Cosmetic Neurotoxin: Can it be fatal?


Doctor administering botox treatment on woman's face, ensuring precise and effective cosmetic results.
All things are poisons and there is nothing that is harmless, the dose alone decides that something is no poison.
As the quote above, the right dosage makes it either a remedy or a poison – water is a thirst quencher, but even drinking too much water may prove to be fatal to a human.
The latest incident surrounding an aesthetic clinic and supposed botox treatment has garnered Mizu Aesthetic much attention, due to our prominence in the Marina Bay area and that the said clinic was confusingly reported to be located in the same area.
Therefore, we would like to clarify that Mizu is not the said clinic in the reports, and at the same time, seek the professional opinion of our Medical Director, Dr. YZ Tan – a trainer in Botulinum Toxin injections, to shed the light on botulinum toxin, and what it can potentially do so as to clear up the stigma surrounding it.

What is Botox?

“Botox” is in fact, a brand name trademarked by its makers, Allergan. Just like how “Pampers” were commonly referred to as diapers by the older generation, the name “Botox” is commonly used as ease of reference by most aesthetic clinics, and the general public in lieu of botulinum toxin injection procedures.

It is a neurotoxin produced by the bacterium Clostridium botulinum, and there are botulinum types A – H – the most commonly used types for commercial/medical usage are types A & B [1]. It is in fact, a lethal toxin – but in minute doses, as with certain poisons, can be beneficial in more ways than one.

There are three leading brands of botulinum toxin A approved by HSA for use in Singapore: Botox (by Allergan), Dysport (by Ipsen) and Xeomin (by Merz).

The above approved labels are prescription drugs, only for use in a clinic, and by a licensed, trained doctor.

Are there other versions of botox in the market?

There are, but these are not FDA nor HSA approved. Some versions would include the Korean KFDA approved botulinum toxins, such as Meditoxin, Innotox, Coretox, Botulex, Nabota and Hutox, etc.

It is important to know what is being injected into your face – if you have doubts, enquire with the clinic about the brand of botulinum toxin(s) available prior to the appointment.

What is “botox” / botulinum toxin commonly used for?

Botox is a commonly done procedure – an estimate of 3 million dollars worth of botulinum toxin injection procedures or more are done per year, worldwide [2]. Despite that, the knowledge as to how it works isn’t as widely understood as it should be!

As a neurotoxin, botulinum toxin, in layman terms, causes relaxation/temporary paralysis of the muscles. This can be both applied in both cosmetic and therapeutic treatment usage, and the effects of botulinum toxin injections usually last anything between 3 – 9 months (depending on the area injected), and may be repeated for maintenance.

Cosmetic TreatmentsTherapeutic Treatments
Globellar (Between the brows,
Frown lines)
Overactive Bladder
Crow's FeetChronic migraines
Forehead LinesEye muscle issues
cervical Dystonia
Excessive Underarm Sweating
“Botulinum toxin blocks presynaptic acetylcholine release, thus preventing the nerve impulses responsible for muscle contraction, and can be used to treat all wrinkles that are the result of normal facial movement. [3]“

“So young, need botox meh?”

As we read the comments online, we saw this one comment that is a commonly known perception by some members of the public – just at what age should one start to consider botulinum injections?

We age everyday.

While aging does play a part in our skin becoming thinner and more prone to wrinkling, these frown/laugh/smile lines are formed due to repeated movements, and botox serves to prevent or lessen these movements by relaxing the muscles involved.

A younger person could have the bad habit of unconsciously and excessively frowning and developing these lines earlier in life, too! Botulinum toxin injections are typically used as a preventive measure, to prevent these movement lines from becoming permanent and static. So yes, while botulinum toxin injections are typically done for adults above a certain age threshold, you do not need to be of a certain age to use botox.

Botox should not lead to a “frozen look” when the right amount is used – this requires trained eye and hands – a licensed doctor who is able to gauge the amount needed.

Can Botulinum Toxin Injections cause cardiac arrest?

Quoting Dr. YZ Tan, “There are no known cases of botulinum toxin deaths directly caused by heart failure. However, an allergic reaction, which is very rare, can result in shock and indirectly result in heart failure when not caught and treated in time.”

Are botulinum toxin injections lethal?

“Botox, when administered properly, is considered safe.”

Botulinum toxin is generally considered to have a wide safety margin [4]. Side effects from cosmetic use are generally non-fatal, and usually results from unintended paralysis of certain facial muscles. These can include partial face paralysis, muscle weakness, trouble swallowing, headaches, and flu-like symptoms. As the effects of botox wears off, one will regain muscle strength and movement, and these symptoms will go away.

However, as with any procedure, there are always risks involved, and while there have been claims of 16 deaths reported to be in relation to receiving botox injections, these cases are extremely rare, and if any, they are typically and possibly due to complication(s) arising from:

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    Off-label usage of the drug [5]
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    Mixing the wrong dosage [6]
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    Allergic reactions to the drug [7]

“Side effects from therapeutic use can be much more varied depending on the location of injection and the dose of toxin injected. In general, side effects from therapeutic use can be more serious than those that arise during cosmetic use. These can arise from paralysis of critical muscle groups and can include arrhythmia, heart attack, and in some cases seizures, respiratory arrest, and death.” – Wikipedia

“Allergan spokeswoman Caroline Van Hove said children with cerebral palsy receive far larger doses injected into their leg muscles than the doses given adults seeking wrinkle care.” – NBC News. [8]

What are the signs that I am suffering from a side effect of botox?

Common and negligible side effects of botulinum injections would include: an achey/sore sensation at the site of injection, possible mild bruising. However, one should seek medical attention should they experience symptoms such as difficulty in swallowing or breathing, unclear speech, extreme muscle weakness, or difficulty holding up their head.

How can one ensure that Botulinum Toxin injections are safe?

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    In Singapore, only licensed doctors are allowed to perform botox injections. Make sure that you visit an experienced doctor.
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    Ask the clinic what it has or uses – At Mizu, we only use the HSA-approved brands of botulinum toxin – Botox, Dysport, or Xeomin.
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    Share your medical history and past allergies with your doctor, however trivial.
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    As a doctor, I always make sure that the botulinum toxin dosage is measured and prepared by myself so as to ensure a correct dosage and safety for the patient.
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