Some bleeding is an inevitable event following procedures with dermal filling agents or botulinum toxin type A. Yet, there are things you can do before and after procedures to reduce the amount of bruising patients experience.
In general, bruising can be minimized by choosing the injectable filler least likely to cause this problem. For example, collagen-containing fillers are less likely to bruise the patient, compared with hyaluronic fillers. This is because of the platelet aggregating effects of collagen. In addition, the presence of lidocaine has been shown to prevent activation of eosinophils that can lead to swelling and bruising.1 This article will discuss other ways to decrease the amount of bruising your patient experiences after a procedure with an injectable. But first, a quick review of the coagulation pathway.
Coagulation Pathway at a Glance
In a healthy individual with a small injury to a capillary, the coagulation process results in a fibrin clot on the damaged area and eventually healing of the vessel. Platelets are an essential component of the coagulation process. They become activated via exposure to the endothelial lining of the damaged blood vessel and produce coagulation factors in addition to adhering to the damaged tissue and forming a platelet clog.
The process of hemostasis also involves the coagulation pathway, a complicated cascade involving two routes — the contact activation pathway, also known as the intrinsic pathway, and the tissue factor pathway, also known as the extrinsic pathway. (See Figure 1.)
Several co-factors are required for the proper functioning of the coagulation pathway. Vitamin K is an essential factor for a hepatic enzyme known as gamma glutamyl carboxylase, which is involved in the synthesis of factors II, VII, IX and X. Calcium is also required in several steps of the coagulation pathway. Also present are natural anticoagulants, such as protein C and S, which are beyond the scope of this discussion.
Following coagulation and clot formation, the fibrinolysis process needed to break down the clot occurs. This pathway begins with activation of plasminogen, a protein synthesized in the liver, which is converted to plasmin via tissue plasminogen activator (tPA) and other factors. (See Figure 2.)
Plasmin degrades fibrin into fibrin degradation products, which are the end result of this cascade.
Prevention and Treatment
The initial bruised area is purplish-red in color, which later changes to green and yellow and eventually disappears. The hemoglobin of the red blood cells is responsible for the red-purple color of the bruise. The two products that result from the natural breakdown of hemoglobin cause a bruise’s change of color. Hemoglobin breaks down to biliverdin (green), which in turn is metabolized to bilirubin (yellow). (See Figure 3.)
When performing a cosmetic procedure with possible bleeding, it is helpful to ask patients about any history of bleeding disorders or anticoagulant medications. Also, remember to ask patients to avoid certain medications prior to undergoing procedures (See Table 1).
Some medications and other agents are well known to inhibit coagulation. For example, non-steroidal anti-inflammatory drugs (NSAIDs), including ASA, are well recognized for their anti-platelet effects. Other supplements, such as garlic and ginko, are also known for inhibitory effects on platelets.2 Green tea also increases the tendency to bleed by anti-platelet activity.3 Vitamin E appears to exert its bleeding effect by inhibition of the intrinsic coagulation pathway.4
Bruising may also be prevented or treated by using certain herbal supplements such as bromelain and arnica, which are briefly discussed here.
Bromelain. Bromelain is a substance naturally present in mature pineapple stems (Ananas comosus), and it contains proteolytic enzymes.5,6 Over the years, it has been used in medical settings for its antithrombotic, fibrinolytic and anti-inflammatory effects.7 It is believed that bromelain exerts anticoagulant activity via inhibition of platelet aggregation.8 Pirotta and De Guili-Morghen explained the fibrinolytic activity of bromelain in rats by activating plasminogen conversion to plasmin.9
Bromelain has also shown to decrease vascular permeability by lowering the levels of bradykinin, resulting in less edema, pain and inflammation.10 Although there is no standard recommended dose for bromelain consumption, this substance has been used in different doses ranging from 200 mg to 2000 mg.11 In treating osteoarthritis, bromelain has been used in doses anywhere from 540 mg/day to 1890 mg/day with successful results.12,13,14 Bromelain is considered safe; however, a higher incidence of adverse events including headache, gastrointestinal symptoms and cutaneous rash have been observed with higher doses.15 It is advisable to avoid recommending bromelain to patients on anticoagulant medications such as warfarin and aspirin prior to consulting their primary care physicians.
