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Objectives: Contrary to the common practice of trying to raise patients eye brows with toxins, there are cases where you should not raise the brow and in some cases, even try to lower the brow

Introduction: Asymmetric brows and hollow eyelids are two indications where it may be better to avoid lifting the brow or even lower the raised brow or brows.

Conclusion: We will look at several cases and the outcome of lowering the brow

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Objectives: Microdroplets of botulinum toxin treatment is a technique of microinjections of properly diluted botulinum toxin type A into intradermal level. This technique is not only used for aesthetic procedures for wrinkle reduction, skin texture improvement and facial lifting with more natural beauty but also applied to clinical indications such as redness relief in rosacea and sensitive skin, anti- inflammation in chronic psoriatic and eczematous plaques and scar remodeling in surgical wounds and keloids. With more and more evidence, intradermal botulinum toxin injection will be a promising treatment

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Objectives: To describe the anatomy of the continuous fibromuscular layer of the lower face, discuss the development of age-related indications and propose neuromodulator-based interventions for this area. We provide evidence-based recommendations on optimal applications of neuromodulators to rebalance the musculoaponeurotic layer for natural results. We demonstrate how careful and deliberate placement of botulinum toxin can create an expressive, well-balanced face that reflects health, vitality and happiness.

Introduction: Surgeons and physicians using neuromodulators to rebalance the facial musculature need to develop an in-depth and holistic understanding of the five tissue layers of the face and how they interact to produce facial expressions. An understanding of the dynamic anatomy of the continuous superficial fibromuscular layer of the face is essential, and how the mimetic muscles exert directional influence through it. Knowledge of how to use neuromodulators to rebalance the musculoaponeurotic layer will facilitate more natural outcomes as demonstrated here in the lower face.

Materials / method: IncobotulinumtoxinA (incoA) was used to reduce directional pull by the mentalis and depressor anguli oris (DAO), while platysmal tension in the lower face was reduced with 2U aliquots of incoA along the mandibular ramus. A second row of toxins was also injected below the mandibular border to further relax upper neck platysmal tension and define the jawline. The directional pull of the DAO on the superficial muscular aponeurotic system (SMAS) and oral commissure was targeted by 2.5U of incoA into the muscle from the middle of the marionette line, as shown in two of our female patients.

Results: The lower face was rebalanced by correcting the platysmal tensioning across the jawline in combination with the mimetic, directional depressor muscles. This resolved the dour facial expression associated with a higher resting tone in this region.

Conclusion: We showed how the mimetic muscles are interconnected and exert a directional pull on the SMAS. The ability to tension or relax the muscular parts of the SMAS further affects resting facial and emotional expressions. Using neuromodulators, these ‘tensioning zones’ and ‘directional mimetic muscles’ can be modulated to effect facial expressions. Rebalancing the muscular tension in the face in combination with skin quality-focused modalities to address wrinkling leads to more natural outcomes.

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Objectives: Botulinum toxin works by inhibiting the release of acetylcholine and resulting in muscle paralysis. Paralysis of certain muscles is the basis of botulinum toxin treatment, but paralysis of adjacent or other muscles can lead to complications. Preventing complications of botulinum toxin injection is an important issue.

Introduction: Intramuscular injection of botulinum toxin is commonly used for the treatment of facial wrinkles. The muscles of facial expression are unique in that they have soft tissue attachments to skin through the superficial muscular aponeurotic system (SMAS), unlike most muscles, which have bony attachments.

Materials / method: We report patients with complications of botulinum toxin injection into the forehead.

Results: The successful treatment for complications is demonstrated.

Conclusion: Knowledge of the anatomy of the mimetic muscles is necessary for botulinum toxin injection. Adverse effects are usually mild and transient. The most common substantive complication is excessive or unwanted weakness, and this resolves as the action of the toxin is lost. Brow ptosis, eyelid ptosis, and eyebrow elevation occasionally happened. Knowledge of the clinical anatomy and experience with the procedure help injectors avoid complications.

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Objectives: The study aimed to investigate the preventive effect of BoNT-A against UVB-induced hyperpigmentation in human subjects.

Introduction: Ultraviolet (UV) exposure contributes to skin hyperpigmentation. Recently, botulinum neurotoxin type A (BoNT-A) showed a promising protective effect on ultraviolet B-induced hyperpigmentation in both in vitro and animal models.

Materials / method: A prospective, double-blinded, randomized controlled trial was performed in 15 healthy participants. Four separate square areas on the abdomen were randomly injected intradermally with different dilutions of BoNT-A (1:2.5, 1:5, 1:7.5) and normal saline (control). Two weeks after injection, hyperpigmented spots were induced by UVB irradiation at the experimental sites. The lightness index and hyperpigmentation scores from blinded physician and participants were evaluated.

Results: Fifteen participants completed the study. One week after UVB irradiation, all BoNT-A-treated sites had a significantly lower degree of hyperpigmentation than the control site in terms of lightness index and hyperpigmentation scores from blinded physician and participants (p < 0.05). However, no statistically significant difference was observed between different concentrations of BoNT-A. No side effects were observed throughout the study period.

Conclusion: Intradermal BoNT-A injection provided a protective effect from UVB-induced hyperpigmentation. It may be used for other hyperpigmentation disorders that are aggravated by UVB.

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