Just as an orchestra requires a skilled conductor to coordinate and harmonise the music it generates, facial harmonic signalling requires a nuanced botulinum toxin practitioner who, when treating the muscular hyperactivity of negative expression, is in effect is performing the role of an orchestra conductor.

All muscles in the face worked together to express our emotions and feelings. In the Covid era with the obligation to wear masks this “orchestration” of expression become practically impossible for a patient to impart. (1)

Botulinum toxin muscle weakening is a balanced aesthetic art. Too often we observe patients after botulinum toxin treatment who relate rather strangely, in isolated in verbal expression but accompanied by the deficit of a rather “dead face”.

When facial musculature is discordant, engendering undesired or negative signalling, practitioners are called upon to correct the undesired impression.

Frequently, Corrugator-Procerus-D. Supercilii induced frowning may impart a negative, angry or overly-concerned signalling. For a person who actually feels content, such signalling a negative demeanour is unintentional and may give a false impression.

Another common example is the unintentional “surprised look” signalling, consequent to Frontalis hyperactivity attempting to raise the brow in its role as secondary elevator of redundantly heavy upper eyelids.

Practitioners working to a standardised templated botulinum toxin approach may need to consider redefining their treatment paradigms.

Classically, botulinum toxin muscle injecting techniques have been directed in a compartmentalised method, primarily addressing muscle regions as wrinkle generators that need to be relaxed.

This rather confined treatment strategy has pre-disposed the face to suboptimal outcomes and frequently inclined to over-treatments.

In the early years of botulinum toxin treatments, we observed a culture of over-injecting to an almost global “paralysis” model where the entire upper face was characterised by a bland expressionless appearance not registering any signal at all.

Such outcomes imparted a vapid appearance to the face. It was as if the face had “nothing to say” to the observer. Wrinkling may have been successfully diminished but at the cost of a dead looking face.

Interestingly, many celebrities and actors of both genders lost the unique character after such excessively compartmentalised toxin treatments. Individualism was diminished or unrecognisable, sacrificing the special expressive characteristic that often endears an actor to his or her public following.

Of course, to a certain degree (and not an ingenuous way) we are all actors in the theatre of life. The importance of maintaining individualism applies to us all. Life interactions would become very boring indeed if we all sported bland, character-free faces.

Accordingly, mindful of past excessively bland outcomes, in more recent times botulinum toxin treatments have become far more nuanced.

Facial muscular activity is often surprisingly asymmetrical. The “practitioner as conductor” must adjust doses per side in order to bring facial orchestration into a more global facial harmony.

However, harmonisation of the facial musculature can be very challenging in the presence of both asymmetrical muscle weakness, synkinesis and compensatory muscle hyperactivity. This is not infrequently observed in cases of Bell’s palsy and other facial nerve pathologies.

The incidence of peripheral facial palsy is in the order of 35 cases in 100,000. Half of all facial palsy cases are idiopathic such as Bell’s palsy (some 70% of cases recover within 3 months) and the remainder are caused by tumour, trauma, surgical trauma, herpes zoster virus and Ramsay Hunt syndrome (2)

In order to understand a patient’s facial aesthetic characteristics, it important to take all the time that is necessary during a consultation to observe the individual’s unique facial muscular orchestration. It is also timely for practitioners to reflect on the extraordinary endowment of the human face, mindful of the signification it imparts to fellow humans, even without the addition of speech. (3)

There is little point observing muscular function in response to extreme exaggerated command. It is the relaxed muscular orchestration during normal conversational interaction that is pertinent. Otherwise, patients will return after treatments claiming that they can “still frown” in exaggerated mimic.

As in all aesthetic treatments, reasonable outcome expectations should be discussed and demands for excessive or extreme expectations declined.

References
(1) Bouzouaya C., Feiner R. “Face Masks & Eye Aesthetics: Yesterday, Today and Tomorrow” https://www.imcas.com/en/academy/blog/903/face-masks-eye-aesthetics-yesterday-today-and-tomorrow
(2) Pourmomeny AA, Asadi S: “Management of synkinesis and asymmetry in facial nerve palsy”: a review article. Iran J Otorhinolaryngol. 2014 Oct;26(77):251-6. PMID: 25320703; PMCID: PMC4196449. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196449/
(3) Feiner, R: “Facial Recognition, Facial Pareidolia, Prosopagnosia & Signalling in Aesthetics” https://www.imcas.com/en/academy/blog/675/facial-recognition-facial-pareidolia-prosopagnosia-signaling-in-aesthetics