“Doctor, I think they ruined my face forever.”
Patricia arrived at our practice on a Saturday night with her left eyelid completely drooped, covering more than half of her eye. She couldn’t open it fully and her pupil was barely visible.
This was the third Botox emergency I’d received that week.
Over the past decade and a half, I’ve documented more than 200 cases of serious complications from improperly administered Botox. Each one taught me something specific about what can go terribly wrong when this treatment is performed without proper medical training.
Here are the 5 complications I see monthly, why they happen, and how to ensure you never become one of these emergencies.
The silent epidemic of complications in major cities
Every week I receive between 2 and 4 emergency consultations for complications from treatments performed at other facilities. 80% are Botox-related problems, 15% are filler issues, and 5% involve other toxins.
The trend has worsened dramatically over the past 3 years. The boom of “accessible” aesthetic medicine brought a proliferation of unregulated centers offering attractive prices but compromising basic safety.
During my European fellowship in aesthetic medicine, these types of complications were exceptional. In the US, they’ve become routine consultations.
The difference isn’t just training—it’s regulation, oversight, and medical safety culture.
Complication #1: Eyelid ptosis (droopy eyelid)
Patricia’s case
Patricia, a 38-year-old accountant, got Botox at a med spa chain. The price convinced her: $180 versus $480 at specialized practices.
Three days later, she couldn’t fully open her left eye.
During my medical evaluation, I identified iatrogenic eyelid ptosis: the toxin had been injected incorrectly and affected the levator muscle of the eyelid.
Why it happens
Eyelid ptosis from Botox results from incorrect technique specifically:
Injection too close to the orbital rim - less than 1 centimeter from the bone edge allows toxin to diffuse to the levator muscle.
Excessive concentrated dose - applying too many units in a small area increases uncontrolled diffusion risk.
Improper injection technique - wrong angle, inadequate depth, or not waiting sufficient time between applications.
Incorrectly diluted product - non-standardized concentrations that alter effect predictability.
What it means for the patient
Patricia required specialized monitoring for 4 months. Ptosis can last 3-6 months, affecting vision, work, driving, and daily activities.
The real cost of her $300 “savings” included: 2 weeks medical leave, emergency consultations, special lubricating drops, ophthalmologic follow-up, and significant emotional impact.
“I was embarrassed to leave home. I had to make up a story about an accident,” she told me during follow-up.
Complication #2: Permanent facial asymmetry
Monica’s case
Monica, 35, consulted after Botox left her eyebrows completely asymmetric. One brow was 8 millimeters higher than the other.
The injector had applied different amounts of product on each side without measuring anatomical distances. When Monica complained, they told her it was “normal” and would “correct itself.”
Why it happens
Asymmetry from Botox results from:
Lack of prior facial analysis - not measuring distances, not identifying pre-existing asymmetries, not planning necessary compensations.
Non-standardized technique - different injection points, depths, and angles between both sides of the face.
Empirical dosing - applying “by eye” without specific protocols based on individual muscle strength.
Not considering anatomical factors - skin thickness, muscle mass, specific movement patterns of each patient.
The complex correction
Correcting asymmetry from improperly applied Botox is technically more difficult than doing the treatment correctly initially.
It requires waiting for the initial effect to partially dissipate (2-3 months), then applying specific corrective doses, and finally rebalancing when the original effect has completely worn off.
Monica needed 3 corrective sessions over 8 months to achieve acceptable symmetry.
Complication #3: Frontal muscle paralysis
Andrea’s case
Andrea, a 29-year-old content creator, arrived after forehead Botox left her completely unable to raise her eyebrows. Her facial expression had lost all naturalness.
“I can’t express surprise, concern, or any emotion that requires moving my forehead. I look like a wax figure,” she explained, visibly distressed.
Why it happens
Complete frontal paralysis results from:
Overdose in frontal muscle - applying more than 20 units in a young woman’s forehead typically generates complete paralysis.
Incorrect injection points - injecting too low near the eyebrows eliminates all elevation capacity.
Not considering compensatory function - the frontalis naturally compensates for other muscle actions; completely paralyzed generates unnatural expression.
Wrong treatment philosophy - seeking total line elimination instead of natural softening.
Impact on expressiveness
Andrea worked as an event presenter and needed natural facial expressiveness. Complete paralysis affected her professionally for 4 months.
“My videos looked strange. Comments asked what happened to my face,” she recalled during follow-up consultation.
Complication #4: Asymmetric smile from diffusion
Lucia’s case
Lucia consulted because after Botox around her eyes, she couldn’t smile symmetrically. The left corner of her mouth wouldn’t elevate fully when smiling.
