Plastic and Reconstructive Surgery Advance Online Article

DOI: 10.1097/PRS.0000000000004695

“Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and

Neck Rejuvenation and a Crossover Clinical Trial.”

Cyril J. Awaida, MD 1; Samer F. Jabbour, MD 2; Youssef A. El Rayess, MD 3; Joseph S. El

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Khoury, MD 4; Elio G. Kechichian, MD 5; Marwan W. Nasr, MD 6

1. Cyril J. Awaida, MD. Department of Plastic and Reconstructive Surgery, Faculty of

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Medicine Saint-Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon.

2. Samer F. Jabbour, MD. Department of Plastic and Reconstructive Surgery, Faculty of

Medicine Saint-Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon.

3. Youssef A. El Rayess, MD. Department of Plastic and Reconstructive Surgery, Faculty of

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Medicine Saint-Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon.

4. Joseph S. El Khoury, MD. Department of Plastic and Reconstructive Surgery, Faculty of

Medicine Saint-Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon.

5. Elio G. Kechichian, MD. Department of Dermatology, Faculty of Medicine Saint-Joseph

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University, Hotel Dieu de France Hospital, Beirut, Lebanon.

6. Marwan W. Nasr, MD. Department of Plastic and Reconstructive Surgery, Faculty of

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Medicine Saint-Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon.

Corresponding author: Cyril J. Awaida, MD, Faculty of Medicine, Saint-Joseph University,

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Hotel Dieu de France Hospital, 1st floor, Khoueiry building, Bonjus street, Fanar, Lebanon.

cyrilawaida@gmail.com

Copyright © American Society of Plastic Surgeons. All rights reserved.

 Financial Disclosure Statement: Dr. Awaida, Dr. Jabbour, Dr. Rayess, Dr. Khoury, Dr.

Kechichian, and Dr. Nasr have nothing to disclose. No funding was received for the article.

List of product used: Dysport© (Ipsen Ltd, Berks, UK)

Short-Running Head:

Microbotox for Lower Face Rejuvenation

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Ethical approval was obtained from the institutional review board of Hotel Dieu de France

Hospital, Beirut, Lebanon. All participating patients gave informed written consent.

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Clinical trial registration information: Name of trial database: ClinicalTrials.gov, Registration

number: NCT03189082, Date registered: October 4, 2017

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 ABSTRACT

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.

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Methods: In this crossover study, patients previously treated with the “Nefertiti Lift” were

injected using the Microbotox technique. Using standardized pre-injection and post-injection

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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
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evaluated.

Results: Twenty-five out 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
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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
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technique. 100 percent of patients were satisfied with both techniques and rated themselves as

improved.
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Conclusions: The Microbotox technique is a useful, simple and safe procedure for the lower face

and neck rejuvenation. It is mainly effective in treating neck and lower face soft tissue ptosis in

contrast to the Nefertiti technique that is more effective on platysmal bands.

Copyright © American Society of Plastic Surgeons. All rights reserved.

 INTRODUCTION

Age-related changes of the neck are due to 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 with a loss of the

mandibular contour (1,4,5). Vertical platysmal bands and horizontal cervical rhytids are caused

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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 but nowadays, noninvasive procedures such as

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botulinum toxin injections are gaining in popularity (6,8–11). In 2007, Levy introduced the

concept of “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
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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 et al 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
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and the superficial fibers of the facial muscles (15,16). Both the deep intramuscular Nefirtiti lift

and the superficial intradermal Microbotox injections showed satisfactory results (13,14).
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However, no clinical trial evaluated the effect of the Microbotox technique on the different

lower-face and neck aging components nor compared it to the Nefertiti procedure. The objective
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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.

Copyright © American Society of Plastic Surgeons. All rights reserved.

 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

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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

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asked to participate in the present study.

Microbotox preparation and technique

We used the same technique described by Wu et al. (14). A 500-unit vial of abobotulinumtoxinA

(Dysport; Ipsen Ltd, Berks, United Kingdom) was reconstituted with normal saline to a final
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concentration of 70 units per ml. Two or three 1ml syringes of 70 units each were used per

patient depending on the neck size. Injections were done into the superficial dermis using 30-

gauge needles. A good injection depth was defined by a small blanched bleb and resistance to

injection. Around 150 injections were delivered over the entire anterior neck in an area bounded
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by a line drawn 5cm above the mandibular border superiorly, a vertical line 1cm posterior to the

depressor anguli oris medially, the anterior border of the sternocleidomastoid muscle posteriorly,
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and the upper border of the clavicle inferiorly (Figure 1). (See Video, Supplemental Digital

Content 1, which demonstrates the Microbotox technique for lower face and neck rejuvenation.
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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 INSERT HYPER LINK HERE.) (Video

Graphic 1)

Copyright © American Society of Plastic Surgeons. All rights reserved.

