Most common facial wrinkles effectively treated with botulinum toxin type A (Botox)
Glabellar frown lines, horizontal forehead lines, and lateral canthal “crow’s feet” are the most common and reliably correctable dynamic facial wrinkles with botulinum toxin type A. 1, 2
Primary, highest-yield targets (maximal benefit to quality of life/cosmesis; strongest evidence)
- Glabellar lines (corrugator/procerus) — FDA-approved; robust RCT/Cochrane data for efficacy and safety 1, 2
- Lateral canthal lines (“crow’s feet”) — FDA-approved; predictable improvement, high satisfaction 1, 2
- Horizontal forehead lines (frontalis) — common off-label but widely practiced with consistent benefit in dynamic rhytids 1, 2
Other commonly treated dynamic lines/areas (effective in experienced hands; augment when needed)
- “Bunny lines” (nasalis) 3, 4
- Perioral rhytids (orbicularis oris) and downturned oral commissures (DAO) 4, 3
- Mentalis “cobblestone” chin 4, 3
- Platysmal bands (neck) for contour-related lines 5, 3
- Adjacent aesthetic concerns often paired with wrinkle treatment: brow lift effect (frontalis/depressor balance), gummy smile, masseter hypertrophy (contour) 4, 5, 3
Evidence hierarchy and rationale
- Most recent, highest-quality synthesis: Cochrane Review (2021) confirms significant wrinkle reduction vs placebo, especially for glabellar lines; similar efficacy across leading BoNT-A brands; main serious AE risk is transient ptosis; effect ~3–5 months. This directly supports glabellar/crow’s-feet/forehead prioritization for predictable cosmetic QOL gains with low morbidity/mortality risk 1.
- Practice data show upper-face regions (glabella, forehead, crow’s feet) are most frequently treated, aligning with patient demand and safety/efficacy profile 6, 5.
- Clinical reviews emphasize FDA-approved cosmetic indications: glabella and crow’s feet; forehead lines are widely and effectively treated off-label in routine practice 2.
Pitfalls and how to avoid them
- Ptosis/eyebrow drop: avoid injecting too low into the frontalis or too medial/superior near the levator; use conservative dosing in small foreheads/heavy brows 1, 2.
- Static (etched) lines at rest respond less; consider staged BoNT-A with adjunct resurfacing/fillers if persistent 2.
- Perioral/mouth corner work: small, precise doses to prevent speech/eating asymmetry 3, 4.
- Neck bands: dose carefully to avoid dysphagia/voice weakness; prioritize mid-to-lower bands with superficial placement 3, 5.
Algorithm (practical)
- Start with upper-face triad (in priority order): glabella → crow’s feet → forehead for dynamic lines; reassess at 2–4 weeks; maintain every ~3–5 months based on response and AE profile 1, 2, 6.
- Add targeted areas (bunny lines, perioral, chin, platysma) if dynamic activity drives the wrinkle and patient desires additional improvement; use conservative, anatomically precise dosing to minimize diffusion-related AEs 3, 4.
Note: Botulism treatment guidelines and antitoxin data are not applicable to cosmetic wrinkle correction and are excluded from influencing this recommendation.