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What is Botox? Is Botox Safe?

by Dr Tan Wang Theng

Chances are, you have heard of Botox - the seemingly "miraculous" anti-wrinkle injection.

In fact, it remains one of the most popular cosmetic treatment done worldwide, relied on for two decades by millions of men and women to stave off visible signs of aging without surgery

How does it work? What can it do? Most importantly, are Botox treatments safe? 



Botox is actually the trade name of the original botulinum toxin type A (BoTN-A) by Allergan.

This purified protein is derived from the neurotoxin produced by the Clostridium Botulinum bacteria, the same toxin that causes botulism, a life-threatening form of food poisoning.     

That sounds scary. But the fact is that Botox has proven itself over decades as a highly successful therapeutic protein with a remarkable safety record, especially considering that tens of millions of patients have been treated. 

Botox was FDA-approved as a medication since 1989, originally for strabismus (crossed eye), and was later approved for smoothing wrinkles in 2002. Other brands of BoTN-A (Dysport and Xeomin) have also been approved for cosmetic use since then, although their formulations are different.



Other than its prized anti-wrinkle properties, Botox Cosmetic also helps with jawline slimming, temporary lifting of the neck, mouth corners and brows (BTX Happy Lift), and calming excessive underarm sweating in those suffering from primary axillary hyperhidrosis.

Beyond cosmetic, Botox is widely prescribed across diverse disciplines to treat a constantly growing list of medical conditions as well. This ranges from bruxism (night teeth grinding/ clenching), cerebral palsy, chronic migraine, severe depression, persistent eye twitching, cervical dystonia (painful neck spasm) and refractory back pain, to overactive bladder. 



When injected into the area to be treated, Botox works by temporarily blocking synaptic chemical signals from motor nerves that tell muscles to contract.

As the treated expression muscles reduce excessive contraction and unwanted creasing of the overlying skin, existing wrinkles soften and formation of new lines are prevented. Used on bulky or overly tensed masseter muscles, it slims down a squarish jawline and soothes night clenching. 

While most notice some improvement within the first few days, full wrinkle-smoothing effects take place gradually over 10-14 days. Facial slimming benefits improve over 4 weeks.

The effect of Botox is localised to the area of injection, with a diffusion distance of about 2cm diameter. This means when administered to forehead wrinkles, Botox is not going to work on the crow’s feet lines at the corner of the eyes, nor will it weaken fingers and toes. This accounts for its good safety profile.  

The Botox protein is subsequently metabolised into harmless amino acids at the site of injection and eliminated through the liver. 

Treatment effects last 4 to 6 months on the average. The bigger and more active the muscle, the faster you will see motion return.

There is no tolerance effect, so your body doesn’t “get used” to Botox. Neither will it “get addicted” to Botox.  



Due to its localised mode of action, possible side effects with cosmetic Botox are usually local and temporary, related either to microinjection or Botox itself. 

These could be minor insect bite like post-injection swelling as the Botox has to be reconstituted with sterile saline, though more so in those with sensitive skin. This usually resolves within hours. Less commonly, mild bruising that lasts a few days may occur at the injection site. 

Others include an excessively “frozen” look, or odd expressions (due to asymmetrical treatment, asymmetrical muscles, or unintended diffusion of Botox into surrounding muscle). Many can be easily corrected, although all will improve spontaneously. Cosmetically ideal Botox should look natural. 

About 1 percent of patients may experience headache for a few days after forehead Botox treatment. This is most likely due to over-contraction of strong, reactive facial muscles before the full effects of Botox kick in.      

Botox does not cause the face to become “numb”, since it does not affect sensory nerves.



Risk of side effects is related to dosage. Taking large doses of anything, whether it is paracetamol, vitamins or water, can potentially cause toxicity.

In the case of Botox, even in rare cases where minute molecules inadvertently find its way into the bloodstream and travel to distant sites, cosmetic doses of Botox are typically small (usually less than 100 units) and significantly lower than the toxic dose that would be harmful systemically (2,500 to 3,000 units).

A study found that the rare serious adverse effects reported with Botox were mostly with therapeutic use, rather than cosmetic use. This may be because of much higher doses are needed to treat the medical condition, or may be related to the underlying medical condition.       



Botox is a safe and effective treatment in skilled hands. Take time to find a qualified and reputable doctor who practices in a clean, safe and certified clinic. He/ She should be well-trained and experienced in administering Botox for the indication you are concerned about. 

Opt for the original, high-quality, FDA-approved products that have gone through rigorous testing for safety and efficacy in clinical trials. Cheaper is not always better, as high-quality products from authorised dealers never come cheap. 

Botox is never given intravenously, so be very suspicious if "Botox" is offered through IV drips. Whitening IV drips are banned in Singapore as serious life-threatening reactions and deaths have been reported.     

You should wait to receive Botox if you are pregnant or breastfeeding, as effects on the baby are not fully studied.  

Though extremely rare, those with previous allergic reactions to another botulinum toxin product (e.g. Xeomin, Dysport, Myobloc) should not receive Botox, and vice versa.  

Talk to your doctor about the results you are hoping to acheive and your past experiences with Botox.    

Bring up to your doctor’s attention of medical issues you have, and of the medications (e.g. blood thinners, muscle relaxants) that you are taking. 

Take care not to rub or massage the treated area vigorously for at least one day after treatment, as this might cause the Botox to spread excessively into unintended surrounding muscles.

To prevent bruising at the micro-injection site, avoid drinking alcohol, physical exercise or sauna right after treatment. You may want to consider skipping your oral supplements (vitamin E, gingko biloba, garlic, fish oils are common examples) that are natural blood thinners as well, if you are very prone to bruising.