Can Bruising After Facial Filler Injections Be Improved?

In this case, the challenge was to improve significant bruising that occurred after facial filler injections, which we accomplished using pulsed dye laser (PDL).

Our Patient

The patient was a 66-year-old woman who failed to discontinue daily aspirin, ibuprofen, and a host of vitamins and herbals prior to perioral filler injection session.

Treatment Issue

Using a PDL to accelerate the resolution of ecchymoses associated with soft-tissue filler injections.

Discussion

Ecchymosis, or bruising, is a common adverse effect resulting from trauma to blood vessels during a surgical procedure. The initial purple color (due to the presence of deoxyhemoglobin) typically undergoes color changes over time as the heme group is degraded—first to biliverdin (green), then to bilirubin (orange-yellow), and eventually fading over the period of days to weeks as the bilirubin binds to albumin and is transported to the liver for recycling.

Most soft-tissue filler injections are performed on the face, oftentimes in locations with very thin skin and prominent vasculature, such as the lips and infra-orbital area. Bruises can be unsightly and draw attention, especially when located on the face where they are often difficult to conceal. This is especially true in men, in whom the use of concealers and makeup is usually not feasible. 

Several techniques may be utilized to try to reduce the risk of bruising when undergoing filler injections. Prior to the procedure, patients can discontinue nonessential anticoagulants like aspirin as long as they are not taking it for a therapeutic purpose (such as a history of myocardial infarction, cerebral vascular accident, blood clot, or atrial fibrillation). Patients are also often instructed to avoid many vitamins and herbals associated with an anticoagulant effect (such as vitamin E, ginseng, garlic, ginger, ginko biloba, and fish oils). Patients may also start arnica pills before the procedure. During the injection, physicians should try to carefully monitor the treatment area for signs of bleeding—and then employ pressure and ice to these specific areas. Also, some injectors incorporate blunt-tipped cannulas in certain treatment areas, which, at least theoretically, have a lower chance of traumatizing a blood vessel. After filler treatment, some injectors incorporate topical products marketed to decrease bruising (such as vitamin K or arnica). Nonetheless, bruising is still often a reality in many of our filler patients.

Flashlamp PDLs have a long history of effectiveness for the treatment of telangiectasias and other vascular lesions and proliferations. The chromophore for PDL is hemoglobin, with both forms (oxyhemoglobin and deoxyhemoglobin) having absorption peaks near the emitted wavelength of 585-595 nm. 

In addition to vascular structures (such as telangiectasias, vascular malformations/port wine stains, and hemangiomas), where absorbed heat is used to damage vessel walls, PDLs also may be used for the treatment of hemoglobin that results from trauma such as filler injections.^1,2

Treatment of Our Patient

The patient was brought back to the office 2 days following filler injections to try to decrease the appearance of the significant bruising using a PDL (Figure 1). The Candela V-Beam Perfecta (Candela,

Massachussetts) was used at a setting of 7.5 J/cm², 6 ms, with a 10-mm spot size for 2 passes to the pronounced oral commissure area bruising. The patient reported significant improvement by phone, but was still brought back the following day and an additional treatment was performed— this time stacking 2 pulses (with a counted 3-second delay in between) using the same settings (Figures 2 and 3). 

Technique

PDL can be used immediately upon discovering an ecchymosis. The laser may be used in most skin types, though to be cautious with darker skin tones longer pulse durations and lower fluences are usually preferred.    

All makeup and sunblocks should be completely removed prior to PDL treatment, as these topical agents on the skin surface may absorb or reflect the laser beam. A proper consent needs to be obtained before the initiation of any laser session. Patients also need to understand that the PDL will accelerate the resolution of a bruise, but certainly will not remove it immediately.

In the treatment of postinjection ecchymoses, subpurpuric settings are usually selected. To achieve that, pulse durations of 3 to 6 ms and also lower fluences are utilized.

Adverse effects of PDL to decrease post filler ecchymoses include transient erythema and some degree of edema (usually mild). Cold packs may be used to ameliorate these symptoms. 

Treatments may be repeated on subsequent days if purple bruising is still very prominent, but once the bruise starts to yellow after a few days then PDL is usually no longer effective.

