Beyond the needle: psychosocial and quality-of-life outcomes following facial aesthetic injectable treatments

Abstract

Background

Facial aesthetic injectables are commonly discussed through an anatomic and cosmetic lens. However, patients often seek treatment for reasons that exceed physical correction or enhancement, including confidence, social functioning, self-perception, and appearance-related distress.

Objective

To identify and critically appraise evidence evaluating psychological, social, and quality-of-life outcomes following single-modality, mixed/comparative, and multimodal facial aesthetic injectable treatments.

Methods

An evidence-based literature review was performed using PubMed, Ovid MEDLINE, and the Cochrane Library from January 2006 through June 2026. Eligible studies included adults undergoing facial aesthetic injectable treatments with botulinum toxin, hyaluronic acid fillers, biostimulatory or hybrid injectable fillers, platelet-rich plasma, polynucleotides/PDRN, or exosome-based injectables. Studies reporting psychological, social, self-esteem, appearance-related distress, social-perception, or quality-of-life outcomes were included. Studies were categorized by treatment modality and appraised using the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

Results

Thirty-one studies were included. Facial aesthetic injectables were generally associated with improvements in psychological, social, self-perception, appearance-related distress, social-perception, and quality-of-life outcomes. The strongest evidence was identified for single-modality botulinum toxin A, largely because of randomized controlled trials. Evidence for hyaluronic acid fillers, mixed/comparative injectable approaches, and multimodal treatments was generally positive but more heterogeneous.

Conclusions

Facial aesthetic injectables are associated with improvements in patient-reported psychosocial and quality-of-life outcomes, although the evidence remains heterogeneous. Emerging data also suggest favourable effects on observer-rated social perception. The proposed MOTIVE framework provides a pragmatic structure for integrating validated patient-reported outcome measures into routine aesthetic practice and warrants prospective evaluation.

Introduction

Facial ageing is a continuous process affecting all anatomical layers of the face, including the skin, fatty layers, muscles, connective tissues, and bone.¹ These changes alter facial shape, expression, and the emotions that the face projects, often referred to as the ageing phenotype.¹ The latter affects not only how the outside world perceives us but also how we perceive ourselves.^1,2 For this reason, aesthetic injectable treatments are not only requested to soften lines or restore volume. Many patients also describe a wish to look less tired, less severe, more rested, or more aligned with how they feel internally.^2,3

This distinction is clinically important. Traditional aesthetic outcomes have relied heavily on investigator grading scales, standardized photographs, and measures of wrinkle severity or volume correction. These tools are useful, but they do not fully capture the patient’s broader psychosocial experience.^4,5 A technically successful treatment may have limited value if it does not improve how a patient functions socially or perceives their appearance. Conversely, even subtle physical changes may have a meaningful effect on confidence, self-perception, and appearance-related distress.⁴

Patient-reported outcome measures have therefore become essential in aesthetic medicine. Instruments such as the FACE-Q, Facial Line Outcomes scales, Self-Perception of Age, Rosenberg Self-Esteem Scale, Dermatology Life Quality Index, and other condition-specific questionnaires attempt to measure the subjective dimensions of aesthetic care.^5,6 However, the literature remains scattered across different products, anatomic regions, study designs, and endpoints of nonsurgical and minimally invasive aesthetic procedures. Importantly, in 2024, nonsurgical procedures exceeded surgical procedures by >3 million treatments in aesthetic surgery practices, confirming their central role in contemporary aesthetic care. Injectable treatments with botulinum toxin and hyaluronic acid soft tissue fillers dominated the rankings.⁷ The objective of this review is to summarize the evidence for psychosocial and quality-of-life benefits after facial aesthetic injectable treatments and to compare single-modality, mixed, and multimodal treatment approaches.

Methods

This manuscript was designed as an evidence-based review using a BestBETs-informed strategy, rather than a formal systematic review, to evaluate the impact of facial aesthetic injectable treatments on the psychological, social, appearance-related distress, social-perception, and quality-of-life outcomes. BestBETs was originally developed to provide rapid access to the best available evidence on a broad range of clinically relevant questions encountered in day-to-day practice.⁸ As described by Quin (2001): “BestBETs represents a modified version of critically appraised topics (CATs)”.⁹ In keeping with this approach, an explicit search strategy was used, selected studies were organized into an evidence table, and included papers were critically appraised and narratively summarized.

