Anti-wrinkle injections and dermal fillers injections and are two of the most popular cosmetic treatments worldwide. Often ‘no downtime’ is expected with these procedures. We often expect to be able to go straight back to our normal activities or work. In reality, there may be a significant risk of bruising. If bruising is significant, it can stay for over two weeks and may be difficult to conceal.

Bruises occur during injectable facial treatments when a needle or cannula strikes a blood vessel such as a vein or artery and breaks the wall of this blood vessel. This allows blood to escape and bruises to form. Most commonly, only a vein is ruptured and a bruise is the only consequence. However, it is also possible to rupture an artery during facial injections. This can lead to more significant bleeding and bruising. Accidental injection of fillers into an artery can be a serious complication of dermal fillers. To avoid all blood vessels can therefore not only help bruising but also reduce the risk of intra-arterial injection.

Detecting veins

The first step in the avoidance of bruising is detecting the location of veins and avoiding the nearby area. Larger more superficial veins may be visible to the naked eye and more easily avoided. Deeper or finer veins, especially on darker skin types, can be more difficult to see without assistance. Tools such as the Accuvein can be used to detect veins underneath the surface of the skin (but not arteries). It does so by projecting a near-infrared light on to the skin which is absorbed by the haemoglobin in the veins. The light reflected is back is analysed and a laser image is projected on to the skin, showing the location of the vein under the skin.

The two lasers work in tandem to provide a real-time image of the subcutaneous vasculature up to 10mm deep.  First, the haemoglobin in the blood absorbs the infrared light, so there is a reduced amount of light reflection from the veins.  Then, a custom detection system uses this change in reflection to determine vein location and pattern, which it digitally projects on the surface of the skin.  Lastly, the red laser makes the vein mapping visible to the clinician.

Once the veins have been visualised by the practitioner, it is possible to use methods to avoid disturbing these veins during facial injections and reduce the risk of bruising.

Detecting arteries

The detection of arteries is more challenging than veins. Arteries cannot be detected by the Accuvein. They can be detected with an ultrasound machine. However, ultrasound is not generally used for dermal fillers or anti-wrinkle injections. Arteries are more likely to be disturbed with dermal filler injections as they are generally injected deeper than anti-wrinkle injections. The complication of injecting a dermal filler into an artery is a serious, although rare complication. It can lead to problems such as restriction of blood supply to the skin or eyes, leading to the death of skin, scarring, and blindness.

As ultrasound is not routinely used by cosmetic practitioners, possibly due to the difficulties in learning to use the machine as well as the cumbersome nature of using an ultrasound whilst injecting. Instead to avoid arteries during facial injections the knowledge of the practitioner in facial anatomy is the key. Facial arteries tend to follow similar pathways in the face, and knowledge of anatomy can help the practitioner avoid danger zones where intra-arterial injection is likely. Although bruising can be a complication of puncturing an artery during an injection, the greater concern is the risk of injecting dermal filler into an artery and occluding blood flow.

Using blunt micro-cannulas

Detecting and avoiding blood vessels can help avoid bruising. However, not all blood vessels can be detected or visualised. Using a blunt micro-cannula instead of a needle to inject dermal fillers can minimise bruises. A blunt micro-cannula is like a needle with a rounded instead of a sharp tip. It is able to pass through the soft tissues and push blood vessels aside. Needles have a greater propensity to pierce through the wall of a blood vessel and cause bruising. A blunt cannula is used by piercing the skin first with a needle. The cannula is then passed through this entry point and can be fed through the soft tissues. Note the needle is only used to break the skin and not pass through the soft tissues. Solely using a needle for dermal fillers means that you need to pass through skin and other soft tissue structures with the sharp point of the needle, increasing the risk of perforating a blood vessel wall and causing bruising.

Anti-coagulant medication or supplements

Often patients will be taking anti-coagulant medication or ‘blood thinners’ for a particular medical condition. These may include warfarin (Coumadin), aspirin, or the newer generation anti-coagulants such as Apixaban. Being on these medications is not an absolute contraindication to having treatment with anti-wrinkle injections or dermal fillers. However, should a blood vessel be ruptured during the procedure, the bruise will be much more significant. Non-steroidal anti-inflammatory drugs (NSAIDS) which are usually used to treat pain can also cause some anti-coagulation of the blood and ideally should be avoided prior to cosmetic procedures.

It is unknown to many patients also that many herbal supplements are anti-coagulants. These include turmeric, ginger, vitamin E, and Ginkgo Biloba. Of note, Arnica Montana and Bromelain, supplements that are taken to speed healing and the removal of bruising, are also anti-coagulants. Often patients take these medications prior to procedures believing that they will reduce their risk of bruising, however, the reverse is true.

Immediate treatment of bruising

If bruising occurs during anti-wrinkle or dermal filler treatment, the first step is for the practitioner to stop and apply pressure. This often needs to be applied for two minutes or more. Further attempts at treatment in the same area may restart the bruising, and it is possible that further treatment needs to be delayed. Ice can also be used to cause vasoconstriction of the blood vessels and reduce the severity of the bruise.

Further treatment of bruising

Once bruising has set in, it will remain for a period of time. However, the duration of bruising can be shortened. Hiridoid cream can be applied to the bruised area and is effective in reducing the duration of bruises. Hiridoid cream contains mucopolysaccharides similar to those found in our own skin, and promotes healing and reduces swelling and inflammation to expedite the duration of any bruises. Oral supplements such as Arnica and Bromelain can also be taken to promote healing and reduce the duration of bruising.

Vascular lasers or lasers that are attracted to haemoglobin in the blood (the main constituent of a bruise) can be used over a bruise also. These lasers specifically heat the haemoglobin in the bruise causing destruction of the haemoglobin and allowing the body to remove it.