Anti-wrinkle injections: side effects and safety

Key takeaways

• Common effects are local and settle within days: pinpoint redness, swelling, bruising, mild headache.
• An eyelid or brow droop is uncommon and temporary, but can last up to about 12 weeks.
• Avoid treatment in pregnancy, breastfeeding, some muscle disorders and with certain antibiotics.
• Seek urgent care for trouble swallowing, speaking or breathing, or double vision.
• Licensed product, written dose and a doctor who reviews you are the main safety steps.

What side effects are common?

Normally I tell people to expect very little. DermNet lists the most common effects as:

• Pain or tenderness at the injection points, for a short time
• Redness and small bumps where the needle went in, usually settling within a short while
• Bruising, more likely if you take blood thinners or certain supplements
• Mild headache, typically a few hours after forehead treatment, which DermNet notes responds to paracetamol

These are local reactions to the injection itself. They do not mean anything has gone wrong.

What are the less common side effects?

See, what happens is, the medicine is placed in one muscle, but a little can spread to a neighbouring one. DermNet describes this as uncommon, happening in fewer than 10% of treatments, and it can cause:

• A drooping upper eyelid (ptosis)
• A heavy or lowered eyebrow, or an uneven brow
• A change in the lip or smile, if treating near the mouth

In clinical trials for frown lines, the US prescribing information reports eyelid drooping in 3% of treated people, against 0% with a dummy injection. When it happens, it is temporary. DermNet notes it can last up to 12 weeks, and prescription eye drops can help a drooping eyelid while it settles.

This is why placement and dose matter so much. That is very important to understand: the face has many small muscles close together, and knowing where each one sits is the job.

What are the rare but serious risks?

The US prescribing information for licensed botulinum toxin products carries a boxed warning about distant spread of toxin effect. In rare cases, effects can spread beyond the injection area and cause:

• General muscle weakness
• Double vision or blurred vision
• Drooping eyelids
• Difficulty swallowing or speaking
• Breathing difficulty

These can appear hours to weeks after the injection. The label says the risk is probably greatest in children treated for spasticity, who receive much larger doses for medical reasons, but adults with certain underlying conditions can also be affected. Cosmetic facial doses are small, which is why these events are rare in aesthetic practice. But you should know the signs.

Seek urgent medical care if you have difficulty swallowing, speaking or breathing, or new double vision, after treatment. Tell the doctor you have had botulinum toxin.

Who should not have anti-wrinkle injections?

I also ask about upcoming events. If you have a wedding or a photograph you care about, do not have your first treatment a few days before it. Give it at least two weeks so we can review and adjust. My article on planning anti-ageing before a big event explains the timing.

Is repeated, long-term use safe?

The evidence we have is reassuring, with honest limits. A retrospective review presented to the American Academy of Dermatology followed 50 adults who had a median of 19 treatment sessions over about six years. Neither the number of treatments nor the interval between them was significantly linked to the risk of side effects. The study was industry-funded and not a large trial, so it is a reassurance, not proof.

One genuine long-term issue is resistance. DermNet advises that injections should generally not be given more often than every 8 to 12 weeks, because frequent dosing raises the risk of antibodies that can make the treatment work less well. That is one more reason I do not do "top-ups" every few weeks.

How does good practice reduce risk?

Basically, most problems I see from elsewhere come down to a few avoidable things. Here is what keeps it safe:

• A proper assessment. Medical history, medicines, how your muscles move, and your brow and eyelid position before treatment.
• A licensed product from a proper supply chain, stored correctly. DermNet notes reconstituted product should be used within 24 hours.
• The product and dose written down. The US prescribing information states that units of different products are not interchangeable, so the dose only makes sense with the product name.
• Conservative doses, with a review at two weeks rather than a large dose in one go.
• A doctor you can reach afterwards, who will see you if something feels wrong.

What should I do after treatment?

Your doctor will give you specific instructions. In general, go about a normal day, avoid pressing or massaging the treated area that day, and get in touch if you notice anything unexpected. Small bumps and redness settle quickly. If your eyelid feels heavy over the next week or two, call us so we can see you.

How we approach this at Dr Tvacha

At our centres in Thane, Andheri, Bandra and Dahisar, safety starts with the Rs 499 face assessment and a full medical history. The product, dose and price are written down before treatment, and I review you at two weeks. If you are pregnant, breastfeeding or have a condition that makes it unwise, I will say no, and we will look at what else can help. You can read about the Long Game Anti-ageing Plan or how the injections work.

Written by

Dr Amit KarkhanisAesthetic Physician · MBBS, Dip. Dermatology (UK) · Reg. No. 2001/02/1124

Founder of Dr Tvacha, practising in Thane since 2005. Leads the weight loss and hair programmes.