Study quality and methodological critical appraisal

Included studies were ranked according to the Oxford Centre for Evidence-Based Medicine (OCEBM) Level of Evidence (LOE) and critically appraised using an adapted BestBETs-informed framework.¹⁰ Appraisal considered study design, comparator use, sample size, follow-up duration, validity of outcome measures, attrition, and potential funding-related bias. Formal risk-of-bias and GRADE assessments were not undertaken, as this review was designed to provide an evidence-based clinical synthesis rather than a formal systematic review. To facilitate the visualization of the study selection process, a PRISMA flow diagram was used (Fig. 1).

Fig. 1.

Prisma flow diagram. Study identification, screening, eligibility, and inclusion.

Search strategy

Following the BestBETs framework, an evidence-based, structured review of the literature was performed using PubMed, Ovid MEDLINE, and the Cochrane Library, including the Cochrane Database of Systematic Reviews and Central Register of Controlled Trials databases to screen for relevant papers. The search covered studies published from January 2006 through June 2026. Search terms combined concepts related to facial aesthetic treatment with injectables and psychological, social, self-perception, appearance-related distress, social-perception, and quality-of-life outcomes. Boolean operators were adapted for each database, and a full search strategy is provided in Supplementary Table A. Additional articles were identified manually from the reference lists of key studies and reviews.

Inclusion criteria

Studies were eligible for inclusion if they met the following criteria: adult participants; facial injectable treatment performed for aesthetic purposes; single-modality, mixed, comparative, or multimodal injectable interventions; and reporting of psychological, social, self-perception, confidence, self-esteem, appearance-related distress, social-perception, or quality-of-life outcomes. Outcomes could be patient-reported or observer-rated when they directly assessed psychosocial or interpersonal perceptions relevant to social functioning. Eligible interventions included botulinum toxin, hyaluronic acid soft tissue fillers, biostimulators or hybrid injectable fillers, platelet-rich plasma/PRP, polynucleotides/PDRN, exosome-based injectables and multimodal injectable protocols.

Mixed/comparative studies were defined as studies in which different treatments were compared or analyzed within the same cohort, whereas multimodal studies were defined as studies in which participants received a planned combination treatment protocol.

Exclusion criteria

Studies were excluded if they were animal studies, unrelated to the review topic, focused on injections for medical rather than aesthetic indications, or reported only technical efficacy, adverse events, treatment satisfaction, Global Aesthetic Improvement Scale outcomes, or appearance-appraisal outcomes without a psychological, social, social-perception, appearance-related distress, or quality-of-life endpoint. Commentaries, letters to the editor, opinion pieces, books, and book chapters were excluded. Non-English articles were excluded unless an English translation was available.

Results

Search outcome

The search generated a total of 687 records published between 2006 and June 2026: 172 from PubMed, 249 from Ovid MEDLINE and 266 from the Cochrane Library databases. After removal of 128 duplicates, 559 unique records were screened by title and abstract. Fifty full-text reports were assessed for eligibility, and four additional full-text reports were identified through reference checking, resulting in 54 full-text reports considered in total. Of these, thirty-one studies, reported across 33 publications, met the inclusion criteria and were included in the evidence review (Table 1).

Table 1.

Summary of the literature review.

