticomaxillary fissure) 0 0 5 5

Lips 2 1 0 3

Nasal dorsum 0 0 7 7

Nasal spine 0 0 3 3

Nasolabial sulcus 2 0 0 2

Posterior inferior temple 0 0 0 0

Posterior superior temple 0 0 5 5

Pyriform fossa 2 0 54 56

Superficial medial cheek fat compartment 11 0 0 11

Total count 17 1 195 213

(Sunmax Biotechnoloy CO., Ltd., Tainan, Taiwan); and Statistical Analyses

Artecoll (Canderm Pharma Inc., St. Laurent, Canada)
(Tables 2 and 4).
Criteria for Positive Blood Aspiration
Each included case was considered a “positive blood as-
piration case” if blood was visible in the needle hub during
needle insertion or during aspiration in the initiation phase
of the filler injection. Aspiration was consistently performed
during each injection process (independent of the amount
injected) and was characterized by the generation of nega-
tive pressure in the needle by retracting the plunger of
the soft tissue filler syringe. The pullback volume until a
positive case was noted was 0.05 to 0.5 cc. The gener-
ated pressure was not measured objectively because the
cases occurred during daily clinical consults of consecu-
tive patients.
If the aspiration procedure was positive (independent
of the amount of blood visible in the needle hub), the pro-
cedure was immediately stopped, the needle removed,
and digital pressure applied. After a minimum time of 5
minutes, a different location in the same facial region
was targeted with a different injection angle utilizing a
different soft tissue filler syringe. In no case was the in-
jection procedure continued after blood appeared in the
needle hub.
Descriptive and comparative analyses were performed
using SPSS Statistics 23 (IBM, Armonk, NY). Statistical sig-
nificance was defined as P < 0.05. 
RESULTS
General Description
Patient demographics noted were: 213 participants aged
an overall mean of 43.9 ± 7.2 years (range, 24-64 years). Of
those, 208 were female (mean age, 43.8 ± 7.2 years; range,
24-64  years) and 5 male (mean age, 46.8 ± 7.8  years;
range, 37-57 years).
No adverse vascular adverse events and especially
no injection related visual compromise occurred during
the evaluation period in patients with a positive aspiration
procedure.
Estimate of Minimum and Maximum
Incidence Rates
Only positive blood aspiration cases were retrospectively
analyzed; no negative injection cases were utilized for
comparisons. During the 48-month study period, an ap-
proximate amount of 11,500 cc of filler material was utilized.
4 Aesthetic Surgery Journal

Table 2.  Number of Observed Positive Blood Aspirations for Products Contained in Syringe and Their Respective Dilution With
Lidocaine

