The Academy for the

Advancement of Aesthetics

Module: Botulinum Toxin Type A

Course C: Avoiding and Managing Adverse Events

Associated with Botulinum Toxins
BoNTs: Contraindications and Interaction
with Medications
► When using BoNTs, you need to be aware of any contraindications specified by the
manufacturer.
► Generally, the contraindications will be similar for different types of BoNT
► However, you should refer to the prescribing information for product-specific details.
► Common contraindications associated with BoNT/As
► Hypersensitivity: BoNT/A is contraindicated in patients with known hypersensitivity to any BoNT
preparation or to any of the components in the formulation1-3
► Infection at the injection site: BoNT/A is contraindicated in the presence of infection at the proposed
injection site(s)1-3
► Generalized disorders of muscle activity: BoNT/A is contraindicated in patients with disorders that affect
muscle activity; these include myasthenia gravis and Lambert-Eaton syndrome1-3
► Pregnancy or breastfeeding: Due to a lack of adequate data in women who are pregnant or
breastfeeding, BoNT/A injections are not recommended1-3

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. BOTOX Cosmetic [highlights of prescribing information].
Irvine, CA: Allergan; 2016. 3. DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP. 2016.
BoNTs: Contraindications and Interaction
with Medications (continued)
► It is also important to understand how BoNTs can interact with other
medications.
► When treating with BoNTs, concomitant use of certain drugs should be observed
closely, as they may potentiate the effect of the toxin.1-3 These drugs include: 1-3
► Aminoglycoside antibiotics
► Muscle relaxants
► Spectinomycin
► Other agents that interfere with neuromuscular transmission (eg, tubocurarine-like agents)

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. BOTOX Cosmetic [highlights of prescribing information].
Irvine, CA: Allergan; 2016. 3. DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP. 2016.
AEs Associated with BoNT/A Products
► AEs associated with BoNT/A injections can be systemic or localized.
► Although always possible, when BoNT/A products are used effectively, AEs are
uncommon
► Those that do occur are generally minor and temporary.
► The majority of AEs can be prevented by good injection technique.1
► AEs are usually caused by suboptimal injection technique, including:2
► Incorrect placement of injections
► Inappropriate dosing
► Localized diffusion of toxin into functionally important muscles

1. Emer J, Waldorf H. Clin Dermatol. 2011;29:678-690. 2. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment.
London, UK; Aesthetic Medicine Expert Group: 2014.
AEs Associated with BoNT/A Products (continued)
► AEs can generally be avoided by optimizing your injection technique.
► In-depth knowledge of facial anatomy is vital for the effective administration
of BoNT/A and to avoid unwanted effects.
► Although there are class effects associated with BoNT/A, the
incidence of AEs can vary between BoNT/A products due to
differences in product characteristics.
► It is important that you are familiar with the AEs associated with the
product you are using.
AEs Associated with BoNT/A Products (continued)
Please note that as these data are from independent studies, they cannot be directly compared.
IncobotulinumtoxinA1 AbobotulinumtoxinA2 OnabotulinumtoxinA3
Very common (≥1/10)
Nervous system disorders — Headache —
General — Injection site reactions —
Common (≥1/100, ≤1/10)
Nervous system disorders Headache Facial paresis (mainly brow paresis) Headache, paresthesia
Musculoskeletal and Muscle disorders (including —
connective tissue elevation of the eyebrow),
disorders sensation of heaviness
Eye disorders Eyelid edema,a dry eyeb Aesthenopia, ptosis, eyelid edema, Eyelid ptosis, eyelid edemab
lacrimation increase, dry eye, muscle
twitching
Gastrointestinal disorders — — Nausea
Skin and subcutaneous — — Erythema, skin tightness
tissue disorders