Author, Year, Country	Patient Group	Intervention	Modality	Study Design	Psychosocial/QoL Outcome Measure	Key Results	Study Weaknesses	OCEBM LOE
Sun et al., 2026, China/Canada/ Taiwan	Adults with masseter muscle prominence (N = 376)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Phase 3 randomized, placebo-controlled trial	Lower facial shape/masseter PROs; psychosocial impact	Treatment improved patient-reported psychosocial impact and lower-face appearance outcomes.	Industry-sponsored; psychosocial outcomes secondary.	Level 2
Liew et al., 2026, Canada/Taiwan	Adults with lower facial shape concerns related to masseter prominence (N = 187)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Secondary analysis of phase 2 dose-escalation study	Lower Facial Shape Questionnaire; psychosocial impact	Treatment improved lower facial shape outcomes and psychosocial impact.	Secondary analysis; limited by parent study design.	Level 3
Humphrey et al., 2026, Canada/United States	Adults with platysma prominence (N = 164)	OnabotulinumtoxinA dose-ranging treatment	Single-modality injectable: BoNT-A	Phase 2 randomized, placebo-controlled dose-ranging study	ANLFQ Impacts; bother; treatment satisfaction	Treatment improved psychosocial impact and reduced bother compared with placebo.	Phase 2 dose-ranging study; descriptive multiplicity handling.	Level 2
Gold et al., 2025, United States/Canada	Adults with moderate-to-severe glabellar lines (N = 297)	RelabotulinumtoxinA ready-to-use liquid formulation	Single-modality injectable: BoNT-A	Phase 3 randomized controlled trial; PRO analysis	FACE-Q Psychological Function; FLTSQ; Natural Expressions Questionnaire	Psychological function improved more with active treatment than placebo.	PROs secondary; industry-sponsored.	Level 2
Shridharani et al., 2025, United States/Europe	Adults with platysma prominence (N = 381)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Phase 3 randomized, placebo-controlled trial	ANLFQ impacts; bother with vertical neck bands/jawline	Treatment improved psychosocial impact and reduced bother versus placebo.	Condition-specific PROs; industry-sponsored.	Level 2
Cox et al., 2024, United States/Europe	Adults with glabellar lines (N = 1272)	LetibotulinumtoxinA	Single-modality injectable: BoNT-A	Phase 3 randomized clinical trials; pooled PRO analysis	Psychological burden of glabellar lines; subject satisfaction	Treatment reduced psychological burden and improved subject satisfaction.	Industry-sponsored; psychosocial outcomes secondary.	Level 2
Dayan et al., 2022, United States	Adults with moderate-to-severe glabellar lines (N = 399)	Escalating-dose abobotulinumtoxinA	Single-modality injectable: BoNT-A	Randomized, dose-ranging clinical trial	Psychological well-being; subject satisfaction	Higher-dose treatment was associated with improved psychological well-being and satisfaction.	Dose-ranging design; industry-sponsored; short follow-up.	Level 2
Ascher et al., 2020, Europe	Adults with moderate-to-severe glabellar lines (N = 185)	Liquid abobotulinumtoxinA formulation	Single-modality injectable: BoNT-A	Phase 3 randomized controlled trial; FACE-Q secondary analysis	FACE-Q Psychological Well-Being; Facial Appearance; Aging Appearance	Psychological well-being improved significantly versus placebo through follow-up.	PROs were tertiary/secondary; industry-sponsored.	Level 2
Cohen et al., 2020, United States	Adults with glabellar lines (N = 60)	AbobotulinumtoxinA using two reconstitution volumes	Single-modality injectable: BoNT-A	Prospective comparative clinical study	Psychological well-being assessment	Psychological well-being improved after treatment.	Small study; limited comparator relevance; short follow-up.	Level 3
Keaney et al., 2020, United States	Male adults with horizontal forehead lines (N = 140)	OnabotulinumtoxinA for forehead lines	Single-modality injectable: BoNT-A	Clinical trial subgroup/PRO analysis	FLO-11 impact items including bother, looking older, and attractiveness	Men reported improvements in bother and appearance-related impact.	Subgroup-focused analysis; psychosocial outcomes secondary.	Level 2
Palm et al., 2020, United States	Millennial adults with horizontal forehead lines (N = 176)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Clinical trial subgroup/PRO analysis	FLO-11 impact domain; bother; self-esteem-related items	Millennials reported improved facial-line impact and reduced bother.	Subgroup analysis; limited generalizability; PROs secondary.	Level 2
