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COSMETIC

Evaluation of the Microbotox Technique:


An Algorithmic Approach for Lower
Face and Neck Rejuvenation and
a Crossover Clinical Trial
Cyril J. Awaida, M.D.
Background: Microbotox consists of the injection of microdroplets of botu-
Samer F. Jabbour, M.D.
linum toxin into the dermis to improve the different lower face and neck
Youssef A. Rayess, M.D.
aging components. No clinical trial has evaluated its effect on the different
Joseph S. El Khoury, M.D. face and neck components and no study has compared it to the “Nefertiti lift”
Elio G. Kechichian, M.D. procedure.
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Marwan W. Nasr, M.D. Methods: In this crossover study, patients previously treated with the Nefertiti
Beirut, Lebanon 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
L- 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.

A
ge-related changes of the neck are caused of the mandibular contour.1,4,5 Vertical platys-
by excessive skin laxity, subcutaneous fat mal bands and horizontal cervical rhytides are
atrophy, herniation of adipose tissue, and caused by either muscle hyperactivity or loss of
resorption of mandibular height.1–3 Fat and soft-
tissue descent result in oral commissure ptosis,
jowl and marionette line formation, and loss Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
From the Departments of Plastic and Reconstructive Sur- external funding was received.
gery and Dermatology, Faculty of Medicine, Saint-Joseph
University.
Received for publication October 5, 2017; accepted March Supplemental digital content is available for
29, 2018. this article. Direct URL citations appear in the
This trial is registered under the name “Microbotox for Low- text; simply type the URL address into any Web
er Face Rejuvenation,” ClinicalTrials.gov registration num- browser to access this content. Clickable links
ber NCT03189082 (https://clinicaltrials.gov/ct2/show/ to the material are provided in the HTML text
NCT03189082). of this article on the Journal’s website (www.
Copyright © 2018 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000004695

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Volume 142, Number 3 • Microbotox for Lower Face Rejuvenation

tone.6,7 Surgery used to be the only available depending on the neck size. Injections were
treatment for the aging lower face and neck; performed into the superficial dermis using
however, today, noninvasive procedures such as 30-gauge needles. A good injection depth was
botulinum toxin injections are gaining in popu- defined by a small blanched bleb and resistance
larity.6,8–11 In 2007, Levy introduced the concept to injection. Approximately 150 injections were
of the “Nefertiti lift,” which consisted of inject- delivered over the entire anterior neck in an area
ing botulinum toxin deep into the platysmal bounded by a line drawn 5 cm above the man-
bands and the inferior border of the mandible.12 dibular border superiorly, a vertical line 1 cm
In a previous clinical trial, we found that the posterior to the depressor anguli oris medially,
Nefertiti lift was effective and particularly help- the anterior border of the sternocleidomastoid
ful in younger patients with platysmal hyper- muscle posteriorly, and the upper border of the
activity and retained skin elasticity.13 Another clavicle inferiorly (Fig. 1). (See Video, Supple-
widely used lower face and neck rejuvenation mental Digital Content 1, which demonstrates the
procedure is the “microbotox” technique, which microbotox technique for lower face and neck
was first described by Wu in 2015. Microdroplets rejuvenation. This video illustrates the microbo-
of diluted botulinum toxin were injected super- tox solution preparation along with a demonstra-
ficially into the dermis.14 Initially called “meso- tion of the injection technique, available in the
botox,” this technique specifically targeted the “Related Videos” section of the full-text article
sebaceous and sweat glands and the superficial on PRSJournal.com or, for Ovid users, available
fibers of the facial muscles.15,16 Both the deep at http://links.lww.com/PRS/C909.)
intramuscular Nefertiti lift and the superficial
intradermal microbotox injections showed satis- Evaluation of Results
factory results.13,14 However, no clinical trial eval- Preinjection and postinjection photographs
uated the effect of the microbotox technique on were taken by the same photographer in a stu-
the different lower face and neck aging compo- dio with consistent camera settings, lens, seating
nents or compared it to the Nefertiti procedure. position, and lighting. Patients were photo-
The objective of this crossover clinical trial is to graphed in four views: frontal and lateral both
evaluate the safety and efficacy of the microbo- at rest and with platysmal contraction. Postinjec-
tox technique using validated scores and to com- tion photographs were taken 15 days after the
pare it to the Nefertiti lift. procedure.
Validated photonumeric scales were used to
assess the oral commissures,17 marionette lines,18
PATIENTS AND METHODS jowls,17 neck volume,2 platysmal bands at rest,19
Patient Recruitment and platysmal bands at maximal contraction.20
Each preinjection and postinjection photograph
Ethical 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 Technique


