Managing Adverse Events Associated with Botulinum Toxin Type A: A Focus on Cosmetic Procedures

February 2005

American Journal of Clinical Dermatology 6(3):141-50

DOI: 10.2165/00128071-200506030-00001



Project: Rejuvenation

Uwe Wollina

Helga Konrad


Abstract: Botulinum toxin A (BTXA) has become a widely used drug in cosmetic dermatology, not only for the treatment of local hyperhidrosis, but also for hyperkinetic facial lines, décolleté wrinkles, and other skin features. The spectrum of possible adverse effects of BTXA is wide, but fortunately those observed with the cosmetic use of this product are generally mild and transient. The main means of preventing negative effects from BTCA are knowledge and skills. Using correct injection techniques is mandatory as most side effects are caused by incorrect technique. Knowledge of target structures, e.g. facial and extra-facial muscles, allowing doctors to choose the optimal dose, timing and technique. The most common side effects are pain and hematoma. In the periocular region, lid and eyebrow ptosis are significant adverse effects. Side effects such as pain, hematoma, ecchymosis, and bruising can also occur on the upper and lower face and in places outside the face. Other potential side effects seen in other indications that the user of BTXA in cosmetic dermatology should be aware of include induced headache and potential interaction with concomitant medications. Induction of neutralizing antibodies due to BTXA cosmetic treatment has not been observed. This article also describes recommendations regarding the use of BTCA. Of these, the most important for avoiding the most unwanted side effects are proper dilution, storage and injection techniques, 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 can be partially corrected using apraclonidine or phenylephrine eye drops. If simple rules are followed regarding the indications and application of BTXA, this is a safe and effective medication in cosmetic dermatology.