aUncommon with glabellar frown line injections, common with periorbital line injections
bObserved only with periorbital line injections
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 6
AEs Associated with BoNT/A Products (continued)
Please note that as these data are from independent studies, they cannot be directly compared.
IncobotulinumtoxinA1 AbobotulinumtoxinA2 OnabotulinumtoxinA3
Common (≥1/100, <1/10) continued
General Injection site hematomab — Face pain, injection site edema,
ecchymosis, injection site pain,
injection site reaction, injection site
hematoma,b injection site
hemorrhageb
Uncommon (≥1/1000, <1/100)
Infections and infestations Bronchitis, nasopharyngitis, — Infection
influenza, infection
Psychiatric disorders Depression, insomnia — Anxiety
Nervous system disorders Brow ptosis, vasovagal Dizziness Dizziness
syncope, paresthesia, dizziness
Eye disorders Eyelid edema,a eyelid ptosis, Visual disturbances, blurred vision, Blepharitis, eye pain, visual
blurred vision, blepharitis, eye diplopia, eye movement disorder disturbance
pain

aUncommon with glabellar frown line injections, common with periorbital line injections
bObserved only with periorbital line injections
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 7
AEs Associated with BoNT/A Products (continued)
Please note that as these data are from independent studies, they cannot be directly compared.
IncobotulinumtoxinA1 AbobotulinumtoxinA2 OnabotulinumtoxinA3
Uncommon (≥1/1000, <1/100) continued
Ear disorders Tinnitus — —
Gastrointestinal disorders Nausea, dry mouth — Dry mouth
Skin and subcutaneous Pruritus, skin nodule, Pruritus, rash Edema, photosensitivity reaction,
tissue disorders photosensitivity, dry skin pruritus, dry skin
Musculoskeletal and Muscle twitching, muscle — Muscle twitching
connective tissue disorders cramps
General Injection site reactions, Hypersensitivity Influenza-like illness, asthenia, fever,
injection site tenderness, injection site parethesia,b injection site
influenza-like illness, fatigue painb
Rare (≥1/10,000, <1/1000)
Skin and subcutaneous — Urticaria —
tissue disorders

aUncommon with glabellar frown line injections, common with periorbital line injections
bObserved only with periorbital line injections
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 8
AEs Associated with BoNT/A Products (continued)
► Headache is a commonly reported AE following BoNT/A treatment of glabellar
frown lines.
► It is usually transient and can be treated with analgesics.
► Occasionally, headache has been reported to last for a few weeks.
► Dry eye is a common eye disorder reported after treatment of periorbital lines.1
► Patients may have eye irritation and the sensation of a foreign body being present in the eye.
► If BoNT/A treatment is continued, symptoms can progress to red eye, lid edema, epiphora,
and scleral show.2
► Mild early symptoms can be relieved with eye drops.

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. Ozgur OK et al. Hawaii J Med Public Health. 2012;71:120-123.
BoNT-associated AEs and Their Management:
Injection Site Reactions
► As with any injection, BoNT injections carry the risk of an injection-
site reaction.
► Although these reactions are common1,2 or very common3 they can
be minimized in a number of ways.

► Minimising bruising:4
► Patients should be advised to avoid aspirin, nonsteroidal anti-inflammatory
drugs (NSAIDs), and blood-thinning supplements (such as fish oils, vitamin E,
gingko, and ginseng) for 2 weeks before treatment
► Pre-cool the injection area for 3–5 minutes before treatment

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA:
Allergan; 2016. 3. DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP. 2016. 4. Inglefield C et al. Expert Consensus on
Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
BoNT-associated AEs and Their Management:
Injection Site Reactions (continued)
► If an injection-site reaction does occur, manage in the following ways:
► Cool the area for 5–10 minutes and advise the patient to continue cooling (in
an aseptic fashion) on and off for at least an hour.
► Avoid pressure to the area and if swelling occurs overnight, cool again.
► Apply creams containing vitamin K, witch hazel, or arnica to help bruises fade
more quickly.
BoNT-associated AEs and Their Management:
Hypersensitivity Reactions
► Hypersensitivity reactions have been reported
with BoNT products.
► However, the incidence of these events is
uncommon (<1 in 100 patients).1
► Nonetheless, hypersensitivity reactions may
lead to anaphylaxis, serum sickness, urticaria, soft tissue edema, or
dyspnea.
► If a reaction occurs it is important to initiate appropriate
management.

