A Chinese language tabloid in Singapore recently broke the sensational news of a young lady’s death. She had allegedly died after receiving Botox injections.

Panic gripped many friends and patients. I received numerous questions: Could Botox really kill someone? Is it still safe to go for Botox? What could have happened?

Ms Lau Li Ting, a 32-year-old property agent, had visited an aesthetic clinic in the Marina Bay area. Reportedly, Li Ting had received Botox previously. However, after this injection was administered, she rapidly developed seizures. Cardiac arrest and coma followed. Li Ting was rushed to hospital but eventually passed away after 5 days in the intensive care unit.

Why Am I Writing About The Recent Botox Death in Singapore?

After the news broke, reactions from patients, fellow doctors and indeed even the general public have been of incredulity and fear. Incredulity because Botox is widely regarded as generally safe and low risk. Fear because there is now great uncertainty as to whether it is dangerous to continue with Botox treatments.

Personally, the news came as a great shock.

It is incredibly tragic for a healthy young lady with such a bright future to pass away suddenly like that.

Li Ting's family must be devastated. My sincere condolences go out to them. Losing a loved one is never easy and they must be going through a lot of pain and confusion right now.

While this incident is a matter of public interest, I feel that given the limited amount of verifiable information available, it is in the best interest of everyone to get the facts right. Publishing unverified or inaccurate details may stimulate discussion about Botox safety but could also potentially make it worse for all parties involved, drawing unwanted attention to Li Ting's family in this difficult time.

Baseless speculation without concrete facts could confuse the public and cause undue distress for patients currently undergoing or considering Botox treatments.

To be honest, I find it quite unbelievable that the death could have been directly caused by the cosmetic usage of Botox.

As a medical aesthetics physician, botulinum toxin injections are a straightforward procedure that I perform very frequently. I feel that it's my duty to give a balanced viewpoint on the scientific facts and what could have gone wrong.

What is Botox?

Botox is a brand of botulinum toxin.

Botulinum toxin is an injectable medicine derived from Clostridium botulinum bacteria.

Medical treatments use two types (A & B) of the eight known types of botulinum toxin (A-H).

There are 3 brands of botulinum toxin A registered for medical use in Singapore: Botox, Xeomin and Dysport.

I’ve used all 3 brands and in my opinion, they work equally well.

How Long Has Botox Been In Use?

Botox was first developed in the 1970s and subsequently used for cosmetic uses beginning in the 1990s.

Many millions of Botox injections are performed annually, making it the most common cosmetic procedure in the world.

With such a long history of medical and cosmetic usage, doctors have access to a wide depth and breadth of research studies and clinical evidence on the safety profile of Botox.

How Does Botox Work?

Botox comes as a freeze dried powder in a glass vial.

We dissolve the powder with specific volumes of saline to obtain injectable concentrations of botox.

We then precisely inject exact amounts of Botox solution into various points.

When injected into specific hyperactive muscles, botulinum toxin causes relaxation via blockage of neurotransmitter release. This improves the appearance of expression lines in the face, preventing the development of deep furrows, thus maintaining a relaxed and youthful appearance.

Sounds simple?

Actually, safe and effective Botox is more complicated than you might imagine.

• the doctor has to assess and determine if Botox is suitable. Botox into the jaw muscles wouldn't produce significant size reduction if the jaw muscles were already tiny, to begin with. Botox into the forehead in a droopy-eyed patient would make the problem worse, not better
• the concentration, amount and location of injections are very important factors
• technical factors such as the depth of injection, needle direction and even the direction of the needle bevel influence Botox's effects.

It can be quite tricky. An effective yet natural looking result requires in-depth knowledge of dynamic facial movement. The doctor also needs to have experience with Botox's effects over many clinical cases.

There is definitely a difference in my Botox technique compared to many years back when I first started out. I've long stopped following the standard recommended doses and injection points, as I've found that it produces unnatural, frozen results.

Can Botox Kill?

Yes, Botox CAN cause death.

But so can any medication or drug ever used.

Even water can cause death.

“All things are poisons and there is nothing that is harmless, the dose alone decides that something is no poison”

Paracelsus (1493–1541)

How Much Botox Does It Take To Kill You?

