Botulinum toxin type A injections: Adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases

Tirbanibulin (KX2-391) analog KX2-361 inhibits botulinum neurotoxin serotype A mediated SNAP-25 cleavage in pre- and post-intoxication models in cells

Botulinum neurotoxins (BoNT) inhibit neuroexocytosis, leading to the potentially lethal disease botulism. BoNT serotype A is responsible for most human botulism cases, and there are no approved therapeutics to treat already intoxicated patients. A growing body of research has demonstrated that BoNT/A can escape into the central nervous system, and therefore, identification of BoNT/A inhibitors that can penetrate BBB and neutralize the toxin within intoxicated neurons would be important. We previously identified an FDA-approved, orally bioavailable compound, KX2-391 (Tirbanibulin) that inhibits BoNT/A in motor neuron assays. Recently, a structural analog of KX2-391, KX2-361, has been shown to exhibit good oral bioavailability and cross BBB with high efficiency in mouse experiments. Therefore, in this work, we evaluated the inhibitory effects of KX2-361 against BoNT/A. Toward this goal, we first evaluated the compound for its effects on cell viability in PC12 cells, via MTT assay, and in mouse embryonic stem cell (mESC)-derived motor neurons, with imaging-based assays. Following, we tested KX2-361 in mESC-derived motor neurons intoxicated with BoNT/A holotoxin, and the compound exhibited activity against the toxin in both pre- and post-intoxication conditions. Excitingly, KX2-361 also inhibited BoNT/A enzymatic component (light chain; LC) in PC12 cells transfected with BoNT/A LC. Furthermore, our molecular docking analyses suggested that KX2-361 can directly bind to BoNT/A LC. Medicinal chemistry approaches to develop structural analogs of KX2-361 to increase its efficacy against BoNT/A may provide a critical lead compound with BBB penetration capacity for drug development efforts against BoNT/A intoxication.

Rare and novel complications of botulinum neurotoxin type A and dermal filler injections

Botulinum neurotoxin type A (BoNTA) and filler injection procedures usually provide predicted outcomes with a low incidence of complications. Most of the complications after these procedures have been extensively discussed. In this study, we report on these injectables' less well-known, recently reported, and novel complications and attempt to clarify the underlying mechanisms. Counterfeit or mishandled BoNTA has been associated with botulism. BoNTA has been linked to uncommon complications, including morphea-like lesions, nontuberculous mycobacterial infections, vascular occlusion, and pseudoaneurysm of the superficial temporal artery. Unusual complications from filler injection include nonscarring alopecia, intraoral necrosis, nontuberculous mycobacterial infections, xanthelasma-like reactions, intracranial perforation, and pneumosinus dilatans. Post-BoNTA injection nodules and filler infection from bone destruction due to cocaine use are new complications. These complications pose a challenge for diagnosis and treatment. This publication aims to assist in promptly identifying and managing these rare and novel complications when necessary.

Botulinum toxin A versus microwave thermolysis for primary axillary hyperhidrosis: A randomized controlled trial

Background

Botulinum toxin A (BTX) and microwave thermolysis (MWT) represent 2 treatment modalities for axillary hyperhidrosis with different procedural and efficacy profiles.

Objective

To compare long-term outcomes following BTX vs MWT treatment of axillary hyperhidrosis.

Methods

A prospective, randomized, within-patient, controlled trial, treating axillary hyperhidrosis with contralateral BTX and MWT. Objective sweat measurement and patient-reported outcome measures for sweat and odor were collected at baseline, 6-month and 1-year follow-up (6M/1YFU). Hair reduction and patient treatment preference was also assessed.

Results

Sweat reduction was significant (all P <.01) for both interventions throughout the study. Objectively, sweat reduction was equal at 1-year FU (ΔP =.4282), but greater for BTX than MWT at 6-month FU (ΔP =.0053). Subjective sweat assessment presented comparable efficacy (6MFU: ΔP =.4142, 1YFU: ΔP =.1025). Odor reduction was significant (all P <.01) following both interventions, whereas only sustaining for MWT (6MFU: ΔP =.6826, 1YFU: ΔP =.0098). Long-term, hair reduction was visible after MWT, but not BTX (ΔP ≤.0001), and MWT was preferred by the majority of patients (76%).

Limitations

The intrinsic challenges in efficacy assessment.

Conclusion

This study exhibited BTX and MWT with similar sweat reduction, but distinguishable odor and hair reduction at 1-year FU. These findings support individualized treatment approaches for axillary hyperhidrosis based on patient-specific symptoms and preferences.

The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

Botulinum Neurotoxin Induces Neurotoxic Microglia Mediated by Exogenous Inflammatory Responses

Botulinum neurotoxin serotype A (BoNT/A) is widely used in therapeutics and cosmetics. The effects of multi-dosed BoNT/A treatment are well documented on the peripheral nervous system (PNS), but much less is known on the central nervous system (CNS). Here, the mechanism of multi-dosed BoNT/A leading to CNS neurodegeneration is explored by using the 3D human neuron-glia model. BoNT/A treatment reduces acetylcholine, triggers astrocytic transforming growth factor beta, and upregulates C1q, C3, and C5 expression, inducing microglial proinflammation. The disintegration of the neuronal microtubules is escorted by microglial nitric oxide, interleukin 1β, tumor necrosis factor α, and interleukin 8. The microglial proinflammation eventually causes synaptic impairment, phosphorylated tau (pTau) aggregation, and the loss of the BoNT/A-treated neurons. Taking a more holistic approach, the model will allow to assess therapeutics for the CNS neurodegeneration under the prolonged use of BoNT/A.

