CATEGORY 68 AUSTRALASIAN DENTIST CLINICAL Botulinum Toxin complications: Prevention, recognition, and management Dr Giulia D’Anna By Dr Giulia D’Anna Founder, Dermal Distinction Academy Complications Expert – Aesthetic Medical Emergency Team (AMET) The use of botulinum toxin has revolutionised both aesthetic and functional treatment. From softening frown lines and improving facial balance to addressing bruxism and muscular pain, its benefits are undeniable. Yet, like any medical procedure, complications can and do occur. For the ethical injector, recognising, preventing, and managing these complications is not just a professional obligation – it’s an essential part of patient care. As an Aesthetic Medical Emergency Team (AMET) complications expert, I’m often contacted by practitioners seeking guidance when things go wrong. Complications can arise even in the most experienced hands, but what separates an expert from an average injector is the ability to respond with calm, clinical precision and a clear plan. At Dermal Distinction Academy, we teach injectors that safe, successful toxin practice begins long before the first syringe is drawn. Complication prevention is a process that combines anatomy, technique, product knowledge, and preparation. 1. Prevention: The foundation of safe injecting The first step in managing complications is preventing them. A structured, safetyfocused approach – such as the 10step complication minimisation plan taught at Dermal Distinction Academy – is fundamental. This includes detailed assessment, thorough consent, anatomical precision, and adherence to aseptic technique. Patient Factors Complications are often patient-related. A full medical and procedural history is critical: X Assess for neuromuscular disorders, autoimmune diseases, medications (especially aminoglycosides or anticoagulants), and prior surgeries. X Always ask about recent dental, vaccination, or inflammatory conditions, as immune activation can alter response or healing. X Screen for Body Dysmorphic Disorder (BDD) – a key predictor of dissatisfaction, regardless of treatment outcome. Planning and Technique A well-structured treatment plan is essential. Standardise your photography and consent process, map muscle activity, and identify “no-fly zones.” X Aseptic preparation must never be rushed: alcohol or chlorhexidine prep, gloved hands, and sterile work flow. X Depth and placement matter. Injecting too superficially risks sweat gland involvement or skin dimpling, while injections too deep can cause ptosis or muscle spread. X Always respect muscular action halos – the invisible borders that define where one muscle’s action ends and another begins. Crossing them often leads to asymmetry or unintended paralysis. 2. Common Botulinum Toxin complications While most toxin treatments are uneventful, a handful of predictable complications occur more frequently. Understanding their cause, prevention, and management allows for faster recognition and patient reassurance. A. Brow and eyelid ptosis Cause: X Injecting too low in the frontalis or too close to the orbital rim causes diffusion into the levator palpebrae superioris. X Over-treatment of the brow depressors without adequate frontalis compensation leads to a “heavy” or dropped brow. Prevention: X Maintain at least 1 cm above the lateral brow and 1 cm from the orbital rim. X Use a finger pinch to stabilise the area and contain the toxin within intended tissue. X Avoid “chasing” lines – inject based on function, not surface wrinkles. Management: X Reassure the patient – this will resolve as the toxin wears off (typically within 6–8 weeks). X In eyelid ptosis, where appropriate, prescribe Apraclonidine 0.5% eye drops, 1–2 drops up to three times daily, to stimulate X Müller’s muscle and elevate the lid slightly. Avoid attempting to “reverse” the toxin; patience and reassurance are key. B. Mephisto or “Spock” Brows Cause: Under-treatment of the lateral frontalis, or injecting the central frontalis too low, leaves the lateral fibres unopposed – creating an arched or exaggerated brow. Prevention: X Observe frontalis movement during assessment and avoid an “M-shaped” injection pattern. X Test lateral elevation with your finger before injecting. Management: X After two weeks, if the appearance persists, inject 1–2 units of toxin into the peak area to rebalance brow symmetry. C. “Crazy Brows” and Glabellar Overactivity Cause: Injecting too high in the glabella can leave untreated depressors active, creating unwanted creasing or angry expressions. Prevention: X Treat depressors completely while maintaining an appropriate frontalis offset. X Always feel for muscle contraction, not just visual lines. Management: X Wait for partial resolution, then retreat the depressor muscles to restore balance. D. Lower-Face Complications: DAO, DLI and Mentalis Ptosis Cause: X Injecting too medially into the depressor anguli oris (DAO) or too laterally into the mentalis can cause asymmetry, lip drop, or smile distortion. Prevention: X Ask the patient to perform a “sad face” to identify DAO,and to show lower teeth to reveal DLI.
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