Tips

1. If possible, prior to filler injections patients should consider discontinuing the use of nonessential over-the-counter agents and vitamins/herbals that are associated with an anticoagulant effect. Of note, we do not discontinue therapeutic aspirin or other anticoagulants, like warfarin, clopidogrel, dabigatran etexilate mesylate—as the risk outweighs the benefit.

2. Subpurpuric settings are selected for the treatment of ecchymoses, as additional purpura would certainly be unsatisfactory to the patient.

3. When the color of the bruise is a very deep, dark purple, we do not stack pulses out of concern of bulk-heating. With less bruising, pulses may be stacked with a slight delay in-between, as in this case. 

Dr. Berlin is president of DFW Skin Surgery Center, PLLC in Arlington, TX. He is also a clinical assistant professor of dermatology at the New Jersey Medical School in Newark, NJ.

Dr. Cohen is the director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology. He is an associate clinical professor of dermatology at the University of Colorado.

Disclosure: Dr. Berlin reports no relevant financial relationships. 

Dr. Cohen has participated in a research project with Syneron-Candela. 

References

1. DeFatta RJ, Krishna S, Williams EF 3rd. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11(2):99-103. 

2. Karen JK, Hale EK, Geronemus RG. A simple solution to the common problem of ecchymosis. Arch Dermatol. 2010;146(1):94-95.

In this case, the challenge was to improve significant bruising that occurred after facial filler injections, which we accomplished using pulsed dye laser (PDL).

Our Patient

The patient was a 66-year-old woman who failed to discontinue daily aspirin, ibuprofen, and a host of vitamins and herbals prior to perioral filler injection session.

Treatment Issue

Using a PDL to accelerate the resolution of ecchymoses associated with soft-tissue filler injections.

Discussion

Ecchymosis, or bruising, is a common adverse effect resulting from trauma to blood vessels during a surgical procedure. The initial purple color (due to the presence of deoxyhemoglobin) typically undergoes color changes over time as the heme group is degraded—first to biliverdin (green), then to bilirubin (orange-yellow), and eventually fading over the period of days to weeks as the bilirubin binds to albumin and is transported to the liver for recycling.

Most soft-tissue filler injections are performed on the face, oftentimes in locations with very thin skin and prominent vasculature, such as the lips and infra-orbital area. Bruises can be unsightly and draw attention, especially when located on the face where they are often difficult to conceal. This is especially true in men, in whom the use of concealers and makeup is usually not feasible. 

Several techniques may be utilized to try to reduce the risk of bruising when undergoing filler injections. Prior to the procedure, patients can discontinue nonessential anticoagulants like aspirin as long as they are not taking it for a therapeutic purpose (such as a history of myocardial infarction, cerebral vascular accident, blood clot, or atrial fibrillation). Patients are also often instructed to avoid many vitamins and herbals associated with an anticoagulant effect (such as vitamin E, ginseng, garlic, ginger, ginko biloba, and fish oils). Patients may also start arnica pills before the procedure. During the injection, physicians should try to carefully monitor the treatment area for signs of bleeding—and then employ pressure and ice to these specific areas. Also, some injectors incorporate blunt-tipped cannulas in certain treatment areas, which, at least theoretically, have a lower chance of traumatizing a blood vessel. After filler treatment, some injectors incorporate topical products marketed to decrease bruising (such as vitamin K or arnica). Nonetheless, bruising is still often a reality in many of our filler patients.

Flashlamp PDLs have a long history of effectiveness for the treatment of telangiectasias and other vascular lesions and proliferations. The chromophore for PDL is hemoglobin, with both forms (oxyhemoglobin and deoxyhemoglobin) having absorption peaks near the emitted wavelength of 585-595 nm. 

In addition to vascular structures (such as telangiectasias, vascular malformations/port wine stains, and hemangiomas), where absorbed heat is used to damage vessel walls, PDLs also may be used for the treatment of hemoglobin that results from trauma such as filler injections.^1,2

In this case, the challenge was to improve significant bruising that occurred after facial filler injections, which we accomplished using pulsed dye laser (PDL).

