To aspirate or not to aspirate? - Casabona et al

Author: Mike Clague BSC Aesthetic Nurse   Date Posted:3 July 2018 


Hi Facecoacher’s,

Assoc Prof Goodman is over in the USA currently speaking about intravascular complications at the American Academy of Dermatology meeting in Sandiego. Recently our Mike Clague attended the Multidisciplinary Conference in Las vegas and saw many live injecting demonstrations. It is common to see safety sessions presented at all aesthetic medical conferences with regard to fillers.


There is still an alarming amount of doctors teaching ‘aspiration’ as a ‘safe’ method of injecting dermal filers. There is still much controversy over whether aspirating before injecting dermal fillers enhances your safety and protects you from having an ischemic event with filler. It is commonly accepted that aspiration on it’s own isn’t the best method of preventing an ischemic event with a filler but how much do you rely on it?

  • How long do you pull back on the plunger for?
  • Does EVERY filler allow aspiration with blood?

We reviewed clinical research by Casabona on the question of aspiration.


Blood Aspiration Test for Cosmetic Fillers to Prevent Accidental Intravascular Injection in the Face.

Casabona G, 2015

Dermatol Surg. 2015 Jul;41(7):841-7.

Our Summary –



Dermal filler complications appear to be increasing each year. Many believe that blood aspiration tests (pulling back on the plunger before injection) are an adequate way of reducing ischemic complications with dermal fillers. Many injectors still perform this aspiration test and it is still widely taught by Key Opinion Leaders on stage at medical symposia. It is important to reduce the risk of ischemic complications, the most catastrophic being blindness or brain injury.


Dr Casabona aimed to evauluate the reliability of the blood aspiration test.


A red ink solution similar in consistency to venous blood was withdrawn from a cup using a syringe containing 0.1 mL filler. The filler was in the manufacturers syringe with only 0.1ml left. 17 different filler products were tested including hyaluronic acid, PLLA (Sculptra) or calcium hydroxyapatite.

The plunger was pulled to see if there was any aspiration. They pulled on the plunger for a maximum of 10 seconds. If there was no aspiration after 10 seconds it was a negative aspiration. They tested 3 syringes for each product and measured the time to aspirate each.

When the aspiration failed the authors retested with larger gauge needles until aspiration was observed.


The aspiration test with an ink solution in vitro was negative with 8 filler products (47%) and positive with 9 filler products (53%); for all products that had a negative aspiration test, the test became positive when a larger-gauge needle was used. Products that initially wouldn’t aspirate in under 10 seconds included Juvederm Ultra XC, Juvederm Ultraplus XC, Perlane (Restylane LYFT), Emervel Classic, emervel Lips, Beletero, Radiesse.

The authors increased the needle gauge on those products that wouldn’t aspirate. Perlane took the longest to aspirate at 8 seconds with a 29g needle.


The aspiration test was reliable with 53% syringes and needles tested. Increasing the needle gauge helped those products that wouldn’t aspirate to become positive.



Aspiration before injecting dermal fillers will not prevent an ischemic event. It is ONE of several tools to help prevent an ischemic event with dermal fillers.

According to this research remember;

  1. not all products will allow a positive result
  2. increasing needle gauge could allow a higher rate of positive results
  3. the longest time required to achieve a positive result was 8 seconds (anything above 10 seconds was a negative). SO remember this if you are going to use aspiration as a safety measure.


Knowing how to treat an ischemic event (from a HA dermal filler) with hyaluronidase is vital.


In our online course and in our Australian training sessions we discuss the main ways to avoid ischemic events with HA fillers and the use of hyaluronidase.

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