Letter to the Editor
Aesthetic Surgery Journal
Updates in the Treatment of the Lower Face
and Neck With Botulinum Toxin Injections
Samer Jabbour, MD ; Elio Kechichian, MD;
Cyril Awaida, MD; and Marwan Nasr, MD
Editorial Decision date: October 12, 2018; online publish-ahead-of-print January 30, 2019.
We read with great interest the systematic review by Sugrue
et  al concerning the treatment of platysmal bands with
botulinum toxin.1 In this systematic review, the authors
included 3 studies published between January 1985 and
December 2017 to assess efficacy, injection techniques,
and complications associated with botulinum toxin injec-
tion for the treatment of platysma bands. These included
studies were not cited in the review, making it difficult
for the reader to find them. In July 2017 we published a
trial in which we evaluated the “Nefertiti lift” technique by
injecting 30 patients with abobotulinumtoxin A;2 however,
this trial was not listed in the references of this systematic
review. Also, as noted by Matarasso and Matarasso, chang-
ing the inclusion criteria to include studies that utilized
“standard photography” would have increased the number
of studies included in this systematic review because we
think that including only studies that used the Merz scale
was far too limiting.3
The “Nefertiti lift” technique was described in Figure 2
of the Sugrue et  al article. In this figure, the depressor
anguli oris (DAO) and the mentalis muscles were injected
along with the inferior mandibular border and the pla-
tysmal bands. We agree that injecting the DAO and the
mentalis muscles could target the signs of lower face
aging, but these injections have never been evaluated
in our original article or in any other article describing
the “Nefertiti lift” technique. By adding the injection of
these 2 muscles to their figure, one might think that the
reported results evaluated the injection of the DAO and
mentalis muscles too. In our article, we evaluated only
the results of the original “Nefertiti” technique described
by Levy.4 All our injections were posterior to the hypo-
thetical line where the nasolabial fold would cross the
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mandible to avoid the depressor labii inferioris muscle.
By following this landmark, we did not report any mod-
ification of the patient’s smiles and lower lip asymme-
tries were avoided. However, the technique described by
Sugrue et al might result in the chemo-denervation of the
depressor labii inferioris muscles by botulinum toxin dif-
fusion. This could modify the patient’s smile and could
create asymmetries in the lower lip. The risk of adding
injections medial to the labionasal fold should be recog-
nized and explained to the patient prior to injection and
should not be a systematic part of every “Nefertiti lift.”
Additional studies should be done to evaluate the effect
of injecting the DAO and mentalis muscles in addition to
the “Nefertiti” lift.
Also, the authors stated, “the maximum dose per band
of incobotulinumtoxin A was 20IU and for abobotulinum-
toxin A was 5IU.” This is an erroneous statement because
in our study,2 every platysmal band was injected with 2 to
4 injections of 5 units of abobotulinumtoxin A each with a
total dose of 10 to 20 units per band.
Sugrue et  al also reported, “By omitting other senes-
cence changes in the neck, this scale is limited to patients
with isolated platysma bands only.” However, in our trial,2
we also assessed the “other senescence changes in the
neck.” We used 6 different photonumeric scales to eval-
uate the jowls, marionette lines, oral commissures, neck
From Saint Joseph University, Beirut, Lebanon.
Corresponding Author:
Dr Samer Jabbour, Faculty of Medicine, 1 Damascus Street, Beirut,
Lebanon 1107 2180.
E-mail: samermed@gmail.com
2
volume, platysmal bands at maximal contraction, and pla-
tysmal bands at rest.
The authors also concluded, “Additionally, the lack
of clinical use of this scale makes difficulty in establish-
ing a subsequent treatment algorithm […] Interesting,
high-quality randomized controlled trials have been
performed when assessing botulinum toxin injections
treatment for the upper face. Similar studies in neck reju-
venation are a necessity comparing different preparations
and dosage.” When our first study2 was published (July
2017)  we agreed with Sugrue et  al’s statement. For this
reason, we later published a crossover clinical trial com-
paring the “Nefertiti lift” technique with “Microbotox”
injections in the neck.5 In the Microbotox technique,
microdroplets of diluted botulinum toxin were injected
superficially into the dermis, specifically targeting the
sebaceous and sweat glands and the superficial fibers of
the facial muscles. We found that Microbotox was mainly
effective in treating neck and lower face soft-tissue pto-
sis in contrast to the Nefertiti technique, which was more
effective on platysmal bands. Based on our findings, we
proposed a treatment algorithm for the lower face and
neck with botulinum toxin combining both the Nefertiti
and Microbotox techniques.
In conclusion, botulinum toxin injections of the lower
face and neck are useful, simple, and safe procedures that
should be part of every aesthetic practitioner arsenal. We
thank Dr. Sugrue and colleagues for their useful contribu-
tion to the literature.
Aesthetic Surgery Journal
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
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The authors received no financial support for the research,
authorship, and publication of this article.
REFERENCES
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Nasr MW. Botulinum toxin for neck rejuvenation: assess-
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