Application of Botulinum Toxin in Facial Diseases

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

Deadline for manuscript submissions: 31 May 2026 | Viewed by 9097

Special Issue Editors


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Guest Editor
Department of Ophthalmology, Hospital Tenon, GHU Est Parisien, 4, rue de la Chine, CEDEX 20, 75970 Paris, France
Interests: ophthalmology; botox injection

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Guest Editor
Service d’ophtalmologie, CHU de Reims, 51100 Reims, France
Interests: clinical ophthalmology; eye diseases; emergency treatment

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Guest Editor
Department of Ophthalmology, Centre Hospitalier Universitaire Dupuytren, 2, Avenue Martin-Luther-King, 87042 Limoges, France
Interests: clinical ophthalmology; oculoplastic surgery

Special Issue Information

Dear Colleagues,

This Special Issue, titled “Application of Botulinum Toxin in Facial Diseases”, will explore the different applications of botulinum neurotoxin (BoNT) in facial treatment, including lacrymal and salivary glands. Since Alan Scott first used BoNT in Strabismus (1989), then in Central Cerebral Dystonias such as Essential Blepharospasm or Meige syndrome, quickly followed by the treatment of abnormal movements as hemi-facial spasm, the use of BoNT has revolutionized our therapeutic capabilities and the quality of life of these patients. This fantastic therapeutic revolution has made it possible to improve the diagnosis of rare diseases such as Blepharospasm and Meige syndrome by offering an effective and safe therapy. BoNT is also used in primary or secondary hemi-facial spasm, as well as in nerve regrowth synkinesis after facial paralysis. Technical improvements in the use of botulinum toxin not only allow us to treat inappropriate muscle contractions but also to improve facial symmetry after idiopathic or post-surgical muscular paralysis, especially after ENT carcinological surgery. Current clinical research highlights botulinum neurotoxin’s therapeutic potential beyond its traditional neuromuscular dystonic applications in managing hyper glandular production. The extension of BoNT indications in the glands also allows us to limit drooling in salivary hypersecretions and to stop an epiphora with patent or obstructed tear ducts. These indications are also very useful in Frey syndrome treatment. In more restricted indications, BoNT can be of great help in the correction of a hypertrophic scar. In patients who are fragile or cachectic, it can allow for the correction of an entropion if surgery is contraindicated. In this Special Issue, we will review the indications, injection techniques, handling of BoNT concentrations and the management of adverse effects in the context of facial treatment.

Dr. Brigitte Girard
Dr. Isabelle Larre
Dr. Juliette Delmas
Guest Editors

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Keywords

  • botulinum neurotoxin
  • blepharospasm
  • hemifacial spasm
  • ptosis
  • drooling
  • lacrymal gland
  • salivary gland
  • movement disorders
  • entropion
  • epiphora
  • facial asymmetry correction

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Published Papers (5 papers)

