Dr Sarah Tonks explores the alternative use of botulinum toxin to achieve whole-face rejuvenation
Botulinum toxin has been widely used for facial rejuvenation. Today it is common for practitioners to treat the whole face with the toxin, rather than confining it to individual areas. The traditional discord seen when the upper face is successfully treated and the hyperkinetic lower is left untreated is now increasingly recognised as a failure of aesthetic result — the disharmony of the face is a certain giveaway of cosmetic intervention. It is our job to educate patients about the use of toxins and other rejuvenation procedures in the mid-face, lower-face, neck and décolletage, as this is something not often covered in the media and patients may be unaware of the options. In order to achieve this whole-face, global change we can use a technique of dilute botulinum toxin, judiciously placed in specific areas.
Mesotherapy was introduced as a medical procedure by Pistor in 1958. It consists of intradermal injection of pharmacologic substances that have been diluted, with the aim of restoring healthy texture of the skin. Material used can include vitamins, minerals, enzymes and other reagents. Mesotherapy promotes rejuvenation by increasing hydration and activating fibroblasts.1 Hyaluronic acid injected into the skin can cause fibroblasts to produce collagen type 1, matrix metalloprotease 1 and tissue inhibitor matrix metalloprotease 1.1 An additional study suggested dermal injection of vitamins causes stimulation of collagen production.2
“Mesobotox” is a term coined for the application of botulinum toxin by papule needle injection into the dermis of the skin. Often these toxins are more dilute than those traditionally used for treating areas such as the glabellar, and in some cases mesotherapy products such as hyaluronic acid, are added to the mixture. It is the injection not of specific muscles, but the treatment of large areas of dermis with dilute botulinum toxin. Mesobotox has four advantages and can be used successfully in people of all skin types. Botulinum toxin has been shown to decrease sebum production and improve acne, so can be used in oily and sebaceous skins.3,4 Botulinum toxin can be used to improve older skins with fine lines and wrinkles by diminishing the pull of the facial depressors, resulting in an improvement of the facial contour.5
Botulinum toxin blocks production of eccrine sweat glands which can give a smoother appearance of the skin.6
The addition of mesotherapy products can produce an additional benefit to the health of the skin.1,2
The facial muscles are classified into levators (frontalis, zygomaticus major and minor, levator labii superioris, alequai nasa, anguli oris) and depressors (procures, corrugator supercilii, orbicularis oculi, platysma, depressor anguli oris, depressor labii inferioris). Levators and depressors are balanced in younger people but with ageing, this balance shifts towards the depressors. By injecting into the dermis, rather than a muscle, we can reduce the strength of the depressors. This works because the facial muscles insert onto the skin rather than onto bone, so when toxin is injected into the dermis it blocks the superficial fibres of the muscle inserted into the skin. Intradermal injection is suitable for flat, sheet like muscles rather than muscle bundles. It can be used where the skin is lax with poor tone. A flat, thin muscle, like platysma, has a medium motor endplate concentration whilst a short, thick muscle, such as corrugator, has a high concentration of motor endplates near the point of injection, influencing the choice of concentration used for the injections.6 In a study of 275 patients selected for cheek droop and mid-cheek groove, 24.9% attained high improvement with the cheeklift, softening of the nasolabial folds and redefining of the facial contour.5 The pattern of injection can be seen in figure 1 with the results in figure 2 and 3. An alternative pattern of injection, more suitable for oily skin, can be seen in figure 4. Mesotherapy can be used as an alternative to the Nefertiti lift, performed by injecting botulinum toxin into the platysma and posterior bands to release the downward pull of the platysma. Those with poorly defined posterior bands or skin laxity might not be good candidates, so the intradermal technique may be useful. Botulinum toxin blocks eccrine sweat glands innervated by cholinergic sympathetic nerve fibres. Apocrine sweat glands are unaffected, innervated by adrenergic sympathetic nerve fibres. This can result in smoother skin after injection.6 Some patients suffer from excessive facial sweating and use of botulinum toxin for nasal hyperhidrosis has been reported.7 Some physicians have claimed that intradermal botulinum toxin injections can cause collagenesis, although, to date, no placebo-controlled trial has been conducted that supports this.8 However the acetylcholine receptor is present on the surface of melanocytes, keratinocytes and other dermal tissue so it is possible that it may give a wider effect than initially thought.9
