A meta-analysis of safety and tolerability in 1678 patients with a mean age of 45 years, 85% women, from 9 research groups in Japan, China and the USA conducted in 2009 found an incidence of direct adverse effects of botulinum toxin of 7.2%:
- Eyelid heaviness and other sensory disturbances 2.5%
- Upper blepharoptosis 1.2%
- Eyelid edema 1.4%
- Blurred vision 1.1%
- Brow ptosis 0.6%
- Formation of new folds and wrinkles, 0.4%
Disadvantages of botulinum toxin
Complications related to the use of botulinum toxin in the upper third of the face could be very frequent if all the medical events that occur in the observation period are taken into account, 40% being half of this percentage a coincidence. If the complications related to the toxin and those related to the injection procedure are added, it has a 12%. That is, at least 1.2 patients out of 100 suffer from a small hematoma, erythema or pain at the injection site to blepharoptosis.
Long-term effects of botulinum toxin:
Practically none. Common symptoms of complaint after the application of botulinum toxin such as:
- Headache (10%)
- Pain at the injection site (1.6%)
- Hematoma/bruising/erythema (3%)
- Conjunctivitis ( 0.5 % )
- Upper respiratory tract infection/bronchitis (1.9%)
They found the same incidence in both the placebo and botulinum toxin groups. The total number of frequent symptoms would add up to 17%, being local, due to the injection, a total of 4.6%. Facial pain, laryngopharyngeal pain, influenza, nausea, migraine, gastroenteritis, constipation, dental abscess, dental caries, depression and others, which we consider casual, totaled a little more than 20% of incidence. The average doses used were a little higher than those used in Latinos, 20 iu in the glabellar region and between 12 and 36 units of Botox in the orbicularis block. The good news is that the greater the number of applications (Cycles), the frequency of complications decreased in a linear trend from the second session.
J Am Acad dermatol 2009 ; 61: 961-70 Brin MF et al. Some situations that occur when non-recommended punctures are performed have not been reported, such as those of the lower portion of the orbicularis oculi, which can cause bags in the lower eyelids and altered motility of the labial commissure; generated by diffusion of the toxin to the zygomatic muscle, when applications are made too low. The lack of injection in these points is a frequent complaint in cases that present folds that extend to the cheek or in people in whom the lateral block will somehow accentuate the lower palpebral rhytides. Something similar occurs with the forehead block, which may not only give effects of raising or lowering the eyebrows in some way, subject to personal criteria. It may be completely unacceptable for the patient to have a complete block and also expect it to have the same duration. The opposite case also occurs, the person who intends to remain without a single wrinkle with raised eyebrows.
Changes in the arrangement of the eyebrows:
Eyebrow asymmetry is the most frequent complication of treatment in the upper third of the face.
- Mr Spock-style eyebrow tail lift
- Machiavellian look, mephisto, samurai, etc.
- Severe look
- Asymmetrical eyebrow level
- Unmasking eyebrow compensation
- Eyebrow feminization in men
- Persistent folds/wrinkles
- Exaggeration of wrinkles after treatment of horizontal forehead lines
Asymmetries occur when the elevation and natural position of the eyebrows are unbalanced after the application of the toxin. Excessive dosage in the glabella can cause the lowering of the eyebrow heads by blocking the frontalis, the only elevating muscle. Blocking the orbicularis muscles in the lateral planes will leave the unblocked portion of the frontalis muscle, the lower one, predominant. If the frontalis muscle is not blocked at the lateral and upper levels, the eyebrows will rise, causing the “Mr. Spock”/Mephisto/samurai look. Excessive dosage in the forehead can give the appearance of a severe look. Blocking the frontalis muscle between the eyebrows will not be possible in the presence of noticeable ptosis of the eyebrows, as it will be accentuated. It is possible to achieve a certain elevation of the eyebrows by blocking the orbicularis and the upper portions of the frontalis. Brow symmetry is sought by maintaining the feminine arch and the straight eyebrow of the man, preserving the lower frontalis muscle as the main tensor. In general, if the infiltration in the forehead is deep, the eyebrow will fall more and the effect will last longer. If the application is more superficial, the eyebrow will not fall, the rhytidosis will be more covered but the duration of the effect of the toxin is a little shorter.
Botulinum toxin blepharoptosis:
Ptosis of the eyelid is reported by Allergan in 3% of cases.
A multicenter study conducted by Carrutiers in 2002 on 264 applications reported it in 14 cases (5.4%). It occurs as a consequence of the diffusion of botulinum toxin to the levator palpebrae superioris muscle in an attempt to block the deep portion of the corrugator muscle. The most likely route is thought to be deep infiltration very close to the supraorbital foramen.
Facial Plast Surg 2012;28:288–293 From Henry Vandyke Carter
– Henry Gray (1918) Anatomy of the Human Body (See “Book” section below)Bartleby.com: Gray’s Anatomy, Plate 894, Public domain, https://commons.wikimedia.org/w/index.php?curid=563563
Complications due to orbicularis oculi block:
– Diplopia, strabismus
– Persistent tearing.
–Ptosis of the lip
-Asymmetric smile
– Bags
-Ectropion Complications related to orbicularis oculi block are related to diffusion in non-recommended applications, which are all the lower ones. In these cases, the muscles that elevate and support the corners of the lips may be blocked, causing asymmetry when speaking or smiling.
Bags in the lower eyelids are generated when the orbicularis oculi muscle relaxes in its lower portion, causing the zygomaticus minor muscle to project, generating a bulging appearance between the lower eyelid and the infraorbital region.