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Toxins
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Study on Botulinum Toxin in Facial Diseases and Aesthetics
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Study on Botulinum Toxin in Facial Diseases and Aesthetics

A special issue of Toxins (ISSN 2072-6651). This special issue belongs to the section "Bacterial Toxins".

Deadline for manuscript submissions: 31 October 2026 | Viewed by 5640

Special Issue Editor

Dr. Giovanni Salti

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Guest Editor
Medicina e Chirurgia Estetica, Medlight Istituto Medico, 50144 Florence, Italy
Interests: cosmetic surgery; plastic surgery

Special Issue Information

Dear Colleagues,

As president of the Italian Association of Aesthetic Botulinum Toxin Therapy (AITEB, Associazione Italiana Terapia Estetica Botulino), it is with great pleasure that I introduce this Special Issue of Toxins. This monograph is dedicated to the diverse applications of botulinum neurotoxin in facial aesthetics and function, a field that has seen remarkable innovation and grown to become a cornerstone of modern medical practice.

Today, its applications range from intricate aesthetic enhancements and subtle facial re-contouring to the management of complex functional disorders. This Special Issue aims to provide a comprehensive overview of this evolution, bringing together cutting-edge research, clinical insights, and expert perspectives from leading professionals around the world.

Our goal is to explore the spectrum of botulinum toxin's utility in the face, covering not only established techniques but also emerging applications. This includes the treatment of hyperfunctional lines, facial asymmetry, and masseter hypertrophy, as well as its role in alleviating conditions such as bruxism and chronic migraines. The contributions within this volume highlight the importance of a deep anatomical understanding, precise injection techniques, and a patient-centred approach to achieve optimal and natural-looking outcomes.

Dr. Giovanni Salti
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a double-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Toxins is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • botulinum toxin
  • cosmetic surgery
  • aesthetic
  • facial diseases
  • facial asymmetry
  • masseter hypertrophy
  • bruxism

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Published Papers (4 papers)

