Side Effects and Dangers of Botox

You may have seen it on television — a celebrity with one side of her face looking completely different from the other, as if she’s paralysed on one side.  Indeed, this is a botched Botox work; so if you are interested in a Botox treatment, you should be aware of the risks involved.

In USA, the use of  Botox to enhance attractiveness began in 2002 after the Food and Drug Administration  approved its usage for cosmetic purposes. Almost four million botox procedures are performed yearly in USA, making it the most sought-after cosmetic surgery.  Currently, more than 18 clinics and two private hospitals in Malaysia offer botox injections, testifying to its growing popularity in the country.  In fact, our neighbouring country Singapore has a whopping 40 over clinics offering botox, while Indonesia, Philippines, Thailand are also seeing the mushrooming of such clinics.

Origins of Botox

Botox is actually a trade name for a type of protein called Botulinum toxin that is extracted from the bacterium Clostridium botulinum. Botox is manufactured by Allergan, Inc. However, it is no longer the only Botulinum toxin available in the market today. In 2009,  Dysport, which has been popular in Europe for several years, was given approval  by the Food and Drug Administration  to join Botox in the fight against wrinkles, and is marketed in USA  under the name Reloxin.

The discovery of the  Botulinum toxin cannot be attributed to a single scientist. As early as 1897, Dr. Emile van Ermengem had identified the bacterium Clostridium botulinum to be the producer of Botulinum toxin. Later, other scientists  refined  the toxin as a therapeutic agent. Finally, in 1986, Dr Richard Clark published his research on the cosmetic effects of Botulinum toxin in the journal Plastic & Reconstructive Surgery.


Botox is injected to reduce frown lines on the forehead, crow’s feet or wrinkles around the eyes, squint lines, wrinkles on the neck and around the side of the lips.  A standard Botox procedure may consist of four or five shots into the frown lines. The initial step is to numb the area to be injected with a local anaesthetic. The next step is to inject small amounts of Botox into the desired space using a thin needle.  The effects of the injections last from three to six months. Men usually need twice as much Botox as women to get the same effect as their facial muscles are larger. The Botulinum toxin works by blocking the release of a chemical called acetycholine. In laymen terms, signals from nerves to the muscles are blocked. As a result, the muscle can no longer contract, thus the wrinkles relax and soften.   After injection, Botox takes effect from three to seven days.

Cosmetic Side Effects

Botox procedures should be customised to an individual’s face, taking into account which muscles the patient uses the most. The cosmetic negative side effects of Botox are often the results of inexperienced injectors or a patient who insists on a certain look despite all evidence that it doesn’t look good. With an experienced doctor or nurse injecting, potential problems should not occur.

A common side effect is termed the frozen forehead. In this condition, the face remains stiff and immobile. The person looks like a robot and unnatural.  What is the cause? Answer: an inaccurate  dosage of  Botox. In the beginning, when working with frown lines, the corrugator muscle (the muscle that functions when people frown) needs to be completely relaxed for a while. Once the frown line dissipates, though, the Botox dosage should be adjusted for a little movement so that the expression looks natural.

Sometimes, one or both eyebrows become arched too high. When the Botox injection is not administered accurately in the desired spot, one or both eyebrows become elevated so much that they sit up too high, giving the patient a surprised look. Additionally, odd wrinkles can occur over the lateral brow.

Drooping eyelids is another common complication. After the procedure, the eyebrows may droop, making the eyelids feel heavy. This condition is temporary as there are prescription drops that will temporarily help elevate the eyelids. When the effects of the Botox dissipate, this problem will go away.

A forehead that feels heavy is another possible undesired result.  This is the result of an over-dose of  Botox on the forehead, specifically the frontalis muscle. If the doctor doesn’t correctly gauge how much the patient uses this muscle, then too much Botox will make the forehead feel heavy. When the forehead comes down, so do the eyebrows.

Medical Risks

Patients also sometimes suffer tingling  or  bruising  at  the  site  of  injection. Botox works by temporarily paralyzing the muscles at the site of injection. In rare cases, this effect may spread to other muscles near the intended area. This can cause temporary paralysis in neighbouring muscles, which can cause facial paralysis. However, such occurrences account for less than one percent of Botox procedures. Other common side effects associated with Botox treatments are headaches, pain in the face, erythema (redness of the skin)  and nausea; however, these are temporary conditions.

More serious risks occur when Botox interacts with other medications, both conventional and herbal. Before undergoing a Botox procedure, a prospective patient should inform the doctor about any medications he or she is taking. Medications that may have adverse reactions if mixed with Botox include antibiotics for treating infections such as gentamicin, tobramycin, clindamycin and lincomycin; medications used to treat heart rhythm problems, such as quinidine; and medications used to treat other conditions, such as myasthenia gravis and Alzheimer’s disease.

Over-the-counter medications may also interfere with the drug formula in Botox. It is best to discontinue using over-the-counter medications before and after receiving Botox treatments and inform the plastic surgeon of any drug usage. A pharmacist can also provide complete information about all drugs that may adversely interact with Botox.

Certain groups of people are at a higher risk of suffering Botox side effects. They include people with pre-existing infections at the injection site and patients with cardiovascular or neuromuscular disorders. Pregnant women and nursing mothers should also avoid Botox injections as the risk to a foetus or a nursing baby has yet to be ascertained.  Potential candidates for Botox treatments should definitely  inform their plastic surgeons of any pre-existing medical condition before the Botox procedure is performed. Also of importance is for the patient and the physician to be aware of any allergies the patient may have to any drugs that make up the Botox formula. An experienced physician will help determine if Botox is the right treatment for each individual.

Botox deaths

Botox can be deadly, and should only  be administered by qualified physicians. In the  September 2005 issue of Journal of American Academy of Dermatology, it was reported that use of Botox resulted in 28 deaths between 1989 and 2003, though none were attributed to cosmetic use.  In 2008, the FDA cautioned that Botox has been linked in some cases to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses due to its ability to spread to areas distant from the site of the injection.

In April 2009, the FDA again warned that the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of  botulism. This warning was echoed by the Canadian Government in 2009 in a statement cautioning that Botox can spread to other parts of the body from the injection site, which can cause muscle weakness, swallowing difficulties, pneumonia, speech disorders and breathing problems.


The cost of a Botox treatment for the face ranges from RM750-RM1,500, excluding consultation costs. Most suitable candidates are those with realistic expectations and are healthy.  Beware of cheap Botox as it may be over-diluted or be a fake.


1. Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM (September 2005). “Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases”. Journal of  American Academy of Dermatology.

2. FDA Gives Update on Botulinum Toxin Safety Warnings; Established Names of Drugs Changed, FDA Press Announcement, August 3, 2009

3. “Botox chemical may spread, Health Canada confirms”. CBC News. 2009-01-13.

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