Ogilvie et al., 2019, United States/Canada/ Ireland	Adults with moderate-to-severe forehead and glabellar lines (N = 391)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Phase 3 randomized, placebo-controlled study with open-label repeat treatment period	FLSQ; FLO-11	Treatment improved satisfaction and appearance-related psychological/emotional impacts versus placebo.	Industry-sponsored; PRO outcomes secondary; open-label repeat treatment period.	Level 2
Dayan et al., 2015, United States	Adults with crow's feet lines (N = 1362)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Randomized, placebo-controlled clinical trial	FLO-11; self-perception of age and appearance	Treatment improved facial-line impact and self-perceived appearance.	Secondary PRO analysis; industry-sponsored; short-term outcomes.	Level 2
Fagien et al., 2007, United States	Adults with glabellar rhytids (N = 70)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Double-blind, randomized, placebo-controlled trial	FLO questionnaire; patient-reported appearance impact	Treatment improved patient-reported bother and negative appearance perceptions.	Short follow-up; psychosocial outcomes focused on facial-line impact.	Level 2
Carruthers and Carruthers, 2007, Canada	Adults with upper facial lines (N = 40)	OnabotulinumtoxinA	Single-modality injectable: BoNT-A	Randomized, placebo-controlled trial with open-label extension	Facial Line Outcomes (FLO-7); Self-Perception of Age (SPA)	Treatment improved FLO-7 scores and reduced self-perceived age.	Industry-sponsored; short follow-up; PRO outcomes secondary.	Level 2
Michon and Hassan, 2022, Canada	Adults receiving facial HA filler treatment (N = 28)	Hyaluronic acid soft tissue fillers	Single-modality injectable: hyaluronic acid filler	Prospective observational clinical study	FACE-Q Psychological Function; Social Function; Appearance-related Psychosocial Distress	HA filler improved psychological function, social function, and appearance-related distress.	Nonrandomized; no untreated control; one-month follow-up.	Level 4
Beer et al., 2021, United States	Adults with chin retrusion/hypoplastic chin (N = 192)	VYC-20 L hyaluronic acid filler for chin augmentation	Single-modality injectable: hyaluronic acid filler	Randomized, controlled clinical trial	FACE-Q Psychological Well-Being; Satisfaction with Chin	Treatment improved FACE-Q psychological well-being and chin satisfaction versus baseline/control.	Industry-sponsored; psychosocial outcome secondary.	Level 2
Di Rosa et al., 2020, Italy	Adults undergoing nonsurgical rhinoplasty (N = 74)	Hyaluronic acid filler for nonsurgical rhinoplasty	Single-modality injectable: hyaluronic acid filler	Prospective observational study	Rhinoplasty Outcomes Evaluation questionnaire	ROE scores improved at 12 months, including social/professional limitation related to nasal appearance.	No control group; attrition; possible selection bias; psychiatric prescreening not clearly reported; granulomas reported.	Level 4
Matecka et al., 2020, Poland	Premenopausal and menopausal women receiving facial HA filler (N = 57)	Hyaluronic acid filler to cheeks and forehead	Single-modality injectable: hyaluronic acid filler	Prospective observational study	My Skin questionnaire; autonomy and well-being items	Patients reported improved facial appearance with associated improvements in autonomy and well-being.	Small sample, especially menopausal subgroup; no control group; nonvalidated questionnaire; selection and reporting bias.	Level 4
Ogilvie et al., 2019/2020, France/Germany/ Netherlands	Adults seeking chin/lower-face restoration (N = 132)	VYC-25 L hyaluronic acid injectable gel	Single-modality injectable: hyaluronic acid filler	Prospective multicenter randomized delayed-control study; long-term follow-up report	FACE-Q Satisfaction with Chin; Lower Face/Jawline; Psychological Well-Being	Psychological well-being improved at 3 months and remained improved through 12–18 months; repeat treatment produced further improvement.	Same cohort reported across two papers; open-label after delayed-control period; industry-sponsored.	Level 2
Dayan et al., 2019, United States	Women undergoing perioral rejuvenation with HA filler (N = 17)	Small-particle HA filler for perioral rejuvenation	Single-modality injectable: hyaluronic acid filler	Prospective, single-arm observational study	Subjective Happiness Scale; Happiness Measures Scale; First Impressions Questionnaire	Perioral filler improved one happiness measure and observer-rated first impressions, including social skills and other social-perception domains.	Small sample; no control group; unblinded treating investigator; short follow-up; some mood measures not significant.	Level 4
