Aesth Plast Surg
DOI 10.1007/s00266-016-0725-7
ORIGINAL ARTICLE
A Dark Side of the Cannula Injections: How Arterial Wall
Perforations and Emboli Occur
Tanvaa Tansatit1 • Prawit Apinuntrum1 • Thavorn Phetudom1
Received: 7 October 2016 / Accepted: 18 October 2016
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2016
Abstract
Background Though most injectors prefer to use a cannula
rather than a needle, there have been reported cases of
blindness following cannula injections. This study inves-
tigated possible situations in which a cannula can injure an
artery to gain more insight about the vascular complication
and its prevention.
Methods To understand how an arterial injury occurs, five
situations favoring vascular injury were simulated and
tested. Experiments were performed in 100 arterial seg-
ments of 10 soft embalmed cadavers with red latex injec-
tions to the arteries. The frontal branch of the superficial
temporal artery with a diameter between 1.2 and 1.5 mm
was chosen for the experiment with a 25G cannula. Five
situations were created to simulate any possibility that the
cannula can penetrate through the arterial wall. Two factors
were varied for simulation of specific danger situations.
Factors that vary were as follows: (1) the angles between
the cannula and the artery when the cannula touched the
artery, and (2) the segments of the artery with different
features.
Results The cannula could penetrate the arterial wall in
some specific situations with a different chance in each
situation. The perpendicular angle between the artery and
the cannula was one of the essential situations for vascular
injury. Situations that had a similar effect of the
& Tanvaa Tansatit
tansatitapinuntrum@gmail.com
1
The Chula Soft Cadaver Surgical Training Center and
Department of Anatomy, Faculty of Medicine,
Chulalongkorn University and King Chulalongkorn
Memorial Hospital, 1873 Rama 4 Road, Pathumwan,
Bangkok 10330, Thailand
BASIC SCIENCE/EXPERIMENTAL
perpendicular arterial surface related to the cannula axis
also favored vascular injuries.
Conclusion During a blinded insertion of cannula injec-
tions to reach the target area, the injector cannot discrim-
inate the sensation at the cannula tip between the resistance
of a fibrous septum in the way of the insertion and the
resistance of encountering an artery. To prevent arterial
emboli, the cannula trajectory should not be close to the
main artery in the region. This allows a physician to safely
perform an intermittent forceful insertion without an arte-
rial injury during an attempt to perform a gentle cannula
insertion.
No Level Assigned This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors. www.springer.com/00266.
Keywords Cadaver
Filler injections
Cannula
Arterial
perforation
Emboli
Introduction
Varieties of hyaluronic acid fillers are available in the
market in different products and brands [1–4]. They are
commonly utilized in aesthetic treatments with different
usages and different results expected. There are injection
procedures for lifting, augmentation, correction of asym-
metry, modification of the shape, softening of folds and
wrinkles, and rejuvenation [2, 5–9]. The injector’s prefer-
ence of the products also varies between individuals based
on injection style and personal design [10–12], although
most injectors prefer a cannula rather than a needle
[13, 14]. Absolute safety cannot be guaranteed in cannula
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injections [15]. In Thailand, there are still personal com-
munications of reported cases of blindness following can-
nula injections. The ocular complication occurs when the
injector focuses only on the aesthetic result. To our
knowledge, both novice and experienced injectors certainly
have a chance of encountering ocular complications [16].
Some injectors feel uncomfortable injecting in a specific
area such as the nose or glabella for the fear that ocular
complications will occur [17]. This study investigates
possible situations in which a cannula can injure an artery.
By understanding how vascular injury occurs, an injector
will have more strategies to prevent the chance of ocular
complication. Thus, this may create a safe and comfort-
able environment for physicians and patients during facial
filler treatments.
Materials and Methods
To understand how arterial injury occurs, factors favoring
vascular injury were established and tested to determine the
crude possibility. Experiments were performed in 100
segments of arteries on both sides of cadavers in ten soft
embalmed cadavers. Red latex was injected to highlight the
arterial system through bilateral cannulations of the com-
mon carotid arteries in all. Only thin cadavers with less
subcutaneous fat were recruited to increase the chance that
blinded insertion can easily hit the target artery causing
arterial injury. The frontal branch of the superficial tem-
poral artery with a diameter between 1.2 and 1.5 mm was
chosen for the experiment with a 25G cannula. The situa-
tions were varied to simulate any possibility that the can-
nula can penetrate through the arterial wall. Two essential
factors were varied for simulation of specific situations.