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Research

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17 pages, 4712 KB  
Article
Botulinum Toxin Treatment Can Enlarge Eye Appearance in Asian Patients and Improves Social and Emotional Attributes
by Maurício de Maio, Kiyoko Kato, Momoko Sato, Yuki Horiuchi, Takuya Toyama, Akiko Imaizumi and Hidenori Ishii
Toxins 2026, 18(3), 145; https://doi.org/10.3390/toxins18030145 - 15 Mar 2026
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Abstract
Aesthetic patients in East Asia are commonly concerned about small apparent eye size. Simultaneous treatment of the glabellar and lateral canthal areas with botulinum neurotoxin has potential to provide improvements. This case series evaluated changes in eye size following treatment of these two [...] Read more.
Aesthetic patients in East Asia are commonly concerned about small apparent eye size. Simultaneous treatment of the glabellar and lateral canthal areas with botulinum neurotoxin has potential to provide improvements. This case series evaluated changes in eye size following treatment of these two areas using standard on-label doses of onabotulinumtoxinA in patients from Japan or China. Outcomes were assessed based on standardised frontal photographs taken before and after treatment (at rest, maximum smile, and maximum frowning). Changes in eye size were examined using a 4-point Likert scale, as evaluated by three independent groups: six injectors; six non-injecting observers; and treated patients. Furthermore, improvements in overall facial impression were analysed using two established tools: ‘emotional attributes’ and ‘social attributes’. Twenty East Asian subjects were included (n = 17 women; mean age: 37.5 ± 6.4 years). The majority of evaluators in all three groups rated patients’ eye size as ‘significantly’ or ‘mildly’ improved post-treatment, whether assessed at rest, when smiling, or during frowning. Furthermore, almost all evaluators noted improvements in one or more emotional and social attributes. This approach has significant potential as a culturally adapted aesthetic technique for improving eye size in East Asian patients. Larger multicentre studies are warranted. Full article
(This article belongs to the Special Issue Application of Botulinum Toxin in Facial Diseases)
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12 pages, 1411 KB  
Article
Artificial Intelligence Analysis of Symmetry and Emotions in Facial Palsy Patients After Botulinum Toxin A Injections
by Seraina L. C. Müller, Chantal Zeier, Pablo Pfister, Nadia Menzi, Bita Tafrishi, Dirk J. Schaefer, Jan A. Plock, Tarek Ismail and Holger J. Klein
Toxins 2025, 17(12), 597; https://doi.org/10.3390/toxins17120597 - 15 Dec 2025
Cited by 2 | Viewed by 1293
Abstract
Facial palsy affects millions worldwide. Botulinum toxin Type A (BoNT-A) is an established treatment for non-flaccid facial palsy, yet objective evidence remains limited. This study evaluates the effects of BoNT-A using AI-based tools and patient-reported outcome measures (PROMs). In this prospective observational study, [...] Read more.
Facial palsy affects millions worldwide. Botulinum toxin Type A (BoNT-A) is an established treatment for non-flaccid facial palsy, yet objective evidence remains limited. This study evaluates the effects of BoNT-A using AI-based tools and patient-reported outcome measures (PROMs). In this prospective observational study, patients with non-flaccid facial palsy received individualized BoNT-A injections. Exclusion criteria included age < 18, hypersensitivity to BoNT-A, or lack of follow-up. Assessments were conducted before and 3 weeks after treatment, including facial symmetry (Emotrics®), emotion expression (FaceReader™), and PROMs (FaCE and FDI). Eleven patients (mean age 50.1 ± 18 years) were included. BoNT-A significantly improved dynamic facial symmetry: eyebrow raising (p = 0.032), smile angle (p = 0.005), and lower lip height (p = 0.042). Emotion analysis showed no significant changes. PROMs revealed improvements in social well-being (FDI, p = 0.004) and aesthetic satisfaction (FaCE, p = 0.035), while functional FDI scores remained unchanged (p = 0.406). BoNT-A improves objective symmetry and patient satisfaction in non-flaccid facial palsy. The lack of change in emotional expression may reflect improved symmetry at the cost of dynamic muscle activation. Full article
(This article belongs to the Special Issue Application of Botulinum Toxin in Facial Diseases)
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15 pages, 1136 KB  
Article
The Effective Way of Botulinum Toxin Injection to Reduce Bite Force: Preliminary Study
by Kun-Hwa Kang, Jae-Kwang Jung, Jin-Seok Byun and Ji Rak Kim
Toxins 2025, 17(10), 519; https://doi.org/10.3390/toxins17100519 - 21 Oct 2025
Cited by 4 | Viewed by 2466
Abstract
This study investigated bite force changes after botulinum toxin type A (BoNT-A) injection into different masticatory muscles. Thirty-five male participants were divided into three groups: masseter only (M), masseter and temporalis (MT), and masseter, temporalis, and medial pterygoid (MTP). Bite force was measured [...] Read more.
This study investigated bite force changes after botulinum toxin type A (BoNT-A) injection into different masticatory muscles. Thirty-five male participants were divided into three groups: masseter only (M), masseter and temporalis (MT), and masseter, temporalis, and medial pterygoid (MTP). Bite force was measured before and up to 6 months after injection with the Dental Prescale II system. Baseline values showed no significant group differences. Group M exhibited significant reduction at 1 and 2 weeks, with recovery within 1 month. Group MT showed a similar transient decrease, also recovering after 1 month. In contrast, Group MTP demonstrated a more pronounced and prolonged reduction, persisting up to 4 months before recovery. These results indicate that the extent and duration of BoNT-A effects depend on the number of muscles injected. Multi-muscle injections, including the medial pterygoid, provide more durable suppression. However, further research involving patient populations is needed to clarify whether multi-muscle injection strategies provide therapeutic benefits in clinical conditions such as temporomandibular disorders or oromandibular dystonia. Full article
(This article belongs to the Special Issue Application of Botulinum Toxin in Facial Diseases)
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9 pages, 440 KB  
Article
Botulinum Neurotoxin A Injections in Spasmodic Entropion: A Clinical Retrospective Cohort Study
by Brigitte Girard, Fabienne Carré and Simon Begnaud
Toxins 2025, 17(8), 383; https://doi.org/10.3390/toxins17080383 - 31 Jul 2025
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Abstract
While surgical procedure has been considered as the golden standard treatment for spasmodic entropion, Botulinum Neurotoxin A can be indicated in the treatment of spasmodic entropion for fragile elderly patients. This retrospective cohort study included 50 outdoor patients treated for spasmodic entropion, for [...] Read more.
While surgical procedure has been considered as the golden standard treatment for spasmodic entropion, Botulinum Neurotoxin A can be indicated in the treatment of spasmodic entropion for fragile elderly patients. This retrospective cohort study included 50 outdoor patients treated for spasmodic entropion, for whom palpebral surgery was recused. The intent of the present study was to describe an alternative outdoor treatment, to detail precisely the Botulinum Neurotoxin (BoNT) treatment pattern, the dosage of BoNT needed, the frequency of re-injection, the efficiency and the complications encountered. Fifty patients, 87.9 years old in average (±14.3) have been injected with BoNT. The average total dosage of BoNT is 7.62 ± 1.38 units of Incobotulinum, 10.2 ± 1.03 units of Onabotulinum and 17.2 ± 1.33 Speywood-units of Abobotulinum. Spasmodic entropion resolved in 3 ± 2 days after the BT injection. The average for re-injection is every 4.25 ± 1.30 months. By adjusting age and total dose, we have not been able to show any statistically significant relationship between time needed for re-injection and type of botulinum toxin A (p = 0.59). Patients with spasmodic entropion have responded significantly to BoNT injection. No systemic complications have been reported in this study. BoNT treatment is safe and effective for fragile elderly patients with spasmodic entropion and can be proposed instead of surgery or while waiting for their procedure. Full article
(This article belongs to the Special Issue Application of Botulinum Toxin in Facial Diseases)
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Review

