Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide

Abstract

Background Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. The therapeutic use of botulinum toxin has generally been safe and well tolerated. Adverse effects are considered mild, transient, and self-limited. However, as with all other injectable procedures, this one is also susceptible to adverse events and complications. When the safety zones are respected, the chance of any of these complications is practically null. Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them. Methods The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Results The main complications secondary to BoNT injections on the upper face are: ptosis of eyelid or eyebrow, eyebrow asymmetry, diplopia, Lakeophthalmos, Palpebral ectropion, and prominence of the palpebral bags. To avoid such complications, it is necessary to have knowledge of the anatomy of this region and adequate and individualized planning based on the existing patterns of the frontalis muscle, glabella, and crow's feet. This review presents the specificities of each of these regions and practical suggestions to obtain satisfactory results, avoiding complications. Conclusion Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Botulinum Toxin Type A: Adverse Events and Management

“…Lymphatic drainage in this region may be a co-actor if impaired and causes eyelid edema, especially in subjects with substantial orbicular muscle laxity and long wrinkles that extend to the malar area. 14…”

“…Correctly balancing the muscle tyrant activity may be especially difficult, mainly when treatment involves several muscles in the same session. 14 The mistakes in the product dilution, selection of injection sites, and injected site units per site (all variables directly related to how wide is the botulinum toxin effect area) are responsible for most of the adverse events associated with botulinum toxin procedures. More injected units mean a wider effect area; the same is true for the injected volume, although the relationship is somewhat different.…”

“…Management is with eye drops and lubricating gels. 14 Ectropion and outward eversion of the lower eyelid conjunctival sac: Palpebral ectropion, occurring in subjects with palpebral laxity, may be a consequence of botulinum toxin injections in the pretarsal region near the margin of lower eyelids. The enhanced orbicular muscle laxity causes the outward projection of fat collections, ultimately leading to the prominence of palpebral bags.…”

“…Lymphatic drainage in this region may be a co-actor if impaired and causes eyelid edema, especially in subjects with substantial orbicular muscle laxity and long wrinkles that extend to the malar area. 14 Eyelid edema: A rare and self-limiting botulinum toxin type A adverse event occurring when local lymphatic reabsorption decreases due to reduced lymphatic drainage. Eyelid edema disappears typically within 2 to 4 weeks without medical treatment.…”

“…Correctly balancing the muscle tyrant activity may be especially difficult, mainly when treatment involves several muscles in the same session. 14…”