COMMENT

Choosing the most appropriate cannula

for dermal filler treatments
Over the past few years, there has been a major shift from the use of sharp needles for dermal filler
injections to blunt cannulas. Although cannulas are considered to be safe and to achieve effective
cosmetic outcomes, there is a lack of clinical studies comparing different products. Marina Landau
reviews the literature and shares her experience in choosing cannulas for this aesthetic procedure

I
njectables have become a mainstay of cosmetic enhancement.
According to the most recent statistics published by the American
Society for Aesthetic Plastic Surgery (2016), 2.4 million dermal
filler injections were carried out in 2015—a 6% increase from
the number of treatments in 2014.
Rising popularity of cannulas
Several dermal fillers are available in the aesthetic market, all of
which are delivered to the target tissue either by using a sharp
needle or a blunt-tipped cannula. In the author’s experience, the
increasing use of blunt-tipped cannulas is related to:
►► The transition from wrinkle correction to three-dimensional
facial volumisation
►► Patients looking for a better ‘treatment experience’ with less
pain during the procedure, minimal bruising in the immediate
post-treatment period and a faster recovery
►► A decreased risk of major complications of filler injections,
© 2017 MA Healthcare Ltd
intradermally in serial punctures, anterograde or retrograde
lines, or in fanning or bridging modes (van Eijk and Braun, 2007;
Bass, 2015). Most of these techniques were relevant in the era in
which dermal fillers were used as ‘wrinkle correctors’.
However, in recent years, there has been a natural evolution
to use dermal fillers for three-dimensional volumisation of the
face. For this purpose, larger areas and deeper planes need to be
addressed (de Felipe and Redondo, 2015). In such circumstances,
using a longer, blunt injection device has numerous advantages,
such as the possibility to cover larger areas of the face through
the use of a single puncture hole.
In addition, some commonly treated facial regions, such
as the tear troughs, mid-face, temples, forehead, cheeks and
marionettes, require ‘inflation’ by a filler as opposed to more
focused intradermal or immediate subdermal filling required to
address individual rhytides.

such as tissue necrosis or remote filler embolism.

MARINA LANDAU
Transition from wrinkle correction Dermatologist, Wolfson Medical Center,
to three-dimensional facial volumisation Holon, Israel.
Traditional dermal filler injection techniques required the use e: mlandau@zahav.net.il
of hypodermal needles to deliver the product subdermally or

Supplement 1 2017 ► Journal of AESTHETIC NURSING 21

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 21, 2017.