 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.

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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

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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 (1 dermatologist and 2 plastic

surgeons). In addition, the Investigtor Global Aesthetic Improvement Scale (IGAIS) was used to
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assess improvement in the overall appearance of the lower face and neck (22). Also, each patient

was given a questionnaire including a Subject Global Aesthetic Improvement Score (SGAIS), a

satisfaction survey (1-very satisfied, 2-satisfied, 3-dissatisfied, 4-very dissatisfied) and questions

about their willingness to repeat the procedure and to recommend it to a friend. The pain
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associated with the injections was assessed by the participants using a visual analogue scale

ranging from 0 to 10. At the 15 days follow-up visit patients were asked to choose between the
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Nefertiti Lift and the Microbotox as their preferred method for neck rejuvenation.

RESULTS
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In total, 25 out 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 female with a mean age of 55.9 (SD ± 5.8) years.

Nine were smokers (36%). The mean dose of ABO used per patient was 154 ± 28.6 U.

Copyright © American Society of Plastic Surgeons. All rights reserved.

 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 commissures scores. When

these same 25 patients were injected using the Nefertiti technique 8 months earlier, we found a

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tendency for improvement of jowls, neck volume, marionette lines and oral commissures but

only the platysmal bands at rest and with contraction reached a statistical significant

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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 Figure 2).

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When comparing pre-and-post photographs, the raters reported an improvement in 84% of

patients for the Microbotox technique compared to 93.3% for the Nefertiti technique (Figure 3).

The mean pain from injection reported on the visual analog scale was 4.6 ± 2.3 for the

Microbotox compared to 0.6 ± 2.3 for the Nefertiti technique. When comparing pre-and-post
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photographs and using the SGAIS, 100% of the 25 patients rated themselves as improved in both

the Microbotox and the Nefertiti techniques (Figure 4). 100% of the 25 patients were satisfied
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with their results in both the Microbotox and the Nefertiti techniques (Figure 5). 22 patients

(88%) were willing to repeat the Microbotox technique compared to 25 (100%) in the Nefertiti
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procedure. 22 patients (88%) would recommend the Microbotox to a friend/family member and

25 (100%) would recommend the Nefertiti procedure. Three patients had injection-point

ecchymosis in the Microbotox technique compared to 6 patients in the Nefertiti technique. They

lasted a couple of days. No patients reported any dysphagia nor muscle weakness with the

Copyright © American Society of Plastic Surgeons. All rights reserved.

 Microbotox technique. Only one patient reported a mild dysphagia that lasted 2 weeks with the

Nefertiti Lift technique.

When asked about their preferred technique for neck rejuvenation, 18 patients chose the

Microbotox technique, 5 preferred the Nefertiti Lift and 2 had no preferences.

DISCUSSION

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This prospective crossover trial is the first to compare the Nefertiti Lift to the Microbotox

technique for the neck and lower face rejuvenation. Different components of the aging lower

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face and neck are targeted by the 2 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
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cervico-mandibular angle (Figure 6 and 7). In contrast, the Nefertiti technique failed to improve

soft tissue ptosis.

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

with the Microbotox technique, most patients presented 15 days after the treatment with varying
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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.
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We believe that the deep fibers of the platysma remained active with the Microbotox injections

in comparison to the Nefertiti technique where the deep platysma fibers were paralyzed. Thus,
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the Microbotox modality for neck rejuvenation was more effective on soft tissue ptosis but less

effective on platysmal bands when compared to the Nefertiti technique (Figure 8 and 9).

Both the physicians and patients noticed an improvement of the skin texture with the intradermal

injection of the botulinum toxin (Figure 10). However, this effect was not evaluated in this trial.

Copyright © American Society of Plastic Surgeons. All rights reserved.

 Most of the patients preferred the Microbotox technique as they were seeking the skin tightening

and soft tissue lifting effects. The 5 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. Non-surgical candidates and patients requesting non-invasive

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neck and lower face treatment can be treated with botulinum toxin injections using the

Microbotox, the Nefertiti technique or a combination of both techniques. The most critical step

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in the non-surgical 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 bands relaxation. The patient’s demand should also

be guided by the practitioner. Thin patients with a predominant platysmal hyperactivity and
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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 re-define the
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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
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technique (13). Hence, selecting the proper technique for each patient is crucial when treating the

aging neck and lower face with botulinum toxin (Figure 11).
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The superficial Microbotox injections precludes 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 124U in the Nefertiti technique, one patient

reported dysphagia and neck muscle weakness that lasted 2 weeks. With the Microbotox

Copyright © American Society of Plastic Surgeons. All rights reserved.

 technique we used higher doses of ABO (154U) without adverse events.

