Aesth Plast Surg (2021) 45:1210–1220

https://doi.org/10.1007/s00266-020-01983-w

REVIEW NON-SURGICAL AESTHETIC

A Review of Complications Due to the Use of Botulinum Toxin

A for Cosmetic Indications
Nitin Sethi1 • Sukhbir Singh2 • Koenraad DeBoulle3 • Eqram Rahman4

Received: 14 August 2020 / Accepted: 5 September 2020 / Published online: 13 October 2020
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020

Abstract Results There are various injection-related adverse effects

Background Botulinum toxin A (botulinum toxin A) was associated (AE) with botulinum toxins such as erythema,
found to provide a wide variety of therapeutic and aesthetic oedema, pain, ptosis of eyelid or brow and ecchymosis.
benefits as one of the most potent toxins in the world. The overall majority of adverse events identified are mild
Injectable remedies, including soft tissue fillers and botuli- and temporary.
num toxin, have become very common in wrinkling and face Conclusion As the use of toxins becomes increasingly
rejuvenation management. While these methods of treat- more common, adverse events can be expected to increase
ment are relatively safe, serious side effects can occur. In as well. The practitioners need to be aware of such AEs,
this review, the complications of BoNTA are highlighted. and the patients should be informed of these before
Methods A literature research considered published jour- undertaking such procedures.
nal articles (clinical trials or scientific reviews). Electronic Level of Evidence III This journal requires that authors
databases (PubMed, Scopus, Science Direct) were searched assign a level of evidence to each article. For a full
using key terms, and for identification of additional rele- description of these Evidence-Based Medicine ratings,
vant studies, reference lists have also been examined. Only please refer to the Table of Contents or the online
articles published in English were included in this review Instructions to Authors www.springer.com/00266.
with a time restriction from 2000 to 2020.
Keywords Botulinum toxin A
Wrinkles
Complication

& Nitin Sethi Introduction

[email protected]
Sukhbir Singh Botulinum toxin A has been created from a toxin and is one
[email protected]
of the mammals’ most toxic poisons with a lethal dose of
Koenraad DeBoulle around one nanogram per kg body weight [1]. The thera-
[email protected]
peutic use of botulinum toxin was introduced about two
Eqram Rahman centuries ago when Justinus Andreas Christian Kerner
[email protected]
recognized the effect of botulinum toxin on skeletal mus-
1
Plastic and Cosmetic Surgery, Fortis Hospital Ludhiana, cles, and it’s a parasympathetic function [2].
Punjab 141001, India There are eight serologically distinct botulinum neuro-
2
Resplendent the Cosmetic Studio, R-9, GK-1, New Delhi toxins, A, B, C1, C2, D, E, F, G. Seven have been linked to
110048, India causing paralysis. Human botulism has often been associ-
3
Aalst Dermatology Clinic, Aalst, Belgium ated with Forms A, B, E and occasionally F and G.
4 Since the first reports in 1994 regarding the effective-
Department of Plastic and Reconstructive Surgery, University
College London and Royal Fre Hospital, Hampstead, London ness of botulinum toxin A for reducing the appearance of
NW3 2QG, UK facial wrinkles, it has been used extensively for various

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Aesth Plast Surg (2021) 45:1210–1220 1211

Fig. 1 Typical Memphisto appearance on the right side after injection in the glabella and central forehead area. View at maximum lifting of
brows. Indication of point of injection of a correction dose of BoNTA (indicated by pencil point). At maximum frown after correction