1. Azzalure. Summary of Product Characteristics. Galderma, 2015.

BoNT-associated AEs and Their Management:
Hypersensitivity Reactions (continued)
► Symptoms of hypersensitivity reactions may include urticarial rash, shortness of
breath, drop in blood pressure, or even anaphylactic shock.1
► For severe hypersensitivity reactions, consider intravenous antihistamines or steroids2
► In cases involving anaphylactic reaction, adrenaline should be used1
► Immediate hypersensitivity is an allergic reaction provoked by re-exposure to
BoNT/A or any of its excipients.
► Clinical manifestations of an immediate reaction typically appear less than 1 hour after
exposure.
► Symptoms may include urticaria, angioedema, and anaphylaxis, or anaphylactic shock.
► These reactions are mostly mediated through immunoglobulin type E.2

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
2. Limsuwan T, Demoly P. Med Clin N Am. 2010;94:691-710.
BoNT-associated AEs and Their Management:
Hypersensitivity Reactions (continued)
► Non-immediate hypersensitivity reactions occur after more than 1
hour and up to several days after exposure, with variable cutaneous
symptoms, such as late-occurring urticaria, maculopapular eruptions,
vasculitis, or epidermal necrolysis.
► The reactions are specifically T-cell–mediated.1

1. Limsuwan T, Demoly P. Med Clin N Am. 2010;94:691-710.

BoNT-associated AEs and Their Management:
Anaphylactic Management and Basic Life Support
► While conducting treatment with BoNTs it is important that you
recognize the signs of a serious complication and know how to
manage it quickly and effectively.
► One of the most serious AEs that can occur, although rarely, is an
anaphylactic reaction.
Recognize the Signs Effective Management
Anaphylaxis Sudden onset of flushing, • Lie patient flat, raise their legs
urticaria, angioedema, • Check airway, breathing and blood pressure
breathing or circulatory problems • Administer intravenous adrenaline
• Administer an intravenous antihistamine
• Administer an intravenous steroid
BoNT-associated AEs and Their Management:
Anaphylactic Management and Basic Life Support (continued)
► To respond to an anaphylactic reaction quickly, you will need an emergency bag
that is readily available when needed.1
Given what you know about anaphylactic reactions, what are the 3 essential items
your emergency bag should contain?
A. Intravenous antihistamines, intravenous steroids, morphine
B. Intravenous antihistamines, morphine, adrenaline
C. Intravenous antihistamines, intravenous steroids, adrenaline
D. Intravenous steroids, intravenous albumin, adrenalin
E. Intravenous steroids, morphine, adrenaline

► Submit answer

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
BoNT-associated AEs and Their Management:
Infection and Antibiotic Use
► As with any type of injection, BoNT injections carry
the risk of a postprocedural infection.
► Data suggest that the incidence of infection following
BoNT/A injections is uncommon (<1 in 100 patients).1,2
► Remember that aseptic techniques are vital in avoiding infection.
► Remember, BoNT/A is contraindicated in patients with an infection at the injection site to
prevent spread of a pre-existing infection.
► The key signs of a skin infection include redness, heat, pain, and swelling
► You and your patients should be aware of these symptoms, as infections can occur quickly or weeks after a procedure.
► When an infection occurs, it should be managed using antibiotics.
► Skin infections often require a higher dose and longer course than other infections.
► Generally, the infections resulting from BoNT are acute and occur within 2 weeks of treatment.

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. BOTOX Cosmetic [highlights of prescribing information].
Irvine, CA: Allergan; 2016.
BoNT-associated AEs and Their Management:
Eyelid/Brow Ptosis
► ‘Ptosis’
is derived from a Greek word meaning ‘to fall.’
► In a medical context, eyelid ptosis refers to when the eyelid or
eyebrow is abnormally low-lying or has fallen to a lower position than
normal.
► Brow ptosis is the medical term for a drooping brow.
► Brow ptosis can be caused by injecting BoNT/A into the incorrect muscle in the
upper face when treating glabellar frown lines or forehead lines.
BoNT-associated AEs and Their Management:
Eyelid/Brow Ptosis (continued)
AE Incidence Cause How to Avoid Management
Brow Uncommon Misplaced injection into Asking the patient to The brow depressors
Ptosis1 (<1 in 100 patients)2 the frontalis muscle when contract the muscle helps (corrugator supercilii,
treating glabellar frown to identify the precise depressor supercilii, and
lines, or excessive position of each corrugator superolateral fibers of the
weakening of the frontalis and, therefore, assists with orbicularis oculi muscle) can
when treating forehead accurately placing the be weakened by further toxin
lines injection injections
Eyelid Common Injection into the Inject upwards into the If eyelid ptosis occurs, it can
Ptosis1 (≥1 in 100 patients)3,4 corrugator can result in muscle at least 1 cm above be treated with iopidine
toxin spread and the bony margin of the (apraclonidine 0.5 %) eye
weakening of the levator orbit, and away from the drops. Apraclonidine is an
palpebrae superioris, which supraorbital notch α2-adrenergic agonist, which
is the muscle that lifts the causes the muscles to contract
upper eyelid quickly; this can raise the
upper eyelid by 1 to 3 mm1,5

