COSMETIC

Arterial Wall Penetration Forces in Needles

versus Cannulas
Tatjana Pavicic, M.D.
Background: If safety is defined as the diminished ability to penetrate facial
Katherine L. Webb
arteries, the goal of this study was to investigate whether different-sized can-
Konstantin Frank, M.D.
nulas are safer than correspondingly sized needles for the application of facial
Robert H. Gotkin, M.D. soft-tissue fillers.
Bhertha Tamura, M.D. Methods: Two hundred ninety-four penetration procedures of the facial and
Sebastian Cotofana, M.D., superficial temporal arteries were performed in four fresh frozen cephalic
Ph.D. specimens using both needles (20-, 22-, 25-, and 27-gauge) and cannulas
Munich, Germany; Albany and New (22-, 25-, and 27-gauge). Continuously increasing force was applied and mea-
York, N.Y.; and Sao Paulo, Brazil sured until intraarterial penetration occurred.
Results: No statistically significant differences were detected when comparing
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forces required to penetrate the facial arterial vasculature between different

sexes, arteries, or sides of the face (all p > 0.05). Forces needed to penetrate sig-
nificantly (p < 0.001) decreased with smaller diameter needles (20-gauge, 1.12
± 0.29 N; 22-gauge, 1.08 ± 0.25 N; 25-gauge, 0.69 ± 0.24 N; and 27-gauge, 0.70
± 0.29 N) and in cannulas (22-gauge, 1.50 ± 0.31 N; 25-gauge, 1.04 ± 0.36 N;
and 27-gauge, 0.78 ± 0.35 N). Comparing 27-gauge injectors, no statistically
significant difference was detected between needles and cannulas; an artery
could be penetrated with a similar force independent of whether the injector
was a needle or a cannula (0.70 ± 0.29 N versus 0.78 ± 0.35 N; p = 0.558).
Conclusions: Cannulas, in all measured sizes except 27-gauge, required greater
forces for intraarterial penetration compared with correspondingly sized needles,
confirming the safety of 22- and 25-gauge cannulas; 27-gauge cannulas, however,
required similar forces as 27-gauge needles, indicating that 27-gauge cannulas are
not safer than 27-gauge needles.  (Plast. Reconstr. Surg. 143: 504e, 2019.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

T
he demand for minimally invasive rejuvena-
tion procedures is steadily increasing today, Disclosure: None of the authors has any commercial
and this trend is underscored by the num- associations or financial disclosures that might pose
ber of soft-tissue filler procedures performed or create a conflict of interest with the methods applied
each year in the United States. According to the or the results presented in this article.
2017 procedural statistics released by the Ameri-
can Society of Plastic Surgeons, the number
of minimally invasive cosmetic procedures has
Supplemental digital content is available for
increased by 312 percent between 2000 and 2017.1
this article. Direct URL citations appear in the
Although U.S.-based health care professionals can
text; simply type the URL address into any Web
choose among 24 different U.S. Food and Drug
browser to access this content. Clickable links
Administration–approved soft-tissue fillers, the
to the material are provided in the HTML text
actual delivery of filler material to the soft tissues
of this article on the Journal’s website (www.
is achieved through either needles or cannulas.2
PRSJournal.com).
From private practice and the Department for Hand, Plastic
and Aesthetic Surgery, Ludwig Maximilian University; the
Department of Medical Education, Albany Medical College;
private practice; and Medical School General Hospital, Uni- By reading this article, you are entitled to claim
versity of Sao Paulo. one (1) hour of Category 2 Patient Safety Cred-
Received for publication May 2, 2018; accepted August 21, it. ASPS members can claim this credit by log-
2018. ging in to PlasticSurgery.org Dashboard, click-
Copyright © 2018 by the American Society of Plastic Surgeons ing “Submit CME,” and completing the form.
DOI: 10.1097/PRS.0000000000005321

504e www.PRSJournal.com
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 Volume 143, Number 3 • Arterial Wall Penetration Forces

