Aesth Plast Surg (2014) 38:413–418
DOI 10.1007/s00266-013-0264-4
ORIGINAL ARTICLE
Vibration Anesthesia for the Reduction of Pain with Facial
Dermal Filler Injections
Pooja Mally • Craig N. Czyz • Norman J. Chan •
Allan E. Wulc
Received: 27 February 2013 / Accepted: 9 December 2013 / Published online: 24 January 2014
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract
Background Vibration anesthesia is an effective pain-
reduction technique for facial cosmetic injections. The
analgesic effect of this method was tested in this study
during facial dermal filler injections. The study aimed to
evaluate the safety and efficacy of vibration anesthesia for
these facial injections.
Methods This prospective study analyzed 41 patients who
received dermal filler injections to the nasolabial folds, tear
troughs, cheeks, and other facial sites. The injections were
administered in a randomly assigned split-face design. One
side of the patient’s face received vibration together with
dermal filler injections, whereas the other side received
P. Mally
A. E. Wulc (&)
Department of Ophthalmology, Drexel University College of
Medicine, Philadelphia, PA, USA
e-mail: awulcmd@gmail.com
C. N. Czyz
Division of Ophthalmology, Section Oculofacial Plastic and
Reconstructive Surgery, Ohio University/OhioHealth Doctor’s
Hospital, Columbus, OH, USA
N. J. Chan
Department of Otolaryngology–Head and Neck Surgery, Temple
University School of Medicine, Philadelphia, PA, USA
A. E. Wulc
Department of Ophthalmology and Otolaryngology, Abington
Memorial Hospital, Abingtonm, PA, USA
A. E. Wulc
Scheie Eye Institute, University of Pennsylvania, Philadelphia,
PA, USA
A. E. Wulc
610 W. Germantown Pike, Suite 161, Plymouth Meeting,
Norristown, PA 19462, USA
NON-SURGICAL AESTHETIC
dermal filler injections alone. The patients completed a
posttreatment questionnaire pertaining to injection pain,
adverse effects, and preference for vibration with future
dermal filler injections.
Results The patients experienced both clinically and
statistically significant pain reduction when a vibration
stimulus was co-administered with the dermal filler injec-
tions. No adverse events were reported. The majority of the
patients (95 %) reported a preference for vibration anes-
thesia with subsequent dermal filler injections.
Conclusions Vibration is a safe and effective method of
achieving anesthesia during facial dermal filler injections.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Vibration anesthesia
Facial dermal filler
injection
Facial cosmetic injection
Topical anesthesia
Dermal filler injections for facial rejuvenation are rapidly
increasing in popularity [1, 2]. Pain associated with cos-
metic procedures is a frequent patient concern [3]. It
therefore is incumbent on the facial plastic surgeon to make
the injection experience as comfortable as possible for the
patient. The ideal topical anesthetic would be consistently
efficacious, with a negligible adverse effect profile and
rapid duration of onset.
Recent literature has highlighted the use of topical
vibration as an effective anesthetic during injectable pro-
cedures [4, 5, 9, 10]. One study published by the authors
suggests that vibration anesthesia significantly decreases
pain during facial cosmetic botulinum toxin-A injections
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[9] and reports minimal adverse effects associated with

topical vibration.
The proposed analgesic effect of vibration is described
by the ‘‘gate control’’ theory of pain, which states that the
intensity of painful experiences can be reduced by con-
current non-noxious stimulation (i.e., vibration) [5].
Because the vibration stimulus reduces but does not elim-
inate pain sensation, its use as an adjunctive anesthetic
during cosmetic procedures may be potentially limited. In
our experience, patients regard dermal filler injections to be
more painful than cosmetic botulinum toxin-A injections.
This study aimed to test whether the analgesic capacity
of vibration is sufficient during facial dermal filler injec-
tions. This finding has considerable clinical significance Fig. 1 The Pin Point Personal Massager (Brookstone, Inc.)
because it speaks to the cost-time-value ratio of using the
method with this patient population.

Methods

An independent institutional review board (IRB) at Ab-

ington Memorial Hospital (Abington, PA, USA) approved
the study protocol before enrollment of participants and
monitored the investigation. Informed consent was
obtained from the subjects as per IRB protocol.

