Dr Dirk Coetzee discusses the nuances of managing one of the most common yet often overlooked complications associated with aesthetic injectable treatments: bruise control. With his background in anaesthesiology and a deep passion for aesthetic and regenerative medicine, Dr Coetzee guides us through the various aspects that contribute to bruise formation following such treatments. The article explores the physiological basis of bruising and considers both patient- and practitioner-related factors that can influence the risk and severity of bruising. Additionally, it provides practical strategies for prevention and treatment, offering invaluable insights for practitioners and patients alike in navigating this common yet challenging aspect of aesthetic treatments.
Any aesthetic injectable treatment carries various degrees of risk for the occurrence of complications. Bruising is one of the more common complications that may occur following aesthetic injectable treatments.
Also known as ecchymosis or a contusion, bruising is simply a collection of blood in the skin or mucous membrane. When an injection is performed anywhere on the body, blood vessel injury is always a possibility. The human face has a very rich blood vessel network, making it prone to bruising.
A bruise may form if the natural mechanisms to stop the blood from exiting the blood vessel fail or happen too slowly. These mechanisms include blood vessel constriction (narrowing), platelet function, platelet plug formation, and the formation of a stable blood clot.
Anything that may affect the blood’s ability to form a clot can be considered a factor that increases the risk of bruise formation. These factors can be divided into patient- and practitioner-related factors.
Patients suffering from some medical conditions – such as clotting disorders, liver disease, kidney disease, and some hormonal conditions – have an increased risk of bruising.
Some medical conditions require patients to take prescription medications such as anticoagulants and antiplatelet treatments to prevent clot formation. These patients require these treatments to reduce the risk of complications from their medical condition. In such cases, it can be dangerous not to take these medications, and caution must be taken by the aesthetic practitioner in stopping certain prescriptions.
Examples of these medical conditions include previous heart attacks (myocardial infarctions), strokes (cerebrovascular accidents), or blood clots in the veins (deep venous thrombosis).
Some pain medications such as aspirin and diclofenac affect the platelet’s ability to form a platelet plug and persist for the lifespan of the platelet, which is seven days. Patients should thus either avoid these before having aesthetic injectable treatments or consideration should be given to postponing the treatment for a week after the above-mentioned medications were taken.
Patients on oral or topical steroids for inflammatory, rheumatological, or dermatological conditions have an increased bruising risk. This is because steroid treatments make the blood vessels more fragile and thus prone to leakage and subsequent bruise formation.
Another often overlooked patient factor is using supplements and herbal treatments. Some supplements and herbal treatments that increase bruising risk include gingko, garlic, ginseng, fish oils (omega-3), and St. John’s wort.
Knowledge of the blood supply of the face is vital for any practitioner considering aesthetic injectable treatments. Such knowledge enables the practitioner to avoid major blood vessels. This, however, is not a foolproof way to avoid bruising, as the small blood vessels on the face are numerous and cannot be mapped out like the major blood vessels.
A practitioner’s cool and calm demeanour goes a long way toward putting the patient at ease. This is because stress and anxiety increase blood pressure, which may worsen bruising if it occurs.
The technique and instruments used also play a role in bruise prevention. The practitioner should aim to minimise the amount of skin puncture and use the smallest-calibre needle possible for the desired treatment effect. There is also a possibility that the use of a cannula instead of needles might lessen the risk of bruising.
Bruise prevention and treatment
The natural course and duration of bruise resolution varies from patient to patient and may be anywhere between 10–21 days. In some cases, the bruise may persist beyond 21 days. This can be attributed to haemosiderin staining. Patients should avoid sun exposure after a bruise occurs to lessen this risk. Haemosiderin staining may be treated with light and laser devices such as KTP or PDL treatments.
Prevention is always better than cure. Therefore, addressing the contributing factors mentioned above goes a long way in bruise prevention. Identifying underlying medical conditions, withholding certain medications (when indicated), and avoiding herbal treatments before the injectable treatment lessens the risk of bruise occurrence.
Other, more active interventions that may be used include the following:
- Using Arnica montana, vitamin K8, and bromelain (enzyme found in pineapple) pre- and post-treatment
- Cold compressions before and after injection (causes blood vessels to become smaller in diameter)
- Avoidance of exercise 24 hours post-treatment (increases blood pressure)
- Avoidance of warm environments such as saunas, steam rooms, etc. (causes blood vessels to become larger in diameter).
It is all about the balance of risk versus benefit. If the risks of bruising outweigh the potential benefits of the proposed injectable treatment, the treatment could either be deferred, or an alternative treatment may be sought.
It is the practitioner’s duty to relay these risks and benefits to the patient so that the patient may make an informed decision with regard to the treatment and choose whether to proceed or defer the proposed injectable treatment. This ensures proper informed consent.
- Hamman, M. S., & Goldman, M. P. (2013). ‘Minimising bruising following fillers and other cosmetic injectables’. The Journal of clinical and aesthetic dermatology, 6(8), 16–18.
- King M. (2017). ‘The Management of Bruising following Nonsurgical Cosmetic Treatment’. The Journal of clinical and aesthetic dermatology, 10(2), E1–E4.
- Brennan, C. (2014). ‘Stop “Cruising for a Bruising”:
Mitigating Bruising in Aesthetic Medicine’. The plastic surgical nursing journal online, 34(2), 75-79
MBChB (Stell), FCA (SA), MMed (Anaes), Dip. Aesth. Med. (AAAM)
- Founder of RP Aesthetics/DrDirk Medical Aesthetics in Somerset West
- Member of AAMSSA (Aesthetic & Anti-Ageing Medicine Society of South Africa)
- Aesthetic medicine trainer
Dr Dirk Coetzee obtained his Anaesthesiology Degree in 2018. In 2020, he changed paths to perform full-time Aesthetic Medicine at his practice in Somerset West, Western Cape, South Africa. Aesthetic and Regenerative Medicine is where his true passion lies, and he has not looked back ever since.