Few et al., 2015, United States	Adults with midface volume deficit (N = 235)	Hyaluronic acid filler for midface volume restoration	Single-modality injectable: hyaluronic acid filler	Multicenter, single-blind randomized controlled study	Look and Feel of the Midface; SPA	Patients reported improved look/feel of the midface and younger self-perceived age.	PROs mainly appearance/self-perception; comparator period limited.	Level 2
Dayan et al., 2026, United States	Adults receiving panfacial injectable treatment; analyzed video subset (N = 8)	OnabotulinumtoxinA and/or HA filler panfacial treatment	Mixed/ comparative injectable study	Prospective real-world observational study	Nonclinical observer social perception ratings; participant self-appraisal	Treatment improved observer-rated first impressions/social perceptions and participant self-appraisal.	Small sample; observational design; social-perception outcomes not traditional QoL.	Level 4
Camargo et al., 2024, Brazil	Women aged 40–60 with facial aging (N = 20)	PRP alone versus PRP plus volume-controlled ozone therapy	Mixed/ comparative injectable study	Randomized controlled pilot study	Rosenberg Self-Esteem Scale; FACE-Q satisfaction	Both protocols improved self-esteem and satisfaction measures.	Pilot sample; short follow-up; regenerative category differs from filler/toxin studies.	Level 2
McKeown, 2021, United Kingdom	Adults presenting for first-time facial injectable treatment (N = 35)	HA filler, BoNT-A, or both; majority treated with HA filler alone	Mixed/ comparative injectable study	Prospective single-center observational study	FACE-Q Psychological Function; Social Function; Appearance-related Psychosocial Distress	FACE-Q psychological function, social function, and appearance-related distress improved significantly two weeks after treatment.	Small single-center cohort; no untreated control; short follow-up; mixed interventions; 20 excluded from analysis.	Level 4
Carruthers et al., 2010, Canada/United States	Women with lower facial rejuvenation concerns (N = 90)	HA filler alone, onabotulinumtoxinA alone, or combination treatment	Mixed/ comparative injectable study	Randomized comparative clinical trial	Subject satisfaction; self-perception of age; look-and-feel outcomes	Combination treatment generally produced greater subjective improvements than either treatment alone.	Older PRO instruments; short follow-up; industry-sponsored.	Level 2
Rullan and Lee, 2023, United States	Patient with multiple medical comorbidities undergoing facial rejuvenation (N = 1)	Hyperdilute CaHA filler and BoNT-A treatment	Multimodal injectable treatment	Case report	FACE-Q Psychological Function; Appearance-related Psychosocial Distress; Aging Appraisal	Marked improvements in FACE-Q psychological function, appearance-related distress, and aging appraisal.	Single patient; very low-level evidence; no comparator.	Level 5
Weinkle et al., 2018, United States	Adults seeking panfacial aesthetic treatment (N = 100)	HA fillers, onabotulinumtoxinA, and bimatoprost	Multimodal injectable + adjunctive	Prospective, multicenter, rater-blinded HARMONY study	FACE-Q Social Confidence; Psychological Well-Being; SPA	Panfacial treatment improved social confidence, psychological well-being, and self-perceived age.	No untreated control; includes eyelash treatment; industry-sponsored.	Level 4
Dayan et al., 2018, United States	Women undergoing full facial rejuvenation (N = 20)	AbobotulinumtoxinA and HA filler plus topical skin regimen	Multimodal injectable + adjunctive	Randomized pilot study	State Self-Esteem Scale	Skin quality improved; self-esteem did not significantly differ over time or between groups.	Small pilot; topical skincare component; short follow-up.	Level 2
Molina et al., 2015, Europe	Adults receiving full-face rejuvenation (N = 60)	AbobotulinumtoxinA and HA fillers	Multimodal injectable treatment	Prospective, multicenter, open-label study	WHO-5 QoL; Heatherton-Polivy State Self-Esteem Scale	QoL and self-esteem improved significantly after full-face combination treatment.	Open-label; no untreated control; satisfaction-heavy endpoints.	Level 4
de Aquino et al., 2013, Brazil	Adults undergoing minimally invasive cosmetic procedures (N = 40)	BoNT-A and HA filler procedures	Multimodal injectable treatment	Prospective observational study	DLQI; Rosenberg Self-Esteem Scale	Quality of life and self-esteem improved after treatment.	No control group; limited treatment-specific attribution; short-to-medium follow-up.	Level 4