Botulinum toxin: a new differential diagnosis for a lytic bone lesion

BACKGROUND

Botulinum toxin, produced by the Gram-positive anaerobe Clostridium botulinum, is composed of seven antigenic subtypes (A, B, C, D, E, F, and G). Currently, only Botulinum toxin type A, commonly referred to as "Botox," is approved for clinical use, given its relatively safe clinical profile. Botulinum toxin type A has a wide range of therapeutic indications, including treatment for dystonia, migraine headache, neurogenic bladder, and large muscle spastic disorders. However, the toxin is most widely known for its cosmetic effects in treating wrinkles and facial lines.

CASE PRESENTATION

This article describes a 62-year-old Caucasian female who presented for investigation and workup of an isolated lytic lesion of her frontal bone a few weeks after administration of botulinum toxin injection into the corresponding site in the frontalis muscle. This presented as a large, palpable, painless forehead lump causing significant psychological distress. After no neoplastic cause for the lesion was found and histopathology was performed, our researchers concluded that the most likely explanation was that the bony lytic lesion resulted from inadvertent injection of the "Botox" neurotoxin through the intended target muscle and into the cortex of the underlying bone.

CONCLUSIONS

Our search of the literature failed to identify any previous cases of this occurring. However, as the popularity of this cosmetic procedure only increases, we believe that this represents an important possible differential for isolated lytic lesion after administration of "Botox" injection.

Histomorphometric Changes of the Masseter Muscle of Rats After a Single Injection of Botulinum Toxin Type A

BACKGROUND

It has been reported that botulinum toxin type A (BoNT-A) produces structural changes in masticatory muscles. However, not all histomorphometric parameters affected by BoNT-A parameters have been assessed. This study investigated the histomorphometric changes in the masseter muscle of rats after a single injection of BoNT-A.

METHODS

Forty-four adult animals were randomly divided into control group (n = 22) and BoNT-A group (n = 22). Controls received a single dose of 0.14 mL/kg of saline in masseter muscles, and the BoNT-A group received a 7 U/Kg of BoNT-A. The groups received the same volume of injected substances. Animals were sacrificed on 7th (n = 5), 14th (n = 5), 21st (n = 5), 28th (n = 4) and 90th (n = 3) days post-treatment. Histological masseter tissue slides were obtained from hematoxylin-eosin treatment and analyzed in optical microscopy regarding muscle cross-sectional area, amount of connective tissue and quantity and diameter of myocytes. For statistical analysis, generalized linear models were used to compare the data (ANOVA). In all test, the significance level of 5% was set.

RESULTS

BoNT-A values of cross-sectional area of the masseter muscle were significantly lower than controls (p < 0.01) throughout the study. Regarding myocytes quantity, BoNT-A subgroups presented higher values than controls (p < 0.0001) since the 14th day until the end of the study; however, the diameter of myocytes was smaller in all BoNT-A subgroups (p < 0.0001) in all assessment points. The amount of connective tissue was higher in BoNT-A subgroups (p < 0.0001) throughout the study.

CONCLUSION

A single injection of BoNT-A altered the structure of masseter muscle of rats, regarding its histomorphometric parameters.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy and Safety Analysis of Botox Application and Iatrogenic Botulism: Panacea or Peril?

Clostridium botulinum toxin-A (BoNT-A) creates temporary paralysis in the muscles by acting on the muscle-nerve junction. It is injected into the mimic muscles when a decrease in the movements of the mimic muscles is desired. Despite many favorable applications, the use of BoNT-A is not without drawbacks. Although there is no expected serious side effect on health in BoNT-A treatments, various problems can be encountered in patients treated for aesthetic purposes. Botulism is a rare but potentially life-threatening syndrome, which is caused by the toxin produced by the bacterium Clostridium botulinum, which acts on the nervous system, vegetative forms of C. botulinum can only survive in anaerobic conditions, while spore forms are common in nature and can withstand harsh conditions. Botulism can stem from bacterial spores which release toxin in the body; in the form of enteric botulism, and wound botulism. The cases that develop 'iatrogenic botulism' after such procedures are usually those receiving high-dose toxin for therapeutic purposes. The treatment of botulism mainly consists of anti-toxin therapy and, if necessary, intensive care to prevent organ failures, including respiratory support. This article aims to cover all these issues related to botulism and other adverse outcomes related to BoNT-A injection in light of the most recent literature.

Skin Toxicities Associated with Botulin Toxin Injection for Aesthetic Procedures: Data from the European Spontaneous Reporting System

Botulinum toxin is a protein deriving from the bacteria Clostridium botulinum and it is widely used for the treatment of a variety of muscle hyperactivity syndromes and for cosmetic indications. Having a long-lasting effect, Botulinum toxin type A (BTA) is one of the most botulin toxin products used. Even if BTA has shown benefits in reducing the vertical lines between the eyebrows, Adverse Drug Reactions (ADRs) have been experienced as well, of which the most common ones are headache and drooping eyelids. In addition, since other local and systemic risks have been identified, a non-interventional post-authorization safety study (PASS) has been started. The aim of the present study was to report cases of skin toxicity associated with this drug, considering Individual Case Safety Reports (ICSRs) existing on the Eudravigilance website. Among 1464 ICSRs sent to the EV database, 718 ICSRs, including 5154 PTs, reported BTA as a suspected drug associated with cutaneous toxicity. The majority of patients experiencing BTA-induced skin toxicity were female (92.1%) belonging mostly to the age group of 18-64 years. The most serious criteria, when reported, were "Other Medically Important Condition" and "Caused/prolonged hospitalization", although the outcome was mainly reported as "Unknown". The most reported PTs, related to skin disorders, were: "Erythema", "Rash", "Pruritus", "Urticaria", "Swelling face", "Brow ptosis", "Eyelid ptosis", "Injection site pain", and "Angioedema". Considering that in most ICSRs, ADRs related to skin disorders were symptoms of hypersensitivity reactions which in some conditions could be life-threatening, further studies are required to better define the safety profile of BTA used for aesthetic procedures.

Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force

The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.

Effect of Botulinum Toxin on Masticatory Muscle Pain in Patients with Temporomandibular Disorders: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

This study aimed to evaluate the efficacy of botulinum toxin type A (BoNT/A) in patients with temporomandibular disorders (TMDs) associated with masticatory muscle pain (MMP) and headaches. This randomized, double-blind, placebo-controlled pilot study is the first clinical trial to evaluate both disorders simultaneously. Twenty-one patients with myogenous TMD were randomly assigned to two groups. The experimental and control groups received injections of either BoNT/A or saline into the sites showing tenderness after palpation of a total of 16 muscle areas, including each masseter, a temporalis, splenius capitis, sternocleidomastoid, and trapezius muscle. During each visit, the clinical effects, based on the intensity of orofacial pain (OVAS), headache (HVAS), number of tender points (TPs), maximum mouth opening (MMO), and headache frequency (HF), were evaluated at four time points, namely, pre-injection and 4, 8, and 12 weeks after the injection, in both groups. Friedman and Mann-Whitney tests were used for the analyses. In the experimental group, the reductions in OVAS, TP, HVAS, and HF showed significant differences over time, excluding MMO, whereas there was no significant difference in any of the variables in the control group. In addition, the decline in TPs was significantly different between the experimental and control groups at all time points, especially after 4 and 12 weeks, compared to that during pre-injection. In conclusion, treatment with BoNT/A was relatively effective for masticatory muscle pain caused by TMDs and headache compared to the saline placebo.

A look at the future-new BoNTs and delivery systems in development: What it could mean in the clinic

Despite the expanding clinical utility of botulinum neurotoxins, there remain problems to be solved for attaining the best outcome. The efficacy and safety need to be reconsidered for commercially available preparations all derived from subtype A1 or B1. Emerging new toxins include A2 or A6 subtypes or engineered toxins with less spread, more potency, longer durations of action, less antigenicity and better safety profile than currently used preparations. Non-toxic BoNTs with a few amino acid replacements of the light chain (LC) may have a role as a drug-delivery system if the toxicity is abolished entirely. At present, efficacy of these BoNTs in animal botulism was demonstrated.

Iatrogenic Botulism: A Case Treated With Botulinum Antitoxin

OBJECTIVE

Botulinum toxin type A is widely used for the treatment of spasticity, focal dystonia, hemifacial spasm, hyperhidrosis, strabismus, chronic migraine, and also cosmetic purposes. Therapeutic use is commonly effective and safe. However, if toxin enters the vascular space and gets through to peripheral cholinergic nerve terminals, it may lead to iatrogenic botulism.

METHOD

We presented a patient who is diagnosed as iatrogenic botulism and treated with antitoxin at the 15th day of the exposure.

RESULTS

After the antitoxin administration, dramatical response to the treatment was observed.

CONCLUSIONS

In this report, we want to evaluate a new case of iatrogenic botulism and emphasize the importance of antitoxin administration regardless the timing of the exposure for patients with progressing paralysis.

Adverse effects following botulinum toxin A injections in children with cerebral palsy

The study aimed to analyze the adverse events associated with botulinum toxin A (BoNT-A) injections in children with cerebral palsy (CP). The literature search was completed using the Medline, PubMed, Google Scholar, Scopus, and Cochrane Library databases from the earliest date possible up to December 2021. Search terms included 'botulinum toxin', 'cerebral palsy', 'spasticity', 'adverse effects', 'side effects', 'undesirable effects', 'complications', 'lower limb', 'upper limb', and 'children' including combinations of index and free-text terms. Fifty-five studies were included in the study. Data on 6333 pediatric patients and more than 14 080 BoNT-A injections were collected. Respiratory symptoms and respiratory tract infections were the most frequently registered adverse events (AEs). Other common AEs included procedural/focal AEs, flu-like symptoms, and asthenia. Sentinel events including four cases of death were reported. AEs were more frequent and severe in high-dose patients; however, the capacity of BoNT-A to spread systemically remains unclear. Since severe adverse events are not common, further research is needed to collect more definitive clinical and homogeneous data to support the findings of the present research and clarify the safety profile of BoNT-A, especially regarding the incidence of respiratory issues and complications in GMFCS IV or V patients.

Off-Label Use of Botulinum Toxin in Dermatology—Current State of the Art

Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacteria. Among seven different isoforms, only BoNT-A and BoNT-B are commercially used. Currently, botulinum toxin has been indicated by the U.S. Food and Drug Administration in several disorders, among others: chronic migraine, hyperhidrosis, urinary incontinence from detrusor overactivity, or cosmetics. However, there are numerous promising reports based on off-label BTX usage, indicating its potential effectiveness in other diseases, which remains unknown to many. Among them, dermatological conditions, such as rosacea, annal fissure, Raynaud phenomenon, hypertrophic scars and keloids, and also hidradenitis suppurativa, are currently being investigated. This article aims to provide a comprehensive update on the off-label use of botulinum toxin in dermatology, based on an analysis and summary of the published literature.

The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves

Extracorporeal shock wave therapy (ESWT) is a safe and effective treatment option for various pathologies of the musculoskeletal system. Many studies address the molecular and cellular mechanisms of action of ESWT. However, to date, no uniform concept could be established on this matter. In the present study, we perform a systematic review of the effects of exposure of musculoskeletal tissue to extracorporeal shock waves (ESWs) reported in the literature. The key results are as follows: (i) compared to the effects of many other forms of therapy, the clinical benefit of ESWT does not appear to be based on a single mechanism; (ii) different tissues respond to the same mechanical stimulus in different ways; (iii) just because a mechanism of action of ESWT is described in a study does not automatically mean that this mechanism is relevant to the observed clinical effect; (iv) focused ESWs and radial ESWs seem to act in a similar way; and (v) even the most sophisticated research into the effects of exposure of musculoskeletal tissue to ESWs cannot substitute clinical research in order to determine the optimum intensity, treatment frequency and localization of ESWT.

