ArticlePDF Available

The Management of Bruising following Nonsurgical Cosmetic Treatment

  • Aesthetic Complications Expert Group
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
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
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
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
Aesthetic complications Guidelines
The Management of Bruising following Nonsurgical Cosmetic Treatment
An Aesthetic Complications Expert Group Consensus Paper
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
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
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
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
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
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.
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
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
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.
1. Brennan C. Stop “cruising for a bruising”: mitigating bruising in
aesthetic medicine. Plast Surg Nurs. 2014;34(2):75–79; quiz 80–81.
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.
5. Tzikas TL. Evaluation of the radiance FN soft tissue filler for facial
soft tissue augmentation. Arch Facial Plast Surg. 2004;6(4):234–
6. Hamman MS, Goldman MP. Minimizing bruising following fillers
and other cosmetic injectables. J Clin Aesthet Dermatol.
7. Cohen JL. Understanding, avoiding, and managing dermal filler
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.
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.
The Management of Bruising following Nonsurgical Cosmetic Treatment
An Aesthetic Complications Expert Group Consensus Paper
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
... Using vitamin K creams for a few days before the procedure will also help to prevent hematomas. [32][33][34] It is recommended that the patient does no strenuous exercise in the previous days/hours. 35 Physical exercise is physiologically a natural vasodilator, so it can increase the risk of bruises or their intensity. ...
... If no new HA injections are administered, the following checkup will be at 6 months. To prevent or reduce possible hematomas, it may be useful to apply a vitamin K or liposomal lactoferrin cream to the area for a few days.[32][33][34] Other complications such as edema TA B L E 5 Undesirable situations and adverse effects with their possible causes Trauma at the time of treatment Disappears spontaneously in 4-7 days. ...
Full-text available
Background Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product. Aims To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.
... The downtime following a cosmetic procedure is an important consideration for patients. 1 Bruising is a common adverse event encountered with injectable dermal fillers. 1,2 with reported incidence of 24 3 or even 68 4 percent. ...
Full-text available
Injectable dermal fillers are in high demand. Patients undergoing this treatment are frequently burdened by bruising in the days following the procedure. Bruises associated with dermal fillers usually resolve spontaneously within 10 to 14 days, but patients want shorter downtime. We present a case of a bruise treatment with Nd:YAG laser consisting of three sessions in two day intervals, where the bruise resolved after seven days from the start of laser treatment. To date, the reports on laser therapy for bruise resolution are mostly limited to intense pulsed light and pulsed dye laser, and this case report contributes to the demonstration of Nd:YAG laser efficacy for this indication. Bruising or ecchymosis is a frequent adverse effect of injection and a primary concern to many patients considering injectable dermal fillers. Nd:YAG laser treatment can accelerate bruise resolution time and can therefore be used by medical practitioners to decrease downtime in patients undergoing this popular aesthetic procedure.
... Bruising is a common complication of medical procedures such as injections, as well as domestic trauma, sport, tourism, combat injuries, abrasions. Bruising causes aesthetic discoloration of the skin and mucous membranes [1,2,3]. Topical agents have most commonly been used to correct aesthetical aspects of the bruise, yet there is no method of correcting bruise pathology by acting upon the mechanisms behind discoloration. ...
Full-text available
Background Currently, there is no available medication for immediate correction of bruise discoloration. Instead, makeup, cosmetic powders, concealers, and various traditional herbal remedies are used to mask discoloration. These approaches have no influence on the pathology behind the discoloration. The purpose of this study was to explore existing methods and current trends in correction of hemoglobin related cutaneous discoloration. Methods This paper describes the treatment methodologies available for proposed correction of hemoglobin related cutaneous discoloration. A thorough literature review was conducted to assess current knowledge of available treatments for bruise discoloration. Results current cosmetics being marketed under the names "Bleacher bruises," "Bleaching agents" and "Blood bleachers" addressing bruise related discoloration do not offer targeted pathological treatment. Several methods for immediate discoloration of the skin and nail plate in the area of bruising and hematoma were found, yet no method offered sufficient clinical data in support of its efficacy and safety. The intricate mechanisms of discoloration associated with hemoglobin extravascular deterioration are not targeted by any treatment method. Only one paper outlining the clinical application of bleaching agents was found. Conclusion The primary blood pigments responsible for the discoloration in bruises include methemoglobin, oxyhemoglobin, carbohymoglobin, verdoglobin, biliverdin, and bilirubin. No existing method targets the degradation of hemoglobin in the area of ecchymosis. The efficacy of existing patented methods remains questionable and unsupported clinically. Future research should focus on developing a drug targeting hemoglobin derivatives, preventing discoloration at an early stage.