Factors that vary were as follows: (1) the angles between
the cannula and the artery when the cannula contacts the
artery, and (2) the segments of the artery with different
features.
Experiments intended to cause arterial wall injury.
Blinded Insertion
In a cadaver, in which the artery could not be precisely
located, a narrow strip of skin flap was raised transversely
at the lateral forehead to locate the artery. A puncture was
made by a 25G needle at a distance of 2 cm near the artery
for cannula insertion. Blinded cannula insertions were
performed next to the exposed segment of artery inten-
tionally to cause injury of the arterial wall. The cannula
trajectory passed through the artery at an angle close to a
right angle to increase the chance of injury. A quick stroke
of cannula insertion was made twice, and the skin over the
artery was pressed during the insertions to confine the
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Aesth Plast Surg
artery in place as the target for the cannula. Dissections to
verify arterial wall injury were performed under an oper-
ating microscope after insertion (Fig. 1). Then dissections
of the whole frontal branch of the artery and one primary
branch were performed to prepare the artery for the next
experiments.
Insertions Under Direct Vision: (Figs. 2, 3)
The straight part of the artery was exposed for experimental
insertion under direct vision. Two different angles of can-
nula insertions related to the artery were used as the negative
and positive controls: parallel and perpendicular angles.
Firstly, the cannula tip was placed at the arterial wall either
perpendicular (nearly a right angle) or parallel (within a
10-degree angle) under an operating microscope. A light
pressure of the cannula tip can engage the tip at the middle of
the artery. A quick stroke of cannula insertion was made to
penetrate the arterial wall. The cannula tip may slip away on
the side of the artery as it usually occurs in parallel insertions
or penetrate through the arterial wall as often occurs in
perpendicular insertions. Three attempts at insertion were
made to perforate the arterial wall if the previous attempts
failed. The number of insertions until the wall was perfo-
rated was documented as 1, 2, 3, or 3 failures.
Different features of the arterial segments were tested
with intentional cannula insertion. These included the
straight segment described above, a tortious segment, and a
bifurcated segment. The most tortious part of the artery and
the bifurcated segment, where the largest branch arose,
were selected after total exposure of the artery by raising
the skin flap and removal of the subcutaneous tissue. At the
tortious segment, the cannula tip engaged and followed
through slowly to keep the tip engaged in the middle of the
artery regardless of the angle between the cannula and the
artery. Then a quick stroke of insertion was made to per-
forate the arterial wall. At the bifurcation, the cannula tip
was engaged at the sharp angle between the artery and the
branch, and a quick stroke of insertion was made. Three
attempts were made to perforate the arterial wall and the
number of insertions until the wall was perforated was
documented as 1 (perforation occurred at the first attempt),
2 (perforation occurred at the second attempt), and 3
(perforation occurred at the third attempt), or 3 failures if
three attempts failed to induce arterial injury (Fig. 4).
Results
The results are summarized in Table 1. Blinded insertions
in limited attempts (40 insertions in 20 specimens) failed to
create arterial wall injury (0 in 20 specimens). These
revealed a very low chance of arterial injury by a blinded
Aesth Plast Surg
Fig. 1 Blinded cannula insertions. The cannula passes through the
artery at an angle close to a right angle to increase the chance of
injury. A quick stroke of cannula insertion was made twice, and the
skin over the artery was pressed during the insertions to confine the
Fig. 2 Insertions under direct
vision: a Parallel insertion.
b Insertion at the tortious part
(at the elbow point). c Insertion
at the bifurcation (at the armpit
point). d Right angle insertion
cannula insertion in the clinical setting even when per-
pendicular insertions were performed. Under direct vision,
parallel insertion also failed to create arterial injury (0 in 20
specimens). The cannula can penetrate the arterial wall in
some specific dangerous situations. The perpendicular
angle was the condition creating a dangerous situation for
vascular injury. Most of the arterial segments were injured
(16 in 20 specimens) when the angle between the cannula
and the artery was close to a right angle. Situations that had
a similar effect to the perpendicular arterial surface related
to the cannula axis also favored vascular injuries. These
included cannula insertions at the bifurcation (18 in 20
specimens) and at the tortious segment (12 in 20
specimens).
artery in place as the target for the cannula. Dissections to verify
arterial wall injury were performed under an operating microscope
after insertion (a low: 910 magnification, b higher: 925
magnification)
Discussion
To the best of our knowledge, there are no precise expla-
nations of why a cannula can injure an artery. The blunt tip
of the cannula is designed to allow an artery lying in the
way of the cannula movement to slip away when the
moving cannula tip accidentally touches an artery during
an insertion. Previous articles discuss the possibility of a
small cannula producing an effect of penetration similar to
a needle [14]. To reduce the chance of arterial injuries, a
large cannula (22G or 25G) is recommended as a safer
device than a small one (27G or 30G) for filler injections.
