ABSTRACT This study aimed to evaluate pain levels, patient satisfaction, and preferences for different anesthetic techniques during the cosmetic application of botulinum toxin A in the upper third of the face. A randomized, double-blind, split-face clinical trial was conducted with 100 women undergoing esthetic procedures for facial wrinkle reduction. Patients were assigned to three groups: vibratory anesthesia versus placebo (Group I), topical anesthesia versus placebo (Group II), and vibratory anesthesia versus topical anesthesia (Group III). Pain levels were assessed using the visual analog scale (VAS). Patients identified the side with better pain control, expressed satisfaction, and provided recommendations for each technique. Group I (vibration 5.02 ± 2.56 vs. placebo 6.00 ± 2.75, p = .034), Group II (topical anesthetic 4.69 ± 2.45 vs. placebo 5.50 ± 2.38, p = .039), and Group III (topical anesthetic 4.89 ± 2.29 vs. vibration 6.06 ± 2.22, p = .048). While satisfaction levels showed no statistically significant differences between techniques, topical anesthesia in Group III received the highest recommendations (p = .010). This study suggests that topical anesthesia and vibratory stimulation both offer small-to-medium analgesic benefits over placebo during BoNT-A injections. Despite comparable satisfaction scores, patients preferred topical anesthesia for future use.

Detrusor underactivity (DUA) significantly impacts the quality of life in patients and is often associated with nonspecific symptoms, including both voiding and storage issues. Current treatment options, such as behavioral modifications, pharmacologic therapy, and sacral neuromodulation, are commonly employed but often result in unsatisfactory outcomes. Botulinum toxin A, known for its ability to temporarily paralyze muscles, is widely used in fields like the treatment of gastroparesis, dysphagia, and anal obstruction, and in cosmetic procedures. This property positions it as a potential option for reducing bladder outlet resistance, potentially improving voiding function in patients with DUA. In this review, we examine the application of botulinum toxin A in the management of DUA and discuss its use in sphincteric injections for other sphincter dysfunction conditions. We provide a comprehensive, up-to-date review of the use of sphincteric injections of botulinum toxin in addressing DUA and other sphincter dysfunctions.

Complex regional pain syndrome (CRPS) is a heterogeneous and disabling chronic pain condition characterized by maladaptive neuroplasticity involving persistent peripheral nociceptive input, autonomic dysregulation, and central sensitization. Despite increasing clinical use, the role of botulinum toxin in CRPS remains controversial, with inconsistent outcomes reported across studies. This review synthesizes mechanistic, translational, and clinical evidence suggesting that these apparent inconsistencies may be partly explained by heterogeneity in anatomical targeting and route of administration rather than absence of biological efficacy. Available evidence suggests that botulinum toxin may exhibit its most consistent therapeutic signal when delivered to neural structures directly implicated in dominant CRPS pathophysiology, particularly the sympathetic nervous system and proximal somatic afferents, whereas superficial or non-specific delivery strategies appear to yield more variable responses. Importantly, differences across anatomical targets should not be interpreted as evidence of comparative effectiveness, as observed variation may reflect phenotype selection, procedural heterogeneity, confounding, and differences in outcome reporting. By integrating experimental data, randomized trials, and case-based clinical evidence, an anatomy-informed, route-specific neuromodulation framework is proposed to reconcile existing findings and inform future research. This mechanism-informed perspective is intended to guide rational trial design and phenotype-aligned clinical application of botulinum toxin in CRPS, rather than to provide a definitive evidence-closing synthesis.

Comparison of lip repositioning and lip repositioning with botulinum toxin application in gummy smile treatment.

ABSTRACTBackgroundIntradermal botulinum toxin injections have been shown to reduce sebaceous gland activity and improve skin texture in patients with oily and acne‐prone skin. However, needle‐based application is associated with discomfort and potential side effects.ObjectiveTo evaluate the clinical efficacy and safety of transdermal delivery of botulinum toxin (150 kDa) using Transdermal Application (TDA) technology for the treatment of oily and acne‐prone skin.MethodsIn this single‐center observational study, 19 participants (aged 20–50) underwent treatment with the DERMADROP MED TDA device according to the BIOBOTOX protocol. Objective assessments included Sebumeter measurements and 2D/3D skin imaging. Subjective evaluation was conducted using validated patient‐reported outcome measures (OSIS, OSSAS) at baseline, 2 weeks, and 4 weeks posttreatment.ResultsA statistically significant reduction in sebum levels was observed, accompanied by notable improvements in self‐reported skin clarity and satisfaction. No adverse events were reported.ConclusionTransdermal application of botulinum toxin using TDA‐based DERMADROP MED technology is a safe, well‐tolerated, and effective noninvasive treatment modality for reducing sebaceous activity and improving the appearance of oily and acne‐prone skin.