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
2. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA:
Allergan; 2016. 4. DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP. 2016. 5. Scheinfeld N. Dermatol Online J. 2005;11:9.
BoNT-associated AEs and Their Management:
Distant Spread of Toxin and Boxed Warning
► Any product containing BoNT carries the potential risk of the toxin
spreading from the site of injection to other parts of the body.
► This spread can lead to the development of a serious condition:
botulism.1-3
► Although the distant spread of toxin is rare, it is important that you
and your patients can recognize the signs of botulism, as the
condition can occur hours to weeks after treatment and can be life-
threatening.1-3

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016.
BoNT-associated AEs and Their Management:
Distant Spread of Toxin and Boxed Warning (continued)
► Symptoms of botulism:1-3
Double or blurred vision and/or drooping eyelids
Difficulty in speaking clearly and/or swallowing
Hoarseness or change/loss of voice
Difficulty breathing
Loss of strength and muscle weakness all over the body

Loss of bladder control

► If you suspect one of your patients has developed botulism, refer them for
emergency care immediately.
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information].
Fort Worth, TX: Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016.
BoNT-associated AEs and Their Management:
Distant Spread of Toxin and Boxed Warning (continued)
► Due to the risk of toxin spread, there is a requirement that all products containing BoNT
carry a boxed warning.
► An example boxed warning is shown below:
WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of all botulinum toxin products may spread from the area of
injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia,
generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary
incontinence and breathing difficulties. These symptoms have been reported hours to weeks after
injection. Swallowing and breathing difficulties can be life-threatening and there have been reports of
death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also
occur in adults treated for spasticity and other conditions, particularly in those patients who have
underlying conditions that would predispose them to these symptoms. In unapproved uses, including
spasticity in children and adults, and in approved indications, cases of spread of effect have been
reported at doses comparable to those used to treat cervical dystonia and at lower doses.
Common Mistakes and How to Avoid Them
► The most common mistakes that occur with BoNT/A treatment relate
to the injection strategy.
► Even small errors in dosing or placement of injections can lead to
poor aesthetic outcomes.1,2

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 2. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment.
London, UK. Aesthetic Medicine Expert Group: 2014.
 Mephisto eyebrow

Common Mistakes and

How to Avoid Them (continued)
Unwanted Effect Cause How to Avoid/Manage
‘Mephisto’ or Too much BoNT/A injected into the glabella and medial Good knowledge of the variable anatomy of the
‘Spock-like’ frontalis, without treatment of the lateral frontalis. This effect muscles in the upper face. This effect can be treated
eyebrow can also be caused by too much toxin injected into the lateral with the selective injection of a small amount of
orbicularis oculi when trying to lift the tail of the eyebrow1 neurotoxin into the frontalis1

‘Frozen look’ – no Too much BoNT/A injected into the corrugator supercilii and Careful patient assessment and injection strategy are
natural movement in procerus muscles, although for some individuals (dependent essential for avoiding the ‘frozen look’
the glabellar region on sex and ethnicity) the ‘frozen look’ might be a desired
outcome
Drooping eyelids or BoNT/A injection into the frontalis muscle and/or orbicularis A careful injection strategy is essential for avoiding lid
eyebrows (true oculi ptosis. Injection into the glabellar region should be
ptosis is a rare kept at least 1 cm above the bony orbital rim and
event) should not cross the midpupillary line.
Iopidine 5 mg/mL eye drops may improve ptosis1
Drooping of the BoNT/A penetration into the zygomaticus major muscle Inject very small doses intradermally ≈1–1.5 cm from
corner of the mouth the orbital rim to avoid the zygomaticus major
Asymmetry Inaccurate BoNT/A placement or inadequate initial patient This effect can be treated by injecting neurotoxin into
assessment the contralateral depressor labii inferioris

