Evaluation of people's satisfaction with botulinum toxin injection for facial rejuvenation based on age

Botulinum toxin type A injections are widely used for facial rejuvenation; however, research on people's satisfaction based on age is limited. This study assessed patient satisfaction with botulinum toxin injections for forehead, glabella, and periorbital wrinkles in Birjand, Iran.


| INTRODUC TI ON
A beautiful face is one of the factors influencing the level of satisfaction with life in humans, so rejuvenation and improving the beauty of the face has received more attention in recent years. 1 It seems that the availability of minimally invasive facial rejuvenation methods has increased this desire.The use of these measures leads to an increase in people's satisfaction with life and mental health. 2 Botulinum toxin injection to reduce facial wrinkles is currently one of the most common rejuvenation methods that has met with great success. 1 The effectiveness of botulinum toxin type A in the target tissue depends on various factors, including the type of botulinum toxin, the manufacturer company, the method of injection, age, physiological conditions of the patient, underlying diseases, etc. 3,4 The increase in satisfaction with the appearance and the improvement of mood after botulinum toxin type A has been shown previously. 5In addition, people's level of satisfaction with their facial appearance is a multifactorial phenomenon that is affected by several factors including public culture. 6For this reason, this study was designed and implemented to investigate the satisfaction of people who visit the plastic surgery clinic and the authors' offices in Birjand, Iran.

| MATERIAL S AND ME THODS
This study employed a descriptive-analytical approach to evaluate patient satisfaction and potential complications resulting from botulinum toxin type A injection.We concentrated on individuals aged between 18 and 70 years who opted for these injections in the forehead, glabella, or periorbital areas at the Birjand Plastic Surgery Clinic and the authors' offices between 2021 and 2022.Dr.

Ghoncheh and Dr. Ghasemian did the injections.
The inclusion criteria were people in the mentioned age range who wanted botulinum toxin injections.Exclusion criteria included the following: pregnant and lactating women, and the existence of any contraindications of botulinum toxin injection.A nonprobability sampling method yielded a total of 150 participants.These samples were selected consecutively from people who requested botulinum toxin injection for facial rejuvenation until reaching the number of 150 people.All participants were provided with a thorough explanation of the study's intent and methodology.After understanding, their informed consent was procured.To rejuvenate the frontal area, we did five-injection points for the glabellar folds and six-injection points for the forehead.Of course, these points differ according to whether people have long or short foreheads.So, in people with short foreheads, the total injection of the glabellar and forehead areas is done in nine points.The injection was performed to rejuvenate the periorbital area at three points in the external part of the orbit.The dose of botulinum toxin that we injected for each person according to the brand was as follows: Neuronox 50 units, Dysport 150 units, and Dyston and Masport 150 units each.The Facial Line Treatment Satisfaction (FTS) Questionnaire, developed by Cox et al. 7 in 2003 and translated into Farsi, was employed for satisfaction evaluation.Its reliability and validity were reported as 0.95 and 0.70, respectively.This two-part questionnaire began by capturing demographic details, the next section consists of 14 questions that assess satisfaction with the result of the injection in terms of smaller components.Clients responded to the questionnaire questions using a 7-point Likert scale ranging from very dissatisfied(1) to very satisfied (7).Information about the injected brand for each person was recorded.
We also included injection-related complications in a separate checklist.We classified the complications caused by the injection into these three categories: severe complications (eyelid drooping, eyebrow sagging, breathing issues, and muscle weakness), moderate complications (lower eyelid area swelling and facial deformities), and mild complications (bruises, skin reactions, and prolonged injection site swelling).
Post-injection, participants were scheduled for a 30-day follow-up.At this juncture, they filled in the FTS and complication questionnaires, reflecting on their satisfaction and any side effects experienced.Detailed notes on potential side effects were meticulously documented.
Data extracted from the questionnaires were processed using SPSS software.Descriptive statistics, including means, standard deviations, and frequencies, captured the study population's demographics, satisfaction metrics, and complication reports.For quantitative data assessment, the t-test was invoked for normally distributed data, and nonparametric tests including Mann-Whitney and Kruskal-Wallis tests catered to nonnormally distributed data.The mean satisfaction score for forehead and glabella injections was 46.42 + 10.1, with a median of 48 (IQR 43-52).For periorbital injections, the mean satisfaction score was 44.52 ± 9.28, with a median of 46 (IQR 40-51).

