Cosmetic treatments - injectables

Cosmetic injections can reduce facial wrinkles and lines, but harmful and unwanted side effects can occur, even when the injections are given by a registered health practitioner. The risk is greater when an unqualified person performs them.

The two main types of injectable substances used are botulinum toxin type A and dermal fillers. To treat deep lines, a practitioner may decide to use both types together to achieve the best result.

How the injectables work#

Botulinum toxin type A is given by intramuscular (IM) injection to weaken muscles in the face and lessen the lines associated with facial expression. The toxin relaxes the underlying muscle and allows the skin to flatten out. Dermal fillers are injected along wrinkles and lines to plump the skin. Examples of dermal fillers include bovine (cow) collagen and the person’s own body fat.

Medical practitioners also use botulinum toxin type A to treat medical conditions including facial tics, muscle spasms and excessive sweating. It is marketed under brand names such as Botox® and Dysport®, and is registered for cosmetic use to treat facial lines and wrinkles.

Botulinum toxin type A is injected into selected facial muscles to soften lines, including lines on the throat (’turkey neck’). A very fine needle is used. Discomfort is minimal and brief, and most people describe it as an ant-bite sting lasting a few seconds. The wrinkle-smoothing effects may last for up to six months.

Common uses for botulinum toxin type A include softening:

• frown lines between the eyebrows
• lines across the bridge of the nose
• forehead lines
• ‘crow’s feet’ wrinkles extending from the outside corners of the eyes

Things to consider before treatment#

Most anti-wrinkle injections and dermal fillers are ‘prescription-only’ medicines that must be administered by a registered health practitioner. Before deciding on any cosmetic treatment:

• Choose and consult a registered medical practitioner in person, and ask about their training and experience in performing the procedure. Check that the practitioner is registered.
• If a nurse is administering the injection on the authorization of a medical practitioner, check that the nurse is also registered to practice.
• Inform yourself fully of the possible risks, side effects and complications.
• Be honest about your expectations. Cosmetic treatment may improve your appearance and self-confidence, but it will not necessarily deliver an ‘ideal’ body image or change your life.
• Think about your financial situation, as cosmetic treatment does not usually qualify for rebates from public health schemes or private health insurance.
• Make sure the clinic offers a ‘cooling off’ period after your first consultation to give you time to take in the information.
• Think about taking a family member or friend as a support person.

Serious, life-threatening complications can occur as a result of cosmetic injections, so be aware of the signs and symptoms of possible complications. If you experience serious complications, call your local emergency number (for example 911 in the US and Canada, 112 across the EU and many countries, 999 in the UK, or 000 in Australia) for an ambulance, or go immediately to your nearest emergency department. Talk to your practitioner about whether you will need a support person with you for a period after the procedure in case of an emergency.

Only registered medical practitioners (and in limited cases dentists) can lawfully prescribe ‘prescription-only’ medicines. Nurses may only administer them when authorized by a registered medical practitioner who has taken responsibility for the care and treatment of the patient. Do not be shy about asking questions and discussing your concerns, make sure you get a full explanation of the anticipated results and what to expect afterwards, and seek a second opinion if you are unsure.

Botulinum toxin type A: medical issues and side effects#

Do not use botulinum toxin type A injections if you:

• have a muscle disorder in other parts of your body, including myasthenia gravis, Eaton Lambert syndrome or amyotrophic lateral sclerosis
• are allergic to any of the ingredients in the formulation
• have an infection in the muscles where it would normally be injected

Tell your practitioner if you are taking any other medications, including prescription, over-the-counter or complementary medicines and supplements. Take extra care, and tell your practitioner, if you:

• are taking drugs that may interfere with muscle function
• are taking or likely to take antibiotics, especially aminoglycoside antibiotics
• are scheduled to have surgery under a general anesthetic
• have inflammation or severe weakness in the muscles where the product would be injected
• are pregnant or intend to become pregnant
• are breastfeeding or planning to start breastfeeding
• have ever had facial surgery
• have angle closure glaucoma
• have problems with your heart or circulation

In some of these circumstances it may not be possible to use botulinum toxin type A injections.

Side effects, if they occur, are usually temporary and around the injection area. They can include drooping of the eyelids, headache, face pain, redness or swelling where you were injected, bruising, skin tightness, muscle weakness, numbness or a feeling of pins and needles, nausea, and blurred vision.