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK. Aesthetic Medicine Expert Group: 2014.
Common Mistakes and How to Avoid Them
(continued)

► You can minimize the development of these unwanted effects

by following these steps:
► Make a treatment plan and stick to it
► Know your anatomy and the danger zones to avoid when injecting
► Read the treatment guidelines, know the treatment guidelines, follow the
treatment guidelines
► Ensure your injection experience is sufficient for the procedure
Common Mistakes and How to Avoid Them:
BoNT/A Handling/Preparation
► Other common mistakes that occur with BoNT/A treatment are due to errors in product
handling or preparation.

Storage
► Two of the key practical differences between the commercial BoNT/A products are their
storage requirements and stability after opening.
► It is important that the products are stored at the correct temperature.
Prior to reconstitution:
► IncobotulinumtoxinA can be stored at room temperature
► AbobotulinumtoxinA and onabotulinumtoxinA must be stored under refrigeration
► This means that abobotulinumtoxinA and onabotulinumtoxinA need to be shipped using
a cold supply chain.
► Once reconstituted, all BoNT products should be stored in the refrigerator and must be
used within 4–24 hours after opening depending on product.
Common Mistakes and How to Avoid Them:
BoNT/A Handling/Preparation (continued)
IncobotulinumtoxinA AbobotulinumtoxinA OnabotulinumtoxinA
Storage before reconstitution ≤25°C (room temperature) 2‒8°C (refrigeration) 2‒8°C (refrigeration)
Use after opening Within 24 hours, Dysport within 8 hours Within 24 hours,
store at 2–8°C Azzalure within 4 hours, store at 2–8°C store at 2–8°C
Durability (months) 36 24 36

Preparing BoNT/A products for use

► Before use, BoNT/A products require reconstitution in sterile, unpreserved,
physiologic saline (0.9% NaCl).
► For specific guidance on reconstitution of BoNT/A, check the product information
► Swab the top of the vial with an antiseptic wipe before you inject through the rubber seal
► Reconstitute the vial contents over plastic-lined paper towels to catch any spillage
► Special care must be taken when disposing of any spills or unused product: check the
product information
Common Mistakes and How to Avoid Them:
BoNT/A Handling/Preparation (continued)
► It is important to reconstitute BoNT/A correctly to ensure all the product goes into
solution.
► Each BoNT/A product needs to be reconstituted differently, as outlined in the manufacturer’s guidelines.
► For all BoNT/A products, reconstitution should be performed in accordance with good practice rules,
particularly with respect to asepsis.1-3
► Reconstitution is covered in detail in Course B: A Practical Guide to Botulinum Toxin Type A ‒ The Scientific
Art of Softening Lines and Wrinkles.
► Dilution of BoNT/A before its administration plays an important role in determining its
potency and efficacy.
► Approved dosing and dilution volumes specific to each BoNT exist (also covered in Course B).
► It should be noted that BoNT/A products are not interchangeable.
► For best results, and to avoid any untoward incidents, it is strongly recommended that you adhere to the prescribed dosages and
check the specific product information.

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016.
Common Mistakes and How to Avoid Them:
BoNT/A Handling/Preparation (continued)
► Not adhering to the specified dosage, or administration of subsequent
treatments before the effects of the prior treatment have worn off, can lead to
overdosing.
► One manifestation of overdosing is the ‘frozen look’, where there is a lack of any natural
movement in the treated muscles.
► Underdosing can result from incorrect reconstitution (where not all the product
goes into solution), incorrect dilution, or improper storage causing it to lose its
potency and efficacy.
► To help avoid suboptimal clinical outcomes, it is important that the product is
stored, reconstituted, and mixed correctly.
Important Details in a Patient’s Medical
History
► To
avoid the AEs that can be associated with BoNT/A injections, it is
important to identify patients who may be at risk.
► BoNT/A treatment should not be considered in people who have
contraindications. In addition, you should think carefully about administering
BoNT/A injections to those with a predisposition for:
► Bruising

