Adverse events can happen in all medical procedures, and botulinum toxin is no exception. Complications for this procedure, however, tend to be short-lived. They are usually mild, so most patients can tolerate them; additionally, they are infrequent and can be attributed to injector inexperience. This article will attempt to elucidate some of the main complications of botulinum toxin injections and categorically arrange them. You will also be informed of the appropriate evidence-based management protocols for when these incidences occur.
Common patient complaints and how to manage them
Treatment expectation mismatch
Complication: It is hard to quantify this issue, as it has extensive variability among patients. In essence, the treatment did not satisfy the patient’s expectations. Usually, patients notice their wrinkles to be either over- or under-corrected.
Management: Do not underestimate the leverage of an adequately conducted consultation process. You must assess patients’ expectations and have a thorough discussion with them regarding their expected outcomes. Use an objective scale to measure the wrinkles in both repose and dynamic states. For example, the Glogau scale is widely used by medical practitioners to great effect. Be concise and straightforward with the patient, as any false or misconstrued information can cause immense dissatisfaction. Prepare the patient psychologically for the treatment, and when it is confirmed, make sure you obtain their informed consent. Motivate them to be present for follow-up appointments by educating them on the importance of post-treatment care, and, if they have any, ask them to prepare a list of concerns for you to address: doing so will help give your patients peace of mind.
In some cases, you can deal with unsatisfactory treatment results by opting to re-treat areas by focusing on the contralateral side. For example, a common complication is “Spock brows,” which occurs when the lateral side of the eyebrow is over-treated. For adequate correction, use a small amount of botulinum toxin at the frontalis elevator muscles just above the eyebrow.
Complication: Asymmetry is a rather fickle subject but for an aesthetically pleasing appearance, ensuring symmetry is a must. This complication is especially common in the eyebrow region usually because of excessive contractions of the frontalis muscle in comparison to the other muscles around this area. It can also occur when inadequate amounts of botulinum toxin are deposited.
Management: To manage this, have the patient attend subsequent follow-up sessions. The affected area can be treated via further injections on either the same side or the contralateral side, so as to balance out the features.
Other complications of botulinum toxin injections
Ecchymosis, patient discomfort, bruises, hypoesthesia, and headaches
Side effect: With any percutaneous procedure, the chances of ecchymosis will be present. Most often it happens at the ocular area. Next, patient discomfort can be amplified if a larger than recommended needle—a 30G—is used. Headaches and hypoesthesia can also occur, but they are transient and self-limiting and typically subside within 48 hours.
Management: Since even the most experienced practitioner can cause ecchymosis, you should advise the patient to stop using any aspirin or other non-steroidal anti-inflammatory medications since they can increase its occurrence and severity. If ecchymosis still occurs, manage it via immediate tamponade for a few minutes. Continue treatment by applying of an ice pack to the affected site since it induces vasoconstriction. Most minimally invasive aesthetic procedures opt for local anesthetics prior to the treatment process to minimize patient discomfort. Injection technique may also play a role in causing some of these complications, so the gentle depositing of Botox and insertion with the needle bevel facing upwards will help. Reassure patients with headaches that it is a result of the muscle spasms from the treatment. If unbearable, advise them to receive an over-the-counter analgesia.
Complication: Allergic reactions manifest as skin reactions and erythema and can quickly progress to life-threatening angioedema.
Management: A typical Botox preparation consists of botulinum toxin A, human albumin, lactose, and/or sodium succinate. Some botulinum toxin preparations, such as Dysport, also contain cow’s milk protein. The patient is contraindicated for Botox treatments if they have a known history of hypersensitivity to any of the constituents of the botulinum toxin preparations they will be using for injection. Any erythema should be resolved in a day. Antihistamines may help with mild allergic symptoms. Anaphylaxis should be managed immediately in the hospital with adrenalin. Protect a patient’s airways at all cost. It should be your responsibility to carry emergency equipment and medications on site. Unexperienced practitioners should practice caution by examining the through medical histories of their patients in order to help exclude patients with prior relevant allergic reactions from receiving botulinum toxin preparations.
Drooping areas and double vision
Complication/side effect: The most frequent complications from toxin injection in the upper face are brow and lid ptosis. This is mainly caused by flawed deposition, especially the displacement of the product too close to the lateral region of the brow, which would affect the lateral frontalis. In turn, this will progress to spread locally to the levator palpebrae superioris. Diplopia may also occur concurrently. If injections are done in approximation to the vermilion borders, there is also a chance of ptosis of the upper or lower lip.
Management: Performing appropriate injection techniques at the brow and lid area are of utmost importance. Avoid injecting the outer brow region to lower the risk of brow ptosis. Do not inject near the vermilion border to treat the perioral region. However, if these complications do occur, it may be ideal to just let it resolve on its own. Review the patient in two weeks’ time and determine if they need any active intervention. However, do keep in mind that upper eyelid ptosis can last for two to 12 weeks, while brow ptosis may last upwards of three months. Alternatively, you may also opt for prescribing ophthalmic eye drops (α 2 -adrenergic agonist) to relieve eyelid ptosis since it stimulates the Müller muscle and can elevate 1 to 2mm of the upper eyelid. You may prescribe 0.5% apraclonidine three times daily. A treatment regimen of 60mg of oral pyridostigmine bromide three to four times a day can also be recommended since it inhibits acetylcholine breakdown; however, side effects such as hypersalivation, vomiting, diarrhea, and muscle cramps may deter some patients. You can also attempt to reduce the strength of the orbicularis muscle and allow the Müller muscle and levator muscle to be more unopposed in terms of their movement by injecting at the subdermal plane above the eyelash line at the extreme medial and lateral parts of the upper eyelid. These various options represent symptomatic treatment that can be continued until the complete resolution of the ptosis. If diplopia occurs, the intraocular muscles may be inadvertently injected, so refer the patient to an ophthalmologist for further management since they may be able to correct it by injecting the antagonistic muscle.
Spreading from the treated area
Complication: Occasionally, botulinum toxin can affect non-target tissues and even glandular tissues, resulting in complications such as lower eyelid laxity, epiphora, decreased strength of eye closure, dry eye, mouth incompetence, difficulties in enunciation, and the inability to whistle. The onset of these symptoms usually depends on the area originally injected.
Management: Strictly follow the manufacturer’s recommended dosages. Many case reports have shown that toxin spread is mainly due to larger doses of botulinum toxin injected. Furthermore, ensure that you have a good understanding of the anatomical structures of the treatment area prior to depositing the agent. Lastly, the patient must be instructed not to rub the area after injection, as it can also increase the risk of the spread of the toxin.
Complication: Whenever stringent protocols to prepare the skin prior to treatment are not followed, the risk for infection is higher.
Management: To effectively reduce the risk of infection, the site must be adequately prepared with an antiseptic solution. Ensure makeup is completely removed. Maintain aseptic technique and standards throughout the treatment process. The patient should also not touch the treated area within the first six hours of treatment. If infection does occur, obtain a culture and sensitivity result while commencing treatment with empirical antibiotics since delaying treatment may increase the risk of scarring.
Botulinum toxin is the treatment choice of for indications involving the treatment of lines and wrinkles, such as frown lines, forehead lines, and crow’s feet. Botox often offers reliable results and can be highly effective while causing few side effects. When complications do occur, most can be resolved with relative ease as long as the practitioner is well-versed in the appropriate management protocol(s). Reassure patients that such side effects are transient and will, in many cases, improve over time. It is the practitioner’s responsibility to help patients make informed decisions. With proper planning and effective communication between practitioner and patient, these complications will have no lasting impact(s) on patients’ quality of life!.