How to avoid complications with botulinum toxin therapy

In recent years, the methodological arsenal of cosmetology has been replenished with a number of minimally invasive manipulations. Among them, the most popular are injection methods, the main of which is therapy with botulinum toxin preparations. However, for all its effectiveness, commercial appeal and the illusion of ease of injection, botulinum toxin therapy is associated with a number of side effects.

Dermatovenereologist, leading specialist in minimally invasive techniques at the clinic "Center for Healthy Aesthetics" Igor Rudenko.

Side effects of botulinum toxin therapy

The appearance of side effects is often directly related to the technique of the procedure. Almost always there are non-specific phenomena associated with the puncture of the skin and muscles with a needle. There may be local pain and hemorrhage. Pharmacologically explainable side effects include excessive weakness of the target muscles and paresis of adjacent muscles.

Side effects vary depending on where the toxin is injected. Their severity and frequency are dose-dependent. The systemic effect of botulinum neurotoxin preparations on the nerve endings of other muscles and cholinergic synapses of the autonomic nervous system has been extremely rarely noted.

All effects (both adverse and beneficial) that occur with botulinum toxin therapy are fully reversible

Requires the use of botulinum toxin preparations with a Level I–II safety profile (evidence obtained from a meta-analysis of a large number of well-designed randomized trials or based on the results of at least one well-designed randomized trial).

Types of preparations with botulinum toxin

Evidence-based clinical practice, while reducing the number of drugs used, significantly increases the safety of the procedures performed. At the moment, there are only two such drugs on the Ukrainian market – botox and dysport.

Botox continues to be the most studied botulinum toxin preparation. In particular, according to the Cochrane Library, this drug has been studied in 192 clinical studies (including 82 international multicenters), which is several times higher than those for other botulinum toxin preparations. Recently, Botox has received a significant contribution from the unique scientific data obtained during the study of its use in the treatment of migraine (PREEMPT Clinical Program).

Let's look at complications in typical areas exposed to botulinum toxin preparations.

Complications in the region of the bridge of the nose (glabella) and forehead

When botulinum toxin preparations are injected into this area, it is most important to avoid ptosis of the eyebrows (heavy eyebrows) and upper eyelids. Eyebrow ptosis (Fig. 1) is the most common complication during forehead manipulation. It is also possible to raise the lateral edge of the eyebrow due to uneven relaxation of the muscle (comical eyebrow, "Dr. Spock's eyebrow" (named after a famous member of the crew of the starship "Enterprise" in the television series "Star Trek"), oblique eyebrow).

Botulinum Toxin in Clinical Dermatology, edited by Anthony V Benedetto. 2006

For the prevention of brow ptosis, it is recommended to inject botulinum toxin 2-3 cm above their edge. This will allow a small amount of m. Frontalis to keep the eyebrow at the same level.

It is recommended to work simultaneously with the forehead area and with the glabella in order to neutralize the depressant effect on the eyebrow m. corrugator supercilii. A good way to prevent is to use small doses of a concentrated solution. Increasingly, muscle relaxation rather than muscle paralysis is being resorted to, although this results in accelerated reinnervation in the treated muscles.

There is no cure for eyebrow ptosis. If it occurs, the patient should be reassured, explaining that the position of the eyebrow will normalize within 3–4 months. It is possible to block the depressor part of m. orbicularis oculi in small dosages, which makes it possible to raise the eyebrow by 2-3 mm.

In order to develop the "Dr. Spock's eyebrow" effect, it is necessary to inject small doses of botulinum toxin into the still functioning part of the muscle. However, it should be remembered that over-correction may result in lowering of the lateral edge of the eyebrow.

Complications in the area of ​​the upper eyelid after botulinum toxin injections

The development of ptosis of the upper eyelid (Fig. 2) occurs with the introduction of botulinum toxin preparations below the orbital septum. In this case, α-adrenergic antagonists in the form of eye drops are recommended, which should be applied 1 to 3 drops every day, as long as symptoms persist. These drugs stimulate the Müllerian muscle and lift the upper eyelid. In this case, it will not be superfluous to prescribe a course of myostimulation procedures.

Hematomas and mild headache are transient side effects and last from a few hours to 1-2 days after injection.