Arnica. Also known as leopard’s bane or mountain tobacco, arnica is an extract derived from several mountain plants including Arnica montana, Arnica chamissonis, Arnica fulgens, Arnica cordifolia, and Arnica sororia. This extract is widely used in homeopathic practice because it contains helenalin, a sesquiterpene lactone, which is its major active ingredient and has anti-inflammatory effects.16 Helenalin has been shown to inhibit the activation of NF-kB in T cells, B cells, and epithelial cells17 and is considered a transcription factor of several cytokines.18
The exact mechanism of action of arnica in the treatment of bruises remains unknown; however, it has been proposed that arnica inhibits platelet function in vitro.19 The clinical trials for treatment of ecchymoses with arnica are conflicting. In a study of 200 patients with removal of a wisdom tooth or apicoectomy, subjects received arnica 3 days prior to the procedure and twice daily post procedure in cases of edema. A 90% success with no swelling or ecchymoses was reported. However, this study lacked a blinded control group. Alonso et al evaluated 19 patients with facial telangiectasia in a double-blinded, placebo-controlled laser study.20 They were divided into pre- and post-treatment groups for treatment with pulsed dye laser. The pre-treatment group received topical arnica gel with vehicle to one side of the face and vehicle only to the other side for 2 weeks prior to laser treatment. The post-treatment group followed the same regimen following the laser procedure. No statistically significant difference was noted in prevention or faster clearing of the ecchymoses.21
Another multicenter randomized, double-blind, placebo-controlled study of 130 patients with phlebectomy also failed to show a difference among patients treated with arnica (pre and post procedure) compared to the control group.22
Good Old-Fashioned Ice
To minimize bruising, applying an ice pack is a standard tactic. Apply the ice pack for 1 minute prior to injection with a filler and for 5 minutes following the injection. Using your finger, directly and immediately apply pressure to any areas that appear to be bruising. Instruct patients to avoid heat in these areas (i.e., a hot shower) for 3 hours after the procedure because heat can cause vessels to dilate.
Informing Patients What to Expect
Although bruising may be prevented by certain measures in dermatology practice, it is considered an inevitable side effect of injectable procedures. Therefore, it is important to inform the patient of this minor side effect. Patients need to be aware that a bruise may take about 7 to 14 days to clear, so they can plan their treatments in advance.
Some bleeding is an inevitable event following procedures with dermal filling agents or botulinum toxin type A. Yet, there are things you can do before and after procedures to reduce the amount of bruising patients experience.
In general, bruising can be minimized by choosing the injectable filler least likely to cause this problem. For example, collagen-containing fillers are less likely to bruise the patient, compared with hyaluronic fillers. This is because of the platelet aggregating effects of collagen. In addition, the presence of lidocaine has been shown to prevent activation of eosinophils that can lead to swelling and bruising.1 This article will discuss other ways to decrease the amount of bruising your patient experiences after a procedure with an injectable. But first, a quick review of the coagulation pathway.
Coagulation Pathway at a Glance
In a healthy individual with a small injury to a capillary, the coagulation process results in a fibrin clot on the damaged area and eventually healing of the vessel. Platelets are an essential component of the coagulation process. They become activated via exposure to the endothelial lining of the damaged blood vessel and produce coagulation factors in addition to adhering to the damaged tissue and forming a platelet clog.
The process of hemostasis also involves the coagulation pathway, a complicated cascade involving two routes — the contact activation pathway, also known as the intrinsic pathway, and the tissue factor pathway, also known as the extrinsic pathway. (See Figure 1.)