We used the same technique described by
Wu.14 A 500-unit vial of abobotulinumtoxinA
(Dysport; Ipsen Ltd, Berks, United Kingdom) Fig. 1. Microbotox injections are delivered intradermally using
was reconstituted with normal saline to a final a 30-gauge needle raising a small blanched weal at each point.
concentration of 70 U/ml. Two or three 1-ml The area injected corresponds to the extent of the platysma
syringes of 70 U each were used per patient muscle.

641
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Plastic and Reconstructive Surgery • September 2018

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.

was cropped to match the photonumeric scale In the microbotox phase of the trial, statisti-
pictures, randomized, and placed on a sepa- cal analysis of regional scores of the lower face
rate scoring sheet. Each scoring sheet was then and neck indicated a tendency for improvement
independently assessed by three blinded raters of platysmal bands at rest and marionette lines;
(one dermatologist and two plastic surgeons). however, only the platysmal bands with contrac-
In addition, the Investigator Global Aesthetic tion, jowls, and neck volume reached a statistically
Improvement Scale was used to assess improve- significant improvement. There was no change
ment in the overall appearance of the lower face in the oral commissure scores. When these same
and neck.21 Also, each patient was given a ques- 25 patients were injected using the Nefertiti tech-
tionnaire including a Subject Global Aesthetic nique 8 months earlier, we found a tendency for
Improvement Score, a satisfaction survey (1, improvement of jowls, neck volume, marionette
very satisfied; 2, satisfied; 3, dissatisfied; and 4,
very dissatisfied) and questions about their will-
Table 1. Primary Endpoint: Region-Specific Scores*
ingness to repeat the procedure and to recom-
mend it to a friend. The pain associated with the Preinjection Postinjection
Score Score p
injections was assessed by the participants using
a visual analogue scale ranging from 0 to 10. At Nefertiti injection
technique
the 15-day follow-up visit, patients were asked to Jowls 1.8 1.8 1
choose between the Nefertiti lift and the micro- Platysmal bands with
botox method as their preferred method for contraction 2.9 0.64 <0.0001†
Platysmal bands at rest 1.0 0.56 0.022†
neck rejuvenation. Marionette lines 1.4 1.28 0.3466
Neck volume 1.9 1.8 0.3872
Oral commissures 1.3 1.2 0.3043
RESULTS Microbotox injection
technique
In total, 25 of the 30 patients injected 8 Jowls 1.8 1.16 <0.0001†
months earlier with the Nefertiti technique were Platysmal bands with
included in this trial. Five patients were lost to contraction 2.9 1.6 <0.0001†
Platysmal bands at rest 1.0 0.88 0.6269
follow-up or did not want to participate in the Marionette lines 1.4 1.28 0.3466
microbotox study. All included patients were Neck volume 1.9 1.52 0.0008†
women with a mean age ± SD of 55.9 ± 5.8 years. Oral commissures 1.3 1.32 0.7698
Nine were smokers (36 percent). The mean *Statistical analysis was performed with IBM SPSS Advanced Statisti-
cal Software Version 22.0 (IBM Corp., Armonk, N.Y.). Preinjection
dose of abobotulinumtoxinA used per patient and postinjection scores were compared using a dependent t test.
was 154 ± 28.6 U. †Statistically significant (p < 0.05).