Dermal fillers: types#

A very fine needle is used to ‘fill’ a wrinkle, line or skin depression with a product. The wrinkle-smoothing effects of most dermal fillers are temporary, and regular treatments are needed to maintain the effect. Types include:

• Collagen – suitable for deep lines and some scars; effects last about four to six months (marketed under brand names such as Zyderm®, Zyplast®, CosmoPlast® and Cosmoderm®).
• Hyaluronic acid – suitable for thin surface lines, such as those around the mouth and across the forehead; effects last about one year (marketed under brand names such as Restylane®, Perlane®, Dermalive®, Juvéderm®, Emervel®, Sub Q®, Esthelis® and Belotero®).
• Hyaluronan (a form of hyaluronic acid) – suitable for deep lines and acne scars, and an alternative for people who are allergic to collagen; effects last about six months (marketed under brand names such as Hylaform®).
• Polylactic acid – suitable for skin depressions and deep lines; it prompts the treated skin to produce collagen (marketed under brand names such as Newfill®, Nufill® and Sculptra®).
• Polyacrylamide – suitable for deep lines; once injected, it forms a soft and permanent implant (marketed under brand names such as Aquamid®).
• Fat injections – fat tissue is taken from other areas of the body using a thin needle, sterilized, and injected into the facial line or wrinkle. Effects can be long lasting, though touch-up injections may be needed. This treatment is also known as ‘microlipoinjection’.

Dermal fillers: medical issues and complications#

Dermal fillers may not be suitable if you have certain medical conditions, such as an autoimmune disease, a history of keloid scarring (thick, raised scars), inflamed or infected skin, severe allergies such as asthma or food allergies, or if you have ever had a life-threatening allergic reaction (anaphylaxis).

Tell your practitioner if you are taking any medications, including prescription and over-the-counter medicines. Some, such as blood-thinning drugs, may increase the risk of complications. Some people are allergic to bovine (cow) collagen, so have a small test injection before treatment to check for an allergic reaction. If you are allergic to chicken, do not use hyaluronan-based dermal fillers, because these products are made from rooster combs (the red part on top of a rooster’s head).

Serious, commonly reported complications of dermal fillers include vascular occlusion, which occurs when filler is injected into or around an artery, causing blood flow to be reduced or to stop. The skin may look pale (blanched) and start to turn blue over a period of 24 hours. This is usually painful and, if untreated, the skin may start to ‘die’ and turn black. These can occur shortly after an injection and all require urgent ‘reversal’ treatment by a medical practitioner to reduce the risk of death or long-term complications.

Other complications of dermal fillers can include blindness, stroke, bleeding, bruising, swelling and redness where you were injected, itching, skin discolouration, bacterial or viral infection, ulceration of the skin, lumps (nodules) forming under the skin, allergic reaction, permanent disfigurement and scarring, and hematoma (a collection of blood under the skin or in deeper tissues).

Additional possible side effects and complications include weakness of the muscles of the face, head and neck, which can affect swallowing, vocal cord function and eye movements (double vision), and inflammatory reactions, especially associated with unregistered dermal filler products, which may require surgery to remove.

Self-care after treatment#

Be guided by your practitioner. General self-care suggestions for the first few days following cosmetic injections include:

• not exposing the treated skin to extremes of temperature (such as saunas)
• keeping the treated skin areas clean
• not touching or rubbing the treated areas
• using paracetamol for pain relief
• seeing your practitioner if you experience unusual symptoms or have any concerns

Making a complaint#

Concerns about cosmetic procedures may be handled by different organizations or government departments, depending on the nature of the complaint, such as the health service itself, the regulator for registered health practitioners, the body responsible for general (non-registered) health service providers, or the authority responsible for the supply and administration of prescription-only medicines. If you are not sure which one to contact, any of them can help or advise you on whom to speak to. If you have had a cosmetic procedure that has gone wrong and do not know what to do, seek advice promptly.

Key points#

• The two main types of injectable substances used are botulinum toxin type A and dermal fillers.
• Inform yourself fully of the possible risks, side effects and complications of the procedure.
• Be aware of the signs and symptoms of possible complications, and seek emergency care for serious ones.
• Tell your practitioner if you are taking drugs that may interfere with muscle function.
• The wrinkle-smoothing effects of most dermal fillers are temporary, and regular treatments are needed to maintain the effect.

Where to get help#