Upper Face Treatment With Botulinum Toxin: A Practical Guide

Overview

This narrative review, published in Aesthetic Plastic Surgery in 2022 under the full title Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide, focuses on the most commonly performed non-invasive procedure for upper-face rejuvenation. Treatment is generally safe, and adverse effects are usually mild and transient. Complications depend largely on technique and on the toxin spreading to muscles that were not targeted.

Main complications

The review describes upper eyelid ptosis, which occurs when the toxin spreads to the eyelid-lifting muscle, and brow ptosis, caused by injecting the forehead muscle too low. It also covers brow asymmetry, including an unnaturally raised lateral brow, and double vision from spread to an eye muscle. Other problems are incomplete eyelid closure, lower lid eversion in patients with lax lids, and more prominent lower eyelid bags or swelling.

Anatomy and safety zones

The authors stress detailed knowledge of the facial muscles. The frontalis is the only elevator of the brow and works against several depressor muscles, so treating one group without the other can distort brow shape. The review defines safety areas above the orbital rim and brow, above the medial canthal region, and around the lateral canthus. Injections around the eye should be superficial and not placed too low, to avoid affecting the upper lip.

Individualised planning

Rather than using a fixed template, the guide recommends identifying each patient's pattern of forehead lines and glabellar frown lines, and placing injection points accordingly. It also covers sex-related differences in treatment goals, such as avoiding a feminised brow shape in men. Crow's feet treatment is planned by asking the patient to smile forcefully.

Clinical implications

The authors conclude that incorporating these safety areas and individualised patterns into daily practice keeps the risk of complications very low. They note that their review did not compare protocols and call for systematic reviews to do so.