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Volume 142, Number 3 • Microbotox for Lower Face Rejuvenation

Table 2. Comparison of the Results of Both technique compared to 93.3 percent for the
Techniques for the Region-Specific Scores* Nefertiti technique (Fig. 3).
Nefertiti Microbotox
The mean pain from injection reported
Postinjection Postinjection on a visual analogue scale was 4.6 ± 2.3 for the
Score Score p microbotox technique compared to 0.6 ± 2.3 for
Jowls 1.8 1.16 0.0011† the Nefertiti technique. When comparing pre-
Platysmal bands with operative and postoperative photographs and
contraction 0.64 1.6 <0.0001†
Platysmal bands at rest 0.56 0.88 0.0026† using the Subjects Global Aesthetic Improve-
Marionette lines 1.28 1.28 1 ment Score, 100 percent of the 25 patients rated
Neck volume 1.8 1.52 0.0054† themselves as improved after both the microbo-
Oral commissures 1.2 1.32 0.0788
tox and the Nefertiti techniques (Fig. 4). One
*Statistical analysis was performed with IBM SPSS Advanced Statisti-
cal Software Version 22.0 (IBM Corp., Armonk, N.Y.). Postinjection
hundred percent of the 25 patients were satis-
scores of both the Nefertiti and the microbotox techniques were fied with their results after both the microbotox
compared using a dependent t test. and the Nefertiti techniques (Fig. 5). Twenty-
†Statistically significant (p < 0.05).
two patients (88 percent) were willing to repeat
the microbotox technique, compared to 25 (100
lines, and oral commissures, but only the platys- percent) with the Nefertiti procedure. Twenty-
mal bands at rest and with contraction reached two patients (88 percent) would recommend the
a statistically significant improvement (Table 1). microbotox technique to a friend/family mem-
When comparing the region-specific scores of ber and 25 (100 percent) would recommend
these two techniques, we found that the microbo- the Nefertiti procedure. Three patients had
tox technique improved the jowls and the neck vol- injection-point ecchymosis with the microbotox
ume more than the Nefertiti technique, whereas technique compared with six patients using the
the platysmal bands at rest and with contraction Nefertiti technique. They lasted a couple of days.
were more improved by the Nefertiti technique No patients reported any dysphagia or muscle
(Table 2 and Fig. 2). weakness with the microbotox technique. Only
When comparing preinjection and postinjec- one patient reported mild dysphagia, which
tion photographs, the raters reported an improve- lasted 2 weeks, with the Nefertiti lift technique.
ment in 84 percent of patients for the microbotox When asked about their preferred technique for

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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Plastic and Reconstructive Surgery • September 2018

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.

neck rejuvenation, 18 patients chose the micro- neck are targeted by the two different injection
botox technique, five preferred the Nefertiti lift, techniques. We hypothesize that the microbotox
and two had no preferences. technique produces a skin-tightening effect by
weakening the superficial fibers of the platysma
muscle. By paralyzing the superficial platysma
DISCUSSION fibers, it allows the skin to conform to the underly-
This prospective crossover trial is the first to ing neck and lower face silhouette, improving the
compare the Nefertiti lift to the microbotox tech- jowls, the neck volume, and the cervicomandibu-
nique for neck and lower face rejuvenation. Dif- lar angle (Figs. 6 and 7). In contrast, the Nefertiti
ferent components of the aging lower face and technique failed to improve soft-tissue ptosis.

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Volume 142, Number 3 • Microbotox for Lower Face Rejuvenation