... Ecchymosis (bruising) is the most common localized event and can occur in up to 68% of patients. 5 Formation of a larger hematoma is less common but can occur within minutes or hours due to inadvertent laceration of facial blood vessels. Rather than forming a bruise, if blood beneath the superficial fascia becomes trapped, a firm mass can appear. ...
Full-text available
Background: Hyaluronic acid is an ideal facial filler, however, although established as both safe and effective, complications do occur. Treatment recommendations that combine both expert opinions and clinical trial data are currently lacking, partly due to difficulties with diagnoses, nonspecific diagnostic investigations, and certain disorders presenting with similar symptoms, thereby confounding diagnosis and treatment. Methods: The purpose of this article was to provide the aesthetic clinician with practical recommendations regarding complication diagnosis arising as a consequence of hyaluronic acid filler rejuvenation treatment. It also provides recommendations for their management using step-wise treatment algorithms that are based on published expert opinions, as well as the author’s clinical experience. Results: Algorithms are provided for the most common categories of complication associated with hyaluronic acid filler treatment, that is, skin discoloration, edema, nodules, infection, and vascular compromise. Conclusions: These guidelines are not intended to be complete or exhaustive but may prove informative for aesthetic clinicians who are responsible for treating patients with hyaluronic acid fillers. It may help to guide them on recognizing potential complications and it provides clear guidance on optimum treatment pathways.
Introduction: Soft tissue filler augmentation has become increasingly popular due to its perceived ease and impressive results. Unfortunately, although the results are impressive, so are the reported complications. This article describes complications specific to peri-oral soft tissue filler injection and then discusses evidence-based, anatomic prevention and treatment guidelines. Areas covered: The authors aimed at providing an overview of the complications associated with peri-oral soft tissue filler. Hyaluronic Acid (H.A) fillers may have devastating complications which are oft undisclosed or published. This narrative review aims to describe the various complications and provide preventative strategies. Expert opinion: Given the paucity of prospective, randomized clinical trials on the subject and in light of complication underreporting, the authors believe that efficacy and safety literature on the subject is lacking. Injectors must rely on the one strength which exists in the lip literature to date, that is anatomy. The basis of all successful injections is a mandatory understanding of normal as well as variations of vital structures in an area, combined with meticulous injection techniques, deposition of small aliquots of product and the ability to recognize unwanted adverse events early enough to act on them.
Bruises is one of the most common side effects of injectable cosmetic procedures, which leads to stress to clients and health care providers. Conventional treatments such as vitamin K preparation, cold compresses, and Arnica cream have been used to treat bruises, yet these treatments do not provide instant results. The purpose of this report is to present a case in which different wavelengths of Q-switch nanosecond laser was used to treat cosmetic injection-related bruises. Four different laser wavelengths were used to treat injection-related bruises. Pictures were taken before and after the treatment and analyzed using the RGB color histogram and the Image color analyzer from Pictures showed a close to complete resolution of the bruises and discoloration. The results of this report suggest that using multiple selective wavelengths, in shorter pulse width but higher fluence would be more effective in resolving bruise-related discoloration compared to using one wavelength with longer pulse width.
Cosmetic neurotoxin treatments may occasionally have complications that are often related to inexperience of the injector (King, J Clin Aesthet Dermatol 9(12):E1–E4, 2016). Except for eyelid ptosis, which has a reported average occurrence of 2–5%, the majority of reported adverse reactions are transient and related to intradermal injection, such as temporary bruising or headache. Other “side effects” include unnatural appearance, asymmetry, brow descent, and lack of individualization of treatment. Neuromodulator injections are the most precise and predictable procedure in the cosmetic field; but a true master injector must learn how to deviate from the “standard pattern” of injections to artfully correct facial asymmetries and obtain the best outcomes.