Patient Selection

This prospective, randomized study enrolled 41 patients

desiring facial rejuvenation with dermal fillers. Naı̈ve
patients (those not previously treated with dermal fillers)
and those previously treated with dermal filler injections
were eligible to participate. The exclusion criteria ruled out
patients younger than 18 years; patients desiring perioral/
lip injections; a history of allergies or adverse reactions to
lidocaine or to Gram-positive bacterial proteins contained
in the fillers; current use of anticoagulant therapy; a history
of bleeding disorders, infection, or inflammation at injec-
tion sites; pregnancy; or lactation.
Study Design
Dermal filler injections were given in one or more of the
following sites: nasolabial folds (NLFs), cheeks, tear
troughs, and ‘‘other’’. ‘‘Other’’ injected sites included the
temples, superior palpebral sulcus, temporal brow, and
submalar hollows. If one side of the face was injected, the
corresponding areas on the other side were treated as well.
The filler materials used in this study included Resty-
lane-L and Perlane-L (Medicis, Scottsdale, AZ, USA),
Juvederm-XC Ultra and Juvederm-XC Ultra Plus (Aller-
gan, Irvine, CA, USA), and Radiesse (Merz Aesthetics, San
Mateo, CA, USA). The first four filler materials were
Fig. 2 The tip of the vibrator is gently placed 1–2 cm from the
injection site
premixed with 0.3 % preservative-free lidocaine. Radiesse
was mixed with 0.2 mL of 1 % preservative-free lidocaine
per 1.5 mL of Radiesse. The fillers were administered
using their prepackaged proprietary Luer-lock syringes and
needles.
Injections were given in a split-face design (right vs.
left), pre-assigned in an alternating manner. A vibration
stimulus was co-administered with the filler injections on
one side (treatment), whereas the other side of each sub-
ject’s face received the filler injections alone (control). No
placebo was given. Vibration was administered with a
small handheld, battery-operated device (Pin Point Per-
sonal Massager; Brookstone, Inc., Merrimack, NH, USA;
Fig. 1).
During the injection procedures, a trained assistant
gently positioned the tip of the vibrator on the subject’s
skin 1–2 cm away from the treatment site (Fig. 2). The
vibration stimulus was administered for 2–3 s before

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initiation of the injection and continued until the needle
had been withdrawn. The vibrator was repositioned in
tandem with the needle so as to stay within 1–2 cm of the
injection site.
If more than one anatomic site was injected, the treat-
ment to one side of the face was completed before the
treatment proceeded to the other side. The same physician
(A.E.W.) administered all the injections.
After the procedure, the vibration device was sanitized
with sterilization wipes (Sanicloth Plus Germicidal Dis-
posable Cloth; PDI, Orangeburg, NY, USA). The patients
then completed an anonymous questionnaire regarding the
treatment after the physician had left the room. The surveys
were collected by the assistant.
Patient Questionnaires
The patients were informed before the procedure about the
required posttreatment questionnaire comparing injection
pain between the two sides of the face. The pain at each
anatomic site (NLF, cheek, tear trough, and ‘‘other’’) was
evaluated separately. The participants were provided with a
5-point Likert-type scale on which to rate the injection pain
as 0 (no pain), 1 (mild pain), 2 (moderate pain), 3 (severe
pain), or 4 (worst pain I have ever felt). The potential
effects of the vibration stimulus were not discussed. The
patients were queried as to whether they would prefer
vibration anesthesia with future dermal filler injections and
given the opportunity to report any postprocedural adverse
effects.
Statistical Analysis
Analysis was conducted with SPSS 19 (IBM Corp., Som-
ers, NY, USA). Appropriate nonparametric analysis
methods were applied to the ordinal data (Mann–Whitney
U test) and the categorical data (Fisher’s exact test) to
determine the statistical significance of differences
between the two sides. Each patient served as his or her
own control for pain analyses. In addition, one-way ana-
lysis of variance (ANOVA) was used to compare data
among three or more patient groups. All statistical testing
was conducted at the 0.05 alpha level.
Results
Demographics
The participants in this study were 41 women with a total
of 70 injection sites. The average subject age was
58 ± 9 years (range 37–76 years). Of the 41 women, 7
were naı̈ve injection patients and 34 had previously
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Table 1 Overall average patient-reported pain at all sites with and
without vibration anesthesia
With vibration (%) Without vibration n (%)
No pain 6 (14) 0 (0)
Mild pain 29 (72) 5 (12)
Moderate pain 6 (14) 11 (27)
Severe pain 0 (0) 18 (44)
Worst pain ever 0 (0) 7 (17)
received dermal filler injections. The filler injections
included Restylane-L received by 29 patients (71 %), Ju-
vederm-XC Ultra received by 12 patients (29 %), Juve-
derm-XC Ultra Plus received by 3 patients (7 %), Perlane-
L received by 4 patients (10 %), and Radiesse received by
4 patients (10 %).
Overall Pain Reduction
An overall pain value was calculated for each patient by
averaging the pain ratings for all the injected sites. The
overall pain score for the patients was 0.9 ± 0.6 on the
vibration-treated side and 2.7 ± 0.9 on the control side.
The mean scale difference of 1.8 was statistically signifi-
cant (p = 0.0001). For the vibration-treated side, 6 patients
(14 %) reported no pain, 29 patients (72 %) reported mild
pain, 6 patients (14 %) reported moderate pain, and no
patients reported severe or ‘‘worst pain ever.’’ For the
control side, no patients reported complete absence of pain,
whereas five patients (12 %) reported mild pain, 11
patients (27 %) reported moderate pain, 18 patients (44 %)
reported severe pain, and seven patients (17 %) reported
experiencing the ‘‘worst pain ever’’ (Table 1).
Of the 41 patients, 40 (97 %) reported that the co-
administration of vibration reduced injection pain at each
anatomic site injected. Only 1 of the 41 patients indicated
no pain reduction with application of vibration. None of the
patients reported increased pain when vibration anesthesia
was co-administered compared with the control side.
Pain Reduction by Anatomic Site
The addition of vibration resulted in statistically significant
pain reduction at each anatomic site. For the 30 patients
who received injections to the NLFs, the reported pain on
the vibration-treated side was 0.8 ± 0.6 compared with
2.5 ± 0.9 on the side that received no vibration
(p = 0.0001). The 17 patients who had injections to the
tear troughs reported an average pain score of 1.0 ± 0.7 on
the vibration-treated side compared with 2.7 ± 1.1 the
untreated side (p = 0.0001). For the 10 patients who
received injections to the cheeks, the pain on the treated
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Table 2 Average patient-reported pain with and without vibration Preference for Vibration
anesthesia
Site Patients (n) With Without p value Of the 41 patients, 39 (95 %) indicated a desire for
vibration vibration vibration anesthesia with future facial dermal filler injec-
tions. Two patients found the vibration sensation to be
Overall average pain 41 0.9 ± 0.6 2.7 ± 0.9 0.0001
uncomfortable and declined vibration anesthesia with
Nasolabial folds 30 0.8 ± 0.6 2.5 ± 0.9 0.0001
future treatments. The first-time patients did not differ
Tear trough 17 1.0 ± 0.7 2.7 ± 1.1 0.0001
significantly with the repeat patients in terms of preference
Cheek 10 0.9 ± 0.6 2.8 ± 1.0 0.0006
for vibration (p = 1.0, Fisher’s exact test).
Other site 14 0.9 ± 0.6 2.9 ± 0.8 0.0001

