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Original Investigation
December 30, 2020

Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection

Author Affiliations
  • 1Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Department of Otolaryngology–Head & Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 3Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 4Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California
  • 5Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
  • 6Department of Dermatology, Alpert Medical School, Brown University, Providence, Rhode Island
  • 7SkinCare Physicians, Chestnut Hill, Massachusetts
  • 8University of Missouri-Kansas City School of Medicine, Kansas City
JAMA Dermatol. 2021;157(2):174-180. doi:10.1001/jamadermatol.2020.5102
Key Points

Question  When injecting fillers, what is the risk of vascular occlusion with needles vs cannulas?

Findings  In this cohort study of 370 participating dermatologists, the risk of vascular occlusion appears exceedingly low (1 in 6410 syringes via needle and 1 in 40 882 via microcannula injector) when board-certified dermatologists inject skin fillers with needles or cannulas. Cannulas appear associated with lower occlusion risk, and most occlusions resolve without sequelae.

Meaning  When it is feasible and appropriate based on patient characteristics, anatomic location, and other clinical factors, dermatologists may consider using cannulas for filler injection to further minimize occlusion risk.


Importance  Soft-tissue augmentation with skin fillers can be delivered with needles or microcannulas, but unwanted vascular occlusions are possible.

Objective  To determine whether filler-associated vascular occlusion events of the face occur more often with injections performed with needles than with microcannulas.

Design, Setting, and Participants  This retrospective cohort study included a random sample of board-certified dermatologists deemed eligible based on membership in relevant professional societies and attendance at relevant national professional meetings. Participants completed detailed forms in which they could enter deidentified data and volume statistics pertaining to patients undergoing filler procedures in their practices. Data were collected from August 2018 to August 2019.

Exposures  Injectable fillers approved by the US Food and Drug Administration delivered via needles or microcannulas.

Main Outcomes and Measures  The primary outcome measure was intravascular occlusion. Occlusion events were graded by severity (no sequelae, scar, and ocular injury or blindness).

Results  A total of 370 dermatologists (mean [SD] years in practice, 22.3 [11.1] years) participated and reported 1.7 million syringes injected. The risk of occlusion with any particular filler type using needle or cannula never exceeded 1 per 5000 syringes injected. Overall, 1 occlusion per 6410 per 1-mL syringe injections was observed with needles and 1 per 40 882 with cannulas (P < .001). Of the 370 participants, 106 (28.6%) reported at least 1 occlusion. Multivariate analysis found that injections with cannula had 77.1% lower odds of occlusion compared with needle injections. Participants injecting fillers for more than 5 years had 70.7% lower odds of occlusion than those who were less experienced. For each additional injection per week, the odds of occlusion decreased by 1%, and 85% of occlusions had no long-term sequelae. Nasolabial folds and lips were most likely to be occluded, with mean severity level of occlusions highest at the glabella.

Conclusions and Relevance  In this cohort study, filler injections with either needles or cannulas were associated with a very low risk of intravascular occlusion events. Moreover, the vast majority of such events were minor and resolved without scar or other injury. Injections with microcannulas were less often associated with occlusion events than injections with needles. Occlusion risk per syringe appeared decreased after the first few years of clinical practice and was also lower among those who more frequently inject fillers. Whether a needle or cannula is most appropriate for injection may depend on patient factors, anatomic site, and the type of defect being treated.

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