► Infection

► An allergic reaction
► Herpetic cold sores if treating periorally (as these can be reactivated by treatment)
Important Details in a Patient’s Medical
History (continued)
► Relevant medical history
► Given these considerations, it is important to establish the following details of
a patient’s medical history before proceeding with treatment:
► Past and current infections
► History of neuromuscular disease
► History of autoimmune disease
► History of herpes simplex virus
► Allergies
► Pregnancy or breastfeeding
► History of bleeding tendencies
► Current medication
► History of immunosuppressant therapy
► Past or current use of blood-thinning agents (eg, aspirin, NSAIDs, vitamin E, warfarin)
► Past or current periorbital edema (in the case of treating periorbital wrinkles)
Considering a Patient’s Individual Anatomy
► In addition to their pertinent medical history, a patient’s individual anatomy will
affect their response to treatment and the risk of an AE.
► For example, any pre-existing facial asymmetry and/or ptosis will need to be
considered when planning and administering treatment.
► Facial asymmetry and eyebrow position are 2 important features that should be
documented and discussed with your patient during their initial assessment.
► Another important feature that should also be considered is eyelid laxity.
► Eyelid laxity indicates the potential for your patient to develop an ectropion following
treatment,1 a condition in which the eyelid is turned outwards away from the eyeball.

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22.

Considering a Patient’s Individual Anatomy:
Important Tests
► The eyelid snap test
► This is performed by pulling the lower eyelid away and down
toward the inferior orbital rim.
► An eyelid without lower lid laxity will return to its original position
without the patient blinking.
► An eyelid with lower lid laxity will remain away from the eye for
several seconds.1

► The eyelid distraction test

► This is performed by pulling the lower eyelid away from the eyeball.
► The eyelid is considered to be lax if it moves more than 6 mm off
the eyeball.1

1. Nerad JA. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial. London; Elsevier: 2012.
Considering a Patient’s Individual Anatomy
(continued)

► Treat patients with lower eyelid laxity with caution.

► You may wish to avoid the lower injection sites that are typically used when
treating periorbital lines with BoNT/A.1

► You can learn more about pretreatment assessments in Course B:

A Practical Guide to Botulinum Toxin Type A ‒ The Scientific Art of
Softening Lines and Wrinkles.

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22.

How to Optimize Injection Techniques
to Avoid AEs
► Although there is always a chance of an AE occurring, there are many ways
in which you can optimize your injection techniques in order to avoid them.
Area Optimal Injection Technique
Glabellar • Carefully assess the patient and determine precise injection sites
Frown Lines • Dosing should be patient-specific and will depend on their individual anatomy1
• In general, to prevent brow ptosis, avoid injecting laterally past the mid-pupillary line; this should be decided based on the
individual patient, as in some cases there will be corrugator activity laterally of this line. In these patients, injections past the
mid-pupillary line will be required and should be very superficial
• Ask your patient to contract their corrugator muscles.1 This will allow you to identify the precise position of each corrugator
muscle and injecting at the correct depth will avoid recruitment of the frontalis muscle
• Avoid injecting too high, as this can block the action of the frontalis
• To avoid lid ptosis and diplopia, do not inject into the levator palpebrae superioris, into the cranial portion of the orbicularis
oculi, or too low when treating the corrugator (<1 cm from the orbital rim)
• The levator palpebrae superioris muscle can be avoided by injecting above the supraorbital ridge found at the boundary
between the forehead and upper eyelid
• Protect the supraorbital rim with the non-dominant hand
• Direct the needle away from the orbit to minimize the risk of adverse effects
How to Optimize Injection Techniques
to Avoid AEs (continued)
Area Optimal Injection Technique
Periorbital • Take great care when injecting the lowest part of the orbicularis oculi1 and do not inject near the zygomaticus major muscle,
Lines which can be avoided by remaining above the orbicularis oculi muscle and injecting very small doses intradermally, ≈1–1.5 cm
from the orbital rim1
• Use small doses initially to determine the effect
• Stop treatment if the patient experiences any sensation in the eye
• Avoid injection in patients with dry eyes, prominent eye bags, scleral show, or morning eyelid edema
• Where possible, avoid injection into veins in the lateral canthus; these veins may be revealed under appropriate lighting and
magnification
• Keep injections superficial and direct the needle away from the orbit to minimize risk of AEs
• Consider the extrusion pressure used during injection; inject slowly to reduce the risk of BoNT/A spreading. This can also help
prevent diplopia when the lateral rectus muscle is affected and eyelid ptosis when the levator palpebri muscle is reached
Forehead • Ensure the injections remain superficial to prevent injection into the supratrochlear and supraorbital blood vessels
Lines1 • In cases of compensatory frontalis hyperactivity, do not treat the frontalis; this will help avoid the risk of ptosis
• Variation in the structure, size, and strength of the frontalis muscle means injection sites and toxin volume should be
adjusted based on the individual’s characteristics
• Consider successive treatments of small doses of toxin
Lateral • Care should be taken to avoid blood vessels to reduce the risk of bruising and bleeding
Eyebrow
Elevation

