Table 3.

Summary of Common BoNT Complications and their Management

	Complications	Management of Complications
Local injection reactions	Pain	Ice, EMLA cream, slow injection technique, pinching, use of smaller needles
	Swelling and bruising	Ice, arnica, avoidance of blood thinners and NSAIDs
	Erythema	Ice
	Headache	Analgesics
	Infection	Aseptic injection technique, antibiotics (topical or oral)
Distant spread from injection site	Ptosis	Injection technique, apraclonidine 0.5% (Iopidine) or phenylepherine hydrochloride 2.5% (Neosynephrine) ophthalmic solution
	Dysphagia or dysarthria	Very rarely requires hospitalizations and tends to self-resolve in a few weeks. Avoid injection into sternocleidomastoid muscle. Symptomatic management and monitoring is key
	Unsatisfactory aesthetic results	Self-limiting. Reassure patient
	Ophthalmic emergencies (ie, acute angle closure glaucoma, retinal detachments)	Emergency medical management
	Respiratory complications (upper respiratory infection, increased cough)	Symptomatic management but emergency medical management if severe
	Urinary complications (urinary tract infections, urinary retention)	Screenings for infection before treatment. Prophylactic antibiotic use
Systemic involvement	Hypersensitivity reaction	Antihistamine, steroids, epinephrine
	Antibodies against botulinum toxin	Patients typically build resistance to treatment. They may require more units for effect or fail to respond to treatment overall. This is non-life-threatening and does not need intervention. May be prevented by avoiding shorter dosing intervals and higher dosages per injection cycle
	Systemic botulism	Avoid any medications that may potentiate botulinum toxin effects (ie, aminoglycosides, quinidine, anticholinergics, muscle relaxants). Emergency medical management

Many of these adverse reactions are self-limiting and can be prevented with proper injection technique. However, it is important to be aware of more serious potential complications to timely manage them.