0.05 cc 0.1 cc Other cc No lidocaine added Total count

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Artecoll 3 6 0 0 9

Belotero Balance 1 1 0 0 2

Elravie Deep Line 5 0 0 0 5

Hyadermis Smile 1 0 0 1 2

Juvederm Ultra Plus 15 1 0 0 16

Juvederm Volift 0 0 0 4 4

Juvederm Voluma 0 0 0 24 24

Princess Volume 1 0 0 0 1

Restylane 53 39 0 3 95

Restylane Lyft (Perlane) 2 0 0 12 14

Restylane Vital 0 1 0 0 1

Sculptra 0 0 38 0 38

Sunmax Collagen Implant 1 0 0 0 1

Unknown 0 1 0 0 1

Total count 82 49 38 44 213

The extrapolation for the computation of the incidence Injection Location

rate was performed based on the amount of filler material
injected rather than from the number of patients treated.
Various amounts of filler material, that is, various numbers
of syringes and injection passes per patient, could be per-
formed, thus influencing the number of performed aspir-
ation procedures per patient.
The smallest amount of product injected during 1
pass (1 pass refers to 1 injection and 1 aspiration proce-
dure per specific location) was 0.02 cc (commonly used
for lips, periorbital areas, nasolabial folds), whereas the
largest amount of product applied during 1 pass was 0.5
cc (commonly used for temples or chin). An approximate
range of incidence for having a positive blood aspira-
tion event may be estimated utilizing this information to
derive the minimum and maximum values. If all of the
filler material (11,500 cc) had been injected in boluses of
0.02 cc per pass during the observational period, there
would have been 575,000 injection passes, resulting in
a minimum incidence rate of 213/575,000 (0.037%), or
1 of 2700 injection passes. If all the filler material had
been delivered in boluses of 0.5 cc per pass, there
would have been 23,000 injection passes, resulting in
a maximum incidence rate of 213/23,000 (0.926%), or 1
of 108 passes.
The most frequent location for positive aspiration was the
pyriform fossa with a total of n = 56 (26.3%), followed by the
injection into the deep midfacial fat compartments (n = 54;
25.4%), anterior superior temple (n = 42; 19.7%), and chin
(n = 15; 7.0%). Detailed information about all facial regions
injected can be found in Table 1 and Figure 1.
Injection Depth
The most frequent plane where aspiration was positive
for blood was the supra-periosteal plane, that is, the injec-
tion was performed with the needle tip being in constant
contact with the bone during the product application with
n = 195 (91.5%), followed by the subdermal plane with n = 17
(8.0%) and the submucosal plane in 1 case (0.5%) (Table 1).
Subdermal/submucosal plane refers to a very superficial
plane right deep to the dermis or the mucosa of the dry
red lip.
In the supraperiosteal plane of the pyriform fossa and
of the deep midfacial fat compartments, n = 54 positive
case were recorded each, representing 25.4% of all cases.
Positive cases were recorded in the subdermal plane of
the superficial cheek fat compartments (n = 11; 5.2%), the
Tseng et al 5

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Figure 1.  Collage of 24 positive blood aspiration cases arranged by region observed in the retrospectively investigated 213
clinical cases. The mean age of the displayed patients is 40.38 ± 7.9 years and the gender distribution is 22 females and 2
males.

nasolabial sulcus (n = 2; 1.0%), the pyriform fossa (n = 2; Table 3.  Number of Observed Positive Blood Aspirations for
1.0%), and the lips (n = 2; 1.0%) (Table 3). Differently Used Needle Sizes (23G-30G) and Whether Needle
Was Already Filled With Product on Injection (Primed) or Not
(Nonprimed)
Needles Utilized Primed Nonprimed Total count

The most frequently utilized needle size was a 27 G 23G, 1” 1 0 1

(n = 125; 58.7%), followed by 25 G (n = 44; 20.7%) and 29
24G, 1” 1 0 1
G (n = 36; 16.9%). Detailed information about needle sizes
and length utilized are given in Table 3. 25G, 1.5”, 1”, 5/8”, ½” 36 8 44
Five positive cases (2.3%) were recorded utilizing a 30
26G ½” 1 0 1
G needle, and 1 case (0.5%) was recorded utilizing a 23G
needle targeting the supraperiosteal plane of the anterior 27G, ½” 102 23 125
superior temple (Table 3).
29G, ½” 29 7 36

30G, ½” 5 0 5
Injection Technique
Total count 175 38 213
The injection angle of the performed needle injections
ranged between 90°C (perpendicular to the bone surface)
performed in 162 cases (76.1%), 45°C (oblique dermal ac- cases injected at a 10°C angle were n = 11 in the superficial
cess) in 38 cases (17.8%), and 10°C (almost parallel to the medial cheek fat compartment (5.2%) and 1 case each in
skin surface) in 13 cases (6.1%). The recorded positive the nasolabial sulcus and the lips (0.5%).
6 Aesthetic Surgery Journal

Table 4.  Cross-Tabulation Between Injected Product and Utilized Needle Sizes and Lengths of 213 Positive Aspiration Events