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
How to Optimize Injection Techniques
to Avoid AEs (continued)
Area Optimal Injection Technique
Perioral • Consider how the juxtaposing muscles work together to move the mouth1
Lines • Avoid unbalanced dosing or asymmetrical injection, as this can lead to loss of the ability to purse the lips and an asymmetrical
smile1
• Avoid injecting around the oral commissures; BoNT/A may spread to the lateral lip elevator muscles and weaken them,
resulting in lip ptosis and drooling.1 Therefore, keep the injection needle 1 cm medial to the oral commissure
• Injecting into the midline should also be avoided to prevent effacement of the ‘Cupid’s bow’ on the upper lip2
• Do not inject into the vermilion
Marionette • Complications, such as an asymmetrical smile, as well as difficulties eating, speaking, and drinking, can arise when BoNT/A
Lines penetrates too deeply into the depressor anguli oris, or when injections are misplaced1
• To avoid such complications, injections into the depressor labii inferioris, orbicularis oris, mentalis, and platysma should be
avoided

► To learn more about these techniques, and how best to avoid AEs in different areas, refer to the
Aesthetic Medicine Expert Group publication, Expert Consensus on Complications of Botulinum
Toxin and Dermal Filler Treatment.1

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London, UK; Aesthetic Medicine Expert Group: 2014.
2. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City, CA; OMICS Group eBooks: 2014.
BoNT/A Overdose and How to Manage It
► Excessive doses of BoNT/A can produce neuromuscular weakness, which manifests
as a range of different symptoms.
► In the case of local overdose, the patient will have a ‘frozen’ appearance to their face.
► However, in the case of a systemic overdose, effects can be observed across the body.
► Thus, in the event of an overdose, the patient should be monitored for symptoms of
excessive muscle weakness or muscle paralysis, and symptomatic treatment may be
necessary.1-3
► In the most severe cases, BoNT/A overdose has caused paralysis of the respiratory
muscles; therefore, respiratory support may be required.1–3

1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016.
BoNT/A Overdose and How to Manage It (continued)
► Posttreatment monitoring should include assessment of the patient’s:
► Breathing
► Pulse
► Arm and leg movements
► However, symptoms of BoNT/A overdose may not present immediately following injection.
Therefore, patients should know who to contact if they experience any posttreatment effects.
► Staff receiving calls from patients with a problem will need to know which questions to ask
and how to triage the issue.
► Any symptoms of overdose should be treated as serious and the patient referred for emergency care.
► The emergency response team should be informed of the possible overdose, as the patient may require
treatment with an antitoxin.1-3
► Should accidental injection or oral ingestion of BoNT/A occur, the person should be medically
supervised for several weeks for signs and symptoms of excessive muscle weakness or
paralysis.1-3
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC, 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP. 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016.
Avoiding and Managing AEs Associated with
BoNTs: Summary
► You should now have an understanding of the following:
► The contraindications associated with BoNTs
► How BoNTs can interact with other medications
► The AEs that can be caused by BoNTs and how these can be effectively
managed
► How a patient’s medical history and anatomy can affect their risk of an AE
► How optimizing your injection technique can minimize the occurrence of AEs