Cannulas are commonly referred to as “atrau- years and a mean body mass index of 25.5 ± 6.1 kg/
matic” because the tip is blunt and rounded and m2. Specimens were screened and not included in
the opening for product delivery is on the side. this analysis if previous facial surgery, facial trauma,
Needles, in contrast, have a sharp tip with the open- or disease disrupted the integrity of the facial anat-
ing for the product at the distal cutting edge.3 Hav- omy. Each body donor had given informed consent
ing a device with a blunt tip is thought to reduce while alive for the use of his or her body for medical,
the risk of perforating and/or penetrating nerves scientific, and educational purposes. All aspects of
and blood vessels during the injection procedure. the study conform to the laws of the country where
This is assumed to occur because of the increased the study was conducted (United States).
pressure needed for a blunt-tip device to penetrate
a structure and a resulting “sliding” phenomenon Penetration Procedure
around the respective neurovasculature. This pur- The lower and the middle face of the four body
portedly reduces the risk of nerve injuries and the donors were dissected in a layer-by-layer approach.
risk of intraarterial injection of the product. The facial artery was exposed between the mandible
This belief in the atraumatic qualities of can- and the modiolus, whereas the anterior branch of
nulas described above was reflected in the results the superficial temporal artery was exposed in layer
of an online survey in which 71 percent of 58 3 of the temple between the zygomatic arch and the
experts (77 percent were aesthetic physicians, 15 temporal crest. Arteries were freed from overlying
percent were dermatologists, and 2 percent were connective tissue, but connecting arterial branches
plastic surgeons) agreed that cannulas are safer of the vessel were saved to provide support during
than needles for injecting fillers to the level of the penetration procedure. Dissections were per-
the periosteum.4 Similarly, Hexsel et al. described formed within 48 hours after death of the respective
less pain (p = 0.03), edema (p < 0.001), redness body donor without latex injection into the arterial
(p = 0.01), and hematoma formation (p < 0.001) system and without embalming of the tissue.
when the nasolabial fold was injected with a can- After the arteries were prepared, different
nula compared with injections using a needle on sized needles and cannulas were used to perform
the contralateral side.3 Investigating intravascu- the penetration procedure. Needles used in this
lar injections with facial soft-tissue fillers, Good- study were 20-gauge 1-inch; 22-gauge 1.25-inch;
man et al. reported that in 83 percent of the 25-gauge 1.5-inch, and 27-gauge 1-inch; whereas
cases in which an intraarterial injection of mate- the sizes of the cannulas were 22-gauge 2-inch,
rial occurred, the injection was performed using 25-gauge 1.5-inch (38 mm), and 27-gauge 1.5-inch.
a needle, as compared with 17 percent when the The different sized injectors (i.e., needles and
injection was performed using a cannula.5 cannulas) were attached by means of a connector
At this time, a plethora of different sized nee- to a force measurement device (DFS 500; Nex-
dles and cannulas are available for performing tech Global Ltd, Bangkok, Thailand) (Fig. 1). The
facial injections. It remains unproven, however, injectors were positioned axial and at a 30-degree
that cannulas are safer than needles. It can be angle to the vessel and introduced into the artery
hypothesized that smaller cannulas require the by penetrating the near arterial wall (Figs. 2 and 3).
same force to penetrate an artery as same-sized (See Video, Supplemental Digital Content 1,
needles; the diameter of the cannula is so thin which demonstrates the penetration procedure
that the blunt, rounded tip behaves like a needle of the facial artery with a 20-gauge needle. The
within the facial soft tissues. The objectives of the DFS 500 force gauge indicates the force required
present study are to measure the force needed for intraarterial penetration. The DFS 500 force
to penetrate an artery using different sized nee- gauge is not affected by lateralizing movements
dles and cannulas and to compare these forces caused by natural tremor of the hand, as it only
between same-sized needles and cannulas for measures axial force, http://links.lww.com/PRS/
their potential to penetrate facial arterial vessels. D286. See Video, Supplemental Digital Content 2,
which demonstrates the penetration procedure
MATERIALS AND METHODS of the superficial temporal artery with a 20-gauge
needle. The DFS 500 force gauge indicated the
Study Sample force required for intraarterial penetration at
We analyzed 294 penetration procedures the end of the video. The DFS 500 force gauge is
performed in both the facial and the superficial not affected by lateralizing movements caused by
temporal arteries of two male and two female Cau- natural tremor of the hand, as it measures only
casian body donors with a mean age of 74.5 ± 8.9 axial force, http://links.lww.com/PRS/D287.) The

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 Plastic and Reconstructive Surgery • March 2019

Fig. 1. Devices and materials used in this study. Needles included 20-gauge 1-inch
(30  mm), 22-gauge 1.25-inch (36  mm), 25-gauge 1.5-inch (40  mm), and 27-gauge
1-inch (37  mm). Cannulas included 22-gauge 2-inch (50  mm); 25-gauge 1.5-inch
(38 mm); and 27-gauge 1.5-inch (38 mm).

injector was placed inside the artery without pen- needed to penetrate one vessel wall and to posi-
etrating the far vessel wall—without a through- tion the injector inside the artery was measured.
and-through perforation. The force (in newtons) Side-to-side movements (left-to-right), caused by
manual motion artifacts, were not registered; the
measurement device detected axial movements
only—movements along the axis of the injector.

