Share this article on:

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

Awaida, Cyril J., M.D.; Jabbour, Samer F., M.D.; Rayess, Youssef A., M.D.; El Khoury, Joseph S., M.D.; Kechichian, Elio G., M.D.; Nasr, Marwan W., M.D.

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 640–649
doi: 10.1097/PRS.0000000000004695
Cosmetic: Original Articles
Discussion
Editor's Pick

Background: Microbotox consists of the injection of microdroplets of botulinum 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 preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, 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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Beirut, Lebanon

From the Departments of Plastic and Reconstructive Surgery 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 Lower Face Rejuvenation,” ClinicalTrials.gov registration number NCT03189082 (https://clinicaltrials.gov/ct2/show/NCT03189082).

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

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Cyril J. Awaida, M.D., Faculty of Medicine, Saint-Joseph University, Hotel Dieu de France Hospital, Bonjus Street, 1st Floor, Khoueiry Building, Fanar, Lebanon, cyrilawaida@gmail.com

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 platysmal bands and horizontal cervical rhytides are caused by either muscle hyperactivity or loss of 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 popularity.6 , 8–11 In 2007, Levy introduced the concept of the “Nefertiti lift,” which consisted of injecting 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 helpful in younger patients with platysmal hyperactivity 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 superficially into the dermis.14 Initially called “mesobotox,” 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 satisfactory results.13 , 14 However, no clinical trial evaluated the effect of the microbotox technique on the different lower face and neck aging components or compared it to the Nefertiti procedure. The objective of this crossover clinical trial is to evaluate the safety and efficacy of the microbotox technique using validated scores and to compare it to the Nefertiti lift.

Back to Top | Article Outline

PATIENTS AND METHODS

Patient Recruitment

Ethical approval was obtained from the Institutional Review Board of Hotel Dieu de France Hospital, Beirut, Lebanon. All participating 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.

Back to Top | Article Outline

Microbotox Preparation and Technique

We 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 mandibular 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, Supplemental Digital Content 1, which demonstrates the microbotox technique for lower face and neck rejuvenation. This video illustrates the microbotox solution preparation along with a demonstration 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.)

Fig. 1

Fig. 1

Video

Video

Back to Top | Article Outline

Evaluation of Results

Preinjection and postinjection photographs were taken by the same photographer in a studio with consistent camera settings, lens, seating position, and lighting. Patients were photographed in four views: frontal and lateral both at rest and with platysmal contraction. Postinjection 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 was cropped to match the photonumeric scale pictures, randomized, and placed on a separate 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 improvement in the overall appearance of the lower face and neck.21 Also, each patient was given a questionnaire 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 willingness to repeat the procedure and to recommend 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 microbotox method as their preferred method for neck rejuvenation.

Back to Top | Article Outline

RESULTS

In 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, statistical 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 contraction, 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 technique 8 months earlier, we found a tendency for improvement of jowls, neck volume, marionette lines, and oral commissures, but only the platysmal 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 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 (Table 2 and Fig. 2).

Table 1

Table 1

Table 2

Table 2

Fig. 2

Fig. 2

When comparing preinjection and postinjection photographs, the raters reported an improvement in 84 percent of patients for the microbotox technique compared to 93.3 percent for the Nefertiti technique (Fig. 3).

Fig. 3

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 preoperative and postoperative photographs and using the Subjects Global Aesthetic Improvement Score, 100 percent of the 25 patients rated themselves as improved after both the microbotox and the Nefertiti techniques (Fig. 4). One hundred percent of the 25 patients were satisfied 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 member 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 neck rejuvenation, 18 patients chose the microbotox technique, five preferred the Nefertiti lift, and two had no preferences.

Fig. 4

Fig. 4

Fig. 5

Fig. 5

Back to Top | Article Outline

DISCUSSION

This prospective crossover trial is the first to compare the Nefertiti lift to the microbotox technique for neck and lower face rejuvenation. Different 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 underlying neck and lower face silhouette, improving the jowls, the neck volume, and the cervicomandibular angle (Figs. 6 and 7). In contrast, the Nefertiti technique failed to improve soft-tissue ptosis.

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Even though the improvement of the platysmal bands at contraction was statistically significant 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 contraction 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).

Fig. 8

Fig. 8

Fig. 9

Fig. 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.

