3-Area Botulinum Toxin

What is 3-area botulinum toxin?

3-area botulinum toxin is the procedure in which three areas in the upper part of the face (the forehead, between the eyebrows and around the eyes) are addressed in the same session. Which areas are treated, and to what extent, is decided at the examination.

The substance used in this procedure, which is popularly known by a brand name, is botulinum toxin. Botulinum toxin is a prescription-only medicinal product for human use (opens in a new tab) that temporarily reduces the contraction of the muscle into which it is administered. Medicinal products for human use are placed on the market in Türkiye once a marketing authorisation has been granted; the procedure is carried out with an authorised product, within the terms of use in its authorisation, and by a physician.

The effect is temporary. How long it lasts varies according to the person, the area and the muscle structure; no duration can be given in advance.

The procedure is performed at the practice (opens in a new tab) by Dr. Suzan Alp, Specialist in Internal Medicine.

Which areas are assessed?

Assessing the three areas together does not mean that the procedure will be performed on all three. The muscles of these three areas balance one another; performing the procedure on one but not another may lead to an unwanted change in eyebrow position and in facial expression. Which areas the procedure is carried out on, and to what extent, is determined at the examination.

Which factors determine whether the procedure is suitable?

The decision on suitability is made at the end of the examination. The decisive factors in the assessment are:

• Muscle structure and muscle strength
• Eyebrow position
• Whether there is sagging or drooping of the eyelid
• Skin structure
• Whether the lines appear with movement, or whether they also remain when the face is at rest
• Whether any procedures have previously been carried out in the area; if so, their type and timing

The type of line is decisive. Lines that appear only with facial movement and lines that remain when the face is at rest are not assessed in the same way. In the latter case, the contribution expected from this procedure is limited.

In which patients is the procedure not performed?

• In patients with a disease affecting the neuromuscular junction (myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis and similar conditions)
• In pregnant and breastfeeding patients
• In patients under 18 years of age
• In patients with a history of allergy to the product to be used or to its components
• In patients with an infection, an open wound or an active skin disease at the site of the procedure

Situations that require separate assessment

• Muscle disease (an assessment by the relevant specialist physician is required)
• Use of medicines that affect neuromuscular transmission (aminoglycoside antibiotics, muscle relaxants and similar)
• Bleeding or clotting disorder, or use of blood-thinning or anticoagulant medicines
• Active infection or febrile illness (the procedure is postponed)
• Eyelid drooping or marked eyebrow drooping (a procedure in this area may make the condition more pronounced)
• A recent procedure in the same area (the timing is adjusted accordingly)
• Expectations beyond what the procedure can meet (these are discussed in detail before planning)

How is the procedure performed?

1. Assessment. Muscle structure and strength, together with eyebrow and eyelid position, are assessed; whether the lines appear with movement is determined. You will be asked about any history of neuromuscular disease, current medication, allergy history and previous procedures. Blood pressure and pulse are measured.
2. Product check. The authorisation status of the product to be used and its compliance with storage conditions are checked.
3. Information and consent. The physician explains, in writing and verbally, the procedure, the fact that the effect is temporary, the possibility of asymmetry and of eyebrow or eyelid drooping, and the possible side effects; a form is signed.
4. Preparation. The area must be free of make-up. It is then prepared with antiseptic.
5. Administration. The product is administered at the determined points with a fine needle.
6. Observation and follow-up. Vital signs and any observations are recorded in the file. A follow-up appointment is arranged, at which the outcome will be assessed.

All materials used are single-use.

When does the effect begin, and how long does it last?

The time it takes for the effect to appear varies from person to person; the full result is assessed between a few days and two weeks. The follow-up appointment is therefore planned for after this period has passed.

The effect is temporary, and how long it will last cannot be stated in advance. The duration varies according to the person, the area, muscle strength and the pattern of procedures. The timing of any repeat is determined at the follow-up.

What should you do before and after the procedure?

Before the procedure, report:

• A list of all the medicines and supplements you use (in particular blood thinners, painkillers and antibiotics)
• Your known allergies
• Any history of nerve or muscle disease
• Your pregnancy and breastfeeding status
• If this area has been treated before, the date of that procedure

Come with no make-up on the area.

