Fixed drug eruption caused by lactose in an injected botulinum toxin preparation

Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies

The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Complications of minimally invasive cosmetic procedures: prevention and management

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.

Managing adverse events associated with botulinum toxin type A: a focus on cosmetic procedures

Botulinum toxin A (BTXA) has become a widely used drug in cosmetic dermatology, not only to treat focal hyperhidrosis but also hyperkinetic facial lines, platysma bands, décolleté bands, and other skin features. The spectrum of possible adverse effects of BTXA is broad but fortunately those that have been observed with cosmetic use of this product are generally mild and transient. The major tools for preventing adverse effects from BTXA are knowledge and skill. Use of correct injection techniques is mandatory since most unwanted effects are caused by incorrect technique. Knowledge of the target structures, e.g. the facial and extrafacial muscles, allows physicians to select the optimal dose, time and technique. The most common adverse effects are pain and hematoma. In the periocular region, lid and brow ptosis are important adverse effects. Adverse effects such as pain, hematoma, ecchymosis, and bruising may also occur in the upper and lower face and at extrafacial sites. Other possible adverse effects seen in other indications that the user of BTXA in cosmetic dermatology should be wary of include induction headaches and possible interaction with concomitant medications. Induction of neutralizing antibodies due to cosmetic BTXA treatment has not been observed. This article also outlines recommendations regarding use of BTXA. Of these, the most important for avoiding most unwanted adverse effects are the proper techniques of dilution, storage, and injection, as well as the careful exclusion of patients with any contraindications. Pain, hematoma, ecchymosis, and bruising can be prevented by cooling the skin before and after BTXA injection. Upper lid ptosis may be partly corrected using apraclonidine or phenylephrine eyedrops. If simple rules relating to the indications for and application of BTXA are followed, this is a safe and effective drug in cosmetic dermatology.

[Botulinum toxin and wrinkles: few side effects and effective combining procedures with other treatments]

Chemical denervation, through the biologic effect of botulinum toxin, provides a very effective, low risk, lasting treatment for hyperkinetic wrinkles, mainly of the upper face. Patients with such rhytides, when treated with surgical myotomies or other alternative medical treatments, are at greater risk and with potentially less lasting results. Botulinum toxin has been widely used for the last 20 years in many areas of medicine. It has been used for 13 years in dermatology and plastic surgery, without important complications or sequellae. Any complications appear to be reversible. In these two specialties, with the minute quantities (units) and volume of material injected, complications are infrequent; some of them are now anecdotal. The only main complication from a cosmetic point of view is blepharoptosis, which is more and more rare. Because of a better anatomical knowledge of the affected muscles, and our improved technique, risks are greatly reduced. In our two latest multicenter studies on glabellar wrinkles, between 2002 and 2004, we saw no blepharoptosis. Conversely, in case of dynamic wrinkles associated with muscle, fat, and skin relapse, and/or deep furrows, only surgical procedures and/or other surface treatments are effective. Botulinum toxin injections are not meant to replace upper, mid, or mandibular face and neck lifts; indeed, botulinum toxin injections may optimize results from these surgical procedures. These injections play a fundamental process in producing long lasting results. The current and future evolution, in cosmetic surgery, is toward full achieved, but focused, natural, and minimally invasive surgical procedures in combination with effective and minimal risk techniques such as the botulinum toxin injections. To optimize the effect of the medical procedures, botulinum toxin should be injected three weeks before surgery. In addition botulinum toxin injections may optimize and prolong the effect of the surface procedures, as lasers, peels and fillers. This medicosurgical combination is one of the examples that best describes the evolution of plastic and aesthetic surgery in 2004.