Several co-factors are required for the proper functioning of the coagulation pathway. Vitamin K is an essential factor for a hepatic enzyme known as gamma glutamyl carboxylase, which is involved in the synthesis of factors II, VII, IX and X. Calcium is also required in several steps of the coagulation pathway. Also present are natural anticoagulants, such as protein C and S, which are beyond the scope of this discussion.
Following coagulation and clot formation, the fibrinolysis process needed to break down the clot occurs. This pathway begins with activation of plasminogen, a protein synthesized in the liver, which is converted to plasmin via tissue plasminogen activator (tPA) and other factors. (See Figure 2.)
Plasmin degrades fibrin into fibrin degradation products, which are the end result of this cascade.
Prevention and Treatment
The initial bruised area is purplish-red in color, which later changes to green and yellow and eventually disappears. The hemoglobin of the red blood cells is responsible for the red-purple color of the bruise. The two products that result from the natural breakdown of hemoglobin cause a bruise’s change of color. Hemoglobin breaks down to biliverdin (green), which in turn is metabolized to bilirubin (yellow). (See Figure 3.)
When performing a cosmetic procedure with possible bleeding, it is helpful to ask patients about any history of bleeding disorders or anticoagulant medications. Also, remember to ask patients to avoid certain medications prior to undergoing procedures (See Table 1).
Some medications and other agents are well known to inhibit coagulation. For example, non-steroidal anti-inflammatory drugs (NSAIDs), including ASA, are well recognized for their anti-platelet effects. Other supplements, such as garlic and ginko, are also known for inhibitory effects on platelets.2 Green tea also increases the tendency to bleed by anti-platelet activity.3 Vitamin E appears to exert its bleeding effect by inhibition of the intrinsic coagulation pathway.4
Bruising may also be prevented or treated by using certain herbal supplements such as bromelain and arnica, which are briefly discussed here.
Bromelain. Bromelain is a substance naturally present in mature pineapple stems (Ananas comosus), and it contains proteolytic enzymes.5,6 Over the years, it has been used in medical settings for its antithrombotic, fibrinolytic and anti-inflammatory effects.7 It is believed that bromelain exerts anticoagulant activity via inhibition of platelet aggregation.8 Pirotta and De Guili-Morghen explained the fibrinolytic activity of bromelain in rats by activating plasminogen conversion to plasmin.9
Bromelain has also shown to decrease vascular permeability by lowering the levels of bradykinin, resulting in less edema, pain and inflammation.10 Although there is no standard recommended dose for bromelain consumption, this substance has been used in different doses ranging from 200 mg to 2000 mg.11 In treating osteoarthritis, bromelain has been used in doses anywhere from 540 mg/day to 1890 mg/day with successful results.12,13,14 Bromelain is considered safe; however, a higher incidence of adverse events including headache, gastrointestinal symptoms and cutaneous rash have been observed with higher doses.15 It is advisable to avoid recommending bromelain to patients on anticoagulant medications such as warfarin and aspirin prior to consulting their primary care physicians.
