eMedicine Specialties > Dermatology > Surgical

Botulinum Toxin: Treatment

Author: Zoltan Trizna, MD, PhD, Private Practice
Contributor Information and Disclosures

Updated: Feb 20, 2009

Treatment

Surgical Therapy

The selected areas are treated by injecting either 2-4 units of BOTOX® or clinically equivalent amounts of Myobloc or Dysport into the thickest part of the muscle.

The injection can be a single-point injection or a skewered injection. With the latter method, which is used primarily in the platysma, the preferred injection site is identified with EMG. The needle is then inserted parallel to the plane of the muscle, and the injection is performed while the needle is carefully withdrawn.

Preoperative Details

Preoperative details include the following: identifying contraindications, if any; discussing the realistic expectations with the patient; identifying the areas to be treated; locating the targeted muscles; and preparing a plan of injection.

For later comparison, the patient's face should be photographed before treatment in both the resting position and in an exaggerated expression (eg, frowning, smiling).

Any makeup should be carefully removed, and the planned injection sites should be cleaned with isopropyl alcohol.

Intraoperative Details

The patient should lie on his or her back, comfortably propped up.

Postoperative Details

To prevent the unwanted diffusion of botulinum toxin into the adjacent muscles, do not massage the injection site, and advise patients to avoid doing so as well. Female patients should not reapply their makeup in the office. All patients should avoid exertion on the day of treatment.

Follow-up

Follow up with the patient in 1-2 weeks, and photograph the patient's face with the same expressions as those in the preoperative pictures.

Re-treat the patient as needed after the effects diminish.

Complications

All unwanted local effects of botulinum toxin are generally transient and gradually wear off. However, some unwanted effects (eg, drooling) can seriously affect the patient's everyday activities. As with any injection, pain, mild bruising, and infection can occur. Diffusion of botulinum toxin can lead to weakness of the muscles adjacent to the injection site. Therefore, advising the patient not to massage the injected areas is important.

Ptosis can occur when injections above the brow are too lateral (past the midpupillary line) or too close to the brow. Some authors use phenylephrine apraclonidine (Iopidine) eye drops to minimize ptosis. Delayed eyelid closure, a decreased blink response, and excessive tearing can occur when injections into the orbicularis oculi muscle in the temporal region are too close to the eyelid. Asymmetry of the face can occur because of differences in injection techniques or doses between the 2 sides of the face. Drooling can occur when injections of the orbicularis oris muscle are too close to the lip.9

Systemic complications are possible. Headache has been reported and is usually transient. Hypersensitivity reactions have not been described. Antibody development is described in patients receiving high doses of botulinum toxin (eg, for the treatment of torticollis or dysphonia); as a result, their muscles become resistant to further therapy.10 One case of necrotizing fasciitis occurred after botulinum toxin was injected into a patient who was immunocompromised.11

During the treatment of hyperhidrosis, complications can result from the use of local anesthetics. Muscular paralysis and a temporary loss of manual functions are possible alarming complications.

Overdosing can theoretically occur by accidental injection or oral ingestion. The patient should be supervised medically for up to several weeks for signs or symptoms of paralysis or systemic weakness. If the overdose or inappropriate injection is immediately known, an antitoxin is available. However, this will not reverse the unwanted effects that were present at the time of antitoxin administration.

The use of unlicensed botulinum toxin product was documented in a series of 4 iatrogenic botulism cases in 2004. Laboratory tests suggested that by receiving injections of a highly concentrated unlicensed botulinum toxin A preparation, these patients might have received doses 2857 times the estimated human lethal dose by injection.12

More on Botulinum Toxin

Overview: Botulinum Toxin
Workup: Botulinum Toxin
Treatment: Botulinum Toxin
Follow-up: Botulinum Toxin
References
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References

  1. Berman B, Seeberger L, Kumar R. Long-term safety, efficacy, dosing, and development of resistance with botulinum toxin type B in cervical dystonia. Mov Disord. Feb 2005;20(2):233-7. [Medline].

  2. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol. Jan 1992;18(1):17-21. [Medline].

  3. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg. Dec 1998;124(12):1315-20. [Medline].

  4. Matarasso A, Matarasso SL, Brandt FS, Bellman B. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg. Feb 1999;103(2):645-52; discussion 653-5. [Medline].

  5. Farrugia MK, Nicholls EA. Intradermal botulinum A toxin injection for axillary hyperhydrosis. J Pediatr Surg. Oct 2005;40(10):1668-9. [Medline].

  6. Heckmann M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. Feb 15 2001;344(7):488-93. [Medline].

  7. Naver H, Swartling C, Aquilonius SM. Palmar and axillary hyperhidrosis treated with botulinum toxin: one-year clinical follow-up. Eur J Neurol. Jan 2000;7(1):55-62. [Medline].

  8. Schulte-Mattler WJ, Wieser T, Zierz S. Treatment of tension-type headache with botulinum toxin: a pilot study. Eur J Med Res. May 26 1999;4(5):183-6. [Medline].

