Introduction: Diverse anatomical characteristics and varied kinetic spectra determine the specific contraction patterns of individuals'''''''' frontal facial musculature.
Objective: To identify and classify the frontal facial musculature contraction patterns in patients who sought care for treating frontal facial wrinkles.
Methods: Retrospective analysis of pictures taken from 83 patients.The muscular contraction pattern was classified according to the predominant hyperkinetic area that was observed in the picture in the frontal muscle''''''''s maximum contraction.
Results: Three contraction patterns were identified: total, medial and lateral. In 50.6% of cases, the total pattern was observed: the horizontal rhytids present in the center of the forehead extend laterally beyond the mediopupillary line, up to the end of the brows.The medial pattern was observed in 25.3% of cases: the horizontal rhytids are concentrated in the central region of the forehead, predominantly contained between the mediopupillary lines.The lateral pattern was observed in 24% of the cases: the horizontal rhytids prevail on the sides of the forehead, mainly occurring laterallyto the mediopupillary line.
Conclusions: The identification and classification of Frontalis muscle contraction patterns provides an individualized approach for each patient, which is one of the most important pillars of a successful treatment plan.

Keywords: A BOTULINUM TOXIN TYPE, MUSCLE CONTRACTION, CLASSIFICATION

Keywords: ANATOMY, BOTULINUM TOXIN TYPE A, INTRADERMAL INJECTIONS

Introduction: For some patients, pain during the injection of botulinum toxin can represent a limitation for performing the procedure. There are doubts about whether the use of topical anesthetic decreases pain or interferes with the treatment's efficacy and duration of effect. Objectives: To study the effect of 4% lidocaine cream in controlling pain during BoNT-A - Speywood Unit botulinum toxin application, comparing it to the vehicle. In addition, the study was aimed at verifying whether the cream influences the treatment's outcome and duration. Methods: An experimental, prospective, double-blind, randomized study was carried out. The pain was assessed through a compartmentalized numerical rating scale (CNRS). The effect was assessed through a four-point contraction qualitative scale. Results: After evaluating the pain scale, higher values were observed in the placebo group when compared to the group that used anesthetic, with statistical significance. Furthermore, there was no statistical difference in the efficacy and duration of effect over weeks 4, 8, 12, and 16. Conclusions: BoNT-A - Speywood Unit toxin was effective and safe for the treatment of glabellar and frontal wrinkles. The use of topical anesthetics (4% lidocaine cream) reduced the pain during the procedure. In addition, there was no interference in the toxin's efficacy and effect duration.

Keywords: BOTULINUM TOXIN TYPE A, LIDOCAINE, PAIN, THERAPY.

Introduction: Although there are differences arising from diverse formulations, botulinum toxin type A is widely marketed in Brazil.
Objective: To compare the efficacy and tolerability of two botulinum toxin type A formulations registered in Brazil: Botulinum toxin type A (Toxin 1) and Onabotulinumtoxin A (Toxin 2), in the treatment of glabellar expression lines through a multicenter prospective, comparative, randomized, double-blind study.
Methods: One hundred fifty-seven patients were randomized at a 1:1 (Toxin 1: Toxin 2) ratio for receiving 20U toxin for the treatment of the glabella's dynamic wrinkles. Photographic records were taken at maximum frowning in five protocol visits by independent evaluators. The assessment of results included: i) percentage of patients with improvement > 1 point in the four-point facial wrinkles scale, at maximum frowning, fifteen days after the treatment; ii) improvement in the static glabellar wrinkles; iii) pain and iv) duration of effect of the toxin.
Results: According to the independent evaluators, two weeks after injection, the rate of response at maximum frowning was 98.4% in the group treated with Toxin 1 and 98.2% in the group treated with Toxin 2. For individuals who received Toxin 1, the authors found an effect's duration of 84.5 ± 38.8 days, while for those who received Toxin 2, the effect's duration was 89.9 ± 41.1 days (p = 0.4303).
Conclusions: Botulinum toxin type A (Toxin 1) and Toxin 2 have similar effectivenesses in the treatment of dynamic glabellar wrinkles. Both preparations were well tolerated.

Keywords: BOTULINUM TOXIN TYPE A; WRINKLES; PROSIGNE; BOTOX

The width of the lower third of the face is mainly determined by the size and shape of the jawbone, the thickness of the masseter muscle and the volume of adjacent subcutaneous tissue. The ideal, culturally recognized pattern for a male face corresponds to a wider lower third and a mandibular angle tending to 90º, while a female face should have a more oval appearance or the shape of a heart, and the middle third wider than the lower third. In order to achieve these aesthetically ideal proportions, botulinum toxin type A (BoNTA) has been successfully applied in the masseter muscle, which is one of the determinates of the lower face's width. Te present article reviews the current literature on the use of botulinum toxin for this purpose, offering the experience of the authors in this practice, aiming at achieving a more harmonious facial contour.