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Research

16 pages, 904 KB  
Article
AI-Based Quantification of Botulinum Neurotoxin-Induced Facial Changes: Wrinkle Reduction, Region-Specific Effects, and Functional Correlates of Facial Muscle Activity
by Ibrahim Güler, Armin Kraus, Gerrit Grieb and Henrik Stelling
Toxins 2026, 18(4), 188; https://doi.org/10.3390/toxins18040188 - 15 Apr 2026
Cited by 1 | Viewed by 763
Abstract
Botulinum neurotoxin (BoNT) treatment outcomes are commonly assessed through visual evaluation of facial wrinkle patterns, a process that remains inherently subjective despite structured grading systems. This study evaluated whether contemporary multimodal artificial intelligence (AI) systems can identify facial changes associated with BoNT treatment, [...] Read more.
Botulinum neurotoxin (BoNT) treatment outcomes are commonly assessed through visual evaluation of facial wrinkle patterns, a process that remains inherently subjective despite structured grading systems. This study evaluated whether contemporary multimodal artificial intelligence (AI) systems can identify facial changes associated with BoNT treatment, using region-specific wrinkle patterns as surrogate markers of underlying muscle activity. A dataset of 46 facial images (23 pre-treatment, 23 post-treatment) was analyzed using four multimodal models, each assessed across five independent runs. Models were tasked with classifying treatment state from single images, detecting wrinkle presence in the forehead, glabella, and periorbital regions, and generating exploratory severity scores and age estimates. Two models achieved 100% accuracy in distinguishing pre- from post-treatment images in this dataset, while region-specific wrinkle detection was variable and frequently did not exceed majority-class baselines. Inter-run reliability varied substantially across models. Exploratory wrinkle severity scores showed directional differences between treatment states, whereas apparent age estimates demonstrated minimal systematic variation. These findings suggest that global facial changes associated with BoNT treatment appear to be detectable in model outputs, but region-specific assessment remains limited, underscoring the need for cautious interpretation and further validation. Full article
(This article belongs to the Special Issue Study on Botulinum Toxin in Facial Diseases and Aesthetics)
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11 pages, 1811 KB  
Article
LetibotulinumtoxinA for Rosacea: A Pilot Study
by Agnieszka Bańka-Wrona, Witold Wrona and Wioletta Barańska-Rybak
Toxins 2026, 18(4), 162; https://doi.org/10.3390/toxins18040162 - 28 Mar 2026
Viewed by 1961
Abstract
Rosacea-associated erythema and flushing often remain inadequately controlled by standard therapies. Intradermal botulinum toxin A has emerged as a potential treatment targeting the neurovascular component of rosacea. This pilot study aimed to evaluate the safety and preliminary efficacy of intradermal letibotulinumtoxinA for persistent [...] Read more.
Rosacea-associated erythema and flushing often remain inadequately controlled by standard therapies. Intradermal botulinum toxin A has emerged as a potential treatment targeting the neurovascular component of rosacea. This pilot study aimed to evaluate the safety and preliminary efficacy of intradermal letibotulinumtoxinA for persistent erythema and flushing in rosacea. Eleven patients with refractory erythematotelangiectatic rosacea received a single session of intradermal letibotulinumtoxinA (20 U total dose). Outcomes at 2 weeks included clinician- and patient-rated erythema severity, patient-reported flushing, skin hydration, sebum, elasticity, and Dermatology Life Quality Index (DLQI). Safety assessments included adverse events and pain. Two weeks post-treatment, 73% of patients showed improvement in Clinician’s Erythema Assessment score and 100% reported reduced flushing. Median hydration and elasticity increased, while the level of sebum decreased. Median DLQI improved from 9 to 2. No serious adverse effects occurred; mild, transient cheek heaviness and dryness were noted in three cases. Intradermal letibotulinumtoxinA was well tolerated, with few reported side effects/complications. The treatment demonstrated preliminary efficacy in reducing rosacea erythema and flushing, and improving skin physiology and quality of life; however, these require confirmation in a larger, controlled study. Full article
(This article belongs to the Special Issue Study on Botulinum Toxin in Facial Diseases and Aesthetics)
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19 pages, 307 KB  
Article
From Muscular Hypertonus to Equilibrium: A Conceptual Framework for Aesthetic Neuromodulation Based on the Index of Muscular Equilibrium (IME)
by Andrea Felice Armenti
Toxins 2026, 18(2), 115; https://doi.org/10.3390/toxins18020115 - 23 Feb 2026
Cited by 1 | Viewed by 1025
Abstract
Facial neuromodulation with botulinum toxin has traditionally been approached from the perspective of wrinkle correction. However, facial expressions primarily arise from coordinated muscular interactions that convey both positive and negative emotional valence. A conceptual framework focused on muscular equilibrium rather than wrinkle severity [...] Read more.
Facial neuromodulation with botulinum toxin has traditionally been approached from the perspective of wrinkle correction. However, facial expressions primarily arise from coordinated muscular interactions that convey both positive and negative emotional valence. A conceptual framework focused on muscular equilibrium rather than wrinkle severity may therefore offer a more comprehensive, reproducible, and clinically meaningful approach. In this article, we propose the Index of Muscular Equilibrium (IME) Framework, a conceptual model for aesthetic neuromodulation that integrates functional muscle mapping, validated severity scales, and a composite IME score to support personalized treatment planning and outcome assessment. The framework is derived from a narrative review of PubMed-indexed literature on facial muscle activity, emotional expression, and validated clinical assessment tools. It combines a Valence Map to classify positive- and negative-valence muscle groups, a standardized evaluation of static and dynamic hypertonus, a conceptual Plan Score to guide selective neuromodulation, and a feedback-based longitudinal workflow (the IME Loop). Together, these components enable structured assessment of muscular imbalance, integration of established wrinkle severity scales, and translation into individualized, function-oriented treatment strategies, with intended benefits including improved objectivity, reproducibility, and patient communication. By reframing treatment success from the duration of muscle blockade to the duration of expressive harmony, the IME Framework introduces testable constructs for future validation and offers a functional perspective on facial neuromodulation aligned with contemporary affective science. Full article
(This article belongs to the Special Issue Study on Botulinum Toxin in Facial Diseases and Aesthetics)
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15 pages, 3409 KB  
Article
Pilot Retrospective Evaluation of a Balancing and Optimizing Injection Pattern for the Frontalis Muscle Using LetibotulinumtoxinA
by Konstantin Frank, Lukas Prantl, Vanessa Brebant and Syed Haq
Toxins 2025, 17(12), 594; https://doi.org/10.3390/toxins17120594 - 11 Dec 2025
Viewed by 1097
Abstract
Signs of aging in the upper face arise from multimodal changes in facial anatomy, contributing to concerns such as eyebrow ptosis and forehead lines. While neurotoxin injections are widely used to address these lines, the anatomical variability of the frontalis muscle presents procedural [...] Read more.
Signs of aging in the upper face arise from multimodal changes in facial anatomy, contributing to concerns such as eyebrow ptosis and forehead lines. While neurotoxin injections are widely used to address these lines, the anatomical variability of the frontalis muscle presents procedural challenges. This retrospective analysis aimed to introduce and preliminarily evaluate a structured injection pattern for forehead treatment, developed with attention to the biomechanics of upper facial musculature. A total of 24 patients (mean age 42.5 ± 9.1 years) treated with a standardized injection scheme using letibotulinumtoxinA were included. All subjects also received concomitant glabellar treatment. The protocol incorporated identification of the line of convergence and targeted injections at defined points to balance elevation, optimize muscular activity, and minimize the risk of eyebrow descent. Forehead line severity was assessed at rest and during animation, and three-dimensional surface imaging was used to quantify vertical skin displacement. At baseline, 79.2% of patients presented with severe dynamic forehead lines, and 29.1% exhibited severe static lines. After two weeks, 62.5% showed no dynamic lines and 41.7% showed no static lines. All subjects demonstrated a ≥1-point improvement in dynamic line severity, with 87.5% achieving a ≥2-point improvement. For static lines, 95.8% achieved a ≥1-point improvement and 20.8% showed a ≥2-point improvement after two weeks. The mean dosage was 17.8 ± 0.7 U. Two patients (8.3%) required a touch-up, and no adverse events were observed. These findings suggest that this structured injection approach may offer a consistent method for addressing forehead lines; however, the results should be interpreted within the limitations of a small, uncontrolled retrospective series. Prospective controlled studies with larger populations are needed to further validate the technique. Full article
(This article belongs to the Special Issue Study on Botulinum Toxin in Facial Diseases and Aesthetics)
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