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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
... This inconvenience makes it difficult to satisfy the necessary conditions during the injection process, such as the syringe should be maintained and held steady while administering the injection, the right hand must remain fixed on the patient's targeting layer, and an appropriate injection speed must be maintained. If the syringe is not held steadily, pain may be caused by stimulation of the surrounding nerves and vascular damage resulting in bruises or hematomas due to bleeding [32]. In addition, multiple injection procedures by the practitioner may cause arthritis and tendinitis. ...
... This inconvenience makes it difficult to satisfy the necessary conditions during the injection process, such as the syringe should be maintained and held steady while administering the injection, the right hand must remain fixed on the patient's targeting layer, and an appropriate injection speed must be maintained. If the syringe is not held steadily, pain may be caused by stimulation of the surrounding nerves and vascular damage resulting in bruises or hematomas due to bleeding [32]. In addition, multiple injection procedures by the practitioner may cause arthritis and tendinitis. ...
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Background and Objectives This study aims to improve the inconvenience of injecting a conventional syringe. We propose a pen-type injection-assisting device that can auto�matically apply pressure to a replaceable cylinder using an electric motor. Generally, injection with a syringe is one of the most important techniques in clinical practice and is particularly used when lipolysis or anesthetic agents are injected. Currently, a general syringe is used for lipolysis injection, and a large amount of drugs are injected, resulting in significant fatigue of the fingers of medical personnel. In addition, it is difficult to inject with a syringe while maintaining a constant pressure due to fatigue. Materials and Methods The assisting device is demonstrated as a model for a 3D automatic syringe assist device. The main body is a plastic syringe detacher, and all internal ac�cessories were made of plastic, except for the holder and motor which are in the form of a metal clip. Results The present invention is a device that uses an electric motor and a cogwheel connected thereto to apply positive pressure to a cylinder while holding the syringe with one hand, like a pen, and pressing a presser bar with the push of a button. Conclusion By improving discomfort during the injection process due to manipulation of both hands, side effects, such as pain and hematoma that patients may experience after surgery can be alleviated
... 18 Bruising is also a common adverse event associated with dermal filler or botulinum toxin injections. 6,7,[19][20][21][22][23][24] Bruising with filler injections, for example, occur with an incidence ranging from 19% to 68%. 25 Bruises after dermal filler injections, however, are typically more superficial and associated with less tissue inflammation and edema compared with post-surgery bruises. 9 A variety of medical and laser-based treatments are available to make bruises heal more quickly. ...
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Background: Cellulite 80%-98% of post-pubertal women and results in cutaneous dimples in the affected area. Aims: Therapies that target collagenous fibrous septae often provide successful outcomes. Materials & methods: Collagenase clostridium histolyticum-aaes (CCH) for injection consists of two collagenases which, under physiologic conditions, disrupt collagen structures by hydrolyzing Type I and III collagen. Results: Subcutaneous CCH was approved in the United States in 2020 for the treatment of moderate-to-severe cellulite in the buttocks of adult women. Although bruising is primarily an aesthetic concern, a conspicuous procedure-induced bruise may limit a patient's social activities and result in hesitation to undergo a similar cosmetic procedure in the future. Conclusion: The purpose of this review is to describe the available techniques for hastening bruise resolution and how they apply to resolving bruises associated with a CCH injectable.
... Bruising is an expected outcome following facelift surgery; however, it is unfavorable to patients as it potentially leads to embarrassment around having had the procedure done, unsolicited questions, or even assumed spousal abuse, all of which amounts to social downtime. 25 Improving and expediting postoperative healing is a common priority for both patients and physicians. 26 In this study, RADA16 treatment appeared to minimize and, in some cases, eliminate postoperative bruising in patients receiving facelift surgery, supporting a more rapid return to social life. ...