To investigate the impact of music and white noise on the pain caused by cosmetic botulinum toxin injections. Seventy-six participants between the ages of 18 and 45 who requested cosmetic botulinum toxin application to the upper face were enrolled in the study in three groups: favorite music (20), white noise (31), and control (25). The first and second groups listened to their favorite music and white noise, respectively, during and 10 min after the procedures, while the control group was exposed to background noise only. The participants rated their pain levels during the procedure and the impact of the sound on their stress level using a visual analog scale ranging from 0 to 10. Additionally, the participants in both the music and white noise groups were surveyed regarding their preferences for sound intervention for future botulinum toxin procedures. The pain scores (95% confidence interval) for the control, music, and white noise groups were 6.80 [6.37-7.23], 5.7 [5.13-6.27], and 5.52 [4.99-6.04], respectively. Both the white noise group and the music group had significantly lower pain scores compared to the control group. Furthermore, individuals receiving botulinum toxin for the first time reported significantly higher pain scores than those who had prior experience with the treatment. Listening to white noise or music during cosmetic botulinum toxin injections can effectively reduce procedure-related pain. However, further studies are required to reveal the mechanism of action of sound applications in pain management during cosmetic procedures and to determine the selection of appropriate candidates and specific application conditions.

ABSTRACTBackgroundSecondary facial defects remain a primary focus in plastic surgery, particularly large defects involving the midface, forehead, and scalp. While tissue expansion of the fronto‐scalp flap offers a viable reconstructive option, the lengthy expansion period and the issue of post‐expansion flap retraction necessitate further solutions.ObjectiveWe conducted a prospective, comparative clinical study to investigate the role of Botulinum toxin in the expansion of fronto‐scalp flaps.MethodBetween December 2019 and December 2024, 40 patients with large upper facial or scalp lesions were enrolled and randomly assigned to either the experimental group or the control group. Control group patients underwent tissue expansion combined with postoperative laser hair removal. Experimental group patients received the same tissue expansion and laser therapy, supplemented with Botulinum toxin injections administered both preoperatively (prior to expander implantation) and postoperatively in the forehead and scalp regions. We analyzed and compared parameters including expansion efficiency, post‐expansion flap retraction force, postoperative pain scores, and complication rates between the two groups.ResultsBaseline characteristics showed no significant differences between the two groups before expander implantation. During the tissue expansion phase, the experimental group demonstrated significantly higher expansion efficiency compared to the control group. At both 3 and 6 months following flap transfer surgery, the post‐expansion flap retraction force was significantly lower in the experimental group than in the control group. However, no significant differences were observed in pain scores or complication rates between the two groups.ConclusionOur prospective, comparative study demonstrates that Botulinum toxin application enhances the efficiency of tissue expansion using the fronto‐scalp flap for reconstructing large secondary facial and scalp defects. It also reduces post‐expansion flap retraction force, ultimately contributing to favorable functional and aesthetic surgical outcomes.Trail RegistrationChiCTR1900027702.

Botulinum toxin (BT) is widely used in cosmetics and clinical practice. This literature review explores the applications of BT for the man­agement of headaches and facial pain. The most widespread, well-re­ported, and ALIMS and EMA approved application for BT is in preventing chronic migraine at dos­es between 165–196 IU. After an incidental discovery, BT was vali­dated through several RCTs, includ­ing most notably, the PREEMPT study. Following validation, BT was approved for use in treating chron­ic migraines. According to current guidelines, BT is used for the pre­vention of chronic migraines in patients who are resistant to other forms of therapy, such as triptans or NSAIDs. The most widely used BT injection protocol was established in the PREEMPT study and recommends 31–39 injection sites. In other primary headaches, such as tension-type headaches, there is little and confounded evidence of the efficacy of BT. However, some small-scale studies report­ed that BT outperformed placebo and improved pain in trigeminal autonomic headaches. BT is also used to treat chronic facial pain, most notably trigeminal neuralgias, with encouraging results in RCTs. While the primary mechanism of action of BT is the inhibition of acetyl­choline release from terminal cholinergic nerves, more specific mechanisms of pain relief are yet to be eluci­dated, especially for migraine headaches. Our review of relevant published literature indicates that BT therapy is safe, generally well-tolerated and efficacious, and is a viable option for the management of certain primary headaches and chronic facial conditions.