The Multispecialty Toxin: A Literature Review of Botulinum Toxin

Botulinum toxin (BoNT) is a potent biological exotoxin produced from Clostridium botulinum. Although it was first used therapeutically to treat strabismus, its clinical role has since expanded rapidly over the years to include treatment of a variety of head and neck, gastrointestinal, urogenital, musculoskeletal, neurological, dermatological, and cosmetic disorders. The main purpose of this review is to provide a brief updated overview of the history, mechanism of action, and clinical applications of BoNT therapy across multiple medical specialties, including the most common adverse effects and recommended Botox dosages.

Evaluation of the Safety and Efficacy of a Biosimilar Abobotulinum Toxin Type A in Treating Moderate to Severe Glabellar Lines: A Non-Inferiority Double Blinded Randomized Controlled Trial

BACKGROUND

Injection of botulinum toxin for cosmetic purposes is a well-established practice.

OBJECTIVES

This study was conducted to compare the safety and efficacy of Dyston^® (investigational biosimilar abobotulinumtoxinA) with Dysport^® (abobotulinumtoxinA, Ipsen) in the treatment of moderate to severe glabellar lines.

METHODS

Out of 193 screened subjects, 126 volunteers with moderate to severe glabellar lines fulfilling eligibility criteria were randomized in a 1:1 ratio to receive either an intramuscular injection of 40-60 units of Dyston^® or Dysport^® . The primary objective was to test the non-inferiority of Dyston^® compared to Dysport^® as measured by the percentage of volunteers who achieved no or mild glabellar lines at maximum frown assessed by the physicians based on the Glabellar Line Severity Score (GLSS) at day 30. Secondary endpoints included the improvement in the glabellar lines at maximum frown and rest states at days 14, 60, 90 and 120 as well as the side effects of the treatment.

RESULTS

Response rates at maximum frown were 75.44% (43/57) in the Dyston^® group and 76.67% (46/60) in the Dysport^® group on day 30 (P value: 0.88, 95%CI: -14.24 to 16.70, diff: 1.23) as per-protocol set, and were 75.81% (47/62) and 76.19 (48/63) (P value: 0.96, 95%CI: -14.59 to 15.35, diff: 0.3) in the Dyston^® and the Dysport^® groups, respectively, based on modified intention to treat population. Adverse events were similar in both groups and mostly mild and well-tolerated.

CONCLUSION

Treatment of moderate to severe glabellar lines with Dyston^® was effective, tolerable, and non-inferior compared to Dysport^® .

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

Sub-acute hypersensitive reaction to botulinum toxin type A following Covid-19 vaccination: Case report and literature review

RATIONALE

Botulinum toxin type A (BTA) is one of the most widely used injectable agents in cosmetic surgery. Corona virus disease 2019 (Covid-19) infection and vaccination, which can induce specific and nonspecific activation of the immune system, has been reported to induce delayed inflammatory reactions to previously injected hyaluronic acid fillers. However, there are no reports about the interaction between BTA and Covid-19. We aimed to report 2 sub-acute cases of allergic reactions to BTA in facial cosmesis following the Covid-19 vaccination.

PATIENT CONCERN

A 35-year-old and a 34-year-old female who has several previous BTA injections without any adverse effects experienced facial swelling, flu-like symptoms after BTA treatment following the Covid-19 vaccination.

DIAGNOSE

According to the typical clinical manifestation, a hypersensitive reaction to BTA was considered.

INTERVENTION

Corticosteroids and antihistamine were administered empirically.

OUTCOMES

The flu-like symptoms recovered over the next day, but the facial swelling gradually faded within 1 to 2 weeks.

LESSONS

A literature review was also conducted to summarize the hypersensitive actions to cosmesis related to Covid-19. We recommend BTA injection be administered at least 2 to 3 months after Covid-19 vaccination.

Litigation Arising From Minimally Invasive Cosmetic Procedures: A Review of the Literature

BACKGROUND

Minimally invasive cosmetic procedures are on the rise. To meet this rising demand, increasing numbers of physicians and nonphysicians are performing these procedures. Understanding malpractice trends and reasons for litigation in cosmetic medicine is important to establish safeguards for patient care and minimize liability.

OBJECTIVE

Perform a comprehensive review of the literature on litigation associated with minimally invasive cosmetic procedures and discuss strategies to avoid facing a lawsuit.

MATERIALS AND METHODS

The authors searched PubMed databases using a variety of keywords to identify studies of lawsuits arising from minimally invasive cosmetic procedures through December 2020.

RESULTS

A total of 12 studies of litigation meeting inclusion criteria were identified: botulinum toxin (1), soft tissue fillers (3), lasers (5), body contouring/liposuction (1), chemical peels/dermabrasion (1), and sclerotherapy (1). Principle factors associated with litigation included negligence, lack of informed consent, vicarious liability for action of delegates, lack of communication, poor cosmetic result, failure to inform of risks, inappropriate treatment or dose, and failure to recognize or treat injury.

CONCLUSION

Understanding malpractice trends and reasons for litigation in minimally invasive cosmetic procedures can strengthen the patient-provider relationship, establish safeguards for patient care, and may minimize future risk of a lawsuit.

Utilities of Botulinum Toxins in Dermatology and Cosmetology

Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacterium with a well-known efficacy and safety profile in the focal idiopathic hyperhidrosis treatment. BoNT comprises seven different neurotoxins; however, only toxins A and B are clinically employed. BoNT is lately practiced in off-label therapies for a variety of skin diseases. Scar prevention, hyperhidrosis, rhytides, eccrine nevus, alopecia, psoriasis, Darier disease, bullous skin disease, pompholyx and Raynaud's phenomenon are some of the novel indications for BoNT in cosmetic and notably non-cosmetic aspects of dermatology. To employ BoNT correctly in clinical practice, we must have a thorough understanding of the functional anatomy of the mimetic muscles. An intensive literature search was conducted to update all dermatology-oriented experiments and clinical trials on the described element of BoNT for this general overview of BoNT use in dermatology. This review aims to analyse the role of BoNT in dermatology and cosmetology.

