Although there has been no official report yet on the exact cause of death, let's go through Botox itself as a procedure and drug and if it can really result in death!
Botulinum toxin is the most common cosmetic procedure performed world wide with an estimate of nearly 3 million injections per year. It works by the action on muscle nerve endings to disturb the transmission of information preventing these muscle from contracting resulting in them being temporarily paralysed.
Hence it would be logical based on how Botox works to say that Yes, Botox can cause death.
But of course as with all things, how much Botox do you need to be causing death and was this what was done in this case?
Studies have shown that a dose of of more than 6 U of botulinum toxin/kg used in children and other medical indications may cause death. [1] A female that weights about 50kg needs to receive almost 300U of botox.
A typical total amount of units for the forehead would be either 8 or 16 units. Crows feet? Maybe 4 units per eye or 12 units per eye.
Jaw muscles, the most I usually use is about 80 units.
As Botox's function is to paralyze muscles, less muscle contraction would lead to better wrinkles. Less muscle contraction would also lead to smaller jaw muscles and hence a more V shape face.
Botox can also be used for lifting with a unique technique called Dermalift. But the dosage used in these is also so low. No way even close enough to result in a Botox Death as what the news claimed.
How can anyone possibly be reaching such high levels of above 300U of Botulinum Toxin if this was done only for aesthetic reasons?! So in order for someone to be using THAT much Botox, it has to be done for medical reasons. But was this the case?
There has been reports in 1990s of people actually having consumed or eaten Botulinium Toxin. As this was produced by a bacteria that was living in canned food, the dose consumed was extremely high. 405 cases were reported to the CDC in America with about 40 death cases. But of course this was some time ago and it was not in Singapore.
Botox actually has many other uses in the medical field that isn't done for cosmetic and aesthetic purposes. Eg, Botox can be used to treat limb muscle spasticity associated with cerebral palsy. These cases need almost about 6.25 to 32 U/kg!
In fact a quick literature search and I found this list of different indications where Botox is useful.
| Dystonias [2] | Cervical dystonia, Oromandibular dystonia, Pharyngolaryngial dystonias, Jaw closure/opening dystonias, Occupational cramps, Limb and axial dystonias |
| Spasticity[3] | Cerebral palsy, Brain injury, Spinal cord injury |
| Eyelid spasm[4] | Blepharospasm, Hemifacial spasm, Eyelid twitch |
| Exocrine gland hyperactivity[5] | Focal hyperhidrosis, Relative sialorrohoea, Crocodile tears syndrome, |
| Movement disorders[6] | Tremors, Bruxism, Tic |
| Pain syndromes[7] | Migraine, Back spasm |
| Urinary bladder dysfunction[8] | Sphincter- detrusor dyssenergia, detrusor hyperreflexia, |
| Opthalmology[9] | Strabismus, Entropion, Protective ptosis |
| Cosmetology[10] | Hyperactive facial lines-brow lines, Frown lines, |
| Gastroenterology[11] | Achalasia, Anal fissures, Anismus |
| Gynecology[12] | Vaginismus |
| Urology[13] | Sterile prostatitis |
Was this in fact a case of a patient needing medical treatment which required a large amount of Botox that resulted in a Botox Death?
Was this in fact NOT actually related to Botox but instead due to some other causes?
What may actually kill was it anaesthesia or a sedative agent injected into a vein?
We do not know for sure as details of the case has not yet been revealed. We shall have to await the pathologist results to come out to identify the true cause of death.
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1. Early communication about an ongoing safety review botox and botox cosmetic and myobloc. [accessed on 2008 Apr 23]. Available from: www.Fda.gov/cder/drug/early_comm/botulinium_toxins.htm
2. Jankovic J. Botulinum toxin therapy for cervical dystonia. Neurotox Res. 2006;9:145–8
3. Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, et al. Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review) Neurology. 2008;70:1691–8.
4. Frei K, Truong DD, Dressler D. Botulinum toxin therapy of hemifacial spasm: comparing different therapeutic preparations. Eur J Neurol. 2006;13:30–5
5. Naumann M, Jost W. Botulinum toxin treatment of secretory disorders. Mov Disord. 2004;19:S137–41.
6. Brin MF, Lyons KE, Doucette J, Adler CH, Caviness JN, Comella CL, et al. A randomized, double masked, controlled trial of botulinum toxin type A in essential hand tremor. Neurology. 2001;56:1523–8.
7. Lang AM. Botulinum toxin type A therapy in chronic pain disorders. Arch Phys Med Rehabil. 2003;84:S69–73.
8. Schurch B, Schmid DM, Knapp PA. An update on the treatment of detrusor-sphincter dyssynergia with botulinum toxin type A. Eur J Neurol. 2007;6:S83–9.
9. Dutton JJ, Fowler AM. Botulinum toxin in ophthalmology. Surv Ophthalmol. 2007;52:13–31.
10. Flynn TC. Update on botulinum toxin. Semin Cutan Med Surg. 2006;25:115–21
11. Madalinski M, Chodorowski Z. Why the most potent toxin may heal anal fissure. Adv Ther. 2006;23:627–34.
12. Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol. 2004;104:922–5
13. Thwaini A, Shergill I, Radhakrishnan S, Chinegwundoh F, Thwaini H. Botox in urology. J Int Urogynecol. 2006;17:536–40.
