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Figure 1.
Sharp Needle (Left) vs Blunt Needle (Right)
Sharp Needle (Left) vs Blunt Needle (Right)
Figure 2.
Participant Enrollment, Randomization, and Analysis
Participant Enrollment, Randomization, and Analysis
Figure 3.
Illustrations of Pain and Hematoma Assessments in Anesthesia Administration by Blunt vs Sharp Needles in Upper Blepharoplasty Procedure
Illustrations of Pain and Hematoma Assessments in Anesthesia Administration by Blunt vs Sharp Needles in Upper Blepharoplasty Procedure

A, The mean visual analog scale pain scores were 5.48 and 4.64 (error bars indicate SD) for sharp and blunt needles, respectively (P = .002). B, The incidence of hematoma produced by blunt (0 of 44) and sharp needles (11 of 44) was ascertained by direct visualization of the surgical wound and evaluation of photographs (P < .001).

Figure 4.
Photographic Documentation of Bruise and Hematoma
Photographic Documentation of Bruise and Hematoma

Prior to the upper blepharoplasty procedure, local anesthesia was injected into the left eye with a blunt needle and the right eye with a sharp needle, and both eyelids were evaluated for bruise (A) and hematoma (B). Both bruise and hematoma were associated only with sharp-needle injection.

Figure 5.
Female Patient Scheduled for Bilateral Upper Blepharoplasty
Female Patient Scheduled for Bilateral Upper Blepharoplasty

A, Preoperative image. B, The left eyelid received local anesthesia injections with a blunt needle, and the right eyelid with a sharp needle; bruising is apparent on the right eyelid (sharp needle) but not on the left (blunt needle). C, One year after blepharoplasty, medial canthoplasty, and rhinoplasty.

1.
Pool  SM, van Exsel  DC, Melenhorst  WB, Cromheecke  M, van der Lei  B.  The effect of eyelid cooling on pain, edema, erythema, and hematoma after upper blepharoplasty: a randomized, controlled, observer-blinded evaluation study.  Plast Reconstr Surg. 2015;135(2):277e-281e.PubMedGoogle ScholarCrossref
2.
Lu  JJ, Yang  K, Jin  XL,  et al.  Epicanthoplasty with double eyelidplasty incorporating modified Z-plasty for Chinese patients.  J Plast Reconstr Aesthet Surg. 2011;64(4):462-466.PubMedGoogle ScholarCrossref
3.
Choi  Y, Eo  S.  A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues.  Plast Reconstr Surg. 2010;126(3):1048-1057.PubMedGoogle ScholarCrossref
4.
Fengzhi  X, Wei  Z, Guo-Kang  F, Jiang  C, Hua  L.  Double eyelid operation recreating the anatomic microstructure.  Ann Plast Surg. 2009;63(3):242-248.PubMedGoogle ScholarCrossref
5.
Akins  EW, Hawkins  IF  Jr, Mladinich  C, Tupler  R, Siragusa  RJ, Pry  R.  The blunt needle: a new percutaneous access device.  AJR Am J Roentgenol. 1989;152(1):181-182.PubMedGoogle ScholarCrossref
6.
Frayer  WC, Jacoby  J. Local anesthesia. In: Duane  TD, Jaeger  EA, eds.  Clinical Opthalmology. Vol 5. New York, NY: Harper and Row; 1987:1-10.
7.
Nelson  JW.  Letter to the editor.  Spine. 2002;3:1-2.Google Scholar
8.
Lazzeri  D, Agostini  T, Figus  M, Nardi  M, Pantaloni  M, Lazzeri  S.  Blindness following cosmetic injections of the face.  Plast Reconstr Surg. 2012;129(4):995-1012.PubMedGoogle ScholarCrossref
9.
Soubihe Junior  NV, Schmidt  A, Albuquerque  AA, Evora  PR.  Presentation of a needle for direct or percutaneous myocardium stem cells injection.  Rev Bras Cir Cardiovasc. 2013;28(3):405-407.PubMedGoogle ScholarCrossref
10.
Heavner  JE, Racz  GB, Jenigiri  B, Lehman  T, Day  MR.  Sharp versus blunt needle: a comparative study of penetration of internal structures and bleeding in dogs.  Pain Pract. 2003;3(3):226-231.PubMedGoogle ScholarCrossref
Original Investigation
Mar/Apr 2017

Occurrence of Bruise, Hematoma, and Pain in Upper Blepharoplasty Using Blunt-Needle vs Sharp-Needle Anesthetic Injection in Upper Blepharoplasty: A Randomized Clinical Trial

Author Affiliations
  • 1Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Plastic and Reconstructive Surgery, Shanghai, China
  • 2Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
 

Copyright 2016 American Medical Association. All Rights Reserved.

