In today’s world, there is a fast-growing trend of patients seeking cosmetic interventions associated with minimal downtime. More and more patients are seeking non-surgical, minimally invasive, office-based procedures (lasers, light-based therapies, injectables such as botox, fillers, kybella- you name it!), which allow them to quickly return to their busy lives looking rejuvenated, yet without having the tell-tale signs of plastic surgery. Those who seek surgery are similarly eager to get back on their feet.

For these reasons, patients frequently spend hours researching surgeons, their techniques, and postoperative/post-procedural care methods that will help optimize healing and minimize any swelling and bruising. Most surgeons also recommend a protocol for achieving the same, which may include homeopathic medications such as arnica montana and a whole slew of post-procedural recommendations such as, sigh, no alcohol.

In today’s post, I will breakdown 5 of the most common recommendations for minimizing downtime and maximizing recovery after cosmetic procedures and surgeries and delve into the evidence and basis for each.

Recommendation #1: Avoid Certain Medications and Supplements

BOTTOM LINE: The best measure you can take to avoid bruising after cosmetic procedures and injections is to discontinue medications and supplements that promote bleeding...but you must obtain physician approval before discontinuing prescription medications!

Certain medications and herbal supplements are known to interfere with blood clotting and therefore, increase the risk of bleeding and bruising.
Some of these medications continue to have lasting effects for 5-10 days even after stopping them.
Therefore, nearly all physicians recommend stopping anticoagulation and anti-platelet medications and herbal supplements approximately 7 days prior to a cosmetic procedure or surgery, IF POSSIBLE.
Physician approval must be obtained before discontinuing prescription medications, as some may be critical to your health and the risks of stopping outweigh the benefits.
Medications that increase your risk of bleeding include:
- Non-steroidal anti-inflammatory drugs (NSAIDs): including aspirin, celecoxib (Celebrex®), diclofenac (Voltaren®), ibuprofen (Motrin®, Advil®), indomethacin (Indocin®), naproxen (Aleve®, Naprosyn®)
- Anti-platelet drugs: including aspirin, aspirin + dipyridamole (Aggrenox®), clopidogrel (Plavix®), prasugrel (Effient®), ticlopidine (Ticlid®)
- Anticoagulant drugs: include apixaban (Eliquis®), dabigatran (Pradaxa®), rivaroxaban (Xarelto®), and warfarin (Coumadin®)
- Again, please discuss the safety of stopping any prescription medications with your physician.
Herbal supplements that increase your risk of bleeding include:
- Chamomile, clove, ephedra, fish oil, garlic, ginger, ginko biloba, glucosamine, grape seed, green tea extract, licorice, saw palmetto, vitamin E, and willow bark
- These should be avoided for 7 days prior to your procedure if possible.

Recommendation #2: Take Homeopathic Medications

BOTTOM LINE: Homeopathic medications most commonly recommended to help with bruising and swelling are arnica montana and bromelain. Although scientific evidence regarding the benefits of these medications is limited, most cosmetic surgeons tend to recommend them because they are relatively safe and may help.

Many surgeons routinely recommend the use of homeopathic medications in their cosmetic practices. Homeopathic medications contain extremely dilute amounts of the active ingredient.
The two most commonly recommended medications are arnica montana and bromelain, typically recommended to start 1-2 days prior to the procedure and continue for one week afterwards.
Arnica Montana
- Arnica is derived from a perennial plant native to the mountains of Europe and Siberia, and cultivated in North America.
- Numerous formulations of varying dosages are available for oral and topical (skin) use. An example of an oral formulation is SinEcch.
- Although nearly 50% of facial plastic surgeons routinely recommend this in their practice for minimizing both bruising and swelling, there is conflicting and insufficient data to support its benefits.
  - Cosmetic Procedures: A recent systemic review (Ho et al. Dermatol Surg. 2016) found that there was limited data to suggest that it is beneficial for use in cosmetic procedures (such as botox and fillers).
  - Rhinoplasty: In one randomized controlled trial (Totonchi et al. Plast Reconstr Surg. 2007), arnica was shown to decrease swelling but not bruising after rhinoplasty.
  - Facelift: In a randomized controlled trial (Seeley et al. Arch Facial Plast Surg. 2006), although arnica was shown to improve bruising in a computer model, neither doctors nor patients could tell any differences.
  - Eyelid Surgery: In a randomized controlled trial (van Exsel DC et al. Plast Reconstr Surg. 2016), 10% arnica ointment did not improve outcomes including swelling, bruising, pain, and patient satisfaction after upper blepharoplasty (upper eye lift surgery).
- Side effects are fairly minimal. Can cause skin irritation when used topically for prolonged time. Arnica is not used as a herbal supplement due to severe side effects such as dizziness, tremors, and heart regularities.
Bromelain
- Bromelain is an enzyme derived from the stem of pineapples.
- Numerous formulations of varying dosages are available for oral use. An example is VitaMedica's Bromelain with Quercetin.
- Bromelain has also been used for centuries for decreasing bruising, swelling, and pain but there are even fewer studies that evaluate its benefit after cosmetic procedures/surgery.
- A recent systemic review (Ho et al. Dermatol Surg. 2016) found that there was insufficient data to suggest that it is beneficial for use in cosmetic procedures (such as botox and fillers).
- Side effects are fairly minimal and can include nausea, vomiting, diarrhea, and headache.
Other
- Other homeopathic remedies that have been shown with limited evidence to improve bruising and swelling include: bilberry extract, cabbage, comfrey, parsley, vitamin C, papaya, and witch hazel.