cosmetic indications [3]. Furthermore, since the approval manually. The keywords used for paper searching included
of botulinum toxin type A for glabellar frown lines by the. onabotulinumtoxinA, abobotulinumtoxinA, incobo-
Food and Drug Administration (FDA), the USA in 2002, tulinumtoxinA, AND ‘‘safety’’, AND ‘‘aesthetic’’, AND
injections of botulinum toxin type A have become the most ‘‘cosmetic’’. A manual search for additional potentially
commonly done aesthetic procedure [2]. applicable studies using references of selected included
Over the years, numerous companies started to manu- articles was also performed. Articles were reviewed, criti-
facture botulinum toxin A with different manufacturing cally appraised, and subsequently, data extraction was done
processes, characteristics and clinical behaviour, and as by the authors’ NS and SS, and any disagreement was
required by the US FDA are named differently [Onabo- resolved by senior authors KDB and ER.
tulinumtoxinA (BOTOXÒCosmetic, Abobotulinumtox-
inA (DysportÒ, Incobotulinum Toxin (Xeomin Ò) and
PrabotulinumtoxinA (JeuveauÒ)]. Result
Botulinum toxin is used to treat an ever-expanding array
of indications including glabellar frown lines, canthal smile A total of 63 studies were selected for this review, while a
lines, horizontal frontal lines, wrinkles around the lips total of thirty-eight studies were assessed to investigate the
(smoker’s lines) and marionette lines, platysmal bands in safety of botulinum toxin for various indications.
the neck besides being used for therapeutic indications like A PRISMA Flow chart for the selection of articles is given
strabismus, blepharospasm, cervical dystonia, hyperhidro- in Fig. 1. The total number of analysed patients was in
sis and synkinesis following facial surgery [4–6]. Not all 9398. The details of each study patient are reported in
indications are approved in all the countries and thus are Table 1. Headache was the most common adverse condi-
considered off label. These include, treatment of facial tion reported (5.38%) followed by hypersensitivity reaction
lines other than glabellar wrinkles, management of hyper- (2.90%) and nasopharyngitis (3.08%). The incidence of
trophic scars and keloids, rosacea, masseteric hypertrophy complications is given in Table 2. The incidence of adverse
and parotid gland hypertrophy [2–22]. events occurring with botulinum toxin A (BoNT-A) for-
While botulinum toxin is generally considered healthy, mulations used for the treatment of glabellar lines, crow’s
its extensive use and the continuously growing evidence feet and forehead lines are given in Tables 3, 4 and 5,
raise safety concerns. This paper aims to review the respectively.
reported complications associated with the cosmetic use of
Botulinum toxin.
Discussion

Material and Methods The use of botulinum toxin for various aesthetic indications
remains the most commonly done non-surgical aesthetic
A literature search was conducted using three electronic procedure globally. As more and more people from mul-
sources (PubMed, Scopus, Science Direct) from January tiple specialities and varying levels of experience start
2000 to January 2020. Only articles published in English inject the toxin, complications associated with the use of
were considered for this review with a time restriction from toxin are bound to increase and thus, having a thorough
2000 to 2020. Furthermore, the reference lists of each knowledge of the same would be very prudent in the near
potentially eligible study were evaluated and searched future. This article looks at a large number of cases (9398)

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Table 1 Clinical symptoms of 9398 BoNT- treated patients

