Why Was my Botox So Painful?

Question

I have been getting Botox for ten years and have never experienced anything like this. When injected, it felt like fire spreading across my forehead. The pain was so severe that I asked her to stop. My mother had the same experience as well that day. Could it have been mixed wrong?

Sam Naficy, MD, FACS · Answer

If the Botox was reconstituted with anything other than buffered saline, yes, it does hurt. I would have asked your provider to start again, with a new unopened vial, and have them explain their reconstitution. Check out the Botox cosmetic website for Q & A...

Luis Villar, MD, FACS · Answer

A 30 gauge needle is small enough that it can pass between nerve receptors in many parts of the body. If it misses the nerve receptors you will barely feel it, if at all. If it hits a nerve receptor, OUCH. It is a hit or miss proposition. That is why some days you feel little pain, and other days, shooting pains from the superior orbital nerve system seem to shoot up through the forehead with ferocity. Ice cold Botox can also be the culprit. The use of xylocaine with epinephrine is off-label and whether it alters the efficacy of the Botox has not been established. We plan to study this. A well trained surgeon that knows the anatomy and its variations is your best bet for safe and effective Botox treatments. Best wishes. Knowledge is power. Luis F. Villar MD FACS

Nelson Lee Novick, MD · Answer

I have been injecting Botox for cosmetic reasons for over twenty-two years. Since its ground-breaking entrance onto the nonsurgical aesthetic stage at that time, much has been learned about storing,  mixing and injecting Botox (as well as the other more recent neuromodulators, Dysport and Xeomin). We now know that rigidly refrigerating these materials immediately before injection is not necessary for keeping them stable and effective, nor is it necessary to reconstitute them with preservative-free saline solution. Injecting with conventional sized needles, refrigerated solutions, and those containing preservative-free saline simply hurt more. Naturally hitting bone, striking sensitive nerves and nicking underlying blood vessels with hematoma formation from poor technique or lack of a good appreciation of the anatomy of the regions being injected are other potential causes of pain or discomfort.

	To reduce the discomfort of the injections we can use especially small, narrow-gauge needles, we can allow the reconstituted material to come to room temperature, and we can reconstitute it with preservative-containing saline mixed with a small amount of local anesthetic and epinephriine (the latter being included to diminish the likelihood of bruising).

	Of course, it goes without saying, that treatment should only be obtained from a board certified aesthetic physician experienced in the proper preparation and injection techniques for these materials.

Martie Gidon, MD, FRCPC, FAAD · Answer

Botox can be mixed with sterile water or bacteriostatic saline.  Both methods are acceptable and are equally effective but sterile water stings when injected.  Ask for bacteriostatic saline next time.

Edward E. Dickerson, IV, MD · Answer

A few different factors can cause the discomfort you are experiencing this time around; a large gauge needle hitting a nerve receptor and/or poorly or wrongly mixed Botox can both cause more discomfort than normal. We have noticed at my practice that applying a small ice pack to the area before treatment gives our patients a bit of more comfort that way if for some reason a nerve receptor was hit, it would be numb, therefore lowering the discomfort level. “Dr. D”

Steven Swengel, MD · Answer

Several things could contribute to painful Botox injections. None would indicate long term damage, but might impact your decision to try another injector next time. If the needle strikes a cutaneous nerve this can cause a lightening like pain away from the injection site. Hitting the underlying bone can also be quite painful and is usually associated with that 'crunching' noise. The diluent is also an issue. Preserved normal saline is the best to use and the least painful.(This is my preferred vehicle and most patients need no skin prep before my injections) Nonpreserved saline is a bit more uncomfortable and usually brings comments. What would really be painful would be the wrong diluent being grabbed off the shelf and used, such as sterile water or sodium bicarbonate. Rest assured there is no long term injury but I would suggest you try a new injector next time.

Jo Herzog, MD · Answer

My best guess would be that the Botox was mixed with sterile water instead of bacteriostatic saline. There is nothing wrong with this as far as the effect goes but it does hurt. The original instuctions from the company were not to mix with bacteriostatic saline but most of us do this "off label" because it is much less painful

Peter J. Malouf, DO · Answer

Hello,

	if you have had it before perhaps with same injector and it hurt more than usual it is possible that it was mixed wrong. For example if sodium bicarbonate was used instead of saline, this would cause intense pain although not otherwise harmful

	Dr Malouf

F. Victor Rueckl, MD (in memoriam) · Answer

It might have been mixed incorrectly, with sterile water instead of saline. When this happens it can feel like fire being injected. It doesn't affect the efficacy of the Botox, but it does hurt badly.

Why Was my Botox So Painful?

Answers (9)