Exploring the role of botulinum toxin in critical care

INTRODUCTION

Botulinum neurotoxin (BoNT) is one of the most potent and extensively studied neurotoxins with clinical applications across several different medical specialties. This review article explores the latest evidence for therapeutic applications of BoNT in patients receiving critical management in an intensive care unit (ICU).

AREAS COVERED

The authors did a literature search in PubMed, Google Scholar, and Texas Medical Center Library database for studies describing the use of BoNT in a critical care setting. They extracted information on study design, patient selection, methodology, and results of relevant studies. Based on initial identification of 85 studies and after conducting screening, the authors identified 61 studies to be included in this review. In an ICU setting, BoNT has been used for several neurological and non-neurological indications. However, the supporting evidence is mostly limited to small observational studies.

EXPERT OPINION

The use of BoNT in this setting is largely underutilized due to paucity of well-designed clinical trials and financial barriers. Further research is needed to provide evidence for the safety and efficacy of BoNT and to optimize the dosing and injection techniques for various conditions encountered in this setting.

Ophthalmic adverse events following facial injections of botulinum toxin A: A systemic literature review

BACKGROUND

Over the years, botulinum toxin has found its place as a neuromuscular blocking agent in numerous medical fields. Since the approval of botulinum toxin by the FDA for cosmetic indications in 2002, it had become the most commonly performed esthetic procedure worldwide, with ever-growing demand. The characteristics of the toxin, along with the facial areas it is injected to, could possibly account for a wide array of complication.

METHODS

The authors conducted a literature search for reported cases of ophthalmic adverse events following Botulinum toxin facial injections in the electronic databases of PubMed and Cochrane Library databases.

RESULTS

The authors found 25 publications, reporting 49 cases of ophthalmic adverse events following botulinum toxin injections. Injections for cosmetic indications accounted for 51% of all injections, treatment of blepharospasms for 22% of cases, protective ptosis for 11% of cases, and treatment of hemifacial spams for 8% of cases. The average quantity of botulinum toxin injected to a single patient ranged between 1.25 and 75 units, with a median of 13.75 units.Majority of injections for cosmetic indications were performed to the lateral canthal area (56%), followed by the glabella (28%) and the forehead (20%).Adverse events following injections included diplopia (64%), ptosis (14%), and decrease in visual acuity or vision loss (8%).

CONCLUSIONS

Botulinum toxin is gaining extreme popularity in the management of a wide area of diseases and for cosmetic indications. Proper knowledge of potential adverse events is crucial for the clinician in attempt to decrease complications.

Adverse Events Associated With Botox as Reported in a Food and Drug Administration Database

BACKGROUND

Botulinum toxin treatment is the most frequently performed noninvasive cosmetic procedure performed in the USA. Because of its widespread use, an analysis of the adverse event (AE) profile of Botox injections is needed.

METHODS

The FDA Adverse Event Report System was queried using an online web-based tool to determine the top 15 adverse events reported for four Botox brand names: Botox/Botox Cosmetic, Dysport, and Xeomin. The proportional reporting ratios (PRR) and relative odds ratios (ROR) were determined. A literature review was performed for eight AEs of clinical significance: eyelid/eyebrow ptosis, asthenia, muscular weakness, facial paresis, dysphagia, botulism, and death.

RESULTS

Botox/Botox Cosmetic had 38367 AEs. Dysport had 3582 AEs. Xeomin had 1405 AEs. All drugs with reported cases of eyelid and eyebrow ptosis had significant PRR and ROR values. The PRR and ROR values for asthenia were not significant in any of the drugs and only reached significance for Dysport for muscular weakness and dysphagia. Both Botox/Botox Cosmetic and Dysport had elevated PRRs and RORs for facial paresis and botulism. While all drugs had at least one reported case of death related to Botox injection use, none of the PRR or ROR values were significant.

CONCLUSION

Known AEs for Botox injection use include eyelid/brow ptosis and muscular weakness. Feared but rare complications of Botox injection use include dysphagia, botulism, and possibly death, owing to systemic spread of the toxin. This is the first study to analyze the AE data reported to the FDA on Botox injection use.

EBM LEVEL

III.

Botulinum toxin in the management of primary and secondary Raynaud's phenomenon

Raynaud's phenomenon (RP) is common in rheumatic diseases. In the setting of systemic sclerosis (SSc), it can be complicated by digital ischemia that includes ulceration and gangrene. Systemic adverse effects may preclude the use of oral or topical vasodilators for the treatment of RP and its complications. In this article, we review effectiveness/efficacy of botulinum toxin injection in primary and secondary RP. We discuss botulinum toxin formulations, dosage, sites of administration, and adverse effects. The evidence for botulinum toxin in the treatment of primary and SSc-associated RP is promising. Consistency across patient populations, treatment options (botulinum serotype, dose, and injection site), and outcome measures will be essential for further research.

The effectiveness of botulinum toxin type A (BTX-A) in the treatment of facial skin oily seborrhea, enlarged pores, and symptom complex of post-acne

BACKGROUND

This study aimed to examine the effectiveness of botulinum toxin type A (BTX-A) in the treatment of acne.

METHODS

The study was conducted in 2018 on 12 patients, 10 females and two males, aged 35 years on average. The injections with BTX-A were given during 2 weeks into the face skin in a dosage of 0.125-0.250 units.