Included studies are grouped by treatment modality as follows: single-modality botulinum toxin, single-modality hyaluronic acid filler, mixed/comparative injectable studies, and multimodal injectable studies. Within each group, studies are ordered from most recent to oldest.

Abbreviations: BoNT-A, botulinum toxin type A; CaHA, calcium hydroxylapatite; DLQI, Dermatology Life Quality Index; FACE-Q, patient-reported outcome measure for facial aesthetics; FLO, Facial Line Outcomes questionnaire; FLTSQ, Facial Lines Treatment Satisfaction Questionnaire; HA, hyaluronic acid; LOE, level of evidence; OCEBM, Oxford Centre for Evidence-Based Medicine; PRP, platelet-rich plasma; PRO, patient-reported outcome; QoL, quality of life; SPA, Self-Perception of Age; WHO-5, World Health Organization-Five Well-Being Index.

The thirty-one included studies represented 6609 participants. Study size ranged from 1 to 1362 participants, with a median sample size of 100. Twenty-two studies were single-modality injectable studies, four were mixed or comparative injectable studies, and five were multimodal injectable studies. According to OCEBM levels, nineteen studies were Level 2, two were Level 3, nine were Level 4, and one was Level 5 evidence (Table 2).

Table 2.

Summary of included primary studies by OCEBM level of evidence.

OCEBM Level of Evidence	Number of Included Primary Studies
Level 2	19
Level 3	2
Level 4	9
Level 5	1

Note: Formal GRADE certainty ratings were not assigned because of heterogeneity in interventions, outcome measures, and study design.

Single-modality botulinum toxin type A studies

Fifteen studies evaluated botulinum toxin type A (BoNT-A) as a single-modality treatment.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 These studies included glabellar lines, horizontal forehead lines, crow’s feet lines, platysma prominence, and masseter prominence. Overall, the BoNT-A literature provided the largest and most methodologically robust portion of the evidence base. In several studies, psychosocial or quality-of-life outcomes were secondary or exploratory endpoints.

Across these studies, treatment was generally associated with improvements in patient-reported facial-line impact, psychological well-being, self-perceived age or appearance, bother, appearance-related emotional impact, or social-emotional impact.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 The newer trials evaluating platysma and masseter treatments are important because they extend the psychological outcome literature beyond traditional upper-face indications.11, 12, 13^,15 However, the interpretation remains cautious because many studies were industry-sponsored, used product-specific outcome instruments, and had short or protocol-defined follow-up.

Single-modality hyaluronic acid filler studies

Seven studies, reported across eight publications, evaluated hyaluronic acid filler as a single-modality treatment. These studies included chin and lower-face augmentation, midface volume restoration, nonsurgical rhinoplasty, perioral rejuvenation, and general facial filler treatment.^4,26, 27, 28, 29, 30, 31, 32 The HA filler literature was positive overall but more heterogeneous than the BoNT-A literature. Several studies used FACE-Q scales or other patient-reported tools to evaluate psychological function, social function, appearance-related distress, self-perceived age, subjective happiness, or social-perception outcomes.

The strongest HA filler evidence came from controlled or randomized treatment studies, particularly for chin, jawline, lower-face, and midface correction.^26,29,30,32 Observational studies also suggested improvements in psychological function, social functioning, autonomy, self-perception, well-being, and appearance-related distress.^27,28 However, HA filler studies were more commonly limited by a lack of untreated control groups, small sample sizes, short follow-up periods, and outcome measures that conflated satisfaction with broader psychosocial benefit.

Mixed and comparative injectable studies

Four studies evaluated mixed or comparative injectable approaches.33, 34, 35, 36 These studies included PRP alone versus PRP combined with ozone therapy, real-world cohorts receiving HA filler, onabotulinumtoxinA, or both, randomized comparison of HA filler alone, onabotulinumtoxinA alone, and combination treatment, and lastly panfacial injectable treatment with onabotulinumtoxinA and/or HA filler assessed through observer-rated social perception and participant self-appraisal outcomes. These studies are clinically relevant because real patients often receive different injectable modalities within the same treatment plan. However, the evidence remains limited because mixed cohorts make it difficult to attribute psychosocial improvement to one product or treatment mechanism.

