What You Need To Know About How Botox Can Go Wrong

We often joke about appointments for Botox® and its fellow neurotoxins (hi, Dysport®, Jeuveau®, and Xeomin®) being as routine as hair color touch-ups or mani/pedis. While it’s great that it may be true, it’s important not to overlook the fact that even a treatment as (relatively) quick and painless as Botox is still a cosmetic procedure that requires the expertise of a skilled injector. With more options on the market and handfuls of injectors offering every type of injectable neuromodulator possible, it’s more pertinent than ever to fully understand the ins and outs of the minimally invasive procedure — including what can go wrong.

Of course, not just anyone should be injecting you, nor should just anything be injected into your face (remember, you only have one face). So, before you let the needle touch your skin, make sure that you have answers to all of your questions, you’ve done ample research on your provider, and you see the product being injected to make sure it’s 100 percent the real deal. Beyond the basics, what else do you need to know about your neuromodulator appointment? Read on for all of our safety tips and considerations.

The Social Effect

Social media is a consortium for all types of images, including neuromodulators gone wrong and the scary side effects that they produce. Case in point: the latest set of terrifying photos show a patient’s forehead covered in lesion-like scabs as the result of illegal botulinum toxin injections.

Neuromodulators are one of the most popular non-surgical procedures for a good reason. In 2020, injectors performed more than 2.6 million botulinum toxin type A procedures according to the Aesthetic Society’s annual statistics report. Botox® and the like are a valuable tool in nearly every aesthetic doctor’s toolbox.

But as elective cosmetic procedures become more common and socially accepted, it creates openings for unlicensed providers to offer bogus services, says Brendan Camp, MD, a board certified dermatologist in New York City. That opening also paves the way for an increase in unsatisfactory and, in some cases, dangerous results. “Sadly, the incidence of ‘botched’ neuromodulator injections has dramatically increased as unqualified injectors enter the industry,” says Jessica Weiser, MD, a board certified dermatologist in NYC.

Besides the fact that counterfeit injectables are not anything close to the real thing, the fakes can consist of anything from other drugs and bacteria to bleach and plain old water. In addition, these illegally obtained products are not typically purified and may contain contaminants. Once contaminants enter the skin, they can lead to allergic reactions, foreign body granulomas, serious infections, skin necrosis, and other complications with severe long-term ramifications, Dr. Weiser cautions.

The net-net: “As the amount of counterfeit product has skyrocketed, unlicensed injectors have started to enter the arena, purchasing product illegally from unauthorized sources or foreign countries and more,” she shares. This has led to what she calls “a completely uncontrolled injection market.”

Don’t Fall for Faux-tox

Years ago, the school of thought was that Botox® and other neuromodulators were just for the rich and famous. But that's no longer the case. With more younger patients dabbling in minimally invasive procedures — like injectables and lasers — the supply and demand for neuromodulators increases.

The growing demand creates a black market (fake injectables are often known as ‘faux-tox’) and an easy entry point for those who are not well-versed in the procedure to be swayed easily, says Roberta Moradfar, NP, a board certified aesthetic nurse practitioner and the owner of EFFACÉ Aesthetics in Los Angeles. “Sadly, several injectors are offering fake versions of the neurotoxin and passing it off as the real thing to either cut their costs or because they are not qualified even to purchase injectables,” she says.

Another reason for the recent rise of counterfeit and illegal neuromodulators is a considerable price increase in the real thing and the supplies associated with them. Syringes, needles, and other medical supplies have skyrocketed in price, especially during the pandemic, says Macrene Alexiades, MD, a board certified dermatologist in NYC. “In contrast, prices have hit a limit, and it is simply not possible to increase prices much further despite the presence of record-breaking inflation in recent months,” she explains. “As a result, it has become challenging for doctors to generate profits, which has led to less reputable doctors and shady operations to resort to black market botulinum toxins, which are extremely dangerous.”

Dr. Weiser adds that, with each subsequent year, the cost per vial rises for Allergan-branded Botox® Cosmetic, Galderma’s Dysport®, and other neuromodulators approved by the United States Food and Drug Administration (FDA). “As more people desire to work in the aesthetic space but want to undercut industry pricing, they buy products cheaper and often without a license,” she says.

Black market injectables have always existed, yet the use of these products is surging right now. “I observed and informed the companies that manufacture injectables of Instagram, Twitter, TikTok, and Facebook accounts posting videos of people injecting themselves with illegal forms of Botox® and fillers,” Dr. Alexiades says. And in this social media-driven world, utilizing black market products opens up Pandora’s box to the world of copycats, which will only lead to problems. Not to mention the rise of DIY injectables and fillers — a scary thought indeed. “There are numerous internet pop-ups that are mailing ‘DIY Botox’ kits for people to self-inject, posing additional levels of concern,” Dr. Weiser notes.

Just because you think you're getting the real deal, even if you're not, doesn't mean that whatever ersatz injectable follows the same production, testing, manufacturing, and FDA-approval processes as their legitimate counterparts. “Unregulated products are not manufactured at the same standards as branded products, and, as a result, the concentration of neurotoxins in an illegal product may be too high,” Dr. Camp warns. “This can cause botulism poisoning, which can present with muscle weakness, trouble swallowing, and difficulty breathing.”

