Unit 5: Indications, Contraindications and Complications

Botulinum toxin is indicated for the treatment of dynamic wrinkles. These are wrinkles that appear on the face when an expression is made, and are caused by muscle contractions in the face. BOTOX® Cosmetic (onabotulinumtoxinA) is indicated in adult patients for the temporary improvement in the appearance of:

  • moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity
  • moderate to severe lateral canthal lines associated with orbicularis oculi activity
  • moderate to severe forehead lines associated with frontalis activity

Contraindications for botulinum toxin treatment includes:

  • Pregnancy or nursing
  • Hypertrophic or Keloid scarring
  • Bleeding abnormality (e.g., anticoagulant use or thrombocytopenia)
  • Active dermatosis in the treatment area (e.g., eczema or psoriasis)
  • Active infection in the treatment area (e.g., herpes simplex or pustular acne)
  • Impaired healing (e.g., due to immunos uppression)
  • Skin atrophy (e.g. chronic oral steroid use, genetic syndromes such as Ehlers-Danlos Syndrome)
  • Sensitivity or allergy to botulinum toxin or its constituents (e.g., lactose, sodium succinate, human albumin)
  • Neuromuscular disorders such as amyotrophic lateral sclerosis, Lambert-Eaton Syndrome, myasthenia gravis or myopathies.
  • Gross motor weakness in the treatment area (e.g., Bell’s palsy or stroke)
  • Uncontrolled systemic condition
  • Inability to actively contract muscles in the treatment area prior to treatment
  • Medications that inhibit neuromuscular signalling and that may potentiate botulinum toxin effects (e.g, aminoglycosides, quinine, calcium channel blockers, penicillamine).
  • Unrealistic expectations or body dysmorphic disorder.
  • Periocular or ocular surgery in the last 6 months.


Complications or side effects can be categorised into either injection related or botulinum toxin-related issues

General injection-related complications:

  • Bruising
  • Tenderness
  • Oedema
  • Erythema
  • Headache
  • Infection
  • Numbness or dysesthesia
  • Anxiety
  • Vasovagal episode or loss of consciousness

Bruising is commonly seen after a Botulinum Toxin treatment, especially around the eyes for treatment of crow’s feet. Bruises can average in size from small pinpoint bruises from where the needle entered to much larger ecchymoses or hematomas. The healing process of a bruise varies between clients as well as the size of the bruise. Typically, these may be visible for 1-2 weeks post treatment. The immediate application of ice and pressure can minimise bruise formation.

Pain or tenderness with Botulinum Toxin is minimal. Injection sites can be cooled with ice packs prior to injection. Oedema and erythema are almost always seen at any injection site and these usually resolve within a few hours post treatment.

Headaches may occur with upper face injections from a few days lasting up to 2-4 weeks in severe cases.

Infections are incredibly rare, but they can occur with any treatment that breaks the skin. The most common are bacterial or reactivation of the herpes simplex virus. If there is pain, tenderness and erythema in the area for more than a few days it is recommended to ask the client to seek medical attention. Numbness or dysesthesia in the area is extremely rare but could be due to injuring a nerve during injections.

Anxiety is common, especially for first time clients. This can be alleviated by undertaking a thorough client consultation and explaining the procedure properly to the client. You can also take steps so that the needles or products to be used are not visible to the client during the procedure. Asking the client to concentrate on breathing and taking slow, deep breaths may also help.

Botulinum Toxin Related Complications

  • Localised burning or stinging during the injection
  • Blepharoptosis (droopy eyelid)
  • Eyebrow ptosis (droopy eyebrow)
  • Epiphora (excess tearing)
  • Xerophthalmia (dry eyes)
  • Lagophthalmos (incomplete eye closure)
  • Ectropion of the lower eyelid (eyelid margin eversion)
  • Diplopia (double vision)
  • Impaired blink reflex
  • Globe trauma
  • Photophobia (light sensitivity)
  • Infraorbital festooning (worsening of eyebags)
  • Lip ptosis with a resultant smile asymmetry
  • Cheek flaccidity
  • Oral incompetence with drooling, impaired eating, drinking and/or speaking
  • Dysarthria (difficulty articulating)
  • Dysphagia (difficulty swallowing)
  • Neck weakness
  • Hoarseness
  • Inadequate reduction of wrinkles or lack of effect expected within the treatment area
  • Weakening muscles adjacent to the treatment area
  • Facial asymmetry, alteration or poor aesthetic result
  • Worsening of wrinkles in the adjacent area
  • Autoantibodies against botulinum toxin. These may be present or develop after injection which render treatments ineffective.
  • Extremely rare, immediate hypersensitivity reaction with signs of urticaria, oedema or anaphylaxis.

Some of the above complications can be improved by using botulinum toxin to treat muscles that antagonise the affected muscle. Unfortunately for many of the complications there are no corrective treatments available, however they will diminish and resolve on their own as the effects of botulinum toxin subsides.

Using precise injection techniques into targeted muscles along with minimising diffusion of botulinum toxin with low reconstitution volumes, as well as reducing the involvement of adjacent muscles will decrease the possibility of any undesired complications.