Despite these limitations, the findings were supportive. Improvements were reported in self-esteem, FACE-Q psychological and social function, appearance-related distress, self-perceived age, subjective look-and-feel outcomes, observer-rated first impressions, and participant self-appraisal. Notably, the randomized comparative design of Carruthers et al. (2010) provided the most direct evidence that combining HA filler and onabotulinumtoxinA may produce broader patient-perceived benefits than either modality alone.³⁵ However, this finding should be interpreted with caution because the outcome instruments were older, the follow-up period was short, and the measures were not fully aligned with contemporary psychosocial PROMs.³

Multimodal injectable studies

Five studies, reported across six publications, evaluated multimodal injectable treatment.^6,37, 38, 39, 40, 41 These studies included panfacial or full-face treatment with combinations of HA fillers, BoNT-A, calcium hydroxylapatite, or other adjunctive non-injectable treatments, such as bimatoprost or topical skincare, and were interpreted separately. Multimodal injectable studies are important because full-face treatment may more closely reflect real-world aesthetic practice than single-area studies. This group also aligns with the biology of facial ageing, which rarely occurs within a single anatomic unit.¹

Most multimodal studies reported improvements in psychological function, social confidence, self-esteem, quality of life, self-perceived age, or appearance-related distress. However, study groups were not homogeneous. Several studies were open-label, uncontrolled, or small pilot studies, and one was a single-patient case report. Adjunctive treatments such as bimatoprost or topical skincare also make it difficult to isolate the independent contribution of injectables.^38,39 Therefore, the multimodal evidence is promising but should be interpreted as hypothesis-generating rather than definitive.

Discussion

The main finding of this review is that facial aesthetic injectable treatments are generally associated with improvements in patient-reported psychosocial and quality-of-life outcomes, with emerging evidence also supporting favourable observer-rated social-perception outcomes.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 The signal was observed across BoNT-A, HA fillers, mixed-injectable approaches, and multimodal treatments. The magnitude and durability of benefit cannot be compared directly because the studies used different endpoints, instruments, treatment areas, and follow-up intervals. Nevertheless, the direction of effect was generally consistent.

The evidence is strongest for BoNT-A.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 This does not necessarily mean that BoNT-A has a greater psychosocial effect than fillers or multimodal treatments. Rather, BoNT-A has been studied more often in larger randomized controlled trials, frequently in the setting of regulatory or product-development studies. These trials provide stronger internal validity but may not fully represent everyday aesthetic practice, where patients pay for treatment, receive individualized dosing, and often combine several modalities.

The HA filler literature supports a positive effect on psychological and social domains, especially when treatment addresses an area that strongly affects facial identity, such as the chin, lower face, nose, midface, or perioral region.^4,26, 27, 28, 29, 30, 31, 32 However, many HA studies rely on satisfaction, attractiveness, naturalness, or self-perceived appearance endpoints. These outcomes are relevant, but they are not interchangeable with psychological well-being or quality of life. Further studies should clearly distinguish aesthetic satisfaction from broader psychosocial health benefits.

The mixed and multimodal studies may be the most clinically intuitive, because facial ageing is multifactorial and most patients do not present with a single isolated concern.33, 34, 35, 36, 37, 38, 39, 40, 41 The available evidence suggests that treating the face more globally may improve social confidence, psychological function, and appearance-related distress. However, multimodal studies also introduce confounding. When several products, treatment areas, and adjunctive therapies are used together, it becomes difficult to determine which element produced the benefit. This does not weaken the clinical value of multimodal care, but it does limit the scientific attribution of effect.

Several recurring limitations were identified. Many studies were industry-sponsored, had short follow-up, used psychosocial endpoints as secondary outcomes, or lacked untreated controls. Some studies used non-validated questionnaires or instruments designed primarily around satisfaction. Many cohorts were small and included highly selected patients, which may not reflect the broader population seeking aesthetic care. In addition, baseline psychological vulnerability, body dysmorphic disorder or related traits, prior treatment history, treatment cost, and practitioner experience were inconsistently reported.

These limitations matter because aesthetic medicine sits at the intersection of appearance, self-perception, social interaction, and mental health. It would be too simplistic to conclude that injectables improve psychological health in all patients. The more defensible interpretation is that, in well-selected adult patients, facial aesthetic injectables can improve patient-reported outcomes and domains related to confidence, social function, appearance-related distress, self-perceived ageing, and quality of life. The benefit is likely context-dependent and may be influenced by patient selection, expectations, facial indication, treatment quality, and whether the measured outcome reflects true psychosocial function or satisfaction with appearance.

