Is it actually dangerous to receive a Botox treatment? The recent incident of botox-related death in Singapore has raised questions on how safe this aesthetic procedure is.

Newspapers reported that on 13 March 2019, a 32-year old property agent Lau Li Ting has allegedly died after receiving a Botox injection from an aesthetic clinic in Singapore. She went into cardiac arrest shortly after receiving the cosmetic treatment on 8 March and fell into a coma. She died five days later.

Until the investigation and post mortem results are completed and known, speculations about what caused the death plus common misconceptions about Botox will only lead one to jump into conclusions and create unnecessary fear.

So what is Botox?

Botulinum Toxin and Botox are not interchangeable terms.

Botox is only the name of a brand of Botulinum Toxin, and there are several other brands of botulinum toxin injections used in Singapore such as Xeomin and Dysport, that are approved by US FDA and HSA Singapore.

They are injectable cosmetic treatments made from botulinum toxin, a neurotoxin produced by the bacterium Clostridium botulinum. It is the same toxin that can cause botulism, a rare and potentially fatal food-borne illness, but the effects vary depending on the amount and type of exposure.

Although botulinum toxin is life-threatening, the cosmetic application of Botox in a clinical setting uses small, targeted doses, which is considered generally safe and carries less risk than therapeutic Botox injections such as for excessive sweating from armpits and hands or muscular spasms. It is a commonly requested treatment especially for anti-ageing concerns.

For commercial use, botulinum toxin is produced under highly strict conditions to ensure the efficacy of treatments and safety of patients. The preparation process includes multiples steps of extractions and purification before it is crystallised and packaged, to be used by doctors on patients.

How does it work?

The use of botulinum toxin in Botox can soften and reduce the appearance of fine lines, wrinkles and crow’s feet on the face. When injected into the forehead, around the eyes or other targeted facial areas, it blocks the ability of the nerve to send a chemical signal to the muscles which tell it to expand or contract. When this interference occur, the muscles are prohibited from moving and will remain relaxed.

It is also used to help the jaw and face look slimmer, causing the muscles to be weaker and contract lesser and achieve a slimmer, V-shaped face. When injected in the facial muscles, such as the forehead area where creases occur when you frown, those forehead lines will improve.

Side effects of Botox

Minor side effects are possible with Botox. These include swelling, pain or bruising at the injection site, unintended relaxation of muscles, headache, fever, muscle weakness and trouble swallowing. Unintentional effects on the muscles can also occur depending on the area of injection such as facial asymmetry, drooping eyelids and drooling. Temporary flu-like symptoms and allergy is very rare.

Because only small, minute doses of injections are used in cosmetic treatments, any side effects are temporary and are not prolonged.

Over a period of 1989 to 2002, there were 1437 reports of adverse events that are Botox injections related received by the US FDA, and 36 of them were due to cosmetic treatments. In cosmetic Botox treatments, there were no death reports from Botox injections, and in 36 of those cases saw allergic reactions and flu-like symptoms due to deviations from factors like recommended Botox dose, administration, storage, handling, dilutation, and site of injection as advised on the approved labelling.

Can Botox cause cardiac arrests?

Botox has a localised mode of action, thus when it is correctly injected to the intended muscle, such as the jaw, it will have a direct effect on the jaw muscles instead of the eye area. In cosmetic purposes where small dosages are used, chances of unintended spread to surrounding muscles after the injection is unremarkable. One study showed the area of diffusion to be 2.4 – 6 cm in approximation, which means there is extremely low likelihood of Botox spreading to the heart and lung muscles.

For the sake of argument, if Botox entered the bloodstream somehow, a lethal dose would have to be given to cause a complication like cardiac arrest or death. One study points to a lethal dose to be an estimated 40U/kg. So for a typical female patient with an average weight of 50kg, the lethal dose for her would be 2000U theoretically, which means she would have to be injected with 20 bottles of Botox using a standard 100U Botox bottle. This likelihood is almost zero as cosmetic dosages vary between 20 – 100 units, well within one Botox bottle.

In rare cases, it is possible for botulinum toxin to spread to other parts of the body and cause botulism-like symptoms such as difficulties in breathing, unclear speech, vision problems, and extreme muscle weakness. One should immediately seek medical attention should any of the symptoms are experienced. With that said, there are no known cases of aesthetic treatments of Botox directly caused by cardiac arrest or heart failure.

Is there Botox allergy, that can lead to death?

Similar to all kinds of other drugs and medications, allergy is certainly a possibility. Allergies typically range from mild reactions like itching to the extreme which is anaphylaxis, a life-threatening condition in which the airways become narrow and obstruct breathing, and the blood pressure plummets. Anaphylaxis reaction requires prior exposure to the trigger, in this case, Botox. It was reported that the deceased patient was known to undergo Botox/botulinum toxin injections before, and if there was any allergic reaction previously, it would have been known to her and her doctor and warned against further injections.

In an anaphylactic reaction, one would display signs of difficulties in breathing, swelling of the throat, lips or tongue, dizziness and/or fainting. According to news report, the patient suffered seizures and cardiac arrest, which are not typical symptoms of an anaphylactic reaction. Separately, there was one reported case of an allergy related to Botox in which the patient was recovered, and another reported case of death due to anaphylaxis caused by Botox allergy, however, the dose was given for neck and back pain, which is much higher as compared to aesthetic treatments.

How can you ensure your safety with Botox?

Only licensed doctors are allowed to perform Botox treatment. Visit a reputable and experienced aesthetic doctor in Singapore, and find out more on the Botox product they use. Consultation is important to assess your suitability and potential side effects and risks. Ensure you also share your medical history and past allergies, however trivial. Patients with certain health conditions such as undergoing chemotherapy, or are currently taking certain types of medications/antibiotics that can trigger adverse reactions or increase the potency of the neurotoxins are generally advised to steer clear of Botox.

Our clinic offers Botox treatments as well as a suite of aesthetic treatments to address various skin concerns including cystic acne, acne marks removal and acne scar treatment. As with any procedure, our doctors will discuss your individual benefits and risks, and what is expected during and after the treatment procedure. You can contact us to book an appointment today.