evaluation of the microbotox technique: an algorithmic ... · plastic and reconstructive surgery...

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

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Age-related changes of the neck are caused by excessive skin laxity, subcutaneous fat atrophy, herniation of adipose tissue, and

resorption of mandibular height.1–3 Fat and soft-tissue descent result in oral commissure ptosis, jowl and marionette line formation, and loss

of the mandibular contour.1,4,5 Vertical platys-mal bands and horizontal cervical rhytides are caused by either muscle hyperactivity or loss of

Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

Copyright © 2018 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000004695

Cyril J. Awaida, M.D.Samer F. Jabbour, M.D.Youssef A. Rayess, M.D.

Joseph S. El Khoury, M.D.Elio G. Kechichian, M.D.

Marwan W. Nasr, M.D.

Beirut, Lebanon

Background: Microbotox consists of the injection of microdroplets of botu-linum toxin into the dermis to improve the different lower face and neck aging components. No clinical trial has evaluated its effect on the different face and neck components and no study has compared it to the “Nefertiti lift” procedure.Methods: In this crossover study, patients previously treated with the Nefertiti lift were injected using the microbotox technique. Using standardized prein-jection and postinjection photographs, the jowls, marionette lines, oral com-missures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated.Results: Twenty-five of the 30 patients previously treated with the Nefertiti technique were injected with a mean dose of 154 U using the microbotox technique. Platysmal bands with contraction, jowls, and neck volume reached a statistically significant improvement. The microbotox technique improved the jowls and the neck volume more than the Nefertiti technique, whereas the platysmal bands at rest and with contraction were more improved by the Nefertiti technique. One hundred percent of patients were satisfied with both techniques and rated themselves as improved.Conclusions: The microbotox technique is a useful, simple, and safe procedure for lower face and neck rejuvenation. It is mainly effective in treating neck and lower face soft-tissue ptosis, in contrast to the Nefertiti technique, which is more effective on platysmal bands. (Plast. Reconstr. Surg. 142: 640, 2018.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

From the Departments of Plastic and Reconstructive Sur-gery and Dermatology, Faculty of Medicine, Saint-Joseph University.Received for publication October 5, 2017; accepted March 29, 2018.This trial is registered under the name “Microbotox for Low-er Face Rejuvenation,” ClinicalTrials.gov registration num-ber NCT03189082 (https://clinicaltrials.gov/ct2/show/NCT03189082).

Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and Neck Rejuvenation and a Crossover Clinical Trial

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COSMETIC

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Volume 142, Number 3 • Microbotox for Lower Face Rejuvenation

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tone.6,7 Surgery used to be the only available treatment for the aging lower face and neck; however, today, noninvasive procedures such as botulinum toxin injections are gaining in popu-larity.6,8–11 In 2007, Levy introduced the concept of the “Nefertiti lift,” which consisted of inject-ing botulinum toxin deep into the platysmal bands and the inferior border of the mandible.12 In a previous clinical trial, we found that the Nefertiti lift was effective and particularly help-ful in younger patients with platysmal hyper-activity and retained skin elasticity.13 Another widely used lower face and neck rejuvenation procedure is the “microbotox” technique, which was first described by Wu in 2015. Microdroplets of diluted botulinum toxin were injected super-ficially into the dermis.14 Initially called “meso-botox,” this technique specifically targeted the sebaceous and sweat glands and the superficial fibers of the facial muscles.15,16 Both the deep intramuscular Nefertiti lift and the superficial intradermal microbotox injections showed satis-factory results.13,14 However, no clinical trial eval-uated the effect of the microbotox technique on the different lower face and neck aging compo-nents or compared it to the Nefertiti procedure. The objective of this crossover clinical trial is to evaluate the safety and efficacy of the microbo-tox technique using validated scores and to com-pare it to the Nefertiti lift.

PATIENTS AND METHODS

Patient RecruitmentEthical approval was obtained from the

Institutional Review Board of Hotel Dieu de France Hospital, Beirut, Lebanon. All partici-pating patients gave informed written consent. In a previous study, we injected 30 patients with abobotulinumtoxinA along the inferior border of the mandible and into the platysmal bands.13 This study was designed to assess the efficacy of the Nefertiti lift in the treatment of the aging neck. These 30 patients were contacted 8 months later and asked to participate in the present study.