Use for licensed purposes only. No other uses without permission. All rights reserved.
 Patients looking for a better treatment experience
Most of the immediate adverse effects of dermal filler procedures
are related to the trauma induced by the injection process
itself rather than the product being delivered (Glogau and
Kane, 2008). A needle’s sharp tip causes a sensation of pain,
traumatises the tissue and may lacerate blood vessels and nerves.
When using a cannula, an introduction opening, performed
by a sharp needle, is always required. Only rarely more than a
single opening is required to cover the whole treatment area.
Therefore, when using a cannula, pain, bruising, oedema and
redness, all associated with the use of a needle, are minimised
(Niamtu, 2009; Hexsel et al, 2012). Nevertheless, some patients
do feel discomfort related to the subdermal movement of the
cannula; however, this is fundamentally different from the pain
sensation induced by sharp needle penetrating the skin. As for
the results, in published studies cosmetic outcomes were found
to be comparable between cannulas and needles, even though
the study design did not differentiate between the areas in which
one tool could have an advantage on the other (Niamtu, 2009;
Fulton et al, 2012).
Decreased risk of major post-filler complications
Accidental intra-arterial filler injection may result in significant
tissue injury and necrosis (Chen et al, 2016). Even more disastrous
is a complication caused by remote arterial obstruction due to
filler embolism (Lazzeri et al, 2012). The true incidence of these
complications is unknown due to underreporting.
It is generally accepted that by using a blunt injection tool,
the blood vessels on its way are pushed and displaced but not
lacerated. Therefore, the risk of vessel wall penetration and
subsequent intravascular injection of the filler material is
reduced. However, it is important to understand that such a risk
cannot be completely avoided. In specific conditions, in which
a blood vessel is fixed due to previous scarring, a small, rigid
cannula can penetrate through the wall. This can explain some
Figure 1. Different cannula tips and opening holes (from left to
right): STERiGLIDE (TSK Laboratory Europe, tapered with the
distally located port), CSH (TSK Laboratory Europe, round tip and
proximal port), Pix’L (Thiebaud Company, round tip and distal
port), SoftFil (Soft Medical Aesthetics, round tip and distal port),
Magic Needle (Needle Concept, round tip and proximal port) and
Silkann (Sterimedix, round with proximal port)
TSK Laboratory Europe
22
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 21, 2017.
of the case reports on intravascular filler injection while using a
blunt cannula (DeLorenzi, 2014).
Cannula characteristics
Cannulas are not entirely new in the field of medical aesthetics,
being used with success for fat injection for years. The design of
those cannulas being used for dermal filler injections (Figure 1)
is different from that used for fat grafting, since dermal filler are
smoother than natural fat. Therefore, dermal fillers cannulas are
smaller and more flexible (DeJoseph, 2012).
Pre-hole and cannula introduction
As mentioned above, a cannula has to be introduced through
an opening that is created by a sharp needle. For novel users,
this step is challenging. Some cannula manufacturers provide a
sharp needle in the set; this needle is to some extent bigger than
the cannula, to ease the introduction step (e.g. TSK Laboratory
Europe and Soft Medical Aesthetics). The direction and depth
of the needle define the gliding plane of the cannula. If the
injection intended to be supraperiosteal, the ‘pilot’ needle has
to be introduced perpendicular to the skin’s surface (Figure 2).
For superficial subdermal injection, the needle in inserted
in  30–45° in the direction in which the injector wishes the
cannula to travel.
In the author’s experience, the easiest way to introduce the
cannula is by holding it in a dominant hand at pencil grip
fashion, while a non-dominant hand stretches the tissue to
make a pre-hole more visible (Figure 3).
Tip and opening configuration
The tip of the cannula is usually rounded and atraumatic, and
therefore does not cut to the tissue. This makes the cannula
travelling less smooth; any fibrotic tissue will resist and block
a cannula’s progress with a subsequent need of a path change.
Therefore, some cannulas have a tapered tip, composing a
hybrid between a completely blunt to sharp ending (Figure 1).
Configuration of the opening port of the cannula is also
an important feature. With a sharp needle, it is clear that the
product leaves the syringe and enters the tissue at the tip of
the needle. When the injection port of the cannula is located
too proximal to its tip, the injector has to consider the exact
deposition point. To do so, the injector has to progress the
cannula distally to the intended product deposition point. If the
opening port is located closer to the tip, the deposition of the
product is more precise.
Gliding capacity
As long as the cannula glides softly in the subdermal or
© 2017 MA Healthcare Ltd
supraperiosteal plane, the procedure is atraumatic. Nevertheless,
almost always points of resistance will be met in the tissue. To
ease the gliding, some cannulas have a special coating layer (e.g.
STERiGLIDE, TSK Laboratory Europe). By wiggling the cannula
during its movement through the tissues, resistance points can
be easily overcome.
Journal of AESTHETIC NURSING ► Supplement 1 2017
Use for licensed purposes only. No other uses without permission. All rights reserved.

