If a filler or botulinum toxin injection at a med spa left you with dead tissue, an infection, a drooping face, blurred vision or a lump that will not go away, more than one person is usually legally responsible. In California, injecting a prescription drug or device is the practice of medicine. It may be done only by a physician, or by a registered nurse or physician assistant under a physician’s supervision, after an appropriate prior examination. The Medical Board says no unlicensed person, “such as medical assistants,” may inject Botox. If the injector was not one of those three, or the spa was owned by someone without a medical license, the claim reaches the injector, the owner, and the physician whose name was borrowed for the arrangement.
That is why the first work on one of these cases is finding out who held the syringe, what was in it, and who owned the business. Those answers decide which statute of limitations applies, whether the MICRA damages cap applies, and whether the product itself was counterfeit.
What goes wrong, in the FDA’s words
The FDA regulates dermal fillers as medical devices, and its own description of the risk is the clearest one. “The most concerning risk associated with the use of dermal fillers is unintentional injection into a blood vessel, leading to blocked blood vessels and poor blood supply to tissues,” which can cause “necrosis (death of tissue), vision abnormalities including blindness, and stroke.” The FDA adds that fillers “sold directly to the public” are not approved and “may be contaminated with chemicals and infectious organisms,” and that injectable silicone is not approved for any aesthetic procedure.
Vision loss is rare but well documented. A 2019 review in Aesthetic Surgery Journal collected 48 newly published cases of partial or complete vision loss after filler between 2015 and 2018, in addition to 98 cases reviewed earlier. The nose, the area between the brows, the forehead and the nasolabial folds were the highest-risk sites, and only about one in five patients recovered full vision. The question in almost every necrosis case is whether the injector recognized the emergency, had the dissolving agent on hand, and had a physician reachable.
The 2024 counterfeit Botox alerts
In April 2024 the FDA warned that a counterfeit version of Botox had been found in multiple states, administered in “non-medical or unlicensed settings.” Reported effects included blurred or double vision, difficulty swallowing, shortness of breath and weakness, and some patients were hospitalized. The FDA’s red flags were specific: lot number C3709C3, a label reading “Botulinum Toxin Type A” instead of “OnabotulinumtoxinA,” 150-unit vials, and non-English packaging. The CDC’s final count was 17 cases in 9 states, 13 of them hospitalized, some involving “counterfeit products or products with unverified sources” and some involving injectors “who did not follow jurisdictional (state or local) requirements.”
California was among the states. On May 8, 2024 the California Department of Public Health issued its own alert that counterfeit Botox had been found “in multiple states, including California,” injected in “non-medical, unlicensed settings,” and warned that “counterfeit or incorrectly administered Botox, even in small amounts, can result in serious health problems and even death.” The Medical Board itself describes “tragic cases of unscrupulous practitioners injecting industrial silicone and toxic counterfeit drugs.”
For a claim, the product question is answered with the lot number. A properly charted injection records the product name, lot and units, and a spa that cannot produce that record has told you something.
Who may inject in California
The Medical Board’s rule is short: “Physicians may inject Botox, or they may direct registered nurses or physician assistants to perform the injection under their supervision. No unlicensed persons, such as medical assistants, may inject Botox.” Business and Professions Code 2069 defines a medical assistant as “a person who may be unlicensed.” An esthetician is further out still: the Board of Barbering and Cosmetology lists “Injections of Any Sort” as prohibited, and Business and Professions Code 7320 says a cosmetology license “confers no authority to practice medicine or surgery.”
Supervision has content. Before a prescription drug is furnished, Business and Professions Code 2242 requires an “appropriate prior examination,” which the industry calls a good faith exam. The Board says that examination may not be delegated to a registered nurse, though a nurse practitioner under standardized procedures may perform it. A nurse cannot “set up a practice in a salon, hire a physician supervisor, or perform medical procedures independently,” and there is no such thing as a “sponsoring physician.” The physician need not be in the room but must be immediately reachable.
So if a registered nurse injected you and no physician ever examined you or was available by phone, the treatment was outside the rules the Board imposes on that license.
The lay-owned spa and the hired medical director
A familiar arrangement in the aesthetics business is a clinic owned by someone with no medical license who contracts with a physician as “medical director.” Business and Professions Code 2400 says corporations and other artificial entities “shall have no professional rights, privileges, or powers,” and the Board’s practice information page lists among violations “a physician acting as ‘medical director’ when the physician does not own the practice,” giving as its example “a business offering spa treatments that include medical procedures such as Botox injections.” Such a business, the Board says, “must be a physician-owned medical practice or professional medical corporation with a physician being the majority shareholder.”
Two more statutes reach the owner. Business and Professions Code 2052 makes practicing medicine without a license, or aiding and abetting it, a public offense, and preserves “any other remedy provided by law,” which includes your civil claim. Business and Professions Code 2417.5 treats a cosmetic clinic that is owned in violation of Section 2400 and employs a physician to facilitate its procedures as having submitted a false health care claim under the Penal Code.
None of that lets the physician off. A doctor who lends a license to a spa is responsible for the supervision that was promised and not delivered, the owner for running a medical practice without the right to do so, and the injector for the injection. Each may have separate insurance.
MICRA or ordinary negligence
If the injector was a physician, registered nurse or physician assistant acting within the scope of the license, the claim is professional negligence under MICRA. Code of Civil Procedure 340.5 gives one year from the date you discovered the injury, and no more than three years from the injury itself. Civil Code 3333.2, as amended by AB 35, caps noneconomic damages at $470,000 in 2026 for each of up to three categories of defendant, rising $40,000 each January 1 through 2033; economic damages such as medical bills and lost earnings are not capped. Code of Civil Procedure 364 requires 90 days’ written notice before the lawsuit is filed.