Statistical Analyses
Each penetration procedure was carried out
three times and the mean value was used for
further statistical analyses. Normal distribution
of the force measurements was tested using the
Kolmogorov-Smirnov test. Differences in force
measurements between injectors (needle versus
cannula), sex (male versus female), side of the face
(left versus right), and artery (facial versus superfi-
cial temporal) were calculated using the indepen-
dent samples t test. Differences across different
sized injectors (20-gauge versus 22-gauge versus
25-gauge versus 27-gauge) were calculated using
analysis of variance testing. Correlations between
body mass index, age, and the force needed to
penetrate one arterial wall were calculated using
Fig. 2. Cadaveric dissection of the left side of a face. The facial the Pearson r test. All calculations were performed
artery (red arrows) is penetrated using a 20-gauge needle con- using IBM SPSS Version 23 (IBM Corp., Armonk,
nected to the DFS 500 force gauge to measure the force required N.Y.) and results were considered statistically sig-
for intraarterial penetration. nificant at a value of p ≤ 0.05 to guide conclusions.

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 Volume 143, Number 3 • Arterial Wall Penetration Forces

Video 2. Supplemental Digital Content 2 demonstrates the

penetration procedure of the superficial temporal artery with a
20-gauge needle. The DFS 500 force gauge indicated the force
required for intraarterial penetration at the end of the video. The
DFS 500 force gauge is not affected by lateralizing movements
Fig. 3. Cadaveric dissection of the left side of a face. The superfi- caused by natural tremor of the hand, as it measures only axial
cial temporal artery (red arrows) is penetrated using a 20-gauge force, http://links.lww.com/PRS/D287.
needle connected to the DFS 500 force gauge to measure the
force required for intraarterial penetration.
Table 1.  Force Required for Intraarterial Penetration
of the Anterior Branch of the Superficial Temporal
Artery and of the Facial Artery*
Mean Force
Required to
Penetrate Mean Force
the Anterior Required to
Branch of the Penetrate Difference
Superficial the Facial between
Temporal Artery ± Arteries
Injector Artery ± SD (N) SD (N) (p)
Needle
 20-gauge 1.18 ± 0.21 1.07 ± 0.35 0.462
 22-gauge 1.13 ± 0.30 1.03 ± 0.20 0.438
 25-gauge 0.75 ± 0.17 0.62 ± 0.28 0.324
 27-gauge 0.75 ± 0.25 0.64 ± 0.34 0.510
Cannula
 22-gauge 1.44 ± 0.36 1.57 ± 0.25 0.474
 25-gauge 0.98 ± 0.39 1.09 ± 0.36 0.577
 27-gauge 0.79 ± 0.43 0.76 ± 0.29 0.849
Video 1. Supplemental Digital Content 1 demonstrates the pen- *The difference between the force required to penetrate the respec-
tive artery is given as a p value.
etration procedure of the facial artery with a 20-gauge needle.
The DFS 500 force gauge indicates the force required for intra-
the right side of the face (n = 56): 0.93 ± 0.36 N
arterial penetration. The DFS 500 force gauge is not affected by
versus 1.03 ± 0.43 N (p = 0.254). No statistical dif-
lateralizing movements caused by natural tremor of the hand,
as it only measures axial force, http://links.lww.com/PRS/D286.
ference was detected between the mean force
required to penetrate the anterior branch of
the superficial temporal artery (n = 49) and the
RESULTS mean force needed to penetrate the facial artery
There was no statistical difference between (n = 49): 1.01 ± 0.38 N versus 0.97 ± 0.41 N (p =
the mean force required to penetrate an artery on 0.640) (Table 1). No statistical difference between
the left side of the face (n = 42) versus that on the force required to penetrate an artery in a male

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 Plastic and Reconstructive Surgery • March 2019