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9 pages, 649 KB  
Review
Retrograde Cricopharyngeal Dysfunction: An Update of Pathophysiological Mechanisms and Future Directions
by Marie Mailly and Jerome R. Lechien
Toxins 2026, 18(1), 8; https://doi.org/10.3390/toxins18010008 - 22 Dec 2025
Viewed by 1741
Abstract
This scoping review aimed to summarize the current literature on the etiological and pathophysiological mechanisms associated with the development of retrograde cricopharyngeus dysfunction (R-CPD) through a PRISMA literature search. According to the current literature, a family history of R-CPD was reported in 28.0% [...] Read more.
This scoping review aimed to summarize the current literature on the etiological and pathophysiological mechanisms associated with the development of retrograde cricopharyngeus dysfunction (R-CPD) through a PRISMA literature search. According to the current literature, a family history of R-CPD was reported in 28.0% of patients across studies, with childhood onset in 55.5% of cases. Gastroesophageal reflux disease and laryngopharyngeal reflux disease prevalence in R-CPD patients ranged from 16.3 to 51.9%, with improvement of heartburn symptoms after treatment. High-resolution manometry revealed dysmotility disorders in 43.5–80.0% of patients, with absent peristalsis in 11–25%. Carbonated drink provocative testing provided diagnostic usefulness in patients with unclear diagnoses by demonstrating failure of cricopharyngeal sphincter relaxation for retrograde gas. Notably, 75.5–79.9% of patients maintained symptom relief beyond the expected pharmacologic duration of botulinum toxin (approximately 6 months), suggesting potential neuroplastic adaptation or learned compensatory mechanisms in overcoming retrograde cricopharyngeal sphincter dysfunction. The pathophysiology of R-CPD remains incompletely understood, with a lack of epidemiological and pediatric studies. The genetic and environmental factors may play a key role, but future studies are needed to clarify their roles in the development of R-CPD. Full article
(This article belongs to the Special Issue Application of Botulinum Toxin in Facial Diseases)
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