Injectables are tricky to master, and anyone who tells you it’s easy, is often not telling the truth. With more experience, I’ve found that I see more and more variation in faces as to what can go wrong, go awry and even lead to unexpected results. Just like with Medicine, there is usually a Dunning-Kruger effect initially- when we are very new and know a little, we think we know a lot and it sometimes veers on arrogance. With actual experience and knowledge, we realise just how limited we are in our understanding, and how much can truly go wrong - not necessarily catastrophically wrong, but inconveniently, sometimes embarrassingly wrong, with areas such as the human face, which we use to emote and express and which is so important for non verbal communication.  This week I’ve had several patients new to some injectable treatments for them, with some glitches reaching out, concerned something has gone wrong, when it is all part and parcel of first time treatment. At Skin Essentials we reach out regularly after someone’s first treatment when things may go wrong, and as our patients feel more confident, we take a far more laidback, hands off approach as is appropriate, reserving advice and discussion for in person reviews. Nonetheless the enquiries this week have me thinking about the things that can potentially occur with anti wrinkle treatments, which are normal, no matter how much we prepare patients for them. So what are the commonest side effects that, while not life threatening or a medical emergency, nonetheless may cause someone to reach out for advice until it all settles?  1. Asymmetry. Among the commonest, asymmetry. Few of us are completely symmetrical, and sometimes the symmetry may be so mild as to not be apparent to us until we begin to undertake injectables. Then, perhaps as we begin to pay more attention to our own faces and the smallest of changes, or sometimes because anti wrinkle treatment may affect one side more than the other initially, even if the same dose was used; or surrounding muscles may pull on one side more than the other, asymmetry may be more obvious to us and to others also till it equalises.                                                      This is fairly common for first time treatment to a given part of the face - I often warn patients of this, and to leave well enough alone till 14 days because we cannot not do anything till then. 9 times out of 10 the asymmetry will settle in a few days, leading to evenness by the 14th day. Problem fixed!  Asymmetry is commonest in areas such as: Eyebrows when treating for frown lines Forehead lines when brows are raised, such as when treating forehead lines The degree of gum on show when treating for gummy smile In paired areas, especially when multiple muscles are involved such as with frowns and smiles, it is impossible to achieve complete symmetry (it is a rare person who's symmetrical anyway), but eyebrow asymmetry is usually easily fixed as are uneven forehead lines. We offer all new patients a complimentary review at 14 days to assess their first treatment in clinic and to address any concerns. This is much easier than emails to and fro, and allows me to standardise for photos taken in clinic if there are symmetry concerns for next time.  2. Heavy forehead/ brows In some patients, this may be an issue when the toxin is first kicking in. The forehead, which is the main elevator of the forehead, may feel heavy. When overdone, eyebrows may flatten and be hard to raise at all, giving women a mannish appearance. In severe cases, patients report not being able to raise their brows at all, and feeling like someone is pressing down on their forehead the whole time. This is different to patients who prefer a more arched appearance to their brows, and who have severe, visible forehead lines because of the regular unconscious raising of their eyebrows. With toxin to the forehead, they may still be able to raise the brows, and the forehead lines may smooth out due to treatment, but they may feel uncomfortable or dislike the effect treatment to this area has for them, unlike overtreatment of the forehead, which causes a flattening of the brows, inability to raise them and drooping of the eyebrow, causing eyelid skin to be pushed down as in the photo above (courtesy of Dr Joe Niamtu) If there is suitable movement retained, the dose is likely not excessive, but all toxin to the forehead will slightly flatten the brows such that if the effect is one that is distressing for the patient, they may prefer forehead lines over the unpleasant feeling/ loss of arch in their brows or prefer a smaller than ideal dose that softens lines without compromising the ability to raise brows (more). Ultimately that is a personal matter that only each patient can decide for themselves. Life is too short to be frustrated about non essential treatments.  Unlike dermal filler, toxin cannot be removed or dissolved and we must wait it out, a process which can begin as early as 6 weeks post treatment. Also unlike dermal filler, the beauty of anti wrinkle treatment is that if unhappy, it’ll resolve itself in time (indeed, nothing CAN be done), whereas when done well, patients want results to last forever, which leads to our next point. 3. Return of lines/ movement sooner than 3 months It is a misconception that faces treated with toxin will remain looking treated until the 3+ month mark when more treatment is needed. Toxin, once injected, depending on the brand used, begins to kick in as early as 3-5 days and peaks (ie has maximum efficacy) at 14 days post treatment which is the best time to assess for effect.  As early