Table 2.  Force Required for Intraarterial Penetration Direct comparisons of forces needed to pen-
in Men and Women* etrate an artery with 22-gauge injectors revealed
Mean Force
that 22-gauge cannulas required a statistically sig-
Required for nificant higher force compared with a 22-gauge
Mean Force Artery needle: 1.50 ± 0.31 N versus 1.08 ± 0.25 N
Required for Penetration (p = 0.001). The same relationship was observed
Artery Penetration in Female Difference
in Male Cadavers ± Cadavers ± between for 25-gauge injectors, in which 25-gauge cannu-
Injector SD (N) SD (N) Sexes (p) las required a significantly increased amount of
Needle force compared with 25-gauge needles to pen-
 20-gauge 1.25 ± 0.27 0.96 ± 0.24 0.71 etrate an artery: 1.04 ± 0.36 N versus 0.69 ± 0.24 N
 22-gauge 1.18 ± 0.27 0.95 ± 0.16 0.85 (p = 0.006).
 25-gauge 0.64 ± 0.18 0.76 ± 0.30 0.37
 27-gauge 0.70 ± 0.26 0.71 ± 0.36 0.92 Comparing 27-gauge injectors, no statisti-
Cannula cally significant difference was detected between
 22-gauge 1.50 ± 0.33 1.52 ± 0.31 0.91 needles and cannulas; this indicates that an artery
 25-gauge 1.08 ± 0.42 0.98 ± 0.31 0.64
 27-gauge 0.80 ± 0.33 0.74 ± 0.41 0.78 can be penetrated with a similar amount of force
*The difference between the genders is given as a p value. independent of the injector: 0.70 ± 0.29 N (nee-
dles) versus 0.78 ± 0.35 N (cannulas) (p = 0.558)
(Fig. 6).
cadaver (n = 56) versus that in a female cadaver
(n = 42) was found: 1.02 ± 0.41 N versus 0.95 ±
0.38 N (p = 0.380) (Table 2). DISCUSSION
Increased age was significantly correlated with The present study measured the force
a reduction in the force required to penetrate an required to penetrate the arterial wall of the facial
artery (rp = −0.29; p = 0.003), whereas increased arterial vasculature, represented by the superficial
body mass index did not display any significant temporal artery and the facial artery, using differ-
relationship with the forces needed to penetrate ent sized needles and cannulas. We performed
(rp = 0.01; p = 0.910). The minimum force neces- measurements in 294 separate arterial penetra-
sary to penetrate the arterial wall was correlated tion procedures and demonstrated no statistically
with the size of the needle; this indicates that significant difference when comparing sex, artery,
smaller needles required less force to penetrate or side of the face. Although increasing body mass
the arterial wall: 20-gauge needle, 1.12 ± 0.29 N; index did not correlate with the force needed to
22-gauge needle, 1.08 ± 0.25 N; 25-gauge needle, perforate the artery, our results did reveal that less
0.69 ± 0.24N; and 27-gauge needle, 0.70 ± 0.29 N. force was required to penetrate a vessel as the age
There was a statistically significant difference of the subject increased. The force required to
across groups of p < 0.001 (Table 3 and Fig. 4). penetrate an artery decreased in a statistically sig-
The same significant relationship was detected nificant fashion with decreasing diameter of both
for different sized cannulas, indicating that smaller needles and cannulas. This indicates that smaller
cannulas required a smaller amount of force to injectors, independent of whether they are nee-
penetrate an arterial wall: 22-gauge cannula, 1.50 dles or cannulas, required less force to penetrate
± 0.31 N; 25-gauge cannula, 1.04 ± 0.36 N; and the investigated arterial walls.
27-gauge cannula, 0.78 ± 0.35 N. Again, there was When comparing same-sized cannulas and
a statistically significant difference across groups needles, 22- and 25-gauge cannulas required sig-
of p < 0.001 (Table 4 and Fig. 5). nificantly more force to penetrate the arterial wall

Table 3.  Difference in Force Required for Intraarterial Penetration*

Difference from Difference from Difference from Difference from
20-Gauge Needle 22-Gauge Needle 25-Gauge Needle 27-Gauge Needle
Mean ± Mean ± Mean ± Mean ±
Needle SD (N) p SD (N) p SD (N) p SD (N) p
20-gauge — 0.06 ± 0.04 0.974 0.43 ± 0.05 <0.001† 0.42 ± 0.00 0.001†
22-gauge 0.06 ± 0.04 0.974 — 0.39 ± 0.01 <0.002† 0.38 ± 0.04 <0.002†
25-gauge 0.43 ± 0.05 0.000† 0.39 ± 0.01 0.002† — 0.01 ± 0.01 1.000
27-gauge 0.42 ± 0.00 0.001† 0.38 ± 0.04 0.002† 0.01 ± 0.05 1.000 —
*Statistical differences are shown as p values.
†Differences that were highly statistically significant (p < 0.005).

