March 7, 2022

It is not uncommon to have a bruise after an injectable treatment.  In fact, it’s one of the most common side effects, some argue, an adverse event, following an injectable treatment.

The rate of incidence is highly variable depending on many factors.  It is however a significant issue for many of our patients and is something we as healthcare practitioners should try to avoid as much as possible, and to support our patients appropriately should one occur.

What is a bruise?

The medical term for bruise depending on its cause can also be known as a contusion, ecchymosis, petechia, purpura and haematoma.  They can occur when small vessels underneath the skin erupt through either penetration of a sharp instrument or blunt force such as injury or a fall, resulting in blood seeping out into the tightly packed tissues beneath the skin or mucous membrane.  They may appear instantly or even delayed but can present as a dark red, purple, bluish irregular, or rounded patch.  They change colour over a period of weeks as the body breaks down the oxygen rich haemoglobin, and reabsorbs the iron and bilirubin content.

Haematomas occur almost immediately after insertion and removal of the needle, it forms a distinct bruised firm or semi-firm mass under the skin or mucous membrane, they can also develop over a matter of hours with a slow trickle into a potential space.  Capillary refill at this area is usually delayed, sometimes confusing inexperienced clinicians and causing a misdiagnosis of vessel occlusion.

Despite this seemingly insignificant side effect, bruises affect our patient’s wellbeing negatively and this needs to risk assessed appropriately before any injectable treatment is carried out and with careful discussion and consent, a treatment may or may not be in the best interests of our patients.

Reducing the risks of bruising

Patient factors:

aesthetics injectionThorough consultation of patients medical, surgical, and psychosocial history is essential to us as medical practitioners working to a medical model.  Focus on patients:

  • Drug history and supplements, vitamins and regular over the counter drugs taken – note vitamins and supplements can have an affect on clotting time as well as prescribed anticoagulant drugs, non-steroidal, anti-inflammatory and corticosteroids.
  • Previous aesthetic experiences and outcomes
  • Susceptibility to general bruising
  • Age of patient and fragility of their skin
  • Haematological disorders
  • Liver disorders
  • Alcohol habits
  • Iron deficiency

Practitioner technique: Prevention is better than cure

It may be very basic but its certainly something that could be prevented, purely examining the patients face and mapping out any visible vessels to steer clear of in a well-lit room.

Having a good mental model of where all the important vasculature under the skin such as arteries and veins and use of appropriate depth of injection to prevent piercing of these larger vessels.

Opting to use a 25G cannula or over a needle to reduce the amount of trauma the patient could undergo allowing the blunt tip tool to glide past important vessels rather than dissecting through them with gentle pressure as opposed to a forceful technique.

Opt for the smallest gauged needle that is appropriate for the product you are injecting.

Have the room cooler for injecting and the bed away from the window in summer months as vasodilation can happen as the patient gets warm or anxious.

A steady hand for injecting also helps prevent you causing additional trauma.  Have yours injecting arm steadied by anchoring it with your other or resting on the bed with wide feet apart to provide better stability.

Ready your patient, let them know the injection is coming to prevent them jumping.

Use a sharp needle, change them regularly especially if you’ve kissed the bone.

Use of products with lidocaine in can help with reduction of bruising if not contraindicated as it has a vasoconstriction effect on vessels.  Only use the maximum strength of lidocaine in topical pre-treatment creams of 4% as stronger variants can have significant blanching or vasoconstriction of the tissues and vessels causing a difficulty in correctly diagnosing vessel occlusion.

Additional to this information, careful discussion around what potential impact could a bruise have on this individual at home from family members, attitudes from friends or colleagues.  Bruising is often a tell tale sign a person has had a treatment and this can cause embarrassment due to presumed domestic abuse at home or antisocial behaviour from peers and public or because we still live with much stigma around the use of injectable treatments.

Management of a bruise

Aftercare advice for our patients needs to be readily available to our patients should they require it so a help sheet with advice could be given to these patient who actively bruise on the day, we can support them verbally and back this up with a support sheet.