| RE SULTS
Table 1 shows the distribution of satisfaction levels among patients after receiving botulinum toxin injections in two primary facial regions: the forehead, glabella, and periorbital areas.In total, 88.7% of the patients were satisfied with the injections in the forehead area and 84% with injections in the periorbital area (the sum of the first three rows of the table).
Table 2 demonstrates the variation in satisfaction with botulinum toxin injections in different facial regions (frontal, glabella, and periorbital regions) across four groups (p < 0.001).There was a significant difference between the mean of the mentioned criteria in different age groups.So, the average score of the two criteria in the age group below 30 years and the age group 30-40 years was significantly higher than the age group above 50 years, and in the age group below 30 years was significantly more than the age group of 30-40 years (p < 0.05).
Table 3 shows the satisfaction of injection in both the forehead/ glabella and periorbital areas based on various brands.The test used to check this difference is the Kruskal-Wallis test.The mean score of satisfaction with injections in the forehead and periorbital region according to the brand of botulinum toxin had a statistically significant difference (p < 0.05).The average score of satisfaction in the Neuronox brand was significantly higher than the Masport and Dyston brands.Also, the average score of satisfaction with the injection in the periorbital area was higher in Neuronox than in the Dysport brand (p < 0.05).Data are presented as mean + standard deviation.The "c" notation indicates significant differences compared to Neuronox.Table 4 displays the significance of satisfaction of forehead and periorbital injections between patients receiving their first injection and those on their second or more injection.Previous injections may have been done by the authors of this article or other doctors, and in this case, no questions were asked.The mean of satisfaction with injection in new clients was significantly higher than that of clients who had repeated injections (p < 0.05).
Table 5 shows that the average score of satisfaction with injections in the forehead and periorbital areas were not significantly different from each other according to gender (p > 0.05).
Of the total participants, 62.7% (n = 94) experienced side effects, while 37.3% (n = 56) did not.The most common complication was bruising at the injection site with a frequency of 49 cases (32.7%).
Among the clients who reported side effects, the severity was categorized as severe for 30.7% (n = 46), moderate for 40.7% (n = 61), and mild for 39.3% (n = 59).Table 6 provides a comparative overview of the number and percentage of patients experiencing side effects versus those who did not.

