MicroBotox: Facial rejuvenation can come from diluted botulinum toxin injections

24 September 2015

The latest American Society of Plastic Surgeons (ASPS) statistics report more than a sixfold increase in botulinum toxin injection procedures since the end of the 20th century. Almost any cosmetic surgeon will say the increased demand has come from patients who opt for a more natural-looking rejuvenation, as opposed to the "frozen" look that traditionally prepared botulinum toxins can give.

Taking these desires seriously, Singapore-based plastic surgeon Woffles Wu, M.D., has pioneered an injection technique, called Microbotox, that rejuvenates the face and skin with botulinum toxin, but without any resulting rigid muscle paralysis.

Taking these desires seriously, Singapore-based plastic surgeon Woffles Wu, M.D., has pioneered an injection technique, called Microbotox, that rejuvenates the face and skin with botulinum toxin, but without any resulting rigid muscle paralysis.

"The Microbotox technique relaxes superficial fibers of the muscle, creating a very natural-looking result," Dr. Wu says. "It can be used to rejuvenate more subtle issues of the face, including passive wrinkles under the eyes, skin improvement in the midface and forehead, and pore reduction."

Dr. Wu describes Microbotox (formerly known as Mesobotox) as an intradermal-to-just-subdermal injection of very dilute Botox (onabotulinumtoxinA, Allergan) that's used to affect the sebaceous glands, sweat glands and superficial layer of facial muscles.

MicrobotoxDr. Wu says he began performing the technique in 2000 to address aesthetic subtleties, including avoiding the frozen look, achieving a smooth lower eyelid and addressing the neck.

Another of his goals was to eliminate lateral brow frown lines without causing depression of the eyebrows, he says.
Dr. Wu has found that patients also want Microbotox to the forehead area, crow's feet, infraorbital and cheek areas and bunny lines.
"Many patients who used to receive traditional onabotulinumtoxinA in these areas now request Microbotox instead, as they feel they look more natural and have less stiffness," he says.
Microbotox has multiple uses and has expanded the scope and range of effects of botulinum toxin beyond just muscle manipulation. "The most important areas for Microbotox use are the forehead and the under-eye region," Dr. Wu says.

In the past, injections of traditional Botox to the forehead resulted in either an undesired "Diablo" brow or a totally frozen forehead and uncomfortable depressed brow. "With Microbotox, the forehead lines are eradicated yet the patient can still move his eyebrows and elevate them," Dr. Wu says.

In the lower lid, one of the main problems with administering traditional Botox to eliminate under-eye wrinkles and fine lines was that this created an unwanted over-relaxation of the orbicularis oculi, leading to the eye bags becoming more prominent, or worse, creating "hound dog" malar bagging, Dr. Wu says.

"With Microbotox, these lines can be significantly reduced without compromising orbicularis oculi activity," he says.
In the neck and lower face, "Microbotox is injected into the skin overlying the distribution of the platysma. This results in a smoothening of platysmal bands, horizontal neck creases and creates a lifting effect of the jawline," Dr. Wu says. A similar smoothening effect can be seen in the décolletage, where patients often have multiple wrinkles and crepey skin.

"I also like intradermal for the neck crepiness and for enlarged pores and rhinophyma of the nose," says Steven Dayan, M.D., a Chicago plastic surgeon who says he's been using the technique for three or four years. "I especially find it great for rosacea. I find the results comparable if not superior to IPL (intense pulsed light)."

Microbotox Mechanics

Here's how the Microbotox technique works: Multiple tiny injections into the dermis or between the dermis and the superficial layer of the muscles weaken the superficial layer of facial muscles, which are attached to the undersurface of the skin. These muscles are responsible for fine lines and wrinkles.

When sweat and sebaceous gland activity is reduced in the skin, the glands become atrophic, which causes the skin to shrink and become tighter. Reducing sebaceous activity also makes the "open" pores appear smaller and fewer in number, thereby refining and smoothing the skin.

"In my patients, I have had pore size reduced by 50 percent, measured using 'before' and 'after' pictures using VISIA (Canfield)," Dr. Wu says. He says these results last two to three months.
Dr. Wu says he uses different dilutions of Microbotox in different parts of the face and neck, especially when treating a patient solely for pore closure or smoothening of the skin to avoid affecting the underlying muscle activity.

"It requires careful preparation of the solution and a sensitive and refined injection technique," he says.
The Microbotox technique uses a more diluted concentration of Botox than traditional applications. First, the clinician should determine the number of units required.
Dr. Wu says he generally uses 24 to 28 units for the entire forehead, including injection to the glabella and eyebrows to decrease corrugator activity.
However, "If the patient already has traditional onabotulinumtoxinA in the glabellar, eyebrow and central forehead region to create a browlift, then 16 units are sufficient for the lateral forehead alone," he says.
When treating the lateral orbicularis he also uses 24 to 28 units, which is enough to also treat the infraorbital and bunny lines.
Results for the brow generally last four months and for the orbicularis three to four months, Dr. Wu says.

Next, he draws up the required number of units into a 1 cc syringe and then tops it up to 1 mL with normal saline. For example, Dr. Wu says, if the forehead requires 24 units of Botox, then you need 24 units of Botox in 1 mL of solution. Draw 0.6 mL of prepared Botox (2.5 mL dilution) into a 1 mL syringe and add 0.4 mL saline to create 1 cc of injectable solution containing 24 units.
"I dilute 100 units with 7 cc saline and place it intraderm. The key is that it stays intradermal," Dr. Dayan says. For rosacea, "I use approximately 10 units per cheek."

As for the technique itself, Dr. Wu says, "Compared to the standard 0.05 mL droplet that contains two units of Botox for routine intramuscular injections, for Microbotox, that same 0.05 mL droplet is injected in 10 to 20 micro drops."

As for cost, "It is about a third to half cheaper because if your injection technique is good, you can spread 28 units into the crow's feet, glabellar and forehead regions," Dr. Wu says. "This would normally require 16 to 20 units per area," i.e., 20 x 3 = 60 units.

"Once U.S.-based surgeons try it out and see the benefits of it, I think it will become widely accepted. It's a revolution," Dr. Wu says.
Dr. Dayan agrees: "It's a wonderful application for Botox and Dysport."

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