Common Temporary Complications
Common short-term complications after botulinum toxin injections include pain, edema, petechiae, purpura, short-term hyperalgesia, short-term post-injection headache, and prolonged migraine (uncommon).
For hyperalgesia and purpura, they can be avoided as much as possible by local anesthesia before injection, proper injection technique, and ice packs before and after injection.
There are two types of post-injection headache: mild headache (which can be treated with general over-the-counter analgesics), and severe headache (reported rarely and treated with strong analgesics and oral corticosteroids if necessary).
To reduce the risk of purpura, patients should be advised to avoid preoperative medications that affect platelet function (non-steroidal anti-inflammatory drugs, aspirin, etc.).
Serious side effects
1. Interbrow complications
Ptosis is one of the most common complications of botulinum toxin injections in the interbrow unit; the cause is thought to be that the levator muscle is paralyzed by the spread of the toxin; this can be improved with adrenergic eye drops (contraction of the mullerian muscle to lift the lid). The best way to avoid the development of ptosis is not to inject patients who have some degree of prior ptosis (whose frontalis muscle is weakened). In addition, vigorous massage or downward massage may also cause ptosis.
When the frown line between the eyebrows extends downward as a wrinkled nasal line, injections of the nasal lift and upper lip lift muscles should be avoided when treating wrinkled nasal lines to prevent sagging of the upper lip. Wrinkle nasal lines injection site; injection of nasal lift upper lip muscle and lift upper lip muscle should be avoided.
2.Forehead and eyebrow complications
In the treatment of horizontal forehead wrinkles, in order to avoid lid brow sagging, the injection point should be located 1-2cm above the orbital rim to reduce diffusion. Injection of a small amount of toxin into the descending brow muscle can also prevent brow sagging. Selecting the right patient is key. Injecting the middle frontalis muscle without making a balanced injection to the lateral frontalis muscle may result in an abnormal expression of lateral brow lift. The corrective measure for this is to supplement the injection of a small amount of toxin to the lateral muscles that were not previously injected.
3. Periocular complications
Any periocular injection may result in ecchymosis, diplopia, paralytic lid ectropion, or orbicularis oculi prolapse. If diplopia occurs, covering one eye may provide relief. To prevent diplopia, the injection site should be located outside the orbital rim to avoid spreading the toxin into the extraocular muscles.
Inadvertent injection into the zygomaticus major or subzygomaticus area may result in cheek and lip ptosis. For orbicularis oculi injections to treat crow’s feet, the injection site should be more than 1 cm above the zygomatic branch incision to prevent midface and lip sagging.
To avoid midface and lip sagging, when injecting the orbicularis oculi muscle, the range should be limited to 1 cm outside the eye socket or within 1.5 cm of the lateral canthus, and avoid approaching the lower edge of the zygomatic arch.
Periorbital muscle group injection sites; injection of zygomaticus major and subzygomatic arch sites should be avoided, and when injecting, there should be a clear grasp of the periorbital muscle group; in addition, superficial injection also helps to reduce bruising.
4.Perioral complications
Although most fillers are used for injections below the face, the adjunctive use of botulinum toxin is also very valuable.
In the treatment of perioral wrinkles, injection of the orbicularis oris muscle should be conservative. The orbicularis oris muscle can be injected via the upper and lower lips, and the injection should be kept symmetrical and superficial.
The periorbital muscle groups should be injected at the point of injection; the injection should be conservative, paying attention to symmetry and superficiality.
Over-injection of the orbicularis oris muscle may lead to significant side effects such as lip closure, difficulty in eating and brushing teeth; in addition, it may lead to smile asymmetry or speech disorders (difficulty in pronouncing consonants such as B and P) and diminished lip proprioception. Therefore, these potential risks must be declared to all patients (especially those with music, broadcasting, or acting as their profession) before surgery.
Atrophy of the orbicularis oris muscle may also lead to secondary flattening of the lip t. In this case, dermal fillers can be injected at the lip margin to correct this.
If the injection site is too high from the orbicularis oris muscle, it may lead to inversion, ectropion, or temporary drooping of the upper lip.
Contraction of the descending labial muscle will form wrinkles and cause the mouth to sag permanently with age. In this case, it can be improved by injecting dermal fillers or botulinum toxin at a point no higher than the midpoint between the lip and jaw in order to soften the labial-chin groove.
The position of the descending labial muscle needs to be determined by palpation. Injections into the descending labial muscle may result in unilateral paralysis if the point is positioned too close to the mouth. A good method is to first have the patient bite down on the upper and lower jaws to confirm the location of the descending labial muscle; next, Botox is injected into the lower part of the descending labial muscle on each side.
Location of the descending labial muscle injection site; avoid getting too close to the mouth
Botox injections for the treatment of nasolabial folds are rarely successful and are therefore best avoided. Botox treatment of the nasolabial folds may affect oral function and cause difficulty in pronunciation. In most cases, the nasolabial folds should be treated with dermal fillers.
5.Chin and neck complications
Botulinum toxin injections into the chin muscle (lateral to midline of the chin) are commonly used to treat chin depressions. Chin depression is caused by the activity of the chin muscle combined with the lack of collagen and subcutaneous fat in the chin. Injections into the chin muscle may cause depression of the lower lip if the descending lip muscle is accidentally injected.
In patients with chin depressions associated with chin muscle hypertrophy, chin injections should be avoided because they are particularly prone to mouth dysfunction.
Excessive injections into the chin sulcus may result in impairment of mouth function or lead to an asymmetrical smile. However, injecting the chin muscle in the chin position does significantly soften the contour of the area. After injection, adequate massage should be performed.
Botulinum toxin is also used to treat the broad cervical band (vertical lines) and horizontal neck lines. Patients with good skin elasticity and little fat loss under the chin are suitable to receive injections in the cervical broad band. Since the broad cervical muscle is a superficial muscle, it is important not to inject too deeply, as this may lead to difficulty swallowing (life-threatening) or voice change.
The injection site of the broad cervical band; the broad cervical muscle is a superficial muscle and should be injected superficially to avoid side effects.
6.Systemic complications
Botulinum toxin sensitization is a dose-dependent complication: in general, the maximum injection dose for cosmetic patients is 20-40 U, and the chances of rejection are much smaller than for therapeutic patients (injection doses up to 300 U).