Botulinum Toxin: Complications and Their Management

Reference work entry
Part of the Clinical Approaches and Procedures in Cosmetic Dermatology book series (CAPCD, volume 4)


In 2014, the International Society of Aesthetic Plastic Surgery published the numbers of non-surgical cosmetic procedures performed around the world, showing that the most popular procedure was botulinum toxin A (BTXA) injections. Although the most popular treatment, complications and adverse events relating to BTXA are rare as knowledge improves every day due to various anatomic studies, clinical studies, and the improvement of doctors’ skills. Due to the mechanism of action of BTXA, its adverse events tend to be transitory and short in duration, but have a negative impact on the patient’s quality of life that needs to be minimized or avoided. Knowledge of facial anatomy, injection techniques, complications, and adverse events is paramount. In this chapter we discuss the possible complications and adverse events of BTXA, how to avoid them, and how to minimize them when they do occur.


Botulinum toxin Complications Adverse events Ptosis of the lids Asymmetry Hypersensitivity Onabotulinum toxin Abobotulinum toxin Incobotulinum toxin Pain 


  1. Cavallini M, et al. Safety of botulinum toxin A in aesthetic treatments: asystematic review of clinical studies. Dermatol Surg. 2014;40(5):525–36.CrossRefGoogle Scholar
  2. Coté TR, Mohan AK, Polder JA, Walton MK, et al. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407–15.CrossRefGoogle Scholar
  3. Dayan SH. Complications from toxins and fillers in the dermatology clinic: recognition, prevention and treatment. Facial Plast Surg Clin North Am. 2013;21(4):663–73.CrossRefGoogle Scholar
  4. Ferreira MC, Sales AG, Gimenez R, Soares MF. Complications with the use of botulinum toxin type A in facial rejuvenation: report of 8 cases. Aesthet Plast Surg. 2004;28(6):441–4.CrossRefGoogle Scholar
  5. Gassia V. Prevention and management of locoregional complications of botulinum A toxin injections in cosmetic treatment. Ann Dermatol Venereol. 2009;136(Suppl 4):S146–51.CrossRefGoogle Scholar
  6. Hassouneh B, Newman JP. Lasers, fillers and neurotoxins: avoiding complications in the cosmetic facial practice. Facial Plast Surg Clin North Am. 2013;21(4):585–98.CrossRefGoogle Scholar
  7. Hefter H, Hartmann C, Kahlen U, Moll M, Bigalke H. Prospective analysis of neutralizing antibody titers in secondary non-responders under continuous treatment with a botulinum toxin type A preparation free of complexing proteins – a single cohort 4-year follow-up study. BMJ Open. 2012;2:e000646.CrossRefGoogle Scholar
  8. Hexsel D, De Almeida AT. Cosmetic uses of botulinum toxin. Editora AGE: Porto Alegre; 2002.Google Scholar
  9. International Society of Aesthetic Plastic Surgery. ISAPS global statistics. 2014. Accessed 15 Oct 2015.
  10. Kim JW, Baek S. Functional and histologic changes in the lacrimal gland after botulinum toxin injection. J Craniofac Surg. 2013;24(6):1960–9. Scholar
  11. Kim MM, Byrne PJ. Facial skin rejuvenation in Asian patient. Facial Plast Surg Clin North Am. 2007;15(3):381–6.CrossRefGoogle Scholar
  12. Kirkpatrick CA, Shriver EM, Clark TJ, Kardon RH. Upper eyelid response to 0.5% apraclonidine. Ophthal Plast Reconstr Surg. 2016;
  13. Klein AW. Complications and adverse reactions with use of botulinum toxin. Dis Mon. 2002;48(5):295–383.CrossRefGoogle Scholar
  14. Klein AW. Contraindications and complications with the use of botulinum toxin. Clin Dermatol. 2004;22(1):66–75.CrossRefGoogle Scholar
  15. Lolis M, et al. Patient safety in procedural dermatology. Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15–24.CrossRefGoogle Scholar
  16. Lorenc ZP, Kenkel JM, Fagien S, et al. Consensus panel’s assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics. Aesthet Surg J. 2013;33(1 Suppl):35S–40S. Scholar