JAMA Facial Plast Surg. 2017;19(2):128-132. doi:10.1001/jamafacial.2016.1376
Key Points

Question  Is there a difference between occurrence of hematoma and pain in upper blepharoplasty using blunt- vs sharp-needle injection of local anesthesia?

Findings  In this randomized clinical trial of 44 women who underwent blepharoplasty with sharp-needle anesthesia injection in one eyelid and blunt-needle injection in the other, hematoma occurred at the sharp-needle site in 11 patients (25%) vs 0 patients at the blunt-needle site. The mean visual analog scale pain scores were 5.48 and 4.64 at the sharp- and blunt-needle sites, respectively.

Meaning  The use of blunt-needle injection for anesthesia administration in upper blepharoplasty may cause fewer complications and allow more accurate and refined work with faster patient recovery.

Abstract

Importance  Though it has been a common practice to use sharp needles to administer local anesthesia for upper blepharoplasty, the evidence for their benefit is lacking.

Objective  To evaluate whether there is any benefit of using blunt-needle injection for local anesthesia when performing upper blepharoplasty to reduce postoperative bruise, hematoma, and pain.

Design, Setting, and Participants  Randomized clinical trial of 44 patients who underwent bilateral upper blepharoplasty in an academic medical setting were randomized to receive local anesthesia injections (lidocaine, 2%; 27-gauge needle) with a blunt needle in one eyelid and a sharp needle in the other eyelid.

Main Outcomes and Measures  Visual analog scale (VAS) score of 0 to 10 (lower score indicating lower level of pain) was used to blindly assess pain in patients receiving anesthesia injections with both needle types. After injection and skin incision, photographs of the eyelids of each patient were taken and used by 2 blinded observers to identify bruise or hematoma.

Results  In the 44 patients (88 eyelids) included in the study (all women; mean age, 31 years; age range, 18-56 years) bruise or hematoma occurred at the sharp-needle injection site in 11 women (25%) vs 0 women at the blunt-needle site (P < .001). The mean VAS scores were 5.48 and 4.64 for pain assessed at sites of sharp- and blunt-needle injections, respectively (P = .002).

Conclusions and Relevance  Use of blunt needles to administer local anesthesia when performing upper blepharoplasty is less likely to cause hemorrhage and require interventional pain procedures than use of sharp needles. Therefore, for a more accurate surgical procedure and faster recovery, a blunt needle may be a preferable choice. The use of the blunt needle presents fewer complications and allows more accurate and refined work with faster patient recovery.

Level of Evidence  1.

Trial Registration  Chinese Clinical Trial Registry identifier: ChiCTR-ONC-16007979

Introduction

Blepharoplasty, one of the most common surgical procedures performed by plastic surgeons, can improve dermatochalasis, a common condition of excess skin hanging over the upper eyelids or even beyond the eyelashes, mostly caused by aging.1 In Asian patients, in particular, double eyelid plasty, also known as Asian blepharoplasty or double eyelid surgery, is frequently performed together with epicanthoplasty to create a superior eyelid with a crease and remove the epicanthal fold in Asian upper eyelids. The surgical procedure creates an illusion of larger, more relaxed eyes and has become one of the most common cosmetic procedures in Asia.2-4

Conventional sharp needles (Figure 1) have been widely used to administer local anesthesia injections in upper blepharoplasty. However, blunt needles have been considered (Figure 1) because they are less prone than sharp ones to produce bleeding from unintended entry into blood vessels.5 Hence, many surgeons use blunt-tip microcannula devices to avoid inadvertent penetration of adjacent vital structures or arteries during surgery.6

In previous studies, complications resulting from hematoma and interventional pain procedures have raised the issue of improved safety when using blunt needles instead of sharp needles in these procedures.7 To our knowledge, this is the first prospective, side-by-side comparison study to evaluate potential advantages of blunt-needle use on complications such as incidence of bruise and/or hematoma and need for interventional pain procedures. Specifically, by using both 1 blunt and 1 sharp needle to inject local anesthesia into contralateral eyes of each patient undergoing upper blepharoplasty, we evaluated whether the blunt needles reduced complications of upper blepharoplasty compared with the sharp ones.

