Dr. Leslie Wei
is a board-certified ophthalmologist specializing in ophthalmic plastic and reconstructive surgery. She completed both her undergraduate and medical degrees at Brown University, followed by residency at University of Colorado and fellowship at University of Wisconsin. She is currently in private practice in upstate New York.
Dr. Ann Tran
is currently a first year ophthalmology resident at the University of Miami Bascom Palmar Eye Institute. She completed her undergraduate degrees in biochemistry at the University of Wisconsin-Madison and pursued her medical degree at the University of Wisconsin School of Medicine and Public Health.
Cat N. Burkat
Dr. Cat Burkat is a board-certified ophthalmologist with expertise in plastic and reconstructive surgery and aesthetic surgery around the eyes. Dr. Burkat has been uniquely dual-fellowship trained in both ophthalmic plastic and reconstructive surgery, as well as cosmetic facial surgery, which allows her to offer an approach that combines the microsurgical precision of ophthalmology with the concepts of aesthetic facial surgery. She graduated from Harvard University and University of Rochester, followed by a dual-fellowship at the University of Wisconsin.Dr. Burkat specializes in a broad range of conditions, with particular interest in surgical repair of droopy eyelids, congenital eyelid abnormalities, tear duct abnormalities, and cancer reconstruction. She also offers a wide array of non-surgical and surgical cosmetic procedures for enhancing the natural beauty of the face, including cosmetic eyelid and forehead surgery, Asian blepharoplasty, cosmetic botulinum and soft tissue filler injections, facial laser resurfacing and other related procedures.In addition to her clinical practice, Dr. Burkat has published numerous peer-reviewed articles and over 35 book chapters, and is on the editorial board and review board of many prestigious journals. She is active in several committees in the American Society of Ophthalmic Plastic and Reconstructive Surgery Society, and leads several courses and breakfast expert roundtables at the annual AAO scientific meeting. She has been invited to speak and teach at numerous national and international courses, and actively participates in volunteer medical trips in Southeast Asia, India, Africa, Central America, and the South Pacific. She has also received multiple awards including the American Academy of Ophthalmology Achievement Award, the American Journal of Cosmetic Surgery Richard B. Aronsohn Founder’s Award for the year’s Best Scholarly Manuscript published, and several Outstanding Surgical Teaching Awards from Ophthalmology Residents. She is also an Associate Preceptor for the University of Wisconsin Fellowship in Ophthalmic Facial Plastic and Reconstructive Surgery, the American Academy of Cosmetic Surgery Fellowship, and is the Administrative Director of the International Fellowship in Ophthalmic Facial Plastic and Reconstructive Surgery at the University of Wisconsin.
Introduction
In 2013, 13.4 million minimally invasive cosmetic procedures were performed in the USA, over 60 % of which were injectables such as botulinum toxin (BTX) and dermal fillers [1]. Botulinum toxin procedures alone accounted for almost 1.5 billion dollars spent on cosmetic procedures [2]. These types of aesthetic procedures are gaining popularity because of their relatively quick effects but shorter procedure and recovery time compared to incisional surgery. The overall complication rate of such procedures is low; however, knowledge of both complications and treatments are vital to a safe and successful cosmetic practice.
Complications of Botox (BTX)
The US Food and Drug Administration approved the cosmetic use of BTX for glabellar rhytids in 2002 and for crow’s feet in 2013, although off-label uses of BTX for face and neck rejuvenation continue to be popular [3, 4]. Commercially available forms of BTX in the USA include onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and rimabotulinumtoxinB (Myobloc) (Table 51.1) [5]. No long-term adverse complications have been reported from BTX for cosmetic indications, although transient side effects may occur (Table 51.2) [6]. While highly debated, Dysport encompasses a larger area of diffusion compared to Botox, which may lead to less localization of clinical effects and increase potential for adverse effects [7].
Table 51.1
Commercially available forms of botulinum toxin
Trade name | Company | Toxin component | Other components | FDA approved uses |
|---|---|---|---|---|
Botox | Allergan Inc. | OnabotulinumtoxinA | Human serum albumin, NaCl | Blepharospasm, cervical dystonia, glabellar lines, chronic migraine, etc. |
Dysport | Medics Pharmaceutical Corp. | AbobotulinumtoxinA | Human serum albumin, lactose | Blepharospasms, cervical dystonia, glabellar lines |
Xeomin | Merz Pharmaceuticals | IncobotulinumtoxinA | Human serum albumin, sucrose | Blepharospasms, cervical dystonia, glabellar lines |
Myobloc | Solstice Neuroscience Inc. | RimabotulinumtoxinB | Human serum albumin, NaCl, disodium succinate water | Cervical dystonia |
Table 51.2
Complications of Botox
Undertreatment |
Injection site pain and bruising |
Asymmetry |
Headache |
Allergic reaction |
Dry eyes |
Brow ptosis |
Eyelid ptosis |
Lip ptosis |
Lower face complications: drooling, dysphagia, and neck weakness |
Contraindications
Absolute contraindications include active infection at injection site and a history of allergic reaction to the constituents of BTX [8]. No deaths have occurred with cosmetic BTX; however, a case of lethal anaphylaxis to a Botox-lidocaine mixture has been reported [9].
