LETTERS AND COMMUNICATIONS

Figure 2. Representative case (dynamic forehead). There was no significant difference in clinical efficacy between the 2
sides. (A) Before treatment, (B) 4 weeks after PraBoNT-A injection.

reconstituted form, similar to other BoNT-A products. 5. Alam M, Yoo SS, Wrone DA, White LE, et al. Sterility assessment of
multiple use botulinum A exotoxin vials: a prospective simulation. J Am
However, this study was limited by the small sample Acad Dermatol 2006;55:272–5.

size. Further studies with a larger number of partic-

ipants are needed. Kui Y. Park, MD, PhD*
Guk J. Jeong, MD*
References Ga R. Ahn, MD*
Seong J. Seo, MD, PhD*
1. Hexsel DM, De Almeida AT, Rutowitsch M, De Castro IA, et al.
Multicenter, double-blind study of the efficacy of injections Choon S. Youn, MD, PhD†
with botulinum toxin type A reconstituted up to six consecutive weeks
before application. Dermatol Surg 2003;29:523–9; discussion 529.
*Department of Dermatology
Chung-Ang University College of Medicine
2. Parsa AA, Lye KD, Parsa FD. Reconstituted botulinum type A
neurotoxin: clinical efficacy after long-term freezing before use. Aesthet Seoul, South Korea
Plast Surg 2007;31:188–91; discussion 192–3.
†Department of Dermatology
3. Alam M, Bolotin D, Carruthers J, Hexsel D, et al. Consensus statement Yemiwon Dermatologic Clinic
regarding storage and reuse of previously reconstituted
neuromodulators. Dermatol Surg 2015;41:321–6. Seoul, South Korea
4. Carruthers A, Carruthers J, Hardas B, Kaur M, et al. A validated
grading scale for forehead lines. Dermatol Surg 2008;34(Suppl 2): The authors have indicated no significant interest with
S155–60. commercial supporters.

A Physical Argument Against the Use of Small Syringes for Hyaluronic Acid Filler Injections

A growing number of dermatologists claim to inject is a physical law that describes laminar flow of an
soft-tissue filler by backloading smaller 0.3- or 0.5-mL incompressible Newtonian fluid through a hollow
syringes that have built-in 6- or 8-mm 31 G needles cylindrical pipe with a constant circular cross-section
(e.g., BD UltraFine; Becton, Dickinson and Company, substantially longer than its diameter, for example, a
Franklin Lakes, NJ). Irrespective of the risk of bacte- hypodermic needle:
rial contamination, we feel that this technique may
potentially be unsafe, simply on the basis of syringe 8hLQ DPpr4
physics and fluid dynamics. DP 5 or Q 5 ;
pr 4 8hL

Currently available hyaluronic acid filler formulations
are gel-like materials that exhibit Newtonian fluid
behavior during flow out of a syringe, where shear and
viscous stresses are low, maintaining a constant vis-
cosity.1 These fillers are considered incompressible
Newtonian fluids, whose density does not change with
variations in pressure. The Hagen–Poiseuille equation
where DP = hydrostatic pressure gradient between
opposing ends of needle; h = dynamic viscosity; L =
needle length; Q = volumetric flow rate = volume/time;
and r = needle radius.
A decrease in volumetric flow rate effectively decreases
the pressure gradient across the needle. Backloading a

46:7:JULY 2020 993

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 LETTERS AND COMMUNICATIONS

smaller (0.3 or 0.5 mL) syringe with a high silicone
lubricant content could thereby actually enhance
control over flow rate by lowering plunger resistance
and, in turn, limit flow rate and injection pressure.
However, when constant force is applied to the piston
of a syringe containing an incompressible Newtonian
fluid, injection pressure is inversely proportional to the
square of the piston radius. This is described in the
following equation:
F F
P5 5 ;
A pr2
face is more likely to overcome the resistance of
distal arterial branches, potentially leading to more
distal retrograde embolization of filler material.2
Given the potential for greater injection pressures with
the use of these smaller syringes in inexperienced
hands, we recommend that they be used with utmost
caution.
References
1. Ilyin SO, Kulichikhin VG, Malkin AY. The rheological characterisation
of typical injection implants based on hyaluronic acid for contour
correction. Rheol Acta 2016;55:223–33.

2. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding and treating blindness

where P = injection pressure; F = force applied to from fillers: a review of the world literature. Dermatol Surg 2015;41:1097–117.
syringe piston; A = syringe piston area; and r = syringe
piston radius.
Daniel P. Friedmann, MD, FAAD*
Jessica Tran, BBA†
Holding constant the force applied to the syringe
Julie M. Dorland, BS, BA†
piston, decreasing a syringe piston radius by half
*Westlake Dermatology Clinical Research Center
equates to a 4-fold increase in injection pressure.
Westlake Dermatology & Cosmetic Surgery
Although a 1-mL BD Luer-Lok syringe has an
Austin, Texas
internal radius of 2.4 mm, a 0.3-mL BD UltraFine
†Baylor College of Medicine
syringe has an internal radius of 1.5 mm, resulting
Houston, Texas
in a 2.6-fold relative increase in injection pressure
out of the smaller syringe. A greater injection pres- The authors have indicated no significant interest with
sure after accidental cannulation of an artery on the commercial supporters.

994 DERMATOLOGIC SURGERY

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.