INTRODUCTION
There are many cosmetic procedures available to improve
age-related facial changes. Treatment with minimally invasive
procedures such as botulinum neurotoxin (i.e. botox)
type A injections, dermal filler injections and cosmetic laser
treatments have become very popular in the field of aesthetic
medicine. In 2008, more than 10 million cosmetic procedures
were performed in the United States, of which 83% were minimally-
invasive procedures.1 The increased demand for minimally-
invasive procedures is largely driven by the minimal discomfort
and low incidence of adverse effects associated with them.2
In aesthetic medicine, the ideal procedure is both effective and
associated with minimal undesirable effects. The injection of
botulinum toxin has demonstrated both efficacy and safety
when used to treat fine lines and wrinkles. It provides the most
predictable results and can be used in the setting of smoothing
overlying skin and reducing wrinkles such as frown lines,
horizontal forehead lines and crow’s feet.3 It is also routinely
used for clinical conditions such as blepharospasm, strabismus,
cervical dystonia, hyperhidrosis, migraines, and muscle
spasticity.4-6 However, as with all procedures, there is a small
margin of technical error associated with its use.
Dermal filler injections are used to minimize the appearance of
facial wrinkles, and have shown particular efficacy in the lower
two thirds of the face.7 Knowledge of the properties and injection
techniques of different types of dermal fillers are essential to aesthetic
practice. Dermal fillers vary by multiple factors including
biochemical composition, mechanism and duration of action, and injection depth and technique, all of which can alter the outcome
of treatment. Consequently, a strong foundation of knowledge of
the properties of dermal fillers as well as adequate experience
with the materials is needed to achieve good outcomes.
This article presents an adverse effect of an aesthetic medical
treatment in a patient who sought treatment for crow’s feet
wrinkles. We discuss the importance of knowing the mechanism
and pathways of cosmetic products and utilizing them to
best accomplish the specific needs of the patient.
CASE REPORT
A 67-year-old woman with a history of hypertension and type
II diabetes mellitus presented to our dermatology practice with
multiple visible and palpable skin-colored nodules outside the
lateral canthus of both eyes. She noticed these nodules nine
months prior to presentation after receiving treatment with botulinum
toxin for the effacement of crow’s feet. This procedure was
performed in a dermatology clinic outside of the United States.
She had previously received treatment with botulinum toxin to
areas of fine lines and wrinkles on the face, but has never had
similar reactions before. She states that the nodules formed immediately
after injection and persisted as painless lesions with
no associated pruritis, change in size, asymmetry or diplopia.
On clinical examination, there were two skin-colored nodules
outside the right lateral bony orbit and above the zygomatic
arch, and a single nodule at a similar location on the left side of
the face (Figure 1). These lesions were firm, non-tender, visible
