Cosmetic Complications: Rare and Serious Events Following Botulinum Toxin and Soft Tissue Filler Administration

May 2015 | Volume 14 | Issue 5 | Original Article | 486 | Copyright © 2015

Eric P. Sorensen BSa,b and Christine Urman MDb

aUniversity of California, San Diego School of Medicine, San Diego, CA
bTufts Medical Center, Department of Dermatology, Boston, MA

Abstract

BACKGROUND: Botulinum toxin (BTX) and soft tissue fillers continue to gain in popularity due to their safety, affordability, quick effects, and short recovery times. With the excellent safety profile of BTX and soft tissue fillers, patients may develop a nonchalant attitude towards treatment with injectables. However, it is important for both patient and physician to be familiar with all the possible complications, both common and uncommon.
OBJECTIVE: This article aims to review the rare but serious complications associated with the injectables used in cosmetic dermatology, and the pathogenesis, diagnosis, and management of each.
METHODS AND MATERIALS: A literature review for case reports pertaining to rare adverse events following botulinum toxin or soft tissue fillers was performed using the MEDLINE database.
RESULTS: Complications of BTX included dry eye syndrome, strabismus and diplopia, superficial temporal artery pseudoaneurysm, neck weakness, hoarseness, and dysphagia. Complications associated with soft tissue fillers included tissue necrosis, inflammatory nodules, hypersensitivity reaction, and blindness and cerebral ischemia.
CONCLUSION: The injector should be comfortable in diagnosing and managing the above complications, and the patient should be counseled about these potentially harmful adverse events prior to injection.

J Drugs Dermatol. 2015;14(5):486-491.

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introduction

Botulinum toxin (BTX) and soft tissue fillers have become a cornerstone of modern cosmetic facial surgery. In 2013, an estimated 15.1 million cosmetic procedures were performed in the United States, of which 6.3 million were botulinum toxin injections and 2.2 million were soft tissue fillers. BTX saw a 3% increase, and soft tissue fillers a 13% increase, when compared with 2012. Combined spending on these injectable procedures was $3.82 billion.1 These procedures continue to gain in popularity due to their safety, affordability, quick effects, short recovery times, and long-lasting nature. With the excellent safety profile of both BTX and soft tissue fillers, and the rarity of long-term sequelae, patients may develop a nonchalant attitude towards treatment with injectables. However, it is important for both patient and physician to be familiar with all the possible complications, both common and uncommon. This article will discuss the rare but serious complications associated with the injectables and their management.

Botulinum Toxin

Botulinum toxin is produced by the bacteria Clostridium botulinum and consists of seven toxin subtypes (A, B, C1, D, E, F, and G). In the United States, botulinum toxin type A is available for use in cosmetic procedures. The mechanism of the toxin is to prevent the release of the neurotransmitter acetylcholine into the motor end plate, thus causing selective paralysis where the toxin is injected. In the treatment of rhytides, weakening of overactive underlying facial muscles causes a flattening of the skin and improved cosmetic appearance. The effect is reversible and muscular function begins to return in approximately 3 to 6 months as new neuromuscular junctions begin to sprout, and eventually the motor endplate is restored.2 There appears to be a very low incidence of adverse events in BTX treatment.3 However, the injector should be comfortable in managing the less common but potentially harmful complications associated with BTX injection including: dry eye syndrome, strabismus and diplopia, superficial temporal artery pseudoaneurysm, neck weakness, hoarseness, and dysphagia.

Dry eye syndrome

There are a number of published case reports of patients developing xeropthalmia after BTX treatment of lateral canthal rhytids.4-7 There are 2 major proposed mechanisms 1) direct diffusion of toxin into the lacrimal gland to decrease secretory function7 or 2) lagopthalmos secondary to paralysis of the orbicularis oculi causing decreased tone and blink strength.8 Dry eye syndrome may be categorized into a spectrum of disease severity. Mild disease may manifest as eye irritation, foreign body sensation, or subtle blink dysfunction; moderate disease as red eye, exposure keratitis, lid edema, scleral show, or moderate epiphora; and severe disease as photophobia, ectropion, and corneal erosion.6 By early recognition of mild symptoms, and discontinuing BTX treatment, the vast majority of complications will self-resolve in approximately 3 to 6 months. However, permanent paralysis of facial muscles has been observed in patients treated with BTX for 1.5 to 2 years,9 and 1 group noted that approximately 1% of patients treated with BTX for over 1 year had persistent moderate symptoms.6

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