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Journal Innoventions

Midface lifting with botulinum toxin: intradermal technique


Chariya Petchngaovilai, MD
Clinicare, Bangkok, Thailand

Summary

Background An intradermal injection technique is a variation of the intramuscular or


subcutaneous injection technique usually performed with botulinum toxin for facial
rejuvenation. The technique applied to realign the imbalance of the facial muscles by
weakening the downward pull of the depressors and allowing the levators to contract in
a compensatory fashion results in midface lifting and rejuvenation.
Aims To address the intradermal injection technique of botulinum toxin for midface
lifting.
Methods A restrospective review of the patients undergoing midface lifting during the
year 2008, the procedure, the details of the injection technique, and outcomes are
described.
Results An intradermal injection technique of botulinum toxin successfully gives rise to
midface lifting and rejuvenation.
Conclusion An intradermal injection technique of botuinum toxin treatment is effective
for aesthetic improvement in the midface.
Keywords: midface lifting, intradermal technique, botulinum toxin

Introduction
Botulinum toxin has been widely used for upper and
lower face rejuvenation, but for the midface, the
indications are limited to the treatment of hypertropic
orbicularis oculi, bunny lines, nasal flares, nasolabial
folds in selected patients, and nasal tip droop.1,2 The first
consideration for midface rejuvenation is always fillers.3
But aging changes in the midface are not only due to
photodamage and loss of subcutaneous tissue and
cutaneous elasticity but also to the muscles of the facial
expression on overlying skin.
The facial muscles of expression are striated muscles
lying just underneath the skin. They originate on bone
and insert directly into the skin of the face to control
facial expression. When these mimetic muscles contract,
they pull on the skin, moving it and causing wrinkling
Correspondence: Chariya Petchngaovilai, Clinicare, 128 Pahonyotin 2
Payathai, Bangkok 10400, Thailand. E-mail: dr.chariya@gmail.com
Accepted for publication August 12, 2009

312

that generally is perpendicular to the direction of the


muscle contraction.
The muscles are classified into two groups that
counteract each other the levators to lift up, and the
depressors to pull down. The main levators consist of the
Frontalis and the levators of the midface Zygomaticus
major and minor. Other levators (the Levator labii
superioris, Levator labii superioris alequae nasi, and
Levator anguli oris) contribute to uplift the lip and
corner of the mouth. The depressors are grouped into
depressors of the upper face or brow depressors
Procerus, Corrugator supercilii and Orbicularis oculi
and depressors of the lower face Platysma and
Depressor anguli oris, and a main depressor of the lip,
Depressor labii inferioris.
For the young adult, the depressors and levators are
counterbalanced to create the facial configuration of an
inverted triangular. As aging progresses, the biological
changes of the facial muscles, together with gravity,
seem to be more pronounced in the depressors rather
than the levators causing sagging and drooping in the

 2009 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 8, 312316

Midface lifting with botulinum toxin: intradermal technique

face. Aging in the midface is caused by the imbalance


between the Platysma and the lateral part of the
Orbicularis oculi along with the levators of the midface.
This can be characterized by sagging in the area of the
upper and midcheek, including a midcheek groove, tear
trough formation, deepened nasolabial fold, and a
transformation of the shape of the face.
Midface lifting with botulinum toxin is a technique to
correct the sagging in the midface. Injections of botulinum toxin will realign the imbalance of the muscles of
the midface by weakening the downward pull of the
depressors and allowing the levators to contract and lift
the skin in a compensatory fashion.
With an intradermal injection technique, botulinum
toxin is injected into the dermis instead of into the
muscle to diminish the strength of the hyperkinetic
depressors, the Platysma and lateral fibers of the
Orbicularis oculi. The technique works for the facial
muscles because these muscles are different from other
skeletal muscles in that they insert into the skin rather
than the bone. Therefore, when toxin is injected into the
dermis, it blocks the superficial fibers of the muscle
inserted on the skin, inhibiting muscle contraction, and
minimizing skin wrinkling. The toxin prevents release of
membrane bound acetylcholine at the neuromuscular
junction and thus produces chemical denervation and
immobilization of the muscle. The toxin injected into the
Platysma and lateral fibers of the Orbicularis oculi not
only diminishes their downward pull but also increases
the lifting function of the levators of the midface and
lateral part of the Frontalis.

C Petchngaovilai

Figure 1 Intradermal injection in two parallel rows along the


mandible for the Platysma.