Background: Botulinum toxin injection is one of the most common esthetic procedures, yet complications may occur due to anatomical variability or suboptimal injection technique. This study aimed to evaluate the upper facial muscles using ultrasound, focusing on inter- and intraindividual variability. Methods: The study involved volunteers aged 21–40 years, excluding those with prior facial treatments, trauma, or muscle disorders. The muscles examined included the occipitofrontalis (frontal belly), procerus, corrugator supercilii, and orbicularis oculi. Muscle thickness and distance from the epidermis were measured using high-frequency ultrasound. Statistical analyses included descriptive statistics, correlation with age and BMI, sex comparisons, and symmetry assessment. Results: A total of 127 participants (103 women and 24 men) were enrolled, with a mean age of 28.8 ± 4.4 years. Age showed no significant correlation with muscle thickness or depth, supporting the internal consistency of the studied age group. BMI showed moderate correlations with the depth of the selected forehead muscles. Males showed greater thickness in the frontal and procerus muscles. Relative side-to-side asymmetry coefficients reached 40% for both thickness and depth, indicating notable individual laterality. Conclusions: The study provides normative ultrasound parameters for the upper facial muscle in healthy adults. The results demonstrate significant anatomical variability depending on sex, BMI, and facial laterality, supporting individualized ultrasound-guided approaches for botulinum toxin injection.

In recent years, orofacial harmonization has gained prominence in dentistry, driven by the growing demand for minimally invasive aesthetic procedures. Among the most widely used techniques, botulinum toxin application has been consolidated as an effective tool for both functional and aesthetic purposes. However, despite its wide clinical acceptance, the literature reports complications that may compromise treatment outcomes and patients’ quality of life. This study aimed to identify and discuss the main complications associated with the use of botulinum toxin in orofacial harmonization, analyzing their clinical relevance, risk factors, and recommended preventive measures. A literature review was conducted through electronic databases (PubMed, SciELO, and Google Scholar), including articles, meta-analyses, and case reports published between 2015 and 2025. Studies addressing complications related to the application of botulinum toxin in aesthetic contexts were selected, considering technical, clinical, and psychological aspects. It is concluded that although botulinum toxin is considered a safe and effective procedure, its application may lead to complications of varying severity, ranging from self-limiting local reactions to more significant systemic adverse effects. Preventing these events depends on professional training, the use of regulated products, and strict adherence to technical and ethical protocols. Therefore, continuous scientific updating and further studies aimed at standardizing safe practices are essential to consolidate orofacial harmonization as a responsible practice in contemporary dentistry.

Hyperhidrosis is a clinical condition characterized by excessive production of sweat, in addition to physiological needs, usually associated with hyperactivity of the sweat glands. This dysfunction significantly compromises the quality of life of individuals, impacting social, emotional and professional aspects. Among the available therapeutic options, the application of botulinum toxin stands out as an efficient and minimally invasive alternative. This study aimed to analyze the effectiveness of botulinum toxin in the treatment of hyperhidrosis, considering its mechanism of action, the main areas of application and the resulting clinical benefits. It is a systematic review of the literature, based on studies published between 2020 and 2025, in the PubMed, Scielo and Google Scholar databases, from the Portuguese, English or Spanish languages. The results highlight that botulinum toxin type A (TBX-A) is highly effective and the gold standard for the treatment of hyperhidrosis. Its mechanism blocks acetylcholine, inhibiting sweat and resulting in rapid and significant reduction of the severity of the condition. The application (intradermal) is safe and provides a substantial improvement in quality of life. Although it requires periodic reapplications (4 to 12 months) and have a high cost, it is the therapeutic option of greatest recommendation in the clinical scenario.