Our Patient

The patient was a 66-year-old woman who failed to discontinue daily aspirin, ibuprofen, and a host of vitamins and herbals prior to perioral filler injection session.

Treatment Issue

Using a PDL to accelerate the resolution of ecchymoses associated with soft-tissue filler injections.

Discussion

Ecchymosis, or bruising, is a common adverse effect resulting from trauma to blood vessels during a surgical procedure. The initial purple color (due to the presence of deoxyhemoglobin) typically undergoes color changes over time as the heme group is degraded—first to biliverdin (green), then to bilirubin (orange-yellow), and eventually fading over the period of days to weeks as the bilirubin binds to albumin and is transported to the liver for recycling.

Most soft-tissue filler injections are performed on the face, oftentimes in locations with very thin skin and prominent vasculature, such as the lips and infra-orbital area. Bruises can be unsightly and draw attention, especially when located on the face where they are often difficult to conceal. This is especially true in men, in whom the use of concealers and makeup is usually not feasible. 

Several techniques may be utilized to try to reduce the risk of bruising when undergoing filler injections. Prior to the procedure, patients can discontinue nonessential anticoagulants like aspirin as long as they are not taking it for a therapeutic purpose (such as a history of myocardial infarction, cerebral vascular accident, blood clot, or atrial fibrillation). Patients are also often instructed to avoid many vitamins and herbals associated with an anticoagulant effect (such as vitamin E, ginseng, garlic, ginger, ginko biloba, and fish oils). Patients may also start arnica pills before the procedure. During the injection, physicians should try to carefully monitor the treatment area for signs of bleeding—and then employ pressure and ice to these specific areas. Also, some injectors incorporate blunt-tipped cannulas in certain treatment areas, which, at least theoretically, have a lower chance of traumatizing a blood vessel. After filler treatment, some injectors incorporate topical products marketed to decrease bruising (such as vitamin K or arnica). Nonetheless, bruising is still often a reality in many of our filler patients.

Flashlamp PDLs have a long history of effectiveness for the treatment of telangiectasias and other vascular lesions and proliferations. The chromophore for PDL is hemoglobin, with both forms (oxyhemoglobin and deoxyhemoglobin) having absorption peaks near the emitted wavelength of 585-595 nm. 

In addition to vascular structures (such as telangiectasias, vascular malformations/port wine stains, and hemangiomas), where absorbed heat is used to damage vessel walls, PDLs also may be used for the treatment of hemoglobin that results from trauma such as filler injections.^1,2

Treatment of Our Patient

The patient was brought back to the office 2 days following filler injections to try to decrease the appearance of the significant bruising using a PDL (Figure 1). The Candela V-Beam Perfecta (Candela,

Massachussetts) was used at a setting of 7.5 J/cm², 6 ms, with a 10-mm spot size for 2 passes to the pronounced oral commissure area bruising. The patient reported significant improvement by phone, but was still brought back the following day and an additional treatment was performed— this time stacking 2 pulses (with a counted 3-second delay in between) using the same settings (Figures 2 and 3). 

Technique

PDL can be used immediately upon discovering an ecchymosis. The laser may be used in most skin types, though to be cautious with darker skin tones longer pulse durations and lower fluences are usually preferred.    

All makeup and sunblocks should be completely removed prior to PDL treatment, as these topical agents on the skin surface may absorb or reflect the laser beam. A proper consent needs to be obtained before the initiation of any laser session. Patients also need to understand that the PDL will accelerate the resolution of a bruise, but certainly will not remove it immediately.

In the treatment of postinjection ecchymoses, subpurpuric settings are usually selected. To achieve that, pulse durations of 3 to 6 ms and also lower fluences are utilized.

Adverse effects of PDL to decrease post filler ecchymoses include transient erythema and some degree of edema (usually mild). Cold packs may be used to ameliorate these symptoms. 

Treatments may be repeated on subsequent days if purple bruising is still very prominent, but once the bruise starts to yellow after a few days then PDL is usually no longer effective.

