The Management of Bruising following Nonsurgical Cosmetic Treatment

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JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2017 • Volume 10 • Number 2 E1
Introduction
Cosmetic treatments amounted to £2.3 billion in the United
Kingdom in 2010, and this amount was estimated to reach £3.6
billion in 2015 with 9 out of 10 of these procedures being
nonsurgical and generating 75 percent of the market share.2
However, downtime following a cosmetic procedure is an
important consideration for patients prior to undergoing a
treatment. Bruising is often a tell-tale sign that a patient has had
something done and can lead to some embarrassment and
unsolicited questions.1In addition to the negative cosmetic effect
of a bruise, facial bruising may also lead some to assume spousal
abuse.3
Incidence
Localized reactions such as bruising are by far the most
common adverse event encountered with procedures such as
dermal filler or botulinum toxin injections. The incidence is
variable and dependent on many factors. One study4reports the
incidence of bruising following dermal fillers to be between 19 and
24 percent, and another study5reports the incidence as high as 68
percent.
Minimizing the Risk
(A) Patient factors. Many factors can influence the risk of
bruising; therefore, it is important to take a full medical history
prior to undertaking treatment with particular reference to
previous treatments and susceptibility to bruising, haematological
and liver disease, coagulopathies, and medication, including
prescribed and over the counter. Older patients with thin and
The Management of Bruising following
Nonsurgical Cosmetic Treatment
Martyn King, MD
Definition
A bruise, also known as a ‘contusion’ or ‘ecchymosis,’ is a small haemorrhagic spot that results from extravasation of blood; it is
found in the skin or mucous membrane and presents as a non-elevated, rounded or irregular, blue or purplish patch.1
JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY
Aesthetic complications Guidelines

The Management of Bruising following Nonsurgical Cosmetic Treatment
An Aesthetic Complications Expert Group Consensus Paper
E2 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2017 • Volume 10• Number 2
fragile skin and slower repair mechanisms are likely to be more
prone to bruising and slower to recover.1Alcohol increases
clotting time and increases risk of bruising. Patients should avoid
alcohol 24 hours prior to treatment.1Patients who are
malnourished may be in a higher risk group; vitamin C deficiency
and iron deficiency increases risk of bruising and prolongs healing
time.
Medication. Many prescribed medications, such as aspirin,1
clopidogril, warfarin, non-Vitamin K-dependent oral anticoagulants
(e.g., dabigatran, apixaban, and rivaroxaban), heparin, and the low
molecular weight heparins all affect blood clotting and will
increase the risk of haemorrhage and bruising. These are often
prescribed in atrial fibrillation, thromboembolic disease,
mechanical heart valves, and in patients with a high risk of or
previous cardiovascular or cerebrovascular infarction. These
medications should not be stopped without specialist advice and
should not be discontinued for an aesthetic procedure. If aspirin is
being taken for another indication, such as analgesia, this should
be avoided for one week prior to the treatment being performed.6
Similarly, non-steroidal anti-inflammatory (NSAID) medications,7
(e.g., ibuprofen, naproxen, diclofenac, celecoxib, and meloxicam)
should be avoided for a similar period of time. Corticosteroids will
also increase the risk of bruising as they increase the fragility of
capillaries within the skin.1If a patient is taking a prescribed
medication, the risks and benefits of the procedure should be
discussed prior to consent being obtained. If a patient decides to
proceed, they should be counselled about the increased risks.
Herbal and vitamin supplements. Over-the-counter herbal
and vitamin supplements are becoming increasingly common and
can have an influence on clotting time and increase the risk of
bruising. In particular, fish oils7,8 omega-3 fatty acids,9garlic,6–9
high-dose Vitamin E,6–9 gingko biloba,6–9 and St. John’s wort8,9 may
all lead to greater bruising. The general consensus is that these
should be avoided for two weeks prior to surgical procedures.
(B) Practitioner factors. Practitioners should have a good
knowledge of venous and arterial vessels of the face to avoid
puncturing larger vessels.1Careful inspection of the skin with all
make-up removed should be done to identify any superficial
vessels, which can then be avoided.6Lighting is important to be
able to see underlying vessels and other aids, such as a magnifying
loop or VeinViewer®Flex6 (Christie Medical Holdings, Inc.,
Memphis, Tennessee), may offer a greater advantage. Ensure the
treatment room is not too hot as such an environment may cause
vasodilatation.