Arnica. Also known as leopard’s bane or mountain tobacco, arnica is an extract derived from several mountain plants including Arnica montana, Arnica chamissonis, Arnica fulgens, Arnica cordifolia, and Arnica sororia. This extract is widely used in homeopathic practice because it contains helenalin, a sesquiterpene lactone, which is its major active ingredient and has anti-inflammatory effects.16 Helenalin has been shown to inhibit the activation of NF-kB in T cells, B cells, and epithelial cells17 and is considered a transcription factor of several cytokines.18
The exact mechanism of action of arnica in the treatment of bruises remains unknown; however, it has been proposed that arnica inhibits platelet function in vitro.19 The clinical trials for treatment of ecchymoses with arnica are conflicting. In a study of 200 patients with removal of a wisdom tooth or apicoectomy, subjects received arnica 3 days prior to the procedure and twice daily post procedure in cases of edema. A 90% success with no swelling or ecchymoses was reported. However, this study lacked a blinded control group. Alonso et al evaluated 19 patients with facial telangiectasia in a double-blinded, placebo-controlled laser study.20 They were divided into pre- and post-treatment groups for treatment with pulsed dye laser. The pre-treatment group received topical arnica gel with vehicle to one side of the face and vehicle only to the other side for 2 weeks prior to laser treatment. The post-treatment group followed the same regimen following the laser procedure. No statistically significant difference was noted in prevention or faster clearing of the ecchymoses.21
Another multicenter randomized, double-blind, placebo-controlled study of 130 patients with phlebectomy also failed to show a difference among patients treated with arnica (pre and post procedure) compared to the control group.22
Good Old-Fashioned Ice
To minimize bruising, applying an ice pack is a standard tactic. Apply the ice pack for 1 minute prior to injection with a filler and for 5 minutes following the injection. Using your finger, directly and immediately apply pressure to any areas that appear to be bruising. Instruct patients to avoid heat in these areas (i.e., a hot shower) for 3 hours after the procedure because heat can cause vessels to dilate.
Informing Patients What to Expect
Although bruising may be prevented by certain measures in dermatology practice, it is considered an inevitable side effect of injectable procedures. Therefore, it is important to inform the patient of this minor side effect. Patients need to be aware that a bruise may take about 7 to 14 days to clear, so they can plan their treatments in advance.
Some bleeding is an inevitable event following procedures with dermal filling agents or botulinum toxin type A. Yet, there are things you can do before and after procedures to reduce the amount of bruising patients experience.
In general, bruising can be minimized by choosing the injectable filler least likely to cause this problem. For example, collagen-containing fillers are less likely to bruise the patient, compared with hyaluronic fillers. This is because of the platelet aggregating effects of collagen. In addition, the presence of lidocaine has been shown to prevent activation of eosinophils that can lead to swelling and bruising.1 This article will discuss other ways to decrease the amount of bruising your patient experiences after a procedure with an injectable. But first, a quick review of the coagulation pathway.
Coagulation Pathway at a Glance
In a healthy individual with a small injury to a capillary, the coagulation process results in a fibrin clot on the damaged area and eventually healing of the vessel. Platelets are an essential component of the coagulation process. They become activated via exposure to the endothelial lining of the damaged blood vessel and produce coagulation factors in addition to adhering to the damaged tissue and forming a platelet clog.
The process of hemostasis also involves the coagulation pathway, a complicated cascade involving two routes — the contact activation pathway, also known as the intrinsic pathway, and the tissue factor pathway, also known as the extrinsic pathway. (See Figure 1.)
Several co-factors are required for the proper functioning of the coagulation pathway. Vitamin K is an essential factor for a hepatic enzyme known as gamma glutamyl carboxylase, which is involved in the synthesis of factors II, VII, IX and X. Calcium is also required in several steps of the coagulation pathway. Also present are natural anticoagulants, such as protein C and S, which are beyond the scope of this discussion.
Following coagulation and clot formation, the fibrinolysis process needed to break down the clot occurs. This pathway begins with activation of plasminogen, a protein synthesized in the liver, which is converted to plasmin via tissue plasminogen activator (tPA) and other factors. (See Figure 2.)
Plasmin degrades fibrin into fibrin degradation products, which are the end result of this cascade.
Prevention and Treatment
The initial bruised area is purplish-red in color, which later changes to green and yellow and eventually disappears. The hemoglobin of the red blood cells is responsible for the red-purple color of the bruise. The two products that result from the natural breakdown of hemoglobin cause a bruise’s change of color. Hemoglobin breaks down to biliverdin (green), which in turn is metabolized to bilirubin (yellow). (See Figure 3.)
When performing a cosmetic procedure with possible bleeding, it is helpful to ask patients about any history of bleeding disorders or anticoagulant medications. Also, remember to ask patients to avoid certain medications prior to undergoing procedures (See Table 1).