The current study provides evidence that a large cannula
(22G or 25G) can tear the artery wall when the artery wall
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 Aesth Plast Surg

further forceful insertion to overcome the resistance

Fig. 3 Diagram illustrating four insertions under direct vision
is relatively fastened into position by fibrous septa or other
conditions in which a large arterial wall goes inward, wraps
around, and holds the cannula tip with its wall. In these
conditions, it cannot slide aside enough to avoid injury,
thus, it will be stretched and further wrapped around the
cannula tip when the tip follows the trajectory. Then, a
believed to be the fibrous septum can inadvertently pene-
trate the arterial wall. This can occur in at least three dif-
ferent situations.
The classic situation is when a segment of the artery in
the way of the cannula insertion aligns perpendicularly to
the cannula trajectory and that segment is fixed to the tissue
by a fibrous septum in a narrow space such as a space
between the periosteum and the fibromuscular layer or the
latter layer and the skin. The cannula hits the artery hard
enough to break the arterial wall because the injector
mistakenly believes that the resistance encountered is due
to fibrous septa. In the current study, we did not exactly
measure each segment that we used in the experiments, but
we recognized that a large artery of 1.5 mm diameter
seemed to be injured easier than a small artery with a
diameter of 1.2 mm.
Another situation is the tortious part of the artery that
can act as a perpendicular segment when the tortious seg-
ment is stretched by the cannula tip and holds the cannula
within the folded segment. The last situation is a bifurca-
tion that the cannula tip can be struck into. At the sharp

Fig. 4 Evidence of arterial

perforations. a The cannula was
retained within the arterial
lumen between the arterial wall
and red latex after the
perforation. b Elevation of the
cannula tip expanded the
lacerated hole and exposed red
latex within the arterial lumen.
c The circular margin of the
hole can be clearly seen around
the cannula. d Red latex within
the artery was exposed after
removal of the cannula

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Aesth Plast Surg
Table 1 Results of the situations established to cause arterial perforations
Intact Tear
artery artery
Blinded insertion (n = 20) 20 0 NA
a. Intentional parallel insertion 20 0 3 failures
(n = 20)
b. Intentional insertion at a tortious 8 12
part (n = 20)
c. Intentional insertion at a bifurcation 2 18
(n = 20)
d. Intentional perpendicular insertion 4 16
(n = 20)
The conditions were varied to make it possible to injury the artery
* 1 = 2 means success at the first attempt in 2 specimens
angle of the bifurcation, two arterial walls of both the main
artery and the branch surround the cannula tip while they
lead into the angle which is known as the weakest part of
the arterial wall. In the cranial cavity, the sharp angle,
between the cerebral arteries, is the common site of
weakness in the wall where the saccular type of cerebral
artery aneurysm usually develops [18].
Normally, the artery can move away from the large
cannula because of the round blunt tip. We did not test a
27G or 30G cannula because of the similarity to a needle.
We decided not to test a 22G cannula because of the dif-
ficulty of arterial wall penetration. A further study may be
needed to determine the relative risks when different can-
nulae are compared. In parallel insertion, which is
approximately a 10-degree angle between the artery and
the cannula, we could not create arterial injury. Various
angles may be tested to compare the individual risks. A
cannula can cause an arterial wall perforation in specific
conditions in which the artery cannot give way to the
cannula. During a blinded insertion of the cannula to reach
the target area, the injector cannot discriminate the sensa-
tion at the cannula tip between the resistance of a fibrous
septum and the resistance of an artery that is held in place
by a fibrous band. To prevent arterial emboli, the cannula
trajectory should not be close to an artery to make sure that
an intermittent forceful insertion intending to pass a fibrous
septum can be performed safely without an arterial injury.