Tips

1. If possible, prior to filler injections patients should consider discontinuing the use of nonessential over-the-counter agents and vitamins/herbals that are associated with an anticoagulant effect. Of note, we do not discontinue therapeutic aspirin or other anticoagulants, like warfarin, clopidogrel, dabigatran etexilate mesylate—as the risk outweighs the benefit.

2. Subpurpuric settings are selected for the treatment of ecchymoses, as additional purpura would certainly be unsatisfactory to the patient.

3. When the color of the bruise is a very deep, dark purple, we do not stack pulses out of concern of bulk-heating. With less bruising, pulses may be stacked with a slight delay in-between, as in this case. 

Dr. Berlin is president of DFW Skin Surgery Center, PLLC in Arlington, TX. He is also a clinical assistant professor of dermatology at the New Jersey Medical School in Newark, NJ.

Dr. Cohen is the director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology. He is an associate clinical professor of dermatology at the University of Colorado.

Disclosure: Dr. Berlin reports no relevant financial relationships. 

Dr. Cohen has participated in a research project with Syneron-Candela. 

References

1. DeFatta RJ, Krishna S, Williams EF 3rd. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11(2):99-103. 

2. Karen JK, Hale EK, Geronemus RG. A simple solution to the common problem of ecchymosis. Arch Dermatol. 2010;146(1):94-95.

Treatment of Our Patient

The patient was brought back to the office 2 days following filler injections to try to decrease the appearance of the significant bruising using a PDL (Figure 1). The Candela V-Beam Perfecta (Candela,

Massachussetts) was used at a setting of 7.5 J/cm², 6 ms, with a 10-mm spot size for 2 passes to the pronounced oral commissure area bruising. The patient reported significant improvement by phone, but was still brought back the following day and an additional treatment was performed— this time stacking 2 pulses (with a counted 3-second delay in between) using the same settings (Figures 2 and 3). 

Technique

PDL can be used immediately upon discovering an ecchymosis. The laser may be used in most skin types, though to be cautious with darker skin tones longer pulse durations and lower fluences are usually preferred.    

All makeup and sunblocks should be completely removed prior to PDL treatment, as these topical agents on the skin surface may absorb or reflect the laser beam. A proper consent needs to be obtained before the initiation of any laser session. Patients also need to understand that the PDL will accelerate the resolution of a bruise, but certainly will not remove it immediately.

In the treatment of postinjection ecchymoses, subpurpuric settings are usually selected. To achieve that, pulse durations of 3 to 6 ms and also lower fluences are utilized.

Adverse effects of PDL to decrease post filler ecchymoses include transient erythema and some degree of edema (usually mild). Cold packs may be used to ameliorate these symptoms. 

Treatments may be repeated on subsequent days if purple bruising is still very prominent, but once the bruise starts to yellow after a few days then PDL is usually no longer effective.

Tips

1. If possible, prior to filler injections patients should consider discontinuing the use of nonessential over-the-counter agents and vitamins/herbals that are associated with an anticoagulant effect. Of note, we do not discontinue therapeutic aspirin or other anticoagulants, like warfarin, clopidogrel, dabigatran etexilate mesylate—as the risk outweighs the benefit.

2. Subpurpuric settings are selected for the treatment of ecchymoses, as additional purpura would certainly be unsatisfactory to the patient.

3. When the color of the bruise is a very deep, dark purple, we do not stack pulses out of concern of bulk-heating. With less bruising, pulses may be stacked with a slight delay in-between, as in this case. 

Dr. Berlin is president of DFW Skin Surgery Center, PLLC in Arlington, TX. He is also a clinical assistant professor of dermatology at the New Jersey Medical School in Newark, NJ.

Dr. Cohen is the director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology. He is an associate clinical professor of dermatology at the University of Colorado.

Disclosure: Dr. Berlin reports no relevant financial relationships. 

Dr. Cohen has participated in a research project with Syneron-Candela. 

References

1. DeFatta RJ, Krishna S, Williams EF 3rd. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg. 2009;11(2):99-103. 

2. Karen JK, Hale EK, Geronemus RG. A simple solution to the common problem of ecchymosis. Arch Dermatol. 2010;146(1):94-95.