COSMETIC

Botulinum Toxin for Neck Rejuvenation:

Assessing Efficacy and Redefining
Patient Selection
Samer F. Jabbour, M.D.
Elio G. Kechichian, M.D.
Cyril J. Awaida, M.D.
Roland R. Tomb, Ph.D.
Marwan W. Nasr, M.D.
Beirut, Lebanon
Background: The “Nefertiti lift” consists of injecting the platysmal bands and
the inferior border of the mandible with botulinum toxin. No clinical trial has
evaluated its effect on the different lower face and neck aging components,
and little is known about the clinical characteristics that predict treatment
success.
Methods: Patients were injected with abobotulinumtoxinA along the inferior
border of the mandible and into the platysmal bands. Using standardized pre-
injection 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: Thirty patients were injected with a mean dose of 124.9 U of abob-
otulinumtoxinA per patient. Platysmal bands at rest and with maximal tension
reached a statistically significant improvement. The other components showed
a tendency for improvement but did not reach statistical significance; 93.3
percent of investigators and patients rated the overall results as improved,
and 96.6 percent of patients were satisfied with their results. When comparing
the patients who improved the most to all the other patients, they had lower
preinjection region-specific scores.
Conclusions: The Nefertiti lift can be used on its own or in conjunction with
other rejuvenating procedures. It is particularly helpful in younger patients
with platysma muscle hyperactivity and retained skin elasticity.  (Plast. Reconstr.
Surg. 140: 9e, 2017.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A
n attractive attribute of youth and beauty
is a slender streamlined neck.1 The devel-
opment of jowls and marionette lines and
the loss of mandibular contouring are unpleasant
signs of aging.2–4 Hyperkinetic activity and loss of
tone of the platysma muscle result in vertical mus-
cle bands and horizontal neck rhytides.5,6 These
bands usually develop when the patients are in
From the Departments of Plastic and Reconstructive Surgery
and Dermatology, Faculty of Medicine, Saint-Joseph Univer-
sity Hotel Dieu de France Hospital.
Received for publication October 7, 2016; accepted Novem-
ber 22, 2016.
The study is registered under the name “Botulinum Toxin
for Neck Rejuvenation,” ClinicalTrials.gov identification
number NCT02864511 (https://clinicaltrials.gov/ct2/
show/NCT02864511).
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003429
their 40s, but can present earlier in slim and active
individuals.7 The platysma muscle stretches the
skin of the neck downward and laterally and, in
synergy with the depressor anguli oris, pulls down
Disclosure: The authors have no financial infor-
mation to disclose. No funding was received for the
article.
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).