Recommendation #3: Ice, Ice, Baby

BOTTOM LINE: Icing just before the procedure and up to 48 hours afterwards has been shown to help with pain and bruising after cosmetic procedures and surgery.

Ice constrict blood vessels, thereby reducing blood flow to the area which limits bleeding/bruising as well as decreases inflammation.
75% of facial plastic surgeons routinely recommend icing after cosmetic procedures and surgery.
Application of ice for 60 seconds for facial areas and 90 seconds for the lips just prior to injecting fillers has been shown to be effective for both pain control and reducing bruising.

Recommendation #4: Avoid Alcohol, Skip the Gym, and Sleep Elevated

BOTTOM LINE: These three recommendations- avoid alcohol, skin the gym, and sleep with head elevated- are routinely recommended by most physicians for physiologic reasons (although specific scientific studies for each are limited).

Avoid alcohol:
- Alcohol inhibits platelet activation/clotting which increases bleeding/bruising.
- It also causes vasodilation, which increases blood flow through the blood vessels that may be injured during cosmetic procedures and surgery, which exacerbates bruising and swelling.
- Most surgeons recommend stopping alcohol at least 24 hours before and 24 hours after treatment for these reasons.
Skip the gym:
- Exercise increases your heart rate, blood pressure, and causes vasodilation of your blood vessels. For the same reasons as for alcohol, many surgeons recommend avoiding exercise except for walking for 24 to 48 hours after treatment.
- If you undergo surgery, your postoperative activity restrictions will likely be of a longer duration!
Sleep elevated:
- Sleeping with your head elevated (equivalent of 2 pillows) allows gravity to aid in drainage of excess fluid and blood from your face.
- The great majority of facial plastic surgeons (over 90%) regularly recommend head elevation after all cosmetic procedures and surgeries, although the duration may vary from a few days to 1 week.

Recommendation #5: Research and Plan Accordingly

BOTTOM LINE: There are many health care providers (and not) offering cosmetic services today. This seems like a no-brainer, but research in choosing a qualified provider can go a long way. Lastly, plan your cosmetic procedure/surgery so that you will have adequate time to heal before any big events!

Believe it or not: There are few enforceable laws and regulations on who can provide cosmetic procedures and surgeries today! In general, the most qualified providers for these services are those who have advanced training in aesthetics (such as fellowship training). Look for physicians who have certifications in Facial Plastic Surgery, Plastic Surgery, Oculoplastic Surgery, and Cosmetic Dermatology. Safety has no price.
Recovery: Discuss with your provider your expected recovery following your desired cosmetic procedure/surgery so you can plan accordingly. For example, it is generally wise to avoid undergoing filler injections less than two weeks before a big event such as a wedding, in case you do develop any bruising or swelling.

We hope these recommendations help. Please leave us a comment if you have any specific questions. Otherwise, best of luck in achieving your aesthetic goals!

References

Ho D, Jagdeo J, Waldorf HA. Is there a role for arnica and bromelain in prevention of post-procedure ecchymosis and edema? A systematic review of the literature. Dermatol Surg. 2016;42(4):445-63.
Ong AA, Farhood Z, Kyle AR, et al. Interventions to decrease postoperative edema and ecchymosis after rhinoplasty: A systemic review of the literature. Plast Reconstr Surg. 2016;137(5): 1448-62.
Shadfar S, Deal AM, Jarchow AM, et al. Practice patterns in the perioperative treatment of patients undergoing septorhinoplasty: a survey of facial plastic surgeons. JAMA Facial Plast Surg. 2014;16(2): 113-9.
Brennan C. Stop “cruising for a bruising”: mitigating bruising in aesthetic medicine. Plast Surg Nurs. 2014;34(2):75-9.
Schlesinger TE, Cohen JL, Ellison S. Purpura and fillers: a review of pre-procedural, intra-procedural, and post-procedural considerations. J Drugs Dermatol. 2013;12(10): 1138-42.
Totonchi A, Guyuron B. A randomized, controlled comparison between Arnica and steroids in the management of postrhinoplasty ecchymoses and edema. Plast Reconstr Surg. 2007;120:271-4.
Seeley BM, Denton AB, Ahn MS, et al. Effect of homeopathic Arnica Montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial. Arch Facial Plast Surg. 2006;8(1):54-9.
Van Exsel DC, Pool SM, van Uchelen JH, et al. Arnica ointment 10% does not improve upper blepharoplasty outcome: a randomized, placebo-controlled trial. Plast Reconstr Surg. 2016;138(1): 66-73.

By Leslie Kim, MD, MPH - Co-Founder and Facial Plastic Surgeon