Negative emotional impact following botulinum toxin treatment for crow's feet lines

Abstract

So far, studies addressing the negative psychological effects of crow's feet treatment with botulinum toxin A (BoNTA) have rarely been published. BoNTA causes neuromuscular paralysis through a process of chemical denervation, temporarily preventing muscle contraction. The ability of botulinum toxin to alleviate dynamic wrinkles was coincidentally discovered after treating patients for benign essential blepharospasm in 1987.1 Since then, it has been widely used in cosmetic dermatology to reduce wrinkles and rejuvenate the skin. We report the cases of three female patients who presented with negative emotional complaints following BoNTA treatment for crow's feet. A 34-year-old Caucasian woman presented 14 days after the first BoNTA treatment. She reported having been injected with onabotulinumtoxinA (10 units per side) in the lateral part of the orbicularis oculi muscles on both sides. She reported a history of depression, treated with citalopram. The injection pattern was 3-4-3 U (Figures 1a and 2). A 28-year-old Caucasian woman presented 12 days after the first BoNTA treatment. She was injected 20 units of incobotulinumtoxinA (10 units per side) in the lateral part of the musculus orbicularis oculi. Her medical history was not relevant for previous diseases. The injection pattern was 3-4-3 U (Figure 1a). A 56-year-old Caucasian woman presented 10 days after the first BoNTA treatment. In this case, she was injected 50 units of abobotulinumtoxinA (25 units per side) in the lateral part of the musculus orbicularis oculi. Her medical history was only relevant to smoking. The injection pattern was 10-10-10 U (Figure 1b). All three cases were attended in our specialised outpatient clinic at Erasmus MC for complications of injectables, reporting a non-natural smile after BoNTA treatment. All patients reported a mental impact in the form of sadness, distress and insecurities, and a socio-psychological impact manifested as limitations in their daily functions, such as going to work or even going outside. All patients stated that their emotional status was normal before the treatment. Physical examination revealed complete paralysis of the lateral part of the orbicularis oculi muscles, resulting in a non-smooth transition with a crease between the lower eyelid and the cheek area (Figure 2). After explaining the anatomy of this area, mechanisms of action and temporary effect of BoNTA, the patients were reassured with a biweekly follow-up. Upon smiling, the zygomaticus major muscles contraction lifts a ‘shelf’ of cheek tissue and rhytids that stops abruptly as it transitions into the smooth paralysed lateral orbital area.2 Among older patients, this effect can be accentuated and even visible at rest, due to the excess skin in the lower lid.3 For most people, this muscle is also an accessory upper cheek elevator. When the lower portion of the lateral orbicularis oculi is totally paralysed, a small loss of upper cheek elevation is observed, resulting in a weaker facial feedback effect.3, 4 The injection pattern used in all three cases was similar (Figure 1a,b) and the doses between the different toxins were equivalent, reflecting a standardised practice in many current medical settings. Published guidelines for the use of BoNTA are an excellent starting point and an important tool for clinicians with little experience; however, each practitioner is likely to develop their own algorithm for facial rejuvenation procedures.5 Different injection patterns and new techniques, such as the microdroplet technique for BoNTA treatment on crow's feet, may possibly achieve a smoother transition between treated and non-treated areas for a more harmonious and natural outcome.6 Besides, appreciation for the aesthetic result desired by the patient, clear explanations about the mechanism of action of BoNTA and appropriate management of expectations result in a better doctor–patient communication and higher patient satisfaction. We think that the negative psychological effects of BoNTA treatment are under-reported. Although temporary, these effects can be very distressing and may lead to decreased client retention. The report of these cases should raise awareness about the importance of a personalised treatment plan for each patient, based on a deep understanding of the patient's unique characteristics combined with appropriate doctor-patient communication. The authors declare no conflict of interest. The patients in this manuscript have given written informed consent to the publication of their case details. I had full access to all the data in the study and I take responsibility for the integrity of the data and the accuracy of the data analysis as well as the decision to submit for publication.