Part 3 - To Aspirate or Not to Aspirate? - Carey et al

Author: Mike Clague Aesthetic Nurse BSC   Date Posted:31 August 2018 

The question of how to best avoid an ischemic event with a dermal filler remains controversial.  The technique of aspirating before you inject the filler is still taught by many experts.  Sometimes in combination with large boluses after the aspiration.

There are now 3 publications in peer reviewed journals showing that aspiration is an unreliable way to prevent an ischemic event with dermal filler. 

We have reviewed the Casabona study, the Van Loghem study and now we will review the 3rd stud in this series on aspiration.  

Retraction of the Plunger on a Syringe of Hyaluronic Acid Before Injection: Are We Safe?

Wayne Carey, MD, FRCP(c), FAAD,* and Susan Weinkle, MD, FAAD†

 ·Dermatol Surg 2015;41:S340–S346 ·DOI: 10.1097/DSS.0000000000000557



The authors wished to determine if blood could be aspirated back into a HA syringe when the needle is primed or filled with HA filler. 


Blood was heparinized.  Two tests were set up to test the aspiration theory.  One test was to pull back on the plunger in a rapid fashion the way many injectors do.  The second test was to pull back on the plunger for a minimum of 5 seconds.  


Review of these data also demonstrates that the usual clinical technique, which involves pulling back quickly with a short wait time before release, in most cases does not allow for sufficient removal of the intra- luminal filler, leading to false negative results in vitro and likely in vivo.

The results show that withdrawal in most cases fails to clear the needle lumen of material allowing return of blood, particularly with the rapid pull–release method. Whether material remains in the narrow lumen or congests the needle hub or both is not certain. The more efficacious technique of the 2 methods to withdraw blood is to maintain a maximum negative pressure with a prolonged waiting period, which may release the material. However, this would be imprac- tical, and not always a certainty. Certain product lines and certain companies have products, which are more likely to block the needle. The Galderma/Medicis products routinely are cleared from the needle using the slow-pull technique.


One can not be certain that they are safely injecting HA filler when using the aspiration technique.  Some products do not aspirate at all with a quick pull back on the plunger.  Even with a pull on the plunger over 5 seconds some products do not aspirate.  The older style Galderma products seem less cohesive and tend to allow for aspiration more easily than others in this study.



Aspiration should not be relied upon as an accurate test to see if you are in a blood vessel with your needle.  Using aspiration as a test could easily lead to an ischemic event with HA filler as many of them will not pull through the needle if it is filled with Hyaluronic acid filler.

We teach-

  • Keep your needle tip moving at all times
  • Consider a large bore 22g cannula in areas that are risky
  • Do not treat noses or glabellas with dermal fillers, it just isn't safe
  • Inject slowly, gentle pressure on the plunger
  • Inject small amounts less than 0.1ml
  • Avoid semi-permanent and permanent fillers - if you can't take it out, don't put it in

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