Study Number of cases Age Adverse event

Bai 2018 86 BoNT 17–63 Headache 20.93%, Dizziness 79.07%, Insomnia 38.37%, Fatigue 86.05%, Blurred
[23] invasion 83.72%, Difficult eyes open 72.09%, Unclear articulation 43.02%,
Dysphagia 70.93%, Drink bucking 40.70%, Constipation 17.44%, Anxiety
41.86%, Nasal feeding 24.42%, Prejudice in normal life 30.23%
Carruthers 203 BoNT-A 61 placebo 18–75 Headache (15.3% vs 15.0%), respiratory tract infection (4.9% vs 8.3%),
2002 [24] blepharoptosis (5.4% vs 0.0%), back pain (1.5% vs 5.0%), acne (1.0% vs 5.0%)
Carruthers 202 BoNT-A 71 placebo 18–75 Headache (11.4% vs 20.0%), blepharoptosis (1.0% vs 0.0%), erythema (3.0% vs
2003 [25] 2.9%), oedema (0.5% vs 4.3%), nausea (2.5% vs 2.9%), dizziness (1.5% vs
2.9%), pain (2.0% vs 1.4%), paresthesia (2.0% vs 1.4%), infection (2.0% vs 0%)
Fagien 2007 34 BoNT-A 31 placebo 30–54 Bruising in injection area in one patient
[26]
Harii 2008 91 BoNT-A (1:1) 49 20–64 Blepharoptosis (2.2% vs 0.0%), heavy eyelids (12.1% vs 2%)
[27] placebo
Wu 2009 170 BoNT-A 57 placebo 18–65 Headache (8.8% vs 1.7%), abnormal sensation in eye (5.3% vs 0.0%), ptosis (0.6%
[28] vs 0%), nasopharyngitis (1.8% vs 0%), diarrhoea (1.2% vs 0%), site pain (1.2%
vs 0%), somnolence (1.2% vs 0%), influenza (1.2% vs 0%), eyelid oedema
(1.8% vs 0%), swollen face (1.8% vs 0%)
Dailey 2011 45 BoNT-A 58 BoNT-A 30–50 35–60 None Headache (12%), soreness or itching at injection site (5%), pressure (2%)
[29]
Stotland 58 BoNT-A 35–60 Headache (12%), soreness or itching at injection site (5%), pressure (2%)
2007 [30]
Carruthers RCT: 80 BoNT-A, of 16–65 Headache (RCT, 11.2%; OL, 7.5%), migraine and tension of forehead (1.2%
2005 [25] which 50% OL enrolled each), eyebrow ptosis (2.5% in both trials), pain upper nose (1.2%), tension
above eyes (OL, 5.0%), tension upper nose (OL, 2.5%)
Kawashima 363 BoNT-A (1:1) 20–64 Abnormal sensation in eye (6.7–11.5%), headache (4.9–7.2%), blepharoptosis
2009 [31] (3.3–4.4%), pruritus (2.7–4.4%), discomfort (2.2–4.4%), pain (1.1–4.4%)
Asher 2004 102 BoNT-A (1:1:1) 17 18–70 Headache, migraine, vertigo, forehead rigidity, forehead muscle spasm (25 and 50
[32] placebo U, 2.9% each vs 0% placebo), forehead ecchymosis (50 U, 2.9% vs 5.9%); no
adverse events in BoNT-A 75 U
Brandt 2009 105 BoNT-A 53 placebo 19–75 Headache (10% vs 8%), eye disorders (9% vs 8%) of which ptosis (3% vs 0%),
[33] blepharospasm (1% vs 4%), nasopharyngitis (11% vs 11%)
Cohen 2009 1,415 BoNT-A B 65, Nasopharyngitis (12.1% fixed, 3.0% variable dose), headache (5.8% fixed, 4.2%
[34] 93% [ 65, variable dose), upper respiratory tract infection (5.7% fixed, 2.8% variable dose),
7% sinusitis (6% fixed, 1.2% variable dose), ptosis (1% fixed, 2% variable dose), dry
eye and eyelid oedema (1% of patients)
Rubin 2009 311 BoNT-A 155 placebo 21–74 Nervous system disorders (17% vs 3%), headache (12% vs 3%), nasopharyngitis
[35] (10% vs 4%), eye disorders (7% vs 3%), sinusitis (4% vs \ 1%), injection site
pain (4% vs \ 1%) or bruising (4% vs 4%), influenza (3% vs \ 1%), acne (3%
vs 0%)
Kane 2009 544 BoNT-A 272 placebo 20–80 Headache (2% vs 3%), ptosis (2% vs 0%), injection site disorders (6% vs 5%)
[36]
Moy 2009 1200 BoNT-A 18–65 Injection site events (18%); nervous system disorders (14%), of which headache
[37] (12%); ocular events (9%), of which ptosis (4%)
Monheit 279 BoNT-A 94 placebo 20–76 Headache (16.8% vs 10.6%), nasopharyngitis (8.6% vs 8.5%), ptosis (0.8%)
2007 [38]
Rzany 2006 146 BoNT-A 75 placebo 18–75 30 U: Hypoesthesia, injection site discomfort, subjectively heavy eyelids, Spock
[39] eyebrow (BoNT-A, 4.1%), headache and pyrexia (placebo, 5.4%)
Imhof 2011 105 BoNT-A 18–65 Nervous system disorders (3.8%), of which headache (2.9%)
[40]
Lowe 2005 120 BoNT-A (1:1:1:1) 32 18–65 Infection (primarily common cold; average 11.5% vs 15.6%), injection-site
[41] placebo bruising (average 9.2% vs 12.5%), headache (average 6.9% vs 3.1%), sinusitis
(average 2.3% vs 6.3%), pharyngitis (average 3.9% vs 3.1%)
Lowe 2002 60 BoNT-A (1:1:1) 35–60 Bruising (11–25%)
[42]
Levy 2004 25 BoNT-A 31–65 Oedema of the lower lid (0.4%)
[43]