The mean level of pain during the Microbotox injection was higher than the Nefertiti lift. In fact,

pain receptors are found in the dermis making superficial injections more painful (21,22). Wu et

al. found that diluting the solution with lidocaine decreased the periprocedural pain level.

Nevertheless, both techniques were associated with high satisfaction rates.

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Six patients had injection-point ecchymosis with the Nefertiti technique compared to 3 patients

with the Microbotox technique. This is probably due to the fact Nefertiti Lift injections are

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delivered deeper into the well-vascularized platysmal muscle. All the ecchymosis disappeared in

a couple of days.

Botulinum toxin may have different onset of action on skin and muscle. Maximal muscle

paralysis has been shown to occur at 2 weeks post injections (23). However, no studies have
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assessed the onset of action of the toxin on the skin and its different components. In this study,

patients were evaluated 2 weeks post-injections, 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
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were injected 8 months apart to make any residual effect insignificant.

CONCLUSION
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The Microbotox technique is a useful, simple and safe procedure for the lower face and neck

rejuvenation. It is mainly effective in treating neck and lower face soft tissue ptosis in contrast to
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the Nefertiti technique that is more effective on platysmal bands. The practitioner must address

specific patients concerns and establish a treatment plan based on his clinical appreciation of the

patient’s neck.

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 References

1. Friedman O. Changes associated with the aging face. Facial Plast Surg Clin N Am. 2005

Aug;13(3):371–80.

2. Sattler G, Carruthers A, Carruthers J, Flynn TC, Geister TL, Görtelmeyer R, et al. Validated

assessment scale for neck volume. Dermatol Surg Off Publ Am Soc Dermatol Surg Al.

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2012 Feb;38(2 Spec No.):343–50.

3. Brandt FS, Boker A. Botulinum toxin for rejuvenation of the neck. Clin Dermatol. 2003

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Dec;21(6):513–20.

4. Wang TD. Rhytidectomy for treatment of the aging face. Mayo Clin Proc. 1989

Jul;64(7):780–90.

5. Dayan SH, Bagal A, Tardy ME. Targeted solutions in submentoplasty. Facial Plast Surg
EP
FPS. 2001 May;17(2):141–9.

6. Matarasso A, Matarasso SL. Botulinum A exotoxin for the management of platysma bands.

Plast Reconstr Surg. 2003 Oct;112(5 Suppl):138S – 140S.

7. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg.
C

1998 Feb;101(2):473–81.

8. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A.
C

Plast Reconstr Surg. 1999 Feb;103(2):656–63; discussion 664–5.

9. Carruthers JDA, Glogau RG, Blitzer A, Facial Aesthetics Consensus Group Faculty.
A

Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and

combination therapies--consensus recommendations. Plast Reconstr Surg. 2008 May;121(5

Suppl):5S – 30S; quiz 31S – 36S.

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 10. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower

face. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2003 May;29(5):477–83;

discussion 483.

11. Spósito MMM. New indications for botulinum toxin type A in treating facial wrinkles of

the mouth and neck. Aesthetic Plast Surg. 2002 Apr;26(2):89–98.

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12. Levy PM. The “Nefertiti lift”: a new technique for specific re-contouring of the jawline. J

Cosmet Laser Ther Off Publ Eur Soc Laser Dermatol. 2007 Dec;9(4):249–52.

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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 Jul;140(1):9e – 17e.

14. Wu WTL. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and
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Its Clinical Effects. Plast Reconstr Surg. 2015 Nov;136(5 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 Off Publ Am Soc Dermatol Surg Al. 2013

Mar;39(3 Pt 1):443–8.
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16. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore

size. J Drugs Dermatol JDD. 2008 Sep;7(9):847–50.

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17. Narins RS, Carruthers J, Flynn TC, Geister TL, Görtelmeyer R, Hardas B, et al. Validated

assessment scales for the lower face. Dermatol Surg Off Publ Am Soc Dermatol Surg Al.
A

2012 Feb;38(2 Spec No.):333–42.

18. Carruthers A, Carruthers J, Hardas B, Kaur M, Goertelmeyer R, Jones D, et al. A validated

grading scale for marionette lines. Dermatol Surg Off Publ Am Soc Dermatol Surg Al.

2008 Nov;34 Suppl 2:S167–72.

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 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 Aug;35(6):NP141–6.

20. Geister TL, Bleßmann-Gurk B, Rzany B, Harrington L, Görtelmeyer R, Pooth R. Validated

assessment scale for platysmal bands. Dermatol Surg Off Publ Am Soc Dermatol Surg Al.

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2013 Aug;39(8):1217–25.

21. Treede RD, Meyer RA, Raja SN, Campbell JN. Peripheral and central mechanisms of

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cutaneous hyperalgesia. Prog Neurobiol. 1992;38(4):397–421.