It goes without saying that non-FDA-approved products should never be injected into the face (or body). This is because these products lack the multi-phase approval process to ensure that a drug is safe and does what it is supposed to, says Peter Vila, MD, a double board certified facial plastic and reconstructive surgeon in San Rafael, CA. “Injectables that have not gone through FDA approval are huge unknowns that can potentially cause harm or just not work because we simply don't know if they are safe or effective," he says.

What Can Go Wrong

One of the more severe and painful known reactions to faux-tox is pyoderma gangrenosum. Dr. Alexiades describes it as a festering wound associated with inflammatory and autoimmune disorders. Yet, there are reports of ulcers forming at injection sites with illegal botulinum toxin injections. It's rare yet severe, and failure to treat pyoderma gangrenosum can lead to further problems and complications. There's also the potential for scarring and pigmentation formation, which causes a whole other host of issues that can trigger long-term management.

In the event of a mishap (especially with black market neuromodulators), the wrong dose, or a contaminated vial, redness, pain, and the formation of a pimple about 24 hours following the injection can occur. In extreme cases, “if it is an overdose within a short time, the patient can have trouble breathing due to paralysis of the diaphragm and muscles of breathing,” Dr. Alexiades shares. Less severe yet still disheartening effects can take upwards of two weeks post-injection to set in. However, any muscle weakness or fatigue symptoms usually become apparent about a week after treatment and may be accompanied by a heavy feeling in the treated area or asymmetries.

And, of course, the worst-case scenarios are the most extreme ones. Dr. Alexiades says that there have been black market botulinum toxin cases causing people to end up on respirators or even dead. “You must be intubated if you go into respiratory failure,” she explains. “And you must have wound care and antibiotics for infection.”

The takeaway is simple: Don’t let just anyone inject just anything into your face — it’s just not worth it.

Neuromodulators Done Right

It seems as though anyone with a pulse can inject fillers and injectables into the face and call it a success. But, truth be told, it's not that simple, nor should it be. Dr. Vila calls injecting neurotoxins “both an art and a science.” As he describes, “the key to getting good results and avoiding complications comes down to good injection technique.”

Precise and accurate product placement is vital to maintain facial harmony while eliminating the appearance of unwanted wrinkles. “Injecting too much neurotoxin or injecting it in undesired areas can cause unwanted effects such as eyelid drooping, the appearance of heavy brows, or, in some cases, an uneven smile,” Dr. Camp says. Overly arched eyebrows, often called ‘Spock eye,’ droopy eyelids, and upper eyelids that appear heavy and hang down low, creating a tired look that can interfere with vision, are other signs of poorly administered neuromodulators. “Additionally, poorly placed Botox around the eyes can result in an unusual smile and ‘shelf’ effect,” Dr. Weiser notes. Even though nobody wants subpar results, the only positive matter is that, usually, these effects are temporary and will slowly start to correct themselves as the body metabolizes the injectable product in the coming weeks.

Hygiene and technique are also crucial to avoid infections and severe bruising. “You must use an immaculate technique and sterile delivery methods,” Dr. Alexiades says. “Injectors must always cleanse the injection area and only administer the drug with sterile needles and syringes.” These rules apply to all treatment areas of the face since not a single square inch of skin is off-limits nor immune to an adverse reaction, no matter how minor or extreme it may be. Also, your provider should always draw the injectable into a new, sterile syringe and fully clean the treatment area with alcohol, Dr. Weiser advises.

How to Fix Bad Results

When it comes to correcting the effects of black market products or just a bad result, there are a few different approaches to take:

• Time heals all wounds. You can let the effects of the product wear away on their own, which takes about three months. Dr. Camp says that, for the most part, the goal is to encourage the body to metabolize the injected product so that the unwanted effects fade faster. “This can include applying vibration to the treated area, warm compresses, increased contractions of the affected muscles, and exercising, which may also help,” he shares.
• Use special drops to mitigate the effects. According to Dr. Weiser, you can use alpha-adrenergic drops, like iopidine, to give mild relief of droopy eyelid or brow by activating the Muller's muscle in the eye to help create a subtle lifting effect.
• Correct it with additional injections. In the case of a droopy lid, the issue should resolve in a few weeks. When there’s an unnatural appearance from poorly injected toxins, Dr. Vila says that the area can usually be treated with a touch-up of extra toxin to create a more natural look.
• Immediately intervene when necessary. “Infections and foreign body reactions are much more serious concerns because they can leave behind permanent tissue damage and scarring,” Dr. Weiser warns. They “require immediate intervention with antibiotics, steroids, debridement, or more,” she adds.

Why You Always Need to Do Your Homework

No matter what injections you are considering, it’s of the utmost importance to always do your research, which includes:

1. Vetting Your Injector: Search for a good, reputable provider in your area. It’s okay to ask around and get recommendations, but make sure the injector you choose is in good standing and does not have a reputation for using fake products or inferior results. “It is the patient’s responsibility to ensure they are seeking care from a vetted professional, such as a board certified dermatologist,” Dr. Camp says.
2. Avoiding Price Shopping: We love a bargain, too, but aesthetic medicine is not the area skimp. If you’re purchasing deeply discounted injectables, there’s always the threat of it not being the real deal, which leads us to...
3. Getting the Real Thing: Only seek treatment from a licensed physician who buys brand-name, FDA-approved injectables directly from the manufacturer. Don’t be afraid to ask your injector to show the bottle and its packaging.

At the end of the day, a little research goes a long way. Even in the best hands, it is always possible for something to wrong, but finding a qualified provider who you trust (and not doctor hopping) is one of the best ways to ensure the safety and efficacy of your treatment.