Other measures to minimize embolic phenomena are ret-
rograde injection in multiple passes with a small aliquot at
a time, gently inserting the cannula with as little force as
possible, and always keeping the cannula traveling along
the superficial subcutaneous plane or at the preperiosteal
plane or at the surface of the deep temporal fascia. The use
of epinephrine mixed with local anesthesia prior to any
subcutaneous injection is one of the most powerful tools to
avoid accidental penetration of arteries and veins.
Average number of attempts to perforate (limited 3 attempts in Crude
all 20 specimens) possibility
Rare
Rare
2.25 attempts (1 = 2, 2 = 5, 3 = 5)* Possible
1.50 attempts (1 = 11, 2 = 5, 3 = 2)* Possible
1.69 attempts (1 = 8, 2 = 5, 3 = 3)* Possible
There is an argument that parallel insertion of the can-
nula related to an artery may be dangerous if the perfora-
tion occurs, as the cannula will follow within the arterial
lumen for a long distance. Perpendicular insertion has a
higher chance of perforation, but the cannula will pass
through within a very short distance in the artery. This is
not true based on our experience from the current study.
Parallel insertion is safer because it is very difficult to
penetrate the arterial wall. We strongly recommend align-
ing the cannula trajectory parallel to the course of the local
artery as much as possible. Because most of the arteries are
curved and tortious, for a practical purpose, alignment of
the cannula trajectory could be related to the estimated
course of the artery. A parallel insertion means that the
cannula aligns at the sharp angle related to and very close
to the course of the artery. A perpendicular insertion means
that the cannula trajectory aligns close to the right angle
related to the course of the artery.
Essential knowledge from the current study can be
applied when performing deep subcutaneous or intramus-
cular injections anywhere in the face where a cannula has
to approach a sizable artery in that region. A good example
is at the nasolabial fold where the facial artery has multiple
minute lateral branches and a large superior labial artery
medially [19–21]. The injector would like to correct a deep
nasolabial crease as an appearance of maxillary prog-
nathism of the patient. The cannula should be inserted
parallel to the nasolabial fold and parallel to the facial
artery. To enter the injection plane, the cannula may enter
the skin above the oral commissure to avoid the tortious
part of the facial artery lying deep to the modiolus, and the
entry site should be placed lateral to the nasolabial fold to
avoid the sharp angle of the bifurcation of the superior
labial artery. When resistance is encountered, reinsertion to
pass around the resistance is a better choice than a forceful
insertion to pass through the resistance. If reinsertion
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cannot pass around the resistance at that point, there may
be a fibrous band surrounding the artery which may occur
from a previous infection or surgical procedure. This pre-
sents a high chance of arterial injury. The injector must
change to a more superficial plane at the point of the
resistance and use a more delicate technique to avoid
creating surface irregularity and lumps. The fibrous band
and local scar can be softened by multiple passes of filler
injections, if no known local artery is lying within.
Using a sharp needle for a deep injection is totally dif-
ferent. A needle can injure an artery from every direction.
Perpendicular alignment of the needle is advised to
approach an artery. Parallel insertion increases the chance
of residing within the arterial segment compared to per-
pendicular insertion.
The current study was different from ordinary clinical
situations. It was intentionally designed to establish the
worst-case scenarios for revealing possible mechanisms of
arterial injuries. The conditions were designed to injure
the artery at the early tries of each situation. All possible
situations in the current study expressed the relative risk
of one situation compared to another. Because the small
sample size and the conditions were different from the
clinical setting, the exact risk of each situation was not
precisely determined and compared to that of other situ-
ations. For precise placement of the cannula, the artery
was exposed and surrounding fibrous attachments were
removed. This resulted in a more mobile artery. To
compensate for the mobile artery due to removal of
fibrous attachments, we used a latex-filled artery for more
rigidity against cannula insertion. This adjustment allowed
for easier artery perforation. In the clinical setting, the
risk is very low compared to the risks in the current study
because of the awareness of vascular injury. Further study
including more similarities to clinical settings is needed.
The experiment should be designed to have experienced
and novice injectors perform cannula insertions to com-
pare the chances of vascular injuries and risks of com-
plications. In the clinical setting, an arterial wall injury by
cannula injection is recognized as being rare but
devastating.
Conclusion
A cannula can cause an arterial wall perforation in specific
conditions. During a blinded insertion of the cannula to
reach the target area, the injector cannot discriminate the
sensation at the cannula tip against the resistance of a
fibrous septum and the resistance of an artery that is fixed
in place by a fibrous band. To prevent arterial emboli, the
cannula trajectory should not be close to an artery to make
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Aesth Plast Surg
sure that an intermittent forceful insertion intending to pass
a fibrous septum during a gentle cannula insertion can be
performed safely without an arterial injury.