RESULTS

Skin moisture indexes increased during the therapy by 4% (P ≤ 0.05), and porosity decreased by 7% (P ≤ 0.01). Maximal changes were recorded for the sulci and pigmentation of the skin, namely, its values decreased by 10 and 9%, respectively (P ≤ 0.01). BTX-A is recommended for an application not only in plastic surgeries but also for local correction of acne on the patient's skin.

CONCLUSION

A positive correlation was revealed between the duration of treatment and reduction of skin oiliness (0.87), pigmentation (0.78), skin sulci (0.84), and skin porosity (0.88), and negative correlation was established with increased skin moisture (-0.64). The obtained dependencies apply for the therapy period of up to 2 weeks. Pharmacological properties of BTX-A allow recommending it as a drug used in post-acne therapy.

Complications of Botulinum toxin A: An update review

Cosmetic surgery procedures have increased manifolds all over the world owing to the ever-increasing demand of people to look beautiful and young. Injectable treatments like botulinum toxin are becoming more popular owing to their rapid, well-defined, and lasting results for the reduction of facial fine lines, wrinkles, and facial rejuvenation. These emerging treatments are quite safe but can have certain adverse effects. In this article, we have highlighted the complications and side effects of botulinum toxin based on the anatomical location. The possible causes and precautions to prevent these complications are also discussed. The search of literature included peer-reviewed articles including clinical trials and scientific reviews. Literature was identified from electronic databases (MEDLINE/PubMed) through January 2021 and references of respective articles and only the articles published in English language were included.

Upper Extremity Deep Vein Thrombosis After Botulinum Toxin Injection: A Case Report

Botulinum toxin (BoNT) injection is widely used to improve spasticity. However, after the treatment, the patient may experience pain, inflammation, swelling and redness at the injection site. In this case, we addressed deep vein thrombosis (DVT) after BoNT treatment of the upper limb. A male aged 37 years had spasticity and dystonia in his left upper extremity. BoNT-A 100 U was injected into the left biceps brachii and an equal amount into the brachialis to relieve spasticity. After three days, he developed redness and painful swelling in the left upper arm and the next day, through the upper extremity computed tomography venography, DVT was identified in the left cephalic vein. The thrombus resolved after the anticoagulation therapy with rivaroxaban (Xarelto). We hypothesized the role of mainly three mechanisms in the development of DVT in this case: repetitive strenuous activity, relative stasis due to reduced muscle tone, and possible direct mechanical damage to the vessel wall.

Menopause, Ultraviolet Exposure, and Low Water Intake Potentially Interact with the Genetic Variants Related to Collagen Metabolism Involved in Skin Wrinkle Risk in Middle-Aged Women

Genetic and environmental factors influence wrinkle development. We evaluated the polygenetic risk score (PRS) by pooling the selected single nucleotide polymorphisms (SNPs) from a genome-wide association study (GWAS) for wrinkles and the interaction of PRS with lifestyle factors in middle-aged women. Under the supervision of a dermatologist, the skin status of 128 women aged over 40 years old was evaluated with Mark-Vu, a skin diagnosis system. PRS was generated from the selected SNPs for wrinkle risk from the genome-wide association study. Lifestyle interactions with PRS were also evaluated for wrinkle risk. Participants in the wrinkled group were more likely to be post-menopausal, eat less fruit, take fewer vitamin supplements, exercise less, and be more tired after awakening in the morning than those in the less-wrinkled group. The PRS included EGFR_rs1861003, MMP16_rs6469206, and COL17A1_rs805698. Subjects with high PRS had a wrinkle risk 15.39-fold higher than those with low PRS after adjusting for covariates, and they had a 10.64-fold higher risk of a large skin pore size. Menopause, UV exposure, and water intake interacted with PRS for wrinkle risk: the participants with high PRS had a much higher incidence of wrinkle risk than those with low PRS, only among post-menopausal women and those with UV exposure. Only with low water intake did the participants with medium PRS have increased wrinkle risk. In conclusion, women aged >40 years with high PRS-related collagen metabolism may possibly avoid wrinkle risk by avoiding UV exposure by applying sunscreen, maintaining sufficient water intake, and managing estrogen deficiency.

Transverse facial artery: Its role in blindness after cosmetic filler and botulinum toxin injections

Masseter injections for cosmetic or pathological reasons are increasingly common, as are filler injections using dual or multiplane techniques in the lateral facial regions or for jawline contouring. The occurrence of blindness following these procedures often remains unexplained. This study aimed to determine the anatomical explanation for this debilitating complication by investigating the transverse facial artery and its relation to the masseter. For this purpose, we dissected 35 cheek specimens with latex injections and 10 specimens without latex. The external carotid artery was dissected up to its bifurcation into the maxillary and superficial temporal arteries. Results showed that the transverse facial artery arose from the superficial temporal or external carotid artery that runs between the zygomatic arch and the parotid duct. Three types of transverse facial arteries were observed: type I: a short artery that did not extend beyond the masseter muscle; type II: a transverse artery that ran to the nasolabial fold and anastomosed to the facial artery; and type III: a sizable transverse artery that substituted the hypoplastic facial artery, continued as the angular artery, and then anastomosed to the dorsal nasal artery. Knowledge of these three types of transverse facial arteries is a prerequisite to study the vascular territory. Type III provides an explanation for the occurrence of blindness after lateral face injections. We consequently define a line that runs from the tragus to the outer quarter of the upper lip as the risk area, while the safe zone is located on either side of this line.

Botulinum Toxin Type A injections for pediatric spasticity: Keeping our patients informed and practices safe

Serious adverse events (serious AEs) following the therapeutic use of Botulinum Toxin Type A (BoNT-A) are infrequent. Children with pediatric spasticity often have comorbidities that can cloud causation around an adverse event (AE). If a serious AE occurs, clear documentation of information sharing and informed consent as well as the provider-patient relationship are critical to minimizing litigation risks. Reviewing the litigation that has occurred following BoNT-A for pediatric spasticity can offer insight into how providers' perspectives regarding this intervention may differ from those of the public who might serve as jurists. This article offers suggestions for content sharing during the consent process to optimize patient understanding about potential adverse events.