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Table 1 continued
Study Number of cases Age Adverse event

Ascher 2009 164 BoNT-A (1:1:1) 54 placebo 18–65 Periorbital hematoma (10% of all subjects), eyelid ptosis
[44] (45 U 0.4%), nasopharyngitis, depression, and bronchitis
(no% indicated)
Carruthers 2007 20 BoNT-A 20 placebo 18–65 Tight feeling across forehead and pulling lines on upper
[45] outer eyelids (10%), heaviness in eyebrow or eyelid
tightness across forehead, occasional muscle spasm in
forehead (5% each side effect); no ptosis
Carruthers 2003 59 BoNT-A (1:1:1) 18–50 Headache (average 22%), bruising (average 10.2%),
[46] eyebrow swelling (average 20.3%), eyebrow ptosis (48
U, 10%; 32 U, 21%
Carruthers et al. 60 BoNT-A (1:1:1) 18–65 Brow ptosis (average 8.3%), skin tightening (average
2009 [47] 6.7%), eyelid swelling (average 6.7%), headache
(average 5.0%); tendency to greater brow ptosis at
higher doses
Bulstrode 2002 52 BoNT-A 23–75 Brow ptosis (22/25), brow lift (2/25)
[48]
Bowler 2005 290 BoNT-A 13–78 Adverse events in 7% of patients, of which mild bruising
[49] (7/20), headaches (6/20), and transient brow heaviness
(7/20)
Carruthers 2007 20 BoNT-A (1:1) 46.3 (group 1) 47.4 Group 1: head colds (2/10), sinus congestion (1/10) Group
[50] (group 2) 2: head cold (1/10), chest infection requiring antibiotics
(1/10)
Ghalamkarpour 40 BoNT-A (1:1) Median 35 None
2009 [51]
Farahvash 2007 115 BoNT-A 20–79 Ecchymosis (8.7%), mild swelling (13%), eyelid ptosis
[52] (15%)
Rzany 2007 945 BoNT-A 21–84 Local bruising (1.25%), lid or brow ptosis (0.46–0.51%),
[53] dry eye or vision disturbance (0.12%), headache (0.1%)
(% of treatment cycle)
Carruthers 2010 30 BoNT-A 30 HA gel 30 BoNT- 35–55 Definitely related to treatment, 6.7%: BoNT-A: elevation
[54] A ? HA gel of lower lip (1), overacting right lower lip depressors
(1), weakness in right depressors (1), or lip (1),
asymmetry of lower left lip (1) HA gel: pain from
swelling at treatment site (1) BoNT-A ? HA gel: lip
swelling (1), muscle weakness, mouth corner (1)
Possibly related to treatment, * 10%: BoNT-A:
occasional chin muscle spasm (1) HA gel: cold sore (1)
BoNT-A ? HA gel: numbness, mouth area (1)
Liew 2008 [55] 34 BoNT-A, Western women (study 10–18 months (study Study group: muscle bulge at angle of mandible (1
group) 48 BoNT-A, East Asian group) 10–24 months unilateral, 1 bilateral, 5.9%), changes of facial
women (control group) (control group) expression and reduction of width of mouth upon
smiling (5.9%), worsening of jowls (2.9%). Control
group: weakness in chewing (6.2%)
Redaelli 2008 95 HA 45% also received BoNT-A 22–67 Common swelling and slight hematoma (no%)
[56]
Mazzuco and 16 BoNT-A (4 groups of different Asymmetric smile (6.2%), difficulty smiling and sad
Hexsel 2010 injection sites) Smile (6.2%)
[57]
Zang 2019 [58] 576 BONT-A 32–50 Slight stiffness (34.02%), Mild Bruising (3.8)
Boulle 2020 1144 BONT A Headache (11.4%), Nasopharyngitis (8.3%), Injection site
[59] bruising (7.4%), upper respiratory tract infection (4.3%),
Injection site hematoma (3.8%), Sinusitis (3.2%),
Eyebrow ptosis (2.6%), Influenza (2.2%), Eyelid ptosis
(1.8%), Oral herpes (1.5%)