Microbotox Preparation and TechniqueWe used the same technique described by

Wu.14 A 500-unit vial of abobotulinumtoxinA (Dysport; Ipsen Ltd, Berks, United Kingdom) was reconstituted with normal saline to a final concentration of 70 U/ml. Two or three 1-ml syringes of 70 U each were used per patient

depending on the neck size. Injections were performed into the superficial dermis using 30-gauge needles. A good injection depth was defined by a small blanched bleb and resistance to injection. Approximately 150 injections were delivered over the entire anterior neck in an area bounded by a line drawn 5 cm above the man-dibular border superiorly, a vertical line 1 cm posterior to the depressor anguli oris medially, the anterior border of the sternocleidomastoid muscle posteriorly, and the upper border of the clavicle inferiorly (Fig. 1). (See Video, Supple-mental Digital Content 1, which demonstrates the microbotox technique for lower face and neck rejuvenation. This video illustrates the microbo-tox solution preparation along with a demonstra-tion of the injection technique, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/C909.)

Evaluation of ResultsPreinjection and postinjection photographs

were taken by the same photographer in a stu-dio with consistent camera settings, lens, seating position, and lighting. Patients were photo-graphed in four views: frontal and lateral both at rest and with platysmal contraction. Postinjec-tion photographs were taken 15 days after the procedure.

Validated photonumeric scales were used to assess the oral commissures,17 marionette lines,18 jowls,17 neck volume,2 platysmal bands at rest,19 and platysmal bands at maximal contraction.20 Each preinjection and postinjection photograph

Fig. 1. Microbotox injections are delivered intradermally using a 30-gauge needle raising a small blanched weal at each point. The area injected corresponds to the extent of the platysma muscle.

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Plastic and Reconstructive Surgery • September 2018

was cropped to match the photonumeric scale pictures, randomized, and placed on a sepa-rate scoring sheet. Each scoring sheet was then independently assessed by three blinded raters (one dermatologist and two plastic surgeons). In addition, the Investigator Global Aesthetic Improvement Scale was used to assess improve-ment in the overall appearance of the lower face and neck.21 Also, each patient was given a ques-tionnaire including a Subject Global Aesthetic Improvement Score, a satisfaction survey (1, very satisfied; 2, satisfied; 3, dissatisfied; and 4, very dissatisfied) and questions about their will-ingness to repeat the procedure and to recom-mend it to a friend. The pain associated with the injections was assessed by the participants using a visual analogue scale ranging from 0 to 10. At the 15-day follow-up visit, patients were asked to choose between the Nefertiti lift and the micro-botox method as their preferred method for neck rejuvenation.

RESULTSIn total, 25 of the 30 patients injected 8

months earlier with the Nefertiti technique were included in this trial. Five patients were lost to follow-up or did not want to participate in the microbotox study. All included patients were women with a mean age ± SD of 55.9 ± 5.8 years. Nine were smokers (36 percent). The mean dose of abobotulinumtoxinA used per patient was 154 ± 28.6 U.

In the microbotox phase of the trial, statisti-cal analysis of regional scores of the lower face and neck indicated a tendency for improvement of platysmal bands at rest and marionette lines; however, only the platysmal bands with contrac-tion, jowls, and neck volume reached a statistically significant improvement. There was no change in the oral commissure scores. When these same 25 patients were injected using the Nefertiti tech-nique 8 months earlier, we found a tendency for improvement of jowls, neck volume, marionette

Table 1. Primary Endpoint: Region-Specific Scores*

Preinjection

ScorePostinjection

Score p

Nefertiti injection technique

Jowls 1.8 1.8 1 Platysmal bands with

contraction 2.9 0.64 <0.0001† Platysmal bands at rest 1.0 0.56 0.022† Marionette lines 1.4 1.28 0.3466 Neck volume 1.9 1.8 0.3872 Oral commissures 1.3 1.2 0.3043Microbotox injection

technique Jowls 1.8 1.16 <0.0001† Platysmal bands with

contraction 2.9 1.6 <0.0001† Platysmal bands at rest 1.0 0.88 0.6269 Marionette lines 1.4 1.28 0.3466 Neck volume 1.9 1.52 0.0008† Oral commissures 1.3 1.32 0.7698*Statistical analysis was performed with IBM SPSS Advanced Statisti-cal Software Version 22.0 (IBM Corp., Armonk, N.Y.). Preinjection and postinjection scores were compared using a dependent t test. †Statistically significant (p < 0.05).

Video. Supplemental Digital Content 1 demonstrates the micro-botox technique for lower face and neck rejuvenation. This video, illustrating the microbotox solution preparation along with a dem-onstration of the injection technique, is available in the “Related Vid-eos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C909.

http://links.lww.com/PRS/C909



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lines, and oral commissures, but only the platys-mal bands at rest and with contraction reached a statistically significant improvement (Table 1). When comparing the region-specific scores of these two techniques, we found that the microbo-tox technique improved the jowls and the neck vol-ume more than the Nefertiti technique, whereas the platysmal bands at rest and with contraction were more improved by the Nefertiti technique (Table 2 and Fig. 2).

When comparing preinjection and postinjec-tion photographs, the raters reported an improve-ment in 84 percent of patients for the microbotox

technique compared to 93.3 percent for the Nefertiti technique (Fig. 3).

