QHow do you address botulinum toxins and fillers with pregnant to nursing patients?

Botulinum toxins and fillers do not have sufficient or dedicated studies looking at their safety during pregnancy or breastfeeding. With this uncertainty most providers, myself included, choose to defer Botox injections and filler during pregnancy. There is an added concern with fillers regarding hormonal changes potentially causing facial swelling and/or weight fluctuations, which could distort the primary anatomy that is being corrected. In addition, if a complication arises from vasooclusion from the filler, hyaluronidase has also not been studied in pregnancy, which could lead to further complications(1).

There have not been sufficient studies looking at Botox or filler in breastmilk. However, botulinum toxin diffusion studies have found that the molecule does not diffuse far from the injection point (2), so detection in breastmilk is highly unlikely (3). There have also been reports of pregnant women with full blown botulism and of nursing mothers with botulism that presented no harm to baby (3, 4).

Most fillers have lidocaine, which at low doses from 1 ml of filler should be minimally present in breastmilk. Lidocaine has not been shown to cause any adverse effects on nursing infants, therefore eliminating the need to “pump and dump” after treatment (5). Theoretically, lidocaine at higher doses could lead to decreased breastmilk production, which can be counteracted by temporarily increasing water intake.

I heavily emphasize all those points with each and every nursing patient that inquires about neurotoxins or fillers, and if they absolutely want botulinum toxin or fillers while nursing I prefer to wait until 3 months post partum and try to limit to the minimum amount of toxin and/or filler as possible. By that time some of the post-partum hormones have settled, baby is bigger and milk supply is already established.

References:

1. Morgan, et.al. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol Neurosurg Psychiatry. 2006;77:117-119.
2. Tang-Liu et.a. Intramuscular injection of botulinum neurotoxin complex vs botulinum-free neurotoxin: time course of tissue distribution. Toxicon. 2003;42:461-9.
3. Botulinum A. Drugs and lactation database. https://www.ncbi.nlm.nih.gov/books 09/21/2020.
4. Polo et.al. Botulism and pregnancy. Lancet. 1996;348:195.
5. Lidocaine. Drugs and lactation database. https://www.ncbi.nlm.nih.gov/books. 11/16/2020.