The use of cannulas for soft-tissue augmentation has been quite popular in Europe for several years. Some cannula devices have more recently been approved in the United States, including Magic Needle (M.V. S.R.L., Italy) and Dermasculpt (CosmoFrance, Miami, FL). Worldwide, there are many companies and manufacturers of cannulas, but the approval process for some of these devices in the United States seems quite confusing. It is also difficult to access a list of both approved devices and specific indications.
For the physicians who perform or who have previously performed fat transfer procedures, the rationale for cannulas can be quite clear and the transition quite easy. When soft tissue augmentation is performed with pre-packaged filler agents, we are well aware of the cosmetic regions more often associated with increased rates of significant bruising and swelling, such as the infra-orbital area. Deeper injections in some regions, including the infra-orbital area and cheeks, are often critical for success, but may also lead to a higher risk of the needle encountering a vessel. In addition, certain injection techniques, such as “fanning” (penetrating the skin though the same point of entry, but directing the needle in different vectors), may be associated with increased swelling and bruising.1
The Potential Benefits of Cannulas
In our experience, using cannulas in some of these regions may offer a way to perform these injections with less risk of encountering a blood vessel and, therefore, less risk of significant bruising and swelling — though a large-scale, controlled, double-blinded study will be necessary to properly evaluate these findings.2 A recent small, split-face trial of 25 blinded patients reported less pain, less edema and fewer hematomas on the nasolabial fold side treated with a cannula versus the needle-treated side.3
At some locations, such as the infra-orbital hollow, where a deep injection is often performed below the orbicularis muscle and on top of the periosteum, the use of cannulas may also make the treatment less painful. In the infra-orbital area in particular, at least one small observational study of 26 patients indicated that the injector noted less product placement irregularities, less inflammatory reactions and also less risk of hematomas with a cannula.4
Over the past decade, many practitioners have evolved from “line-fillers” (focusing on the nasolabial folds) to “pan-facial” more global injectors (focusing on multiple areas that are volume depleted). Common regions for volume filling include: the forehead, temples, infra-orbital, glabella, cheek, jawline, dorsal hand and décolleté.
Though the term is frequently overused and often not adhered to, a “natural look” is also preferred by many experienced injectors — leaving some lines and wrinkles in areas such as the nasolabial folds (see Figure 1) to avoid a “flat” appearance. With cannulas, we have completely changed our approach to augmentation of many of these regions to restore volume — most specifically, using cannulas in the infra-orbital hollows, supra-orbital brow, cheek and dorsal hands, as well as the décolleté. Many cannula users also incorporate these devices into treatments of other more traditional areas of augmentation, including the nasolabial fold, oral commissure and lips. In our opinion, the lips are best treated with a needle that is placed at the appropriate tubercle rather than a cannula, as the cannula may potentially be more likely to result in more linear and uniform aliquots in each hemi-lip (“sausage lips”) rather than specific projection points from focal deposits of product with a needle.5,6 Forehead and temple filler treatments for volume and contour-lifting of concavities are very deep injections that need to penetrate through musculature directly to bone7 and are thus also best treated with a needle.
Our Patient Experiences
Figure 1 (click on the image for a full-size view) shows a 52-year-old patient who was treated with 2.4 mL of JuveDerm Ultra Plus XC in the mid-face (infra-orbital, deep medial fat pad,8 nasolabial fold and oral commissure) using a combination of a 30-gauge and a 27-gauge cannula. To emphasize the “natural” appearance, some wrinkles or folds, such as the nasolabial folds, were purposely left untreated or not fully corrected.
Figure 2 (click on the image for a full-size view) shows an 81-year-old patient injected in the infra-orbital hollow with a 30-gauge cannula. She received 1.0 mL of Perlane-L in this region (about 0.5 cc in each side) and showed no significant bruising or swelling 2 days after the injections.
In our practice, we often perform filler injections several weeks prior to lateral-canthal and inferior-canthal neuromodulator use to allow time for the peri-ocular muscles to help in pumping away swelling after filler placement. Laser resurfacing may be done after the neuromodulators take full effect to help prevent muscle contraction from imprinting the resurfaced wound.9,10 Therefore, our next step with this patient is to proceed with botulinum toxin to the lateral canthal area, followed by an aggressive fractional ablative laser treatment to the whole peri-ocular area.
Photos courtesy of Joel Cohen, MD, FAAD
Our technique for using cannulas is to make a small nick in the skin with a slightly larger needle and then introduce a smaller-caliber cannula.
• For the supra- and infra-orbital areas, we utilize a 27-gauge needle and a 30-gauge, 1½-inch cannula.
• For the cheek and oral commissure, we use a 25-gauge needle and a 27-gauge, 1½-inch cannula.
• For the nasolabial fold, we use a 27-gauge needle and a 30-gauge, 1½-inch cannula.
• For the dorsal hand and décolleté, we use a 27-gauge needle and a 25-gauge, 1½-inch or 2-inch cannula.
One trick to ensure that the small needle-stick orifice is not lost after it is made is to pinch the skin with the non-injecting hand and introduce the needle with the injecting hand. With the needle in place, the practitioner can use the injecting hand to pick up the syringe with the affixed cannula. The assistant removes the needle while the cannula is introduced into the resulting small opening in the skin visible with a pinpoint of bleeding.
Since moving to cannulas, we have resumed “fanning” as the preferred injection technique specifically for cheek augmentation; other areas, such as the periocular area, may be best treated with “linear threading” of cannulas. In our practice, cannulas help to address many areas of pan-facial augmentation and volume replacement with seemingly less bruising and swelling than previously seen with needles alone, often accompanied by less patient discomfort.
Dr. Cohen is the Director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology.
Dr. Berlin is President of DFW Skin Surgery Center, PLLC, in Arlington, TX. He is also Clinical Assistant Professor of Dermatology, New Jersey Medical School in Newark, NJ.
Disclosure: Dr. Cohen has no relevant conflicts related to cannulas. Regarding fillers, however, he has served as a consultant and/or clinic trial participant for Allergan, Medicis and Merz. Dr. Berlin has no disclosures to report.