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. 2022 Apr 12;42(5):NP327-NP336.
doi: 10.1093/asj/sjac036.

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis

David Zargaran  1 , Florence Zoller  1 , Alexander Zargaran  2 , Eqram Rahman  1 , Alexander Woollard  1 , Tim Weyrich  3 , Afshin Mosahebi  1
Affiliations

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis

David Zargaran et al. Aesthet Surg J. .

Abstract

Background: Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health.

Objectives: The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate.

Methods: A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed.

Results: Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%.

Conclusions: Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications.

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Figures

Figure 1.
Figure 1.
Flow chart of the reviewing process.
Figure 2.
Figure 2.
Forest plot. Complication rate of botulinum toxin A.
Figure 3.
Figure 3.
Forest plot. Complication rate of onabotulinum toxin.
Figure 4.
Figure 4.
Forest plot. Complication rate of incobotulinum toxin.
Figure 5.
Figure 5.
Forest plot. Complication rate of abobotulinum toxin.
Figure 6.
Figure 6.
Forest plot. Complication rate placebo.
Figure 7.
Figure 7.
Forest plot. Complication rate of onabotulinum toxin and placebo.
Figure 8.
Figure 8.
L’Abbé plot. Complication rate of onabotulinum toxin and placebo.
Figure 9.
Figure 9.
Forest plot. Complication rate of abobotulinum toxin and placebo.
Figure 10.
Figure 10.
L’Abbé plot. Complication rate abobotulinum toxin and placebo.
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