“InTOXication” is a noun that may be newly defined as an affliction of patients who have demanded overtreatment with Botulinum Toxin (BT) in their quest for facial enhancement.

For patients insisting on such over treatment, the consequences can be a bland, vapid face, virtually devoid of meaningful expression. While some patients appear to favor such outcomes, it can be counterintuitive and uncomfortable for most treating physicians, who aspire to create natural aesthetics.

Aesthetic divides between treating physician and patient are not unusual. For example, a familiar scenario exists when a surgeon suggesting modest breast enhancement surgery is countered by a patient demanding an exaggerated outcome.

All aesthetic practitioners have a coterie of patients who habitually return to clinics complaining that the BT: “didn’t work”; “I can still frown”; “You must have had a bad batch”; “What brand did you use?”; “It worked better with the last doctor”; “How many units did you use”…

Such patients then “demonstrate” how it “didn’t work” by displaying bizarre facial hyper-expressions and contra-force expressions to illustrate such alleged treatment “failures”!

To make a point this display of facial expressions that can virtually morph into facial contortions (aka “TOXOcontortionists”).

Of course, the treatment objective using facial BT is not the induction of facial muscle paralysis but to diminish the negative aspects of normal expressiveness.

Yet, despite a full and frank discussion beforehand, there are patients who fail to appreciate treatment objectives and limitations of aesthetic BT injections. For the physician who has explained all risks, there can remain an insistence from some patients for the practitioner correct a perceived outcome deficiency with further BT.

Interestingly, BT treatment studies have shown a patient satisfaction rate of 65-90% (1) (2). Furthermore, a study on patient retention rates has demonstrated that the most common reasons cited for discontinuance of BT treatments were procedural cost, patient failure to reschedule, perceived lack of product longevity, and clinical effect falling short of expectations. However, after initiation of the mandatory 2-week post-treatment office evaluation, a 67% patient retention rate was achieved. (3)

While this may well represent a high satisfaction rate, in terms of clinical practice dynamics it means that at least one in 10 patients may be dissatisfied with BT treatments. At least one patient a day will return to the practice dissatisfied (or not return at all and seek further treatments elsewhere).

Accordingly, practitioners must explain to patients that aesthetic BT facial treatments are not designed to obliterate forced, unusual and bizarre expressive maneuvers.

Furthermore, patients need to understand that BT cannot address all aesthetic concerns and that other treatment modalities may need to be considered.

This commonly applies to the forehead, a region where patients frequently insist on absolute wrinkle free outcomes.

Despite the risks being fully explained, many patients still fail to appreciate treatment limitations and risks, particularly the undesirable side effect of brow ptosis.

Alternative treatments such as filler frontoplasty (4) and filler enhancement of peri orbicular/temple regions should be considered in suitable cases (5).

Prendergast et al stated: “One of the biggest challenges amongst aesthetic surgeons is managing the ever-increasing patient expectations. When an elective surgery is aesthetically based, the doctor’s and the patient’s idea of the “good” outcome can be drastically different. A technically perfect surgery might not meet a patients’ expected outcome due to an unrealistic expectation of the result.” (6).

In conclusion, there are consequences for surgeons who acquiesce to excessive patient demands. Reputational compromise is of foremost concern. Most surgeons seek to achieve professional standing for achieving natural aesthetic outcomes rather than a degree of notoriety for excessive ones. Furthermore, there looms the penalty of professional burnout secondary to frustration.

References
1. A comprehensive review of patient-reported satisfaction with botulinum toxin type a for aesthetic procedures: Steven Fagien, Jean D A Carruthers Plast Reconstr Surg 2008 Dec;122(6):1915-25.
2. A retrospective study in the use of botulinum toxin type-A in a UK multidisciplinary cosmetic practice. Bowler, P.J. Journal of Cosmetic Dermatology (2005) 4: 89-92.
3. Improving patient retention after botulinum toxin type A treatment Lucille White  , Elizabeth L Tanzi, Tina S Alster Dermatol Surg . 2006 Feb;32(2):212-5.
4. Novel Forehead Augmentation Strategy: Forehead Depression Categorization and Calcium-Hydroxyapatite Filler Delivery after Tumescent Injection: JongSeo Kim, Plast Reconstr Surg Glob Open. 2018 Sep; 6(9): e1858
5. Hyaluronic Acid Filler for Forehead, Temporal, and Periorbicular Regions Fabiana Braga França Wanick “Botulinum Toxins, Fillers and Related Substances” (pp 1-17)
6. Burnout in the Plastic Surgeon: Implications and Interventions: Christina Prendergast, Erika Ketteler, Gregory Evans, Aesthetic Surgery Journal, Volume 37, Issue 3, 1 March 2017 Pages 363-368