Botulinum therapy: adverse events

Yana Yutskovskaya, MD, professor, doctor of the highest category, owner of the Yu System group of companies, founder of the “Professor Yutskovskaya School” project, president of the Euro-Asian Association of Aesthetic Medicine Specialists, member of the board of directors of NADC, freelance expert of Roszdravnadzor of the Ministry of Health of the Russian Federation, editor-in-chief of the magazine “Cosmetics and Medicine”, member of the editorial board of the magazine MJDR (Russia)

Alena Kislitsyna, resident physician, Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology, Department of Health (DZM) (Russia)

Galina Naumchik, Ph.D., dermatovenerologist, cosmetologist of the Professor Yutskovskaya Clinic LLC, director of the Professor Yutskovskaya School, chairman of the expert council of the Hyalual Institute in Russia, trainer of the Ipsen Pharma company, authorized trainer of the company Rhana, trainer at LaserMedSystem (Russia)

Anastasia Saibel, Ph.D., dermatovenerologist, cosmetologist, Professor Yutskovskaya Clinic LLC, expert at Merz Aesthetics (Russia)

And it seems impossible to make a mistake. But, as you know, in clinical practice, all cases are unique and the result can be unpredictable. In this article we will look at three clinical cases, share our experience, results and ways to solve situations related to the occurrence of undesirable moments after botulinum therapy

The most common complaint of a patient at a cosmetology clinic is the presence of facial wrinkles. Fortunately, professionals in the field of aesthetic medicine have known the key to solving this problem for more than 20 years.

Botulinum therapy occupies one of the first places in the practice of a cosmetologist. According to US statistics, 6.8 million botulinum toxin type A (BTA) injections were performed in 2015, which was a record number for aesthetic procedures. The modern patient's request for botulinum therapy is live facial expressions without excessive activity, the so-called living face, or all moving face. The competent work of a specialist consists of an individual approach to the patient, taking into account the anatomical features of the face, age and morphotype of aging.

Currently, there are several different registered botulinum toxin preparations in the world, each of which proves its effectiveness in use. Every year, a huge number of studies are conducted showing the high safety profile of botulinum therapy for the aesthetic correction of facial wrinkles, age-related changes in the face and neck.

From practice, we see that over time, botulinum therapy becomes “younger”. Patients aged 18–25 years also come for their first correction with botulinum toxin type A, which accounts for 20% of the total demand for this procedure. In this regard, the relevance of the use of botulinum toxins type A in cosmetology is only growing every year.

Using a personalized approach to the patient, the cosmetologist ensures the effectiveness of the procedures performed and minimizes the number of unforeseen consequences. We, in turn, want to share our experience of botulinum therapy and discuss the results obtained.

Analysis of clinical cases

At the clinic of Professor Yutskovskaya, in December 2017, botulinum therapy was performed on three patients who subsequently applied for adverse events after correction of facial wrinkles. Let's consider each case separately.

Clinical case No. 1

Patient, 29 years old. She complained of facial wrinkles in the forehead, between the eyebrows, the appearance of “crow’s feet” around the eyes, as well as uneven chin relief due to hyperactivity of the mental muscle fibers. The patient regularly undergoes botulinum therapy for 5 years, once every 6 months. The patient was satisfied with the results of previous procedures for correcting facial wrinkles. After the injections, swelling of the periorbital area is always observed in the patient and disappears within 14 days.

For botulinum therapy, a preparation of incobotulinum toxin type A was used. For intramuscular injections, 100 units of the drug are reconstituted with 1 ml of 0.9% physiological sodium chloride solution. Thus, we get 1 unit in 0.01 ml. Before injection of BTA, a preliminary assessment of facial activity was carried out.

We see the need for botulinum therapy in the area of all facial patterns. We also pay attention to the mobility of the tip of the nose when smiling and active articulation.

Botulinum therapy was performed using the all moving face technique. Thus, in the region m . frontalis , 11 units of incobotulinumtoxin type A were distributed for uniform diffusion of the drug (1 unit per point). To correct the lateral and medial portions of m fibers . orbicularis oculi , a total of 12 units were administered (1 unit per point, superficial injections). The total dose for correction of the glabellar zone - area m. corrugator supercilli and m. p rocerus – amounted to 25 units. 2 units were also introduced on each side of the transverse portion m . nasalis . Next, to correct the lower third of the face, 1 unit was injected into the muscle that depresses the nasal septum ( m. depressor septi nasi ), 2 units on each side into the area of the muscles that depress the angle of the mouth ( m. depressor anguli oris , DAO), and a total of 8 ED into the mentalis muscle ( m. mentalis ). The patient has activity of the m cords . platysma , therefore, a total of 22 IU of incobotulinumtoxin type A was injected. 2 IU were injected into the upper points located on the line of the edge of the lower jaw, and into subsequent points at a distance of 2 cm from each other, and 1 IU at the lowest injection points.

On the 14th day, the patient noted swelling of the periorbital area, “heaviness” of the eyebrows, especially the medial part, and a frowning facial expression, as well as slight asymmetry of the eyebrows.

Upon examination, we detect tension under the medial part of the eyebrows due to the preservation of the tone of the muscle that lowers the eyebrow ( m. depressor superciliae ). In addition, the lateral part of the right eyebrow is raised. Based on the existing clinical picture, we carried out the second stage of botulinum therapy in the area of the lower portion of the frontal abdomen above the right eyebrow and in the area of m. depressor superciliae (total 5 units of incobotulinumtoxinA).

On the 28th day, we observe a state of absolute symmetry at rest and with active facial expressions, and no feeling of heaviness in the patient’s eyebrows.

