Journal Logo


Botulism due to Cosmetic Injection of Botulinum Toxin: Five-Year Experience

Chen, Zong M.D.; Chen, Zhi-You M.D.; Liu, Wen-Hui M.D.; Li, Guang-Shuai M.D.

Author Information
Plastic and Reconstructive Surgery: August 2021 - Volume 148 - Issue 2 - p 335e-337e
doi: 10.1097/PRS.0000000000008173
  • Free

Botulism is characterized by rapid paralysis of the neuromuscular system, which develops into severe dysphagia and dyspnea.1 Cosmetic injection–induced botulism is a type of botulism that has appeared gradually thanks to the growth of cosmetic medicine in recent years. It differs from other types of botulism (foodborne, infant, and wound) in that patients receive direct injections of botulinum toxin without the presence of Clostridium botulinum infection.2 However, specific diagnostic and treatment methods for cosmetic injection–induced botulism have not been elucidated. Clinical experience is the main way to diagnose and treat it. Therefore, it is a considerable challenge for plastic surgeons. We retrospectively reviewed the medical procedures for patients with botulism caused by cosmetic injection admitted to our department in the past 5 years. In this way, we aimed to share our experience diagnosing and treating cosmetic injection–induced botulism. The present study was approved by our hospital’s ethics committee.

Thirty-one patients (all women) were identified. Their mean age was 35 years (range, 25 to 50 years). Nearly half of them did not know the dose of botulinum toxin administered. Most patients did not know the brand of botulinum toxin that had been administered, or could not confirm that it was a legitimate product. Nearly half of patients developed clinical symptoms within 24 hours, whereas the incubation period of cosmetic injection–induced botulism for most patients was 48 hours or less (Table 1). Neuromuscular symptoms (e.g., limb weakness, ocular symptoms, pharyngeal symptoms, and dyspnea) were common, as were nonspecific symptoms (e.g., dizziness and fatigue) (Table 1). Symptoms were acute and bilateral but did not develop downward in all cases. Seventeen patients had mild botulism, nine had moderate botulism (with dysphagia or severe diplopia), and five had severe botulism (with dyspnea). There were no significant abnormalities found in patient examinations, except that electromyography showed repetitive nerve stimulation in five patients, with strength of the gastrocnemius muscle of grade less than or equal to 3.

Table 1. - Clinical Symptoms, Incubation Period, and Proportion of Patients with Cosmetic Injection–Induced Botulism
Clinical Symptoms No. of Cases Percentage Incubation Period No. of Cases Percentage
Blurred vision 27 87.10% <24 hours 15 48.39%
Dizziness and fatigue 22 70.97% 2 days 7 22.58%
Limb weakness 21 67.74% 3 days 2 6.45%
Dysarthria 15 48.39% 4 days 1 3.23%
Diplopia 12 38.71% 5 days 3 9.68%
Ptosis 11 35.48% 6 days 1 3.23%
Dysphagia 10 32.26% 7 days 2 6.45%
Constipation 7 22.58% >8 days 0 0
Dyspnea 5 16.13%
Tinnitus 4 12.90%
Palpitations 3 9.68%

Treatment included botulinum antitoxin, 3,4-diaminopyridine (3,4-DAP), therapy (antistress, with dexamethasone and vitamin C; prometabolism, with phosphocreatine and vitamin B6; neurotrophic, with gangliosides), and symptomatic support. Patients were encouraged to mobilize as early as possible, since increasing muscle activity is associated with promoting metabolism of botulinum toxin.3 The injection dose was limited in patients with cosmetic injection–induced botulism, which is a different scenario than that of continuous production of botulinum toxin after C. botulinum infection. Therefore, for cosmetic injection–induced botulism, the amount of botulinum antitoxin used would be much smaller. Ten patients with mild botulism who were administered antitoxin had significantly shorter hospitalizations than the seven patients who were not administered antitoxin (11.85 ± 2.85 days versus 9.10 ± 2.33 days, p < 0.05). The mean dose of botulinum antitoxin was 9.46 × 104 U (range, 6 to 17 × 104 U) over 24 patients. Antitoxin therapy showed a marked effect, even after 72 hours; in most cases, symptoms were markedly relieved after antitoxin administration. Hence, we speculate that for cosmetic injection–induced botulism, botulinum antitoxin has more than just a neutralizing effect. The mean duration of hospitalization was 13 days (range, 7 to 38 days). With a mean follow-up duration of 11 months (range, 6 to 24 months), all clinical symptoms disappeared in 4 to 6 months, except for a few cases of dizziness or tinnitus.

In conclusion, plastic surgeons should pay more attention to (1) the mental health and improving negative emotions of patients with cosmetic injection–induced botulism; (2) providing information on cosmetic procedures to enhance patients’ understanding of cosmetic injection–induced botulism; and (3) the safety and standardization of the preservation, dissolution, dilution, and injection dose of botulinum toxin.


This work was supported by Key Scientific Research Projects of Colleges and Universities in Henan Province (grant 20A320033).


The authors declare that they have no conflicts of interest to report.


1. Chalk CH, Benstead TJ, Pound JD, Keezer MR. Medical treatment for botulism. Cochrane Database Syst Rev. 2019;4:CD008123.
2. Cherington M. Botulism: Update and review. Semin Neurol. 2004;24:155–163.
3. Ramirez-Castaneda J, Jankovic J, Comella C, Dashtipour K, Fernandez HH, Mari Z. Diffusion, spread, and migration of botulinum toxin. Mov Disord. 2013;28:1775–1783.


Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

  • Text—maximum of 500 words (not including references)
  • References—maximum of five
  • Authors—no more than five
  • Figures/Tables—no more than two figures and/or one table

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

Copyright © 2021 by the American Society of Plastic Surgeons