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 Volume 143, Number 3 • Arterial Wall Penetration Forces

face was examined. This indicates that the force

needed to penetrate an artery is similar, inde-
pendent of whether this artery is located in the
midface or the temple, whether the injected indi-
vidual is a man or a woman, or whether the injec-
tion is performed on the left or the right side of
the face. From a clinical perspective, this is impor-
tant because it shows that a similar resistance can
be expected during the implantation of soft-tis-
sue fillers independent of the above-mentioned
factors. This provides important safety guidance
during soft-tissue filler procedures when trying to
avoid an intraarterial injection. Another strength
of the present study is that the body donors used
were not embalmed; there was no tissue altera-
Fig. 4. Bar graph showing the mean force required to penetrate tion because of the effects of infused chemicals,7
an artery for 20-, 22-, 25-, and 27-gauge needles. The force nor was latex injected into the arterial vascular
required for penetration differed significantly for the investi- system. The latter can significantly influence the
gated needles (p < 0.001). The 25-gauge needle required the forces measured during the penetration proce-
smallest force until penetration (0.69 N). Error bars = 95 percent dures because the lumen of the vessels is filled
confidence interval. with latex.8
A limitation of the analysis, however, is the
compared to 22- and 25-gauge needles. There was small sample size of n = 4 body donors. A larger
no statistical difference in the measured forces, sample size would provide a more valid basis for
however, when comparing 27-gauge cannulas to the results obtained and the conclusions reached.
27-gauge needles. This indicates that the arterial However, we performed 294 penetration proce-
wall could be perforated by applying the same dures in total and used the mean of three to con-
force independent of whether a 27-gauge cannula duct statistical analyses.
or a 27-gauge needle was used. The use of soft-tissue fillers is not free of
A strength of the present study is the large risk and can lead to a variety of adverse events.
number of penetration procedures conducted These may range from local and transient side
(n = 294) that were performed both in the facial effects such as ecchymosis and edema to more
artery and in the anterior branch of the superficial severe adverse events such as infection, herpetic
temporal artery. The arteries chosen are branches outbreak, and the formation of nodules and
of the external carotid arterial system and have granulomas.9–16 The most serious adverse events,
been shown to have multiple connections to the however, are related to intraarterial injection of
internal carotid arterial system and ultimately to soft-tissue fillers, leading to subsequent tissue loss,
the ophthalmic artery and its branches.6 Another blindness, stroke, and even death.12,17–21 Current
strength of this study is the statistical analysis per- explanatory models are incomplete, but the most
formed. There was no statistically significant dif- probable pathophysiologic mechanism is that soft-
ference in the forces required to penetrate an tissue filler material is introduced into the arterial
artery between the two sexes, the two arteries circulation, then transported distally to regions
chosen for this investigation, or which side of the that are particularly vulnerable to ischemia. This

Table 4.  Difference in Force Required for Intraarterial Penetration When Using 22-, 25-, and 27-Gauge
Cannulas*
Difference from Difference from Difference from
22-Gauge Cannula 25-Gauge Cannula 27-Gauge Cannula
Cannula Mean ± SD p Mean ± SD p Mean ± SD p
22-gauge — — 0.46 ± 0.05 0.003† 0.72 ± 0.05 <0.001†
25-gauge 0.46 ± 0.05 0.003† — — 0.26 ± 0.0 0.121
27-gauge 0.72 ± 0.05 0.000 † 0.26 ± 0.00 0.121 — —
*Statistical differences are given as p values.
†Differences that were highly statistically significant (p < 0.005).

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 Plastic and Reconstructive Surgery • March 2019

symptomatic internal carotid artery occlusion.