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

Even though the improvement of the platys- technique, the Nefertiti technique, or a combina-
mal bands at contraction was statistically signifi- tion of both techniques. The most critical step in
cant with the microbotox technique, most patients the nonsurgical management is determining the
presented 15 days after treatment with varying patient’s aesthetic concern. Some patients seek-
degrees of residual banding. Also, there was no ing lower face and neck rejuvenation request cor-
improvement of the platysmal bands at rest. In rection of the jowling and neck skin ptosis/laxity,
contrast, the platysmal bands at rest and contrac- whereas others desire platysmal band relaxation.
tion improved significantly with the Nefertiti lift. The patient’s demand should also be guided by
We believe that the deep fibers of the platysma the practitioner. Thin patients with a predomi-
remained active with the microbotox injections in nant platysmal hyperactivity and minor soft-tissue
comparison with the Nefertiti technique, where ptosis should be counseled to undergo the Nefer-
the deep platysma fibers were paralyzed. Thus, titi technique, whereas patients with predominant
the microbotox modality for neck rejuvenation soft-tissue ptosis should be advised to undergo
was more effective on soft-tissue ptosis but less the microbotox technique. Patients requesting an
effective on platysmal bands compared with the overall neck and lower face improvement should
Nefertiti technique (Figs. 8 and 9). receive microbotox injections into the anterior
Both the physicians and the patients noticed neck to enhance the cervicomental contour and
an improvement of the skin texture with the redefine the mandibular border. At the 2-week
intradermal injection of the botulinum toxin follow-up, each residual platysmal band should
(Fig. 10). However, this effect was not evaluated then be injected with a vertical series of two to
in this trial. four points 2 cm apart as described in the Nefer-
Most of the patients preferred the micro- titi technique.13 Thus, selecting the proper tech-
botox technique, as they were seeking the skin- nique for each patient is crucial when treating the
tightening and soft-tissue–lifting effects. The five aging neck and lower face with botulinum toxin
patients that preferred the Nefertiti technique (Fig. 11).
were thin patients with major platysmal hyperac- Superficial microbotox injections preclude
tivity and minor tissue ptosis and neck skin laxity. unwanted diffusion of the toxin into the deep
Therefore, we believe that the choice of the injec- neck structures, minimizing adverse events such
tion technique should be tailored to the patient’s as dysphonia, neck muscle weakness, and swallow-
preferences and aging pattern. Nonsurgical can- ing difficulties. With a mean dose of 124 U in the
didates and patients requesting noninvasive neck Nefertiti technique, one patient reported dyspha-
and lower face treatment can be treated with gia and neck muscle weakness that lasted 2 weeks.
botulinum toxin injections using the microbotox With the microbotox technique, we used higher

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Plastic and Reconstructive Surgery • September 2018

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.

doses of abobotulinumtoxinA (154 U) without delivered deeper into the well-vascularized platys-
adverse events. mal muscle. All of the ecchymosis disappeared in
The mean level of pain during the microbotox a couple of days.
injection was higher than with the Nefertiti lift. Botulinum toxin may have a different onset of
In fact, pain receptors are found in the dermis, action on skin and muscle. Maximal muscle paralysis
making superficial injections more painful.21,22 Wu has been shown to occur at 2 weeks after injection.23
found that diluting the solution with lidocaine However, no studies have assessed the onset of action
decreased the periprocedural pain level. Never- of the toxin on the skin and its different compo-
theless, both techniques were associated with high nents. In this study, patients were evaluated 2 weeks
satisfaction rates. after injection, at the peak of the paralytic effect.
Six patients had injection-point ecchymosis A randomized controlled trial would have
with the Nefertiti technique, compared with three eliminated any residual effect from the previous
patients with the microbotox technique. This is injections of the Nefertiti lift technique. However,
probably because the Nefertiti lift injections are in this prospective crossover trial, patients were

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Volume 142, Number 3 • Microbotox for Lower Face Rejuvenation

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.

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.

injected 8 months apart to make any residual rejuvenation. It is mainly effective in treating neck
effect insignificant. and lower face soft-tissue ptosis, in contrast to the
Nefertiti technique, which is more effective on
platysmal bands. The practitioner must address
CONCLUSIONS specific patient concerns and establish a treat-
The microbotox technique is a useful, sim- ment plan based on his or her clinical apprecia-
ple, and safe procedure for lower face and neck tion of the patient’s neck.

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Plastic and Reconstructive Surgery • September 2018

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

Cyril J. Awaida, M.D. 4. Wang TD. Rhytidectomy for treatment of the aging face.
Faculty of Medicine Mayo Clin Proc. 1989;64:780–790.
Saint-Joseph University 5. Dayan SH, Bagal A, Tardy ME Jr. Targeted solutions in sub-
Hotel Dieu de France Hospital mentoplasty. Facial Plast Surg. 2001;17:141–149.
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