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Background Hematomas are consistently cited as the most common complication of facelift surgery, with reported incidence rates ranging from 1 to 9% despite preventative measures. A self-assembling RADA16 peptide solution (PuraSinus, 3-D Matrix, Newton, MA) designed to aid in wound healing, adhesion prevention, and bleeding control has demonstrated hemostatic control of intra- and postoperative bleeding associated with various surgical procedures, including nasal and sinus surgery. Objectives To report surgical experience using novel application of RADA16 hemostatic agent in facelift procedures. Methods Through exploring incorporation of RADA16 hemostatic agent into standard of care, 15 higher-risk facelift patients were treated intraoperatively between December 2020 and July 2021. Postoperative follow-up was on post-procedure day 1 and 3 and at approximately one week. During follow-up, potential complications were assessed subjectively, including hematoma, swelling, and bruising; postoperative observations recorded; and photographs taken. Results Among facelift patients receiving intraoperative RADA16 hemostatic agent there were no hematomas or protracted ecchymosis events. The only significant complication was one patient admitted for intravenous hydration due to post-operative nausea and vomiting. All patients had minimal bruising or a dramatic absence of bruising and experienced no hemorrhage or hematoma. Through surgical experience, technique for RADA16 hemostatic agent placement was optimized and procedural details are provided. Conclusions Intraoperative administration of topical RADA16 hemostatic agent appears to deter acute hematoma and hemorrhage formation and early experience suggests that RADA16 hemostatic agent may also attenuate post-operative bruising in facelift patients. These observations warrant further investigation in a larger randomized controlled study.
... 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.
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Purpose Unlike ordinary 30-gauge needles, insulin syringe needles are thinner and shorter and have a comparatively blunt tip. Therefore, insulin syringes may reduce injection discomfort, bleeding, and edema by minimizing tissue damage and vascular penetration. This study aimed to evaluate the potential benefits of using insulin syringes for local anesthesia in ptosis surgery. Methods This randomized, fellow eye-controlled study included 60 patients (120 eyelids), conducted at a university-based hospital. An insulin syringe was used on one eyelid, and a conventional 30-gauge needle was used on the other. Patients were instructed to score pain in both eyelids using a visual analog scale (VAS) ranging from 0 (no pain) to 10 (unbearable pain). Ten minutes after the injection, two observers scored degrees of hemorrhage and edema in both eyelids on five- and four-pointing grading scales (0–4 and 0–3) for each value, and the average score between the two observers was calculated and compared. Results The VAS score was 5.17 in the insulin syringe group and 5.35 in the 30-gauge needle group (p = 0.282). Ten minutes after the anesthesia, the median hemorrhage scores were 1.00 and 1.75 (p = 0.010), and the median eyelid edema scores were 1.25 and 2.00 (p = 0.007) in the insulin syringe and 30-gauge needle groups, respectively (Fig. 1). Conclusion Injecting local anesthesia using an insulin syringe significantly reduces hemorrhage and eyelid edema, but not injection pain, before skin incision. Insulin syringes are useful in patients at high risk of bleeding because they can reduce the penetrative tissue damage caused by needle insertion. Fig. 1Schematic abstract of patient enrollment, comparison, and result analysis
Trauma is one of the leading causes of death and maxillofacial injuries are more common in Road traffic accident. Post traumatic hematoma is more common and a self limiting one. Hematoma in maxillofacial injury following an RTA is usually associated with fracture of facial bones. It occurs mainly due to breach in periosteum and osseous bleeding from fractured bone segments. Here we present a case report of expanding post traumatic hematoma following RTA with no associated fractures and its management.
Purpose of review: Nonsurgical rhinoplasty (NSR) continues to grow in demand and popularity. Consequently, there has been a rise in the number of reported complications. This review will summarize and discuss the current evidence for the prevention and management of adverse events related to NSR with a specific emphasis on practical clinical applications. The review is based on recent systematic reviews and multidisciplinary expert consensus recommendations. Recent findings: First, NSR has overall favorable outcomes with rare complications. Second, vascular compromise is a rare event, but the number of reported severe complications is rising. Third, providers should be intimately familiar with preventive measures, early signs and symptoms, and appropriate management algorithms of all possible complications. Fourth, having a readily available 'toolbox' of recommended therapies may improve timely management of emergent complications. Summary: The number of complications associated with NSR is expected to rise congruent with the increased demand for the procedure. Although NSR has a favorable safety profile, complications can occur in the best of hands even when using appropriate risk reduction strategies. Early detection and appropriate treatment of known complications may eliminate or minimize sequelae and allow providers to continue to safely perform NSR.
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.
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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.
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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.