30 G, 1/2” 29 G, 1/2” 27 G, 1/2” 26 G, 1/2” 25 G, 1.5” 25 G, 1” 25 G, 5/8” 25 G, 1/2” 24 G, 1” 23 G, 1” Total count

Artecoll 1 8 9

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Belotero Balance 2 2

Elravie Deep Line 5 5

Hyadermis Smile 2 2

Juvederm Ultra Plus 16 16

Juvederm Volift 4 4

Juvederm Voluma 24 24

Princess Volume 1 1

Restylane 23 72 95

Restylane Lyft (Perlane) 12 2 14

Restylane Vital 1 1

Sculptra 9 4 23 1 1 38

Sunmax Collagen Implant 1 1

Unknown 1 1

Total count 5 36 125 1 9 4 23 8 1 1 213

Needle Priming frequent location for positive aspiration was the pyriform

In 175 of the positive cases (82.2%), the needle was primed
with product (independent of the product utilized), whereas
the needle was empty during the aspiration procedure in
38 of the positive cases (17.8%). No statistically significant
difference in the distribution of the depth of injection vs the
priming of the needle was detected (P = 0.890).
Time Until Blood Was Visible
In n = 210 (98.6%) cases, blood was visible in the needle
hub within less than 2 seconds after the initiation of the
aspiration procedure, whereas in n = 3 cases (1.4%) no
aspiration was needed as the blood rushed into the hub
during needle advancement. In the cases where no as-
piration was needed, injections were performed in the
supraperiosteal plane of the pyriform fossa, the subdermal
plane of the pyriform fossa, and the subdermal plane of the
nasolabial sulcus.
DISCUSSION
This retrospective clinical study analyzed n = 213 cases
of soft tissue filler injections positive for blood aspiration
performed in Asian patients by the same doctor during a
period of 48  months. The results revealed that the most
fossa (n = 56; 26.3%), followed by the deep midfacial fat
compartments (n = 54; 25.4%), anterior superior temple
(n = 42; 19.7%), and chin (n = 15; 7.0%). The most frequent
plane where aspiration was positive for blood was the
supra-periosteal plane (n = 195; 91.5%), followed by the
subdermal plane (n = 17; 8.0%) and the submucosal plane
in 1 case (0.5%). Positive cases were recorded for various
needle sizes: 27 G (n = 125; 58.7%), followed by 25 G
(n = 44; 20.7%) and 29 G (n = 36; 16.9%). More positive
cases were identified when the needle was primed com-
pared with an unprimed needle (175 vs 38 cases), which
was independent of the product present in the needle. In
the great majority of the cases (n = 210; 98.6%), blood was
visible in the needle hub within less than 2 seconds after
the initiation of the aspiration procedure, whereas in n = 3
cases (1.4%) no aspiration was needed as the blood rushed
into the hub during needle advancement. The latter 3
cases were observed in the pyriform fossa (2×) and in the
nasolabial sulcus (1×). Utilizing the 213 positive cases evalu-
ated in this study, we may estimate the incidence rate to be
in the range of 0.04% to 0.9% per pass (1 pass refers to 1
injection and 1 aspiration procedure per specific location).
The major strength of the study is that this is the first in
vivo case series, to our knowledge, analyzing cases posi-
tive for pre-injection blood aspiration. Previous studies ana-
lyzed influencing factors like pullback time,12 priming of the
Tseng et al 7

Table 5.  Review of Previous Studies Analyzing Product Type Injected, Needle Size/Length Utilized, Time Measured Until Blood
Visible in Needle Hub, and Pull-Back Volume
Study Present study Torbeck et al, 2019 Van Loghem et al, 2018 Casabona G, 2015 Carey et al, 2015

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Description In vivo In vitro In vitro In vitro In vitro
retrospective, case series using EDTA-coated using EDTA anticoagulated ink solution (saline + wa- slow pull test,
vacutainers blood bag pressurized ter-based red ink) in small cup using test tube heparinized
to 150 mmHg blood with rubber stopper

Procedures N = 213 clinical aspiration N = 20 experimental N = 340 experimental N = 30 experimental N = 153 experimental
performed aspiration aspiration aspiration aspiration