Correct positioning of the patient can reduce the risk of
bruising by preventing any unnecessary movement and trauma.
The ideal patient position is semi-reclined at a 30-degree angle
with the head supported by a head rest.6Also, the practitioner’s
injecting hand may be braced to the patient to avoid movement.6
A fanning or threading technique with a sharp needle into the
dermal or immediate subdermal plane is more likely to result in
bruising when compared to a single or serial puncture technique.4,11
Less bruising is observed when using the depot or aliquot
technique with product placed at the supra-periosteal level.8
Larger gauge needles are more likely to damage blood vessels
and lead to bruising.1Where possible, smaller gauge needles are
preferable,8but this may be in part dependent on the product
being injected. Administration of botulinum toxin should be via a
30G needle. The use of a 32G needle did not show any statistical
difference in the rate of bruising compared with a 30G needle.12
There is some evidence that the use of a fanning technique with
a blunt-ended cannula reduces the incidence of bruising,3,13,14
although very thin cannulas can still cause considerable trauma.
Cannulas are also generally longer than their counterpart needles
and; therefore, less entry points are needed, again minimizes the
risk of bruising.6,8
Increased rate of injection and volume are both linked to
greater incidence of bruising6,8 with treatments performed more
slowly and with less volume having better outcomes in turns of
local reactions including bruising.1
There is some evidence that cooling the skin using a contact
cooling device prior to injection reduces the incidence of
ecchymosis by 60 to 88 percent.15
There are reports in the literature that prophylaxis with Arnica
montana leads to less bruising following cosmetic surgery which
was statistically significant on Day 1 and Day 7 when compared to
a control group.9
(C) Product factors. The use of adrenaline (epinephrine)
with lidocaine can limit bruising as the adrenaline leads to a
vasoconstriction of surrounding vessels and inhibits the activation
of eosinophils which play a part in bruising.8Adrenaline should be
used with caution as it will cause blanching of the skin and may
the mask the symptoms of an acute necrosis. Hyaluronic acid has
innate anti-thrombotic qualities.

The Management of Bruising following Nonsurgical Cosmetic Treatment
An Aesthetic Complications Expert Group Consensus Paper
JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2017 • Volume 10 • Number 2 E3
Areas of caution
¥Periorbital region (particularly the lateral canthus where the
skin is thin and veins more superficial)3
¥Perioral region and oral commissures
¥Temporal region
Treatment
As part of an informed consent, patients should be prepared for
bruising which may in rare cases be difficult to camouflage and
may inhibit social activities, particularly those patients in high-risk
groups. When obtaining consent, use appropriate language for the
patient (e.g., black eye). Ecchymosis will usually resolve in healthy
individuals within 10 to 14 days but it may persist for longer. The
application of cold packs within the first 48 hours followed by
heat can aid resolution.
Application of local compression following injection reduces
bruising risk1,6 as does the use of a cold compress1,8 to encourage
vasoconstriction.6
The topical application of arnica,1vitamin K8, or bromelain1can
lead to a reduction in the development of a bruise and may also
increase the speed of resolution,16,17 Bromelain is an enzyme
derived from pineapple that can be taken at a dose of 200 to
400mg three times per day to speed healing and help the body
clear metabolic waste following an injury.1
Persistent bruising or hemosiderin staining as a result of
ecchymosis may be amenable to laser treatment with devices,
such as the pulsed dye light (VBeam®, Syneron Candela, Irvine,
California) or potassium titanyl phosphate (KTP) laser, where
hemoglobin serves as the chromophore.8Patients who develop
bruising should be advised to stay out of the sun initially to limit
the risk of persistent staining.8
Vigorous exercise can increase blood pressure and aggravate
any bruising that is developing; therefore, exercise should be
avoided for the first 24 hours following an aesthetic procedure.1,8
Patients should also be advised to avoid extreme heat.
Finally, if unacceptable bruising does develop, camouflage
make-up may be applied.
