Complications After Botox

The nature of complications after Botox depends primarily on the injection site. Understanding what types of issues may appear, and why their likelihood depends on the treated area, helps patients make an informed decision and prepare for the procedure more responsibly.

Ptosis

The most common complication after Botox is eyelid ptosis, either true or false.

With true eyelid ptosis, the upper eyelid does not lift: the patient cannot fully open the eye, or the eye remains half-open.

False ptosis occurs when the frontal muscle is completely blocked, which leads to immobility of the brows and their slight descent.

Both true and false ptosis are reversible. If other factors are present (neuritis, neurological complications, herpes), the situation can become more complicated. 

Botulinum therapy of the masseter muscle (M. masseter) may cause undesirable changes in the facial contour — the appearance of jowls. Such injections are usually performed to treat hypertonicity of the masseter, bruxism, or for aesthetic narrowing of the lower jaw angle.

After injection, the muscles stop working and decrease in size, just like any muscles without load, which results in a loss of soft tissue volume. The doctor must evaluate the patient’s skin turgor, masseter prominence, and warn in advance that thread lifting, fillers, laser resurfacing, or other skin-supporting procedures may be required. This correction method is not suitable for every facial shape.

Can a double chin sag after platysma injections? Only in cases of excess subcutaneous fat: if previously supported by a tense platysma, after its relaxation heavy tissues may sag. Usually, however, working with the platysma provides a very good lifting effect. In practice, the author has not observed platysma sagging, though it has been mentioned at conferences.

Compensatory Wrinkles After Botox

Redistribution of facial expressions around the eyes and/or above the brows may lead to the appearance of new wrinkles. But for them to become permanent, it takes quite some time. Such folds can be corrected by additional Botox injections into specific points or by introducing filler/biorevitalizant.

A perpendicular fold extending from the brow to the temple indicates undercorrection of the orbicularis oculi muscle. This often occurs when the product is injected only laterally into crow’s feet.

With facial expression redistribution, wrinkles can also appear from the inner corner of the eye to the nose (“bunny lines”). This is likewise a sign of insufficient correction of the orbicularis oculi muscle.

Sometimes patients skip follow-up visits, assuming compensatory wrinkles are normal. Sometimes doctors leave the issue uncorrected. But such complications can and should be corrected. Therefore, the rule exists: return for a check-up 2–3 weeks after injection. Even if everything seems fine — come in. The doctor may notice early signs of compensatory folds, add 2–3 units, and neutralize them.

Asymmetry After Botox

When working with the upper third of the orbicularis oculi muscle, the doctor may inadvertently affect the zygomaticus major and minor muscles, inject too low, or diffusion of the product may spread into the zygomatic muscles. This results in facial asymmetry when smiling.

When working with the lower third of the face — with the depressor anguli oris muscle or the mentalis — asymmetry of the mouth corners may appear, creating a characteristic grimace when smiling or difficulties during eating. This complication can be corrected by injecting antagonist muscles and/or slightly relaxing the same muscle on the opposite side.

If correction is impossible, the action of botulinum toxin can be reduced by taking vitamin B complex and undergoing microcurrent therapy to improve microcirculation.

Edema

Edema is not considered a complication; it is listed in the instructions as a possible reaction to botulinum toxin. In some cases, edema may persist for up to 3 weeks.

Hypothyroidism may cause strong swelling after botulinum therapy, usually appearing on the 2nd day and completely resolving by the 7th.

Headaches

After Botox relaxation of the frontalis muscle, occipital pain may appear as a form of bodily compensation. After relaxing the masseters, trapezius muscles may hurt. Temporary migraine-like conditions are possible. With time, muscle work rebalances and the pain subsides, though additional correction may be needed.

Migraines and headaches are sometimes treated with Botox as well — neurologists use it to relax specific muscles.

Rare Complications After Botox

According to the instructions, possible side effects include “general weakness, fatigue.” This applies to patients with myasthenia or myasthenia-like syndrome. Myasthenia is a separate condition characterized by muscle weakness, which may remain unnoticed until after Botox injections. This is extremely rare, and the author has not encountered such cases in 13 years of practice.

Convergent strabismus is another rare complication, usually caused by excessive dosage. It is temporary, and ophthalmologists may prescribe beta-blocker eye drops, but usually one just waits until the Botox wears off.

Another very rare complication is impaired articulation (dysarthria) and drooling, which may occur when working with the orbicularis oris muscle.

Herpes and Other Risk Factors

A herpes recurrence before the procedure or frequent herpes flare-ups in general can make the outcome of injections unpredictable. Herpes affects the facial nerve ganglia, and the diffusion of the drug can spread uncontrollably, causing asymmetry. Even when correcting the upper third of the face, herpes can cause asymmetry of the smile or mouth, and pronounced eyebrow asymmetry — even with minimal forehead injections.

Patients with neuritis should be referred to a neurologist or treated after consultation with one, since botulinum toxin may act unpredictably even in the hands of very experienced doctors with very small doses.

Follow-up Control

After injection, a follow-up visit after 2 weeks is mandatory. Doctors cannot predict exactly how each patient’s muscles will respond. Patients have very different anatomical features and variations.

In cosmetic practice, it is believed: if a doctor has never encountered complications, it simply means they have too little experience. Overall, without correction, all Botox-related complications resolve within 3 months.