Adverse effects of the aesthetic use of botulinum toxin and dermal fillers on the face: a narrative review

Abstract

Objective: To evaluate the adverse effects of facial aesthetic treatments using botulinum toxin and biomaterial implants.

Methods: The bibliographic research for this narrative review considered articles published in journals from the Medline, Pubmed, Embase and Lilacs databases with the following terms: "dermal fillers AND complications, vascular complications AND dermal fillers, adverse reaction, AND toxin botulinum and adverse reaction AND dermal fillers". Inclusion criteria were articles available in English on adverse events with the aesthetic use of botulinum toxin and dermal fillers/biostimulators.

Results: The demonstration of complications increases simultaneously with the progressive performance of facial aesthetic procedures. Quantitative statistics of the procedures and the countries that use them are skillfully classified, as well as the prosperity trends of these procedures. Complications do not receive the same relevance. There is a deficiency in dissemination of the information by the scientific community, or in other words, there is a publication bias in favor of successful results as opposed to adverse events.

Conclusion: The lack of knowledge about complications arising from so widely publicized and performed procedures prevents the development of evidence-based guidelines. Complications in aesthetic procedures have become a public health problem, an epidemic that occurs under the supervision of health authorities. Mandatory reporting of adverse events occurring in aesthetic procedures that require medical care aims to fill this gap. With reliable and technical data, it will be possible to identify the causes and perform interventions capable of minimizing irreversible sequelae and deaths. Complications should be promptly recognized by the dermatologist so that, when possible, they can be reversed or adequately managed.

Keywords: Biocompatible materials; Botulinum toxins, type A; Dermal fillers; Disease notification; Drug-related side effects and adverse reactions; Health planning guidelines; Hyaluronic acid.

Fig. 1

Hematoma in the right orbital arch immediately after application of BT with a 6 × 0.25 mm 31 G needle. There were two previous punctures.

Fig. 2

Contraction of occipitofrontalis muscle fibers after treatment of the glabrous portion of the frontal region. Probable lengthening of the superior frontal muscle with relative reduction of the epicranial aponeurosis.

Fig. 3

Loss of the ability to close the eyelids due to inadequate relaxation of the fibers of the inferior orbicularis muscle. Note: upper blepharoplasty scar.

Fig. 4

Urticarial reaction immediately after BT application.

Fig. 5

(A and B) Non-inflammatory infraorbital nodule 60 days after hyaluronic acid filling. (B) Four days after hyaluronidase treatment. Note: the brand of the product or the quantity injected were not known.

Fig. 6

(A‒D) Inflammatory nodule. After drainage with the presence of seropurulent secretion. (A and B) Left malar region. Palpable nodule around the entire perimeter delineated in white. Erythema, edema, increased local temperature and pain on palpation. Onset occurred 20 days after supraperiosteal hyaluronic acid filling, according to information from the professional who performed the procedure. (C and D) Drainage and cleaning of the cavity. Purulent, thick and odorless material. Scar with loss of volume in the drained region. Permanent (severe) adverse effect.

Fig. 7

(A‒D) Histopathology of the nodule. (A) Deep reticular dermis with mixed inflammatory and tuberculoid granulomatous infiltrate in palisade surrounding amorphous and eosinophilic material with the characteristics of hyaluronic acid (Hematoxylin & eosin, ×100). (B) Detail showing the palisaded tuberculoid granulomatous infiltrate (Hematoxylin & eosin, ×200). (C) Amorphous and eosinophilic material surrounded by intact and degenerated neutrophil leukocytes (Hematoxylin & eosin, ×200). (D) Strongly positive colloidal iron staining demonstrating hyaluronic acid. Colloidal iron, ×200.

Fig. 8

(A‒B) Appearance of nodules in the right malar region, 45 days after the procedure and 30 days after the appearance of the contralateral nodule, with the same characteristics. The patient was already taking broad-spectrum antibiotics due to the presence of the nodule on the left. It is worth noting that there are three nodules, probably at the implant injection sites.

Fig. 9

(A‒D) Inflammatory reactivation in sites treated with biomaterial after distant infection, in this case, tonsillitis. (C and D) Ultrasound appearance: increased vascularization around the biomaterial.

Fig. 10

Xanthelasma-like lesion.

Fig. 11

(A‒J) Evolution since the day of application (A); tissue suffering (B‒D). (E–J) Inflammation and necrosis.

Fig. 12

Aspiration positive for blood.