Some medications and other agents are well known to inhibit coagulation. For example, non-steroidal anti-inflammatory drugs (NSAIDs), including ASA, are well recognized for their anti-platelet effects. Other supplements, such as garlic and ginko, are also known for inhibitory effects on platelets.2 Green tea also increases the tendency to bleed by anti-platelet activity.3 Vitamin E appears to exert its bleeding effect by inhibition of the intrinsic coagulation pathway.4
Bruising may also be prevented or treated by using certain herbal supplements such as bromelain and arnica, which are briefly discussed here.
Bromelain. Bromelain is a substance naturally present in mature pineapple stems (Ananas comosus), and it contains proteolytic enzymes.5,6 Over the years, it has been used in medical settings for its antithrombotic, fibrinolytic and anti-inflammatory effects.7 It is believed that bromelain exerts anticoagulant activity via inhibition of platelet aggregation.8 Pirotta and De Guili-Morghen explained the fibrinolytic activity of bromelain in rats by activating plasminogen conversion to plasmin.9
Bromelain has also shown to decrease vascular permeability by lowering the levels of bradykinin, resulting in less edema, pain and inflammation.10 Although there is no standard recommended dose for bromelain consumption, this substance has been used in different doses ranging from 200 mg to 2000 mg.11 In treating osteoarthritis, bromelain has been used in doses anywhere from 540 mg/day to 1890 mg/day with successful results.12,13,14 Bromelain is considered safe; however, a higher incidence of adverse events including headache, gastrointestinal symptoms and cutaneous rash have been observed with higher doses.15 It is advisable to avoid recommending bromelain to patients on anticoagulant medications such as warfarin and aspirin prior to consulting their primary care physicians.
Arnica. Also known as leopard’s bane or mountain tobacco, arnica is an extract derived from several mountain plants including Arnica montana, Arnica chamissonis, Arnica fulgens, Arnica cordifolia, and Arnica sororia. This extract is widely used in homeopathic practice because it contains helenalin, a sesquiterpene lactone, which is its major active ingredient and has anti-inflammatory effects.16 Helenalin has been shown to inhibit the activation of NF-kB in T cells, B cells, and epithelial cells17 and is considered a transcription factor of several cytokines.18
The exact mechanism of action of arnica in the treatment of bruises remains unknown; however, it has been proposed that arnica inhibits platelet function in vitro.19 The clinical trials for treatment of ecchymoses with arnica are conflicting. In a study of 200 patients with removal of a wisdom tooth or apicoectomy, subjects received arnica 3 days prior to the procedure and twice daily post procedure in cases of edema. A 90% success with no swelling or ecchymoses was reported. However, this study lacked a blinded control group. Alonso et al evaluated 19 patients with facial telangiectasia in a double-blinded, placebo-controlled laser study.20 They were divided into pre- and post-treatment groups for treatment with pulsed dye laser. The pre-treatment group received topical arnica gel with vehicle to one side of the face and vehicle only to the other side for 2 weeks prior to laser treatment. The post-treatment group followed the same regimen following the laser procedure. No statistically significant difference was noted in prevention or faster clearing of the ecchymoses.21
Another multicenter randomized, double-blind, placebo-controlled study of 130 patients with phlebectomy also failed to show a difference among patients treated with arnica (pre and post procedure) compared to the control group.22
Good Old-Fashioned Ice
To minimize bruising, applying an ice pack is a standard tactic. Apply the ice pack for 1 minute prior to injection with a filler and for 5 minutes following the injection. Using your finger, directly and immediately apply pressure to any areas that appear to be bruising. Instruct patients to avoid heat in these areas (i.e., a hot shower) for 3 hours after the procedure because heat can cause vessels to dilate.
Informing Patients What to Expect
Although bruising may be prevented by certain measures in dermatology practice, it is considered an inevitable side effect of injectable procedures. Therefore, it is important to inform the patient of this minor side effect. Patients need to be aware that a bruise may take about 7 to 14 days to clear, so they can plan their treatments in advance.