Quality attributes of partially hydrolyzed collagen in a liquid formulation used for skin care

BACKGROUND

The deterioration of the skin accentuates over time, affecting its aesthetic appearance. This is characterized by the weakening of the mechanisms involved in the regeneration and repair of the dermal matrix. Consequently, the skin losses elasticity and smoothness resulting in the formation of wrinkles. The alternatives for facial rejuvenation include surgery, injection of botulinum toxin, and the application of masks. Topic products are less invasive, can be self-applied, and have an increased benefit/risk relationship.

AIM

We developed a liquid formulation containing collagen hydrolyzed and evaluated the product by cutting-edge technology in order to define proper its quality attributes.

METHODS

We employed nuclear magnetic resonance (NMR), size-exclusion chromatography (SEC), and mass spectrometry (MS). Additionally, we analyzed its cosmetical effect in five volunteers and we demonstrate the product safety.

RESULTS

Our results demonstrate the following: (a) a stable secondary structure identity associated to the known triple helix arrangement in liquid and solid states; (b) a typical conformational flexibility depending on its hydration state; (c) thermal stability confirmed by liquid- and solid-state nuclear magnetic resonance schemes; and (d) a molecular mass distribution of peptides between 0.5 and 19.5 kDa. The product faded wrinkles in the forehead, an effect that remained after removing the mask. The formula was non-irritating and hypoallergenic.

CONCLUSION

We characterized, using state-of-the-art methodologies, the quality attributes that are critical for the safety and beneficial effect of a new collagen-containing formula.

Intraoperative Botulinum Toxin Chemodenervation and Analgesia in Abdominal Wall Reconstruction

Purpose. To analyze the impact of botulinum toxin chemodenervation on postoperative opiate consumption through a novel intraoperative injection protocol. Methods. A retrospective review of the implementation of a novel intraoperative botulinum toxin injection into both rectus and oblique musculature. Patients undergoing open retrorectus release, with and without intraoperative chemodenervation with Botox, were retrospectively collected between 2015 and 2019. Demographics, comorbidities, and opioid use in morphine milligram equivalents (MMEs) were retrospectively captured. Basic descriptive statistics and linear regression analysis were performed. Results. 19 patients in the Botox and 22 in the no Botox group were analyzed. Basic demographics were similar with female preponderance in the Botox group, 58% vs 27%, P = .05. Median hernia length was 15 cm for both groups (P = .57), median hernia width was 8 vs 9 cm (P = .39), epidural catheter used in 0 vs 4 (P = .11), transverse abdominal plane blocks in 3 vs 4 (P = 1), median MME usage was 191 vs 230 (P = .37) in the inpatient setting, 225 vs 300 (P = .17) in the outpatient setting, and 405 vs 568 (P = .07) in total for Botox vs no Botox groups. Stepwise linear regression analysis identified Botox as the only predictor for MME usage, P = .048. Conclusions. Chemodenervation was the only factor associated with reduced opioid usage compared to a standard group using multimodality analgesia. The role of muscular pain in laparotomy is likely underappreciated and understudied. Intraoperative selective muscular chemodenervation may play a significant role in recovery from abdominal surgery and requires further study.

Long-term efficacy and safety of a new botulinum toxin type A preparation in mouse gastrocnemius muscle

A new type A botulinum toxin (BoNT/A) preparation, JTM201 (NCBI chromosomal DNA ID: CP046450), has been developed, which comprises 900-kDa complexed toxin purified from Clostridium botulinum (strain: NCTC13319), but its safety and efficacy have not yet been evaluated. The purpose of this study was to evaluate the long-term efficacy and safety of JTM201 at different concentrations in comparison to another commercially available BoNT/A product, Botox® (onabotulinumtoxin A, ONA), using a mouse model. The LD₅₀ of JTM201 was similar to that of ONA, but the intrinsic activity of JTM201 was higher than that of ONA. Functional recovery of the nerves and muscles in SKH-1 mice after administration of the two BoNT/A preparations (JTM201 and ONA) to the right gastrocnemius muscle was observed over 24 weeks. In addition, JTM201 did not induce any skin or muscle inflammatory response in 24 weeks. Paralysis induced by neurotransmitter blockade after JTM201 administration was comparable to that of ONA treatment. Both muscle weight and volume decreased in a concentration-dependent manner following JTM201 or ONA toxin injection until week 4. Reduced muscle fiber size due to atrophy and consequent fibrosis were detected following injection of JTM201 or ONA. Moreover, we assessed the extent of diffusion of JTM201 or ONA to the tibialis anterior and quadriceps femoris muscles, demonstrating limited diffusion to off-target muscles. In conclusion, JTM201 demonstrated long-term efficacy and safety equivalent to those of ONA based on compound muscle action potential, muscle volume, and histology analyses. These data suggest that JTM201 is a new BoNT/A formulation with safety and efficacy comparable to those of ONA.

Case Series of Botulinum Toxin Administered to Pregnant Patients and Review of the Literature

Objective: To evaluate a case series of patients who received medically necessary botulinum toxin during pregnancy. Materials and Methods: Retrospective chart review of three patients who underwent repeated intralaryngeal injections of botulinum toxin during pregnancy. Chart reviews were also conducted on the children to further evaluate the safety. Results: No evidence of harm to the mothers or fetuses were found in our series, including data from pregnancy and birth records using standard measures of gestation, APGAR scores, neonatal intensive care unit stay, and time until discharge. Clinical data for 3-5 years were available for the children. No evidence of muscular weakness was noted and all diagnoses were listed. Conclusion: Botulinum toxin injection for functional airway issues was not associated with any adverse effects to the mother or fetus during pregnancy in any of the cases reviewed. We recommend further investigation to evaluate the current contraindication of elective botulinum toxin use in pregnancy.