22. Dubin AE, Patapoutian A. Nociceptors: the sensors of the pain pathway. J Clin Invest. 2010

Nov;120(11):3760–72.

23. Kassir R, Kolluru A, Kassir M. Triple-Blind, Prospective, Internally Controlled

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Comparative Study Between AbobotulinumtoxinA and OnabotulinumtoxinA for the

Treatment of Facial Rhytids. Dermatol Ther. 2013 Dec;3(2):179–89.

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 Figures legends:

Figure 1: Microbotox injections are delivered intradermally using a 30G needle raising a small

blanched weal at each point. The area injected corresponds to the extent of the platysma muscle.

Figure 2: Pre-injection and post-injection scores. Jowls and neck volume were most improved

with the Microbotox injection technique whereas platysmal bands at rest and with contraction

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were most improved with the Nefertiti injection technique. *: statistically significant.

Figure 3: Investigators Global Aesthetic Improvement Scores for the Microbotox injection

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technique: raters reported an improvement in 84% of patients when showed the pre and post

injection photographs.

Figure 4: Subject Global Aesthetic Improvement Scores for the Microbotox injection technique:

100% of patient reported improvement when showed the pre and post injection photographs
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Figure 5: Patient satisfaction for the Microbotox injection technique: 100% of patients were

satisfied with the results.

Figure 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
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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
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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
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improvement of the cervicomental angle and soft tissue ptosis with the Microbotox technique.

Figure 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 cervicomental contour with the

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 Microbotox technique.

Figure 8: Lateral views of a 53-year-old patient before the procedures (left), 15 days after the

Nefertiti lift using 105 U of abobotulinumtoxinA (center), and 15 days after the Microbotox

injections with 210 U of abobotulinumtoxinA (right). Note the improvement of the neck volume

and the cervicomental angle with the Microbotox technique. The Nefertiti technique failed to

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improve soft tissue ptosis.

Figure 9: Frontal views of a 59-year-old patient with maximal contraction of the platysma before

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the procedures (left), 15 days after Nefertiti lift using 125 U of abobotulinumtoxinA (center), and

15 days after the Microbotox injections (right). Note the persistence of platysmal banding after

the Microbotox technique.

Figure 10: Frontal views of a 55-year-old patient before the Microbotox (left) and 15 days after
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the injection of a total of 140 U of abobotulinumtoxinA (right). Note the improvement of skin

texture.

Figure 11: Algorithm for lower face and neck rejuvenation.

Video Graphic 1. See Video, Supplemental Digital Content 1, which demonstrates the
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Microbotox technique for lower face and neck rejuvenation. This video illustrates the

Microbotox solution preparation along with a demonstration of the injection technique, available
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in the “Related Videos” section of the Full-Text article on PRSJournal.com or, for Ovid users,

available at INSERT HYPER LINK HERE.

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Copyright © American Society of Plastic Surgeons. All rights reserved.

 Table 1. Primary endpoint: Region specific scores
Preinjection score Postinjection score p-value
Nefertiti injection technique
Jowls 1.8 1.8 1
Platysmal bands with contraction 2.9 0.64 <0.0001*
Platysmal bands at rest 1.0 0.56 0.022*
Marionette lines 1.4 1.28 0.3466
Neck volume 1.9 1.8 0.3872

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Oral commissures 1.3 1.2 0.3043
Microbotox injection technique
Jowls 1.8 1.16 <0.0001*

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Platysmal bands with contraction 2.9 1.6 <0.0001*
Platysmal bands at rest 1.0 0.88 0.6269
Marionette lines 1.4 1.28 0.3466
Neck volume 1.9 1.52 0.0008*
Oral commissures 1.3 1.32 0.7698
Statistical analysis was done with SPSS advanced Statistical software version 22.0 (SPSS Inc.,
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Chicago, IL). 1: Pre and post injection scores were compared using a dependent t-test.
Statistical significance was set as p<0.05. *: statistically significant.
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Copyright © American Society of Plastic Surgeons. All rights reserved.

 Table 2. Comparison of the results of both techniques for the region specific scores
Nefertiti Microbotox
postinjection score postinjection score p-value
Jowls 1.8 1.16 0.0011*
Platysmal bands with
0.64 1.6 <0.0001*
contraction
Platysmal bands at rest 0.56 0.88 0.0026*
Marionette lines 1.28 1.28 1
Neck volume 1.8 1.52 0.0054*

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Oral commissures 1.2 1.32 0.0788
Statistical analysis was done with SPSS advanced Statistical software version 22.0 (SPSS Inc.,
Chicago, IL). Post injection scores of both the Nefertiti and the Microbotox techniques were

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compared using a dependent t-test. Statistical significance was set as p<0.05. *: statistically
significant. EP
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 Figure 1

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