  1. Do – At sign of bleeding, immediately apply compression to the site and remain there for a couple of minutes to prevent the spreading of blood into the tissues or mucous membrane.  If bleed is significant a haematoma can easily form, so don’t be too eager to move on before the bleed is stemmed.
  2. Do – Elevation would normally be advised should this be a limb but as most of our treatments involve the face staying upright for at least a couple of hours should be encouraged and sleeping on their back or unaffected side, if possible, the first night.
  3. Do – Encourage the patient for the next 24 hours or longer if significant bleeding or haematoma occurred to rest.  Elevation of the heart rate and blood pressure will agitate the bruise so advice against exercise or extreme heat from steam rooms, saunas etc.
  4. Do – Gently hold an ice pack or pack of frozen peas wrapped in a tea towel to the affected area for 10- 20 minutes at a time and repeat regularly for next couple of days particularly if the eye is involved.
  5. Do not – Do not put Ice directly onto the skin.
  6. Do – Take simple analgesia such as paracetamol or ibuprofen if there is pain but where possible avoid ibuprofen or aspirin unless required as this can encourage bleeding.
  7. Do not – Do not stop taking aspirin if this is prescribed by a doctor for their health needs.
  8. Do – After a 48 hour period switching over to a warm compress (not hot) is advised and applied to the affected area regularly throughout the days following.
  9. Do not – Do not press or rub the affected area especially if it is around the eye.
  10. Do – Apply makeup to conceal any bruising if desired after 24 hour

Less frequent management

Management of a haematoma is usually the same as a bruise but may take longer to reach resolution, in some cases some very large haematomas can be drained with a needle and syringe if dealt with swiftly, before the blood becomes a solid clot.  But this procedure can also cause additional bleeding and bruising too.  Very rarely does surgical intervention have to be sought.

The use of injecting hyaluronidase into a haematoma to break it down is another practice opted by some practitioners, however this comes with risk of further bleeding and bruising and potential allergic reaction – therefore most practitioners opt to allow nature to take its course and allow the body to naturally break down the clot over the next couple of weeks or months in some cases.  Verbal and written reassurance is often required for these patients.

Topical support

There is some evidence to say that topical applications of some herbal and medicinal remedies such as arnica or aloe vera, bromelain or vitamin K could reduce the development of the bruise and also speed resolution.  If safe to do so ie no allergies or contraindications for use, this can be suggested but this is an additional measure, the above steps should be primary advise.

After effects of bruising

Some significant bruising can have a long-lasting effect on the skin, in particularly if there was bleeding within the orbit where the skin is very thin and practically transparent.   Any bleeding where the skin is thin, like hands, shins and ankles in elderly patients could result in a haemosiderin staining of the skin.  This results in a brown or darkened area where the blood has been trapped and the haemosiderin accumulates under the skin.  When the haemoglobin breaks down it releases iron.  This iron is then stored as haemosiderin beneath you skin.  Treatment of this less frequent effect can be improved with laser if natural resolution didn’t occur.

Hematomas can take many weeks or months to totally resolve but don’t be surprised to find they are quite textual and gritty during this stage and even once the discoloration has settled the clotting process involves fibres of a protein called fibrogen that mesh to form a clot.  This will naturally resolve in time as your body breaks down the excess fibrin.

So who knew there would be so much to reflect on when it comes to a simple bruise but ultimately these factors need to be considered for our patients, sometimes if the risk of a bruise or the potential worry to cause a bruise because of the potential negative impact on the patients wellbeing is too high, it certainly could be a better decision not to treat.  Should we cause a bruise, our patients need the emotional support to feel reassured and that is the backbone of our roles, and ensuring we are actively doing all we can to avoiding giving bruises in the first place, as ultimately this affects our business too.  Patients are more likely to return to a practitioner who gave them a bruise but was well supported than someone who just shrugged them off.

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