Evaluation of The Microbotox Technique An.12

 

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. D  o w n l      o  a  d   e  d  f    r    o m h   t     t      p :    /     /      j      o  u r   n  a l      s  .l     w w .  c   o m  /      p l      a  s  r    e  c   o n  s   u r   r     g  b    y  B  h  D M f     5   e P  H K   b  H 4  T  T  I    m   q  e n V  M  t    m  b  m   y  f    2    C  D P  k    J   2   n B  z  H 2   M F   u H N B  i     h   0     q  b  h  r    C  F   o  S   9    3   v    y  L   o R  o n 1    0    /     0    3    /    2    0   1    8  

Samer F. Jabbour, M.D.  Youssef A. Rayess, M.D.  Joseph S. El Khoury, M.D. Elio G. Kechichian, M.D. Marwan W. Nasr, M.D. Beirut, Lebanon 

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. Methods: In this crossover study, patients previously treated with the Nefertiti lift were injected using the microbotox technique. Using standardized prein jection and postinjection 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 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 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 proced ure 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 by excessive skin laxity, subcutaneous fat atrophy, herniation of adipose tissue, and resorption of mandibular height.1–3 Fat and softtissue descent result in oral commissure ptosis,  jowl and marion marionette ette line format formation, ion, and loss  From the Departments of Plastic and Reconstructive Sur-  gery and Dermatology, Faculty of Medicine, Saint-Joseph University. Received for publication October 5, 2017; accepted March 29, 2018. This trial is registered under the name “Microbotox for Low-  er Face Rejuvenation,” ClinicalTrials.gov registration num-  ber NCT03189082 (https://clinicaltrials.gov/ct2/show/  NCT03189082). Copyright © 2018 by the American Society of Plastic Surgeons 

of the mandibular contour. 1,4,5  Vertical platysmal bands and horizontal cervical rhytides are caused by either muscle hyperactivity or loss of Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

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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 treatment for the aging lower face and neck; however, today, noninvasive procedures such as botulinum toxin injections are gaining in popularity.6,8–11 In 2007, Levy introduced the concept of the “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 hyperactivity and retained skin elasticity. 13  Another  widely used lower face and neck rejuv rejuvenati enation on procedure is the “microbotox” technique, which  was first describ described ed by Wu in 2015. 20 15. Microdropl Micr odroplets ets of diluted botulinum toxin were injected superficially into the dermis.14  Initially called “mesobotox,” this technique specifically targeted the sebaceous and sweat glands and the superficial fibers of the facial muscles. 15,16  Both the deep intramuscular Nefertiti lift and the superficial intradermal microbotox injections showed satis-

depending on the neck size. Injections were performed into the superficial dermis using 30-gauge needles. A good injection depth was defined by a small blanched bleb and resistance to injection. Approximately 150 injections were delivered over the entire anterior neck in an area bounded by a line drawn 5 cm above the mandibular border superiorly, a vertical line 1 cm posterior to the depressor anguli oris medially, the anterior border of the sternocleidomastoid muscle posteriorly, and the upper border of the clavicle inferiorly (Fig. 1). ( See Video, Supplemental Digital Content 1, which demonstrates the microbotox technique for lower face and neck rejuvenation. 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 http://links.lww.com/PRS/C909 .)

factory results.13,14 However  However,, no clinical trial evaluated the effect of the microbotox technique on the different lower face and neck aging components or compared it to the Nefertiti procedure. The objective 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.

and postinjection photographs  werePreinjection taken by the same photographe photo grapher r 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.  Validated photonume photonumeric ric scales were used to assess the oral commissures commissures,,17 marionette lines,18   jowls, 17  neck volume,2  platysmal bands at rest,19  and platysmal bands at maximal contraction.20  Each preinjection and postinjection photograph

PATIENTS AND METHODS Patient Recruitment  Ethical approval was obtained from the Institutional Review Board of Hotel Dieu de

Evaluation of Results

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 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 techniq technique ue described by 14  Wu.   A 500-unit vial of abobotulinumtoxinA

(Dysport; Ipsen United  was reconstituted reconsti tutedLtd, withBerks, normal saline Kingdom) to a final concentration of 70 U/ml. Two or three 1-ml syringes of 70 U each were used per patient

Fig. 1. Microbotox injections are delivered intradermally using a 30-gauge needle raising a small blanched weal at each point.  The area injected corresponds to the extent of the platysma muscle.

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Plastic and Reconstructive Surgery • September 2018

Video. Supplemental Supplemental   Digital Content 1 demonstrates the microbotox technique for lower face and neck rejuvenation. This video, illustrating the microbotox solution preparation along with a demonstration of the injection technique, is available in the “Related Videos” 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 pictures, randomized, and photonu placed meric on a separate scoring sheet. Each scoring sheet was then independently assessed by three blinded raters (one dermatologist and two plastic surgeons). In addition, the Investigator Global Aesthetic Improvement Scale was used to assess improvement in the overall appearance of the lower face and neck.21 Also, each patient was given a questionnaire including a Subject Global Aesthetic Improvement Score, a satisfaction survey (1,  very satisfied; 2, satisfied; 3, dissatisfi dissatisfied; ed; and 4,  very dissatisfie dissatisfied) d) and question questionss about their willingness to repeat the procedure and to recommend it to a friend. The pain associated with the injections was assessed by the participants using a visual analogue scale ranging from 0 to 10. At the 15-day follow-up visit, patients were asked to choose between the Nefertiti lift and the microbotox method as their preferred method for neck rejuvenation.

RESULTS In total, 25 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  women with smokers a mean age ag(36 e ± SD of 55.9 55. 9 ± 5.8 mean years. Nine were percent). The dose of abobotulinumtoxinA used per patient  was 154 15 4 ± 28.6 28 .6 U.

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the microbotox statistical In analysis of regionalphase scoresofofthe thetrial, 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 commissure scores. When these same 25 patients were injected using the Nefertiti technique 8 months earlier, we found a tendency for improvement of jowls, neck volume, marionette Table 1. Primary Endpoint: Region-Speci 󿬁c Scores*   Nefertiti injection technique  Jowls   Platysmal bands with contraction   Platysmal bands at rest   Marionette lines   Neck volume   Oral commissures Microbotox injection technique  Jowls   Platysmal bands with contraction   Platysmal bands at rest   Marionette lines   Neck volume

Preinjection Postinjection Score Score

 p 

1.8

1.8

1

2.9 1.0 1.4 1.9 1.3

0.64 0.56 1.28 1.8 1.2