Complications with the use of botulinum toxin
Section snippets
Conditions caused by muscle spasms
Local injections of botulinum toxin type A (Botox) directly into excessively contracting muscles have been successful in treating dystonia, spasticity, and other conditions characterized by inappropriate muscle spasm [16], [17]. Botox is considered a safe therapy for these inappropriate muscle spasms and is generally well tolerated, with adverse effects being typically self-limited [18].
Effects of a localized injection of botulinum toxin to nearby or adjacent muscles are believed to be a result
Resistance to botulinum toxin
The possibility of antibody production with resulting immunoresistance has always been a concern with the use of Botox [26]. Hypersensitivity reactions to the injection of the substance do not occur. The only consequence is that Botox no longer is effective as a treatment. With the original Allergan batch [27], it was recommended that not greater than 100 U be used at treatment sessions that occur at not less than monthly intervals. Antigenicity of a foreign material, however, is almost
Cosmetic use of botulinum toxin
Facial wrinkles are frequently caused by repeated muscle contraction. Botulinum A exotoxin can produce weakness or paralysis of these muscles and offers a novel approach for the treatment of certain facial rhytides. Botulinum toxin type A weakens the overactive underlying muscle contraction, causing a flattening of the facial skin and an improved cosmetic appearance [35]. The effect, although temporary, is extremely popular with patients, has a very low incidence of side effects, and is a
Glabella
The most common complication in treatment of the glabellar complex is ptosis of the upper eyelid. Eyelid ptosis is a significant risk if injections are placed at or under the middle of the eyebrows in the vicinity of the mid-pupillary line. This is cause by diffusion of the toxin through the orbital septum, where it affects the upper eyelid levator muscle. This can occur as early as 48 hours or as late as 7 to 10 days following injection when the aesthetic effect is beginning to appear and can
Brow
The most significant complication of treatment of the frontalis is brow ptosis. Botulinum A exotoxin should not be injected above the middle brow so as to avoid brow ptosis. Injection should also be avoided within 1 cm of the bony superior orbital rim for the same reason. Botox works best in younger female patients (20 to 45 years of age). In some older patients and in some male patients, redundant skin can be created under the brow (pseudoptosis), so such patients should be approached with
Crow's-feet
Reported complications in this area are bruising, diplopia, ectropion, or a drooping lateral lower eyelid and an asymmetric smile caused by injection of zygomaticus major. To avoid these complications, one should inject at least 1 cm outside the bony orbit or 1.5 cm lateral to the lateral canthus, and not inject close to the inferior margin of the zygoma. Just as it is important not to inject too close to the eye, injections should not be placed too far below it or too deep, because the
Nasolabial folds
Some physicians have treated levator labii superioris alaeque nasi to soften the superomedial part of the nasolabial fold. They have used relatively low doses (2 to 3 U of Botox per side) including EMG localization of the site but report unimpressive response. In those individuals who did get softening of the folds, some showed lengthening of the upper lip, which of itself is aging. Initially, several nasolabial injections were given. Although they reduced the nasolabial groove, they also
Injecting the lower face and neck
Many of the muscles in the lower central face, especially those used in facial expression, are also involved in the functions of the mouth and cheeks. An asymmetric smile, biting the inside of a flaccid cheek, or incompetence of the mouth manifest by drooling and dribbling are possible complications of the overly enthusiastic use of Botox in the lower face. Small doses, however, can be used satisfactorily (eg, into mentalis, nasalis, and levator labii superioris alaeque nasi). More recently
Complications in treating hyperhidrosis
Chronically sweaty palms are uncomfortable and socially debilitating. Superficial injection of botulinum toxin can provide dramatic relief from this disorder. Injections should be at the level of the superficial dermis and no deeper. Given the ability of Botox to diffuse radially in the axillary skin in a 1.5-cm radius, the physician must first identify the surface area of involvement using the starch-iodine test. Intercurrent doses of intradermal botulinum toxin can then be placed spaced at
Treatment of migraine headaches
In a double-blind clinical study of migraine headache treatment conducted by Silberstein et al [45], there were no reported cases of true eyelid ptosis, diplopia, facial nerve or expression problems, keratopathy, or idiosyncratic or allergic reactions attributable to Botox treatment. Two subjects reported transient brow ptosis; other adverse effects were limited to transient local pain and ecchymosis at the injection site [45].
In another double-blind clinical study conducted by Brin et al [46],
Informed consent
In the informed consent, it must be brought to the patient's attention that Botox has been approved by the FDA as a safe and effective therapy since 1989 for use in blepharospasm, strabismus, and hemifacial spasm and since 1992 for glabellar lines. The National Institutes of Health consensus conference of 1990 also included Botox as safe and effective therapy for the treatment of adductor spasmodic dysphonia, oromandibular dystonia, and cervical dystonia. The treatment of facial wrinkles other
References (46)
- et al.
Mapping of protective and cross-reactive domains of the type A neurotoxin of Clostridium botulinum
Vaccine
(1996) - et al.
The current use of botulinum toxin
J Clin Neurosci
(2000) Sequelae of botulinum toxin injection
Am J Ophthalmol
(1985)- et al.
Ptosis associated with botulinum toxin treatment of strabismus and blepharospasm
Ophthalmology
(1986) Negative antibody response to long-term treatment of facial spasm with botulinum toxin
Am J Ophthalmol
(1988)- et al.
Botulinum A toxin therapy: neutralizing and nonneutralizing antibodies—therapeutic consequences
Exp Neurol
(1997) - et al.
Severe, intractable headache following injection with botulinum A exotoxin
J Am Acad Dermatol
(2002) - et al.
The use of botulinum A toxin to ameliorate facial kinetic frown lines
Ophthalmology
(1996) - et al.
History of the cosmetic use of botulinum A exotoxin
Dermatol Surg
(1998) - et al.
Clinical indications and injection technique for the cosmetic use of botulinum A exotoxin
Dermatol Surg
(1998)