Complications from Neurotoxin Injections – Revive Aesthetics Training Protal

Injection Techniques Indications, Anatomical Considerations, and Injection Technique for the Identified Facial Injections Complications from Neurotoxin Injections

Complications with cosmetic botulinum toxin injections are uncommon and those that occur are usually mild and transient. They can be categorized into injection reactions and undesired botulinum toxin effects.

Injection Reactions

Mild erythema, edema, and tenderness at injection sites are expected and resolve within a day. Bruising is common and ranges from pinpoint needle insertion marks to quarter-sized ecchymoses that can take up to two weeks to resolve. Application of ice and pressure to a bruise can minimize enlargement.

Headaches can occur with facial injections; most are mild and spontaneously resolve a few days after treatment. There are reports of idiosyncratic severe headaches lasting two to four weeks.

Infection is rare, but can occur with any procedure that breaches the skin barrier. Paresthesia or dysesthesia in the treatment area is rare, and may be caused by nerve trauma. Anxiety with injection procedures is common. Vasovagal episodes associated with severe anxiety can occur and it is advisable to have appropriate emergency protocols and medications available in the office when performing injection procedures.

Complications

Complications related to botulinum toxin effects 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; incidence declines as injector skill improves. Temporary blepharoptosis (upper eyelid droop) is uncommon (1% to 5%) but is distressing for patients. It is almost always unilateral, seen as a 2- to 3-mm lowering of the affected eyelid that is most marked at the end of the day with muscle fatigue.

Blepharoptosis is caused by deep migration of botulinum toxin through the orbital septum fascia to the levator palpebrae superioris, an upper eyelid levator muscle. Incidence of blepharoptosis is reduced by placing botulinum toxin injections at least 1 cm above the supraorbital ridge at the midpupillary line when treating the corrugator muscles. Blepharoptosis may be treated using ophthalmic solutions that have alpha-adrenergic effects, such as over-the-counter naphazoline 0.025%/pheniramine 0.3% or prescription apraclonidine 0.5% (Iopidine). Both medications cause contraction of Müller muscle, an adrenergic levator muscle of the upper eyelid, resulting in elevation of the upper eyelid.

Eyebrow ptosis and undesired eyebrow shape are usually related to unintended botulinum toxin effects in the frontalis muscle. Some of these complications can be corrected with botulinum toxin injection in muscles that antagonize the affected muscles; however, complications caused by involvement of adjacent muscles are temporary and will spontaneously resolve as botulinum toxin effects diminish. Facial asymmetry can result from uneven dosing of botulinum toxin. Consistent technique and careful attention to injection volumes at the time of treatment can reduce the incidence of asymmetries.

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300727/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874868/
[3] https://pubmed.ncbi.nlm.nih.gov/35178552/
[4] https://pubmed.ncbi.nlm.nih.gov/33128076/
[5] https://my.clevelandclinic.org/health/treatments/8312-botulinum-toxin-injections
[6] https://academic.oup.com/asj/article/42/5/NP327/6530404?login=false
[7] https://emergency.cdc.gov/han/2024/han00507.asp
[8] https://www.plasticsurgery.org/cosmetic-procedures/botulinum-toxin/safety

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