Indications for Neurotoxin: Upper Face

Botulinum neurotoxins type A (BoNT/A) smooth out wrinkles by relaxing the underlying muscles, thereby creating a more refreshed, alert appearance. Although the effects are temporary, lasting approximately 3–6 months, consistent use can lead to longer-term benefits such as prevention of additional lines and increased muscle memory. Patients with active facial muscles that lead to dynamic lines are ideal candidates for BoNT/A treatment, and the forehead, glabella, and orbital areas are on-label uses. However, some of the off-label applications of BoNT/A include the infraorbital muscles to treat fine wrinkles and the nasalis muscle to treat bunny lines. Most patients with superficial to deep lines that are apparent while the face is at rest (static lines) benefit from BoNT/A treatment. Patients with lines that are visible only with muscle contraction, but disappear at rest, also benefit from treatment because BoNT/A prevents those lines from becoming grooved into the superficial layer of the skin. In some cases, the unique composition and strength of the patient’s facial musculature create deep grooves, most commonly in the glabella area. These deep grooves usually require more aggressive treatment that may also include a small amount of dermal filler to attain the desired smooth effect. Regardless if filler is used, more than one BoNT/A treatment would likely be necessary to decrease the appearance of deep glabellar grooves. Patients who have lines caused from muscle contraction are candidates for neurotoxin treatment, and this chapter will discuss upper face treatment indications.