Keywords: BOTULINUM TOXINS, TYPE A; MASSETER MUSCLE; HYPERTROPHY

Introduction: The use of botulinum toxin in the periorbital muscles is aimed at reducing expression lines in that site, correcting the eyebrows' height and treating blepharospasm. However, the application of botulinum toxin in this area can lead to undesirable side effects, such as ptosis, edema in the lower eyelids, artificial appearance of the demarcation area between the orbicularis muscle's treated area and the malar region, ectropion and hematomas.
Objective: To treat the dynamic wrinkles in the lower portion of the orbicularis oculi muscle through injections of microdoses of botulinum toxin.
Methods: A prospective monocentric study with the analytical longitudinal observation of 300 patients undergoing treatment with botulinum toxin microdoses in the lower eyelids' rhytids was carried out. Sociodemographic data, patient satisfaction, dose quantification and complications were analyzed.
Results: Sixty-six percent of the patients showed a total improvement of the wrinkles after the first session. The other required an additional session. Eighty-six percent preferred the treatment with this therapeutic modality.
Conclusions: Despite the great benefit offered by the classic injection points for the treatment of periorbital rhytids types I to III, the authors observed the need to treat rhytids type B (presence of wrinkles on the lower eyelid). Due to the high rate of complications in this region, microdoses of botulinum toxin were proven to be effective and safe.

Keywords: BOTULINUM TOXINS, TYPE A; ESTHETICS; DERMATOLOGY

Introduction: The application of botulinum toxin in the perioral region is a minimally invasive procedure that leads to substantial improvement in the signs of aging in addition to increasing the volume of the lips. However literature on this procedure is still scarce.
Objective: To evaluate changes in shape and volume of the lips, as well as the patients' satisfaction after the application of botulinum toxin in perioral lines.
Methods: Nineteen patients underwent evaluation, photographic record and measurements following the application of botulinum toxin in the perioral region, being subsequently assessed for changes in the lips and satisfaction.
Results: Most of the patients rated their lips as moderately or significantly more attractive after the application of botulinum toxin (p = 0.039). Fifteen women deemed the changes in the lips as a major factor in the overall improvement of their faces.
Conclusions: The use of botulinum toxin in the perioral region leads to the elevation of the upper lip, causing the shortening of the philtrum and the extension of the vermilion. The application of botulinum toxin in the vermilion's border leads to the relaxation of the orbicularis muscle, favoring a more intense tonus effect arising from the upper lip lifting muscles. The patients' satisfaction with the appearance of their lips was evaluated by four additional questions (linked to the lip's shape, volume, attraction and beauty), receiving positive answers. Side effects were minimal.

Keywords: LIP; BOTULINUM TOXINS, TYPE A; BOTULINUM TOXINS

Introduction: Standard dilution of botulinum toxin is performed with 0.9% saline solution. Some studies show that when diluted in lidocaine and epinephrine, the toxin preserves its function without compromising effectiveness or safety.
Objective: To establish whether the paralyzing effect of ona-toxin type A reconstituted in anesthetic (2% lidocaine) and vasoconstrictor agent (1: 50,000 epinephrine) is as effective as that of the same toxin reconstituted in saline solution, at 48 hours, 1 week, 2, 4, 12 and 24 weeks, for the treatment of periocular lines. To compare the tolerance to pain between the two reconstitution alternatives.
Methods: Fifteen patients with periocular wrinkles were randomized to receive onabotulinum toxin diluted in lidocaine with epinephrine or in saline. Re-evaluations were carried out in 48 hours, 1 week, 2, 4, 12 and 24 weeks.
Results: The data indicate that there was no difference in the symmetry and durability of the botulinum toxin, nor in the pain during the application.
Conclusions: There was no statistically significant difference in the frequency of lateral periocular muscle paralysis and symmetry resulting from the applications of onabotulinum toxin reconstituted in lidocaine with epinephrine or in saline solution. This outcome is consistent with those of previous studies.

Keywords: BOTULINUM TOXINS, TYPE A; DILUTION; LIDOCAINE

INTRODUCTION: Raynaud's phenomenon (RP) is an exaggerated physiological response of the extremity vessels, mainly to cold and stress. Patients refractory to clinical treatment or intolerant to its adverse events may be treated with local injection of botulinum toxin (BTX).
OBJECTIVE: To describe the experience of botulinum toxin use in severe cases of RP.
METHODS: Observational, descriptive, retrospective, and unicenter study of case series of severe RP treated with BTX-A, from 2011 to 2015. Parameters of pain, numbness, color, and stiffness were scored by visual analogical scale (VAS) and tabulated and compared before and after the treatment.
RESULTS: Total pain improvement in 71.4% of cases and partial improvement in 28.6%. Numbness disappeared in 57.1% of cases and improvement in 42.9%. There was a total regression of stiffness in 57.1% of cases and partial improvement in 28.6%. The color was completely reversed in 57.1% of the patients. There was ulceration healing in the only case in with they were present. Ischemic attacks were reduced in 85,7% of cases. No complications occurred.
CONCLUSIONS: This study suggests that the use of BTX-A in patients with severe RP is a promising therapeutic option.