Clinical case No. 2

Patient, 35 years old. She complained of facial wrinkles in the forehead, between the eyebrows, and the periorbital area. Previously, botulinum therapy was carried out at the “Clinic of Professor Yutskovskaya” only once, 11 months before the present visit. The patient was satisfied with the result of the first correction of facial wrinkles.

For botulinum therapy, the drug incobotulinumtoxin type A was used. For intramuscular injections, 100 units of the drug are reconstituted with 1 ml of 0.9% physiological sodium chloride solution. Thus, we get 1 unit in 0.01 ml. Before injection of BTA, a preliminary assessment of facial activity was carried out.

When assessing the activity of the patient’s facial expressions, we see asymmetry when blinking on the left side, that is, less pronounced activity of the orbicularis oculi muscle on the left, as well as asymmetry in the lower third of the face when the superficial muscle of the neck is tense.

Botulinum therapy was performed using the all moving face technique. Taking into account the facial pattern of the forehead area, a total of 10 units of incobotulinum toxin type A were injected in a checkerboard pattern (1 unit per point). To correct the lateral portion of fibers m . orbicularis oculi , a total of 10 units were administered (1 unit per point, superficial injections). To correct the glabellar zone - area m. corrugator supercilli and m. p rocerus – the total dose was 21 units. 1 unit was also introduced on each side of the transverse portion m . nasalis . In the lower third of the face, injections were made into the muscles that lower the angle of the mouth (2 units each) and 1 unit in the m. mentalis . Total dose for correction m . platysma amounted to 22 IU of incobotulinumtoxin type A. 2 IU were injected into the upper points located on the line of the edge of the lower jaw, and into subsequent points at a distance of 2 cm from each other, and 1 IU at the lowest injection points.

On the 14th day after botulinum therapy, the patient’s main complaint was muscle tension in the lower third of the face on the right when lowering the corners of the mouth. The patient also noted that the left upper eyelid “lags” when blinking (photo 5). It should be noted that a small myasthenic-like syndrome of the left upper eyelid was present initially.

At rest, visual symmetry is observed in the periorbital region on both sides. When making facial expressions, there is a “lag” in the activity of the left upper eyelid when blinking.

In the area of the lower third of the face we see an uneven distribution of muscle activity in the projection of the corner of the mouth on the right. This is due to the preservation of the activity of DAO and medial platysma fibers, which was identified before correction.

The patient underwent the second stage of botulinum therapy due to the initial dynamic asymmetry with incobotulinum toxin (2 units) in the DAO area on the right.

On the 28th day we see a state of absolute symmetry at rest and with active facial expressions; myasthenic-like syndrome of the left upper eyelid is absent.

Clinical case No. 3

Patient, 45 years old. I came for a scheduled appointment for botulinum therapy. It should be noted that the patient has been observed in the clinic for more than five years. The patient was satisfied with the results of previously performed procedures for correcting facial wrinkles.

For botulinum therapy, the drug abobotulinumtoxin type A was used. For intramuscular injections, 500 units of the drug are reconstituted with 2.5 ml of 0.9% physiological sodium chloride solution. Thus, we get 2 units in 0.01 ml. Before injection of BTA, a preliminary assessment of facial activity was carried out.

We see the initial dynamic asymmetry in the area of the frontal belly of the occipitofrontalis muscle ( venter frontalis musculi occipitofrontalis ) and a more pronounced DAO tone on the right.

Botulinum therapy was performed using the all moving face technique. 30 units of abobotulinumtoxin type A were distributed in the forehead area for uniform diffusion of the drug (2 units per point). To correct the lateral and medial portions of m fibers . orbicularis oculi , a total of 28 units were injected (2 units per point of the lateral portion, 1 unit per point of the lower portion of the orbicularis oculi muscle, superficial injections). Taking into account the asymmetry of the eyebrow position, an injection was performed at one point under the left lateral segment of the eyebrow (2 units) and at two points under the right lateral segment of the eyebrow (2 units each). The total dose for correction of the glabellar zone - area m. corrugator supercilli and m. p rocerus – amounted to 40 units. 2 units were also introduced on each side of the transverse portion m . nasalis . To correct the lower third of the face, 2 units were injected into the muscles that lift the upper lip and alaeque nasi ( m. levator labii superioris alaeque nasi ), 2 units on each side into the area of the muscles that depress the angle of the mouth (DAO), and a total of 4 units into the mentalis muscle ( m. mentalis ). In active cords m . platysma, only 16 units of abobotulinumtoxin type A were injected (4 units per point).

At the control after 14 days, the first emphasis is on eyebrow asymmetry. Upon examination, we see that the lateral part of the right eyebrow is raised, and with tension in the frontal abdomen, this asymmetry intensifies, which indicates uneven relaxation of the muscle.

Next there was a complaint of discomfort during active articulation. When examined at maximum voltage, we see preservation of DAO tone on the right.

The second stage of botulinum therapy was carried out, injections of abobotulinumtoxin in the DAO area on the right and in the area of the lower portion of the frontal abdomen above the right eyebrow (2 units per point.

When examined on the 28th day, we see a state of absolute symmetry at rest and with active facial expressions. The patient notes the absence of discomfort with active articulation.

Conclusion

In this article, we want to emphasize that with a correct assessment of all facial patterns, it is possible to predict the results of botulinum therapy and clearly explain to the patient why an additional stage of correction with botulinum toxin type A is necessary. Such situations can hardly be called undesirable events with the professional approach of a cosmetologist to procedure. It would be more correct to call this a personalized approach to the patient, taking into account all his individual characteristics. It is important to emphasize that the doctor and patient must be in touch after the injections in order to monitor changes and results from the procedures. This will minimize unwanted effects and, if necessary, carry out additional correction steps in a timely manner to achieve the desired effect.

First published: Les Nouvelles Esthetiques 2017/№2