What Are the Side Effects of Botox?

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Do you have wrinkles, frown lines, and crow’s feet? Botox treatment can help reduce facial wrinkles and make you look younger. Like any treatment, however, it can have certain side effects. Understanding these side effects can help you decide if a botox injection is right for you.

Overview of Botox and How It Works

Botox stands for botulinum toxin type A, which sounds scary, but in small doses it can treat a variety of health problems. In addition to smoothing out wrinkles, botox can help with various conditions including uncontrollable blinking, chronic migraine, cervical dystonia (pain in the neck), TMJ disorder, and overactive bladder. Botox injections either weaken or paralyze certain muscles or block certain nerves. Cosmetic botox injections are a lower dose than those used for therapeutic treatment of cervical dystonia and other conditions.

When treating wrinkles it blocks signals from the nerve to muscles in your face, specifically the ones associated with dynamic wrinkles such as crow’s feet and frown lines. It’s the most frequently performed cosmetic procedure in the United States.

Botox treatment can only help with dynamic wrinkles, not facial sagging, which may be best treated by using fillers. Botox is considered safe, with few adverse effects and generally high patient satisfaction. It is less invasive than plastic surgery, but does only have a temporary result, with many patients repeating the treatment every few months. However, it is one of the most common procedures in aesthetic medicine.

Common Side Effects of Botox

The most common side effects of botulinum toxin injection are:

  • Pain, swelling, or bruising at the injection site. This typically fades quickly.
  • Headache
  • Flu-like symptoms
  • Crooked eyebrows
  • Droopy eyelids
  • Crooked smile
  • Water or dry eyes
  • Infection at the injection site

The risk of these botox side effects can be reduced by choosing an experienced provider, as many are caused by errors when inserting the needle. Most common side effects occur near the botox injection site.

More rarely, botox can cause:

  • Trouble talking
  • Trouble swallowing
  • Vision problems
  • Muscle weakness
  • Breathing problems
  • Loss of bladder control
  • Dizziness
  • Nausea
  • Dry skin at the injection site.
  • Numbness at the injection site.

It is also possible to be allergic to botox, and reactions can be severe. However, a severe allergic reaction is rare.

Short Term Side Effects of Botox

The majority of botox side effects are localized and transient and vanish without treatment. These short term, common side effects include:

  • Bruising. This is typically caused when the needle hits a blood vessel and is particularly common if you are having an injection near the eye, such as to treat crow’s feet. This affects between 11 and 25% of patients. Your provider will recommend that you avoid anything which inhibits clotting for two weeks before treatment, including aspirin, NSAIDs, vitamin E, and certain herbal remedies. Ice applied before the injection can also reduce the risk of bruising.
  • Localized pain. There is normally some pain from the needle penetrating the skin, but this is mild and, again, transient. If you are sensitive to pain, a topical anesthetic cream can help.
  • Dry, flaky skin, which is rarer but can occur in some patients. Botox can reduce sweat gland activity, causing dry skin.
  • Headache. The toxin effect causes muscle spasms, which can cause a mild headache that lasts no more than a few days. Some people may also get a headache because they are anxious about the injections. NSAIDs are useful for managing these headaches. Occasionally, a severe headache that can last as long as two to four weeks and may require opioid treatment can occur. If you have a severe headache or it lasts more than a couple of days, talk to your doctor.
  • Hypoesthesia, or numbness at the injection site. This typically lasts no more than 48 hours.
  • Mild allergic reactions.
  • Drooping eyelid. This happens with forehead injections and is called blepharoptosis. It is unilateral, affecting only one eye, and resulting in visible droopiness that looks worse at the end of the day. This is also temporary, but can persist for two to four weeks. It can also be a delayed reaction, occurring as long as ten days after the injection. Eye drops can be used to help contract the muscle and return the eyelid to normal position until it resolves.
  • Increased forehead wrinkles. Sometimes, botox injections on the forehead can actually cause a temporary increase in wrinkles due to the effect on the frontalis. The upper frontalis is paralyzed and the lower part tenses up, causing a muscle contraction that wrinkles more visible, including ones you might not have noticed. This usually disappears spontaneously, but can make it look as if the treatment did not work well.

All of these side effects are temporary and typically go away on their own, but they are things that you should be aware of if you decide to have botox treatment. It’s generally best to time treatment for a couple of weeks before any event at which you want to look your best. As headaches are common, make sure that you have your preferred NSAID available.

Medium Term Side Effects

Some botox side effects last longer, and may require treatment to resolve them. These include:

  • Mephisto sign. This means that the distal ends of your eyebrows raise and point upwards. This can last as long as three months and may require extra treatment. It is also called Mephisto brows or Spock brows, and is a cosmetic issue that can cause embarrassment.

Long Term Side Effects

Long term side effects of botox are rare, but can occur.