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the lateral corners of the mouth. It extends from
the sternoclavicular joint, clavicular bone, and
scapular acromion inferiorly to join the superficial
musculoaponeurotic system of the face superiorly.8
The muscle fibers contribute to the appearance
of the aging neck as they gradually detach from
deep planes and become attenuated.9 The ease of
minimally invasive upper face rejuvenation proce-
dures can result in a disproportionately youthful
appearance, with an apparently aging neck, nega-
tively impacting the patient’s mental well-being.10
Previously, the only treatment modality for lower
face and neck rejuvenation was surgery.7 To meet
the patient’s increasing demands of a minimally
invasive, convenient, and painless antiaging proce-
dure, botulinum toxin has been used in neck reju-
venation with high rates of patient satisfaction.9,11,12
Brandt and Bellman were the first to use botulinum
toxin in the antiaging treatment of the neck.13 This
was then followed by numerous reports.4,14–16 In
2007, the concept of the “Nefertiti lift” was intro-
duced by Levy, who injected the platysmal bands
with botulinum toxin, along with the inferior bor-
der of the mandible.17 The technique was named
after Nefertiti, an Egyptian queen renowned for
her well-defined mandibular contour.17 Since
then, no clinical trial has evaluated the effect of
the Nefertiti lift on the different lower face and
neck aging components, and little is known about
the clinical characteristics that predict treatment
success. This prospective proof-of-concept study
was designed to assess these shortcomings. It will
quantify the effect of the Nefertiti lift on the dif-
ferent components of the aging lower face and
neck using region-specific validated scores. It will
also evaluate the overall subjective assessment and
patient satisfaction rate and define the ideal candi-
date for this procedure.
PATIENTS AND METHODS
Patient Recruitment
Ethical approval was obtained from the Insti-
tutional Review Board of Hotel Dieu de France
Hospital, Beirut, Lebanon. All participating
patients gave informed written consent. Included
patients in this prospective trial were women
presenting to our clinic for neck rejuvenation
who (1) were deemed nonsurgical candidates,
(2) were not willing to undergo invasive surgical
procedures, or (3) had a medical contraindica-
tion to surgery. Excluded from this study were (1)
patients with botulinum toxin injection in the past
12 months, (2) patients who had resorbable filler
injection in the past 12 months, (3) patients with
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2017
previous permanent filler injection, (4) pregnant
or lactating patients, (5) patients with preexisting
neuromuscular conditions (e.g., myasthenia gra-
vis, Lambert-Eaton syndrome), (6) patients using
medication that could potentiate the effect of bot-
ulinum (e.g., aminoglycoside antibiotics), and (7)
patients with hypersensitivity to botulinum toxin
or human albumin.
Injection Technique
A 500-unit vial of abobotulinumtoxinA
(Dysport; Ipsen Ltd, Berks, United Kingdom) is
reconstituted by adding 2.5 cc of sterile saline.
Using 30-gauge needles and 1-ml syringes, four
injections are first administered subcutane-
ously 1 to 2 cm apart on a horizontal line under
the mandibular border. They are located poste-
rior to the hypothetical line where the nasola-
bial fold would cross the mandible to avoid the
depressor labii inferioris muscle. Each platys-
mal band is then injected with a vertical series
of two to four points 2  cm apart. The band is
held between the thumb and index finger of
the nondominant hand and injected intra-
muscularly. Five units of abobotulinumtoxinA
is injected in each point, with a maximum of
125 units of abobotulinumtoxinA for the global
neck treatment. (See Video, Supplemental Dig-
ital Content 1, which shows the Nefertiti lift
markings and injection technique. This video
illustrates the marking of the injection points
along with a demonstration of the injection
technique, http://links.lww.com/PRS/C193.) Fol-
low-up is performed 15 days later for retouch-
ing, and each residual or new platysmal band is
reinjected using a similar technique.
Video. Supplemental Digital Content 1 shows the Nefertiti lift
markings and injection technique. This video illustrates the
marking of the injection points along with a demonstration of
the injection technique, http://links.lww.com/PRS/C193.
 Volume 140, Number 1 • Botulinum Toxin for Neck Rejuvenation

Evaluation of Results RESULTS

Preinjection and postinjection photographs
were taken in a studio with consistent lighting,
background, seating position, camera system, and
lens. Patients were photographed without smil-
ing from four different views by the same photog-
rapher: frontal and lateral both at rest and with
platysmal contraction. The standardization of
photographs results in equivalent shadowing in
all views. If no retouching was done, pictures were
taken 15 days after injection. When retouching
was needed, the photographs were taken 15 days
after retouching.
The validated photonumeric scales were
used to assess the jowls,18 marionette lines,19 oral
commissures,18 neck volume,20 platysmal bands
at maximal contraction,21 and platysmal bands
at rest22 (Table  1). The patient’s photographs
were cropped to match the pictures of the pho-
tographic scales. Each preinjection and postinjec-
tion photograph was deidentified, randomized,
and placed on a separate scoring sheet. Each
scoring sheet was then independently assessed
by three blinded raters (two plastic surgeons and
one dermatologist). In addition to region-specific
scales, the overall appearance of the lower face
and neck was evaluated by the Investigator Global
Aesthetic Improvement Scale.23
The pain was assessed by the patients using a
visual analogue scale ranging from 0 to 10 during
the injection session. Also, each patient was given
a questionnaire including the Subject Global Aes-
thetic Improvement Scale, 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 recom-
mend it to a friend.
In total, 30 patients were included in this
trial. All were female, with a mean age of 54.8 ±
5.3 years. Thirteen patients were smokers (43
percent). The mean dose of abobotulinumtox-
inA used per patient was 114.3 ± 13.7 U. Only 10
patients needed additional toxin at day 15, with a
mean of 31.7 ± 16.1 U per patient.
Statistical analysis of regional scores of the lower
face and neck indicated a tendency for improvement
of jowls, marionette lines, and oral commissures,
but only the platysmal bands at rest and with con-
traction reached a statistically significant improve-
ment. There was no change in the neck volume
scores (Table 2). When comparing preinjection and
postinjection photographs, the raters reported an
improvement in 93.3 percent of patients (Fig.  1).
Eight patients were rated as “much improved” on
the Investigator Global Aesthetic Improvement
Scale. When compared to all the other patients,
they had lower preinjection region-specific scores
(Fig. 2). However, only the neck volume and jowls
showed a statistically significant difference.
The mean pain from injection reported on the
visual analogue scale was 1.2 ± 1.1. When compar-
ing preinjection and postinjection photographs and
using the Subject Global Aesthetic Improvement
Scale, 93.3 percent of patients rated themselves as
improved (Fig. 3), and 96.6 percent of patients were
satisfied with their results (Fig. 4). This satisfaction
rate was not correlated to any other variable (i.e.,
age, smoking status, botulinum toxin dose, pain
score, and preinjection and postinjection region-
specific scores). Twenty-seven patients (90 per-
cent) were willing to repeat the procedure and 28
patients (93.3 percent) would recommend the pro-
cedure to a friend or family member. Five patients