Marina Landau
Figure 2. A pre-hole needle is inserted perpendicular to the skin’s
surface for supraperiosteal deposition of the filler
Extrusion force
Cannulas are longer than the majority of traditional sharp
needles. Therefore, the effort required from the injector to deliver
the filler through the ‘dead space’ of the cannula is significantly
higher. Using ULTRA-thin wall technology has been reported to
decrease the extrusion force by 35% (Humzah, 2013).
Size and length
The best cannulas strike the right balance between their
flexibility and rigidity. These features are partially dependent
on the manufacturing technology; Pix’L cannulas (Thiebaud
Company), for example, are softer and more flexible than the
others. In addition, bigger cannulas are always more rigid, while
smaller ones are more flexible. The smallest cannula is 30 gauge—
these cannulas are very flexible, require high extrusion force and
are almost as sharp as needles. Because of this, the author only
uses 30 gauge cannulas exceptionally rarely.
In periorbital and perioral areas, 27 gauge cannulas are used to
deliver small and well-controlled amounts of filler. Since these
cannulas are more flexible and less rigid, they can not travel
long distances and are more appropriate to fill up small areas.
The author uses these cannulas for enhancement of upper eyelid
deflation exclusively.
While 25 gauge cannulas are the gold standard for the most
facial areas, 22 gauge cannulas can be used on the face and hands
to address longer distances using a single hole. These cannulas
have an added value when a combination of filling and subcision
is required, such as when treating acne scars.
The length of cannulas varies between 2.5 and 7 cm. Longer
cannulas are available, but are less popular. Cannula length
defines the area that can be treated from a single opening.
Thinner, longer cannulas tend to bend easily. Therefore, by
choosing higher gauge, longer cannulas provide better safety
against breakage. In the author’s experience 5 cm is generally the
24
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 134.148.010.013 on March 21, 2017.
Marina Landau
Figure 3. The cannula is inserted while the injector’s non-
dominant hand stretches the skin
gold standard for the cannula on the face, while 7 cm is safely
used on the hands.
References
American Society for Aesthetic Plastic Surgery (2016) New statistics reflect
the changing face of plastic surgery. http://tinyurl.com/hzq795l (Accessed
10 January 2017)
Bass LS (2015) Injectable filler techniques for facial rejuvenation,
volumization, and augmentation. Facial Plast Surg Clin North Am 23(4):
479–88. https://dx.doi.org/10.1016/j.fsc.2015.07.004
Chen Q, Liu Y, Fan D (2016) Serious vascular complications after nonsurgical
rhinoplasty: a case report. Plast Reconstr Surg Glob Open 4(4): e683. https://
dx.doi.org/10.1097/GOX.0000000000000668
de Felipe I, Redondo P (2015) The liquid lift: looking natural without lumps. J
Cutan Surg 8(3): 134–8. https://dx.doi.org/10.4103/0974-2077.167267
DeJoseph LM (2012) Cannula for facial filler placement. Facial Plast Surg Clin
N Am 20(2): 215–20. https://dx.doi.org/10.1016/j.fsc.2012.02.007
DeLorenzi C (2014) Complications of injectable fillers, part 2: vascular
complications. Aesthet Surg J 34(4):5 84–600. https://dx.doi.
org/10.1177/1090820X14525035
Fulton J, Caperton C, Wienkle S, Dewandre L (2012) Filler injection with
blunt-tip microcannula. J Drugs Dermatol 11(9): 1098–103
Glogau RG, Kane MA (2008) Effect of injection techniques on the rate of
local adverse events in patients implanted with nonanimal hyaluronic
acid gel dermal fillers. Dermatol Surg 34(Suppl 1): S105–9. https://dx.doi.
org/10.1111/j.1524-4725.2008.34251.x
Hexsel D, Soifermann M, Porto MD, Siega C, Schilling-Souza J, Brum C (2012)
Double-blind, randomized, controlled clinical trial to compare safety and
efficacy of a metallic cannula with that of a standard needle for soft tissue
augmentation of the nasolabial folds. Dermatol Surg 38(2): 207–14. https://
dx.doi.org/10.1111/j.1524-4725.2011.02195.x
Humzah D (2013) TSK striglide: Hybrid technology, the next generation in
cannulas. Prime 3: 40–1
Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S (2012)
© 2017 MA Healthcare Ltd
Blindness following cosmetic injections of the face. Plast Reconstr Surg
129(4): 995–1012. https://dx.doi.org/10.1097/PRS.0b013e3182442363
Niamtu J (2009) Filler injection with micro-cannula instead of needles.
Dermatol Surg 35(12): 2005–8. https://dx.doi.org/10.1111/j.1524-
4725.2009.01323.x
van Eijk T, Braun M (2007) A novel method to inject hyaluronic acid: the
Fern Pattern Technique. J Drugs Dermatol 6(8): 805–8
Journal of AESTHETIC NURSING ► Supplement 1 2017
Use for licensed purposes only. No other uses without permission. All rights reserved.