Complications in the periorbital region after botulinum toxin injections

Botulinum toxin injections in this area can highlight excess fatty tissue located under the lower eyelid (bags under the eyes). Frequent side effect – the formation of puffiness. In addition, lowering and drooping of the lower eyelid with insufficient closure and / or development of a tearing disorder with the subsequent occurrence of a dry eye symptom are possible.
A rare complication with a significant overdose or violation of an adequate safe distance from the eye may be diplopia and paralysis rectus lateralis oculi due to local diffusion of the toxin. With the introduction of the drug in m. zygomaticus major may develop smile asymmetry and/or drooping of the corner of the mouth and increased grief lines.

It is necessary to diagnose the possible development of side effects in the form of increased bags under the eyes. In patients with excess skin near the lateral canthus of the eye, the administration of botulinum toxin preparations results in an undesirable skin fold under the eye and an increase in diagonal wrinkles in the zygomatic zone. As in the forehead area, it is good practice to administer small, concentrated doses at a distance of 1-1.5 cm from the lateral edge of the orbit.

In patients with a positive sluggish snap test, it is not recommended to inject the drug into the medial infraorbital region, as this will cause persistent looseness, scalloping of the skin and cause a negative cosmetic effect.

Loss of the sphincter function of the orbicular muscle of the eye (Fig. 3) is possible when the drug diffuses to the palpebral part, which leads to the development of involuntary blinking or forced closure of the eye. In cosmetic practice, this is typical for elderly patients with a weakened septum orbital, as well as patients who have undergone lower eyelid blepharoplasty.

Botulinum Toxin in Clinical Dermatology, edited by Anthony V Benedetto. 2006

If swelling occurs, it is recommended to prescribe decongestants for a week (veroshpiron, furosemide).

In case of lower eyelid sagging and lacrimation disorders, symptomatic treatment is necessary with the obligatory involvement of an ophthalmologist to prevent the development of keratitis.

Complications in the mouth, chin, neck

Working with the orbicular muscle of the mouth can lead to partial failure of m. orbicularis oris, with temporary loss of the ability to whistle or drink through a straw. Sometimes short-term (within 7-10 days) speech impairment is possible.

There is an unspoken rule that recommends that you do not perform the procedures on the upper and lower lip at the same time, but perform them sequentially.

Excessive weakness m. depressor anguli oris can make the smile appear asymmetrical, especially if the toxin is injected too medially. During the procedure, asymmetry of mouth movements can be observed in the chin area and, theoretically, insufficient closure of the mouth is possible.

An overdose of botulinum toxin preparations in the neck area can lead to the development of dysphagia, a change in the timbre of the voice, and weakness of the levator muscles of the neck. It must be remembered that platysma lies superficially, so injections must be given intra- or subcutaneously. The incidence of complications in this area is low, and all of them, as a rule, are associated with excessive use of the drug and injections that are too deep.

In most cases, adverse reactions in the mouth and neck area resolve on their own within 1-2 weeks, provided that moderate dosages are used.

Side effects and contraindications for botulinum toxin injections

1. Frequent mild adverse reactions of a short duration.

Developed by injection:

• a feeling of tingling, burning or pain;
• swelling;
• redness;
• mild headache.

Injection technique dependent:

• ecchymosis lasting 3 to 10 days;
• asymmetry;
• asymmetrical smile;
• neck weakness;
• insufficient cosmetic effect.

Rare, idiopathic:

• numbness and paresthesia;
• local tonic contractions;
• mild nausea and sudden vomiting;
• mild malaise and myalgia (local and general).

2. Long-term serious adverse reactions depending on injection technique:

• blepharoptosis;
• eyebrow ptosis;
• diplopia;
• excessive lacrimation or xerophthalmia with or without keratitis;
• ectropion (with possible development of xerophthalmia);
• lagophthalmos;
• dysphagia;
• dysarthria.

3. Long-term serious adverse reactions independent of injection technique:

• hypersensitivity reactions;
• urticarial rash;
• shortness of breath;
• soft tissue edema;
• anaphylaxis.

Contraindications for botulinum toxin therapy

• emotional lability of patients with high expectations;
• neuromuscular diseases (myasthenia gravis, Eaton – Lambert syndrome);
• allergy to any of the components of the drug (botulinum toxin, gelatin, lactose);
• taking drugs that can alter the effect of botulinum toxin (eg aminoglycosides, quinine, calcium channel blockers);
• pregnancy or breastfeeding period.

Thus, botulinum toxin preparations are an effective tool in the fight against mimic wrinkles. However, along with a positive result, a number of side effects are possible. To prevent the development of adverse events, it is necessary to use drugs with proven safety and minimal diffusion. Knowledge of the features of the use of botulinum toxin preparations allows you to avoid side effects, and if they occur, it helps to effectively deal with them.

According to kiai.com.ua