'I'm a cosmetic doctor. Here are 4 common things that can happen with anti-wrinkle injections.'

Injectables are tricky to master, and anyone who tells you it’s easy, is often not telling the truth.

With more experience, I’ve found that I see more and more variation as to what can go wrong, go awry, and even lead to unexpected results. 

Just like with medicine, there is usually a Dunning-Kruger effect when cosmetic professionals are very new and know a little. We think we know a lot, and it sometimes veers on arrogance.

With experience and knowledge, we realise just how limited we are in our understanding, and how much can truly go wrong. 

Not necessarily catastrophically wrong but inconveniently, sometimes embarrassingly wrong - with areas such as the human face.

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Recently I’ve had several patients, new to injectable treatments, reaching out with some glitches - concerned something has gone wrong, when it is all part and parcel of first time treatment. 

At Skin Essentials, we reach out regularly after someone’s first treatment, and as our patients feel more confident, we take a far more laid-back, hands-off approach as is appropriate, reserving advice and discussion for in-person reviews.

Nonetheless, the recent enquiries have me thinking about the things that can potentially occur with anti-wrinkle treatments, which are normal - no matter how much we prepare patients for them. 

So, what are the common side effects that, while not life-threatening or a medical emergency, may cause someone to reach out for advice?

1. Asymmetry.

Among the most common side effects is asymmetry. 

Few of us are completely symmetrical, and sometimes the symmetry may be so mild as to not be apparent to us until we begin to undertake injectables. 

Then, as we begin to pay more attention to our own faces and the smallest of changes, or sometimes because anti-wrinkle treatment may initially affect one side more than the other (even if the same dose was used) or surrounding muscles may pull on one side more than the other, asymmetry may be more obvious to us and to others.


This is fairly common for a first time treatment to a given part of the face. I often warn patients of this, and to leave it well enough alone until 14 days, because we cannot not do anything until then. 

Nine times out of 10 the asymmetry will settle in a few days, leading to evenness by the fourteenth day. Problem fixed!

Asymmetry is most common in areas such as:

  • Eyebrows when treating for frown lines
  • Forehead lines when brows are raised, such as when treating forehead lines
  • The degree of gum on show when treating for 'gummy smile'.

In paired areas, especially when multiple muscles are involved such as with frowns and smiles, it is impossible to achieve complete symmetry (a symmetrical face is rare, anyway), but eyebrow asymmetry is usually easily fixed as are uneven forehead lines.

2. Heavy forehead/brows.

In some patients, this may be an issue when the toxin is first kicking in. The forehead, which is the main elevator of the forehead, may feel heavy. 

When overdone, eyebrows may flatten and be hard to raise at all, giving women a masculine appearance. In severe cases, patients report not being able to raise their brows at all, and feeling like someone is pressing down on their forehead the whole time.

With toxin to the forehead, they may still be able to raise the brows, and the forehead lines may smooth out due to treatment, but they may feel uncomfortable or dislike the effect treatment to this area has for them.

If there is suitable movement retained, the dose is likely not excessive, but all toxin to the forehead will slightly flatten the brows. 

If the effect is one that is distressing for the patient, they may prefer forehead lines over the unpleasant feeling/loss of arch in their brows or prefer a smaller than ideal dose, that softens lines without compromising the ability to raise their brows.

Ultimately, that is a personal matter that only each patient can decide for themselves. Life is too short to be frustrated about non-essential treatments.

Unlike dermal filler, toxin cannot be removed or dissolved and we must wait it out, a process which can begin as early as six weeks post-treatment. 

Also unlike dermal filler, the beauty of anti-wrinkle treatment is that if unhappy, it’ll resolve itself in time (indeed, nothing CAN be done), whereas when done well, patients want results to last forever, which leads to our next point. 

3. Return of lines and movement sooner than three months.

It is a misconception that faces treated with toxin will remain looking treated until the three-month mark when more treatment is needed.

Toxin, once injected, depending on the brand used, begins to kick in as early as three to five days and peaks (i.e. has maximum efficacy) at 14 days post-treatment which is the best time to assess for effect.


As early as six weeks post-treatment, it begins to wear off as new nerves supplying the muscles that move the face begin to regenerate.

How soon this occurs is dose dependent. If you opt for a heavier dose, it may last a little bit longer before it begins to wear off but also leave you feeling more 'frozen' initially with more natural movement several weeks later. 

With a lower dose to allow more movement all along, this may occur sooner - so it’s important to have that discussion with your doctor first and to budget appropriately.  

Irrespective of your choice, muscle movement may begin to return as early as six weeks and increases in strength by three months. Most of us intending to continue to be treated will book in for further treatment for best results, especially if lines are present even at rest.

Ways to prolong the 'no movement' phase include a higher starting dose (which may temporarily paralyse / freeze the area treated such that no movement is possible) with a higher cost, as well as more frequent treatment in some cases.

I personally refuse to treat sooner than three months for returning lines/activity because over regular subsequent treatment, this will settle. Further to this, treating too often may increase risk of antibodies to the toxin, whereby the treatment is less effective or no longer works.

It is unrealistic to expect to be frozen for the entire three months. Movement will gradually return until it’s close to pre-treatment around the three to four-month mark.

4. Accidentally injecting a neighbouring muscle when treating certain parts of the face.

This is a true mistake and anyone who's been injecting long enough has likely done it. While not life threatening, it is among the more annoying, frustrating and challenging to manage. 

With something like this, we have to wait until the toxin begins to wear out, which usually takes four to six weeks - occasionally longer depending on the dose. 

This may happen due to diffusion of toxin from the treated area to a nearby muscle, thereby affecting it. It can also occur when patients rub the treated area soon after treatment, spreading toxin across, or accidentally injecting some fibres of a nearby muscle.

This is especially common when treating areas of the face, especially the lower face, which is the most mobile part. This area consists of many muscles that help us to smile, speak and much more. If injected accidentally, it may cause a lopsided smile or movement until the toxin begins to wear off.

If you would like to hear more from Dr Imaan Joshi, follow her on Instagram.

Have you ever experienced any of these side-effects? Share your thoughts with us in the comment section below.

Feature Image: Getty

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