Patients and methods


Over a period of 1 year (from January 2008 to December
2008), 275 cases226 females and 49 maleswere
treated at a private office with an intradermal injection
technique to achieve midface lifting. The age ranged
from 27 to 72 years.
The patients selected were those who had sagging in
the midface area which was manifested by cheek droop
with or without tear trough formation or development of
a midcheek groove, and mild to moderate deepening of
the nasolabial fold. Sagging in the jowls was also found
in conjunction with sagging in the midface.
Prior to injection, each patient was assessed by pulling
the skin of the cheeks perpendicular to the direction of
the contraction of the Platysma to determine the
strength of the depressor muscles and the points of
injection.
All of the cases were treated with botulinum toxin A
(Dysport, Ipsen Limited, Berkshire, UK). A vial of

 2009 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 8, 312316

Figure 2 Intradermal injection for the lateral fibers of the Orbicularis oculi, the injection was made along the lateral border of
the muscle, in the temporal area.

500 U of Dysport was reconstituted with 7 mL of


nonpreserved normal saline. The procedure was performed with a 1 mL syringe and a 32 gauge needle.
When the needle was in the dermis, the toxin was
injected to create a wheal of about 0.5 cm in diameter.
The technique was applied to the Platysma and lateral
part of the Orbicularis oculi muscle. The injection was
performed in two parallel rows. For the Platysma, the
lateral row started from about the tempero-mandibular
joint, down along the mandibular line, at about 1-cm
intervals. The medial row was about 1 cm from the
lateral row, with the injection points between those of
the lateral ones (Figs. 1 and 3).

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Midface lifting with botulinum toxin: intradermal technique

C Petchngaovilai

For the lateral part of Orbicularis oculi, the injection


was made along the lateral border of the muscle, in the
temporal area (Figs. 2 and 3).
The total units of toxin used for injection was about
5070 units per side.

Results
Intradermal injection applied to both the depressor
muscles (Platysma and Orbicularis Oculi) resulted in
midface lifting and rejuvenation, which could be
assessed by pre- and post-treatment photographs. The
cheeks were uplifted with softening of the midcheek
groove and nasolabial fold (Fig. 4a and 4b). Facial recontouring and smooth, shiny, wrinkle-free skin were
also obtained (Fig. 5a and 5b).

Figure 3 Intradermal injection diagram.

(a)

(b)

Figure 4 Before (a) and after (b) treatment, the cheek was uplifted with softening of the nasolabial folds.

(a)

(b)

Figure 5 Before (a) and after (b) treatment resulted in midface lifting and rejuvenation. Facial re-contouring with smooth, shiny, wrinklefree skin.

314

 2009 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 8, 312316

Midface lifting with botulinum toxin: intradermal technique

(a)

C Petchngaovilai

(b)

Figure 6 (a and b) In some of the cases, the improvement could be seen immediately after the injection.

A total of 275 cases underwent intradermal injection


technique for midface lifting, with 14 cases (5.09%)
excluded due to loss of follow up. The rest of the cases
achieved a visible but varying degree of improvement:
65 cases (24.90%) attained the high improvement with
cheeklift, softening of the nasolabial folds and re-defining
of the facial contour; 171 cases (65.52%) reached the
moderate improvement with cheeklift and facial recontouring; and 25 cases (9.58%) had only minimal
improvement of the facial contour.
In some of the cases, the progress developed instantaneously (Fig. 6a and 6b), but in most cases, the
changes were seen within 510 days. The more noticeable improvements could be achieved after touch up
treatments, 12 weeks later.
Only eight cases (3.07%) developed minor asymmetry
of the face, which could be easily corrected by injecting
more toxin intradermally into the Platysma and Orbicularis oculi of the larger side.
The effects of the treatment lasted 1014 weeks.

Discussion
Generally, the factors to be considered while injecting
botulinum toxin are muscle and skin conditions.

Intradermal injection is suitable for flat, sheet-like


muscles rather than the muscle bundles, and when the
muscle is flaccid or poorly defined. It can also be applied
when the skin is lax or loose with poor skin tone. The
fact that intradermal injection is unable to remove all of
the wrinkles, just soften them and preserve some muscle
functions, is good for those who prefer to keep the
natural expression and do not mind if some wrinkles
remain. Moreover, the intradermal injection technique is
safer to use in the more dangerous zones of the face.
Finally, this technique may be used as an alternative
treatment technique to re-define the facial cervical angle
contour in place of the conventional intramuscular
technique which is not suitable for everybody. When
speaking of re-defining facial cervical angle contour, one
usually thinks of a Nefertiti lift technique which is
performed by injecting botulinum toxin into the Platysma and its posterior band to release the downward
pull of the Platysma and alleviates the depressor effect on
the cheeks.4 However, the ideal candidate for this
technique is one who possesses a prominent posterior
band. Those with poorly defined posterior bands or with
skin laxity might not be good candidates. That is why
the intradermal technique comes in as an important
alternative treatment.

