A型肉毒毒素注射治疗咬肌肥大后并发症分析及其防治

Analysis and prevention of complications after botulinum toxin type A injection for masseter hypertrophy

目的:总结A型肉毒毒素注射治疗咬肌肥大后发生的并发症及防治方法。方法:回顾性分析2019年1月至2021年9月在山西白求恩医院接受A型肉毒毒素注射治疗咬肌肥大的患者临床资料。注射方法:用2 ml 0.9%氯化钠注射液将100 U A型肉毒毒素配置成浓度为50 U/ml的溶液,标记咬肌"安全注射区",前、后边界分别为咬肌的前、后边缘,上界为嘴角至耳垂连线,下界为下颌骨的下边缘,在此区域内标记3个或4个注射点,注射点距离4个边界至少1 cm,每侧注射25~40 U。治疗后对患者进行随访,记录并发症种类,总结治疗措施。结果:共纳入160例患者,男8例,女152例,年龄(30.6±6.2)岁。随访1~6个月,所有患者咬肌均有不同程度的缩小,下面部线条更加柔和,面部轮廓得到了改善。并发症发生率为81.3%(130/160),主要有以下有4类:(1)非肌肉源性的并发症,包括淤斑5例(3.1%),一般于5~7 d可自行消退;头痛2例(1.3%),适当休息,2~3 d症状可消失。(2)与毒素效应相关的并发症,主要是咀嚼力下降,共86例(53.8%),随着药物的代谢3~12周逐渐恢复。(3)与注射剂量相关的并发症,包括面部下垂4例(2.5%),单次注射剂量双侧各30~40 U,2例未予特殊处理,约8~12周逐渐恢复,1例行A型肉毒毒素注射提升下颌缘后约2周逐渐恢复,1例于外院使用热玛吉治疗后逐渐恢复;反常性硬性咬肌膨出9例(5.6%),5例给予补充注射4 U A型肉毒毒素后1周内消退,其余4例未予特殊处理,1~2周后自行消退。(4)与注射部位相关的并发症,包括微笑异常3例(1.9%),嘱患者正确练习微笑动作,4~12周逐渐恢复;面颊凹陷21例(13.1%),1例患者通过注射透明质酸改善症状,其余患者未予特殊处理,8~12周逐渐恢复。结论:A型肉毒毒素注射治疗咬肌肥大后并发症发生率较高,临床表现具有多样性;在推荐的咬肌安全区域内进行注射,合理把握注射剂量和注射深度,可以减少并发症的发生。

Objective To summarize the complications and prevention after botulinum toxin type A(BTA)injection for masseter muscle hypertrophy(MMH).Methods The clinical data of patients with masseter hypertrophy who received BTA injection in Shanxi Bethune Hospital from January 2019 to September 2021 were retrospectively analyzed.Injection method:100 U BTA was prepared into a solution with a concentration of 50 U/ml with 2 ml 0.9%sodium chloride injection.The"safe injection zone"of the masseter muscle was marked.The anterior and posterior boundaries were the anterior and posterior edges of the masseter muscle,respectively.The upper boundary was the line from the corner of the mouth to the earlobe,and the lower boundary was the lower edge of the mandible.The injection points(3 or 4 points)were at least 1 cm away from the four borders,and 25-40 U was injected on each side.The patients were followed up after treatment,the types of complications were recorded,and the treatment measures were summarized.Results A total of 160 patients were enrolled,including 8 males and 152 females,with a mean age of(30.6±6.2)years.All patients were followed up for 1 to 6 months.The masseter muscle of all patients was reduced to varying degrees,the lower facial lines were softer,and the facial contour was improved.The incidence of complications was 81.3%(130/160).There were four main types of complications:(1)Complications with a nonmuscular etiology include ecchymosis in 5 cases(3.1%)which resolved spontaneously in 5 to 7 days and headache occurred in 2 cases(1.3%)which disappeared in 2-3 days with proper rest.(2)The complication related to the toxin effect mainly was the decrease of masticatory power in 86 cases(53.8%),which gradually recovered with the drug metabolism for 3-12 weeks.(3)Dose-related complications include facial ptosis in 4 cases(2.5%)with 30-40 U dose per side.2 cases without special treatment,gradually recovered in about 8-12 weeks.One patient underwent the BTA injection to raise the mandibular margin and gradually recovered about 2 weeks later.One patient recovered gradually with the treatment by Thermage in another hospital.There were 9 cases(5.6%)of paradoxical rigid masseter muscle bulge.5 cases resolved within 1 week after supplementary injection of 4 U botulinum toxin,and the other 4 cases resolved spontaneously within 1 to 2 weeks without special treatment.(4)Complications related to the injection site include abnormal smiles in 3 cases(1.9%).Patients were instructed to practice the smile correctly and gradually recovered in 4-12 weeks.Twenty-one patients(13.1%)had sunken cheeks.One patient improved by injection of hyaluronic acid,and the other patients recovered gradually within 8-12 weeks without special treatment.Conclusion The incidence of complications after BTA injection for MMH is high,and the manifestations are diverse.The injection should be performed in the recommended safe area of the masseter muscle.A reasonable dose and depth of injection can reduce the occurrence of complications.