The mean pain from injection reported on a visual analogue scale was 4.6 ± 2.3 for the microbotox technique compared to 0.6 ± 2.3 for the Nefertiti technique. When comparing pre-operative and postoperative photographs and using the Subjects Global Aesthetic Improve-ment Score, 100 percent of the 25 patients rated themselves as improved after both the microbo-tox and the Nefertiti techniques (Fig. 4). One hundred percent of the 25 patients were satis-fied with their results after both the microbotox and the Nefertiti techniques (Fig. 5). Twenty-two patients (88 percent) were willing to repeat the microbotox technique, compared to 25 (100 percent) with the Nefertiti procedure. Twenty-two patients (88 percent) would recommend the microbotox technique to a friend/family mem-ber and 25 (100 percent) would recommend the Nefertiti procedure. Three patients had injection-point ecchymosis with the microbotox technique compared with six patients using the Nefertiti technique. They lasted a couple of days. No patients reported any dysphagia or muscle weakness with the microbotox technique. Only one patient reported mild dysphagia, which lasted 2 weeks, with the Nefertiti lift technique. When asked about their preferred technique for

Table 2. Comparison of the Results of Both Techniques for the Region-Specific Scores*

Nefertiti Postinjection

Score

Microbotox Postinjection

Score p

Jowls 1.8 1.16 0.0011†Platysmal bands with

contraction 0.64 1.6 <0.0001†Platysmal bands at rest 0.56 0.88 0.0026†Marionette lines 1.28 1.28 1Neck volume 1.8 1.52 0.0054†Oral commissures 1.2 1.32 0.0788*Statistical analysis was performed with IBM SPSS Advanced Statisti-cal Software Version 22.0 (IBM Corp., Armonk, N.Y.). Postinjection scores of both the Nefertiti and the microbotox techniques were compared using a dependent t test. †Statistically significant (p < 0.05).

Fig. 2. Preinjection and postinjection scores. Jowls and neck volume were most improved with the microbotox injec-tion technique, whereas platysmal bands at rest and with contraction were most improved with the Nefertiti injec-tion technique. *Statistically significant.


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neck rejuvenation, 18 patients chose the micro-botox technique, five preferred the Nefertiti lift, and two had no preferences.

DISCUSSIONThis prospective crossover trial is the first to

compare the Nefertiti lift to the microbotox tech-nique for neck and lower face rejuvenation. Dif-ferent components of the aging lower face and

neck are targeted by the two different injection techniques. We hypothesize that the microbotox technique produces a skin-tightening effect by weakening the superficial fibers of the platysma muscle. By paralyzing the superficial platysma fibers, it allows the skin to conform to the underly-ing neck and lower face silhouette, improving the jowls, the neck volume, and the cervicomandibu-lar angle (Figs. 6 and 7). In contrast, the Nefertiti technique failed to improve soft-tissue ptosis.

Fig. 3. Investigators Global Aesthetic Improvement Scores (IGAIS) for the microbotox injection technique: raters reported an improvement in 84 percent of patients when showed the preinjec-tion and postinjection photographs.

Fig. 4. Subject Global Aesthetic Improvement Scores (SGAIS) for the microbotox injection tech-nique: 100 percent of patients reported improvement when shown the preinjection and post-injection photographs.



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Even though the improvement of the platys-mal bands at contraction was statistically signifi-cant with the microbotox technique, most patients presented 15 days after treatment with varying degrees of residual banding. Also, there was no improvement of the platysmal bands at rest. In contrast, the platysmal bands at rest and contrac-tion improved significantly with the Nefertiti lift. We believe that the deep fibers of the platysma remained active with the microbotox injections in comparison with the Nefertiti technique, where the deep platysma fibers were paralyzed. Thus, the microbotox modality for neck rejuvenation was more effective on soft-tissue ptosis but less effective on platysmal bands compared with the Nefertiti technique (Figs. 8 and 9).

Both the physicians and the patients noticed an improvement of the skin texture with the intradermal injection of the botulinum toxin (Fig. 10). However, this effect was not evaluated in this trial.