One of the most compelling studies, a split face study of nine patients, noted a global improvement in skin texture in six of the patients, and moderate improvement in resting and dynamic facial lines, with maximal effect lasting two months.10 Interestingly, histologic samples taken from this study showed no significant difference in haematoxylin and eosin staining with the exception of increased staining density of procollagen. For those with oily skin, botulinum toxin can offer relief. Extraneuronal acetylcholine plays a role in sebum production and sebocyte differentiation.9 In a study of 25 patients, 91% reported a 50-75% improvement in the oil production.3 In a separate study of 20 patients, 17 noted an improvement in sebum production and decrease in pore size.4
Injection pattern and reconstitution vary according to the issue needing treatment and a practitioner’s clinical judgement. To prepare the skin, it is first cleaned with chlorhexidine while anatomical landmarks and injection points are marked up, if lifting the mid-face. For oily skin I use Azzalure, reconstituted with 130 Speywood units bacteriostatic saline, mixed with 1ml Filorga NCTF 135HA, applied via a bevel up superficial nappage technique to the dermis using a 32g, 6mm (TSK) needle, causing a blanching effect in the skin. Points are placed approximately 5mm apart and areas with excessive oiliness, such as the T-zone, are targeted. For drier areas of skin on the oily face, the remaining 2ml mesotherapy product is used plain, without the addition of toxin unless facial sculpting is indicated. Areas such as the cheeks, neck, hands and décolletage can be targeted. The patient is reviewed at two weeks and the treatment can be repeated if indicated. If not, the patient undergoes a further four mesotherapy treatments using the Filorga NCTF 125HA alone, in order to derive the maximum benefits from mesotherapy.
For patients with mid-face droop, the skin can be assessed by pulling it in the direction of the contraction of platysma to determine the strength of the depressor muscles and points of injection. Here I use Azzalure reconstituted with bacteriostatic saline and applied to the dermis with a 34g, 8mm needle (Japan Bio Products), into predetermined injection points, causing blanching. For the platysma the first row starts from the TMJ down the mandibular joint at 1cm intervals. The second row is placed 1cm superiorly to this with the injection points between the ones beneath. The lateral orbicularis oculi injections are made across the lateral border of the muscle in the temporal area, as seen in figure 1. Each injection placed in the superficial dermis should cause blanching of approximately 3-4mm diameter. For these patients I use Azzalure reconstituted with 130 Speywood units. Bacteriostatic saline is mixed with Filorga 135HA in a 1:1 ratio and is applied to the remaining skin, as seen in figure 4. Practitioners’ should use their clinical judgement to decide which areas of the patient’s face would benefit from treatment. The most common areas are the cheeks and forehead. The remaining Filorga is used plain in other areas such as the hands and décolletage. The patient is then reviewed at two weeks and a further four sessions of mesotherapy are carried out. A clinical judgement should be made to decide whether to add more toxin at the follow up or not.
“Mesobotox” is a safe way of improving the texture and tone of the skin, often giving a subtler and more global result compared with using botulinum toxin in the upper face alone. It is a way of bridging the gap for patients who are not ready to make the jump into having traditional dermal fillers and botulinum toxin.
Figure 1. Reproduced from ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.
Figure 2. Reproduced from ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.
Figure 3. Reproduced from ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.
Figure 4. Reproduced from ‘The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A’, International Journal of Dermatology 2008; 47:1287- 1294. SH Chang, HH Tsai, WY Chen, WR Lee, PL Chen.