Adverse Effects

None of the patients in our study reported perceiving that

any adverse effects were associated with vibration.
Table 3 Patient-reported pain versus number of injection sites
Sites (n) Patients (n) With Without p value
vibration vibration Discussion

1 22 0.9 ± 0.6 2.6 ± 0.9
2 12 1.3 ± 0.7 3.1 ± 0.5
3 4 0.9 ± 0.5 2.2 ± 0.8
4 3 0.9 ± 0.6 3.0 ± 0.8
side was 0.9 ± 0.6 compared with 2.8 ± 1.0 on the
untreated side (p = 0.0006). For the 14 patients who
received injections to ‘‘other’’ anatomic sites, the average
pain was 0.9 ± 0.6 on the side that received vibration
stimulation compared with 2.9 ± 0.8 on the untreated side
(p = 0.0001) (Table 2).
Pain Versus Number of Injection Sites
In this study, 22 patients received injections to only one
site on the face. The pain on the treated side was 0.9 ± 0.6
compared with 2.6 ± 0.9 on the untreated side
(p = 0.0001). The 12 patients who received injections to
two different sites rated their pain at 1.3 ± 0.7 on the
treated side and at 3.1 ± 0.5 on the untreated side
(p = 0.001). Four patients received injections to three sites
and reported statistically significant pain reduction with
vibration (0.9 ± 0.5 vs 2.2 ± 0.8; p = 0.001). The three
patients who received injections to four sites also noted
statistically significant pain reduction with vibration,
reporting their pain at 0.9 ± 0.6 on the vibration-treated
side and at 3.0 ± 0.8 (p = 0.001) on the untreated side
(Table 3). The overall average pain scores on the vibration-
treated side of the patients who received injections to one,
two, three, or four sites did not differ significantly
(p = 0.31, one-way ANOVA). In addition, the overall
average pain scores on the control side did not differ sig-
nificantly among these patient groups (p = 0.06, one-way
ANOVA).
0.0001 Pain remains a primary concern of patients seeking cos-
0.001 metic injection procedures [3], as reflected in the emphasis
0.001 placed on anesthetic techniques in the cosmetic literature.
0.001 Our findings demonstrated that vibration anesthesia is a
safe and effective method of achieving pain control for
patients receiving dermal filler injections for cosmetic
facial rejuvenation.
In this study, vibration anesthesia induced both clini-
cally and statistically significant pain reduction when co-
administered with dermal filler injections, regardless of the
facial anatomic site injected. Without vibration anesthesia,
most patients (88 %) rated injection pain as moderate to
severe. However, when a vibration stimulus was adminis-
tered during the injections, only 14 % of patients experi-
enced moderate to severe pain. An overwhelming majority
of the patients in this study (95 %) indicated that they
would prefer to have vibration anesthesia with subsequent
soft tissue injections.
The analgesic capability of a vibration stimulus can be
explained by Melzack and Wall’s ‘‘gate control’’ theory of
pain, which proposes that the intensity of painful experi-
ences can be reduced by concurrent non-noxious stimula-
tion [5]. A vibratory stimulus activates skin mechano-
receptors, primarily Meissner’s corpuscles located in the
superficial dermis, but also Pacinian corpuscles in the deep
dermis and primary endings of muscle spindles [5]. Acti-
vation of these mechanoreceptors leads to stimulation of
large-diameter Ab fibers and subsequent closure of a
‘‘gate’’ controlling pain signals attempting to travel to the
brain [12] (Fig. 3). Although the ‘‘gate control’’ theory is
imperfect, a growing body of clinical research indicates
that vibration is an effective local anesthetic [4–6, 9, 10].
This study established vibration to be an effective
anesthetic during facial dermal filler injections, and future
studies of interest may compare vibration anesthesia with