Methods

This prospective, observer-blinded, randomized clinical trial was approved by the investigational review board of the Shanghai Ninth People’s Hospital. All patients provided their written informed consent. The study protocol is available in the Supplement. We recruited study participants from October 2014 through October 2015 among patients throughout the Shanghai Ninth People’s Hospital who were scheduled for bilateral upper blepharoplasty (Figure 2). Patients who had undergone previous surgery on the upper eyelids were excluded.

Prior to the operation, local anesthesia (lidocaine, 2%) was injected into both eyelids of each patient using a blunt needle (27-gauge, 2 inches long [50 mm]) for one upper eye lid and a sharp needle (27-gauge, 1.4 inches long [35 mm]) for the other eyelid. The selection of each upper eyelid to be injected with either needle type was determined by a randomization procedure: when the random sequence software was applied (http://www.dxy.cn/bbs/topic/21117904), it produced a randomized number sequence from 1 to xx; then random sequence numbers were assigned to the patients. Blunt needles were used in the left eye, sharp needles in the right, of patients assigned odd numbers. Sharp needles were used in the left eye, blunt needles in the right, of patients assigned even numbers. Upper blepharoplasties were performed by a plastic surgeon at the Shanghai Ninth People’s Hospital.

Interventional Pain Procedures

To assess the difference in need for interventional pain procedures between the use of blunt and sharp needles for local anesthesia injections, patients were asked to score the pain of both upper eyelids, without knowing which needle was used in which, by means of a visual analog scale (VAS) ranging from 0 (no pain at all) to 10 (unbearable pain). This score was used to measure the pain in eyes receiving local anesthesia injections with each type of needle (Figure 3A).

Bruise and/or Hematoma

A bruise and/or hematoma is caused by blood from a broken blood vessel that has accumulated under the skin, a mass of blood in the tissue as a result of trauma, or other factors that cause the rupture of blood vessels. When blood vessels are injured by a needle, localized subcutaneous bleeding can lead to red or dark red spots. The difference between the incidence of bruise and/or hematoma at the sites of local anesthesia injections given to study patients by using a blunt needle for one upper eyelid and a sharp needle for the other was assessed by photographic evaluation. Immediately after injection (Figure 4A) and again after skin incision (Figure 4B), photographs of both eyelids were taken. Photographic evaluation was performed by 2 plastic surgeons who were blinded to the intervention: they did not know which needle type was used in which eye at the sites of local anesthesia injections. The results of their evaluation are illustrated in Figure 3B.

Data Analysis

The descriptive statistics of the study population were analyzed by frequency for categorical variables, mean (SD) for normally distributed continuous variables, and median (interquartile range) for nonnormally distributed continuous variables. Differences in pain by sharp and blunt needles were assessed using the Wilcoxon signed rank test, while occurrence of bruise and/or hematoma was compared using the χ2 test. P < .05 was considered statistically significant. All the analyses were performed using SPSS 19.0 (IBM Corporation) and GraphPad Prism 5 (GraphPad Software Inc) software packages.

Results

A total of 52 patients were included in this study who were evaluated for the occurrence of hematoma, but 8 patients were excluded because of lack of pain evaluation. Finally, there were 44 patients who underwent the full study analysis. All 44 patients (100%) were women whose ages ranged from 18 to 56 years (mean age, 31 years).

Interventional Pain Procedures

To assess the pain produced by the use of blunt and sharp needles for local anesthesia injections in upper blepharoplasty, the patients self-evaluated their pain by assigning it a VAS score from 0 (no pain) to 10 (worst pain). The mean (SD) VAS scores were 5.48 (1.59) and 4.64 (1.67) for sharp and blunt needles, respectively (Figure 3A). The difference in VAS scores between sharp and blunt needles was statistically significant (P = .002, with 95% CIs, 4.13-5.14 for the blunt-needle sites and 4.99-5.96 for sharp-needle sites), which suggests that using blunt needles for local anesthesia injections in upper blepharoplasty causes less pain than using sharp needles.