Botox generally does not produce effects beyond the area of injection. A rapid systemic effect would be difficult to produce without injecting intravenously (into the bloodstream).

The lethal dose for a person by the intravenous route is estimated to be 90 to 150 nanograms. With a mean concentration of BoNT/A neurotoxin in Botox of 0.73 nanograms per 100 unit vial, it would take more than 100 vials and more than 10,000 units to kill someone.

Most doctors don't even have that many vials of Botox in their clinic.

In clinical practice, aesthetic doctors would never utilize such large amounts of Botox in a single patient.

Has Botox killed before?

In 2008, there were claims that Botox caused nearly 16 reported deaths during 1997–2006. These alleged deaths were associated with high doses of Botox for medical, not cosmetic purposes.

Death after Botox administration for cosmetic indications had never been documented with standard approved formulations.

Another high profile case was splashed across the headlines in November 2018, when a top Hong Kong banker suddenly collapsed and died. She had presumably undergone botox injections by an 86 year old veteran plastic surgeon. However:

• the patient had significant past history of asthma
• postmortem autopsy failed to find the cause of death
• unnamed "dangerous drugs" were found off the record at the clinic
• toxicology analysis is still pending

Botox was not confirmed to be the cause of death.

Is Botox The Likely Cause of Death?

When I use botox for aesthetic medicine (typically to treat wrinkles), I inject small amounts (1 to 5 units) at precise points in the face into specific muscles. I am particularly careful to avoid puncturing blood vessels as:

1. Bruising may result, which may inconvenience the patient
2. It makes the treatment go more slowly as I’ll have to compress the area to stop bleeding
3. The target muscle does not absorb the toxin, resulting in wastage.

The total amount of botox used may be about 5 to 20 units per area.

This is extremely far off from even the lowest estimated dose of Botox that could cause death.

Even if directly injected into the bloodstream, this small amount of Botox is extremely unlikely to cause any effects.  The tiny amount is diluted in the bloodstream and spread throughout the body resulting in negligible effects.

Moreover, we use tiny needles and syringes to inject Botox. One syringe can only hold a fraction of a vial of Botox. Even if the doctor were to accidentally inject the full syringe of Botox intravenously (which in itself is unlikely), this would only amount to tens of units of Botox - a fraction of a percentage of the lethal dose.

Lastly, if you've ever had Botox before, you'll know that it takes time (3 to 7 days on average) for Botox to be taken up into the nerves and produce muscle relaxation. In other words, it is quite difficult for Botox to produce an immediate effect, even if we wanted it to. How likely is it then to cause seizures and collapse shortly after injection?

How could Botox have possibly caused Li Ting's death?

What Could Have Happened?

Given that the facts and circumstances of this case are incomplete, it is not healthy to speculate too much about what could have happened. Dire consequences could result from irresponsible reporting and groundless allegations.

What we do know from the reports:

• Li Ting had undergone Botox injections before
• the onset of seizures and collapse was immediate or very rapid
• the injection was carried out in a licensed aesthetics clinic
• the content of the injection was unconfirmed

Since the news of this case broke, many rumours have been spreading about what could have actually caused this 'botox death'. Some whispers even suggest that illegal unlicensed treatments were involved.

By now, you should have probably realized this: the balance of research and clinical evidence show that Botox is a safe and effective treatment. Of course, it has to be used with appropriate techniques in the hands of a licensed doctor with the proper training and clinical experience.

Many patients asked: but if the death is not due to routine cosmetic usage of Botox, what could have caused it? I thought long and hard about what could have happened based on my medical knowledge and past experience with medical aesthetics procedures.