Table 1.  Scoring Scales

Score
Region 0 1 2 3 4
Jowls18 No sagging Mild sagging Moderate sagging Severe sagging Very severe sagging
Platysmal bands No relevant Mild promi- Moderate promi- Severe prominence Very severe prominence
with contrac- prominence nence nence
tion21
Platysmal bands No platysmal Mild platysmal Mild platysmal Moderate platysmal Severe platysmal bands evi-
at rest22 bands visible bands; bands bands evident bands evident along dent along the full length
do not appear along the full the full length of of the neck, elevation
along the full length of the the neck, elevation at least 5 mm from the
length of the neck, <5 mm of at least 5 mm from surrounding tissue with
neck elevation from the the surrounding additional soft-tissue ptotic
surrounding tissue tissue banding laterally
Marionette No lines Mild lines Moderate lines Severe lines Very severe lines
lines 19

Neck volume20 No sagging Mild sagging Moderate sagging Severe sagging Very severe sagging
Oral commis- No downturn Mild downturn Moderate downturn Severe downturn Very severe downturn
sures18

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 Plastic and Reconstructive Surgery • July 2017

Table 2.  Primary Endpoint: Region-Specific Scores* had injection-point ecchymosis that disappeared
in a couple of days. Only one patient reported a
Preinjection Postinjection
Region Score Score p mild dysphagia and a minor neck muscle weakness
Jowls 18
2.0 1.9 0.414 that lasted 2 weeks after injection. Figure  5 shows
Platysmal bands with the results of the patient injected in Supplemental
contraction21 2.7 0.6 <0.001† Digital Content 1, http://links.lww.com/PRS/C193.
Platysmal bands at rest22 0.9 0.6 0.009†
Marionette lines19 1.8 1.7 0.096 Figures  6 through 11 show additional results of
Neck volume20 1.9 1.9 0.786 patients injected using this technique.
Oral commissures18 1.4 1.2 0.305
*Statistical analysis was performed with IBM SPSS Advanced Statisti-
cal Software Version 22.0 (IBM Corp., Armonk, N.Y.). Preinjection DISCUSSION
and postinjection scores were compared using a dependent t test.
Statistical significance was set at p < 0.05. In this trial, we analyzed the effect of botuli-
†Statistically significant. num toxin injection in the neck using validated

Fig. 1. Investigator Global Aesthetic Improvement Scale (IGAIS). Investigators

reported an improvement in 93.3 percent of patients after comparing the pre-
injection and postinjection photographs.

Fig. 2. Preinjection characteristics of the patients with the highest Investigator Global Aesthetic Improve-
ment Scale score (blue) compared to all other patients (red). Preinjection scores were compared using an
independent t test. Statistical significance was set at p < 0.05. An asterisk indicates values that are statistically
significant.

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 Volume 140, Number 1 • Botulinum Toxin for Neck Rejuvenation

Fig. 3. Subject Global Aesthetic Improvement Scale (SGAIS); 93.3 percent

of patients reported improvement after comparing their preinjection and
postinjection photographs.

