Botox!

Botulinum toxins (Botox) are among the most toxic poisons, with a wide spectrum of both therapeutic and cosmetic indications for use. Injections with botulinum toxin are effective for many clinical disorders that involve involuntary muscle activity or increased muscle tone. It is also the most common cosmetic procedure performed world-wide, with estimates of nearly 3 million injections per year. Dynamic wrinkles are the main cosmetic indications for the use of botulinum toxin.

There are multiple serotypes of botulinum toxins A-G varying with the molecular size, biosynthesis and cell mechanisms. Type A (BoNT-A) is the most potent and it is used the most commonly. At present, there are three BoNT-A products available worldwide: AbobotulinumtoxinA (Dysport), OnabotulinumtoxinA (Botox), and IncobotulinumtoxinA (Xeomin).

Treatment with botulinum toxin is widely viewed as safe, effective and largely devoid of serious side effects. After effects that can occur at any site after a botulinum toxin injection include pain, edema, erythema, ecchymosis, and short-term hypesthesia. These do not differ from side-effects after other types of injections. When botulinum toxin is used properly, the incidence of these complications is low.

There are no long-term or life-threatening adverse effects related to botulinum toxin treatment for any cosmetic indications. Moreover, the risk of possible complications can be reduced by means of a thorough analysis of the patient’s medical history and the use of the appropriate dose and technique for the injection. On the other hand, injections with botulinum toxin may be responsible for more severe side-effects. They are associated with systemic and generalized botulinum toxin diffusion. There are two classes of adverse events reported so far – transient and benign events, and potentially serious events.

Transient and benign side effects are usually well-localized, reversible and self-limited complications which develop within a few days of the injection, and they usually disappear without any additional treatment. Most of them are injection site adverse effects. Bruising often results from injuring a blood vessel at the site of the injection and most commonly occurs around the eye area. Mild bruising affects 11% to 25% of patients.

A more severe complication related to blood vessel injuries is hematoma. It can develop immediately after injection and can last for a longer period. The hematoma usually requires prevention against abscess formation with antibiotics. Managing this with simple tamponade at the time of the bleeding can decrease the size of the bruise formed or even prevent it from appearing. Pressure and ice packs on the injection site should be applied immediately after blood vessel injuries to reduce ecchymosis and bruising. Preventative methods for bruising include applying ice to the site prior to the injection, causing vasoconstrictive effects, and also ensuring that the patient is not taking any blood-thinning medications such as warfarin or aspirin, and does not have any underlying clotting problems. Precautions and suggested recommendations for clients to avoid medications that inhibit clotting such as vitamin E, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) for a period of 10–14 days prior to treatment minimize the incidence of bruising. Moreover, herbal remedies, such as ginseng, ginkgo, and high doses of garlic, may be associated with higher rates of bruising.

Another injection site complication is localized pain, which is associated with the needle puncturing the skin. Pain that is greater than normal is often associated with using the incorrect needle size. Topical anesthetic creams can be used to minimize pain associated with the injection. Suggested and safe techniques include having the needle bevel up and injecting slowly. Pain can also be minimised by using a preservative containing saline solution to dilute the botulinum toxin.

Infection is a rare possible injected site complication and can occur with any procedure that breaches the skin barrier. Infection can develop at any injection site if the area is not adequately prepared. To prevent infection, the injection site should be cleaned with an antiseptic solution with all makeup residue removed. To avoid contamination, an aseptic technique should be employed. Additionally, after the treatment, you should be instructed not to touch the area until it has healed or apply makeup for at least 6 h to allow the open injection sites to close.

Headache is a common short-term side effect, as the toxin initially causes muscle spasm and then complete paralysis. Another explanation for mild headaches is the needle hitting the periosteum or deep muscle hematomas. Moreover, the stress of the injections themselves may be an important factor in patients who experience transient headaches. Headaches can occur with facial injections. Most of these headaches are mild and resolve a few days after treatment.

