major complications.1,6 Furthermore, a recent randomized trial comparing three different BoNTA formulations in patients with synkinesis observed no major adverse events.4
Many facial muscles were treated that would not normally be included in aesthetic BoNTA procedures for non-palsy patients – such as zygomaticus major, risorius, levator labii superioris, depressor labii inferioris, and endopalpebral orbicularis oculi. Thus, a deep knowledge of the functional anatomy of the facial muscles is required. Furthermore, injection depth is crucial; some muscles must be treated at their deep origin, some at their cutaneous insertion, and others may potentially be treated at either (based on individual patient needs).
Following initial BoNTA treatment, each subsequent round of therapy should be adapted as required. Indeed, injection quantities in the two patients described here varied somewhat between sessions (Table 2). We noted that some asymmetries reduced in severity between sessions. For example, the chin area was always hyperactive and synkinetic, but showed a high degree of improvement even as the pharmacologic effect of BoNTA declined over time. We also attained sustained symmetrization of the eyebrows. Our findings align with previous data suggesting that BoNTA continues to be effective over multiple treatment sessions in patients with facial palsy.9
Both patients were extensively treated in the platysma to achieve a lifting and anti-aging effect within the lower third of the face. Normally, to obtain a lifting effect during non-palsy aesthetic treatment, we would reduce the action of the platysma, which has a depressive activity in its mandibular insertion, thereby fostering the antigravity effects of the muscles of the