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Fig. 3 Schematic diagram of
the gate control theory of pain
alternative topical anesthetic methods. Multiple techniques
for diminishing pain from cosmetic injections have been
described including verbal reassurance, handholding, ice
packs, cooled air, and topical anesthetic creams, gels, and
ointments [3, 7, 8, 11, 12]. Contact cooling is the current
standard of comparison for other topical analgesic methods
[7].
The potential adverse effects of vibration anesthesia are
minimal. No patients in this study reported perception that
any adverse effects were associated with vibration. In a
previous study of vibration anesthesia performed by our
group, only 10 % of the patients (5 of 50) experienced
transient effects attributed to the vibration stimulus [9]. To
the best of our knowledge, the low-intensity, focal vibra-
tion applied by handheld vibration devices causes only
minor transient tingling sensations that dissipate after
withdrawal of the stimulus and are not associated with any
significant temporary or permanent side effects. Although
it is possible that application of a vibrating device may
affect the dermal filler injection process, our experienced
injector did not note any disruptive movements or vibration
of the skin or soft tissue at the injection site. However,
injector experience may influence the level of difficulty
performing the injection with a vibrating device.
One criticism of vibration anesthesia is that it does not
induce complete analgesia. However, if additional pain
reduction is desired, the technique could easily be used in
conjunction with topical anesthetics, nerve blocks, or cry-
oanesthesia. For instance, to maximize patient comfort, we
elected to use dermal fillers mixed with preservative-free
lidocaine.
Clinical judgment should be used in selecting the proper
technique to achieve adequate pain control, with particular
attention paid to the injection site. For instance, perioral
dermal filler injections are typically more painful than
those administered to other facial sites. In fact, patients
417
who received dermal filler injections to the lips were
excluded from this study because it was anticipated that the
anesthetic effect of vibration alone would not be sufficient
for patient comfort. To maximize patient comfort, infra-
orbital and mental nerve blocks are routinely performed for
all patients receiving lip injections in our office, and it was
thought that the addition of nerve blocks would confound
the vibration data.
One limitation of this study was the lack of a placebo.
No suitable medium can mimic a vibration stimulus
without providing confounding counter-stimulation. Oth-
ers have used a placebo consisting of a ‘‘switch-off’’
vibration device applied to the skin while another vibra-
tion device is activated nearby to provide patients with
the noise of an active vibration device [4]. Such a method
was not used in this study because it was thought that the
mere act of applying the vibration device to the skin
already provides confounding counter-stimulation to the
test subject.
Other potential limitations of our study included the
subjective nature of rating pain and the fact that the
patients were made to fill out the questionnaire after
treatment rather than after each injection. However, the
tendency of each individual to over- or underestimate pain
likely was canceled out when the data were analyzed in
aggregate.
The efficacy and low adverse effect profile of vibration
anesthesia allows vibration anesthesia to be a method that
we consistently apply for our patients receiving facial
dermal filler injections. When combined with gentle
injection techniques, use of small-gauge needles, and
injections of the least possible volume, vibration anesthesia
can provide patients with a comfortable facial dermal filler
experience. Further study may demonstrate vibration to be
an efficacious adjunctive anesthetic for many injectable
procedures.
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Conclusion
Vibration anesthesia is a safe and effective means of
achieving clinically significant pain reduction for patients
receiving cosmetic dermal filler injections. The efficacy,
safety, ease of use, and affordability of vibration render it a
suitable adjunctive technique that can be used to induce
local anesthesia for most minimally invasive procedures as
well.
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