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Table 2 Incidence of adverse events occurred in 9398 BoNT- treated Table 3 Incidence of adverse event occurred with Botulinum Toxin
patients A (BoNT-A) Formulations used treatment for Glabellar Lines
Event Case no. Percentage incidence Event Case no. Percentage incidence

Headache 506 5.38 Headache 324 23.23

Dizzeness 71 0.76 Dizziness 3 0.22
Insomnia 33 0.35 Difficult in eye opening 62 4.44
Fatigue 75 0.80 Respiratory tract infection 90 6.45
Blurred invasion 72 0.77 Blepharoptosis 28 2.01
Difficult in eye opening 124 1.32 Acne 3 0.22
Unclear articulation 37 0.39 Erythema 6 0.43
Dysphagia 61 0.65
Oedema 15 1.08
Drink buking 35 0.37
Nausea 5 0.36
Constipation 15 0.16
Pain 12 0.86
Anxiety 36 0.38
Paraesthesia 4 0.29
Nasal feeding 21 0.22
Infection 4 0.29
Prejudice normal life 26 0.28
Bruising 1 0.07
Respiratory tract infection 90 0.96
Heavy eye lid 12 0.86
Blepharoptosis 28 0.30
Eye brow ptosis 31 2.32
Acne 3 0.03
Erythema 6 0.06 Eye lid ptosis 2 0.14
Oedema 30 0.32 Diarrhoea 1 0.07
Nausea 5 0.05 Hypersensitivity reaction 261 18.71
Pain 12 0.13 Migraine 1 0.07
Paraesthesia 4 0.04 Pain in upper nose 1 0.07
Infection 4 0.04 Tension above eyes 4 0.29
Bruising 51 0.54 Tension in upper nose 2 0.14
Heavy eye lid 28 0.30 Pruritus 10 0.72
Nasopharyngitis 96 1.02 Discomfort 8 0.57
Diarrhoea 1 0.01 Nasopharyngitis 238 16.99
Hypersentivity reaction 273 2.90 Sinusitis 84 6.02
Migraine 1 0.01 Nerve system disorder 52 3.73
Pain in upper nose 1 0.01 Influenza 12 0.86
Tension above eyes 4 0.04 Acne 12 0.86
tension in upper nose 2 0.02
Eye lid ptosis 39 0.41
to study the safety of toxin used for various aesthetic
Eye brow ptosis 92 0.98
indications. The incidence of most of these indications
Pruritus 10 0.11
remains low, and most of the times, these complications are
Discomfort 8 0.09
mild, reversible and self-limiting.
Nasopharyngitis 237 2.52
Headache, which was frequently reported, may be
Sinusitis 124 1.32
related to the injection procedure for different causes, such
Nerve system disorder 52 0.55
as periosteal trauma or intramuscular hematomas, anxiety
influenza 12 0.13
in new patients and temporary muscle spasm. Still, a few
Acne 12 0.13
episodes of long-lasting headaches after forehead and
Bruising 16 0.17
glabellar injections have been reported [60, 61].
Ecchymosis 10 0.11
Elevation of lower lip 1 0.01
Overacting right lower lip 1 0.01
Stiffness 196 2.09
Allergic and Hypersensitivity Reactions
UTRI 49 0.52
Injection site hematoma 43 0.46
Careta et al. reported the allergic response to Chinese
Influenza 25 0.27
botulinum toxin serotype A (CBTX-A) [21]. Although this
Oral herpes 17 0.18
is a rare adverse event for an injector, it is clinically
significant.

