title: Botulinum Toxin and Muscle Atrophy: A Wanted or Unwanted Effect.
abstract: While the facial rejuvenating effect of botulinum toxin type A is well known and widespread, its use in body and facial contouring is less common. We first describe its use for deliberate muscle volume reduction, and then document instances of unanticipated and undesirable muscle atrophy. Finally, we investigate the potential long-term adverse effects of botulinum toxin-induced muscle atrophy. Although the use of botulinum toxin type A in the cosmetic patient has been extensively studied, there are several questions yet to be addressed. Does prolonged botulinum toxin treatment increase its duration of action? What is the mechanism of muscle atrophy and what is the cause of its reversibility once treatment has stopped? We proceed to examine how prolonged chemodenervation with botulinum toxin can increase its duration of effect and potentially contribute to muscle atrophy. Instances of inadvertent botulinum toxin-induced atrophy are also described. These include the "hourglass deformity" secondary to botulinum toxin type A treatment for migraine headaches, and a patient with atrophy of multiple facial muscles from injections for hemifacial spasm. Numerous reports demonstrate that muscle atrophy after botulinum toxin type A treatment occurs and is both reversible and temporary, with current literature supporting the notion that repeated chemodenervation with botulinum toxin likely responsible for both therapeutic and incidental temporary muscle atrophy. Furthermore, duration of response may be increased with subsequent treatments, thus minimizing frequency of reinjection. Practitioners should be aware of the temporary and reversible effect of botulinum toxin-induced muscle atrophy and be prepared to reassure patients on this matter.
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Durand
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Rafael A
authors.initials: RA
authors.lastname: Couto
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Raymond
authors.initials: R
authors.lastname: Isakov
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Donald B
authors.initials: DB
authors.lastname: Yoo
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Babak
authors.initials: B
authors.lastname: Azizzadeh
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: Bahman
authors.initials: B
authors.lastname: Guyuron
authors.affiliation: Drs Durand and Couto are Residents, Dr Isakov is an Assistant Professor, and Dr Zins is Chairman, Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH. Drs Yoo and Azizzadeh are facial plastic surgeons in private practice in Beverly Hills, CA. Dr Guyuron is Chairman, Department of Plastic Surgery, Case Western Reserve University, Cleveland, OH.
authors.forename: James E
authors.initials: JE
authors.lastname: Zins
mesh_terms: D065087:Acetylcholine Release Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D000328:Adult; D000367:Age Factors; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000009:adverse effects*; D003357:Cosmetic Techniques / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000187:drug effects* / Q000473:pathology / Q000503:physiopathology; D009133:Muscular Atrophy / Q000139:chemically induced* / Q000473:pathology / Q000503:physiopathology; D012060:Rejuvenation; D018570:Risk Assessment; D012307:Risk Factors; D015595:Skin Aging; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D065087:Acetylcholine Release Inhibitors; D019274:Botulinum Toxins, Type A