Fig. 4. Patient satisfaction rate; 96.6 percent of patients were satisfied with
the results.

scores for the platysmal bands at maximal ten-
sion and at rest, jowls, marionette lines, oral com-
missures, and neck volume.18–22 Although yet not
commonly used, these scales were chosen because
they all have been rigorously validated.
With a mean dose of 124.9 U of abobotu-
linumtoxinA per patient, we improved the pla-
tysmal bands at maximal tension by 2.1 grades
(Table 2). Figures 5, 7, and 8 illustrate the results
obtained with this technique. In 2015, Prager et
al. used botulinum toxin injection to treat pla-
tysmal bands and evaluated their results with the
same scoring scale.24 They used 50.2 U of incobot-
ulinumtoxinA per patient (equivalent to 150.6 U
of abobotulinumtoxinA with a conversion rate of
1:325,26). They injected each platysmal band with
15 U of incobotulinumtoxinA (equivalent to 45 U
of abobotulinumtoxinA) using six injection points
compared to our 20 U of abobotulinumtoxinA
injected with a maximum of four points per band.
Fifteen days after the procedure, we reached a
mean improvement of 2.1 grades, whereas Prager
et al. obtained 1.7 grades of maximal improve-
ment.24 We believe that the four submandibular
injection points of the platysma resulted in a more
global platysmal paralysis, thus diminishing the
dose of botulinum toxin needed to be injected in
each platysmal band. Similarly, by adding subman-
dibular injection points, Tamura only required
a median dose of 36 U of onabotulinumtoxinA
(equivalent to 108 U of abobotulinumtoxinA with
a conversion rate of 1:325,26) to treat platysmal
bands.8 The lower dose of botulinum toxin used
per patient results in a lower rate of complica-
tions.8,15,16,27 Thus, to minimize the risk of adverse
events, we limited the maximal dose of abobotu-
linumtoxinA to 125 U per session. Fifteen days
after treatment, some patients (n = 10) presented
with residual banding. Two types of residual bands
were noted: (1) very strong bands where the

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 Plastic and Reconstructive Surgery • July 2017

Fig. 5. Frontal views of a 56-year-old patient before the procedure (above, left) and 15 days after the injection
of a total of 125 U of abobotulinumtoxinA into the neck (above, right). Note the improvement of mandibular
contour, jowls, marionette lines, and oral commissures. Lateral views of the patient with maximal contrac-
tion of the platysma before the procedure (below, left) and 15 days after the procedure (below, right).

Fig. 6. Frontal views of a 55-year-old patient before the procedure (left) and 15 days after the injection of a total of 125 U of abob-
otulinumtoxinA into the neck (right).

maximum dose of 20 U of abobotulinumtoxinA
per band was reached at the first treatment ses-
sion but was not enough (Fig.  7); and (2) new
bands that appeared days later, after chemode-
nervation of the main medial and lateral bands
(Fig. 8). These new bands were not foreseeable at
the first session, and the only way to avoid them
would have been to use larger amounts of toxin to
completely paralyze the muscle, jeopardizing the
safety of the patient. We found that starting with
low doses and performing some retouching at a
later date tailored the treatment to the patients’
anatomy, optimizing the cosmetic results and min-
imizing the risk of adverse events.
In 1999, Kane described an improvement of
the platysmal bands at rest using botulinum toxin
injections.16 In this trial, we demonstrated a statis-
tically significant improvement of the bands at rest

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 Volume 140, Number 1 • Botulinum Toxin for Neck Rejuvenation

Fig. 7. Frontal views of a 56-year-old patient with maximal contraction of the platysma before the procedure (left) and 15 days
after injection of 125 U of abobotulinumtoxinA (center). Note the persistence of a less prominent right medial platysmal band that
was reinjected with 20 U of abobotulinumtoxinA. Note the complete disappearance of the residual platysmal bands, 15 days after
retouching (right). This type of band was found in five of 10 patients who needed retouching.

Fig. 8. Lateral views of a 57-year-old patient with maximal contraction of the platysma before the procedure (left) and 15 days
after injection of 80 U of abobotulinumtoxinA (center). Note the appearance of new bands (asterisk) after chemodenervation of the
initial lateral platysmal bands (pound sign). Note the complete disappearance of all platysmal bands, 15 days after retouching with
30 U of abobotulinumtoxinA (right). This type of band was found in five of 10 patients who needed retouching.