Gauge/ Secs mL Gauge/ Secs ML Gauge/ Secs mL Gauge/ Secs mL Gauge/ Secs mL
length length length length length

Restylane Lyft 27, ½”; <2 0.05-0.5 29, ½” 4; 0.2; 27, ½”; >10; 0.5 29, ½”; 29 Neg; N/A 29, ½”; <5 0.2; 0.3
(Perlane) 29, ½” 2 0.5 29, ½” 1-10 8 30, ½”

Restylane 27, ½”; <2 0.05-0.5 27, ½” 4; 0.2; 27, ½”; ~1 0.5 29, ½” 3 N/A 29, ½”; <5 0.2; 0.3
29, ½” 7 0.5 29, ½” 30, ½”

Restylane Vital 30, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A 30, ½” 2 N/A 29, ½”; <5 0.1; 0.05
30, ½”

Juvederm 27, ½” <2 0.05-0.5 27, ½” 2; 0.2; 27, ½” ~1 0.5 27, ½” 2 N/A 27, ½” <5 0.3
Voluma 2 0.5

Juvederm Volift 30, ½” <2 0.05-0.5 30, ½” 2; 0.2; 30, ½” ~1 0.5 30, ½” 1 N/A 30, ½” <5 0.2
2 0.5

Juvederm Ultra 27, ½” <2 0.05-0.5 27, ½” 11; 0.2; 27, ½” 1-10 0.5 27, ½”; 25 Neg; N/A 27, ½” <5 0.2
Plus 8 0.5 3

Belotero 27, ½” <2 0.05-0.5 27, ½” 30; 0.2; 27, ½” ~1 0.5 N/A N/A N/A N/A N/A N/A
Balance 23 0.5

Hyadermis Smile 27, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Elravie Deep Line 27, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Princess Volume 27, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Sculptra 25, ½”, 5/8” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A 27 3 N/A N/A N/A N/A
1”,1.5”
24, 1”;
23,1”

Sunmax Collagen 27, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Implant

Artecoll 25, ½”; 26, ½” <2 0.05-0.5 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

EDTA, ethylenediaminetetraacetic acid; mL, pullback volume; secs, aspiration time until blood was visible in the needle hub.