Table 1 Botulinum toxin reconstitution and dosage


Botulinum toxin

Reconstitution (mL)

Dose by units

Dose by volume (mL)

Dysport
Botox

7
5

5070
2030

0.81
11.5

 2009 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 8, 312316

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Midface lifting with botulinum toxin: intradermal technique

C Petchngaovilai

The unfavorable side effects from the treatment of the


lateral fibers of the Orbicularis oculi are rarely encountered if the toxin is not injected below the zygomatic arch.
The injections in the area of the lower face are more
complicated and carry higher risks of complications5
because small muscles are joined together in that area
and they are difficult to distinguish from one another.
The risk is even higher when the injection is performed
with more diluted toxin. Higher dilutions of botulinum
toxin result in greater areas of diffusion and therefore a
greater incidence of adverse effects.6 If the toxin diffuses
to the nontargeted muscles, it may cause an asymmetrical smile, difficulty in smiling, or drooping of the angle
of the mouth. That is why the intradermal injection
should be confined to the lateral part of the face to avoid
unfavorable side effects. If those complications accidentally occur, they are temporary and reversible.7
The duration of the toxin when injected intradermally
may not be as long lasting as the conventional
intramuscular injection, because this technique inhibits
only the superficial fibers of the muscle. Usually, patients
return for another treatment every 12 weeks.
When intradermal injection technique is performed
with Botox (Allergan, Irvine, CA, USA), the reconstitution is preferably with 5 mL of normal saline. The total
toxin per side for both the Platysma and the lateral part
of Orbicularis oculi is about 2030 units (Table 1).
However, each toxin possesses its own characteristics
the onset of action, the consequences, and the longevity
may be dissimilar.
The advantages of this midface lifting with the
intradermal injection technique is a minimally invasive
procedure that can be accomplished as a lunch time
procedure, without interfering with daily activities.
The procedure is simple to perform with no downtime
or permanent complications. The technique is justified to
be used as a treatment for those with poor muscle
tonicity or skin laxity, in which the intramuscular
injection may induce unpleasant result rather than the
pleasing one.

316

A disadvantage for some patients is that it may take


more than one session to get a satisfactory result. Also,
the treatment needs periodic maintenance. Intradermal
injection technique with wheal formation can cause
some pain from the dissection of the toxin fluid into the
skin, and multiple injection points are required. The
procedure is applied to soften but not completely
eliminate the wrinkles, and the results are predicted
upon case selection.
Midface lifting with an intradermal injection technique is a variation of the intramuscular or subcutaneous injection technique usually performed with
botulinum toxin for facial rejuvenation. This technique
may be applied in combination with other conventional
procedures, or with the injection of fillers to create
additional favorable outcomes, and bring about the
harmony of the entire face.

References
1 Carruthers J, Carruthers A. Aesthetic botulinum toxin in
the mid and lower face. Dermatol Surg 2003; 29: 46876.
2 Carruthers J, Carruther A. Aesthetic botulinum A toxin in
the mid and lower face and neck. Dermatol Clin 2004; 22:
1518.
3 Carruthers J, Glogau RG, Blitzer A, and the Facial Aesthetics
Consensus Group Faculty. Advances in facial rejuvenation:
botulinum toxin type A, hyaluronic acid dermal fillers, and
combination therapies consensus recommendations. Plast
Reconstr Surg 2008; 5: 5S30S.
4 Levy PM. The Nefertiti lift: a new technique for specific
re-contouring of the jawline. J Cosmet Laser Ther 2007; 9:
24952.
5 Lehrer MS, Benedetto AV. Botulinum toxin, an update on
its use in facial rejuvenation. J Cosmet Dermatol 2005; 4:
28597.
6 Carruthers A, Carruthers J, Cohens J. Dilution volume of
botulinum toxin type A for the treatment of glabellar
rhytides: does it matter? Dermatol Surg 2007; 33:
S97104.
7 Benedetto AV. Asymmetrical smiles corrected by botulinum
toxin serotype A. Dermatol Surg 2007; 33: S326.

 2009 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 8, 312316

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