Clinical implications

Clinicians should recognize that the value of injectable treatment is not limited to visible correction. For many patients, the meaningful endpoint is how they feel and function after treatment. This supports the use of validated PROMs in aesthetic practice and research.^5,6 At the same time, clinicians should avoid overpromising psychological benefits. The literature supports a positive association, but it does not prove that injectables are a treatment for psychological distress.

Further studies should be designed around real clinical scenarios. Ideal studies would include pragmatic treatment plans, validated PROMs, longer follow-up periods, careful patient selection criteria, reporting of baseline psychological risk, and comparisons of single-area versus panfacial treatment strategies. Studies should also include patients who pay for treatment, because cost and expectations may meaningfully influence satisfaction and psychosocial outcomes.

Based on the findings of this review, we propose the MOTIVE framework (Fig. 2) as a pragmatic approach to incorporating psychosocial assessment into routine injectable practice. MOTIVE comprises six stages: Motivation; Objectives and expectations; Target psychosocial domain; Individualized treatment; Validation of the outcome using the same validated PROM; and Evaluation and evolution of the treatment plan based on aesthetic outcomes and patient-reported psychosocial change. The framework is not intended to replace validated screening tools or established PROMs. Rather, it provides clinicians with a simple structure for clarifying why treatment is being requested, defining what would constitute a meaningful psychosocial benefit for the patient, and determining whether that benefit was achieved. This approach may help move aesthetic outcome assessment beyond technical correction and satisfaction alone towards more comprehensive, patient-centred care.

Fig. 2.

Proposed MOTIVE framework for integrating psychosocial outcome assessment into facial aesthetic injectable practice. Motivation, objectives and expectations, and the target psychosocial domain are assessed before treatment. An individualized treatment plan is then delivered, followed by validation of the outcome using the same validated patient-reported outcome measure and evaluation of subsequent care. Within the MOTIVE framework, validation refers to structured reassessment of patient-reported change using a validated PROM. The framework is intended as a pragmatic clinical structure and has not undergone formal validation as a screening or psychometric instrument.

Limitations of this review

This review was evidence-based and followed a BestBETs-informed framework but was not designed as a systematic review or meta-analysis. Due to the studies' heterogeneity, pooling of the outcomes was not appropriate. Some relevant studies may have been missed despite the database and reference search strategies. The evidence table includes studies with variable quality of outcomes, and some reported psychosocial outcomes only as secondary or exploratory endpoints. The OCEBM level provides a useful hierarchy of study design but does not replace formal risk-of-bias assessment.

Conclusion

The available evidence suggests that facial aesthetic injectable treatments can improve patient-reported psychological, social, and quality-of-life outcomes in selected adult patients. The most robust evidence currently comes from BoNT-A studies, while HA filler, mixed/comparative injectable, and multimodal injectable studies provide a consistent but more heterogeneous signal. Emerging evidence also suggests that panfacial injectable treatment may favourably influence observer-rated social perception, although this remains preliminary. The field of aesthetic medicine would benefit from independent, pragmatic, longer-term follow-up studies that use validated facial aesthetic PROMs and clinically realistic treatment plans. Until then, the psychosocial benefits of aesthetic injectables should be presented as a meaningful, yet incompletely defined, dimension of care and an essential component of a holistic approach to aesthetic medicine. The proposed MOTIVE framework provides a pragmatic structure for integrating validated psychosocial PROMs into routine injectable practice and warrants prospective evaluation.

Ethics statement

This is an evidence-based review of published literature. No human or animal subjects were involved, and institutional review board approval was not required.

Data availability statement

No new datasets were generated or analyzed for this article. All data discussed are derived from previously published studies.

AI assistance disclosure

During the preparation of this work, the author used ChatGPT (OpenAI; GPT-5.6 Pro) to assist in generating the initial explanatory diagram for Fig. 2. The author subsequently reviewed, edited, and verified all output and takes full responsibility for the content of the published article.

Funding

No funding was received for the preparation of this manuscript.

Declaration of competing interest

Dr Alain Michon is a consultant for Allergan Aesthetics and SkinCeuticals. Given his role as a guest co-editor of the JPRAS Open Special Edition on Injectables, Dr Michon had no involvement in the peer review process of this article and had no access to information regarding its peer review. Full responsibility for the editorial process for this manuscript should be delegated to another journal editor.