Fig. 9. Frontal views of a 58-year-old patient at rest before the procedure (left) and 15 days after the injection of 125 U of
abobotulinumtoxinA (right). Note the reduction in size and prominence of the platysmal bands at rest.

using a validated scale (Table 2). Figures 9 and 10 Even though not statistically significant, this
illustrate the improvement of the platysmal bands technique showed improvement of the jowls,
at rest. This is probably because of the diminished marionette lines, and oral commissures (Table 2).
global tone of the platysma muscle at rest. However, this effect was not enough to allow a

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 Plastic and Reconstructive Surgery • July 2017

Fig. 10. Frontal views of a 53-year-old patient at rest before the procedure (left) and 15 days after the injection of 100 U of abob-
otulinumtoxinA (right). Note the reduction in size and prominence of the platysmal bands at rest.

Fig. 11. Frontal views of a 56-year-old patient at rest before the procedure (left) and 30 days after the injection of 145 U of abob-
otulinumtoxinA (right).

statistically significant improvement using the
validated scales. Figures 5, 6, and 11 illustrate the
types of results we can expect with this technique.
The changes may be subtle and not enough to
improve the scores statistically with a small sample
size. However, the improvement was sufficient to
grant good patient and physician overall scores
and patient satisfaction rates. Matarasso et al.
attributed the improvement of the jowls and the
lower face components to an unopposed upward
pull of the superficial musculoaponeurotic system
when the lateral aspect of the platysma is treated.15
A theoretical concern of some practitioners is
that the platysma injection will result in increased
skin laxity as a consequence of the loss of mus-
cular tone and heavy, loose, paralyzed platysmal
cords.15,28 Consequently, overall neck volume could
increase. However, we did not find any change in
neck volume scores after injection (Table 2).
To define the ideal patient, we examined the
baseline characteristics of the subjects who had
the highest Investigator Global Aesthetic Improve-
ment Scale scores. We found that the best results
are obtained in patients with less advanced aging
signs (Fig.  2). In fact, muscle hyperactivity plays
an important role in the early stages of neck and
lower face aging, in contrast to the predominance
of skin and ligament laxity in more advanced
stages.29 The best results are usually obtained in
younger patients with retained skin elasticity. For
botulinum toxin to produce a significant improve-
ment, the primary indication is muscle hyperactiv-
ity. Thus, patient selection is of utmost importance
when treating the neck with botulinum toxin.
The reported low level of pain during injec-
tion (1.2 of 10) in conjunction with the low rate
of adverse events (one of 30) and the significant
improvement noted by the patients yielded a
patient satisfaction rate of 96.6 percent. Compa-
rably high satisfaction rates have also been noted
in other reports using botulinum toxin in neck
rejuvenation.15,24
Patients reported that the time of onset
of botulinum toxin in the neck was relatively
short, usually between 2 and 5 days. This could
not be confirmed, as all the patients were only
seen at day 15 for reevaluation and postinjection
photographs.
Although most of the patients were satisfied
with the results, botulinum toxin injection in
neck rejuvenation is not meant to replace inva-
sive surgical procedures such as liposuction, face

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 Volume 140, Number 1 • Botulinum Toxin for Neck Rejuvenation
lifting, or neck lifting. However, this technique
can be used in young patients who are not yet
surgical candidates or as an alternative for older
patients in whom surgery is contraindicated or
for those requesting nonsurgical procedures.
Furthermore, it can be used as an adjunct to
surgery to optimize the cosmetic outcome. This
technique is, in fact, another method to be added
to those available to the practitioner in the battle
against aging.
CONCLUSIONS
The Nefertiti lift is a useful, safe, standardized,
and simple nonsurgical addition to the treatments
of the aging neck and lower face. It can be used on
its own or in conjunction with other rejuvenating
procedures. It is particularly helpful in younger
patients with platysma muscle hyperactivity and
retained skin elasticity.
Samer F. Jabbour, M.D.
Faculty of Medicine
Saint-Joseph University Hotel Dieu de France Hospital
Alfred Naccache Boulevard
Achrafieh, Beirut 1100 2160, Lebanon
samermed@gmail.com
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17e