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 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).
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.
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.
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