Are Your Botox Injections Safe?

Botulinum toxin Type A/B injections are one of the most common cosmetic procedures performed worldwide. A cosmetic star that quickly rose to popularity in the early 2000s, this is the anti-wrinkle injection well-loved and endorsed by celebrities, used by thousands of men and women to starve off the visual effects of aging.

However, Botox allegedly causes rare but serious complications, including death. Recently, a young woman died after allegedly receiving cosmetic Botox injections in Singapore. While it is not clear at the time of writing this article what treatments the lady received exactly, and until clarifications can be made officially, should you be going for Botox again?



There is no doubt that despite reports of these serious complications, cosmetic injections of Botox have a remarkably safe history. In case you weren’t aware, what worries people is that Botox is actually derived from a toxin produced by Clostridium botulinum, the same toxin that causes botulism, a form of life-threatening food-poisoning.

Botox injections work by weakening or paralyzing muscles and in the process, exerts its intended therapeutic effect, lasting for months.

In 1977, Botox was first approved by the FDA to treat strabismus. Minute injections into the the extraocular muscles would improve squints as an alternative to strabismus surgery. And Botox has since gone on to become the only toxin approved for cosmetic use currently – for temporary improvement of glabellar (frown) lines, forehead wrinkles and crow’s feet. Now, Botox is also FDA-approved for cervical dystonia, blepharospasm (involuntary twitching of the eyelid) and primary axilliary hyperhidrosis.

Of course, off-label uses of Botox are not uncommon, for example, for migraines, palmar sweating, and cosmetically, for jaw slimming, temporary lifting of neck muscles (Nefertiti lift), and even for slimming of calf muscles.



Botox comes in powder form, sealed in a sterile glass bottle, which is then prepared by your doctor, who will dilute it with saline to make it an injectable. When injected into the muscle, Botox blocks the firing of the muscle, preventing it from activity. When muscles are unable to contract, the skin smoothens out and wrinkles soften or disappear altogether.

The effects of Botox are localized – so having botox done in your face will not see effects in your toe, although, Botox has a diffusion effect of about 2cm from the injection point (therefore may result in unwanted side effects such as affecting other areas that were not intended for relaxation, resulting in odd stiffness or expressions). In the body, once the protein stops functioning, it is broken down into amino acids, which are then recycled for use again by the body or removed from the body altogether by the kidneys.

Apart from these, the injection itself can cause mild redness or bruising which are usually minor and resolve within a hours or days.



Apart from Botox®, there are two other injectable neuromodulators that work similarly. Xeomin® and Dysport® work the same way, but have slightly different formulas of the same substance. Both have received FDA approval for similar areas (Dysport – 2009, Xeomin – 2011). There are no other formulations that are currently approved for cosmetic use.



All things are poisons and there is nothing that is harmless, the dose alone decides that something is no poison” –Paracelsus.

Most people wouldn’t consider the white, granulated sugar we stir into coffee as dangerous, but excessive sugar consumption and consumption of other forms of it such as high-fructose corn syrup in the long run have been associated with multiple health problems. Similarly, Vitamin A is toxic and has serious life-threatening side effects in large doses.

According to Head of Plastics Surgery of the SW1 Clinic, Consultant Plastic Surgeon Dr Tan Ying Chien, Botox can travel into the bloodstream, unintendedly, and travel to distant sites. However, cosmetic doses are usually very small, typically less than 100 units, which is significantly lower than the dose that would be harmful systemically. In other words, used appropriately, Botox is safe.

According to Dr Tan, to further ensure safety, the consumer should opt for

  1. Safe, FDA-approved treatments. These would have gone through rigorous tests for safety and efficacy in trials.
  2. Cheaper is not always better, and if its too good to be true, you could be using a bootleg version of the real thing. Botox® is manufactured by Allergan. In Singapore, only licensed clinics and doctors are allowed to perform Botox injections. Always ask if you are having Botox® injected, or something else.
  3. Look up the clinic and the doctor you are doing Botox with – are their lasers and injectables FDA-approved, and are their doctors reputable and licensed to do aesthetic procedures?
  4. Never go for cosmetic treatments that require access to your body intravenously. Skin whitening injections such as intravenous Vitamin C injections are illegal in Singapore.
  5. Women who are pregnant or breastfeeding should not have Botox done, and should consult with their doctors first before embarking on any treatment.

In conclusion, having your wrinkles sorted with Botox has risks, but these have been very minimal and FDA-approved procedures are generally safe. If in doubt, always check with your doctor first.



Dr Tan is the Consultant Plastic Surgeon at SW1 Clinic Plastic Surgery Centre. He remains a Visiting Consultant to the Plastic Surgery Departments at both KK and SGH, providing pro bono ear reconstructive surgery for needy patients. He continues to serve as one of the only two surgeons in Singapore providing ear reconstruction surgical care.

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