by John Evans,
Assistant Editor, The Chronicle
A facial aesthetic technique referred to as ‘micro-Botox’ that involves clinicians intradermally injecting highly dilute onabotulinumtoxin A in much smaller droplets than what is typically used appears to be effective and offer increased benefits, said Dr. Woffles Wu, a cosmetic and craniofacial surgeon from Singapore who developed the technique and outlined the technique during Cosmetic Update Congress in April 2013
“Some of the micro-Botox technique benefits include smoothing of the skin and concealing of pores. In addition, it allows patients to retain some movement in the face and avoid the slackness that can appear under the eyes from traditional onabotulinumtoxin A injection delivery,” said Dr. Wu.
The concept of micro-Botox was originally developed to allow patients to retain some brow mobility after treatment with onabotulinumtoxin A for brow lifting, said Dr. Wu. “The concept is that when you inject superficially into the dermis, and into that intrasubdermal layer, only the superficial fibers of the frontalis are relaxed,” said Dr. Wu.
“So the fine wrinkles are removed, because you know that the muscles of the face all attach with fibers into the undersurface of the dermis—that is why you get these fine lines and wrinkles. So that the frontalis still moves, and looks more natural.”
In addition to the primary effect of onabotulinumtoxin A, other subtle effects were seen when using the micro-Botox technique, said Dr. Wu. Overall, the benefits of using the micro-Botox technique, he said included improvements in skin texture; skin and pore quality; as well as some acne control and scar improvement.
“I find that you get a smoother appearance without decreasing the deep muscle activity,” Dr. Wu said. “Also, it improves the sheen look of the skin because you get a smoother appearance with smaller pores. Additionally, it decreases oiliness by reducing sebaceous gland activity, and it can improve acne.” Reducing the size of sweat and sebaceous glands also tightens the skin, he said.
An injected droplet of onabotulinumtoxin A is typically 0.1 or 0.05 mL, said Dr. Wu, but with the micro-Botox technique he is injecting droplets roughly one tenth that volume. Traditional onabotulinumtoxin A droplets, containing 2 to 4 units, are actually fairly large, he said. “We sometimes don’t realize that when we inject just a little bit more, we’re actually injecting a very big blob of fluid which can travel to places we don’t want it to,” he said.
Creating micro-Botox’s smaller droplets is a technique that requires some practice, Dr. Wu said. “I always recommend putting some saline into a syringe, and squirting it out on the table so that you can see what the control is, and how much pressure you need to apply,” he said.
“Using the micro-Botox technique general allows you to cover the whole face using one syringe,” said Dr. Wu. He said he will put between 8 and 28 units into 1 mL of saline, with a typical operating dose of 20 to 28 units. “If you remember using a 2.5 mL dilution in the bottle, what I do is I’ll do the dilution of the micro-Botox in the syringe. With a 1 cc syringe I will withdraw 20 units which is 0.5 mL. Then I’ll add another 0.5 mL of saline into that syringe, to make up the solution that I want.” Doing the micro-Botox dilution in the syringe allows the bottle of Botox to still be used for traditional application, he said.
“In the forehead I like to give 16 units,” said Dr. Wu, describing a typical treatment with micro-Botox. “In the infraorbital area I give 8 units. In the cheeks and nasal area, I use about 8 units, and for the jaw line I’ll put 24 units per syringe. In the neck it can go up to 28 units in three syringes.”
Injecting the tiny droplets of Botox intradermally raises tiny white blebs, Dr. Wu said. While Dr. Wu said he typically spaces the injections 1 cm apart and covers all areas with prominent lines, he did say that adjustments should be made based on patient preference and how much mobility they want to retain.
The micro-Botox technique is particularly useful in the intraorbital area, lower eyelids and cheeks, said Dr. Wu.
He added that traditional onabotulinumtoxin A treatment in the glabellar and crow’s feet areas can give some patients unwanted slackness under the eyes, producing a sad ‘bloodhound’ appearance.
“Paradoxically the eye bags are worse, because the orbicularis muscle has become weakened,” Dr. Wu said.
“The fat begins to protrude. So if you’re giving tiny little blebs of very weak Botox into the skin itself, you can again relax the superficial fibers of the orbicularis without compromising too much function.” He said he injects approximately 4 units on either side of the lower eyelid, and a little into the bunny line area as well.”
Visible pores are a big concern to his patients in Asia, said Dr. Wu, and the micro-Botox technique has been helpful for them as well. “We found that after a session of micro-Botox in the cheek area you can reduce the number of countable pores by nearly 50 per cent,” he said. “Of course the pores are still there, they don’t go away, but they’re smaller and there is less sebaceous activity.” Men in particular come into his clinic and ask for micro-Botox to improve skin texture, he said.
Dr. Wu said his clinic is also using micro-Botox as an adjunct for treating keloids. In a treatment with steroids and intense pulsed light, the micro-Botox is added as a physical blocker of muscle activity.