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Table 4 Incidence of adverse event occurred with botulinum toxin A

(BoNT-A) formulations treatment for lower face rhytides
Event Case no. Percentage incidence

Fatigue 1 0.05
Oedema 14 0.78
Bruising 21 1.18
Heavy eye lid 16 0.9
Eye brow ptosis 28 1.57
Eye lid ptosis 17 0.96
Hypersensitivity reaction 12 0.67
Sinusitis 3 0.16
Ecchymosis 10 0.56
Elevation of lower lip 1 0.05
Overacting right lower lip 1 0.05 Fig. 2 Typical ‘‘Mephisto’’ appearance on right side after injection in
glabella and central frontal area, view at max lifting of brows—
indication of point for injection of a correction dose of BoNTA
(indicated by pencil point)—at max frown after correction of
Mephisto appearance. (Image courtesy Dr. K De boulle)
Table 5 Incidence of adverse event occurred with Botulinum Toxin
A (BoNT-A) Formulations Treatment for crow’s feet and forehead
lines Other confounding factors like reactions to benzyl alcohol,
bacteriostatic saline or antiseptic solutions used to disinfect
Event Case no. Percentage incidence
the skin before the procedure need to be taken into account.
(BoNT-A) formulations treatment for forehead lines
Headache 153 8.47
Dizzeness 68 3.77 Injection Site Reactions
Insomnia 33 1.83
Fatigue 74 4.10 They include local oedema, erythema, bruising, pain at the
Blurred invasion 72 3.99 injection and adjacent sites. Bruising can be limited by
Difficult in eye opening 62 3.43 using a small gauge needle and paying close attention to
Unclear articulation 37 2.05 the superficial vessels, especially around the lateral canthus
Dysphagia 61 3.38
region. The application of cold compression can also
Drink Buking 35 1.94
reduce bruising. Some patients may complain of dull and
Constipation 15 0.83
transient headaches with malaise following botulinum
toxin injection. However, severe reactions such as ana-
Anxiety 36 1.99
phylaxis, soft-tissue oedema and dyspnoea are rare in
Nasal Feeding 21 1.16
occurrence. In a multicentre, double-blind, randomized,
Prejudice normal life 26 1.44
placebo-controlled, parallel-group study (BoNT-A vs pla-
Bruising 85 4.71
cebo), the incidence of erythema was 3.0% vs 2.9% and for
Stiffness 196 10.85
oedema was 0.5% vs 4.3% (Table 1) [58]. In the present
Eyebrow ptosis 30 1.66
review, however, the incidence of erythema and oedema
Eyelid ptosis 20 1.11
are 0.06% and 0.036%, respectively (Table 2).
Upper respiratory tract infection 49 2.71
Injection site hematoma 43 2.38
Oral herpes 17 0.94
Muscle-Related Complications
(BoNT-A) formulations treatment for crow’s feet
Oedema 1 0.4 Ptosis
Eye Brow Ptosis 1 0.4
Bruising 7 2.81 Ptosis of eyelid or eyebrow is defined as the downward
displacement of these anatomical entities due to distur-
bance in the agonist and antagonist muscle functions. This
Hypersensitivity reactions, although reported rarely, complication can occur as a result of the treatment of the
need to be determined, if they are type I or type IV frontalis muscle for addressing horizontal forehead lines or
hypersensitivity reactions or pseudo-allergy reactions. the procerus/corrugator complex for treatment of frown

