Diagnose, manage and avoid bruising from cosmetic injectables

Bruising can be scary for patients – they immediately think “you have injured me” – but it can also be scary for aesthetic clinicians – aside from being blamed – because bruising as a side effect can go along with some of the things that we fear the most, particularly vascular occlusion. Of course, as medical aesthetic injectors, we know that bruising is just the body’s response to trauma and usually does not represent a concern. However, it is vital to explain this to your patients, and understand yourself how to diagnose and manage normal bruising and more serious consequences.

In this blog, Dr Tim Pearce provides a guide to managing bruising from cosmetic injectables. He explains how to spot the early signs of a bruise, diagnose and manage a haematoma or a vascular occlusion, and how to explain bruising to your patients. There are also some top tips on how to reduce the risk of haematoma formation and how do we reduce the risk of causing bruising. Download Dr Tim’s bruising checklist to help you to prevent and minimise bruises from injectables.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

How to diagnose and manage a haematoma

The first indication that you are dealing with a hematoma is that it bleeds quite quickly after the procedure – you remove the needle and often there is a gush of blood that comes out of the skin or stays underneath the skin and starts to balloon. The initial change from pink skin to bruised skin very quickly highlights the first sign of a haematoma. The next step is therefore to apply some pressure to the injection site to reduce the amount of bleeding that is occurring under the skin.

Read up on how to diagnose, manage and avoid a haematoma in the lips.

How to diagnose and manage a vascular occlusion

A simple vascular occlusion will typically present differently to a haematoma with pallor being the first sign. The cosmetic injection will have blocked the blood supply to the skin, and there may not be any associated bruising, resulting in an area of pallor that develops into a reticular pattern with blotchy pink and white tissue next to each other within the area affected.

This very early stage, immediately after the first injection, is where you will find that carrying out a capillary refill test (CRT) is most useful. If there is a delay in capillary refill at this early stage, and it is a significant delay without any serious bruising or only a small, new bruise appearing, then the CRT is a much more sensitive tool for diagnosing a vascular occlusion.

If you find there is a delay in capillary refill when you review a patient after a couple of days, or even after a few hours, there is often an existing hematoma next to it and this make the CRT much less sensitive for diagnosing a vascular occlusion because one of the characteristics of a haematoma is some delay in capillary refill which can cause confusion as to the seriousness of the situation.

How do we reduce the risk of haematoma formation

According to Dr Tim, the simplest thing you can do is use an instrument for injection that causes less trauma, where possible, and if it does not compromise the aesthetic result; you could, therefore, try using a cannula. Cannulas have a blunt tip and do not cut through vessels as frequently as a needle, meaning you cause less bleeding under the skin and less bruising, if you are gentle!

Sadly, it is not practical to use cannulas all the time when performing aesthetic injectable treatments because they can compromise the aesthetic result. A blunt tip tends to gravitate towards soft tissue on insertion, meaning placement is usually in the middle plane (the fat) because it gravitates away from connective tissue, the skin, or bone. Cannulas are good for volumising in certain areas of the face, and for certain indications for dermal filler, but are often not appropriate where definition is required.

How to explain bruising to patients

Patients are frequently worried about bruising for two reasons. One, the aesthetic result – they now have a bruise that they did not want, and two the thought that you have hurt them. This second reason is usually of more concern because they regard bruising as a sign of injury or a complication. As aesthetic clinicians, it is our role to educate our patients and help them to differentiate between bruising that is associated with injury or complication and bruising that is simply part and parcel of the process.

When explaining this to your patients, the biggest difference to get across is that between pain and tenderness. It is normal for a bruise to feel tender. If you inject a patient and two days later, they have no pain, but if they push on the area where there is a bruise, it will feel tender and that is normal. Whereas an increase in pain, with an associated haematoma, in the first twelve hours or so could be associated with a vascular occlusion. It is vital patients and practitioners understand the distinction between a ‘dangerous’ and a normal bruise.

As noted, patients tend to think that bruising equals injury, but are often relieved to learn that, in this instance, a bruise is simply caused by the needle passing through a vessel which then bleeds underneath the skin. Rather than blood appearing on the surface, it creates a pool of blood which we see as a bruise.

How do we reduce the risk of causing bruising

Dr Tim recommends that one of the main things you can do to reduce the risk of bruising is to home in on the precision of your injecting. Precision starts with stable injecting which starts with you stabilising your body as you inject. Begin with your feet, then your pelvis, your upper body and arm can be stabilised on the patient, and usually this should result in only your wrist being able to move with your fingers controlling the needle. This allows you to inject very carefully and in a controlled manner into a specific plane that you understand with some detail.

With experience, higher understanding and visualisation of the anatomy and location of the vessels, you will cause less trauma and your instance of causing bruises will reduce. For more top tips on how to inject well and stabilise your injections, read Dr Tim’s:

• Injection Techniques 101: good injection techniques for dermal fillers
• How to improve needle control when injecting!

These blog from Dr Tim also provide additional insight:

• Management of a bruise following an injectable treatment
• How to reduce bruising whilst injecting Botox® and filler
• 5 tips to prevent bruising from cosmetic injections.

What do you think? Dr Tim loves to hear from his followers, so why not drop him a comment or question on social media; you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

Aesthetics Mastery Show

Diagnose, Manage & Avoid Bruising From Injectables

In this episode Dr Tim shares the knowledge necessary to reduce bruising altogether. Whether you’re a healthcare professional, a patient, or simply curious about the intricacies of injection techniques, this video is your go to guide for managing bruising from injectables. Prevention is always better than a cure. Watch the full Aesthetics Mastery Show here.

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Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• Botulinum Toxin Complications Mastery
• Dermal Filler Complications Mastery

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.