Keywords: Raynaud disease; Botulinum toxins; Botulinum toxins, type A

INTRODUCTION: Patients often request anti-aging treatments of the perioral and periorbital regions. Most of the time, it is necessary to use a combination of procedures, so the result meets the patient’s expectations.
OBJECTIVE: This is a prospective, single-center, and comparative study assessing the rejuvenation of the perioral and periorbital regions after treatment with medium depth chemical peel using phenol 88% with or without the previous application of botulinum toxin.
METHODS: Sixteen patients underwent regional peel with phenol 88%; eight received botulinum toxin application two weeks before. The assessment was conducted using standard photographs and evaluation scales by doctors and patients.
RESULTS: The overall evaluation by doctors and patients on the 45th day was considered excellent or good for all patients, with little advantage for combined treatment in the periorbital region.
CONCLUSION: Combining these two relatively low-cost procedures, often overlooked by dermatologists, resulted in a significant improvement in the changes related to aging in these areas.

Keywords: Botulinum toxins type A; Chemexfoliation; Phenol; Rejuvenation

INTRODUCTION: Facial erythema is a frequent and often distressing complaint in patients with rosacea. Botulinum toxin has been proposed as a treatment of facial erythema with relatively good results.
OBJECTIVE: This study aims to assess botulinum toxin’s safety and efficacy in a split-face trial in two different administration modalities: intradermal injections on one side of the face and facial electroporation on the other side.
MATERIALS AND METHODS: The trial enrolled 20 subjects aged between 25 and 75 years with erythematotelangiectatic rosacea. Subjects received five units of Botulinum toxin through intradermal injections on the right side of the face. The same amount was introduced through electroporation technique on the left side. We conducted the evaluation using a standardized erythema grading system (System Vectra) and digital photographs at baseline, 2, 6, and 12 weeks.
RESULTS: The effectiveness in reducing the erythema of botulinum toxin with both the injection and electroporation was evident from the second week and persisted until week 12. Both techniques were effective.
CONCLUSIONS: Intradermal injection of botulinum toxin and electroporation seems both effective and safe for treating erythema related to rosacea. The mechanism of action is still controversial.

Keywords: Erythema; Mesotherapy; Botulinum Toxins, Type A

Frontal fibrous alopecia is a primary lymphocytic scarring alopecia that is difficult to control, with a perifollicular lichenoid infiltrate marking its histology. Since its description in 1994 by Kossard, there has been an increase in cases reported worldwide. This article reports two cases that underwent incisional biopsies with longitudinal and transverse sections in areas presenting higher disease activity and reviews some aspects of this dermatosis. It also addresses the suspicion of a possible relationship with the application of botulinum toxin – a question already raised by other authors but with no established confirmation.

Keywords: Alopecia; Botulinum toxins; Botulinum toxins type A

BACKGROUND: The SARS-CoV-2 infection has spread worldwide rapidly since its identification at the end of 2019. Globally, until April 2021, there have been more than 150 million confirmed cases of Covid-19, including over 3 million deaths. Therefore, a race was promptly started to produce an effective vaccine against the new virus. Botulinum toxin injection remains the leading non-surgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction.
AIMS: This study aims to analyze the association between the SARS-CoV-2 vaccine and the immediate botulinum toxin response.
MATERIALS AND METHODS: This was an observational, retrospective, and multicenter study. Data were collected between April and June 2021, and a medical record review of 71 patients from 27 to 76 years old treated with botulinum toxin injection.
RESULTS AND CONCLUSION: There were no meaningful changes in the immediate outcome of patients vaccinated for Covid-19 and botulinum toxin. However, it is vital to underline that follow-up and further studies are needed to define whether the Covid-19 vaccine can alter the duration of effect and efficiency of the botulinum toxin.

Keywords: Covid-19; Botulinum toxins type A; Vaccination

Harlequin syndrome is a rare autonomic disorder characterized by anhidrosis and lack of unilateral flushing of the face, which may affect the cervical and thoracic regions. Paradoxically, there is compensatory flushing and sweating on the contralateral side to the alteration. It is idiopathic in most cases, but it can be congenital or secondary to structural or post-surgical iatrogenic lesions. Treatment is directed at the causative factor. We describe the case of a patient with a diagnosis of idiopathic Harlequin Syndrome with botulinum toxin application in the hemiface affected by compensatory symptoms with good therapeutic respons

Keywords: Hyperhidrosis; Blushing; Botulinum toxin type A

Notalgia Paresthetica (NP) is a sensory neuropathy characterized by itching, with or without a macule. The Botulinum Toxin A treatment may have beneficial effects on pruritus, possibly by inhibiting the substance P. This study aims to evaluate the benefits/limitations of Botulinum Toxin in NP treatment. The methodology consisted of the selection of publications in PubMed, filtered by predefined criteria. Five articles were compiled, and the results were favorable in four of them. The study concluded the effectiveness of Botulinum Toxin A treatment in most of the articles, especially in the pruritus improvement.

Keywords: Pruritus; Botulinum toxins type A; Hyperesthesia; Hyperpigmentation.