Botulinum toxin type A injectables have been increasingly used for over 20 years in cosmetic surgery and medicinal purposes. The uses in cosmetic and dermatologic surgery have increased in numbers treated per year and areas of the body treated as well. However, with expanded use in the field of cosmetic surgery, various complications may arise depending on the anatomy, dilution, patient factors, and skills of the injector. This article discusses the complications of botulinum neurotoxins used in cosmetic surgery.
Full-text available
The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase. To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance. Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided. Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique. For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.
Full-text available
Objectives. Consensus guidelines developed for the use of hyaluronic acid dermal fillers describe the use of cooling the skin to reduce patient discomfort during injection. The vasoconstrictive effects of cold may provide reduced ecchymosis and swelling at the site. However, the effect of applying ice or cooled air is unpredictable because these modalities do not deliver precise temperature, which may result in cold burn or insufficient effect to targeted areas. This open-label, randomized, single-blinded, split-face trial was conducted to measure the extent to which applying a spot cooling device reduces patient discomfort and ecchymoses in the clinical setting in patients undergoing a dermal filler procedure. Subjects. Twenty male and female subjects of any race, ages 35 to 65 years, with moderate and severe nasolabial folds were included in this study. Seven (35%) subjects had received previous small gel particle hyaluronic acid injections. Methods. Prior to injection, the topical cooling system was set at 35 degrees F and a cooled applicator was applied for 20 seconds on one nasolabial fold. A control using a noncooled applicator was applied for 20 seconds on the other nasolabial fold. Postprocedure ice packs were prohibited so as not to confound the subject's perception of procedure-related pain. Subjects (using visual analog pain scales) and blinded investigators rated pain and ecchymosis using predetermined scales and satisfaction surveys. Results. Use of the cooling system was associated with mean pain reduction of 61, 70, and 42 percent compared to control, as measured by visual analog pain scales, immediately following and one hour and three hours post small gel particle hyaluronic acid injection. Additionally, use of the cooling system was associated with mean ecchymosis reduction of 88, 89, 80, and 66 percent compared to control immediately following injection, one hour, three hours, and next-day postinjection. Conclusion. The cooling system provided adequate pain management (both subjectively and objectively through blinded evaluations) during and after small gel particle hyaluronic acid dermal filler injections for the correction of moderate nasolabial folds. Furthermore, results demonstrate that the cooling system is associated with decreased ecchymosis. Future studies are needed comparing the use of topical anesthetics to a cooling system for the reduction of pain and ecchymosis associated with the use of dermal filler injections.
The quest to restore a more youthful appearance by filling and volumizing facial deformities and deficiencies continues to be an ongoing pursuit in the noninvasive aesthetics market. Bruising can result from the delivery of neuromodulators and dermal fillers-common tools in the aesthetic provider's armamentarium to combat the ravages of aging. There are steps both the aesthetic provider and the client can take to minimize the potential for bruising. This article focuses on the etiology of bruising, the pharmacological and herbal agents to avoid prior to an aesthetic procedure, techniques to utilize during aesthetic procedures that lessen the potential of bruise formation, and pharmacological and herbal agents to administer after an aesthetic procedure to ultimately mitigate bruise formation.
Background: Microcannulas with blunt tips for filler injections have recently been developed for use with dermal fillers. Their utility, ease of use, cosmetic outcomes, perceived pain, and satisfaction ratings amongst patients in terms of comfort and aesthetic outcomes when compared to sharp hypodermic needles has not previously been investigated. Objective: To compare injections of filler with microcannulas versus hypodermic needles in terms of ease of use, amount of filler required to achieve desired aesthetic outcome, perceived pain by patient, adverse events such as bleeding and bruising and to demonstrate the advantages of single-port injection technique with the blunt-tip microcannula. Materials and methods: Ninety-five patients aged 30 to 76 years with a desire to augment facial, décolleté, and hand features were enrolled in the study. Subjects were recruited in a consecutive manner from patients interested in receiving dermal filler augmentation. Each site was cleaned with alcohol before injection. Anesthesia was obtained with a topical anesthesia peel off mask of lidocaine/tetracaine. Cross-linked hyaluronic acid (20 mg to 28 mg per mL) was injected into the mid-dermis. The microcannula or a hypodermic needle was inserted the entire length of the fold, depression or lip and the filler was injected in a linear retrograde fashion. The volume injected was variable, depending on the depth and the extent of the defect. The injecting physician assessed the ease of injection. Subjects used the Visual Analog Scale (0-10) for pain assessment. Clinical efficacy was assessed by the patients and the investigators immediately after injection, and at one and six months after injection using the Global Aesthetic Improvement Scale (GAIS) and digital photography. Results: Overall, the Global Aesthetic Improvements Scale (GAIS) results were excellent (55%), moderate (35%), and somewhat improved (10%) one month after the procedure, decreasing to 23%, 44%, and 33%, respectively, at the six month evaluation. There was no significant differences in the GAIS score between the microcannula and the hypodermic needle. However, the Visual Analog Scale for pain assessment during the injections was quite different. The pain was described as 3 (mild) for injections with the microcannula, increasing to 6 (moderate) for injections with the hypodermic needle. Bruising and ecchymosis was more marked following use of the hypodermic needle. Conclusion: Using the blunt-tip microcannula as an alternative to the hypodermic needles has simplified filler injections and produced less bruising, echymosis, and pain with faster recovery.
