Aspirating & Fillers: Why I was WRONG in my response to Dr Harris
Dr Tim Pearce would like to give an update and apology to his most recent blog on dermal fillers injections: is aspirating dangerous?
The blog referenced a thought-provoking piece posted by award-winning aesthetic doctor, Dr Steven Harris on his Instagram feed about the practice of aspirating when injecting dermal filler, calling it ‘unreliable practice’ as a safety measure due to the ‘large numbers of false negatives’. The post and comments went on to discuss the issues and whether aspirating is dangerous.
In this blog, Dr Tim reveals how he misquoted Dr Harris and was mistaken in his original interpretation of his stance on aspiration with dermal fillers. He goes on to share a new way to help you understand the benefit of aspirating when carrying out dermal filler injections; why it is effective, and how you can feel confident performing this safety step whilst avoiding the confusion surrounding the wider debate.
Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>
Dr Tim Pearce apologises for misquoting Dr Steven Harris
Dr Tim admits that the overall message that he got from the original Instagram post by Dr Harris was that aspirating is dangerous. This was quoted in several pieces of content published on Dr Tim’s blog and social media feeds.
He acknowledges that his perception that this was Dr Harris’ position was fuelled in part by one of the references provided alongside it that included a published paper with the cheeky title, Aspiration before tissue filler – an exercise in futility and unsafe practice.
In his own words, Dr Harris’ position is not that aspirating is unsafe or dangerous, but that it is intrinsically flawed and an unreliable safety measure for aesthetic clinicians.
Of course, there is a considerable difference between saying something is dangerous and saying it is unreliable, thus Dr Tim is grateful that he was wrong in his initial understanding of Dr Harris’ position.
It is very important for new injectors to not get the impression that aspirating increases risk or is inherently unsafe. Although the statement that aspirating is flawed or unreliable is true, Dr Tim asserts that it still dramatically reduces the chance of vascular injury.
He also notes that he has some serious concerns when antagonists to aspirating embark on making judgements about the safety of those injectors who choose to aspirate, regarding them as unsafe – a completely baseless position in his opinion. On the flip side, Dr Tim accepts that you can also be safe without aspirating in many situations. However, there is zero basis, in his view, to tell aesthetic practitioners not to aspirate.
Why aspirating before dermal filler injection is effective
As an illustration for the aspirating debate, let’s consider a medical intervention scenario, one which has the same mathematical structure. The same data can be used to make the case that this intervention is highly unreliable, when you look at it in a certain way, yet extremely powerful from an alternative perspective.
During the COVID-19 pandemic, many people were surprised to learn that ventilators used to treat patients suffering from acute respiratory distress only saved a minority of patients. Many studies indicate a survival rate for patients on ventilators of often less than 50%. The argument therefore that ventilators are only 50% reliable could be made, but in fact the efficacy of ventilators could be looked at from a profoundly different perspective. The population upon which ventilators are used have an extremely high likelihood of dying. Without ventilation, it is nearly 99%, thus even a 30% survival rate – which on the face of it sounds dire – represents a 3000% improvement in survival. Suddenly it becomes clear that ventilators are extremely effective when we are viewing their use in the proper context.
This illustration shows that things do not have to be 100% reliable in their ability to save lives to still be extremely effective.
Study findings on aspirating show that it only works 30-50% of the time, so this can be viewed in a similar way to ventilators.
We must consider the population for whom these positive aspirations apply, just like the patients on ventilators who without them are nearly certain to die, our equivalent aesthetic population are the patients who have a needle in an artery that is about to be injected with dermal filler.
This cohort are the people at maximum risk of necrotic injury, thus aspirating a positive is an extremely high leverage event for reducing risk. It does not have to be anywhere near 100% reliable to be extremely effective at reducing the risk of vascular occlusion, because 100% of people with a needle in the lumen of a vessel are about to be injected with filler. The act of getting a positive aspiration and stopping the procedure will multiply the chances of avoiding injury by many thousands of percent.
Aspirating is a screening tool
Evidence that aspirating will allow blood to appear in the needle is abundant in published literature, we know it works a significant proportion of the time in this extremely high-risk population. With every positive aspirate, we are reminded of this fact, and you cannot assess the value of aspirating looking only at the negatives. The true value comes from what we can take it to mean when it is positive, i.e., when you see a dermal filler syringe filled with blood. Intuitively you know this means,
“do not inject here, there is a very high probability that came from a blood vessel”.
Our goal should therefore not be to dismiss the test on the basis that it cannot always detect intraluminal placement, but instead to learn as many ways as possible to increase the sensitivity of aspiration yet further.
This is the key take home message – a negative aspirate means very little for your patient’s safety, but a positive aspirate is extremely significant.
Dr Tim maintains that most aesthetic clinicians intuitively understand this, that is, until they start reading academic papers from people who are not framing the problem correctly.
Aspirating is a screening tool, much like an unreliable PSA test for prostate cancer, for example, which has a 70% false positive rate and a 20% false negative rate, yet still saves thousands of lives, or an unreliable faecal occult blood test which only picks up 19% of bowel cancers yet saves thousands of lives.
Why not have a read of some previous blogs on the subject including:
- Does aspirating work?
- Does ultrasound provide the evidence to support aspirating with fillers?
- How many seconds should you aspirate for when injecting?
Dr Tim concludes that he believes strongly that the confusion surrounding whether to aspirate or not will risk injury to patients and hopes that he has exposed a deep flaw in the logic which shows clearly that something marked as ‘unreliable’ can still be highly effective in terms of reducing injury.
You can find Dr Tim Pearce on Instagram if you want to drop him a comment or question to discuss aspiration or other patient safety techniques for performing dermal fillers.
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Aesthetics Mastery Show
Why I was WRONG in my response to Dr Harris
In this episode, Dr Tim reveals how he misquoted Dr Harris in his recent video on aspiration. He also shares a new way to help you understand the benefit of aspirating so you can feel confident performing this safety step and avoid confusion surrounding the wider aspiration debate. Watch the full Aesthetics Mastery Show here.
The show has active discussion from aesthetics professionals. Some of the latest comments include:
“Bottom Line: You cannot be too careful when providing a service that could potentially have significant adverse effects. Learn how to aspirate properly and DO IT!!”
Dr. Edwin Giron
Expressions of thanks:
“Thank you, Dr. Pearce. Your analogies can apply to other areas in healthcare, not just injectable fillers. I strongly believe nurses should aspirate before injecting medications yet we are now taught not to do that. I value your insight and logic regarding screening tools that have far less than 100% reliability and their value in saving lives and keeping patients safe.”
Further thoughts on aspiration:
“Thank you Dr Tim, very well explained. Aspiration is a screening test, a negative aspiration can be false negative, but a positive aspiration is “true positive”, allowing the injector to move the needle. However aspiration, in general, is as reliable as relying on general non medical person taking their own COVID RAT tests, either the swab wasn’t deep enough or the swab wasn’t in the nasal cavity long enough. Aspiration is only reliable in injectors who understand the physics of a semi-solid material of various viscosity moving through the lumens of needles of different sizes, as well the negative suction force applied pulling the syringe plunger backwards. It hasn’t change my views, I’ll still be aspirating, plus all the other risk mitigating techniques, which unfortunately means, in my hands, dermal fillers is never a fast treatment.”
Read more and join in the debate on our YouTube channel.
Filler Complications eLearning Courses
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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