  17. Lowe NJ, Ascher B, Heckmann M, et al. Double-blind, randomized, placebo-controlled, dose–response study of the safety and efficacy of botulinum toxin type A in subjects with crow’s feet. Dermatol Surg. 2005;31:257–62.CrossRefGoogle Scholar
  18. Molgó J, Lemeignan M, Thesleff S. Aminoglycosides and 3,4-diaminopyridine on neuromuscular block caused by botulinum type A toxin. Muscle Nerve. 1987;10(5):464–70.CrossRefGoogle Scholar
  19. Molgó J, Lemeignan M, Thesleff S. Aminoglycosides and 3,4-diaminopyridine on neuromuscular block caused by botulinum type A toxin. Muscle Nerve. 1987;10(5):464–70.CrossRefGoogle Scholar
  20. Naumann M, et al. Immunogenicity of botulinum toxins. J Neural Transm. 2013;120(2):275–90. Scholar
  21. Ozgur OK, Murariu D, Parsa AA, Parsa FD. Dry eye syndrome due to botulinum toxin type-A injection: guideline for prevention. Hawaii J Med Public Health. 2012;71(5):120–3.PubMedPubMedCentralGoogle Scholar
  22. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower face. Dermatol Surg. 2003;29(5):477–83.Google Scholar
  23. Pena MA, Alam M, Yoo SS. Complications with the use of botulinum toxin type A for cosmetic applications and hyperhidrosis. Semin Cutan Med Surg. 2007;26(1):29–33.CrossRefGoogle Scholar
  24. Ricciardi L, Bovea F, Fasanoa A. Xeomin® use in patients with systemic immune reactions to other botulinum toxins type A. Eur J Neurol. 2013;20:e45–6.CrossRefGoogle Scholar
  25. Santos JI, Swensen P, Glasgow LA. Potentiation of Clostridium botulinum toxin aminoglycoside antibiotics: clinical and laboratory observations. Pediatrics. 1981;68(1):50–4.PubMedGoogle Scholar
  26. Schlessinger J, Dover JS, Joesph J, et al. Long-term safety of abobotulinum toxin A for the treatment of glabellar lines: results from a 36-month, multicenter open-label extension study. Dermatol Surg. 2014;40(1):176–83.CrossRefGoogle Scholar
  27. Skaf GS, Domloj NT, Salameh JA, Atiyeh B. Pseudoaneurysm of the superficial temporal artery: a complication of botulinum toxin injection. Aesthet Plast Surg. 2012;36(4):982–5.CrossRefGoogle Scholar
  28. Tamura B. Estudo imuno-histoquímico da pele antes e após tratamento da hiperidrose axillar com a toxina botulínica [doctorate thesis]. 2005.Google Scholar
  29. Tamura B. Toxina botulínica: concepção de beleza e da estética atual. Editora Santos: São Paulo; 2007.Google Scholar
  30. Tamura B. Anatomia da face aplicada aos preenchedores e à toxina botulínica. Parte I. Surg Cosmet Derm. 2010a;2(3):195–204.Google Scholar
  31. Tamura B. Anatomia da face aplicada aos preenchedores e à toxina botulínica. Parte II. Surg Cosmet Derm. 2010b;2(4):291–303.Google Scholar
  32. Tamura B. The effect of botulinum toxin on platysma muscle. Curr Derm Rep. 2012;1(2):89–95.CrossRefGoogle Scholar
  33. Tamura B, Odo MY. Classificação das rugas periorbitárias e tratamento com a toxina botulínica tipo A. Surg Cosmet Derm. 2011;3(2):129–33.Google Scholar
  34. Tamura BM, Cucé LC, Rodrigues CJ. Allergic reaction to botulinum toxin: positive intradermal test. Dermatol Surg. 2008;34(8):1117–9. Scholar
  35. Vartanian AJ, Dayan SH. Complications of botulinum toxin A use in facial rejuvenation. Facial Plast Surg Clin North Am. 2005;13:1–10.CrossRefGoogle Scholar
  36. West TB, Alster TS. Effect of botulinum toxin type A on movement associated rhytides following CO2 laser resurfacing. Dermatol Surg. 1999;25(4):259–61.CrossRefGoogle Scholar
  37. Zagui RM, Matayoshi S, Moura FC. Efeitos adversos associados à aplicação de toxina botulínica na face: revisão sistemática com meta-análise. Arq Bras Oftalmol. 2008;71(6):894–901.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Cosmetic DermatologyFaculdade de Medicina do ABC in Santo AndréSão PauloBrazil
  2. 2.Faculdade de Medicina do ABC in Santo AndréSão PauloBrazil
  3. 3.Barradas and Bourroul’s Ambulatório de Especialidades in Sao PauloSao PauloBrazil
  4. 4.Sorocaba’s Ambulatório de Especialidade in SorocabaSao PauloBrazil
  5. 5.Clínicas Hospital of São Paulo of the University of Sao PauloSao PauloBrazil

Personalised recommendations