• Unlicensed drug or fake botox - In China, up to 70% of the Botox and hyaluronic acid may be either counterfeit or smuggled illegally. Given the strict regulations in Singapore on importation, licensing and drug safety, this is very unlikely. Most doctors abide by the law and would not risk patient safety. It is possible that something was wrong with the product injected that the doctor was not aware of.
• Medical error - Technical error could have occurred during the administration of the injection:
  • Wrong drug: The doctor could have mistakenly taken the wrong syringe or vial and administered the wrong drug that caused side effects.
  • Wrong dilution: Even so, even administering a complete vial of Botox is unlikely to cause immediate seizures and collapse.
  • Intravascular injection: By itself, the accidental injection of Botox into a blood vessel should not pose a major problem. However, the injection of other substances such as fillers into blood vessels could potentially cause a blockage. Even the injection of significant quantities of air into a blood vessel can block blood supply. Given that the blood vessels of the face communicate extensively with the blood vessels of the brain, it is plausible that emboli could have entered the brain triggering seizures.
• Idiosyncratic or allergic drug reaction - While she apparently had no issues with previous Botox treatments, it is still possible that Li Ting developed a severe anaphylactic reaction to Botox during her latest injection. The chances of this happening are very low. Only 1 case of anaphylaxis to Botox has been reported. The Botox used in the reported case was suspected to be fake. All licensed medical clinics have emergency drugs on hand to treat severe drug allergies.
  While allergic reactions can be rapid, they usually do not result in immediate reactions and seizures are uncommon. If Li Ting had developed an allergic reaction, it is likely that there would have been sufficient time to administer emergency treatment before the collapse.
• Pre-existing health condition - We're not sure about what past medical history Li Ting may have had. It is possible that she experienced a flare-up or new onset of an underlying health condition, completely unrelated to the injection. It's also possible that the injection triggered or worsened her existing condition.

Bear in mind, however, that the above is based on what we currently know about the case from news reports. It is just meant to give insights into what could have happened. What actually happened may be completely different and perhaps totally unexpected.

What Now? Is Botox Still Safe?

To be honest, we’re not even sure if Botox was indeed administered to the victim before she collapsed.

All we have to go on are the published accounts in the mainstream news and tabloids, which should not be relied upon to provide an accurate account of the incident.

What really happened? Probably only the doctor involved has a clear picture of what transpired.

While I do not know the doctor personally, no doctor would want to cause harm to their patient and I’m sure the doctor is feeling terrible as well. Most doctors try to do their best by their patients; as a responsible doctor myself, I only want the safest and most effective treatments for my patients.

Without a thorough investigation, it would unfair to the doctor to be accused of causing the death of a patient which he/she might not actually be directly responsible for. Regardless, to be fair to the victim’s family, I hope that a sound and thorough investigation will be carried out soon to clear the air.

In my professional opinion, it is highly unlikely that Botox directly caused the death of this unfortunate lady.

If Botox is so dangerous as to be able to cause death in clinical usage, no doctor would want to use it, much less for aesthetic purposes.

But the facts are that Botox is known to be very safe, so much so that most aesthetics doctors, in fact, use it on themselves regularly and repeatedly.

In the right hands, Botox is one of the safest yet most powerful anti-ageing treatments. Find a careful and experienced doctor you can trust and listen to their advice.

Still have doubts about Botox or worry that it may cause problems? Drop me a message and I'll be glad to help!

References

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3. Ram Kumar Dhaked, Manglesh Kumar Singh, Padma Singh, and Pallavi Gupta. Botulinum toxin: Bioweapon & magic drug.  Indian J Med Res. 2010 Nov; 132(5): 489–503.
4. Eugenia Yiannakopoulou. Serious and Long-Term Adverse Events Associated with the Therapeutic and Cosmetic Use of Botulinum Toxin.  Pharmacology 2015;95:65–69
5. Adriano Ferrari, Mario Manca, Valeria Tugnoli and Luigi Alberto Pini. Pharmacological differences and clinical implications of various botulinum toxin preparations: a critical appraisal. Funct Neurol. 2018 Jan-Mar; 33(1): 7–18.
6. Frevert J. Content of botulinum neurotoxin in Botox®/Vistabel®, Dysport®/Azzalure®, and Xeomin®/Bocouture®. Drugs R D. 2010;10(2):67-73.
7. Moon, I. J., Chang, S. E., & Kim, S. D. First case of anaphylaxis after botulinum toxin type A injection. Clinical and Experimental Dermatology, 42(7), 760–762.
8. Pickett, A. Can botulinum toxin cause anaphylaxis after an aesthetic treatment? Clinical and Experimental Dermatology, 43(5), 599–600.