Minutes after treatment, everything looked perfect. But by the time I got home, the reality was lumpy and irregular. I texted photos; the response was always the same: “Give it time. It’ll settle.”
For years, I lived in a cycle of “fixes.” Instead of addressing the lumps and irregularities, the solution was always more product. I was fed a steady diet of clinical gaslighting:
“It’s just inflammation.”
“A burst of prednisone will calm everything down.”
“Try a little Kenalog.”
“It’ll look better with time.”
It didn’t. In 2023, the corporate distractions fell away and I saw the truth: I had become the “overfilled” patient, and I was completely unaware. The haunting part was that none of the experts who injected me spoke up.
Nobody filed a report. That silence is how 1.5 million complications are erased from the record, leaving us with a fire alarm that only works 0.1% of the time.
<0.1%
Estimated percentage of aesthetic BoNT-A adverse events reported to the FDA.
If the fire alarm only works 0.1% of the time… is it a fire alarm?
(1.5 million expected. Fewer than 1,000 reported.)
Approximately 9.8 million aesthetic BoNT-A procedures were performed in the US in 2024. Published meta-analyses document a complication rate of roughly 16%. That translates to 1.5 million adverse events in the US alone.
The reality? The FDA’s Adverse Event Reporting System logged fewer than 1,000, or 0.1%.
A 2026 international pharmacovigilance analysis, the largest ever conducted, examined 43,809 adverse event reports across four global databases over 23 years. The US contributed 87.5%. It’s not because Americans have more complications. It’s because the rest of the world isn’t reporting. Australia, with a thriving aesthetics market, recorded 127 events in 23 years. That’s six per year from a nation doing hundreds of thousands of procedures annually.
The authors politely affirm “the current pharmacovigilance systems…inadequately capture” aesthetic medicine adverse events. In other words, our industry’s reporting is flimsy window dressing.
Why doesn’t anyone report? The same reason Hollywood, the church, and collegiate athletics kept quiet.
Practitioners don’t report because it threatens malpractice premiums, online reviews, referral relationships, and, if you’re in a PE-owned chain, your employment. The system incentivizes handle it quietly, settle if necessary, and move on. Reporting engenders self-incrimination.
Patients don’t report because they’re told not to worry. “The bump is normal. It’ll go down.” “Swelling takes two weeks.” “That’s just bruising.” By the time they realize something is wrong, they’ve been gaslit past the window where reporting feels relevant. Embarrassment and blame obfuscate the systemic failure they’ve become the lowest rung on.
The lack of data does not equal a lack of existence, but it does create a false sense of safety. Practices proclaim, “We’ve never had an adverse event.” The reality is they haven’t acknowledged one.
One of the most compelling publications to come out this year gets to the heart of what this industry is capable of when operating at its highest level.
A clinical review of the corrective patient archetype, patients with facial paralysis, hemifacial microsomia, post-cancer reconstruction, trauma, demonstrated injectable treatments can profoundly transform lives. A 44-year-old man with facial paralysis after a herpes zoster infection shied away from eye contact and withdrew from social gatherings. After treatment with HA filler and neurotoxin, he resumed social activities, started creating content on social media, and “started living again.”
That’s the burning point. It’s what’s possible when injectors operate with anatomical mastery, multimodal fluency, and clinical sophistication.
Acknowledging our mistakes is how we learn. If we don’t report adverse events, we stay in the dark. Hiding from our mistakes also means hiding from our beauty.
As an industry, we’ve swept complications under the rug for so long, the rug is starting to buckle. Before this industry has its #MeToo moment, we have to do three things:
“We’ve never had a lawsuit” is not a safety metric. “The patient didn’t complain” doesn’t mean they didn’t want to or try to complain. “I’ve been doing this for 15 years” is a timeline not a protocol.
Our safety systems, made for big pharma, don’t work for aesthetics where business and medicine are so tightly linked. When reporting a complication feels like hurting your brand, people stay silent. Aesthetic-specific safety frameworks are the only way to survive our own growth. They are a must-have not nice-to-have.
Real safety is a culture, not a one-time workshop. If a specialist clinic from Issue 4 is seeing a 59.2% necrosis rate, then no one is immune. If the experts aren’t safe, nobody is. Train accordingly.
It’s time we throw away the rug and build the floor.
Sources: Global Pharmacovigilance of Aesthetic Botulinum Toxin Type A (Zargaran et al., JOCD 2026), Minimally Invasive Aesthetic Treatments for the Corrective Patient Archetype (Shturman et al., Aesth Plast Surg 2026), Risk Factor Analysis for Vascular Occlusions After Dermal Filler Injections (Chakhachiro & Waseem, Cureus 2025)
BEFORE YOUR NEXT INJECTION DAY
Three questions:
If you hesitated on any of them, your rug is already buckling.
“Hiding from our mistakes also means hiding from our beauty.”
One more question before you go.
What’s one thing happening in aesthetics that leadership isn’t paying enough attention to?
I read every response.
