# Management of Complications Following Botulinum Toxin Facial Injections: A Narrative Review

## TL;DR

This review summarizes complications from botulinum toxin facial injections and their management, highlighting the need for better evidence and standardized approaches.

## Contribution

The paper provides a narrative synthesis of facial complications and management strategies following botulinum toxin injections, emphasizing current gaps in evidence.

## Key findings

- Upper eyelid ptosis is the most common complication, often treated with topical alpha-adrenergic agonists.
- Diplopia is rare but disabling, managed with occlusion, prisms, or targeted BoNT injections.
- Most complications are mild and self-limiting, with limited evidence supporting current management strategies.

## Abstract

Botulinum toxin (BoNT) is widely used in the management of neurological disorders and in aesthetic medicine. Although generally safe, facial injections may be associated with complications with relevant functional or aesthetic impact. This narrative review aimed to summarize reported facial complications following BoNT injections and to describe available management strategies.

A PubMed search up to November 2025 identified 239 articles; after screening and full-text review, 20 studies met the inclusion criteria. Data were synthesized narratively due to the heterogeneity of study designs.

Upper eyelid ptosis was the most frequently reported clinically significant complication and was mainly managed with topical alpha-adrenergic agonists. Diplopia was rare but functionally disabling and was treated conservatively with occlusion or prisms or with targeted extraocular BoNT injection in selected cases. Ocular surface changes, facial asymmetry, perioral dysfunction, local reactions, and headache were generally mild and self-limited. Systemic adverse events were uncommon but occasionally required hospital evaluation. Overall, management strategies were predominantly conservative and supported by low-level evidence.

Facial BoNT injections are generally safe, but clinically relevant complications can occur. Management is largely conservative, apraclonidine 0.5% is most commonly used for toxin-induced ptosis, and oxymetazoline 0.1% (FDA-approved for acquired blepharoptosis) is an additional option; other events are treated symptomatically. Overall, evidence is limited, supporting the need for prospective studies and standardized management pathways.