arTICle | boTulInum ToxIn A |
Figure 15 Note the erythema and edema in the pattern of the injections 10 minutes after a
treatment of onabotulinum- toxinA of the
forehead and glabella
closure can occur when onabotulinumtoxinA diffuses
into the palpebral portion of the orbicularis oculi, causing undue eyelid weakness. Asymmetry is a minor adverse sequelae that sometimes
is unavoidable, particularly when a patient is treated for the first time with onabotulinumtoxinA. There are three types of asymmetry, most of which can be corrected with injections of onabotulinumtoxinA; iatrogenic; idio- syncratic; and incidental or acquired. An example of incidental or acquired asymmetry is bell’s or facial (7th cranial) nerve palsy, or when one side of the face acquires a weakness because of an illness (e.g. cerebral vascular accident), or an accidental or traumatic injury. This type of asymmetry is the least correctible by injections of bonT. Idiosyncratic asymmetry occurs when a person is born with the inability to control or move a facial muscle to its fullest extent, while its counterpart muscle on the contralateral side of the face is unaffected. This can result, for example, in one eyebrow or eyelid being higher than the other (Figure 13). The best way to avoid additional difficulties
Figure 14 (A) This 57-year-old patient with compensatory left brow lifting before treatment with onabotulinumtoxinA injections. (B) Same patient 2 weeks after onabotulinum- toxinA demonstrates a slight pseudoblepharoptosis on the left
asymmetry is a minor adverse sequelae that
with patient rapport and confidence is to keep carefully documented written and photographic clinical notes. Discuss the physical findings with the patient and point out existing idiosyncratic asymmetries, anatomical differences, and potential adverse outcomes prior to treatment. Informing the patient of such findings before any treatment commences always is considered by the patient an accurate diagnosis of a unique situation. Explaining the circumstances and reasons for a particularly poor outcome after treatment always is considered by the patient an excuse for an improperly executed therapeutic procedure. Iatrogenic asymmetry arises when an injection of
onabotulinumtoxinA causes one side of the face to become weaker than the other (Figure 14a). The primary reason for this occurring after an injection of onabotulinumtoxinA is
sometimes is unavoidable, particularly when a patient is treated for the first time with onabotulinumtoxina.
when the stronger side is not injected with the equivalent dose of onabotulinumtoxinA as the contralateral side. This could be the result of the onabotulinumtoxinA not diffusing as equally and completely through all the fibers of a muscle or group of muscles. Another reason could be that some of the fibers might have been physically resistant to the onabotulinumtoxinA, because those particular fibers were idiosyncratically thicker or stronger than the rest of the area and may have required a higher dose of onabotulinumtoxinA. Another possibility is that the injection was not given precisely symmetrically or in the thickest and strongest part of the muscle, causing a particular section of muscle to retain most or some of its strength. Iatrogenic asymmetry is probably the easiest to rectify. Generally with a few additional units of onabotulinumtoxinA injected into the appropriate area, iatrogenic asymmetry can be easily and expeditiously ameliorated (Figure 14b).
General side effects other untoward sequelae of more limited significance and duration can occur. These are the same adverse sequelae as those
experienced with any type of subcutaneous or intramuscular injection. They include ecchymoses, edema, and erythema at the injection sites (Figure 15), headache, and flu-like malaise. Rarely, if ever, do any of these side effects last beyond the day of the treatment, except for ecchymoses, which can last up to 10 days or more. For some patients, a dull and transient headache with or
Figure 16 This 43-year-old patient at rest before and 2 weeks after an onabotulinum- toxinA treatment of the glabellar frown lines
46 ❚
without general body malaise occurs after injections of onabotulinumtoxinA that can last beyond 24–72 hours *b. The occurrence of headache immediately after an onabotulinumtoxinA injection seems paradoxical since onabotulinumtoxinA injections also are used to treat tension and migraine headaches by neurologists and other medical specialists. Headaches seem to occur more frequently in first time patients after their initial and subsequent treatment sessions. They stop occurring with repeat treatments, usually after the third, fourth or fifth treatment session. Also, for the first time recipient of a periorbital treatment of onabotulinumtoxinA, the presence of periorbital edema lasting a few hours to days may occur. This could be attributed to lymph stasis, possibly produced by a non-detectable attenuation of the sphincteric pumping action of the orbicularis oculi, reducing the efficiency of lymph fluid clearance from the surrounding soft tissue. Serious reactions, particularly those of immediate
March 2011 |
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