After:

• The area must not be massaged or rubbed on the day of the procedure
• You are asked to avoid bending forward, keeping the head down for long periods and lying face down for the period specified
• Hot environments, saunas, sunbeds and intense exercise are avoided for a period
• Temporary raised bumps, redness and slight bruising may occur at the points of administration
• It is recommended that alcohol and products with a blood-thinning effect be avoided for a period

Recommendations and periods specific to you are given in writing at the end of the procedure.

Risks and side effects

General risks that may occur with any minor procedure

• Pain, redness, swelling and bruising
• Infection at the site of the procedure
• Headache
• Vasovagal syncope (fainting)

Risks related to the effect of the product used

• Eyebrow drooping and a change in eyebrow position
• Eyelid drooping
• Asymmetry (a different appearance across the areas treated)
• A change in facial expression; a greater reduction in facial movement than expected
• A feeling of heaviness or tightness in the forehead
• Allergic reaction
• Flu-like symptoms

These side effects are temporary; however, the time they take to resolve varies from person to person and may take weeks. It is not possible to reverse the effect of the botulinum toxin; when an unexpected outcome occurs, the effect of the product is expected to diminish.

Results vary from person to person.

When should you see a physician without delay?

If you experience these symptoms during treatment, contact your physician without delay:

• Drooping of the eyelid, or a change in vision
• Increasing redness, increased warmth, swelling or discharge at the site of the procedure
• A high fever
• Widespread rash, itching

In the event of difficulty swallowing, disturbance of speech, double vision, shortness of breath, widespread muscle weakness, or swelling of the lips or eyelids, go directly to the emergency department.

Frequently asked questions

Which areas does 3-area botulinum toxin cover?

It covers three areas in the upper part of the face: the forehead, between the eyebrows and around the eyes. Assessing the three together does not mean that the procedure will be performed on all three; which areas the procedure is carried out on, and to what extent, is determined at the examination.

Why are the three areas assessed together?

The muscles of these three areas balance one another. Performing the procedure on one but not another may lead to an unwanted change in eyebrow position and in facial expression. For this reason the three areas are assessed as a whole.

How long does the effect of botulinum toxin last?

The effect is temporary and its duration cannot be stated in advance. It varies according to the person, the area, muscle strength and the pattern of procedures. The timing of any repeat is determined at the follow-up consultation.

When will I see the result?

The time it takes for the effect to appear varies from person to person; the full result is usually assessed between a few days and two weeks. The follow-up appointment is planned for after this period has passed.

Will my facial expression be frozen after botulinum toxin?

A change in facial expression and a greater reduction in facial movement than expected are among the reported side effects. This possibility is discussed beforehand; going over expectations in detail is an important part of this procedure.

Will my eyebrow or my eyelid droop?

Eyebrow drooping and eyelid drooping are among the reported side effects. For this reason eyebrow and eyelid position are assessed before the procedure; if drooping is already present, the procedure is addressed separately.

Can botulinum toxin be reversed?

It is not possible to reverse the effect of the botulinum toxin. When an unexpected outcome occurs, the effect of the product is expected to diminish over time; this period varies from person to person.

My lines remain when my face is at rest; will botulinum toxin be enough?

Lines that appear only with facial movement and lines that remain when the face is at rest are not assessed in the same way. In the latter case, the contribution expected from this procedure is limited; which of the two applies is determined at the examination.

Is botulinum toxin carried out during pregnancy or breastfeeding?

No. The procedure is not carried out during pregnancy or breastfeeding. Please state whether you are pregnant or breastfeeding at the beginning of the consultation.

Sources

1. Ministry of Health of the Republic of Türkiye, Turkish Medicines and Medical Devices Agency, Beşeri Tıbbi Ürünler Ruhsatlandırma Yönetmeliği, Official Gazette 11 December 2021 / 31686. https://www.resmigazete.gov.tr/eskiler/2021/12/20211211-5.htm (opens in a new tab)
2. Ministry of Health of the Republic of Türkiye, Ayakta Teşhis ve Tedavi Yapılan Özel Sağlık Kuruluşları Hakkında Yönetmelikte Değişiklik Yapılmasına Dair Yönetmelik, Official Gazette 7 January 2025 / 32775. https://www.resmigazete.gov.tr/eskiler/2025/01/20250107-3.htm (opens in a new tab)