Exclusion criteria include patients with neuromuscular conditions (such as myasthenia gravis, amyotrophic lateral sclerosis) who may be at increased risk of neuromuscular crises even with low doses of toxin [10].
Women currently pregnant, lactating, or planning on becoming pregnant should avoid BTX, as it is a category C medication with little knowledge of breast milk absorption of excretion [10].
Relative contraindications include immunocompromised patients at increased risk of infection, over the age of 65, those with unrealistic expectations or with body dysmorphic disorder [10, 11]. BTX should be avoided in patients taking medications that interfere or interact with the metabolism of the drug such as aminoglycosides or cholinesterase inhibitors (Table 51.3).
Table 51.3
Contraindications to botulinum toxin injection
Absolute contraindications |
Active infection at injection site |
Sensitivity or allergy to constituents of botulinum toxin product |
Relative contraindications |
Age >65 – safety and efficacy unknown |
Actors or singers dependent on facial expression |
Botulinophilia (body dysmorphic disorder) |
Immunocompromised states (e.g., diabetes or alcoholism) |
Inflammatory skin diseases (e.g., eczema, psoriasis, history of keloid scarring) |
Medication use with aminoglycoside antibacterials (e.g., streptomycin or neomycin), cholinesterase inhibitors, calcium channel antagonist, local anesthetics, curane depolarizing agents, chloroquine, cyclosporine A, and penicillamine |
Neuromuscular disorder (e.g., amyotrophic lateral sclerosis, Lambert-Eaton syndrome, myasthenia gravis, or other peripheral motor neuropathies) |
Pregnancy or lactation |
Pre-existing eyelid or brow ptosis |
Relative Complications
Undertreatment
Undertreatment may often result in consumer dissatisfaction, as residual lines or redundant skin in surrounding areas may become more noticeable. Clinicians should counsel patients for realistic expectations, need for additional treatment or adjunctive therapy with soft tissue augmentation or skin laser treatments, especially for maximal correction of rhytids. In addition, patient sensitivity and resistance vary; thus, more BTX may be needed for some compared to others.
Over time, repeated doses of BTX injections can elicit an immune response leading to the development of neutralizing antibodies against the neurotoxin in 0.49 % of patients [12]. These patients may become unresponsive despite increasing doses of BTX [13]. A trial of a different serotype can be beneficial in refractory cases as neutralizing antibodies against one serotype do not appear to block the activity of others [14, 15]. To prevent future loss of efficacy, current practices advocate for the lowest effective dose and the longest time interval between treatments.
Bruising
In clinical trials, treating crow’s feet, bruising, and pain were reported in 10–25 % of patients [16, 17]. The lateral canthal region is particularly susceptible as the orbicularis oculi is very thin with a rich network of superficial veins. To minimize bruising:
Stop herbal products such as vitamin E, garlic, ginger, ginseng, Ginkgo biloba, and St. John’s Wort and aspirin 1–2 weeks prior to treatment [18]. Take a thorough medication history as half of cosmetic patients may report using herbal supplements [19].
Use small needles (30–32 gauge) on a tuberculin syringe.
Inject in areas with minimal vascularity.
Inject on top rather than into the muscle in periocular region.
Apply ice to the areas of increased vascularity for vasoconstriction.
Injection Site Pain
To reduce injection pain:
Apply topical anesthetic cream 15–30 min prior to injection, if needed [20].
Place cool compresses or ice before and after the procedure to minimize discomfort [20].
Pinch the skin or tap a finger nearby injection site as a distraction technique.
Preservative-containing saline as the diluent produces less pain with no difference in efficacy than non-preservative formulations [21].
Asymmetry
Facial asymmetry can be reduced with dosing adjustments based on the preexisting muscle activity, proper technique, and knowledge of facial anatomy. Inappropriate injection to the glabella and frontalis may lead to an upside-down V-shaped or “cocked” eyebrow from incomplete weakening of the lateral frontalis that can be corrected with additional BTX to the lateral frontalis muscle [22]. Injection in close proximity to the orbicularis oris in the treatment of sad lines may produce flaccid cheek or asymmetric smile. To minimize, place injections 1 cm away from the lateral caudal lip at the jaw angle behind the nasolabial folds [22].
Headache
BTX may cause headaches due to microtrauma from needle insertion or neurotoxin-induced muscle spasm [23]. Headache frequency varies from 11 % to 15 % [24, 25]. Most headaches are mild lasting for a few hours and relieved by over-the-counter analgesics [24]. Only 1 % of patients experience severe debilitating headaches lasting 2–4 weeks [23].