Fig. 10

Fig. 10

Most of the patients preferred the microbotox 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 hyperactivity and minor tissue ptosis and neck skin laxity. Therefore, we believe that the choice of the injection technique should be tailored to the patient’s preferences and aging pattern. Nonsurgical candidates 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 combination of both techniques. The most critical step in the nonsurgical management is determining the patient’s aesthetic concern. Some patients seeking lower face and neck rejuvenation request correction 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 predominant platysmal hyperactivity and minor soft-tissue ptosis should be counseled to undergo the Nefertiti 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 Nefertiti technique.13 Thus, selecting the proper technique for each patient is crucial when treating the aging neck and lower face with botulinum toxin (Fig. 11).

Fig. 11

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 swallowing difficulties. With a mean dose of 124 U in the Nefertiti technique, one patient reported dysphagia and neck muscle weakness that lasted 2 weeks. With the microbotox technique, we used higher 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. Nevertheless, 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 platysmal 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 components. 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 injected 8 months apart to make any residual effect insignificant.

Back to Top | Article Outline

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. The practitioner must address specific patient concerns and establish a treatment plan based on his or her clinical appreciation of the patient’s neck.

Back to Top | Article Outline

REFERENCES

1. Friedman O. Changes associated with the aging face. Facial Plast Surg Clin North Am. 2005;13:371–380.
2. Sattler G, Carruthers A, Carruthers J, et al. Validated assessment scale for neck volume. Dermatol Surg. 2012;38:343–350.
3. Brandt FS, Boker A. Botulinum toxin for rejuvenation of the neck. Clin Dermatol. 2003;21:513–520.
4. Wang TD. Rhytidectomy for treatment of the aging face. Mayo Clin Proc. 1989;64:780–790.
5. Dayan SH, Bagal A, Tardy ME Jr. Targeted solutions in submentoplasty. Facial Plast Surg. 2001;17:141–149.
6. Matarasso A, Matarasso SL. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg. 2003;112(Suppl):138S–140S.
7. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. 1998;101:473–481.
8. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg. 1999;103:656–663; discussion 664665.
9. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: Botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies. Consensus recommendations. Plast Reconstr Surg. 2008;121(Suppl):5S–30S; quiz 31S36S.
10. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower face. Dermatol Surg. 2003;29:477–483; discussion 483.
11. Spósito MM. New indications for botulinum toxin type A in treating facial wrinkles of the mouth and neck. Aesthetic Plast Surg. 2002;26:89–98.
12. Levy PM. The ‘Nefertiti lift’: A new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9:249–252.
13. Jabbour SF, Kechichian EG, Awaida CJ, Tomb RR, Nasr MW. Botulinum toxin for neck rejuvenation: Assessing efficacy and redefining patient selection. Plast Reconstr Surg. 2017;140:9e–17e.
14. Wu WT. Microbotox of the lower face and neck: Evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(Suppl):92S–100S.
15. Rose AE, Goldberg DJ. Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin. Dermatol Surg. 2013;39:443–448.
16. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore size. J Drugs Dermatol. 2008;7:847–850.
17. Narins RS, Carruthers J, Flynn TC, et al. Validated assessment scales for the lower face. Dermatol Surg. 2012;38:333–342.
18. Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale for marionette lines. Dermatol Surg. 2008;34(Suppl 2):S167–S172.
19. Gupta S, Biskup N, Mattison G, Leis A. Development and validation of a clinical assessment tool for platysmal banding in cervicomental aesthetics of the female neck. Aesthet Surg J. 2015;35:NP141–NP146.
20. Geister TL, Bleßmann-Gurk B, Rzany B, Harrington L, Görtelmeyer R, Pooth R. Validated assessment scale for platysmal bands. Dermatol Surg. 2013;39:1217–1225.
21. Dubin AE, Patapoutian A. Nociceptors: The sensors of the pain pathway. J Clin Invest. 2010;120:3760–3772.
22. Treede RD, Meyer RA, Raja SN, Campbell JN. Peripheral and central mechanisms of cutaneous hyperalgesia. Prog Neurobiol. 1992;38:397–421.
23. Kassir R, Kolluru A, Kassir M. Triple-blind, prospective, internally controlled comparative study between abobotulinumtoxinA and onabotulinumtoxinA for the treatment of facial rhytids. Dermatol Ther (Heidelb.) 2013;3:179–189.

Supplemental Digital Content

Back to Top | Article Outline
©2018American Society of Plastic Surgeons