Hematoma
Rather than forming a bruise, if there is a collection of blood
beneath the skin or within the muscle, this may become trapped
resulting in a firm mass appearing. The blood within the
hematoma is initially liquefied and can often be aspirated and
drained if it is dealt with before it becomes completely solid. A
hematoma will almost always naturally resolve over several weeks
or months as the body breaks it down through normal processes.
If a hematoma is very large or is causing damage to surround
tissue due to compression, it may be removed surgically.
Hematomas rarely occur following nonsurgical aesthetic
procedures.1
Refer
Bruising will normally resolve spontaneously within 10 to 14
days and is best managed conservatively. However, if bruising is
particularly distressing or a hematoma has developed, it is best to
review the patient as soon as possible. Keep contemporaneous
notes with good documentation and photography. Reassurance is
often all that is required or simple measures included in this
document.
Hematoma development may need referral to a colleague for
aspiration and drainage or surgical excision if it is causing
compression to nerves or vessels. A patient who experiences
bruising that fails to resolve over time or worsens over time
should be referred to his or her general practitioner as this may be
a sign of an underlying medical condition and should be
investigated further.
References
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2. Review of the Regulation of Cosmetic Interventions. Department
of Health, April 2013.
3. Niamtu J III. Filler injection with micro-cannula instead of needles.
Dermatol Surg. 2009;35(12):2005–2008.
4. Glogau RG, Kane MAC. Effect of injection techniques on the rate
of local adverse events in patients implanted with nonanimal
hyaluronic acid gel dermal fillers. Dermatol Surg.
2008;34(s1):S105–S109.
5. Tzikas TL. Evaluation of the radiance FN soft tissue filler for facial
soft tissue augmentation. Arch Facial Plast Surg. 2004;6(4):234–
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complications. Dermatol Surg. 2008;34:S92–S99.
8. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of
adverse events and treatment approaches. Clin Cosmet Investig
Dermatol. 2013;6:295–316.
9. Nettar K, Maas C. Facial filler and neurotoxin complications.
Facial Plast Surg. 2012;28:288–293.
10. Broughton G II, Crosby MA, Coleman J, Rohrich RJ. Use of herbal
supplements and vitamins in plastic aurgery: a practical review.
Plast Reconstr Surg. 2007;119(3):48e–66e.
11. Gladstone HB, Cohen JL. Adverse effects when injecting facial
fillers. Semin Cutan Med Surg. 2007;26(1):34–39.
12. Price KM, Williams ZY, Woodward JA. Needle preference in
patients receiving cosmetic botulinum toxin type A. Dermatol
Surg. 2010;36(1):109–112.
13. Fulton J, Caperton C, Weinkle S, Dewandre L. Filler injections
with the blunt-tip microcannula. J Drugs Dermatol.
2012;11(9):1098–1103.
14. Zeichner JA, Cohen JL. Use of blunt tipped cannulas for soft tissue
fillers. J Drugs Dermatol. 2012;11(1):70–72.
15. Nestor MS, Ablon GR, Stillman MA. The use of a contact cooling
device to reduce pain and ecchymosis associated with dermal filler
injections. J Clin Aesthet Dermatol. 2010;3(3):29–34.
16. MacKay D, Miller AL. Nutritional support for wound healing.
Altern Med Rev. 2003;8(4):359–377.
17. Leu S, Havey J, White LE, et al. Accelerated resolution of laser-
induced bruising with topical 20% arnica: a rater-blinded
randomized controlled trial. Br J Dermatol. 2010;163(3):557–563.
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The Management of Bruising following Nonsurgical Cosmetic Treatment
An Aesthetic Complications Expert Group Consensus Paper
E4 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2017 • Volume 10• Number 2
The Management of Bruising following Nonsurgical Cosmetic Treatment Expert Group: Dr Martyn King, MD (Chair); Emma Davies, RN,
NIP (Vice Chair); Stephen Bassett, MD; Sharon King, RN, NIP
The Management of Bruising following Nonsurgical Cosmetic Treatment Consensus Group: Helena Collier RN, NIP; Ben Coyle, MD;
David Eccleston, MD; Ravi Jain, MD; Askari Townshend, MD; Patrick Treacy, MD