Abstract: Stroke is a sudden and prevalent neurological condition classified as ischemic or hemorrhagic. One of its main sequelae is spasticity, a motor disorder characterized by increased muscle tone, which can limit movement and cause pain. Botulinum toxin type A (BTA) has emerged as an important therapeutic option for this condition. It works by blocking the release of acetylcholine at the neuromuscular junction, promoting temporary muscle relaxation that improves function and prevents contractures. Recently, Ruling No. 609/2023 regulated the application of BTA by properly trained physiotherapists with COFFITO-approved courses. However, there is a significant lack of knowledge about this therapy among healthcare professionals. Objective: Review the scientific evidence to elucidate the efficacy and safe application of botulinum toxin in the treatment of spasticity in chronic post-stroke patients, guiding clinical practice based on best evidence. Methodology: For this study, the PubMed database and the field research BOTULINUM TOXIN: A randomized study to evaluate clinical and hospital adjuvant care were consulted. Result: Based on the established inclusion and exclusion criteria, 25 original articles were selected that addressed the use of botulinum toxin as a treatment for spasticity in chronic post-stroke patients. Conclusion: Therefore the lack of knowledge about the use of botulinum toxin in chronic post-stroke patients is understandable, as solid evidence is lacking. BoNT is a valuable but costly adjunct, requiring reinjections and better academic guidance.

This study aimed to evaluate the accuracy, reliability, and clarity of information provided by artificial intelligence (AI)-based language models regarding botulinum toxin applications for bruxism treatment. Eighty-five open-ended questions were developed under 7 specific domains by a team comprising an oral and maxillofacial surgeon and 2 orthodontists. These domains included indications, contraindications, procedures, complications, prognoses, advantages, and disadvantages of botulinum toxin use in bruxism treatment. The questions were input into 3 AI chatbots: ChatGPT-4.0, Google Gemini, and Microsoft Copilot. The generated responses were independently evaluated by the researchers through 5 predefined accuracy categories: "Objectively True," "Selected Facts," "Minimal Facts," "Incorrect," and "Misleading." Statistical analysis, including χ2 and the Fisher exact tests, was conducted to assess differences in response accuracy among the AI models, with significance set at P<0.05. A statistically significant association was found between the AI model and response accuracy (P<0.001). ChatGPT-4.0 predominantly delivered answers classified as "Objectively True," surpassing Google Gemini and Microsoft Copilot. Across all domains, ChatGPT-4.0 maintained higher rates of accurate responses, whereas Google Gemini and Microsoft Copilot frequently provided answers categorized as "Selected Facts" or "Minimal Facts." While AI-based language models, particularly ChatGPT-4.0, may serve as a useful adjunct for preliminary patient education and professional reference regarding botulinum toxin use in bruxism, they cannot replace evidence-based clinical judgment. Practitioners should remain vigilant about the risk of misinformation and ensure validation of AI-generated content against established guidelines and authoritative sources before applying it in patient care.

Skin aging triggers structural changes such as loss of firmness, facial volume reduction, and wrinkle formation, factors that drive the demand for minimally invasive aesthetic procedures. In this context, hyaluronic acid and botulinum toxin stand out as widely used substances in facial harmonization but are associated with complications of varying severity. This study aimed to analyze the main complications related to the application of hyaluronic acid and botulinum toxin in facial aesthetics through a systematic literature review. The research was conducted through searches in the PubMed, SciELO, and Google Scholar databases, covering articles published between 2020 and 2025, in Portuguese and English, that addressed complications resulting from the use of these materials and their clinical management approaches. The results showed that, in procedures with hyaluronic acid, the most frequent complications were pain, edema, erythema, and, in severe cases, tissue necrosis and vascular occlusion. In botulinum toxin applications, the most common complications were bruising, eyelid ptosis, asymmetry, and occasional allergic reactions. Although most adverse effects are mild and easily manageable, the study emphasizes the need for well-defined protocols to ensure patient safety and minimize severe complications. Therefore, professional training, appropriate techniques, and standardized clinical protocols are essential for the effective prevention and management of complications, reinforcing the importance of safe and responsible practices in injectable aesthetic procedures.