Moderate Complications
Allergic Reaction
Hypersensitivity and allergic reaction to BTX are extremely rare and typically manifest as pruritus or unspecified rash [26]. Skin rashes such as psoriasiform eruption, pseudo-segmental exanthema, and sarcoid nodules after intramuscular injection have been seen [27–29]. Systemic reactions such as botulinum toxicity have only been reported in four cases [30]. The use of epinephrine and methylprednisolone for management of severe allergic reactions is recommended over diphenhydramine (Benadryl) due to the anticholinergic effects [31].
Upper Face Complications
Brow ptosis occurs in up to 5 % of patients treated for glabellar and forehead rhytids leading to partial obstruction in vision [32]. Older patients with increased hooding and brow laxity may develop pseudo-ptosis. To avoid this complication, injections should be placed approximately 1cm above the supraorbital rim for glabellar rhytids, and no lower than the mid-forehead level for frontalis creases (Fig. 51.1).
Fig. 51.1
Muscles of facial expression. X = high-risk injection areas – injections here should be performed with caution and expertise. O = typical injection sites in cosmetic BTX treatment
Eyelid ptosis can occur after injection to any number of areas, including the lateral orbicularis oculi, glabella, and forehead. Blepharoptosis after crow’s feet injection occurred in 5.4 % patients in early studies but has decreased to 0.3 % in later studies [33, 34]. Symptomatic patients can be treated with α-adrenergic agonist drops to contract Muller’s muscle and produce 1–2 mm of eyelid elevation [10]. In refractory cases, apraclonidine drops can be used [35].
Injection too close to the lateral orbicularis oculi is associated with an increased risk of dry eyes, diplopia, ectropion, and lagophthalmos. The mechanism of dry eyes is thought to be secondary to decreased tear production and tear film stability [36]. Anti-inflammatory drops can be prescribed to alleviate this condition [37]. Diplopia from diffusion to the lateral rectus can develop into diplopia that can be symptomatically relieved with patching of the affected eye and follow-up with an ophthalmologist [38]. Ectropion can occur from lower orbicularis oculi paralysis, particularly if injected near or into the pretarsal orbicularis oculi portion. Performing the snapback test to assess lower eyelid laxity will allow for better patient selection.
Midface and Lower Face Complications
Lip ptosis is a rare complication of BTX treatment of crow’s feet and bunny lines and can last up to 6 weeks with no real treatment options. Injections too close to the zygomatic arch can weaken the zygomaticus major muscle and create an appearance similar to Bell’s palsy [39]. Treatment of fine lateral nasal smile lines, known as bunny lines, can cause weakening of the levator labii superioris [40].
Treatment of vertical platysmal bands can lead to side effects such as neck stiffness, weakness, and dry mouth that may last up to 3 weeks [41]. Severe complications such as dysphagia and dysphonia arise if diffusion or direct injection occurs into the sternocleidomastoid. Superficial, small dose injections can avert accidental paralysis.
Complications of Fillers
Dermal fillers, also called soft tissue fillers, are one of the most sought-after minimally invasive procedures, second only to Botulinum toxin [42]. 2.2 million soft tissue fillers were administered in the USA in 2013, an increase of 13 % compared to 2012 [1]. Commonly used fillers types are listed in Table 51.4. Complications range from mild transient effects such as bruising and erythema to sequelae as severe as skin necrosis and blindness (Table 51.5). Judicious administration by an experienced injector is crucial to avoid complications. Should a complication occur, timely treatment and close follow-up are warranted to obtain an acceptable cosmetic outcome.
Table 51.4
Dermal fillers
Nonabsorbable | Absorbable synthetic | Absorbable natural | |||
|---|---|---|---|---|---|
Major component | PMMA | Hydroxylapatite | Poly-L-lactic acid | Hyaluronic acid | Collagen |
Brand name | Artefill Artecoll | Radiesse | Sculptra | Juvederm Restylane Perlane Belotero Hylaform Elevess Prevelle Captique Voluma | Zyderm Cosmoderm Evolence Fibrel |
Table 51.5
Complications of dermal fillers
Undertreatment |
Overtreatment |
Asymmetry |
Bruising |
Edema and erythema |
Contour irregularities/ridging/beading |
Tyndall effect |
Granuloma formation |
Allergic reaction |
Skin necrosis |
Blindness |
Contraindications
Absolute contraindications to dermal fillers are an active infection at the injection site, history of allergy/hypersensitivity to filler or an allergy to lidocaine, and bleeding disorders [43, 44]. Relative contraindications include a history of herpetic eruption at injection sites and history of keloid formation, hyperpigmentation, or hypertrophic scarring (Table 51.6) [44]. Women who are pregnant or breastfeeding should delay elective cosmetic procedures, as there is a lack of controlled trials assessing the safety of fillers during pregnancy and postpartum periods [45].
Absolute contraindications |
Active infection at injection site |
Sensitivity or allergy to filler OR lidocaine |
Bleeding disorders |
Relative contraindications |
History of herpetic eruptions at injection site |
History of keloid formation, skin hyperpigmentation, or hypertrophic scarring
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