Ecchymoses, also known as bruises, occur as a result of an injury to the capillaries, allowing blood to leak into the underlying tissue (Figs. 21-1 and 21-2). This is a benign process that resolves within a few days. Hematoma is a more serious entity, when an injury to a blood vessel results in the collection of blood in the surrounding tissue. The enlarging size of the hematoma may push on vital organs or lead to tissue necrosis; therefore, they should be avoided. Hematomas may be treated conservatively with pressure dressings, if active bleeding is not present, or by drainage, if there is active bleeding or the hematoma is enlarging in size.
A. Bruising after Juvéderm to the under eye area. B. Bruising after Hylaform to the under eye area.
Bruising 2 days after treatment with Botox to bunny lines in a patient on ibuprofen.
In a healthy individual with a small injury to a capillary, the coagulation process results in a fibrin clot in the damaged area and eventually healing of the vessel. Platelets are an essential component in the coagulation process. They become activated via exposure to the endothelial lining of the damaged blood vessel, and produce coagulation factors in addition to adhering to the damaged tissue and forming a platelet clog. The process of hemostasis also involves the coagulation pathway, a complicated cascade involving two routes: the contact activation pathway, also known as the intrinsic pathway, and the tissue factor pathway, also known as the extrinsic pathway (Fig. 21-3). Several cofactors are required for the proper functioning of the coagulation pathway. Vitamin K is an essential factor for a hepatic enzyme known as gamma glutamyl carboxylase, which is involved in the synthesis of factors II, VII, IX, and X. Calcium is also required in several steps of the coagulation pathway. In addition, there are natural anticoagulants present, such as proteins C and S, which are beyond the scope of our discussion.
Following coagulation and clot formation, the fibrinolysis process, which is necessary for breaking down the clot, occurs. This pathway starts with the activation of plasminogen, a protein synthesized in the liver that is converted to plasmin via tissue plasminogen activator (tPA) and other factors (Fig. 21-4). Plasmin degrades fibrin into fibrin degradation products (FDPs), which are the end result of this cascade.
At this time there are no published scales rating bruise severity. Rating bruise severity is important ...