Abstract
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Background: Hypertrophic and unesthetic scarring remains a major concern in aesthetic and dermatologic
practice. Conventional measures such as silicone or corticosteroids show inconsistent benefit and lack standardized protocols. Botulinum toxin A (BoNT-A) has emerged as an adjunct through muscle relaxation and fibroblast modulation. This review evaluates its efficacy, safety, and patient-reported outcomes in surgical and traumatic scars, with specific focus on timing, dose, and anatomical site as key clinical modifiers.
Methods: This review followed PRISMA 2020 and was registered in PROSPERO. MEDLINE, Embase, Cochrane, and Clinical Trials.gov were searched through September 2025. Eligible studies included RCTs or prospective comparative trials evaluating peri- or early postoperative BoNTA in adults. Primary outcomes were scar quality using validated scales. Secondary outcomes included patient satisfaction, pruritus, pain, and adverse events. Timing, dose, and anatomical site were assessed as effect modifiers within dermatologic dosing ranges.
Results: Sixteen studies with 456 patients were included. BoNT-A consistently improved scar quality at 3-6 months and enhanced overall skin characteristics. Observer-rated scales showed improvements in pigmentation, pliability, vascularity, and texture, with reduced hypertrophy. Patients reported greater satisfaction, less pain and pruritus, and visible decreases in redness. Scar scales showed benefit in 6/7 VSS and 4/5 mSBSES trials, with 5/7 reporting
narrower scars. Improvements were most pronounced in cosmetically sensitive
regions (face, neck, hands) and in keloid-prone areas (chest, shoulders, jawline). Early administration and higher dosing in high-tension sites yielded superior results. Reported adverse events were mild, transient, and limited to local erythema or ecchymosis, with no serious complications.
Conclusion: BoNT-A improves scar cosmesis and patient outcomes with a favorable safety profile. Timing, dose, and anatomical site are modifiable factors that optimize efficacy, positioning BoNT-A as a practical, evidence-based adjunct in both aesthetic and dermatologic practice. Standardized protocols are essential for broader clinical adoption.
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