Most of the patients preferred the micro-botox technique, as they were seeking the skin-tightening and soft-tissue–lifting effects. The five patients that preferred the Nefertiti technique were thin patients with major platysmal hyperac-tivity and minor tissue ptosis and neck skin laxity. Therefore, we believe that the choice of the injec-tion technique should be tailored to the patient’s preferences and aging pattern. Nonsurgical can-didates and patients requesting noninvasive neck and lower face treatment can be treated with botulinum toxin injections using the microbotox

technique, the Nefertiti technique, or a combina-tion of both techniques. The most critical step in the nonsurgical management is determining the patient’s aesthetic concern. Some patients seek-ing lower face and neck rejuvenation request cor-rection of the jowling and neck skin ptosis/laxity, whereas others desire platysmal band relaxation. The patient’s demand should also be guided by the practitioner. Thin patients with a predomi-nant platysmal hyperactivity and minor soft-tissue ptosis should be counseled to undergo the Nefer-titi technique, whereas patients with predominant soft-tissue ptosis should be advised to undergo the microbotox technique. Patients requesting an overall neck and lower face improvement should receive microbotox injections into the anterior neck to enhance the cervicomental contour and redefine the mandibular border. At the 2-week follow-up, each residual platysmal band should then be injected with a vertical series of two to four points 2 cm apart as described in the Nefer-titi technique.13 Thus, selecting the proper tech-nique for each patient is crucial when treating the aging neck and lower face with botulinum toxin (Fig. 11).

Superficial microbotox injections preclude unwanted diffusion of the toxin into the deep neck structures, minimizing adverse events such as dysphonia, neck muscle weakness, and swallow-ing difficulties. With a mean dose of 124 U in the Nefertiti technique, one patient reported dyspha-gia and neck muscle weakness that lasted 2 weeks. With the microbotox technique, we used higher

Fig. 5. Patient satisfaction for the microbotox injection technique: 100 percent of patients were satisfied with the results.


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doses of abobotulinumtoxinA (154 U) without adverse events.

The mean level of pain during the microbotox injection was higher than with the Nefertiti lift. In fact, pain receptors are found in the dermis, making superficial injections more painful.21,22 Wu found that diluting the solution with lidocaine decreased the periprocedural pain level. Never-theless, both techniques were associated with high satisfaction rates.

Six patients had injection-point ecchymosis with the Nefertiti technique, compared with three patients with the microbotox technique. This is probably because the Nefertiti lift injections are

delivered deeper into the well-vascularized platys-mal muscle. All of the ecchymosis disappeared in a couple of days.

Botulinum toxin may have a different onset of action on skin and muscle. Maximal muscle paralysis has been shown to occur at 2 weeks after injection.23 However, no studies have assessed the onset of action of the toxin on the skin and its different compo-nents. In this study, patients were evaluated 2 weeks after injection, at the peak of the paralytic effect.

A randomized controlled trial would have eliminated any residual effect from the previous injections of the Nefertiti lift technique. However, in this prospective crossover trial, patients were

Fig. 6. Frontal views of a 58-year-old patient before lower face treatment (above, left), 15 days after the Nefertiti lift (above, center), and 15 days after the injection of a total of 140 U of abobotulinumtoxinA with the microbotox technique into the lower face and neck (above, right). Note the improvement of mandibular contour, jowls, and marionette lines with the microbotox technique. Lateral views of the patient before the procedure (below, left), 15 days after the Nefertiti lift (below, center), and 15 days after the microbotox technique (below, right). Note the improvement of the cervicomental angle and soft-tissue ptosis with the microbotox technique.

Fig. 7. Lateral views of a 57-year-old patient before botulinum toxin injections (left), 15 days after the Nefertiti lift (center), and 15 days after injection of 140 U of abobotulinumtoxinA with the microbotox technique (right). Note the improvement of the cervico-mental contour with the microbotox technique.



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injected 8 months apart to make any residual effect insignificant.

CONCLUSIONSThe microbotox technique is a useful, sim-

ple, and safe procedure for lower face and neck

rejuvenation. It is mainly effective in treating neck and lower face soft-tissue ptosis, in contrast to the Nefertiti technique, which is more effective on platysmal bands. The practitioner must address specific patient concerns and establish a treat-ment plan based on his or her clinical apprecia-tion of the patient’s neck.

Fig. 9. Frontal views of a 59-year-old patient with maximal contraction of the platysma before the procedures (left), 15 days after the Nefertiti lift using 125 U of abobotulinumtoxinA (center), and 15 days after the microbotox injections (right). Note the persis-tence of platysmal banding after the microbotox technique.

Fig. 10. Frontal views of a 55-year-old patient before (left) and 15 days after injection of a total of 140 U of abobotulinumtoxinA (right). Note the improvement of skin texture.

Fig. 8. Lateral views of a 53-year-old patient before the procedures (left), 15 days after the Nefertiti lift using 105 U of abobotu-linumtoxinA (center), and 15 days after the microbotox injections with 210 U of abobotulinumtoxinA (right). Note the improve-ment of the neck volume and the cervicomental angle with the microbotox technique. The Nefertiti technique failed to improve soft-tissue ptosis.


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Cyril J. Awaida, M.D.Faculty of Medicine

Saint-Joseph UniversityHotel Dieu de France Hospital

Bonjus Street, 1st Floor, Khoueiry BuildingFanar, Lebanon

[email protected]

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Fig. 11. Algorithm for lower face and neck rejuvenation.

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