INTRODUCTION
In 2012, 13 million minimally invasive cosmetic procedures
were performed in the U.S., an increase of 6% compared
to 2011. The most popular interventions are injection-based,
particularly use of soft tissue fillers and botulinum toxin type
A.1 In comparison, the number of invasive cosmetic surgical
procedures decreased by 2% in 2012.1 The reasons patients prefer
minimally invasive methods to surgery include their convenience
and ease, decreased risks and side effects and significant
but sometimes elusive effects. The private nature of these treatments
and patient satisfaction with them is significantly impaired
when bruises result. One of the most frequent concerns
for new and return patients undergoing injection-based cosmetic
procedures is the potential for bruising. Bruises are one of the
most common complications associated with botulinum toxin2,3
and soft tissue filler injections3,4. While bruises have no long-term
negative health effects, they can be emotionally distressing for
patients and can interfere with work and social obligations. Patients
usually do not want others to realize they have undergone
a cosmetic procedure and all individuals wish to avoid bruising.
An experienced practitioner is often able to reduce the risk of
bruising by avoiding visible superficial vessels and injecting
into the superficial subcutis, which contains fewer vessels. It
should be noted that hyaluronic acid fillers are at times purposely
placed in the superficial reticular dermis, which has
been verified by ultrasound analysis.5 Using side lighting and
cleansing the skin with alcohol may make it easier to see superficial
dermal vessels. The fanning and cross hatching techniques
have been shown to increase bruising risk in at least one study
and ought to be avoided where possible.6 Also helpful is careful
patient selection and screening for medications associated
with decreased ability of the blood to clot such as aspirin, other
non-steroidal anti-inflammatory drugs, warfarin, clopidogrel
and alcohol consumption. Certain herbal supplements including,
but not limited to garlic, ginger, ginkgo, ginseng, omega-3
fatty acids, St. John’s wort and Vitamin E may also increase risk
of bleeding and subsequent bruising. Post-treatment pressure
to injected areas will often prevent or minimize bruising. Yet,
even with every precaution, bruising can happen.
When bruises do occur there are several interventions to
decrease the amount of time to their resolution. Multiple
medical therapies have been reported including application of
hydrogen peroxide 15% carbamide gel under occlusion,7 perioperative
oral and topical Arnica Montana,8,9 topical Vitamin
K9 and bromelain3. However, their effect is unpredictable and
minimal in some cases. More marked improvement is achieved
by employing laser and light-based procedures that target the
chromophores present in bruises. These include the 585-595nm
pulsed dye laser (PDL), pulsed 532nm light, 1064 nm longpulsed
neodymium-doped yttrium aluminum garnet (Nd:YAG)
laser and intense pulsed light (IPL). (Figure 1)
Scientific Theory
Bruising is the clinical representation of extravasated red blood
cells resulting from compromise of the skin’s vasculature. Red
blood cells contain hemoglobin, an oxygen-transporting, tetrameric
protein. Oxy-hemoglobin is red and absorbs a broad
spectrum of wavelengths. Absorption peaks for oxy-hemoglobin
include 418nm, 542nm and 577nm.10 (Figure 2).