The toxin had diffused from the crow’s feet area to muscles controlling her smile.
Why it happens
Smile impairment results from:
Too-deep injection near the orbital area - toxin diffuses to non-target muscles.
Excessive dose in crow’s feet - more than 12-15 units per side in the orbital area increases diffusion risk.
Anatomically incorrect technique - not respecting specific muscle planes or injecting too close to oral expression muscles.
Wide-diffusion product - some toxin brands have greater spreading tendency than others.
Correction complexity
There’s no antidote for botulinum toxin. Once incorrectly applied, you can only wait for the effect to naturally dissipate.
Lucia needed facial rehabilitation exercises for 3 months to recover smile symmetry.
Complication #5: Persistent headaches and muscle rigidity
Carmen’s case
Carmen developed intense daily headaches and severe neck and shoulder rigidity after massive Botox application to forehead, glabella, and temples.
“I feel like I’m wearing a tight helmet 24 hours a day,” she described during emergency consultation.
Why it happens
Post-Botox headaches result from:
Compensatory muscle imbalance - paralyzing specific muscles forces others to work excessively.
Excessive total dose - more than 50 units in the upper facial area can generate systemic effects.
Injection at inadvertent trigger points - some patients have specific tension points that worsen with forced muscle relaxation.
Overly aggressive technique - applying toxin to muscles that weren’t hyperactive generates postural imbalances.
Complex treatment
Carmen required multidisciplinary treatment: pain management with specific analgesics, physical therapy to relax compensatory muscles, and relaxation techniques to manage secondary tension.
Headaches persisted 6 weeks until the toxin effect began diminishing.
Why these complications are preventable
95% of the serious Botox complications I see could have been avoided with correct technique, appropriate dosing, and adequate prior medical evaluation.
Critical prevention factors
Detailed anatomical evaluation before any application - measuring distances, identifying previous asymmetries, evaluating specific muscle strength, and planning individualized treatment.
Standardized, conservative technique - scientifically validated injection points, specific depths by treated area, appropriate injection angles.
Evidence-based dosing - specific amounts according to age, sex, muscle strength, and treatment objectives, not generic protocols.
Structured follow-up - 2-week control to evaluate effect and detect any early irregularity.
The questions you must ask before any injection
About the injector’s training
“Where did you complete your aesthetic medicine specialization and how many years of experience do you have specifically with botulinum toxin?”
The answer should include specific university training and minimum 3 years of documented experience.
About the safety protocol
“Do you perform prior medical evaluation, individualized planning, and post-treatment follow-up?”
The protocol should include medical history, specific facial analysis, personalized plan, and minimum 2-week follow-up.
About complication management
“What protocol do you have for managing complications and who will see me if any problem arises?”
They should have specific protocol, immediate availability, and identified responsible specialist.
Why choosing board-certified specialists makes the difference
At our practice, we’ve performed over 8,000 botulinum toxin applications without serious complications. This statistic isn’t coincidental.
Our protocol includes:
45-minute prior medical evaluation with detailed facial analysis, individualized planning according to specific anatomy, standardized technique based on European training, conservative and graduated dosing, and structured follow-up for 30 days.
We use only original FDA-approved products with complete traceability and documented cold chain.
Our specialists have specific university training and documented experience of over 10 years.
We include emergency management protocol with 24/7 availability during the first 2 weeks post-treatment.
What I learned correcting 200+ complications
Most serious complications come from centers that prioritize volume over safety. Quick applications, without prior evaluation, with standardized technique that doesn’t consider individual anatomy.
Extremely low prices always hide safety compromises. An original Botox vial costs approximately $400 from authorized suppliers. If the complete treatment costs $180, it’s mathematically impossible for it to be original product.
Complications are exponentially more expensive than treatment done right initially. The average cost of correcting serious complications is 4-6 times the cost of the original treatment.
Some complications can generate permanent sequelae. Although most are temporary, severe cases can leave permanent alterations in facial expression.
Your most important decision
Are you considering Botox and unsure where to get treatment?
The difference between a successful result and a complication that affects your life for months lies in the technical competence of the specialist and quality of safety protocols.
It’s not about choosing the most expensive option. It’s about choosing board-certified specialists who prioritize your safety over their commercial margins.
A serious medical evaluation includes analysis of your specific anatomy, detailed explanation of risks, individualized planning, and clear follow-up protocol.
Ready for genuinely safe treatment? I invite you to compare safety protocols before deciding where to trust your face.
Dr. Oscar Barón - Board-Certified Plastic Surgeon
European Fellowship in Aesthetic Medicine
ALMO Clinic - Over 8,000 applications without serious complications