Botulinum neuromodulators and injectable dermal fillers have become part of the armamentarium in the treatment of facial aging. Their successful use requires a fundamental knowledge of anatomy and physiology and a sound understanding of their risks and complications. Although neuromodulators and fillers continue to demonstrate a strong record of safety, several notable risks exist.
Background Dermatological procedures can result in disfiguring bruises that resolve slowly. Objectives To assess the comparative utility of topical formulations in hastening the resolution of skin bruising. Methods Healthy volunteers, age range 21–65 years, were enrolled for this double (patient and rater) blinded randomized controlled trial. For each subject, four standard bruises of 7 mm diameter each were created on the bilateral upper inner arms, 5 cm apart, two per arm, using a 595-nm pulsed-dye laser (Vbeam; Candela Corp., Wayland, MA, U.S.A.). Randomization was used to assign one topical agent (5% vitamin K, 1% vitamin K and 0·3% retinol, 20% arnica, or white petrolatum) to exactly one bruise per subject, which was then treated under occlusion twice a day for 2 weeks. A dermatologist not involved with subject assignment rated bruises [visual analogue scale, 0 (least)–10 (most)] in standardized photographs immediately after bruise creation and at week 2. Results There was significant difference in the change in the rater bruising score associated with the four treatments (anova, P = 0·016). Pairwise comparisons indicated that the mean improvement associated with 20% arnica was greater than with white petrolatum (P = 0·003), and the improvement with arnica was greater than with the mixture of 1% vitamin K and 0·3% retinol (P = 0·01). Improvement with arnica was not greater than with 5% vitamin K cream, however. Conclusions Topical 20% arnica ointment may be able to reduce bruising more effectively than placebo and more effectively than low-concentration vitamin K formulations, such as 1% vitamin K with 0·3% retinol.
In the US, soft tissue fillers are currently administered using sharp, hypodermic needles. The choice in length and gauge of needle is determined by the injector's preferences, as well as the physical properties of the filler itself. While some adverse events are injector-dependent, others may be due to risks inherent to using sharp needles. The use of new, flexible cannulas with blunt tips may potentially both lower these risks and change the techniques by which fillers are administered in the future.
Patients often complain of pain and bruising from needle injections. Some clinicians believe smaller gauge needles cause less pain. Thirty-gauge needles are currently the standard needles employed for administering botulinum toxin type A (BTX-A). This study sought to determine whether patients receiving BTX-A have a preference for 30-gauge or 32-gauge needles based on the amount of pain and bruising experienced. Thirty-seven subjects received BTX-A on the right side of the face using a 30-gauge needle and on the left side using a 32-gauge needle. Subjects were masked to needle size. They were then asked to rate injection pain on an 11-point numerical rating scale and to note any bruising. Physician preference was also evaluated. There were no statistically significant differences in the amount of intra-procedural pain (p=.37) or the level of post-procedural pain and discomfort (p=.76) experienced. Twenty-seven percent of subjects reported greater bruising with the 32-gauge needle, versus 29.7% with the 30-gauge needle. The physician injector did not have a preference. Lastly, 83.8% of subjects did not detect a difference in BTX-A paralysis effect. We do not recommend using 32-gauge needles in place of 30-gauge needles for administering BTX-A.
The author has indicated no significant interest with commercial supporters.