Botulinum toxin type A is a potent neurotoxin and was first approved for use in 1989; since there has been a surge in its uses. The latest international trend is the unapproved use of botulinum toxin for allergic and nonallergic rhinitis, being advertised as "Haytox." A single-group open-label non-randomized Phase 1 clinical trial was completed. Rhinitis and nonallergic rhinitis were confirmed via formalized examination and testing with total IgE and radioallergosorbent test (RAST). Participants received 40 units of botulinum toxin type A, administered topically intranasally, 20 units per nostril, using the LMA MAD Nasal Intranasal Mucosal Atomization Device. Safety of the intervention was assessed with adverse event tracking logs. Symptom scores were used to assess symptom reduction, including total nasal symptom score (TNSS), visual analog scale (VAS) measurements at Weeks 0, 2, 4, and 12. In addition, peak nasal inspiratory flow (PNIF) was measured at Weeks 0 and 4, with the minimum clinically important difference (MCID) being used to demonstrate any clinically significant change in the TNSS score. A TOTAL OF: 15 participants enrolled, of which 14 participants received treatment, with no serious adverse or related adverse events reported. There was a statistically and clinically significant reduction in TNSS and a statistically significant reduction in VAS from Weeks 0 to 12. In this Phase 1 trial, topical application of botulinum toxin via spray was shown to be safe, without any significant adverse events. It reduced the TNSS and VAS across the cohort. However, the treatment efficacy should be taken in context as there was no blinding, alternative dosing, or comparison against placebo or recognized active treatment options. This safety data should embolden future research trials. TGA number: CT-2024-CTN-02905-1; ANZCTR number: ACTRN12624000772549.

Background: The Functional beauty is a new analytic technique which combines aesthetic treatment and functional maintenance of structures taking into account the myomodulation that occurs over time. This new approach seeks to improve perception and sensitivity so that it is possible to capture the essence of Beauty and expand the vision of facial harmony. Objective: Describe the fourth principles of the Functional Beauty technique and present the application of facial botulinum toxin based on it. Method: This publication brings a historical perspective of beauty and provides information on the specific characteristics of the technique and focuses on the fourth principles that guide facial assessments and the treatment panel. Results: Recommendations on injection techniques are provided for face based on the particular anatomy of each area, the focus is on the technique (fourth principles) and devices of injection of botulinum toxin. Marking photos are presented for illustration. Conclusion: Functional Beauty is an innovative aesthetic treatment technique, which aims not only at aesthetic benefits, but also at the absence of functional impairment in the short and long term not just treating defects and wrinkles.

Ocular surface disease (OSD) encompasses a range of conditions that not only include the well-described dry eye disease (DED) components - such as hyperosmolarity, inflammation, ocular surface damage, and neurosensory compromise - but also eyelid-related disorders. These can stem from anatomical abnormalities or as consequences of DED, leading to various mechanical and inflammatory issues. These may include friction between the eyelids and the globe; irregular blink mechanics; and incomplete protection or even frank exposure of the ocular surface. Eyelid-associated ocular surface disease (EAOSD) includes conditions such as superior limbic keratoconjunctivitis, orbicularis oculi spasm (Jumping Orbicularis Sign), lid wiper epitheliopathy, and tight eyelid syndrome. Botulinum toxin, produced by the bacterium Clostridium botulinum, works by blocking the release of acetylcholine at the neuromuscular junction, leading to temporary muscle weakening. When mindfully injected into the orbicularis oculi, frontalis, or tarsal plate, botulinum toxin may reduce muscle tension around the eyelids, which improves eyelid tone and anatomic apposition between the eyelid and ocular surface tissues. Botulinum toxin can also be used to address abnormal blink patterns, incomplete blinking, nocturnal lid seal insufficiency, and lagophthalmos. Such interventions may alleviate symptoms associated with EAOSD. This paper examines the applications of botulinum toxin in the treatment of EAOSD. Other applications of botulinum toxin for addressing photophobia and excess trigeminal nerve tone are separately addressable topics.

Subcutaneous Versus Combined Subcutaneous and Intramuscular Botulinum Toxin for Androgenetic Alopecia: A Randomized Clinical Trial.

Subcutaneous Versus Combined Subcutaneous and Intramuscular Botulinum Toxin for Androgenetic Alopecia: A Randomized Clinical Trial.

Comparative analysis of different dilution methods in botulinum toxin application.