Bruise/Hematoma

Immediately after injection, bruises appeared on the upper eyelids (Figure 4A). Immediately after skin incision, accumulations of blood (hematomas) were visible (Figure 4B). Figure 5 shows the bruising pattern from before the injection, after the injection, and 1 year postoperatively. The occurrence of a bruise and/or hematoma at the sites of injection with sharp and blunt needles were confirmed by direct visualization of the surgical wounds and evaluation of photographs. These observations revealed that occurrence of bruise and/or hematoma in 11 (25%) eyelids treated with sharp needles vs 0 eyelids treated with blunt needles. The difference observed in side-by-side comparison between sharp and blunt needles in each patient was statistically significant (P < .001; 95% CI, 1.12-1.58), which indicates that blunt needles may reduce the incidence of bruise and hematoma in upper blepharoplasty compared with sharp needles (Figure 3B).

Discussion

To our knowledge, this is the first prospective, side-by-side comparison study revealing that the use of a blunt needle for local anesthesia injections in upper blepharoplasty is associated with a lower level of pain and a lower incidence of bruise and/or hematoma. This indicates that the use of blunt needles can minimize patient discomfort and allow for greater surgical precision when performing the upper blepharoplasty procedure and thus lead to fewer complications and faster recovery.

The practice of using sharp needles for local anesthesia injections in the upper blepharoplasty procedure is widespread. However, the complications observed with this type of needle, such as bleeding, hematoma, and bruising greatly favor using blunt needles for this procedure.8-10

Blunt needles have been considered easier to use and less likely than sharp ones to produce bleeding because of inadvertent penetration of arteries or adjacent vital structures. Accordingly, blunt needles are used to reduce the complications resulting from the use of sharp ones, which include bleeding, bruising, blood vessel impalement and subsequent intravascular injection and hemorrhage.

In a study of blunt vs sharp needle use in dogs, Heavner et al10 directly observed the bleeding and penetration through a surgical wound caused by the insertion of blunt and sharp needles (18-, 20-, 22-, and 25-gauge), directly or percutaneously, into liver, intestine, spinal nerve and/or nerve root, kidney, or renal artery. Their results showed that compared with sharp needles, blunt needles are less prone to enter vital structures and produce hemorrhage.10 In addition, another dog study5 found that blunt needles may reduce the unintended entry into blood vessels and produce less bleeding than sharp ones.

Our study of upper blepharoplasty shows a decrease in bruise and/or hematoma incidence and in level of pain by using blunt needles for local anesthesia injections rather than sharp needles. These findings are consistent with our observation that the use of blunt needles for local anesthesia injections in upper blepharoplasty is associated with fewer complications, superior outcome, and improved recovery. Patients were satisfied with the procedure, and complications were minimal. It is important to the patient to achieve a satisfying aesthetic result without severe bruising, swelling, and disfigurement.

In this study, bruises and/or hematomas were observed in the eyelids of 11 (25%) of 44 patients who were injected by using a sharp needle in the upper blepharoplasty procedure, while no bruises and/or hematomas were observes in the contralateral eyelids of the same patients injected with a blunt needle. Moreover, the results of this study clearly show that blunt needles are less likely to enter blood vessels than sharp ones. Furthermore, for the upper blepharoplasty procedure, local anesthesia injections with blunt needles is also less likely to produce bleeding and hematoma than sharp needles. These results are also consistent with results from previous studies, where fewer complications were observed from blunt needles than from sharp needles.8-10

It has been noticed that in some patients undergoing a second upper blepharoplasty procedure, it was difficult to apply local anesthesia by using the blunt needle due to the scar formation from the previous surgery. In fact, it may be easier to puncture and inject the anesthesia by using a sharp needle in scar formations.

Limitations

The bruise and/or hematoma was assessed by photographic evaluation immediately after injection and again after skin incision, but patients were not evaluated between 2 hours postprocedure to 6 days after upper blepharoplasty; therefore, significant bruising of the eyelids might have missed in this period because of the choice of time points (after 1 hour, 1 week, and 1, 3, and 6 months), which are in line with the regular follow-up time points after upper blepharoplasty used in the daily practice of our hospital.