Botulinum toxin can result in allergic reactions. These reactions consist of a wide range of symptoms, ranging from fluid retention or redness limited to the site of injection, through major redness and generalised urticaria (Hives) to anaphylactic shock. Redness should settle within 24 h; if it lasts any longer, an antihistamine can be helpful. If it is an anaphylactic reaction, then this is a medical emergency. To help to prevent allergic reactions, a thorough medical history should be taken to rule out previous allergic reactions to other brands of botulinum toxin and practitioners should exercise extra caution in treating someone with multiple allergies, as they may have a higher risk of being allergic to botulinum toxin.

In addition to injection site complications, there is a group of aesthetic and functional adverse effects associated with different muscle responses to botulinum toxin or with the misplacement of botulinum toxin. They are specific for botulinum toxin and are an effect of the direct pharmacological action of the toxin. They occur less frequently than injection reactions, and are primarily caused by temporary denervation of adjacent muscles outside of the intended treatment area. These complications are technique-dependent, because they are usually due to misplacement of the toxin or to different muscle reactivity. When adjacent muscles are inadvertently paralysed, both aesthetic and functional problems may arise.

There are a few potentially important factors for the prevention of side effects after botulinum toxin use. First of all, physicians should establish indications for these procedures properly. They should be familiar with the anatomy of the muscles involved and with any alterations to the anatomy due to prior surgical procedures. Thorough knowledge of the anatomy of the muscles being treated is imperative to avoid serious adverse events, especially those resulting from generalised diffusion. Altered anatomy as a result of previous plastic facial surgery predisposes to more severe botulinum toxin-related side effects. Proper storage of the product, selection of the correct dose, and proper reconstitution and administration techniques are important. Selected adverse effects in cosmetic use of botulinum toxin may be limited by modifications of the technique. Intradermal injection of botulinum toxin has a similar anti-wrinkle efficacy compared to intramuscular injection, but is characterized by a lower risk of eyebrow ptosis and by eyebrow heaviness. This modification may be effective and safe for reducing wrinkles on the forehead.

Many studies recommend the dosing of botulinum toxin based on fat-free mass or on body weight. Another important factor can be the interval between injections. Botulinum toxin binds to specific receptors irreversibly at the nerve terminal. With repeated injections, the receptor-binding capacity may be exceeded, which can lead to systemic spread. To prevent the accumulation of botulinum toxin on failure of the treatment, a certain interval between successive injections is to be respected. Dilution of botulinum toxin and the number of muscles injected are considered to be important factors for avoiding serious adverse effects.

In general, botulinum toxin is contraindicated in patients with a known hypersensitivity to the components of the formulation or with disorders of the neuromuscular junction. Patients taking aminoglycoside antibiotics or anticoagulants should not be treated with botulinum toxins. Patients with diseases of the neuromuscular junction, such as myasthenia gravis, multiple sclerosis and Lambert-Eaton syndrome, are particularly susceptible to the adverse events of botulinum toxin. Patients with anterior horn disorders are also reported to have hypersensitivity to botulinum toxin. In any state where neuromuscular transmission is compromised, botulinum toxin injections may potentially worsen symptoms of the existing disease state. Botulinum toxin treatments are not administered during pregnancy or while nursing.

It is a lesson, here, as to why anyone needs to be very careful about checking the qualifications and experience of any practitioner offering Botox; not only the qualifications and standards but also the name and type of injection product being used. The above is NOT MY OWN WORK but taken from an open access article, the details of which are shown below. I have "translated" some medical terms. If you are considering this treatment I would suggest that you read the article in full:

Witmanowski H (1), Błochowiak K (2). The whole truth about botulinum toxin - a review. Postepy Dermatol Alergol. 2020 Dec;37(6):853-861. doi: 10.5114/ada.2019.82795. Epub 2019 Feb 5. PMID: 33603602; PMCID: PMC7874868.

1. Department of Plastic, Reconstructive and Aesthetic Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland

2. Department of Oral Surgery and Periodontology, Poznan University of Medical Sciences, Poznan, Poland