Category Archives: Botox Complications

Can Botox be reversed?

Can we undo the effects of Botox?

Unlike hyaluronic acid fillers such as Juvederm, Botox cannot be reversed by injecting another agent into the same area.

Using Botox to fight Botox

Like using fire to fight fire.  Well, probably more effective than that.   Botox injected in other parts of the muscle or an opposing muscle might lessen the undesirable original Botox effect.

Injecting Botox into the antagonistic muscle

But sometimes, Botox effects can be offset by additional injections of Botox into the opposing muscle (antagonistic muscle).  Most of the structures in our body are affected by muscles on a push and pull balance.  Botox affects that balance, but we can again re-establish a new balance point by working on the opposing muscle.  However Botox only works to relax a muscle.   For example if an eyebrow looks like it has dropped, then we can further inject Botox in the muscles which normally depress the eyebrow such as the corrugator muscle or the obicularis oculi muscle – this could help spring the eyebrows back up.

Injecting Botox into the compensatory part of the same muscle

Another way to help with Botox problems is the consider relaxing other parts of the same muscle.   Sometimes we get a particular “surprised” look in the eyebrows with Botox.  This is the look where the eyebrows on the side go way up when we try to raise the eyebrow.  Sometimes this is called the “M” look or the “Spock” look and there are other names to this such as the “Mephisto” look.  I think the Spock look explains it quite well – with the pointed eyebrows.  This is usually caused by an unequal weakening for the frontalis muscle (forehead muscle) at the central component of this muscle.  When the central part of the frontalis muslce is weaker the lateral part tries to compensate by becoming eve more active.  We can compensate for this by injecting the lateral parts of the frontalis muscle with more Botox.

What about eye drops for lid ptosis (droop)?

If there is a eyelid droop, there are certain medications that can help the lid raise.  But there are other side effects associated with this technique.  I hope to come back to this topic in another blog.

Time heals Botox

With time, Botox effects wear off.  Fortunately some of the ill-effects of Botox are due to drifting of small quantities of the injected Botox.  Thus a few weeks might be all it takes for some of the effects to wear off.

The info here is just for informational discussion

This info isn’t meant as some sort of personalized medical advice.  Please see your Botox doctor or injector in person to have a discussion regarding Botox and any need for Botox correction.

All the topics mentioned here is considered off label FDA usage of Botox.

My Botox practice is in Modesto, CA.   I respect Botox injections as challenging procedures.  I’ve had my share of Botox problems and need for corrective Botox solutions.  I look at each of these Botox problems as an opportunity to improve for my Modesto, California patients.

Can Botox Cause Botulism?

Botox cause Botulism?

Yes, when injected incorrectly and with certain patient factors.  But please read on.

Botox from Allergan is a highly purified protein derived in the laboratory from a bacteria which can cause botulism.

What Bacteria does Botox come from?

Botox is purified in the lab from a bacteria known as Clostridium botulinum.  It is a gram-positive, rod-shaped, anaerobic, spore-forming bacterium.

Botulism and the Bacterial cause

Botulism is a rare illness that causes paralysis of the body including breathing muscles.  It can be caused by several different strains of Clostridium: Clostridium botulinum, Clostridium butyricum, and Clostridium baratii.

Various forms of Botulism

There are about 5 various forms of botulism, but the three main forms are  foodborne botulism, wound botulism, and infant botulism (which can be caused by honey ingestion in infants).  The bacterial spores from clostridium botulinum are common in soil and water.

Various forms of Botulinum Toxin

The Botulinum toxin are a varied group and consist of 8 types.  Botulinum toxin types A, B, E, F, and H affect humans.  The other types affect other mammals.  Botox is Botulinum toxin type A.  There are three forms of Botulinum toxin type A used medically:  Botox, Dysport, and Xeomin, and there is a botulinum toxin type B called MyoBloc which is also used medically.

Iatrogenic = accidental overdose.  Another form of Botulism.

An iatrogenic form of botulism (in addition to the three main types described above) can occur from accidental overdose of these botulinum toxins.  How can an overdose occur?  Too high of a dosage, injected into blood vessels or accidental spread from intended medical targets.

“Botox is to Botulism as Penicillin is to Mold”

But one elegant way to think about Botox is this analogy:  “Botox is to Botulism as Penicillin is to Mold.”  That statement is trying to say that Botox is harnessing the good powers of something considered harmful; just like how penicillin was derived from mold.

With cosmetic dosing and usage, the chance of overdose related (iatrogenic) Botulism is small.

“Good Medicine given in dangerously high doses is a Bad Poison”

Medicine can become a poison when given in supra-physiologic amounts.  That goes for just about every medicine.  This is my own quote, but in many ways, this can be considered common sense and applicable to many facets of life.  The common quote is “too much of a good thing is bad.”

In my opinion, when genuine cosmetic Botox is injected properly, it is one of the safest drugs I’ve used.