  9. Matarasso SL, Matarasso A. Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids. Plast Reconstr Surg. Jul 2001;108(1):208-14; discussion 215-7. [Medline].

  10. Smith ME, Ford CN. Resistance to botulinum toxin injections for spasmodic dysphonia. Arch Otolaryngol Head Neck Surg. Apr 2000;126(4):533-5. [Medline].

  11. Latimer PR, Hodgkins PR, Vakalis AN, Butler RE, Evans AR, Zaki GA. Necrotising fasciitis as a complication of botulinum toxin injection. Eye. 1998;12 ( Pt 1):51-3. [Medline].

  12. Chertow DS, Tan ET, Maslanka SE, et al. Botulism in 4 adults following cosmetic injections with an unlicensed, highly concentrated botulinum preparation. JAMA. Nov 22 2006;296(20):2476-9. [Medline].

  13. Connor KM, Cook JL, Davidson JR. Botulinum toxin treatment of social anxiety disorder with hyperhidrosis: a placebo-controlled double-blind trial. J Clin Psychiatry. Jan 2006;67(1):30-6. [Medline].

  14. Odergren T, Hjaltason H, Kaakkola S, et al. A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport and Botox in the treatment of cervical dystonia. J Neurol Neurosurg Psychiatry. Jan 1998;64(1):6-12. [Medline].

  15. Baumann L, Slezinger A, Halem M, et al. Pilot study of the safety and efficacy of Myobloc (botulinum toxin type B) for treatment of axillary hyperhidrosis. Int J Dermatol. May 2005;44(5):418-24. [Medline].

  16. Nelson L, Bachoo P, Holmes J. Botulinum toxin type B: a new therapy for axillary hyperhidrosis. Br J Plast Surg. Mar 2005;58(2):228-32. [Medline].

  17. Chapman MA, Barron R, Tanis DC, Gill CE, Charles PD. Comparison of botulinum neurotoxin preparations for the treatment of cervical dystonia. Clin Ther. Jul 2007;29(7):1325-37. [Medline].

  18. Trindade de Almeida AR, Marques E, de Almeida J, Cunha T, Boraso R. Pilot study comparing the diffusion of two formulations of botulinum toxin type A in patients with forehead hyperhidrosis. Dermatol Surg. Jan 2007;33(1 Spec No.):S37-43. [Medline].

  19. Annese V, Bassotti G, Coccia G, et al. Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia. The Gismad Achalasia Study Group. Aliment Pharmacol Ther. Oct 1999;13(10):1347-50. [Medline].

  20. Aoki KR. Pharmacology and immunology of botulinum toxin serotypes. J Neurol. Apr 2001;248 Suppl 1:3-10. [Medline].

  21. Armstrong MW, Mountain RE, Murray JA. Treatment of facial synkinesis and facial asymmetry with botulinum toxin type A following facial nerve palsy. Clin Otolaryngol Allied Sci. Feb 1996;21(1):15-20. [Medline].

  22. Bigalke H, Wohlfarth K, Irmer A, Dengler R. Botulinum A toxin: Dysport improvement of biological availability. Exp Neurol. Mar 2001;168(1):162-70. [Medline].

  23. Braune C, Erbguth F, Birklein F. Dose thresholds and duration of the local anhidrotic effect of botulinum toxin injections: measured by sudometry. Br J Dermatol. Jan 2001;144(1):111-7. [Medline].

  24. Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl. 1997;6:S146-68. [Medline].

  25. Huang W, Foster JA, Rogachefsky AS. Pharmacology of botulinum toxin. J Am Acad Dermatol. Aug 2000;43(2 Pt 1):249-59. [Medline].

  26. Lowe NJ. Botulinum toxin type A for facial rejuvenation. United States and United Kingdom perspectives. Dermatol Surg. Nov 1998;24(11):1216-8. [Medline].

  27. Matarasso SL. Complications of botulinum A exotoxin for hyperfunctional lines. Dermatol Surg. Nov 1998;24(11):1249-54. [Medline].

  28. Naumann M. Evidence-based medicine: botulinum toxin in focal hyperhidrosis. J Neurol. Apr 2001;248 Suppl 1:31-3. [Medline].

  29. Naumann M, Jankovic J. Safety of botulinum toxin type A: a systematic review and meta-analysis. Curr Med Res Opin. Jul 2004;20(7):981-90. [Medline].

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Further Reading

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Keywords

botulinum toxin, botulinum toxin type A, botulinum toxin type B, BOTOX®, BOTOX, Myobloc, Elan, Neurobloc, Dysport, Clostridium botulinum, C botulinum, botulism, wrinkles, crow's feet, frown lines, bunny lines

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Contributor Information and Disclosures

Author

Zoltan Trizna, MD, PhD, Private Practice
Zoltan Trizna, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Désirée Ratner, MD, Director of Dermatologic Surgery, Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center, New York Presbyterian Hospital
Désirée Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Mary Farley, MD, Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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