What Are the Most Commonly Reported Complications With Cosmetic Botulinum Toxin Type A Treatments?

PURPOSE

The purpose of the present study was to determine the most commonly reported complications with cosmetic botulinum toxin type A (BTX-A) treatments.

MATERIALS AND METHODS

The present study was a cross-sectional review of the US Food and Drug Administration (FDA) Adverse Event Reporting System. From January 2014 through September 2019, records were included in the study sample if they implicated Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA), or Jeuveau (prabotulinumtoxinA-xvfs), and if the indication for use had been to perform a cosmetic skin procedure. The study predictors included patient (ie, age, weight, gender) and treatment (ie, product, country of treatment, 10 most common reactions) characteristics. The study outcome was the frequency of serious events as defined by the standard FDA definition for biologic products. A multivariate logistical regression model was created for the study outcome using all significant univariate predictors.

RESULTS

The final sample included 10,577 reports detailing 29,471 adverse events and covering 1,473 reactions. The mean patient age was 48.4 ± 11.2 years, and nearly all patients were women (95.0%). The most commonly reported events were pain (9.3%), swelling (6.4%), and eyelid/brow ptosis (6.1%). Serious outcomes occurred in 13.5% of patients. In the multivariate model, serious outcomes were independently associated with older age, heavier weight, headache, allergy, vision changes, fatigue, facial paresis, and dizziness but notably were not associated with pain, swelling, or ptosis.

CONCLUSIONS

A wide range of alleged complications have been reported to the FDA, many of which were likely not mediated through injection or direct toxin effects. Patients may have inaccurately attributed some of their symptoms to BTX-A, and providers should be prepared to dispel any misinformation. Local complications such as pain, swelling, and ptosis were the most common reactions but were not associated with serious patient outcomes. However, constitutional symptoms should be approached more carefully.

New analgesic: Focus on botulinum toxin

In 2010, Kissin concluded pessimistically that of the 59 new drugs introduced in the fifty-year period between 1960 and 2009 and still in use, only seven had new molecular targets. Of these, only one, sumatriptan, was effective enough to lead to the introduction of multiple drugs targeting the same target molecules (triptans) (Kissin, 2010). Morphine and acetylsalicylic acid (aspirin), introduced for the treatment of pain more than a century ago, continue to dominate biomedical publications despite their limited effectiveness in many areas (e.g., neuropathic pain) and serious adverse effects. Today, are we really closer to ideal analgesics that would work hard enough, long enough, and did not have unwanted side effects? The purpose of the present article is to analyze where we are now. Several drugs, like long-acting opioids or botulinum toxins open some hope. Advantage of botulinum toxin A is unique duration of action (months). New discoveries showed that after peripheral application botulinum toxin by axonal transport reaches the CNS. Major analgesic mechanism of action seems to be of central origin. Will botulinum toxin in the CNS bring new indications and or/adverse effects? Much more basic and clinical research should be in front of us. Although relatively safe as a drug, botulinum toxin is not without adverse effect. Policy makers, clinicians and all those applying botulinum toxin should be aware of that. Unfortunately the life without the pain is still not possible.

Botulinum toxin injections associated with suspected myasthenia gravis: An underappreciated cause of MG-like clinical presentation

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BoNTA can diffuse to several muscles and result in myasthenia gravis symptomatology.

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BoNTA diffusion can result in increased jitter on single-fiber-EMG.

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Patients may not inform their physicians about the previous cosmetic use of BoTNA.

Introduction

The application of botulinum toxin type A (BoNTA) is accelerating, and this includes the uncontrolled cosmetic use of the BoNTA. Diffusion of BoNTA can disturb neuromuscular transmission in several surrounding and distant muscles and result in clinical manifestations similar to myasthenia gravis (MG).

Case presentations

We report two cases of patients referred for neurophysiological evaluation of suspected MG. A 55-year-old female who experienced dysphagia, dysarthria, right-sided ptosis, and neck extensor muscle weakness; and a 46-year-old male who presented with episodic double vision and right-sided ptosis. Both had the history of previous BoNTA use for cosmetic purposes and for the treatment of migraine before the presentation of their symptoms. In both cases examination revealed normal RNS, quite remarkably increased jitter, and signs of denervation and reinnervation in muscles surrounding the injection sites. After extensive neurophysiological evaluations, the primary cause of their symptoms was found to be related to previous BoNTA injections rather than a primary neuromuscular transmission disorder. It could also be concluded that patients do not automatically inform their physicians about cosmetic BoNTA use and they may not be aware of the potential risks associated with BoNTA therapy.

Conclusions

The presented cases illustrate the neurophysiological findings in two patients with suspected MG after the use of BoNTA and emphasize the importance of inquiring about previous BoNTA injections and highlight that it is essential that patients are informed about possible side effects of BoNTA therapy.

Botulinum toxin: Pharmacology and injectable administration for the treatment of primary hyperhidrosis

Hyperhidrosis is a dermatological condition defined by excessive sweating beyond thermoregulatory needs with significant effects on patients' quality of life. Hyperhidrosis is categorized as primary or secondary: primary hyperhidrosis is mostly focal and idiopathic, whereas secondary hyperhidrosis is commonly generalized and caused by an underlying medical condition or use of medications. Various surgical and nonsurgical therapies exist for primary hyperhidrosis. Although botulinum toxin is one of the deadliest toxins known, when used in small doses, it is one of the most effective therapies for primary hyperhidrosis. Botulinum toxin injections are widely used as a second-line primary hyperhidrosis treatment option once topical treatment strategies have failed. This article provides an overview of the commercially available botulinum toxin formulations and their applications in the treatment of primary hyperhidrosis.