The risk of Botulism from Botox is extremely small

Hopefully this discussion isn’t too scary.  What I mean to say is that if Botox is injected in huge amounts and incorrectly, there is a risk of Botulism.  There may also be risks when patients inadvertently push the Botox away from their intended targets.  But when injected in small amounts (ie. for cosmetic use) and carefully (and with experience), the risk of Botulism is extremely small.   Medical Botox usually is a higher dose of Botox than Cosmetic Botox.  Medical Botox is frequently 10 times higher dosage than Cosmetic Botox.  But even so, the risk of iatrogenic Botulism is miniscule.   As with any potential risk, we should be aware and treat Botox with respect.

Treat Botox with respect – a message to myself as a Botox injector.  Here are some tips to avoid Botox complications

As injectors we should continue to watch out for high doses of Botox.  Perhaps we should break up those doses into a staged approach, meaning that the patient could come back a few days later for more Botox instead of cramming it all in at once.

We need to watch out for blood vessels.  We should aggressively seek out vessels that we can see or feel with our hands and avoid them, and consider taking notes of offending vessels when repeated Botox is anticipated.

We should take care to think of Botox as a three-dimentional injection.   The depth of injection matters to me.

And it goes without saying, that we should use the proper Botulinum toxin for the indication.  No shortcuts here.

As for patient factors, I continue to warn my patients to avoid large amounts of pressure on the injected spots and avoid rattling the area with devices such as clarisonic for a few days after the injections.  This is just my own thoughts on the topic of Botox migration.

Please visit us in person for more of your concerns and questions about Botox.

Calvin Lee, MD

More info on Botox and Botulism

Our website: Modesto Botox –  or visit the home page of our Modesto Botox Blog or visit our Plastic Surgery page.

Please see your own doctor or Botox injector for a personalized discussion.  There is no medical advice here, just medical information.  This is just my own opinion for this blog.  Allergan has nothing to do with this blog.  In fact Allergan sales people have said things to me before which make me believe that they wouldn’t agree with this blog.  Please double check facts in this blog which may change with time.


What to do in case of Dermal Filler Emergency

In case of Dermal Filler Complication of Vascular Occlusion


This “essay” shows depth of knowledge. Proud of Surgical Artistry Team member, Karla, for her answer to this question when a student nurse from San Jose called asking for advice on a school project, “What should one do and have available in the event of a dermal filler emergency where vessels get occluded.” This is her expert response:

I am the Patient Care Coordinator for Surgical Artistry, Dr. Tammy Wu and Dr. Calvin Lee‘s office in Modesto, CA. You contacted our office regarding information for a nursing program project. I wanted to take this opportunity to answer any other questions you may have regarding the “mini-crash cart for injectables” for your project. I am very sorry for the delay in response and I hope this information is still helpful. We would include the following: a butterfly needle, a towel for warm compresses, nitro paste to dilate the vessels, and Hylenex to dissolve the filler. I can provide you with a little bit of background information.

Juvederm, Restylane, Perlane, Belotero, Prevelle Silk are HA fillers

juvederm boxBelotero Box

We use hyaluronic acid fillers, commonly referred to as HA fillers. The brand names of the fillers we use are Juvederm and Belotero. One of the benefits an HA filler is that they are dissolvable. There are two main products used for this purpose. They are Hylenex (hyaluronidase human injection) and Vitrase (hyaluronidase Ovine). Vitrase has an animal source; Hylenex has a bacterial source and is synthetic. Therefore, Vitrase sometimes requires a skin test/allergy testing. This would not be ideal in an emergency situation.

belotoro balance shelf

Emergency Kit: Butterfly needle with tubing, Hylenex 150 units, and Nitropaste

220px-Butterfly_needle hylenex(image)

If you had a vascular occlusion complication while injecting filler, you would use a butterfly needle to attempt to get into the occluded vessel by aspirating for a “flash”. If you get the “flash” then you are within the vessel and Dr. Lee would inject Hylenex – perhaps even up to 150 units of Hylenex. Even without a “flash”, Dr. Lee would still consider injecting the Hylenex. Then Dr. Lee might apply 2% nitropaste (for vasodilation) or a warm compress to this area with some massaging of the area to keep the blood flowing through the area.  The patient would then apply nitropaste at home 2-3 times per day if patients didn’t get severe headaches or light headedness from the nitropaste.

He would do the same even if a HA filler wasn’t used – such as Radiesse. He thinks that the Hylenex would dissove some of the body’s native HA and thus make more room for the vessel and hopefully un-occlude the obstruction.

Dr. Lee asked me to tell you that this is an excellent project idea, especially if you are an aspiring nurse injector. He says that filler emergencies are rare but it’s good to be prepared. Please do not hesitate to call me at (209) 551-1888. Also feel free to read Dr. Lee’s Botox blog.

Feel free to visit our main Modesto Botox home page.