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Skin and Soft Tissue Infections
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Botulinum Toxin Procedures: A Practical Approach to Cosmetic Injections

Rebecca Small, MD

American Family Physician. 2026;113(5):449-456.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Botulinum toxin injection for treatment of facial wrinkles is the most commonly performed minimally invasive cosmetic procedure in the United States. Cosmetic indications approved by the US Food and Drug Administration include treatment of wrinkles in the upper face (eg, glabellar lines [frown lines], frontalis lines [horizontal forehead lines], lateral orbicularis oculi lines [crow’s feet]). Treatment offers predictable results with high patient satisfaction and few adverse effects. Facial wrinkles are formed by dermal atrophy and repetitive contraction of underlying musculature. Injection of small quantities of botulinum toxin, a potent neurotoxin, into specific overactive muscles causes localized muscle relaxation, smoothing the overlying skin and thereby reducing wrinkles. Clinical effects of botulinum toxin typically take 2 weeks to fully develop and last approximately 3 to 4 months. Treatment of dynamic wrinkles, seen during muscle contraction, yield more dramatic results than static wrinkles, which are visible at rest. Botulinum toxin injection is contraindicated in patients with keloidal scarring, neuromuscular disorders (eg, myasthenia gravis), and allergy to constituents of the botulinum toxin product. Minor bruising and swelling can occur with these injections. Temporary blepharoptosis and eyebrow ptosis are technique-dependent complications, and their incidence declines as injector skill improves. Clinicians can attain procedural proficiency through formal instructional courses and precepting with an experienced aesthetic medicine clinician.

REBECCA SMALL, MD, FAAFP, is a clinical professor in the Department of Family and Community Medicine at the University of California–San Francisco (UCSF) School of Medicine, San Francisco. She is also the director of medical aesthetic training at UCSF-Natividad Family Medicine Residency, Salinas, and at Morehouse School of Medicine–Dominican Hospital Family Medicine Residency Program, Santa Cruz, California.

Address correspondence to Rebecca Small, MD, at drsmall@rsmd.me.

Author disclosure: No relevant financial relationships.

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