needle,11 or the pullback volume13 dependent on the type
of product utilized.11-13 Despite their interesting diversity, all
the referenced investigations employed an in vitro model
for their analyses, which lacks real-life conditions. These in
vitro models are absent of arterial blood pressure, which
can influence the retrograde blood flow during the aspira-
tion procedure. Additionally, these models lack appropriate
tissue temperature, which can influence the physiochem-
ical and rheological properties of the soft tissue filler and
therefore increase the shear forces of the product inside
the lumen of the needle at room temperature. Both factors
can result in false lower aspiration rates compared with a
clinical real-life scenario. Another strength of the present
study is the large sample size, which was retrospectively
evaluated during a 48-month period. This sample repre-
sents the largest case series of positive blood aspirations
published to date. Another strength of this study is that
all analyzed cases were injected and reevaluated by the
same investigator. This assures consistency during the in-
jection process, the aspiration procedure, and the retro-
spective case analyses and their interpretation. However,
this could also be regarded as a limitation of the study be-
cause no verification of the data by a second expert in-
jector occurred.
8
One weakness of the study is that only positive cases
for blood aspiration were analyzed. No detailed informa-
tion on negative aspiration cases, the number of total in-
jection passes, or the precise amount of filler material
injected during the 48-month observational period was
collected. This unfortunately excludes the identification
of influencing factors by which the specificity of aspiration
procedures during soft tissue filler injections could be in-
creased. This also limits the statistical analyses to descrip-
tive analyses only. The reported incidence rates are based
on the estimation of the average utilization of filler material
over several months and then extrapolation to 48 months.
Weekly/monthly fluctuations in filler material utilization
might influence the numbers employed for extrapolation
and might thus influence the incidence rates presented.
The incidence rates presented could be additionally bi-
ased by the preference of the injector, for example, selec-
tion of injection plane, needle type utilized, injection angle,
product type, or by regional/country-specific influencing
factors, for example, products being approved in some
countries only. It could thus be possible that the “real” fre-
quency of positive cases significantly differs compared
with other injectors, with a non-Asian study population, or
with other centers. Future studies will need to validate the
numbers presented herein. To account for the limitations
inherited in this descriptive analysis (ie, selection bias),
no clear recommendations can be given. The study was
designed and is presented as a retrospective descriptive
analysis of in vivo positive aspiration cases. However, to
date this is the largest case series summarizing cases pos-
itive for blood aspiration. It is also the only systematically
analyzed series obtained in a clinical scenario as opposed
to an experimental setting.
The results of this retrospective case series reveal that
in all 213 cases (100%), blood was visible in the needle hub
within less than 2 seconds after the initiation of the aspi-
ration procedure in contrast to other reports.11 This was in-
dependent of the type of product employed, the injected
plane, the size of the needle utilized, or if the needle was
primed. In 3 cases (1.4%), blood was visible even without
aspiration. These results are contradictory to currently per-
formed standards where a minimum time of 4 seconds is
recommended to aspirate before injecting the product.
One explanation why in 100% of the cases the aspiration
time was less than 2 seconds could be the combination be-
tween the injected product and the utilized needle.14 This
could be due to the preselection of the product/injector
combination, which is supported by the results of previous
experimental investigations (Table 5, correspondence with
at least 50% of the published literature): Juvederm Voluma
injected with a 27G 0.5-inch needle, Juvederm Volift in-
jected with a 30G 0.5-inch needle, Juvederm Ultra Plus in-
jected with a 27G 0.5-inch needle, Restylane Lyft injected
with a 29G 0.5-inch needle, Restylane Vital injected with a
Aesthetic Surgery Journal
30G 0.5-inch needle. Respecting product/needle combin-
ations could result in a reduced time until blood is visible in
the needle hub because a variety of products are known to
have inadequate aspiration times even ex vivo. A reduced
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time until blood is visible will increase the clinical applica-
bility because aspiration times longer than 2 to 4 seconds
would lead to increased discomfort of the patient and of
the treating physician. Additionally, longer aspiration times
would increase false negative results due to potential
needle tip movement or reposition with subsequently de-
creased accuracy during injection procedures.
The differences between the presented results and
previous investigations (Table  5) could be caused by the
different study setup because the aspiration procedures
reported in this retrospective analysis relied exclusively on
clinical cases, whereas previous studies obtained their re-
sults from an experimental study design. It is hoped that
the results of the present investigation show that aspira-
tion can be performed with an acceptable aspiration time,
that is, less than 2 seconds, if a suitable product/needle
combination is chosen. A larger needle diameter should be
chosen if a more viscous product is injected. A large pull-
back volume, that is, >0.2 cc, could help to prevent false
negative errors. However, a thorough understanding of fa-
cial anatomy should be mandatory for each practitioner. It
is important to understand the layered arrangement of fa-
cial structures and to be aware of facial danger zones and
especially of the variations in facial arterial vasculature.
CONCLUSIONS
The analysis of this retrospective case series of 213 posi-
tive blood aspiration procedures revealed that almost all
positive aspirations were evident within 2 seconds (1.4%
of the cases, blood rushed into the needle hub under its
own pressure). The pyriform fossa was the most frequent
location (n = 56; 26.3%), the most frequent depth was the
supra-periosteal plane (n = 195; 91.5%), and the most fre-
quent needle utilized was a 27 G needle (n = 125; 58.7%).
The estimated incidence rate for a positive aspiration event
ranged from 0.04% to 0.9% per pass. However, the results
are biased towards a preselected product/needle com-
bination; this is in line with previous experimental studies.
Accurate relative risk assessment or causal relationships
cannot be concluded from the data presented.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
Tseng et al
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