| DISCUSS ION
The current study examined patient satisfaction of botulinum toxin injection in the forehead and periorbital areas.The results demonstrate high satisfaction levels among patients receiving this cosmetic procedure, although some key factors like age and brand selection impacted outcomes.
The most common age group of clients was 30-40 years with a frequency of 69 cases (46%).In the study of Parviz et al., 8 the age group of 35-50 years and then the age group of 20-35 years were the most common age groups who wanted botulinum toxin injection, which was consistent with our study.In the study by Kabodi et al., 9 most of the people who wanted injections were in the age group of 35-50 years old, which was consistent with our study.It seems that with the appearance of facial wrinkles at the age of 30-40, the demand for botulinum toxin injection increases in this age group.
After 40 and to a greater extent after 50 years old, due to the decrease in people's satisfaction with botulinum toxin injections (which we will explain later), the amount of demand will decrease.
Forty of the clients were male (26.7%) and 110 (73.3%) were female.The gender distribution of our study was also consistent with the study by Parviz et al. 8 and the study by Kabodi et al. 9 In our study, it was found that women are still more willing to inject botulinum toxin, although studies show that men's willingness to use these methods is increasing. 10 the present study, the overall level of satisfaction of the patients (the sum of the three options: somewhat satisfied, satisfied, and very satisfied) was significant.So, 88.7% of the patients were satisfied with the result of botulinum toxin injection in the forehead/glabella area, and 84% of the patients were satisfied with the injection in the periorbital area.The satisfaction rates found in this study align with previous research indicating botulinum toxin injections yield high levels of patient satisfaction. 11,12 important finding was the difference in the level of satisfaction with injections in different age groups.Satisfaction ratings were significantly higher for those under 30 and 30-40 versus those over 50 years old.The study by Iozzo et al. 13 investigated the effects of botulinum toxin injections on facial aesthetics.The study found that younger people experienced complete wrinkle removal, while older people experienced partial improvement.In our opinion, this effect may be due to higher or more unrealistic expectations of the elderly.Also, physiological factors such as a decrease in skin elasticity 14   trary to our study and concluded that satisfaction with botulinum toxin injection is higher in older people. 15We think that this difference is probably due to differences in the type of questionnaires and differences in the researcher's view of satisfaction.So, in our study and the study of Iozzo et al., the FTS Cox questionnaire has been used and similar results have been obtained, but Chang 15 and his colleagues have used the FACE-Q questionnaire to check people's satisfaction and have reached a different result.However, it seems that there is a need for more comprehensive studies to investigate the relationship between age and the level of satisfaction with botulinum toxin injection.Communicating realistic outcomes and addressing expectations is vital when treating older patients to maximize satisfaction.We believe that at older ages and especially over 50 years of age, to achieve a desirable aesthetic result, it may be necessary to combine botulinum toxin injection with other rejuvenation methods such as hyaluronic acid gel injection.Some studies also confirm our opinion. 16,17ere was a significant difference in the average score of satisfaction with injections in the forehead/glabella and periorbital area according to the brand of botulinum toxin (p < 0.05).Significantly higher satisfaction emerged for the Neuronox brand over competitors Masport and Dyston for both facial sites.At the beginning of the study, it was decided that the distribution of the brands should be symmetrical as much as possible so that it is possible to compare between the brands.However, since clients were free to choose the brand, the number of cases of the Neuronox brand was less than that of other brands.Therefore, although this difference is statistically significant, due to the small number of Neuronox brands in our study, it does not seem to be reliable.In their study, Chang 15 and his colleagues did not find a statistically significant relationship between the level of satisfaction of people with different types of botulinum toxin.
An interesting result was the comparable satisfaction between first-time and second-and more-time clients.In their study about reinjection of botulinum toxin to remove the lines of the upper part of the face, Rzany et al. 18 found that these repeated injections did not cause a decrease in satisfaction.Of course, in their study, 57.5% of people, in addition to injecting botulinum toxin, also used another cosmetic method.This decrease in satisfaction among second-time clients of our study can be justified by the same decrease in terms of age groups, but it may need further studies.
Although 94 patients (62.7%) had complications, in most cases, these complications were mild, so injection site bruising was the most common complication with 47 cases (32.7%).In a meta-analysis study, Zargran D et al. estimated the complications caused by botulinum toxin injection in the forehead and glabella area to be about 16%.The authors have stated that in different articles, researchers' views on complications are different.This has caused the number of complications reported in different studies to be diverse, and an accurate comparison is not possible.In their study, headache and skin reactions were the most common side effects. 19None of our clients had permanent or life-threatening complications that required hospitalization or special care.Proper injection methods, sterile technique, and an experienced clinician can help further reduce side effects.Realistic pretreatment counseling on potential side effects is also advocated to avoid diminishing patient satisfaction.
muscle in the elderly, the medial part of the eyebrow becomes droopier, and during the first days and weeks, the faces of these people look frowning.The results of Chang et al.'s study are con-

Satisfaction level Forehead and glabella (percentage, n) Periorbital (percentage, n)
The mean score of satisfaction by age groups.
TA B L E 1 Distribution of satisfaction level for botulinum toxin injection.TA B L E 2a Significance difference with the age group of 50 years and older.bSignificance difference with the age group under 30 years old.
Patient satisfaction of injection by botulinum toxin brand.The mean score of satisfaction by age and gender.
and an increase in facial soft tissue sagging in old age can reduce the aesthetic results of botulinum toxin injection.In our experience, with paralysis of the frontal TA B L E 3 a Significance difference with the Neuronox brand.