The Unseen Risks of Non-Surgical Cosmetic Enhancements

From trout pouts to frozen foreheads, we’ve all seen people who look a bit odd after overdoing the Botox or facial fillers. Then there are the horror stories of people left blinded or with festering wounds after botched cosmetic injections.

The market for non-surgical cosmetic treatments is booming; the desire for plump, youthful-looking skin or the perfect “Instagram face” apparently trumps any fears of bad results or medical complications. Injections of botulinum toxin and dermal fillers are now the most common non-surgical cosmetic procedures worldwide, and the market for such “tweakments” is anticipated to grow a further 15.4% by 2030.

Advocates insist it is possible to get work done safely with beautiful results. But recent research is prompting some doctors to question how much we really know about the long-term effects of such injectable enhancements, and as their popularity continues to grow, regulators are weighing how best to keep people safe.

The Rise of Dermal Fillers and Botulinum Toxin Injections

Dermal fillers are gel-like substances used to fill lines and wrinkles and plump up areas such as cheeks or lips. They have been in use since the 1970s when bovine collagen started being injected into people’s faces, but they really took off in the early 2000s, when the first fillers based on hyaluronic acid – a water-attracting substance found throughout the human body – were approved.

At around the same time, botulinum toxin injections – the best known brand being Botox – also started being used cosmetically, after years of use treating muscle spasms. These work by temporarily relaxing the facial muscles they’re injected into, helping to smooth out crow’s feet, frown lines and wrinkles.

In the early days, such treatments were predominantly the closely guarded secret of older women seeking a discreet solution to ageing skin. Increasingly though, younger women (and men) are using them to enhance their features, inspired by social media and reality TV show contestants.

“Since Love Island, it seems that having bigger lips has become just a kind of rite of passage for enormous numbers of young women,” says Alice Hart-Davis, a beauty journalist and founder of The Tweakments Guide, which aims to help people make informed decisions about such procedures.

The Growing Number of Complications

Tracking the boom in these treatments has been a rise in medical complications and complaints about botched jobs. Save Face, a UK register of accredited cosmetic practitioners that campaigns for improved safety standards, says it received 2,824 complaints during 2022 – up from 2,436 in 2021 and 2,083 in 2020. More than two-thirds of these related to dermal fillers and almost a quarter to Botox-like treatments.

Save Face director Ashton Collins believes these figures are reflective of the sheer number of filler procedures that are occurring, as well as the nature of the injections – which in inexpert hands can result in infections, blocked blood vessels and tissue death, or work that simply looks lumpy or overdone.

“In safe, expert hands the risk of any of those complications is minimised considerably, and if they did occur, the practitioner would have the expertise to identify the signs really early on and manage them effectively. But because anybody and everybody is now doing these treatments, we’ve seen a huge increase in the number of complications,” Collins says.

The Importance of Competence and Regulation

Compounding the problem are poorly-qualified therapists who refuse to take customers’ concerns seriously. Of the complaints received by Save Face last year, 84% of people claimed that they were ignored or blocked by their practitioner when they tried to seek help.

Collins says: “We had one girl who was literally hours away from having to have her lips surgically removed, because the filler was blocking the blood supply. The person who treated her kept telling her it was a bruise and would go away, but obviously it didn’t. Luckily, she didn’t have to have that surgery, but it was very touch and go for a while.”

Witnessing such complications prompted Zargaran to start investigating who was carrying out these cosmetic procedures. Together with colleagues at University College London, he evaluated the websites of 3,000 UK aesthetic clinics, cross-checking their practitioners with professional bodies such as the General Medical Council and the Nursing and Midwifery Council.

“I think fundamentally, it comes down to competence,” says Zargaran. “If you’re competent to properly consent the patient, to administer the intervention cognisant of the risks and potential pitfalls, and at least able to recognise potential complications, and if possible, treat them, that is a step in the right direction.

“The challenge we have is that many individuals undertake limited educational courses where they attend for one or two days, and this provides the basis on which they get insurance to practice independently. Some people don’t even have insurance, which just speaks to the lack of robust regulation in this sector.”

The Need for Greater Transparency and Safety

While most experts agree that botulinum toxin injections tend to be safer – particularly as the effects of poorly administered injections usually wear off after three to four months – there are concerns that practitioners aren’t reporting all of the side-effects experienced by customers. This makes it hard to know what the real-life complication rates of such procedures are, Collins says.

When Zargaran’s team conducted a review of the medical literature relating to botulinum toxin injections, they found that issues such as bruising, headaches, nausea and “frozen” features affected around one in six users. Yet even though an estimated 900,000 Botox-like injections are carried out in the UK each year, just 188 adverse reactions had been reported to Britain’s medicines regulator the MHRA in the preceding 29 years.

Botulinum toxins are a prescription-only product, meaning that by law they should only be injected following a face-to-face meeting with a qualified medical practitioner such as a doctor, dentist, pharmacist or nurse prescriber. While this should mean that injectors have a sound knowledge of anatomy and how to handle adverse reactions, the prescriber isn’t always the person doing the injections.

There are plenty of therapists who will perform injections without offering a medical consultation. “Instead, they work with somebody who is willing to [prescribe] the products without seeing the patient, or more worryingly, we’re seeing a big increase in people buying cheap botulinum toxins on the internet, where they don’t actually know what’s in it,” says Collins. “We’ve seen some horrific cases where people have injected with what they believed was Botox, but turned out to be beef gelatin – causing some of them to have really serious anaphylactic reactions.”

Of the people who complained to Save Face about Botox-like procedures last year, 92% said they did not have a face-to-face consultation with a licensed prescriber and, based on the side-effects they reported or their practitioners’ unwillingness to supply further information, more than 20% of these cases are believed to have involved unlicensed or counterfeit products, Collins said.

“People often say to me, ‘I’ve never seen good work done with fillers,’ and I say, ‘You absolutely have – but you won’t notice it if it’s good’,” says Alice Hart-Davis. Scary as all of this sounds, there are plenty of reputable practitioners out there who can help you achieve the look you desire while prioritizing your safety. Do your research and choose wisely.

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