  • Lack of facial animation. Extensive use of botox over the long term can cause a reduction in facial animation that can be particularly problematic for teachers, actors, broadcasters, etc. The face can become expressionless and mask like. However, this only occurs when somebody has received a large number of injections over time. Because botox is temporary and only lasts a few months, some people will keep coming back to be “touched up.” Taking a break from botox can resolve it. However, some people may also find that long term muscle weakness caused by multiple injections improves their cosmetic results.
  • Frontal alopecia, that is to say a receding hairline. This is also typically caused by multiple injections, specifically for forehead wrinkles.

There is also the possibility of a severe adverse effect. Botulinum toxin can in very rare cases, usually after multiple injections, spread into your system and lead to a serious condition called botulism or to anaphylactic shock. This is particularly rare after botox cosmetic injections, which are a much lower dose than therapeutic injections for conditions such as excessive swearing and overactive bladder. However, it can still happen and cause dysphagia (difficulty swallowing), muscle weakness, and hoarseness. These symptoms generally resolve quickly, but some patients might experience recurring bouts of muscle weakness over years. Some may need to temporarily change to a soft diet or if really severe may require nasal feeding or intravenous nutrition. Again, this is very rare with cosmetic injections and when it does occur is typically very mild, resulting in headaches, fatigue, and dizziness. Severe botulism can, however, cause respiratory failure.

Who Should Not Get Botox Injections

Some people should not get botox injections due to a higher risk of adverse effects. You should not get botox if:

  • You are pregnant or breastfeeding. Botox has not been properly evaluated for safety during pregnancy, and while it has not been demonstrated to cause harm to a fetus, you should wait until your child is weaned.
  • You have had an allergic reaction to botox in the past. Also tell your doctor if you are allergic to cow’s milk, as cow’s milk protein is sometimes found in botox products.
  • You have been treated with botulinum toxin for another condition in the last four months. Botulinum toxin is used to treat a variety of conditions including excessive sweating, cervical dystonia (pain in the neck) and overactive bladder.
  • You are unwell. You should reschedule your injection if you have a cold or the flu, or any other kind of malaise, or if you have a skin infection. Botox injections put unnecessary strain on your body and immune system.
  • You have myasthenia gravis, multiple sclerosis, or another neuromuscular condition. People with these conditions are more likely to experience muscle spasms and other side effects from botox.
  • You are taking aminoglycoside antibiotics. Reschedule when you are no longer taking the antibiotics, as they can affect the way botox works and also because it is not good to have botox when you have an active infection.
  • You are on anticoagulants or long-term blood thinners. These can significantly increase the risk of bleeding. Depending on your condition, you may be able to temporarily discontinue these medications.
  • You are over 75 years old. Botox is generally not recommended for extremely elderly patients due to a high risk of some side effects, including the possibly of entropion. This is when your eyelid turns inward, risking damage to your cornea.

You should also discontinue muscle relaxants taken for another reason. Talk to your doctor about what medications you should stop taking as they might interfere with the action of botox.

How to Minimize the Risk of Side Effects from Botox Injections

The best way to minimize the risk is to choose an experienced provider. Do not get botox injections anywhere other than a dermatologist’s office or a plastic surgeon. Do not get botox injections at a medical spa. Do not do botox parties where people attempt to inject botox into each other. Incorrect injection technique can greatly increase your risk of side effects.

Some other things you should do:

  • Tell your dermatologist about all medications, herbal medicines and supplements you are taking. Checking a medication guide can help too.
  • Do not drink alcohol for 24-48 hours before the procedure. Drinking alcohol can increase the risk of injection site bruising.
  • Do not massage or rub your face for three days after the procedure.
  • Do not sunbathe or use a sunbed or sauna for two days.
  • Avoid vigorous exercise for two days. If you work in an intensely physical job you may want to take a couple of days off or time your treatment for before your regular time off.
  • Do not lie down for two to four hours after the procedure. Typically your procedure will be scheduled early in the day to make this easier. Lying down can increase the risk of the toxin spreading through your system.

What to Do If You Experience Severe Side Effects from Botox

Most side effects from botox are mild and self-limiting, that is they go away on their own. You should call your doctor if side effects last more than a few days. If you have a severe headache that lasts more than 48 hours, talk to your doctor. While these headaches do go away, they will be able to give you medication to help in the interim. If you experience drooping eyelids, talk to your opthalmologist. Eye drops can help with this annoying side effects.

If you have difficulty breathing after receiving botox, get medical attention immediately, as this can indicate severe botulism caused by botulinum toxin spreading through your system. If you or another person shows signs of anaphylactic shock or another severe allergic reaction, this is a medical emergency and you should go to the emergency room.

For the most part, side effects from botox are mild and very transient. Most people only experience a little bit of redness at the injection site and perhaps a mild headache. The best way to avoid side effects is to choose an experienced, licensed botox specialist who can give you the right advice and dosage and has good technique. Most people who get botox are able to return to work immediately and see results in as soon as a week or two. However, botox works better on dynamic wrinkles that are caused by muscles, and not as well on static wrinkles, which are better treated with dermal fillers.

Botox is a great alternative to facial plastic surgery for most people.