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Banishing the bruise

Article-Banishing the bruise

lip injection bruise

Dermatologist Heidi A. Waldorf, M.D., doesn’t guarantee that patients won’t bruise post-injectables or other treatments, but she knows that by taking certain steps she greatly reduces bruising risk among her cosmetic patients.

And whether it’s to reduce bruising after an injectable or post-surgery, Manolis G. Manolakakis, D.M.D., F.A.C.S., has a toolbox of options that he recommends to patients before, during and after cosmetic procedures. The natural options, he says, are harmless and go a long way to reduce, even banish, bruises.

Drs. Waldorf and Manolakakis share their favorite post-procedure bruise fighters with The Aesthetic Channel.

Bruise Prevention Starts Days, Weeks Before Procedures

To reduce bruising risk, Dr. Waldorf tells her patients to avoid all non-essential prescription and over-the-counter anticoagulants and alcohol for 10 days before the treatment and two to three days after.

“It takes seven to 10 days for platelets to recover,” she says.  

Her advice to patients also is to avoid cardio exercise right before treatments and for two days after to avoid excessive vasodilation. The same goes for hot yoga or any activity where a patient’s head hangs downward, according to Dr. Waldorf. 

Dr. Manolakakis, who has a facial surgery practice in New York City and Shrewsbury, N.J., and directs the facial cosmetic surgery fellowship at the RWJ Barnabas-Monmouth Medical Center, also instructs patients to avoid supplements and medications known to promote bruising, as well as alcohol, a week or two before procedures, including surgery. He adds green tea, ginger and garlic to the list of supplements to avoid.

“These are things that can cause a tremendous amount of bruising from just a simple injection,” Dr. Manolakakis says.

Put it On Ice

Both doctors are fans of cold or ice compresses.

Dr. Manolakakis ices the treatment area prior to injection of any type of filler or neuromodulator, in order to shrink area blood vessels, he says.

Dr. Waldorf uses ice immediately after injections.

“We provide the patients with what I call ‘applause gauze.’ We freeze wet gauze in a Ziplock and slide that into a glove, clap them together to say ‘Yay, you are done!’ And then use them on the affected area for 10 to 20 minutes an hour while awake, up to 48 hours,” Dr. Waldorf says. “Unlike ice, they don’t melt or drip, and they can be re-frozen.”

This option costs the practice pennies and patients don’t have to hide applause gauze as they might a ice gel pad with the practice’s logo, she says.

Shine the Light (& Other Tips)

Dr. Manolakakis says he makes sure to have bright overhead lighting during injection procedures. Good lighting is especially helpful for injecting around the periorbital area, where skin is thin.

“Sometimes, just by shining a light on the periorbital area and stretching the skin you can see some of those blood vessels that are beneath the skin,” he says.

Novice injectors should consider vein finding devices for locating blood vessels beneath the skin and avoiding them, according to Dr. Manolakakis. 

Dr. Waldorf says she chooses the tools for injections based on the filler type and location for safety, comfort and to reduce bruising.  When injecting highly vascular areas she might use a cannula, so that her entry point can be in a less vascular area. 

“For filling fine lines, I use a 34-gauge needle for almost imperceptible entry points,” she says. “I add 1% lidocaine with epinephrine to most of my fillers and inject a bleb of lidocaine with epinephrine at my cannula entry points.”

Dr. Waldorf immediately applies firm pressure if she sees a filler patient is bleeding during treatment. She then has a nurse continue to apply firm pressure while she continues treatment. 

Providers should apply pressure for five to 10 minutes, which can stop the development of a hematoma, according to Dr. Waldorf.

When Dr. Manolakakis notices a patient getting a bruise during a procedure, he’ll ice it immediately to shrink or limit the amount of bruising. He agrees the putting pressure on the area helps to keep the bruise from expanding and a hematoma from forming.

Bruise Reduction in a Pad

Dr. Waldorf, who practices in Nanuet, N.Y., uses Cearna OcuMend gel pads, which are high-potency medical grade arnica and ledum hydrogel pads that patients apply to the areas at risk for bruising. She offers the pads to all her filler and Silhouette InstaLift (Sinclair) patients. 

“The pads provide a higher dose of arnica directly into the skin than any pills or creams/gels available. The company’s studies show a marked reduction in bruising after injectables and surgical procedures. Plus, my patients love them. They find them immediately soothing and self-report that bruising is reduced relative to having treatment without the pads,” Dr. Waldorf says.
Not all patients want the pads, according to Waldorf. Some don’t want anything visible on their faces after procedures. Others are confident that they won’t bruise, she says.

The recommended dosage is for four pads, immediately after procedures. Patients leave the pads on for six hours, then apply four more pads at bedtime, according to Dr. Waldorf. 

“From a practical standpoint, we vary the dosage,” she says.

For patients who rarely if ever bruise, Dr. Waldorf recommends applying two pads for one to six hours right after having fillers.

“We stress the first hour as the most important and recommend they leave them on as long as possible to six hours. We give them the packaging, so if they need to run into a store or a meeting, they can remove them briefly and then reapply,” she says.

For patients with a significant propensity to bruise, Dr. Waldorf recommends applying four pads immediately and giving the patient four more to apply at bedtime. 

“It is important to educate the patient not to overlap the pads – the transdermal delivery only works when in contact directly with the skin.  The pads do not need to be directly over the injected site--there’s a six-inch spread of absorption,” she says.

Dr. Waldorf says the pads greatly reduce bruising for even the big bruisers. The pads aren’t a miracle cure for bruising, however. They won’t stop bruising caused by hitting a vessel, nor will they overcome the effects of warfarin, aspirin and fish oil, she says.

Dr. Manolakakis says he prefers to use oral arnica montana and puts patients with a history of bruising on not only oral arnica montana but also bromelain, a pineapple extract.

Among the at-home bruise reduction remedies that Dr. Manolakakis recommends for post-procedure healing: mixing cayenne pepper with Vaseline, cooling the mixture in the refrigerator and applying it to the skin.

He also suggests that patients increase vitamin C intake and eat more foods rich in vitamin K, including spinach, parsley, broccoli, brussels sprouts and romaine lettuce.

Laser Bruise Remedies

“After the first 48 hours, depending on the amount of bruising, we then have the patient apply warm compresses. We do that to open up the blood vessels so the body can get rid of that bruise,” he says. 

Patients that experience bad bruising, which Dr. Manolakakis describes as dark and red and not yet greenish, can come to the practice within 48 hours of having their injections for treatment with his potassium titanyl phosphate (KTP) 532 nm laser.

“That works very well to reduce the amount of bruising and significantly improves the resolution of the bruise,” he says.

Dr. Waldorf says her patients have the option of returning to the practice two days post-procedure for a free Vbeam (595 nm pulsed dye laser, Syneron-Candela) laser treatment for bruises. But most don’t take advantage of the offer because they don’t need treatment after using the Cearna pads.  

Dr. Waldorf says she never guarantees a patient won’t bruise.

“I still don’t recommend having injectable fillers the week of an important work or social event or photo shoot.  That’s just Murphy’s law — the one time you can’t bruise, you will. However, we can limit or minimize bruising,” she says.