When the injector was a medical assistant, an esthetician or someone with no license, or the defendant is a lay-owned business rather than a licensed provider, the claim is ordinary negligence. Code of Civil Procedure 335.1 gives two years, and there is no cap. Section 340.5 defines a health care provider as a person licensed under Division 2 of the Business and Professions Code, and limits professional negligence to services within the scope of the license “and which are not within any restriction imposed by the licensing agency.” A medical assistant injecting filler is outside any license. Whether a registered nurse injecting with no physician supervision is outside MICRA on the same reasoning is a live argument with no published California appellate decision on the point. It is an argument to raise, not a promise.
The California Supreme Court has read MICRA narrowly, holding in Flores v. Presbyterian Intercommunity Hospital (2016) that Section 340.5 reaches only negligence in “the provision of medical care to patients,” and in Gutierrez v. Tostado (2025) that a claim which “sounds in general negligence” gets the two-year period under Section 335.1. A slip on a wet floor in the spa lobby is ordinary negligence under those cases. A botched injection by a licensed nurse is not.
Until the injector’s license is confirmed, assume the one-year clock. Our guide to the California personal injury statute of limitations covers the general rules, and our post on laser burns at Encino and Sherman Oaks med spas applies the same analysis to laser and IPL injuries.
How to find out who injected you
Most people leave a med spa knowing the injector’s first name and nothing else.
- Request your records in writing: the intake and consent forms, the examination note, the treatment record with product name, lot number and units, and the names and license numbers of the injector and the supervising physician. Keep the request and the response, or the silence.
- Look up every name at search.dca.ca.gov, the Department of Consumer Affairs license search that covers physicians, nurses, physician assistants and cosmetologists, and screenshot the results. A name that returns no license, or a cosmetology license, changes the case.
- Check the business. Secretary of State filings show whether the entity is a professional medical corporation and who its officers are.
File a complaint with the Medical Board as well; its consumer line is (800) 633-2322 and its categories include “Unlicensed Activity” and “Quality of Care.” If an esthetician was involved, file with the Board of Barbering and Cosmetology through breeze.ca.gov. Board investigations gather records and statements that become evidence in the civil case.
What a claim can recover
A filler or toxin injury claim covers the corrective treatment, often the largest item: dissolving agent, wound care, scar revision, sometimes hyperbaric oxygen for necrosis, and later cosmetic work to repair what the first injection did. It covers the medical bills for the emergency visit and every follow-up, measured under Howell v. Hamilton Meats by the amounts actually paid or owed, lost income during recovery, and the pain, disfigurement and effect on daily life, subject to the MICRA cap when MICRA applies and without a cap when it does not.
The consent form you signed does not change that list. Civil Code 1668 voids any contract that tries to excuse a party from “violation of law, whether willful or negligent,” and under Tunkl v. Regents (1963), which struck down a hospital’s release for its own negligence because medical care affects the public interest, a med spa release for negligence in a medical procedure is vulnerable to the same challenge.
Manoukian Law Firm handles injury cases throughout California from its Chatsworth office, a short drive from the Ventura Boulevard corridor and Calabasas. The practice areas page describes the kinds of cases the firm handles, and the about page describes how the firm works: every case is handled personally by the attorney you hire and prepared as if it will be tried.
Key points
- Botox and filler injections are the practice of medicine in California; medical assistants and estheticians may not inject.
- A lay-owned spa with a hired “medical director” is a prohibited structure under Business and Professions Code 2400, and the owner, the injector and the physician can each be responsible.
- The injector’s license decides the deadline and the cap: one year and a $470,000 noneconomic cap under MICRA for a licensed provider, two years and no cap for an unlicensed injector or a lay-owned business.
- The FDA and CDPH warned in 2024 about counterfeit Botox in unlicensed settings; the lot number in your record answers the product question.
- A signed consent form does not excuse an unlicensed injector, a skipped examination or a counterfeit product.
Frequently asked questions
The spa says the nurse who injected me works “under a doctor.” Is that enough?
Only if it is true in the way the Board requires: the physician performed or properly delegated the appropriate prior examination, was immediately reachable during treatment, and owns the practice. If the physician never saw you or the spa is owned by a non-physician, the arrangement itself is one the Board prohibits.
My face has a hard lump months after filler. Is that a claim?
Possibly. Granulomas and persistent nodules can follow contaminated or unapproved product, or product placed incorrectly. The lot number in your chart and a dermatologist’s or plastic surgeon’s evaluation are the starting points, and the one-year clock under Code of Civil Procedure 340.5 runs from discovery.
I got injections at a “Botox party” in someone’s home. Does that matter?
The Board says the law does not restrict where injections are given, as long as a physician, or a supervised nurse or physician assistant, gives them. What matters is who injected, whether an examination was done, and where the product came from.
Can I recover if I signed a waiver before the injection?
Usually yes. A release for a provider’s own negligence in a medical procedure is vulnerable under Tunkl, and Civil Code 1668 bars any release for a violation of law, which an unlicensed injection is.
If an injection at a med spa left you with necrosis, infection, vision changes or a face that does not look like yours, call Manoukian Law Firm at (818) 818-5031 or reach us through our contact page. Consultations are free and there is no fee unless we recover for you.
