Absolute contraindications (not to be done)
Botox is not administered in certain medical conditions because the drug's mechanism can severely worsen the existing problem. Foremost among these are neuromuscular junction diseases: myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis (ALS). In these diseases, the nerve-muscle signal is already impaired; botox can further weaken this signal, causing serious problems, including respiratory muscles.
Second category: known allergy to botulinum toxin or excipients (albumin, lactose). Third category: active infection in the area to be injected — acne flare-up, herpes lesion, local cellulitis. Fourth category: antibodies developed previously against the same toxin (immune resistance). In this case, product change or postponement of the application is discussed.
Relative contraindications (postponed)
In some cases, botox can technically be done, but in clinical practice, it is preferred to postpone it. Pregnancy and breastfeeding are at the top of this group. Placental transfer or transfer to milk of the toxin has not been clearly demonstrated with solid evidence, but there is also insufficient safety data. In this case, the "let's not do it" preference is the most reassuring for both the patient and the physician.
Febrile infection, active flu, severe sinusitis, early period after COVID — in these periods, the immune system is already busy, adding a new foreign protein is not clinically necessary. The menstruation period is not an absolute barrier; only the risk of bruising may increase slightly, and the patient decides knowing this.
Absolute contraindications
- Myasthenia gravis
- Lambert-Eaton syndrome
- ALS / motor neuron diseases
- Botulinum toxin allergy
- Albumin allergy
- Active infection at the injection site
- Previous toxin resistance (severe)
Relative — we postpone
- Pregnancy and breastfeeding
- Febrile / acute infection
- Severe immunosuppression
- High dose blood thinners
- Heavy period of menstruation (optional)
- Recent dental procedure (for masseter)
Blood thinners and additional medications
The risk of bruising increases in patients using anticoagulants such as warfarin, apixaban, rivaroxaban, dabigatran, and high-dose aspirin/clopidogrel. It is not correct to say that botox cannot be applied to these patients; however, the bruising plan is explained to the patient beforehand. It is not clinically necessary to stop low doses of routine aspirin such as 81 mg, but supplements such as Omega-3, ginkgo biloba, turmeric, vitamin E can increase bleeding. I recommend stopping these supplements 5 days before the procedure.
Antibiotic use is a rare but important issue. Aminoglycoside antibiotics (gentamicin, tobramycin) can increase the effect of botox. In patients using these drugs, botox is postponed. Magnesium-containing supplements can also theoretically prolong the effect, but their clinical significance is low.
Clinical note:Almost half of the first appointment in my clinic is a discussion of "what not to do" rather than "what to do". A needle is not held without a detailed patient history. Leave the clinic where you hear the phrase "Let's hurry, it'll be done in two minutes".
Age limits — very young and very old
The lower age limit for botox in Turkey is 18. However, clinically, cosmetic botox is rare in the 18-20 age range; even dynamic lines have not yet settled at this age. Although the concept of "preventive botox" is fashionable on social media, its scientific basis is thin — touching before the age of 25 can even disrupt the normal development of facial expression muscles. In my clinic, aesthetic botox is almost never applied before 25; medical indications such as sweating (hyperhidrosis) are evaluated regardless of age.
There is no upper age limit, but the approach changes after 65. Since the muscle structure is thin and the skin is loose, doses are kept low, and expectations for static lines are managed. In the 70s, botox alone may not give meaningful results; a device/laser/thread-supported plan is more appropriate.
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Medical History and Safety Approvals of Botox