Conclusions

In conclusion, a comparison of blunt- vs sharp-tip needles was the focus of this study. To our knowledge, this study provides the first prospective side-by-side comparison of sharp and blunt needles used for local anesthesia injections in upper blepharoplasty. The results indicate that blunt needles may reduce the entry into vital structures and reduce the occurrence of hemorrhage and hematoma. In addition, blunt needles may be more beneficial for performing interventional pain procedures than sharp needles. Therefore, the use of blunt needles has the potential to become a conventional application to reduce the complications during the administration of local anesthesia injection in upper blepharoplasty and lead to a faster recovery.

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Article Information

Corresponding Author: Xiaoxi Lin, MD, PhD, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Department of Plastic and Reconstructive Surgery, No. 639 Zhizaoju Road, Shanghai, Shanghai 200011, China (linxiaoxi@126.com).

Accepted for Publication: July 3, 2016.

Correction: This article was corrected on March 16, 2017, to fix an author’s reported affiliation.

Published Online: November 23, 2016. doi:10.1001/jamafacial.2016.1376

Author Contributions: Drs Yu and Jin were contributed equally to this work and should be considered co–first authors. Drs Yu and Jin both had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ma, Chen, Yang, Chang, Lin.

Acquisition, analysis, or interpretation of data: Yu, Jin, Yang, Ma, Qiu, Chen, Yang, Chang.

Drafting of the manuscript: Yu, Chen, Chang.

Critical revision of the manuscript for important intellectual content: Yu, Jin, Yang, Ma, Qiu, Yang, Chang, Lin.

Statistical analysis: Yu, Jin, Yang, Qiu, Chen, Yang, Chang, Lin.

Administrative, technical, or material support: Ma, Qiu, Chen, Yang, Lin.

Study supervision: Ma, Chen, Chang, Lin.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patients for granting permission to publish this information.

References
1.
Pool  SM, van Exsel  DC, Melenhorst  WB, Cromheecke  M, van der Lei  B.  The effect of eyelid cooling on pain, edema, erythema, and hematoma after upper blepharoplasty: a randomized, controlled, observer-blinded evaluation study.  Plast Reconstr Surg. 2015;135(2):277e-281e.PubMedGoogle ScholarCrossref
2.
Lu  JJ, Yang  K, Jin  XL,  et al.  Epicanthoplasty with double eyelidplasty incorporating modified Z-plasty for Chinese patients.  J Plast Reconstr Aesthet Surg. 2011;64(4):462-466.PubMedGoogle ScholarCrossref
3.
Choi  Y, Eo  S.  A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues.  Plast Reconstr Surg. 2010;126(3):1048-1057.PubMedGoogle ScholarCrossref
4.
Fengzhi  X, Wei  Z, Guo-Kang  F, Jiang  C, Hua  L.  Double eyelid operation recreating the anatomic microstructure.  Ann Plast Surg. 2009;63(3):242-248.PubMedGoogle ScholarCrossref
5.
Akins  EW, Hawkins  IF  Jr, Mladinich  C, Tupler  R, Siragusa  RJ, Pry  R.  The blunt needle: a new percutaneous access device.  AJR Am J Roentgenol. 1989;152(1):181-182.PubMedGoogle ScholarCrossref
6.
Frayer  WC, Jacoby  J. Local anesthesia. In: Duane  TD, Jaeger  EA, eds.  Clinical Opthalmology. Vol 5. New York, NY: Harper and Row; 1987:1-10.
7.
Nelson  JW.  Letter to the editor.  Spine. 2002;3:1-2.Google Scholar
8.
Lazzeri  D, Agostini  T, Figus  M, Nardi  M, Pantaloni  M, Lazzeri  S.  Blindness following cosmetic injections of the face.  Plast Reconstr Surg. 2012;129(4):995-1012.PubMedGoogle ScholarCrossref
9.
Soubihe Junior  NV, Schmidt  A, Albuquerque  AA, Evora  PR.  Presentation of a needle for direct or percutaneous myocardium stem cells injection.  Rev Bras Cir Cardiovasc. 2013;28(3):405-407.PubMedGoogle ScholarCrossref
10.
Heavner  JE, Racz  GB, Jenigiri  B, Lehman  T, Day  MR.  Sharp versus blunt needle: a comparative study of penetration of internal structures and bleeding in dogs.  Pain Pract. 2003;3(3):226-231.PubMedGoogle ScholarCrossref
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