Patient-Reported Aesthetic Outcomes of Botulinum Toxin Type A: A Systematic Review and Meta-Analysis of Placebo-Controlled Randomized Trials

Botulinum toxin type A (BoNT-A) is widely used for facial rejuvenation, but patient-perceived benefit is best evaluated against an inert control. This systematic review assessed whether BoNT-A, compared with placebo, vehicle, or saline placebo, improves aesthetic self-perception and related patient-reported outcomes. PubMed/MEDLINE, Embase, Scopus, Web of Science, and CENTRAL were searched from inception through September 25, 2026 using a sensitivity-oriented strategy. Randomized controlled trials in adults were eligible when they contained an extractable BoNT-A-versus-placebo contrast and a patient-reported aesthetic outcome. Seventy-five reports were retained: 70 contributed direct comparative evidence from 65 unique placebo-containing RCTs enrolling 18,581 participants across all randomized arms, and five linked reports were retained only for contextual mapping. Four clinically homogeneous responder subsets were quantitatively pooled; all favored BoNT-A, with pooled risk ratios ranging from 5.53 to 14.74 and I2=0% in each analysis. BoNT-A consistently improved treatment or appearance satisfaction, patient-rated facial-line severity or bother, perceived age/youthfulness, and selected appearance-related psychosocial outcomes. Overall RoB 2 was Low in 39/65 RCTs (60.0%) and Some concerns in 26/65 (40.0%). GRADE certainty was moderate for satisfaction/global aesthetic improvement, patient-reported facial-line severity/appearance appraisal, and perceived age/naturalness; low for appearance-related psychological well-being; and very low for general quality-of-life/self-esteem constructs. Placebo-controlled evidence supports a consistent patient-perceived aesthetic benefit of BoNT-A, while broader psychological and quality-of-life claims remain less certain.