The authors concluded that cerebral perfusion
to focal regions of the brain may strongly depend
on the contribution of the external carotid artery
ipsilateral to the side of the internal carotid artery
occlusion; this relies on a patent pathway by means
of the ophthalmic artery.22 This finding empha-
sizes the significance of the ophthalmic artery as
an essential vascular bridge between the external
carotid artery and internal carotid artery circula-
tory systems.
The face is highly vascularized, with a mul-
titude of anastomoses between arteries located
both on the ipsilateral side and on the contralat-
eral side. Thus, it is plausible that soft-tissue fill-
Fig. 5. Bar graph showing the mean force required to penetrate ers, accidentally injected into the arterial system,
an artery for 22-, 25-, and 27-gauge cannulas. The force required can gain access to the ophthalmic circulation and
for penetration differed significantly for the investigated cannu- cause serious adverse events. Using a blunt tip can-
las (p < 0.001). A 27-gauge cannula required the smallest force nula was thought to prevent an intraarterial pen-
until penetration (0.78  N). Error bars = 95 percent confidence etration because of the shape of the tip—blunt
interval.
and round—and the belief that cannulas “slide”
around an artery rather than penetrate it. This
reduced ability to penetrate vessels (and other
structures) led some health care professionals to
deem cannulas safer when compared to sharp-
tip needles; the latter were felt to have a greater
risk of vascular penetration. The results of this
study, however, suggest that these generalizations
should be reexamined. We identified that the
force needed to penetrate an artery is not signifi-
cantly different when comparing 27-gauge nee-
dles to 27-gauge cannulas; both devices required
a similar force to be inserted into an artery: 0.70
± 0.29 N (needle) versus 0.78 ± 0.35 N (cannula)
with p = 0.558. This finding reveals that cannulas,
when being advanced in facial soft tissues, can
penetrate an artery (and potentially introduce
Fig. 6. Bar graph showing the mean force required to penetrate soft-tissue filler material into the arterial system)
an artery for 20-, 22-, 25-, and 27-gauge needles and for 22-, 25-, just as easily and at the same force as a needle. If
and 27-gauge cannulas. Cannulas and needles of the same size safety is defined as the diminished ability to pen-
were compared to each other. Force required for penetration
etrate the facial arterial vasculature, then using
differed significantly for the 22-gauge and 25-gauge injectors
a 27-gauge cannula provides no increased safety
(p = 0.001 and p = 0.006, respectively), whereas there was no
when compared to a needle for avoiding an intra-
difference in the required force between 27-gauge needles and
arterial penetration.
cannulas. Error bars = 95 percent confidence interval.
The results of the present study also revealed
that the larger the diameter of the injector—for
enhanced susceptibility to ischemia is often caused both needles and cannulas—the greater the force
by the lack of any collateral blood supply. One of needed to penetrate an artery. From a purely
the most vulnerable regions is the retina, which physical perspective, the factor ultimately leading
receives its arterial blood supply from branches of to an arterial wall penetration is the local pres-
the ophthalmic artery. The ophthalmic artery is an sure generated by the tip of the injector on the
important connective pathway between the exter- arterial wall. Pressure is defined as the amount of
nal carotid artery and the internal carotid artery force per area applied to the surface of an object;
vascular territories. This finding was confirmed by if the force is kept constant, a change in area
a recent investigation performed in patients with determines the pressure generated on the object:

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 Volume 143, Number 3 • Arterial Wall Penetration Forces

a greater area generates a smaller amount of pres- was detected. This indicates that a 27-gauge can-
sure, whereas a smaller area generates a greater nula is not safer than a 27-gauge needle.
amount of pressure. If the pressure on the arterial
Sebastian Cotofana, M.D., Ph.D.
wall exceeds the resistance of the tissue, arterial Albany Medical College
wall penetration occurs. The results of our study 47 New Scotland Avenue, MC-135
are in line with this physical concept; we dem- Albany, N.Y. 12208
onstrated that larger injectors, independent of cotofas@amc.edu
whether the injector was a needle or a cannula, Instagram: @professorsebastiancotofana
Facebook: professorsebastiancotofana
required significantly (p < 0.001) greater forces
for intraarterial penetration. The pressure gener-
ated by 27-gauge injectors, however, exceeded the ACKNOWLEDGMENT
resistance of the facial and the superficial tempo- The authors thank Jeremy Green, M.D., for fruitful
ral arterial wall at a similar magnitude of applied discussions during the enrollment of the study and for
force: 0.70 ± 0.29 N versus 0.78 ± 0.35 N (needle support during the writing of the manuscript.
versus cannula) (p = 0.558). This is important
from a clinical perspective; assuming a constant REFERENCES
force when advancing the injector in facial soft
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Drug Administration. Soft tissue fillers approved by the Center
it can be deduced that a 22-gauge cannula is safer for Devices and Radiological Health. Available at: https://www.
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