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Fig. 3 Typical spread of BoNTA into left muscle depressor labii inferioris, with consequent inability to lower the left side of the lip creating an
asymmetric smile. (Image courtesy Dr. K De boulle)

Fig. 4 Upon injection of crow’s feet spread of BoNTA into the lifting muscles of corner of the mouth, resulting in aberrant smile, drooping of
the corner of the mouth, and accentuation of the marionette line. (Image courtesy Dr. K De boulle)

lines with botulinum toxin. It results from the passage of Eyebrow Ptosis
the toxin through the orbital septum (eyelid ptosis) or due
to the weakness of the lower fibres of the frontalis muscle The incidence of brow ptosis has been recorded from 1%–
(brow ptosis). 2% to as much as 50%, with an average of 13.4%. This

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Fig. 5 Injection into the

masseter muscle to reduce Records idenfied through Addional Record idenfied

Idenficaon
hypertrophy resulting in abscess database searching (n=25)
formation at the injection sites. (n=1284)
The abscesses were resistant to
routine antibiotic treatment and
needed drainage and anti-
tubercular treatment to resolve
the problem. (Image courtesy Records aer Overlapping/duplicates
Dr. Ruchi Mutneja and Dr. Nitin removed (n =21)
Sethi)

Screening
Records screened Records excluded
(n = 1288) (n = 1225)

Full-text arcles assessed Full-text arcles excluded,

for eligibility with reasons
Eligibility

(n = 63) (n = 0)
Included

Studies included in final

Review
(n = 63)

problem can be prevented by remaining at least 2–3 cm suffer from such a complication have to wait for several
above the supraorbital margin or 1.5–2 cm above the weeks until the effects of the toxin wear off. In this series
eyebrow when injecting into the frontalis muscle. This of cases, the author advocated the use of apraclonidine eye
technique saves the role of the lower frontal muscle fibres drops as a treatment option to reverse the eyelid ptosis [14].
in the area, preventing eyebrow ptosis [12]. The overall incidence of eyelid ptosis in our study is
Botulinum toxin treatment of the brow depressors pro- 0.71% and eyebrow ptosis 0.98% (Table 2). The investi-
duces a small degree of brow elevation in the majority of gators attributed the substantial reduction in the rate of
the patients. The eyebrow is a mobile structure, elevated by adverse events over the 10-year duration of treatment to
the frontalis muscle. The medial brow depressors are cor- clinical experience and improved injection technique [16].
rugator supercilli, depressor supercilli, procerus and the
medial portion of orbicularis oculi whilst the lateral portion Brow Shape Abnormalities
of orbicularis oculi is responsible for depressing the lateral
brow [13]. To avoid this complication, it is advisable to Brow asymmetries post-injection are quite commonly
treat the elevator and the depressors at the same time, to reported and are often the result of improper injection
avoid unopposed action of one group of muscle. procedures or occasionally result due to anatomical dif-
ferences in the patient. The ‘‘Memphisto’’ eyebrow or
Eyelid Ptosis more popularly known as the ‘‘Spock’’ brow after the
popular Hollywood character Mr Spock, is one of the
A case series by Ferreira reported that the complications most common asymmetries reported. This is a devilish
experienced by patients were probably caused by the dif- curvature of the lateral portion of the brow, which hap-
fusion of the botulinum toxin to the levator palpebrae pens when the central frontalis is disabled, but the lateral
superioris muscle and the extrinsic muscles of the eye, side frontalis is still functional and raises the brow tail
leading to eyelid ptosis and diplopia [15]. Patients who only. (Fig. 2).

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1218 Aesth Plast Surg (2021) 45:1210–1220

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lines: a review. Plast Reconstr Surg-Glob Open 8(3):e2669 jurisdictional claims in published maps and institutional affiliations.

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