Compliance with Ethical Standards
Conflicts of interest All authors have no conflicts of interest to
disclose.
References
1. Fischer TC, Sattler G, Gauglitz GG (2016) Hyaluron filler con-
taining lidocaine on a CPM basis for Lip augmentation: reports
from practical experience. Facial Plast Surg 32:283–288
2. Chiu A, Fabi S, Dayan S, Noguira A (2016) Lip injection tech-
niques using small-particle hyaluronic acid dermal filler. J Drugs
Dermatol 15:1076–1082
3. Ho D, Jagdeo J (2015) Biological properties of a new volumizing
hyaluronic acid filler: a systematic review. J Drugs Dermatol
14:50–54
4. Bogdan Allemann I, Baumann L (2008) Hyaluronic acid gel
(Juvederm) preparations in the treatment of facial wrinkles and
folds. Clin Interv Aging 3:629–634
5. Youn SH, Seo KK (2016) Filler rhinoplasty evaluated by
anthropometric analysis. Dermatol Surg 42:1071–1081
6. de Felipe I, Redondo P (2015) The liquid lift: looking natural
without lumps. J Cutan Aesthet Surg 8:134–138
7. Moers-Carpi MM, Tufet JO (2008) Calcium hydroxylapatite
versus nonanimal stabilized hyaluronic acid for the correction
of nasolabial folds: a 12-month, multicenter, prospective,
randomized, controlled, split-face trial. Dermatol Surg 34:
210–215
8. Riyaz FR, Ozog D (2015) Hand rejuvenation. Semin Cutan Med
Surg 34:147–152
9. Franca Wanick FB (2016) Skin remodeling using hyaluronic acid
filler injections in photo-aged faces. Dermatol Surg 42:352–359
10. Lee SK, Kim HS (2014) Recent trend in the choice of fillers and
injection techniques in Asia: a questionnaire study based on
expert opinion. J Drugs Dermatol 13:24–31
11. Gilbert E, Calvisi L (2014) Midface and perioral volume
restoration: a conversation between the US and Italy. J Drugs
Dermatol 13:67–74
12. Bass LS (2015) Injectable filler techniques for facial rejuvena-
tion, volumization, and augmentation. Facial Plast Surg Clin N
Am 23:479–488
13. Fulton J, Caperton C, Weinkle S, Dewandre L (2012) Filler
injections with the blunt-tip microcannula. J Drugs Dermatol
11:1098–1103
14. Beleznay K, Carruthers JD, Humphrey S, Jones D (2015)
Avoiding and treating blindness from fillers: a review of the
world literature. Dermatol Surg 41:1097–1117
15. Hwang CJ (2016) Periorbital Injectables: understanding and
avoiding complications. J Cutan Aesthet Surg 9:73–79
16. Goodman GJ, Roberts S, Callan P (2016) Experience and man-
agement of intravascular injection with facial fillers: results of a
multinational survey of experienced injectors. Aesthet Plast Surg
40:549–555
17. Liew S, Scamp T, de Maio M, Haistead M, Johnston N, Silbeberg
M, Rogers JD (2016) Efficacy and safety of a hyaluronic acid
filler to correct aesthetically detracting or deficient features of the
Asian nose: a prospective, open-label, long-term study. Aesthet
Surg J 36:760–772
Aesth Plast Surg
18. Lazzaro MA, Ouyang B, Chen M (2012) The role of circle of
Willis anomalies in cerebral aneurysm rupture. J Neurointerv
Surg 4:22–26
19. Zhou SB, Xie Y, Chiang CA, Liu K, Li QF (2016) A randomized
clinical trial of comparing monophasic monodensified and biphasic
nonanimal stabilized hyaluronic acid dermal fillers in treatment of
Asian Nasolabial folds. Dermatol Surg 42:1061–1068
20. Lombardo GA, Tamburino S, Tarico MS, Perrotta RE (2016)
Lateral nasal artery perforator flaps: anatomic study and clinical
applications. Arch Plast Surg 43:77–83
21. Camuzard O, Foissac R, Georgiou C, Andot L, Alcaraz F, Baque
P, Bronsard N, Poissonnet G (2015) Facial artery perforator flap
for reconstruction of perinasal defects: an anatomical study and
clinical application. J Craniomaxillofac Surg 43:2057–2065
123