Complex Facial Clinic - Botulinum toxin injections as part of the clinic treatment

Botulinum toxin type A contains the active substance Clostridium Botulinum that blocks the release of acetylcholine, a chemical that acts between the nerves and muscles, at the neuromuscular junction. The toxin temporarily weakens the muscle(s) it is injected into. Injecting botulinum toxin into overactive muscles reduces muscle over-activity. The aim of the injection is to have the desired clinical effect without causing excessive weakness.

Botulinum toxin can be injected into the unaffected side of the face to improve symmetry/stop the affected muscles on the opposite side of the face from being over-lengthened which can cause secondary weakness. Botulinum toxin injections can be used in combination with neuromuscular facial rehabilitation and provide a window of opportunity to improve facial movement, function and aesthetics.

The dosage of botulinum toxin used in this treatment is very low and therefore the risks are small. It is generally a safe and effective treatment method. Nevertheless, side effects can occur and these usually develop in a few days and may last up to two weeks. It is important to note that sometimes it may take a few weeks for side effects to appear. Side effects can include: 

• Bruising or swelling at the site of the injection. 
• Slight feeling of nausea or headache. 
• Tiredness or pain in the arms and legs. 
• Temporary drooping of the eyebrow or upper eyelid. 
• Brief visual disturbances (double vision). 
• Dry mouth/eyes. 
• Skin rash or itching. 
• Breathing difficulties/swallowing difficulties. 
• Muscle wasting. 
• Generalised weakness.  
• Flu-like symptoms.  

Please tell the therapist/doctor treating you if: 

• You are allergic to botulinum toxin or any other ingredients in the injection.  
• You have had an allergic reaction to a botulinum toxin in the past.  
• You have an infection at the proposed site of the injection. 
• You have problems swallowing.  
• You have any history of bronchitis, pneumonia or problems with breathing. 
• You are pregnant or breast feeding.
• You have myasthenia gravis. 
• You have a bleeding disorder.  
• You take medication to thin your blood (e.g. warfarin, apixaban, rivaroxaban, dabigatran, edoxaban or heparin injections). 
• You are taking any antibiotics for an infection (e.g. aminoglycosides such as Gentamicin or amikacin). 
• You have a fear of needles (needle phobia). 
• You have had any problems with injections into your muscles in the past. 
• You have glaucoma. 
• You are scheduled to have any surgery in the near future. 
• You object to blood donor products because botulinum toxin contains human serum albumin.

Synkinesis will have to be managed by stretching and exercises only. This can be effective for people with mild synkinesis.

All patients will have a neuromuscular rehabilitation programme which might include generalised massage. Botulinum toxin is an adjunct to the facial therapy programme for a proportion of patients. There are no alternatives to botulinum toxin available. You can decline these injections and manage with your current interventions.

No specific preparation is necessary. It is helpful to wear loose clothing in case we need to access the muscles in your neck. The injections will be administered during the clinic appointment. If preferred, you can bring someone to accompany you on the day. If you are on medication to thin your blood (e.g. warfarin, rivaroxaban, dabigatran, apixaban, edoxaban, or heparin injections), we will need to be aware of this prior to the injections. If you experience severe bleeding or bruising after the injection please seek medical advice.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent. We will ask you to sign a consent form before your first injections. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. 

The facial therapist will give injections either into the side of your face that is affected and/or the opposite side as clinically indicated. The skin will be cleaned with a sterile alcohol wipe. The botulinum toxin will be injected just under the skin at the appropriate muscle sites. The needle used for injecting is very fine and therefore patients experience very little pain other than feeling very brief, slight pain due to the sharpness of the needle, which is over immediately.

When initiating treatment, we start with low doses of botulinum toxin. The initial effects of treatment occur within 48-72 hours. The maximum effect is reached in about one to two weeks. The area injected might feel more relaxed and / or you might also notice less unwanted movement in the muscles that have been treated. The effect of treatment generally lasts approximately three months after which further treatment may or may not be required. 

Allow 24 hours after injections before you recommence your exercise programme. It is very important to carry out any exercises and stretches given to you by your therapist after having botulinum toxin treatment, until your next appointment. This will ensure that you get the full benefit of the botulinum toxin treatment. 

On rare occasions patients may have an adverse reaction to botulinum toxin injection(s). Please contact your doctor and seek medical attention immediately if you develop any of the following:

• Breathing, swallowing or speech difficulties. 
• Severe allergic reaction, (hives, swelling including swelling of the face, lips, tongue and/or throat, wheezing, feeling faint or shortness of breath).  
• Please note that this may even occur a few weeks after the injection. 
• Allow 24 hours after injections before you recommence your exercise programme.

Facial Palsy UK  

Bell’s Palsy information site  

Facial Therapy Specialist UK

The NHS Clinical Knowledge Summaries website  

NHS Direct is also another very useful source of health information  

UCLH cannot accept responsibility for information provided by other organisations.

The Complex Facial Clinic 

The National Hospital for Neurology and Neurosurgery 

Queen Square 

London 

WC1N 3BG 

Tel: 07908 175 469 or 07852 220 407 

Email: uclh.referrals.toupati@nhs.net  

Website: www.uclh.nhs.uk

We are currently located in the Royal London Hospital for Integrated medicine (RLHIM), outpatient department, 3rd floor.